Recovery Planning in Behavioral HealthCan we honor the person and still satisfy the chart?

Janis Tondora and Dan WartenbergMHTTC Webcast

June 5th and June 19th, 2019

Introductions & Housekeeping

Janis Tondora, Psy.DAssociate Professor, Yale Program for

Recovery and Community Health

Dan Wartenberg, Psy.D., M.P.H.Chief Clinical Officer,

Newport Mental Health

Agenda – PCRP Webinar SeriesJune 5th

• Introduction and Background

• 4 Ps Key PCRP Practices

• Preview of documentation

• Implementation barriers• Lessons learned in implementation

• Leadership commitment

• Competent, motivated workforce

• Organizational infrastructure and work flow

• Activated/empowered clientele

June 19th

• Deeper dive into documentation

• Person-centered assessment

• Integrated, holistic understanding

• Core documentation elements & common quality errors

• Writing a plan that honors the PERSON and satisfies the CHART

• Lessons learned in the design of EHRs platforms and planning templates

• Promise and pitfalls of EHRs in supporting (or undermining!) person-centered thinking and practice

How We’ve Learned What We’ve Learned…

• NIH R01, Culturally Responsive Person-Centered Care for Psychosis (Peer-Supported)

• CMS Real Choice Systems Change Grant, Person-centered Planning Implementation and Evaluation for Connecticut Department of Mental Health and Addiction Services

• SAMHSA, Transformation State Incentive Grants (T-SIG)

• NIH R01, Person-centered care Planning (PCCP) and Service Engagement (Supervisor Focus)

• Phase I and II SBIR Grants: Recovery Roadmap: A Collaborative Multimedia Tool for Person-centered Care Planning

• Broad scale training and consultation work in 20+ US states and internationally; Current intensive work in multi-agency BH partnership in Rhode Island

• Regular collaboration with national accreditation & fiscal bodies, e.g., CMS, JCAHO, CARF, etc.

Together We Can

The Person-Centered Train: Who’s on Board?

Forces Behind PCRP• Values-driven approach first and foremost! Golden Rule

• Endorsement by state behavioral health authorities

• Federal/national endorsement (Freedom Commission, SAMHSA, NCAPPS, etc.)• Funders (e.g., CMS) and accrediting bodies (e.g.,

CARF, JCAHO)

• Accumulating evidence/data showing improved outcomes

• Voice of service recipients: • When I have a voice in my own plan, I feel a

responsibility to “work it” in my recovery. • You keep talking about getting me in the driver’s seat

when half the time I am not even in the damn car!

Poll: PCRP Implementation Concerns:Which of these is of most concern in YOUR organization?

1. PCRP devalues the role of clinical expertise; what is the professional’s role if the person is in the driver’s seat?

2. People receiving services are too impaired or uninterested to partner in the way PCRP requires.

3. PCRP documentation puts us at risk for compliance issues, e.g., it might not meet medical necessity criteria.

4. The forms/templates/EHRs don’t have the right fields for PCRP documentation.

5. There is not enough time to do PCRP, caseloads are too high

6. If PCRP increases choice, how do we manage risk issues that might emerge in the face of “bad” choices?

7. Don’t we already do PCRP? Is it really any different?

Common Concerns/Barriers

PCRP: Don’t we already do it?

• In the experience of the persons served

• when we “take stock” of current planning practices

• and in the written recovery plan itself…

http://www.ct.gov/dmhas/lib/dmhas/publications/PCCQprovider.pdfhttp://www.ct.gov/dmhas/lib/dmhas/publications/PCCQperson.pdf

Yale PRCH/CT DMHAS Person-Centered Care Questionnaire

Tondora & Miller, 2009

Person-Centered Care...A Fuzzy Concept?• Consumers demand it, public service systems

endorse it, medical and professional programs are encouraged to teach it, and researchers investigate it. Yet, people struggle to understand exactly what “It” is and what “It” might look in practice.

• Tondora et al., 2005, Implementation of Person-Centered Care and Planning: How Philosophy Can Inform Practice

• PCRP represents a unique opportunity to move from person-centered THEORY to person-centered PRACTICE

The 4 “Ps” of PCRP Recently Released Web-based Video & Tips Sheet Serieshttp://www.promise.global/propel.html

Tondora & Davidson (YALE) andRae, & Kar Ray (CAMBRIDGE)

• Can change what people “do”… but also need to change the way people feel and think.

