Transforming Behavioral Health Organizations to a Person-Centered

Approach to Care

BHA Annual ConferenceMay 3, 2017

Diane Grieder, M.EdAliPar, Inc.

• Promotes Individual Preferences, Strengths and Dignity

• Promotes Natural Supports• Promotes an Individualized Approach to care• Promotes Self-Determination• Promotes Partnership with Professionals• Promotes Sharing of Knowledge; Free Flow of

Information

Adams/Grieder

Some definitions:A Person-Centered System

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Person-centered planning:

– is a collaborative process resulting in a recovery oriented treatment plan

– is directed by consumers and produced in partnership with care providers and natural supporters

– supports consumer preferences and a recovery orientation

Adams/Grieder

Ultimate Goal of Transformation

A system that—– Is consumer and family driven—

each adult and child will have access to the full spectrum of services needed to support recovery

– Focuses on recovery—a process, sometimes lifelong, through which a consumer achieves independence, self-esteem, and a meaningful life in the community

– Builds resilience—the ability to face life’s challenges

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Current Thinking

• The PCCP can be the bridge between the system as it exists now and where we need to go in the future

PCCPs are a key lever of personal and systems transformation at all levels:

Individual and family

Provider

Administrator

Policy and oversight

What are the Benefits of PCCP?

• Provides a road map that guides the treatment process

• Forces critical thinking to develop methods and strategies for intervention

• Assists with ensuring accountability

• Assists in coordination of care with other healthcare professionals (e.g., primary care physicians, social workers, housing and employment counselors, etc.) Healthcare Partnerships are key!

IOM

AACP

JCAHO

Bazelon

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ACA

CARF

National Perspective

For Effective SU Treatment NIDA says:

• “Addiction is a complex but treatable disease that affects brain function and behavior

• No single treatment is appropriate for everyone

• Treatment needs to be readily available

• Effective treatment attends to multiple needs of the individual, not just his or her drug abuse

• Remaining in treatment for an adequate period of time is critical

• Counseling—individual and/or group—and other behavioral therapies are the most commonly used forms of drug abuse treatment

• Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies

• An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs

NIDA, cont…

• Many drug-addicted individuals also have other mental disorders

• Medically-assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse

• Treatment does not need to be voluntary to be effective

• Drug use during treatment must be monitored continuously, as lapses during treatment do occur

• Treatment programs should assess patients for the presence of HIV/AIDS, Hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling to help patients modify or change behaviors that place them at risk of contracting or spreading

PCCP History in Maryland

• Under the SAMHSA Transformation Grant which was awarded to the then MHA, that project included a Recovery Initiative, for which Maryland sought consultation from Janis Tondora at Yale, after having heard Dr. Tondora when she addressed this same Annual Conference in 2007 as the keynote speaker. For the Recovery Initiative, Dr. Tondora advised MHA and the Recovery Subcommittee that implementing person centered care planning was the way to accomplish a truly recovery oriented system. So under that Recovery Initiative, PCCP training was included as a key component of that project.

MD PCCP History cont.

• Steve Reeder, in both his prior position as chief of EBPs at MHA/BHA and his current one as director of Adult Services, then furthered the work of bringing PCCP to Maryland. Working collaboratively with the EBP Center at the University of Maryland, it was determined that all EBPC trainers and the staff at MHA/BHA who routinely did training, would be trained by an expert consultant on PCCP, in order to embed those principles in all EBP implementation efforts and BHA trainings. Dr. Tondora recommended Diane Grieder, and using Adult Services Training funds, Ms. Grieder has provided training and ongoing consultation for the past 10 years.

Also in Maryland….

• PCCP has become one of the bedrock philosophies of all EBP implementation efforts throughout Maryland, with training on it provided to all programs implementing an evidence-based practice.

• PCCP Trainings have been held at state-wide conferences for 10 years (including TCM in 2012), and for ACT teams, Supported Employment providers, other provider organizations by consultants

• Technical assistance has been offered to ACT and SE supervisors via meetings, phone calls and case based consultations

• Specialized PCCP and Supervisory training, TA, and follow-up has been given to a cadre of in state Master Trainers (10), including opportunities for them to be evaluated by me conducting trainings and for them to view other trainings

• An introduction to PCCP online webinar was developed by the University of Maryland and posted at http:mdbehavioralhealth.com

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A Logic Model for Building Person Centered Recovery Plans

Request for services

Assessment

Services

Understanding

Goals

Objectives

Outcomes

Prioritization

Strengths/Barriers

Adams & Grieder, 2004

Consider the Whole Person

• All of these factors must be viewed in context of the individual’s life/societal role, culture, family and community.

