The Maintaining Adherence Programme

Practical use of psycho-education for schizophrenia and bipolar disorder

Dr Llew LewisConsultant Psychiatrist

Medical Lead Maintaining Adherence Programme (MAP) UKDeputy Medical Director

South Essex Partnership Foundation University Trust(SEPT)

June 2013

Overview

1. Our organisations-partnership between SEPT and Janssen

2. The Munich Compliance Programme

3. Developing our model: The Maintaining Adherence Programme (MAP)

4. Practical tips for psycho-education based on our experience in the MAP

5. Interim results

South Essex Partnership University Foundation Trust

• Integrated care including mental health, learning disability, social care, forensic and community health services

• 200 locations across Bedfordshire, Essex, Luton and Suffolk

• Employ approximately 7,000 people• Serve a population of 2.5 million• Annual turnover of approximately £350m

The “Munich Compliance Program”

• Dr Werner Kissling and colleagues, Munich:

• Recognised significant relapse rates in the year post discharge from hospital

• Non-adherence to treatment a factor• Developed a model to address non-

adherence:

Munich Compliance Program developed to address low adherence and high readmission rates

The impact of schizophrenia on healthcare budgets is substantial, typically between 1.5 and 3% of total national healthcare expenditures.

*Rummel-Kluge & Kissling. Curr Opin Psychiatry 2008; 21: 168–172*Mueser et al. Psychiatr Serv 2002;53:1272–1284; Mueser & McGurk. Lancet 2004; 363: 2063–2072

THE SOLUTIONTHE PROBLEMS

One year readmission rates = 45%

>50% of patients are non-compliant

Compliance programmes are lacking

Annual costs of 5 billion Euros in Germany

Frustrated patients, payers, carers and

healthcare providers

Clinical studies have demonstrated that psycho-education and wellness programmes significantly increase patient compliance and outcomes*

Benefits of Psycho-education

Patient knowledgeof disease

Therapeutic alliance

Self-managementof symptoms

Adherence to medication

Functional outcomes

Risk of relapse/hospitalization

Symptom severity

Munich Compliance Program

1. “Differential diagnosis” of non-adherence- a standardised approach to assessment of risk factors (at baseline and 3 monthly):

• Insight• Drugs/alcohol• Side effects• Beliefs and attitudes to treatment• Cognitive factors, carer support…

Cont.

2. Psycho-education for all patients and relatives:

• group setting, two facilitators• 11-12 modules, manualised approach• 1-2 hours per week• Topics: symptoms, diagnosis, treatments,

early warning signs of relapse, crisis planning, drugs/alcohol, relationships, recovery

Cont..

3.Peer-to-peer psycho-education

4.Family-to-family psycho-education

5.Shared Decision Making:

•High quality information

•Collaborative partnership approach

Cont..

7. Incentives for patients:

• Financial

• Pleasant lounge atmosphere for groups

• Good coffee

8. Reminder systems

9. Home treatment

10.Wellness Elements:

• “Nordic Walking”, ”Coffee and Culture”

11.Depot clinic

12.Evaluation

13.Publication

The Joint Working Agreement & funding arrangements

The “Maintaining Adherence Programme”Objectives of the Project

• To partner with Janssen under a Joint Working agreement*:

• To translate and modify an Adherence model originally developed in Munich to a UK context-working with Dr. Werner Kissling

• To test the model within SEPT, an innovative mental health Trust in the south east of England.

• To produce an evaluation of the clinical and economic benefits and outcomes

*Department of Health Joint working guidelines : http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_082370

Why is this approach being considered?

• Despite advances in psychopharmacology and service innovations(UK National Service Framework 1999), patients still relapse,

• Therefore, the aim is to:• Improve the quality of care and outcomes for

people with diagnoses of schizophrenia, schizoaffective and bi-polar disorders through a focus on relapse prevention

• Improve productivity: reduce overall resource usage in a climate of radical financial pressures

Who is the MAP team?

• Consultant Psychiatrist (0,4 WTE)• 3 WTE nursing staff (inc. 1 WTE team leader)• 2 0,5 WTE occupational therapists

Supported by:• Project management: SEPT/Janssen)• IT support (ipad data collection/synching with

Trust data systems)

What interventions does the UK model provide?

• “Differential Diagnosis of non-adherence”o initial and 3 monthly formal review of risks associated

with poor adherence• Psycho-education for service users:

o Schizophrenia & Schizoaffective Disorder + Bi Polar Disorder

• Psycho-education for families & care giverso Peer to peer Psycho-education

• Reminder Service (telephone/text)• Shared Decision making approach• Wellness Activities

A.Establishing the team

1. Identify the team• Experience in working with schizophrenia and bipolar

disorder • Not necessarily group facilitation nor education skills

2. Familiarise with content of modules

3. Challenge clinician beliefs and assumptions• “Patients wont understand the content”• “I don’t understand the scientific/psychological

models”• “I have never facilitated a group”

cont…

4. Role play: – Being the facilitator– Learning how to facilitate in pairs– Being a member of a group– Enacting different scenarios or answering questions– Getting used to using flip chart, writing on white

board, operating the iPad

5.Operational structure• Guidelines, paperwork, ipad data syching

B. Identifying the patients

5. Raising awareness:• Designing flyers• Road-shows on wards, at CMHTs• Developing referral criteria: an admission to a

ward, episode under CRHTT in the past 3 years

6. Recruiting and consenting patients

7. Designing and equipping a “Recovery Lounge”

C. Creating a process

8. Creating a process:a) Streamingb) Setting upc) Settling ind) Structuringe) Summationf) Skills

a) Streaming

• Be aware of differing chronicity of illness and functional/ cognitive abilities