• *4 Essential Ps:• Philosophy – core values• Process – new ways of partnering• Plan – concrete roadmap• Purpose – meaningful outcomes

• The practice of PCRP can only grow out of a culture that fully appreciates recovery, self-determination, and community inclusion.

http://www.promise.global/propel.html

The Process of PCRP:Key Practices

• Person is a partner in all planning activities/meetings; advance notice (person-centeredness)

• Person has reasonable control over logistics (e.g., time, invitees, etc.)

• Person offered a written copy/transparency

• Shift in structure/roles in planning meetings

• Education/preparation regarding the process and what to expect (Toolkit/ Recovery Roadmap)

The Recovery Roadmap Project

• NIH-supported Phase I and II SBIR grants

• Developed innovative, multimedia tools to support the uptake of PCRP in behavioral health settings

• Versions for practitioners AND service recipients

• Randomized trial underway in State of CT

The Process of PCRP:Key Practices

• Recognize the range of contributors to the planning process

• Capitalize on role of peers wherever possible• distribution of effort based on unique talents…promotes

efficiency AND quality

• Understand/support rights such as self-determination

• Value community inclusion/life - “While,” not “after”

• Strengths-based approach in both language and assessment/planning

15

Community Inclusion: Word of Caution…

Building a life in the community is NOT a task that comes AFTER discharge.

CommunityLife

Love, Work& Play

Housing,Faith &Belonging

TREATMENT(Clinical Stability)

Strengths-based Language For the last 18 mos., the patient has been compliant with meds and treatment. As a

result, she has been clinically stable and has stayed out of the hospital. However, patient has no-showed for last two visits and the team suspects she is flushing her meds. Patient was brought in for evaluation by the Mobile Crisis Team today after she failed to report to Clozaril clinic for bloodwork.

In the last 18 months, Sandra has worked with her doctor to find meds that are highly effective for her and she has been active in activities at the clinic and the social club. Sandra and team all feel as though she has been doing very well, e.g., returning to work, spending time with friends, and enjoying her new apartment. However, people have become concerned lately as she has been missed at several activities, including a bloodwork appointment at Clozarilclinic. The Mobile Outreach Team did a home visit to see if there was any way the staff could assist her.

Common Concerns Revisited

Common Concerns/Barriers

• PCRP is NOT

• …incompatible with the concept of medical necessity required in clinical documentation

• ...reserved for those who are “high functioning” or well on their way to recovery. It is a universal right and applies across all service populations but application of specific PCRP practices may look different in different settings

• …“anti-clinical/anti-tx”; invalidating of professional expertise

• …an “add-on” or special new program

• but rather an integrating framework for quality care

A Few Words About What PCRP is NOT…

If the person is in the driver’s seat, where does that leave ME?

• Does PCRP devalue the role of the professional or clinical treatment?

• NO! PCRP is based on a model of PARTNERSHIP…

• Respects the person’s right to be in the driver’s seat but also recognizes the value of professional co-pilot(s) and natural supporters

Does “Partnering” Mean We Always Have To Reach Agreement?

NO! But…it doesrequire mutual

respect and understanding of the person’s view

Are some people “too sick” to engage in PCRP?

• Perception• Clients may be too sick to engage in this kind of

partnership; have no goals; are unrealistic; comfortable in “system,” unmotivated

• Reality• PCRP is a fundamental right of all individuals; how it looks in practice

may vary • Need to communicate a message of hope and a belief that their life can

be different, or offer education/training/tools on recovery-oriented care• Need to assess and plan for stage of change• Need to be creative in how we listen and solicit preferences

The Documentation Challenge:But, I feel like I keep trying to force a square peg

into a round hole. And it just doesn’t fit!

CT Case Manager on trying to be “person-centered” in the context of clinical treatment planning and all the regulatory/fiscal requirements that go with it…

Meet Mr. Gonzalez

Mr. Gonzalez, a 31 year-old married Puerto Rican man, is living with bipolar disorder and he struggles with addiction to alcohol which he often relies on to manage distressing symptoms. During a recent period of acute mania, Mr. Gonzalez was having increasingly volatile arguments with his wife in the presence of his two young sons, ages 3 and 5. On one occasion, he shoved his wife to the floor which prompted her call to the police. When the police arrived at the home, Mr. Gonzalez was uncooperative and agitated, and he was subsequently admitted to an inpatient psychiatric facility for evaluation and treatment. His wife is open to reconciliation, and she is actively involved in his treatment at the hospital. Mr. Gonzalez states that his love for his family and his faith in God are what keep him going in difficult times.

