Self-Management for Persons with SMI in a Behavioral Health Home

Jaspreet S. Brar, MD, PhDSenior Fellow, Department of Psychiatry, WPIC &

Community Care Behavioral Health, Pittsburgh, PA&

Suzanne Daub, MSW, LCSWSenior Director of Physical Health / Behavioral Health Integration

Community Care Behavioral Health, Pittsburgh, PA

Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.

Session #: A2aOctober 17, 2014

Faculty Disclosure

Please include ONE of the following statements:

• We have not had any relevant financial relationships during the past 12 months.

Learning Objectives

At the conclusion of this session, the participant will be able to:

1. Identify the similarities and differences between two models of behavioral health homes.

2. List the central component’s of the Wellness Coaching model used by Community Care Behavioral Health

3. Discuss the structure of Self-Management in the Wellness Coaching Model, including the roles of the Wellness Coach and the Person-In-Care

4. Learn of web-based Self-Management Resources

Bibliography / Reference

Lorig, K., Holman, H., Sobel, D., Laurent, D., Gonzalez, V., 2012, Living a Healthy Life with Chronic Conditions: Self-Management of Heart Disease, Arthritis, Diabetes, Depression, Asthma, Bronchitis, Emphysema and Other Physical and Mental Health Conditions. Fourth Edition. Bull Publishing Company, Boulder, CO.

Bartels S, Desilets R. Health Promotion Programs for People with Serious Mental Illness (Prepared by the Dartmouth Health Promotion Research Team). Washington, D.C. SAMHSA-HRSA Center for Integrated Health Solutions. January 2012.

Mrazek, P. J., & Ritchie, G. F. (2012). Becoming a Preventionist: Making Prevention Part of Your Mental Health Practice; A Continuing Education Course. Alexandria, VA: National Association of State Mental Health Program Directors (NASMHPD).

Reardon, C., 2010. Integrating Behavioral Health and Primary Care - The Person-Centered Healthcare Home. Social Work Today, Vol. 10 No. 1 P. 14.

Swarbrick, M. (2010). Peer Wellness Coaching Supervisor Manual. Freehold, NJ: Collaborative Support Programs of New Jersey, Institute for Wellness and Recovery Initiatives.

Learning Assessment

• A learning assessment is required for CE credit.

• A question and answer period will be conducted at the end of this presentation.

Health Homes: A One Stop Shop

Superb Access to

Care

Patient Engage-ment in

Care

Clinical Infor-

mation Systems

Care Coor-dination Team Care Patient

Feedback

Publicly Available

Infor-mation

Triple Aim: Improve Outcomes, Reduce Cost, Improve Patient Experience

Health Homes: A Vehicle for Integrating Care

Patient-Centered Medical Home (PCOM)

– Moving from physician-centered care to involving all members of the healthcare team (“Reinvent Primary Care”)

– Patient at the center of care

Embedding behavioral health services in medical settings

– Behavioral Health Consultant

Behavioral Health Homes (BHH)

– Improving the capacity of behavioral health settings to support physical health challenges

– CCBH model: Use of a Wellness Coach / Health Navigator

The Community Care Experience Initially 2 agencies in North Central PA in 2009 11 agency added in 2013 (PCORI), 10 additional in 2014 Wellness Nurse at each agency Wellness coaching training for nurses and case managers Used the IHI’s Learning Collaborative model for implementation Population-based care + Use of a disease registry Outcomes monitoring Case conferences to support best practices Self Management resources

Components of the Community Care Model

Wellness Coaches Nurse Case Manager Peer Specialist

Wellness Coaching training Self Management Toolkits Member Registry

Key Pharmacy and BH data Tiers 1 and 2

Development of connections with Primary Care Support of Psychiatrists

Wellness Coaching

Developed by Peggy Swarbrick, PhD at the CSPNJ Institute for Wellness and Recovery & UNDMJ

Help persons-in-care to identify strengths, needs and areas to improve, maintain or create

Clarify the person’s priorities

Establish a clear and specific goal (SMART goal)

Brainstorm action, steps and methods to support the person’s goal achievement

Set accountability, steps, including a time frame

What is Self-Management?

Carrying out health-promoting or (disease) risk-reducing activities and behaviors by persons with with chronic conditions

Self-management activities are: Activities that people can do by themselves Problem-based and Self-tailored

Self Management areas:Healthy Weight Smoking CessationPhysical Activity Taking Medications Effectively

PH/BH Care Improving SleepStress Reduction

Wellness Coach’s Role in Self-Management Engage persons-in-care in an exploration of wellness and

physical health. Support person-in-care’s effort in identifying self-

management goals (Physical Wellness Satisfaction Scale).

Case Manager’s Role in Self-Management Review cognitive strategies

Involving information processing (i.e., learning, reasoning, problem-solving, and decision making)

Review behavioral strategies The manner in which one functions and behaves

Tasks and strategies: Must be doable May involve modification of existing everyday tasks or

learning new tasks May address the specific area either directly

or indirectly

Case Manager’s Role in Self-Management Review strengths, needs, and barriers

– Strengths: personal strengths for person-in-care• Have control over practice of task or strategy?• Enjoy the activity or past history?• Can share experience with a friend or family member?• Access to resources?

– Needs: needs for person-in-care• Needs additional information?• Necessary tools? (weighing scale, pedometer, etc.)

– Barriers: anticipated problems in carrying out tasks• Not able to carry out the task/strategy?

Case Manager’s Role in Self-Management

Assist persons-in-care in identifying resources

(more later)

Facilitate the use of these resources by persons-in-care

Explain the Web-based tools (Community Care’s Member Portal) and support its use

Support person-in-care’s efforts to carry out self-management strategies

Measure the effect of self-management on specific area(s)

What is the Role of the Person-In-Care?

Choose an area for self-management (7 areas)

Select one or more tasks or strategies presented by the case manager

Number of tasks or strategies can increase incrementally

Review the tasks or strategies with the case manager in order to understand how the task or strategy is practiced or carried out

• Set a goal (S-M-A-R-T goal)

– Example: I plan to lose 3 pounds of weight in the next month by walking 1 mile 3 times a week, cutting down sugars and reducing portion size

• Develop a plan to carry it out

• Implement the plan

• Monitor how the plan is working

• Adjust plan as needed

What is the Role of the Person-In-Care?

Self-Management Resources

Other resources at the behavioral health provider’s facility

Resources at the area hospital(s) Special consultation for example dietician

or nutritionist Local community centers, grocery stores, service

clubs (i.e., Lions, Rotary, Kiwanis) Parochial/faith-based organizations, churches, etc.

Self-Management Resources

• Flip-Charts and guides1. Significance

Significance/relevance of the specific area for self-management

2. Self-management tasks & strategiesCognitive, behavioral, and other strategies for self-management

3. Resources

Self Management ResourcesSteps of Hope

Self-management support and educationhttp://www.ccbh.com/healthchoices/educational/stepsofhope/index.php Recovery educational

materials Tobacco cessation

materials Weight management

materials

Wellness Resources External websites

http://www.ccbh.com/healthchoices/educational/wellness/index.php Healthy Weight & Physical Activity Taking Medications Effectively Improving Sleep Quitting Smoking Preventive Health Care Stress Reduction Diabetes, Hypertension, Dyslipidemia COPD and Asthma Hepatitis C and HIV Traumatic Stress Heart Disease and Stroke

Session Evaluation

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!