Importance of Understanding

• The Integrated Summary is the bridge between the data that is collected and the creation of the individual’s Goal and Recovery Plan.

Integrated Summary (Understanding) – Guiding “Ps”

1. Pertinent history: e.g., personal; psychiatric; & legal

2. Predisposing factors: e.g., trauma history, head injury, co-occurring medical issues, family hx

3. Precipitating factors: e.g., What led to current admission or forensic involvement?

4. Perpetuating factors: e.g., What factors contribute to repeated adverse outcomes, e.g., cycle of readmissions?

5. Previous treatments and responses: e.g., A synthesis (not a chronological listing) of adverse and positive responses to range of previous treatments

10 P’s to Understanding, cont.

6. Protective factors/preferences: e.g., strengths/ assets that will improve a person’s chance of achieving stability and recovery

7. Presenting symptoms: symptoms and functional impairments as a result of the diagnosis

8. Prioritization: what’s important to the individual now? Maybe legal mandates, family

9. Prognosis: likely outcome for this person?

10. Possibilities: what is available to the person in the community; what will help his/her recovery?

A Logic Model for Transforming Organizations to a Person-Centered

Approach:the 10 P’s

1. Patience/Perseverance2. Practice3. Personal Responsibility4. Parsimony5. Persuasion6. Purpose7. Performance Improvement8. Passion9. Planning10. Playful

1. Patience/Perseverance

• Recovery 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. Leaders need to recognize that--and so do clinicians and consumers!

Everybody has accepted by now that change is unavoidable. But that still implies that change is like death and taxes—it should be postponed as long as possible and no change would be vastly preferable. But in a period of upheaval, such as the one we are living in, change is the norm.

—Peter DruckerManagement Challenges for the

21st Century

Leading Effective Change

Change takes a long time…involves numerous steps and skipping any of the steps only creates the illusion of speed…and never produces a satisfying result.

John KotterLeading Change

Premise I

While we may have evidence based

practice models for the delivery of

services…..

…we do not have research based

methods for implementing those

practices to change current systems.

Although we may do a good job of teaching the best mental health practice available today…

…we do a poor job of teaching ourselves how to decide when what we learned in the past is no longer good enough and needs to be changed.

Premise II

Premise III

Toolkits, manuals and other resources are helpful in defining an evidence based practice and can be a catalyst for change…

…but are in and of themselves not sufficient to direct implementation and support scalability.

Change

associated

with EBPs

Consumer

access

and

engagement

Provider

knowledge

and behavior

Organization

structure and

climate

External

environment

(stigma,

financing)

System-wide Change as Part of EBP Implementation

Perspective of a Maryland Master Trainer…

• “It is the closest thing to a narrative summary I have ever seen. What was even more interesting is that we completed a DLA-20 as part of the PCCP planning. I scored her using my copy of the narrative and then the group scored her. I didn’t know the client, but their score and mine were almost identical.”

• “We are s l o w l y getting there” -2017

2. Practice

• Practice, practice, 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.

Competencyknowledge, skills and abilities

Project

Management

work / business

flow

Culture

Management

behavior and

attitude

“Training” is necessary, but not sufficient

Transformation

Change Model

3. Personal Responsibility

• In order to adopt a person-centered approach to behavioral healthcare, attention to provider/administrator attitudes and beliefs about recovery and consumers, etc., is imperative. Person-centered planning cannot co-exist with professional stigma and lack of a recovery orientation by individuals.

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Business NOT as Usual!

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Thoughts

Attitudes & feelings

Subconscious

Dreams

Sense of purpose

Intention

Behaviors

Skills & competencies

Public commitments

Purpose

Values & norms

Feelings--e. g. safety & connection

Alignment of group

& individual

intentions

Collaborative

agreements

Budgets

Systems

Structures

Individual

Group

Interior Exterior

Dimensions of Change

ADKAR* Model

Awareness of the change

Reinforcement to

sustain the changeAbility to implement

required skills & behaviors

Knowledge of how to change

Desire to support &

participate in the change

*Developed by Prosci Research

4. Parsimony

• Start small ( pilot project). Like person-centered planning being strengths based and infused with the notion of “less is more” in terms of documentation, building on strengths and successes, as opposed to wholesale implementation models, is preferred and seems to work well for those organizations/states adopting this approach.