Snapshot: A Traditional Plan• Goal(s):

• Achieve and maintain clinical stability; reduce assaultive behavior; comply with medications

• Objective(s):• Pt will attend all scheduled groups on unit and mall; pt will take all meds as

prescribed; pt will complete anger management program; pt will demonstrate increased insight re: clinical symptoms; pt will recognize role of substances in exacerbating aggressive behavior

• Services(s): • Psychiatrist will provide medication management; Social Worker will provide anger

management groups; Nursing staff will monitor medication compliance

Traditional Plan

• Take my lithium • Increase insight• Reduce assaults• Comply with group schedule

I’m here to return YOUR goals.You left them on MY recovery plan!

Strengths/Assets to Draw Upon

Barriers /Assessed Needs That Interfere

Short-Term ObjectiveS-M-A-R-T

Toward Person-Centered Documentation

GOALLife goal, as defined by person;

what they are moving “toward”…not just eliminating

Interventions/Methods/Action Steps• Professional/“billable” services, including purpose• Clinical & rehabilitation• Action steps by person in recovery• Roles/actions by natural supporters

Life Goal:I want to get my family back.

I don’t want my boys to ever be afraid of me.

Strengths to Draw Upon:

Devoted father; motivated for change; supportive wife; Catholic

faith and prayer are source of strength/comfort; positive

connection to Peer Specialist; intelligent

Barriers Which Interfere:

Acute symptoms of mania led to violence in the home; lack of coping strategies to manage distress from

symptoms; abuse of alcohol escalates behavioral problems

Sample Short-Term Objective(s)

Within 30 days, Mr. Gonzalez will apply learned coping strategies to have *positive interactions with wife and children during one supervised visit in family therapy session.

Services & Other Action Steps- Doc to provide med management daily for 2 weeks to reduce irritability & acute manic sx-Family Specialist to provide family therapy sessions 2X weekly to coach Mr. Gonzalez to provide psycho-education to family regarding mental health and recovery-CSP Specialist to provide weekly coping and communication Skills-Training to improve Mr. Gonzalez’s ability to manage distressing symptoms and to have healthy relationships at home (use of teaching, role playing, coaching, etc.)-Referral to spiritual counseling agency chaplain to promote use of faith/daily prayer as positive coping strategy to manage distress-Wellness Recovery Action Plan with Peer Specialist to promote illness self-management

• Meaningful relationships• A place of my own• Valued social roles• Independence• Freedom to Make Choices• Cultural and personal

preferences• Faith and spirituality• A job, a career

• Basic health and safety

• Management of clinical symptoms

• Maslow’s basic needs

• Harm reduction

• Management of risk

• Legal obligations and mandates

Important TO the Person Important FOR the Person

Lessons Learned from the Field…Representative Advances in PCRP Implementation

Recipe for Success:

• Leadership Commitment• Competent, Motivated

Workforce• Organizational Infrastructure

congruent with PCRP values• Activated/Empowered Clientele

who come to expect that their views will be driving planning and service delivery

Leadership: Patience/PerseveranceRecovery oriented person-

centered approaches reflect a

significant cultural change and a

new way of doing business that is

not going to happen overnight

and can’t be achieved simply

through staff training.

Leadership: Aligning Mission with Policy

• Policy & Program Development – …The Plan of care shall be developed in collaboration with the person. Focusing solely on

deficits in the absence of a thoughtful analysis of strengths leads to disregarding the most critical resources an individual has on which to build on his or her efforts to advance in his or her unique recovery journey. The primary focus of recovery planning is on what services the person desires and needs in order to establish and maintain a healthy and safe life in the community.

» CT DMHAS Commissioner’s Policy Statement #33

– Individualized Recovery Planning is a service designed to assist an individual in the ongoing development, review and modification of a course of care that supports his or her identified path to recovery. The course of action is based on an assessment process and the individual's personal preferences and desired life roles. Such course of care is reflected in an individualized recovery plan (IRP), which includes the identification of medically necessary services and which supports the individual's goals and desires.

» NY OMH Personalized Recovery Oriented Services

Leadership: Managing the Change

• Change Management focuses on:• Planning how to put a change in

place, • Creating the infrastructure and

tools to support the change, and• Building acceptance of the

change through communication, involvement, and education.