• The presence of positive or negative symptoms• Whether symptoms are controlled or not• Differing social skills• Use wellbeing activities or baseline assessments

to form an opinion (MOCA)

Negative symptoms/ lower Global Assessment Functioning (GAF)

• Smaller groups (up to 5)• Slower pace, more didactic, more repetition• Adapt video clips..often shorter• More active facilitation,• Encouragement and positive feedback• Take time to tease out symptoms and help

participant relate content to experience

Cont...

• May need to revisit content in one to ones• E.g. Early warning signs identification and crisis

planning...• Be sensitive to educational attainment• Participants may lack basic reading and writing

skills• May be ashamed, may not admit to deficits in a

group...check this out beforehand

Higher functioning/social skills

• Up to 8 manageable • Often more engaged• Ask challenging questions• More likely to read materials and do inter-group

tasks• As group matures, the group facilitation

becomes delegated: empathic, supportive and encouraging of one another

b) Setting up

• Soft incentives add value• The "Recovery Lounge"• Comfortable chairs, couches, temperature• Refreshments, coffee, tea, water• Toilet access• iPad and TV connected• Name labels

Cont..

• Participant and facilitator manuals• Pens and paper• Group "rules" and "expectations" displayed• Other resources: leaflets for support groups,

patient medication info leaflets,

Flip charts and whiteboards

• Agenda and group structure• Open questions referencing manual content• Prompts for video and activities• Whiteboard for recording group answers and

using "own words"• Ordering spontaneous responses into clear

domains e.g. side effect types or classes of antipsychotics

Prepare for surprises

• Ideally two facilitators• If required one may have to leave the group with

a participant if distressed to handover to another team member to contain

• Aim not to stop the group• Managing distress well sends message

facilitators can contain difficult scenarios- the group is safe

c) Settling in

• Report to reception• Customer care approach: our values

Positive hellos/goodbyes, common courtesies, keeping promises, active listening

• Offer refreshments• Make introductions• Remind each other of names• Facilitators support informal social interactions

d) Structuring/timing

1. "Welcome..how are you?"a. Needs to be time limited( especially in Bipolar

groups)

2. Recap:"what did we learn last week?"

3. "Any questions"

4. Make time to review any homework

5. Introduce new topic: aim to use open questions to gauge knowledge of the group

For example:

• What medications do you know?– Use whiteboard to capture responses

• Facilitate as much from the group as possible.• Arrange information into understandable groups

like:– Antipsychotics, antidepressants, side effect

medication

• Group quite possibly has experience of many different types

Continued...

• Get the group to do the work• Fill in the gaps at the end• Encourage participation• Acknowledge the lived experience and

knowledge of the group• Move away from didactic stance to collaborative

participation

Continued ...

6. Review, recap and summarizea) Consolidate using participant language if possible

7. Questions and answers

8.Hand out materials…homework

9.Feedback:"How do you think the group went?"

"Did we pitch it at the right level?"

"What could we do better?"

e)Summation

• Process notes• Signposting as required:

– To consultant clinic– To review or booster sessions– Shared decision making session– One to one work on relapse signatures/ crisis

planning– "Choice and medication“ website

• www.choiceandmedication.org

f) Skills

• Communication • Verbal and non verbal• Group facilitation techniques• Educative techniques• Clinical skills: listening, empathising, limited

disclosing• Customer service : values into action

Beyond the group..

• Operational staff: Wellbeing activities Three monthly adherence review

• Medical: Shared decision making Urgent assessments and reviews

…principles…

• Reminding… linking back to group content to answer questions about: The need for medication How medication works Dopamine and psychosis Types of medications/comparisons Identifying early warning signs Crisis plans

How will we evaluate the MAP program?

Retrospective evaluation to include: Resource use

Prospective evaluation to include: Resource use Clinical measures Patient satisfaction Staff satisfaction

Recruitment summary

Demographics

Total number of MAP attendances

(clients at 12 months post MAP entry)

Nature of MAP contacts (clients at 12 months post MAP entry)

MARS score (medication adherence rating scale) - baseline Vs most recent

Risk score (baseline Vs most recent)

Resource use in 12 months pre and 12 months post MAP entry

Client and carer MAP experience questionnaires

Which parts of the program did you find most helpful?

How well has the psychoeducation programme helped your understanding of

the following......?

Psychoeducation evaluation forms

Staff feedback

• Staff interview participants were overwhelmingly positive about the MAP Program, describing many benefits from it for both patients and staff. Where potential improvements were identified, these related mainly to support for the service; for administrative tasks and for appropriate referral of patients into and onward from the Program, and not to changes needed in the Program itself. However there was great willingness to learn from continuing feedback from patients and carers, to improve the Program if necessary.

Summary

• MAP interventions in addition to usual care plan

• Psycho-education, reminder service, wellbeing components, SDM, rapid access to consultant if required

• 12 month Qualitative and economic evaluation promising

• Awaiting final evaluation

Thank you