Overview Report Context. Getting Started with Monthly Overview Reports. Materials Needed. Metrics Captured In Overview Report

Transcription

1 SIF Webinar: Overview Reporting and Organizational Relapse Prevention Planning Overview Report Context Getting Started with Monthly Overview Reports Juliann Salisbury Program Assistant, UW AIMS Center Materials Needed Previously received for Implementation Coaching Calls with Rita Frequency Ideally, Monthly Importance Track on quality of care goals Track IMPACT over time Helps to identify signs of Organizational Relapse Metrics Captured In Overview Report 1. OR Template Excel Spreadsheet Provided by AIMS Center 2. How To Guide Provided by AIMS Center 3. SIF CMTS (or MHITS) Caseload Statistics Page Active Patients Page Inactive Patients Page Color Coding from the HowͲTo Guide 1

2 Yellow Highlights Update As Needed Care Manager FTE Information Source: Program Leadership Where to Update: Directly in Main OR Table Yellow Highlights Update As Needed Active Caseload Minimum Information Source: CM FTE + CM Type columns Where to Update: NA, Automatic Formula Blue Highlights Update Monthly % Contacts with PHQ 9 Information Source: CMTS Caseload Statistics Where to Update: Main OR Table Green Highlights Update Monthly Information Source: CMTS Active or Inactive Patients Where to Update: Patients Treated Table 2

3 Green Highlights Update Monthly Contact >2 Months Information Source: CMTS Active Patients Where to Update: Active>2mos column within the Patients Treated table Getting Started with OR What s Next Cohort 1 Received templates and guides last year Cohort 2 Receive Template and How to guide after final implementation support call Questions? Juliann, salisj2@uw.edu Learning Objectives Organizational Relapse Prevention Planning (ORPP) Rita Haverkamp MSN, PMHCNS BC, CNS Clinical Trainer, UW AIMS Center Social Innovation Fund (SIF) May 10, 2017 By the end of this presentation, participants should be able to: Discuss the value of doing an ORPP Understand the items to consider Be able to analyze organizational processes that will assist in ORPP 3

4 Core Principles of Collaborative Care Collaborative Care Team Approach Patient Centered Care. Primary care and mental health providers collaborate effectively using shared care plans. Population Based Care. A defined group of patients is tracked in a registry so that no one falls through the cracks. PCP New Roles Core Program Treatment to Target. Progress is measured regularly and treatments are actively changed until clinical goals are achieved. Patient Care Manager Psychiatric Consultant Evidence Based Care. Providers use treatments that have research evidence for effectiveness. Other Behavioral Health Clinicians Additional Clinic Resources Accountable Care. Providers are accountable and reimbursed for quality of care and clinical outcomes, not just volume of care. Substance Treatment, Vocational Rehabilitation, CMHC, Other Community Resources Outside Resources IMPACT Workflow What is ORPP? Identify & Engage Establish a Diagnosis Initiate Treatment Follow-up Care & Treat to Target Complete Treatment & Relapse Prevention Plan to empower clinic to maintain the full model of CC after the support of AIMS/grant services are terminated Plan to prevent recurrence of usual MH care System Level Supports 4

5 Why an ORPP? We have seen the model get off track without careful attention to the detail Takes more planning to do this than to just revert back to usual BH care Ending well is as important as starting well Many believe it will continue or we just know what to do RPP works well for patients and for clinics Changes that Happen Can Affect Fidelity to the Model New staff need to be acculturated New management need to know model and the processes to maintain it PCP turnover and conflicting demands from other care initiatives New PC needs to know the system and support it Timing the ORPP Relapse Throughout Prevention Grant Coaching calls Your reports Start on Monitoring and Maintenance The systems you have already put in place ORPP End of Grant Provides a structure for ending AIMS involvement Prepares for changes SIGNS OF ORGANIZATIONAL RELAPSE 5