Leadership: Keeping the Focus

• Keeping the focus amongst competing priorities

• Avoiding the flavor of the month syndrome

• PCRP framed as the core approach that underlies and connects all agency initiatives

Workforce/Competencies• Highly Complex Skill Set

• Understand and embrace the underlying PCRP values

• Engage and elicit goals, preferences• Formulate assessment information• Negotiate to come to a joint understanding

of what should be in the plan• Put it in writing• Technical skills to negotiate EHR’s

*

Workforce: Competencies & Quality Management

Date Provider IDIdentifying

Record Information

Client Local ID

1. The Recovery Plan includes a description of the

recovery goals and objectives based upon the assessment, and expected

outcomes of the plan.

2. At least one of the goals statements reflects a

meaningful life role/recovery goal or the pursuit of a

valued activity outside of the mental health system.

3. The Recovery Plan

goals are written in the individuals

own words.

4. The Recovery Plan includes a description of the presenting problem/barriers

to goal attainment as a result of the mental health or substance abuse issues.

5. The Recovery Plan includes a description of the presenting problem/barriers

to goal attainment as a result of the mental health or substance abuse issues.

6. The Recovery Plan includes the expected date by

which the recovery goals, objectives, and interventions

will be achieved.

7. The target dates for the

objectives in the Recovery Plan

vary (if relevant).

8. The Recovery Plan includes a description of

the individual’s strengths

9. The individual's strengths are actively used in the

Recovery Plan rather than just identified in the

strengths field.

10. If cultural issues are identified in the assessment,

they are addressed in the Recovery Plan unless a clear

rationale is provided for deferring issues from the

Recovery Plan.

11. If physical health issues are identified in the assessment,

they are addressed in the Recovery Plan unless a clear

rationale is provided for deferring issues from the

Recovery Plan.

12. If co-occurring substance use is identified in the

assessment, it is addressed in the Recovery Plan unless a

clear rationale is provided for deferring issues from the

Recovery Plan.

13. If trauma issues are identified in the assessment,

they are addressed in the Recovery Plan unless a clear

rationale is provided for deferring issues from the

Recovery Plan.

14. The objective(s) can be linked back to

barriers and issues identified in the comprehensive

assessment.

15. The objectives are expressed in overt, observable actions of the individual. The objectives are written to address observable

changes in behavior, functioning or skills that foster the individual’s

ability to achieve their goals

16. The objectives are measurable.

17. The objectives are attainable and realistic and are based on the individual's current

functioning and stage of change.

18. The interventions specify the frequency,

number of units, duration, staff member responsible, and type of services to be provided.

19. The interventions

specify the purpose/intent as

it relates to the Recovery Plan

goals and objectives.

20. The Recovery Plan incorporates

actions/contributions by natural supports

(friends, family, peers, and

community).

21. Interventions include self-directed

action steps based on the individuals strengths and

identified interests.

22. There is a description of the individual’s participation in the recovery planning process and there is evidence that the

Recovery Plan was completed in consultation with the individual. This may be evidenced by quotes, documentation of input, and/or signature(s) from the person

receiving services and/or LAR.

Workforce Competencies: Sample PCRP Meeting-Observation Tool

Massachusetts Department of Mental Health in Collaboration with The Transformation Center

Competencyknowledge, skills and abilities

ProjectManagement

work / business flow

Culture Management

behavior and attitude

“Training” is Necessary, but Not Sufficient

Transformation Change Model

Workforce: Practice• Since most clinicians, of any discipline or degree,

have not received previous training, education or supervision in a person-centered approach to planning, competency–based training must be offered, and then reinforced.

• Ongoing follow-up via telephone/plan reviews, clinical supervision including record reviews, and ongoing experiential in-service training with staff are but a few of the strategies for reinforcing the improvement and application of new skills.

Workforce: Motivation - Listen & Respond To Common Concerns – REVIEW POLL FEEDBACK

1. PCRP devalues the role of clinical expertise; what is the professional’s role if the person is in the driver’s seat?

2. People receiving services are too impaired or uninterested to partner in the way PCRP requires.

3. PCRP documentation puts us at risk for compliance issues, e.g., it might not meet medical necessity criteria.

4. The forms/templates/EHRs don’t have the right fields for PCRP documentation.

5. There is not enough time to do PCRP, caseloads are too high

6. If PCRP increases choice, how do we manage risk issues that might emerge in the face of “bad” choices?

7. Don’t we already do PCRP? Is it really any different?

Common Concerns/Barriers

Infrastructure: Build PCRP into the Daily Fabric of the Work

• Modify documentation templates to reflect core values

• Structure Supervision to include PCRP-based chart review

• Carve out time in regularly occurring Team Meetings

• Redesign Job Descriptions/Performance Reviews to include PCRP competencies

• Collect, review and use data to continuously improve and sustain momentum

Infrastructure: Templates• The round peg in the square hole

syndrome• The power of forms• Documentation should be as efficient as

possible• Bundling of requirements around recovery

planning time• Modify documentation templates to reflect

core values• Do not restrict person centered

approach to the recovery plan, need to embed in all aspects of documentation

Infrastructure: Lost in Translation

The Work The Plan

“What gets measured, gets done.”