Small can be better!

• In Maryland the Master Trainers have “targeted” agencies who seem ready for change and willing to receive PCCP training in order to build upon their readiness for change

• We have worked with one ACT team at a time to bolster their competencies and abilities to do PCCP, worked extensively with SE Supervisors in a group setting, trained TBI Medicaid Waiver providers, etc., in an effort to implement PCCP in an efficient and effective manner

5. Persuasion

• A la motivational interviewing techniques used with the recipients of services;persuasion of staff to adopt new business practices, new ways of viewing the person receiving services, a new style of treatment planning meetings and the writing of plans, is necessary. Persuasion can come in many forms….

Attempting change

without leadership is like putting a

car in gear without a

driver behind the wheel.

Leadership Change Strategies

• set the tone

– vision/mission/expectations of a recovery oriented system of care

• clarify policy

• use data

• focus on person-centered planning and QA/QI activities

• provide training and TA/coaching

• promote and support innovation, and incorporate PCCP into other initiatives

• articulate competencies and workforce development in person-centered planning

Support at all levels is needed

to implementthis practice

change!

Change Agents

• EVERYONE can make a difference, no matter your role in the organization!

• How?

– Choice of language (using person-first language)

– Believing that recovery is possible

– Sharing success stories

– Embracing and using peer support

– USING and valuing the PCCP

The Comprehensive Person-Centered Plan

Incorporates Evidence-Based Practices:

SE, ACT, IMR, IDDT,TAY, Family Psycho-

Education, CHES grant

Informed by Stages of

Change & MI Methods

Encourages Peer-Based

Services

Maximizes Self-

Determination & Choice

Promotes Cultural

Responsiveness

Focuses on Natural

Supporters/Community

Settings

Respects Both Professional &

Personal Wellness Strategies

Consistent w/ Standards of

Fiscal & Regulatory Bodies,

e.g., CMS, JCAHO, CARF

6. Purpose Driven

• What are we about? What are our beliefs?

• “Purposeful value driven companies outperform their counterparts”: John Kotterand James Haskett, Corporate Culture and Performance”

Setting the Compass

Experience of Individuals, Families and Communities

Microsystems of CareWhere care occurs

Health Care Organizations

External Environment of CarePolicy/Financing/Regulation

Key Elements of Supervising to Client/Family-Centered Outcomes

• Clients are the focus of all our activities.• The ultimate criterion of organizational performance is

improving client outcomes.• Managerial performance is identical to organizational

performance.• Primary role of supervisor is to help staff do their job

more effectively and efficiently.

University of Kansas, Supervising to Outcomes

Person-Centered Planning Success Stories

Testimonials

• Not everybody thought it was a good idea for me to try to get my daughter back. But they realized that without her, I didn’t have a reason to be well.

• So, we figured out a plan for what to do if I couldn’t handle the stress, and my whole team has stood beside me every step of the way. Was it “too stressful” at times? You bet! But every day is a blessing now that I wake up and see her smiling face!

Person in recovery

Testimonials

• It made such a huge difference to have my pastor there with me at my planning meeting. He may not be my father, but he is the closest thing I’ve got. He knows me better than anyone else in the world and he had some great ideas for me.

Consumer in CT.

First-Person Perspective of PCCP

• “It gives me a chance to speak and talk about what I want and need to succeed in my recovery…”

• “I like the fact that I can talk to [RS] about my everyday life stressors and how to overcome them in my own way. I’m learning to make smarter decisions on my own.”

• “Understanding I’m not alone and the importance of planning.”

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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 UNDERESTIMATEconsumers’ desire to be involved (Chinman et al, 1999) –NH example

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

Involvement of ALL Stakeholders is Critical

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

7. Performance Improvement

• Beginning the transformation to a person-centered approach to care, it is valuable to know where one wants to go and to measure/benchmark progress over time. Is the goal to “have 95% of all treatment plans be person-centered within 2 years” or improve individual outcomes, such as reduce hospitalizations, less incidence of criminal justice involvement, move individuals out of personal care homes, obtain meaningful work, have a safe place to live, etc.?

Key Questions for Improvement

• Aim

• Measure

• Improvement Strategies

What are we trying to accomplish?

