Learning Objectives. Follow up and Treatment to Target. Collaborative Care Workflow. Initial Assessment. Clinical Roles: Patient Centered Team Care

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1 Learning Objectives Follow up and to Rita Haverkamp, MSN, PMHCNS BC, CNS Expert Care Manager and AIMS Trainer By the end of this training, participants should be able to: List strategies to optimize follow up care and measurement based treatment Recognize patients that need to have treatment adjusted Prioritize patients to discuss during caseload consultation Clinical Roles: Patient Centered Team Care PCP Patient Care Manager Role Community Partner PCC New Roles Psychiatric Consultant Initial Assessment Systematic information gathering Presenting complaints, symptoms and relevant history Essential part of building therapeutic alliance bond Have systems in place to discuss patients with your partner in care Review of case early with team/consultant 1

2 Why do we care about diagnosis? Guides treatment and clinical decision making! Provisional Assessment by BHP and PCP and CBO Screeners filled out by patient Psychiatric Consultant case review or direct evaluation Provisional diagnosis and treatment plan 9 Planning Patient, PCP & Care Manager all involved in making the treatment plan plans individualized because patients differ in: Medical comorbidity Psychiatric comorbidity Prior history of depression and treatment Current treatments preferences response 3 Critical Elements of Alliance Tasks? Goals? Bond? Working Alliance Discussing treatment options helps facilitate all of these elements. 2

3 Discussing Options Review all treatment options available: For follow up, this discussion is critical in case you need to add a treatment later if patient isn t progressing Psychotherapeutic interventions Behavioral Activation, Problem Solving, Cognitive Behavioral, etc. Evidence based! Medications Discuss pros and cons of each option so patient can make an informed choice Discussing Options The treatment that WORKS is the best one Person centered care means selecting treatments based on client preference, not clinician preference Try to be unbiased when offering treatment options Be eclectic: One size fits few Medication therapy is not right for everyone Psychotherapy is not right for everyone; different therapies Supporting whole person treatment is important This may include medication therapy You can support medication therapy within scope of practice Why We Focus on Follow up and Measurement Based Overall model of care If it isn t working fix it, whether it is therapy or medications Critical to help make sure patients get better Follow Up Contacts Weekly or every other week during acute treatment phase In person or by telephone to evaluate symptom severity (PHQ 9, GAD 7) and treatment response Initial focus on: Adherence to medications Side effects Follow up on activation and PST plans Later focus on: resolution of symptoms and restoration of functioning Long term treatment adherence Each Appointment is a Decision Point Three requirements: Frequent contacts and information gathering use a PHQ 9 each time Track and consider what is happening Do I need to consult and/or change what I am doing? What does the patient want to do? How satisfied are they with progress? Are they willing to do something else? 3

4 1. Frequent Contact Improves compliance Enhances engagement bond Sharing goals and tasks Gather more information Get a pattern to PHQ 9 scores Intensity of Early ment Drives Improvement In studies, patients with early follow up were less likely to drop out and more likely to improve (Bauer, 2011) Patients who have a second contact in less than a week are more likely to take their medications Follow up contact within four weeks of the initial assessment is key to early improvement (Bao, 2015) Frequent Contacts as It Relates to Behavioral Activation/PST Report on progress increases patient s motivation to act Reminder to patient if they haven t done it Time to make a new plan Frequent Contacts as It Relates to Medications Check on adherence Time to talk about side effects/ concerns regarding medications Maximize treatment effects if problems are addressed early Consulting in a timely manner Typical Frequency of Care Management Contact Active Until patient significantly improved/stable Minimum 2 contacts per month Mix of phone and in person Monitoring 1 contact per month After 50% decrease in PHQ 9 Monitor for ~3 months to ensure patient stable relapse prevention 4