Unknown Author

45

PCRP Process: What Does It Look Like?

46

PCRP Documentation: What Does It Look Like?

InfrastructureMeaningful Use of DATA

• Data is used for • Evaluation of your work

• Identifies what you need to supervise to

• Identifies core values at the system level

• Helps employees understand the “why” of their jobs

• Debunks myths

48

Infrastructure: Performance Improvement -Fidelity and Outcome

It is valuable to know where one wants to go and to measure/ benchmark progress over time.

• 95% of all recovery plans will include goals stated in the persons own words; or

• improve individual outcomes, such as reduced hospitalizations, less incidence of criminal justice involvement, finding desired housing, obtain meaningful work, reducing substance use

Individually Tailored Services

Diversity of Treatment Options

Client Choice

LIFE GOALS

RSA Subscales

Consumer Involvement

Empowerment: Invest In Consumer Involvement!

• Recovery Self Assessment (RSA)

• Programs which score high on Consumer Involvement consistently score higher on overall recovery orientation

• If you get ONE thing right…

51

Nothing about us, without us (REALLY!)

Primacy of meaningful participation in ALL aspects of system from design to delivery to evaluation

Research showing we typically UNDERESTIMATE consumers’ desire to be involved (Chinman et al, 1999)

And… that consumer involvement often has the single-most critical impact on recovery-oriented systems transformation

A Word of Caution…

“We want to include you in this decision without letting you affect it.”

Empowerment: Peer Specialists• Engaging in discovery process to identify strengths, barriers • Assisting person to clearly identify their life goals• Advocating for the person in planning meetings• Inspiring hope

Closing Q & A… Your Thoughts and Ideas

For more information:janis.tondora@yale.eduwartdan@optonline.net

mailto:janis.tondora@yale.edumailto:wartdan@optonline.net

We just need to stop accepting what is and start creating what should be…

Dale DiLeo

A Take Home Message: Together…

Recovery Planning in Behavioral Health� Can we honor the person and still satisfy the chart? Introductions & HousekeepingAgenda – PCRP Webinar SeriesHow We’ve Learned What We’ve Learned…Together We Can The Person-Centered Train: �Who’s on Board?Forces Behind PCRPPoll: PCRP Implementation Concerns:�Which of these is of most concern in YOUR organization? PCRP: Don’t we already do it? Person-Centered Care...�A Fuzzy Concept?The 4 “Ps” of PCRP �The Process of PCRP:�Key PracticesThe Recovery Roadmap ProjectThe Process of PCRP:�Key PracticesSlide Number 15Strengths-based Language Common Concerns RevisitedSlide Number 18If the person is in the driver’s seat, where does that leave ME? Does “Partnering” Mean We Always Have To Reach Agreement?Are some people “too sick” to engage in PCRP?�Slide Number 22Meet Mr. GonzalezSnapshot: A Traditional PlanTraditional PlanToward Person-Centered Documentation �Slide Number 27Slide Number 28PCRP Honors Both Professional Expertise and the Wisdom of Lived ExperienceLessons Learned from the Field…�Representative Advances �in PCRP Implementation Recipe for Success:Leadership: Patience/PerseveranceSlide Number 33Leadership: Managing the ChangeLeadership: Keeping the FocusWorkforce/CompetenciesWorkforce: Competencies & �Quality Management�Workforce Competencies: �Sample PCRP Meeting-Observation ToolSlide Number 39Workforce: PracticeWorkforce: Motivation - Listen & Respond To Common Concerns – REVIEW POLL FEEDBACKInfrastructure: Build PCRP into the Daily Fabric of the WorkInfrastructure: TemplatesInfrastructure: Lost in Translation�����PCRP Process: What Does It Look Like?�Slide Number 47Infrastructure�Meaningful Use of DATAInfrastructure: Performance Improvement - Fidelity and OutcomeEmpowerment: �Invest In Consumer Involvement!Slide Number 51Slide Number 52Empowerment: Peer SpecialistsClosing Q & A… Your Thoughts and IdeasA Take Home Message: Together…