How will we know that achange is an improvement?

What changes can wemake that will result in

an improvement?

from Langley and Nolan

“What Gets Measured, getsdone.”

Unknown Author

Understanding Through 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

• The PCCQ and FDCQ are measurements of person-centered and family-driven practice standards

Which ones for PCCP?

CARF: Effectiveness Indicators

• More people working

• # of individuals with safe housing

• Less people in the hospital

Empowered,HopefulConsumer

ProductiveInteractions

Receptive,CapableTeam

Recovery / Wellness Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Behavioral Health System

Resources and Policies

Community

Health Care Organization

Integrated Health Care Model

SocialInclusion and Opportunity

8. Passionate

• Having someone within the organization who can be the coach/cheerleader/mentor/change agent for person-centered planning is imperative for real change (in an era of competing initiatives) to occur. Training and consultation ends, the life of an organization goes on.

• Someone who can promote and support innovation

“Leadership is creating a shared vision and mobilizing others toward specific organizational goals consistent with the vision.”

William Anthony and Kevin Ann Huckshorn, Co-authors of Principled Leadership

Leadership Challenge

Do we have the leadership traditions and experience in our field to make all of this real? There is pressing need to support those with the vision, passion, courage and willingness to take on the challenge of leadership along with the risk and responsibilities that come with being a change agent. Supporting those willing to “step up to the plate” of leadership will be essential if we are to succeed in transformation.

Leadership in Action

• Working the tipping point– Create an “epidemic” around your idea– Seed your idea

• connectors, mavens and salesmen– Make your ideas contagious

• memorable, motivating, practical and personal

– Make your agents infectious• use early adopters

– Plan your attack on the susceptible population• communicate, train, mentor, reinforce

*

9. Planning

• As with plans for individuals receiving services, the organization/system of care should have an implementation plan with timelines, strategies, costs and responsibilities identified

• Does your agency’s strategic plan include PCCP implementation?

• Articulate competencies and workforce development in person-centered planning

I get up each day determined to change the world – and to have one hell of a good time.

Sometimes this makes planning the day difficult.

E.B. White

What is Change Management?

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.

PCCP Competencies

• Providers should be able to– understand the concepts of recovery,

resilience, wellness, person-centered and culturally competent approaches

– understand and value the centrality of the individual planning process as a roadmap to recovery and wellness

– understand how emerging new frameworks differ from past and current practice

– identify the elements of a plan and the criteria for each element

PCCP Competencies

• Providers should be able to– understand the concept of

medical necessity and key elements of documentation

– conduct a strengths based person-centered and culturally competent assessment

– create a formulation or integrated summary based upon the assessment

– evaluate the individual’s/families stage of change to inform and guide the planning process

– help individuals/families articulate person-centered goals and discharge/transition needs

PCCP Competencies

• Providers should be able to– help individuals/families articulate person-

centered goals and discharge/transition needs

– identify barriers and establish priorities to attaining the goal's

– elaborate objectives to resolve barriers in partnership with the person and family served

– build on strengths, choices, preferences and stage of change to recommend interventions, services, supports and other strategies to promote positive change

What are your goals?

“Begin with the end in mind.”

Stephen Covey

10. Playful

• Have some fun while you are in the midst of change and implementing new practices! It doesn’t have to be dreary!

• We have shared with many providers the PCRP version of Jeopardy, played the “The Glass Half Full/the Glass Half Empty game (language counts), done role-plays, shared some funny stories, laughed at our own mistakes, etc.

Implementations Are Often Haphazard

Some Quotes About Change

“Sensible and responsible women do not want to vote.”—Grover Cleveland, 1905

“Everything that can be invented has been invented.”—Charles H. Duell, Director of U.S. Patent Office, 1899

“Heavier than air flying machines are impossible.”—Lord Kelvin, President, Royal Society, c. 1895

“There is no likelihood man can ever tap the power of the atom.”—Robert Millikan, Nobel Prize in Physics, 1923

“Who the hell wants to hear actors talk?”—Harry M. Warner, Warner Brother Pictures, c. 1927

Don’t be afraid to reach high!

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

SOMETHING TO THINK ABOUT....

What is one thing you can do, something new that you are not already doing, that can further a recovery oriented , person-centered system of care?

For More Information contact:

• Diane Grieder

–AliPar, Inc.

–diane@alipar.org

–757-647-8716