6 Signs of Organizational Relapse (1) Signs of Organizational Relapse (2) Signs What do these indicate? Signs What do these indicate? Referring to IMPACT as therapy Cancelling meetings with psychiatric consultant Meeting with the psychiatric consultant on an as needed basis Losing team approach Segregating BH from PC Less focus on meds for patients Patients not wanting therapy opt out Not likely to be changing treatment plans or doing T2T Inactive PC not part of team Increasing percentage of patients in care long term Goal: Less than 20% Less or no phone clinical contacts Not using evidence based treatment No T2T, less use of evidenced based care Going back to idea that patients have to want care, less reaching out to patients Doing eclectic therapy possibly no clear goal/end point for treatment, longer term treatment Signs of Organizational Relapse (3) Signs of Organizational Relapse (4) Signs Few treatment changes Decrease in warm connections Waiting lists What do these indicate? No T2T, consults don t result in treatment changes New PCPs, poor PCP buy in, conflicting demands, education needed Keeping patients too long in treatment, less oversight of care model Few RPP Signs Patients make decisions on when to end treatment No training of new staff What do these indicate? No awareness of T2T being met, poor staff buy in to model No room for new patients, no T2T being met, they want to leave so opt out Model will end 6

7 SIF Webinar: Overview Reporting and Organizational Relapse Prevention Planning Signs of Organizational Relapse (5) Signs No discussion of metrics between team members Less use of PHQͲ9 new metric on CMTS What do these indicate? No accountable care Not doing T2T, less accountability PatientͲCentered Care Regular team meetings Regular presentations to PCPs Meetings with PC are regularly held Check communication process with PCPs Review warm connection process regularly Hire new staff who are comfortable with modelͳ explain it before orientation, before decision PROCESSES THAT SUPPORT THE CORE PRINCIPLES OF COLLABORATIVE CARE PopulationͲBased Care Scheduled review of registry by CM? Regular review of registry by supervisor to look for gaps missed by CM? Review includes checking these issues Long term treatment, no treatment changes with patients who aren t improving, no RPP, few PHQͲ9s 7

8 Treatment to Target Review by whole team of improvement rates? Regular meeting to discuss this review PC also reviews improvement and plans for consultation on cases that may be missed by CM? Evidence Based Care Plans to maintain PST skills? Review intermittently with CM s what EBTs are used and evaluate the effectiveness of what is being used. Accountable Care Review of statistics and look for gaps in care? Ask the hard questions. Have we fallen back to care as usual? How do we get back on course? CHECKPOINT Discussion 8

9 How To Develop an Organizational Relapse Prevention Plan (ORPP) Signs of Relapse Who will monitor? How will they monitor? Organizational Processes to Support Plan How will you replace AIMS monitoring and reporting support? Training Plans What ongoing staff training is needed? How will you train new staff? Distribute Plan and Review Plan Signs of Relapse Pick some measurements that are hard for you to maintain now or you had to work to get established Pick the signs that mean the most to you Signs of Relapse Example Less warm connections, overall lower caseload Patients staying for long term therapy calling this a therapy program Less PHQ 9s being done Few RPP done Patients not improving without a consult Waiting list Who will Monitor? Determine who is responsible for monitoring which signs of organizational relapse. 9

10 Who will Monitor? Example CM for their caseload Lead for the whole team PC for review of caseload stats as well All to bring up good issues How to Monitor Signs of Relapse? Where will signs of relapse be found? How will sign of relapse be addressed when they arise? How to Monitor Signs of Relapse? Example CM/therapist will review their caseload and follow up with patients accordingly CM do report for manager monthly Team meeting discusses registry information weekly Manager discusses variations with individuals first as a team discussion to help CM find out how others are keeping to the model and later if needed 1:1 Organizational Processes In Place to Support Our Plan How to ensure fidelity to ORPP 10

11 Organizational Processes In Place to Support Our Plan Example Weekly team meetings with PC Weekly team meetings just CM and therapists Monthly program review meeting Chart monitors quarterly to see if care model, PST, EBT is being done Keep upper management in the process so they support its maintenance All clinic staff meeting every 6 months to discuss how things are working for all involved Organization Processes Needed to Replace AIMS Support Organization Processes Needed to Replace AIMS Support Example will do a monthly report of the statistics similar to AIMS Overview Report Set a standard that is expected and review each month CM s review of registry together in team meeting Policy and procedure book Training Plans for Existing and New Staff 11

12 Training Plans for Existing and New Staff Example Distributing the Plan/Review of Plan Review of PST skills training in other brief EBT models Use of modules from the SIF website/more careful monitoring of adherence to the model in the beginning Distributing the Plan/Review of Plan Example Have a book for materials Write procedures for new employees Evaluate program monthly and do a full review yearly ORPP Presentations Wednesday, June 14, :30 AM Pacific 11 12:30 PM Mountain 9 10:30 AM Alaska 12