5 Typical response to treatment changes 6 months is average treatment length Only 30 50% patients respond fully to 1st treatment 50% 70% of patients need at least one change in treatment to improve. Each change of Tx moves an additional ~20% of patients into response or remission Checkpoint Discussion Who is using the phone now or has in the past? How have you made it work? What did patients like about it? If you haven t done it what do you think is a value to it? Using the Telephone A Way to Increase Contact and ment Under utilized tool Client centered approach Convenient Pro active Improved bonding with patient The Many Circumstances in Which to Use the Telephone Patient who missed an appointment Call NS s within 15 minutes and use this time for a telephone contact Patient who has transportation difficulties Patient doesn t want to or can t come in Patient who has children at home Check in on patient between other in person visits I.e., patient who just started a new medication and is worried about side effects Helpful Hints for Scheduled Telephone Contacts This Is an Appointment Have a block of time in your schedule for this 1 2 hours so you can make numerous calls Set them about minutes apart Give patients a time for the call. Ask them if that time would be convenient free of distractions Mail them or send them a PHQ 9 so it is more easily done you can ask them to do it before the call so it is ready for discussion Structure for Telephone Contacts Ask them if this is still a good time set another time if not Have no distractions yourself and ask them not to have them either Set agenda for the call check on PHQ 9, medications and behavioral activation or have a PST session Do PHQ 9 early in call this helps to plan for the rest of the call End with plan for next appointment or call 5

6 2. Track and Consider Review the treatment history page and the graph of PHQ 9 Think about: Improving or not could they improve more? How long in this treatment? Are they engaged? Involved in treatment outside of sessions? Are there other challenges and how will we overcome them? Checkpoint Discussion Tendency to Want to Decrease Use of PHQ 9 What are your concerns about doing it each time? Behavioral Health Measures as Vital Signs Behavioral health measures are like monitoring blood pressure! Identify that there is a problem Need further assessment to understand the cause of the abnormality Help with ongoing monitoring to measure response to treatment Advantages of Using Behavioral Health Measures Objective assessment Creates common language Focuses on function Avoids potential stigma of diagnostic terms Helps identify patterns of improvement or worsening Flexibility of administration Reasons to start each session with PHQ 9 Sets evaluation of progress as the first step at each appointment with the patient Begins that discussion with patient Gives you a measurement on which to base decisions and discussions Helps patients know what better looks or feels like Helps engagement with patient shared goals Common Measures Anxiety, Substance Use, PTSD, Bipolar, ADHD, etc. Can be expanded when want to use 6

7 and to 1/15/16 Expectancies Tracking Clinical Outcomes Outcome Expectancy Prevents patients from falling through the cracks Facilitates treatment planning and adjustment Is treatment working? Shared goals SelfͲEfficacy Expectancy What am I doing to help myself get better? Shared tasks Combats clinical inertia: patients staying on ineffective or partially effective treatments Know when it is time to get consultation and when it is time to change treatment Track Measurements Over Time! IDENTIFY A PROBLEM IN THE FOLLOWING CASELOADS OR PATIENT REPORTS:

8 3. Seek Consultation Early and Often Too much consultation is better than not enough Major factor in improvement rates is the use of consultation Ask consultant when they like to increase a med that has some effectiveness but not full Any person you think maybe I should consult, then do consult Checkpoint Discussion Where and how are you deciding about cases to be discussed in consultation? Priorities for Consultation 1. All patients who have 8 10 weeks of treatment with no improvement/not in remission 2. Patients you or consultant have flagged 3. Patients where there is a diagnostic question and/or concern if they need behavioral health program Severely depressed (PHQ 9 score 20) Fails to respond to treatment Has side effects from medication Has complicating mental health diagnosis, such as personality disorder or substance abuse Is bipolar or psychotic Has current substance dependence Is suicidal or homicidal Priorities for Consultation (cont d) 4. Patients who aren't engaged or have other difficulties in their care 5. Patients who are on a low dose of an antidepressant for 4 weeks or longer with only little or no improvement 6. New patients, especially those who are more complex and Relapse Include asking the patient to make time to review their own PHQ 9 score on a regular basis so they can keep track of how they are doing. 8

9 Checkpoint Discussion Any questions/ comments? Case Call Next Month Feb. 17, 2016 Care Managers should come prepared to discuss a specific case involving follow up and treatment to target Selecting a Case 1. Review your caseload and find a case that isn t improving or process of follow up that can be improved 2. Implement a change before the next call For example: Find a pattern of a problem by looking at your registry and think about what barriers there are. Find a patient with few consults and think about why? Do a consult and see what changes can occur. Use scheduled telephone contacts with someone you haven t before and report what happened. Think about whether you are holding on to a therapy model with a patient when another treatment might be needed. Change the treatment. Change how you describe the treatment options to the patient and see what happens. 9