Behavioral Health Integration Complex Care Initiative SHARED CARE PLANNING Stacey Devenney, MA, CDP Kitsap Mental Health Services Marc Avery, MD, Psychiatrist University of Washington School of Medicine

Why use a Shared Care Plan? Primary Reasons: Assure that providers are incorporating patient values and care preferences. Assure that providers consistently address key health/treatment goals as defined by the patient. Secondary Reasons: Facilitate ongoing engagement in care. Improve patient self-management. Facilitate Coordination of Care

The Art of “Sharing: NOT just a compilation of each provider’s care plan. Is often different thant WHAT primary care clinicians are used to – it is different than many “CHECK:IST” style EMR “care plans” SHOULD be incorporated into CARE MANAGER’s routine appointments (NOT something that is just done once every 3 months!!! The “Shared” part of Shared Care Planning means that the over-arching wellness goals are shared between providers and caregivers where appropriate. Few EMR platforms contain the full functionality for this – especially for sharing between different providers. Providers therefore need to develop tools or workflows for achieving this goal, e.g: Patient “wallet cards” (example to follow) Registries Plain old paper/fax

What is a Shared Care Plan? An over-arching set of patient-expressed health goals, values and preferences. Strengths: What are the patient’s strengths that will help him/her reach their health goals Barriers: What might get in the way of them being where they want to be Action Steps: - This is the part that might be new or different for some of you. This is not goal or objectives as you know them. These are 2-3 things that the Client/Patient will do You – the Clinician will do Measures - These may come in 2 foms Standard Measures – ie PHQ9 Patient Centered Measures – crying less Care Team – anyone who has Action Steps Family, Patient, Pastor, Clinician other Natural Supports

Developed collaboratively with the patient/client What makes an Effective Shared Care Plan? Developed collaboratively Written in “plain language” Incorporated into routines Identifies specific actions Indicates who is involved Developed collaboratively with the patient/client Written in “plain language” in patient’s own words where possible. literacy level sensitive Is incorporated into routine workflows Huddles and Systematic Caseload Reviews. Care Management Appointments. Is updated frequently Identifies specific steps or actions to be carried out by patient and healthcare team Indicates who is involved in the patient’s care/care team--including specialty providers, and family or other natural supports.

Example Example of CCC: Meant to be something patient can take home AND be filed in the chart. Would be modified by providers

Example, part 2 As you can see this care plan incorporates the items that Stacey has already mentioned.

Example folding SCP from Tuolumne County NOT just a compilation of each provider’s care plan. Is often different thant WHAT primary care clinicians are used to – it is different than many “CHECK:IST” style EMR “care plans” SHOULD be incorporated into CARE MANAGER’s routine appointments (NOT something that is just done once every 3 months!!!

Practice with Partner Exercise, (5 minutes X 2) Partner A:Pretend you are the patient. You can use yourself or the vignette provided. Partner B: Pretend you are the care manager Practice eliciting from partner A at least: One Goal statement One strength and one barrier One Action Step Decide how progress/success will be measured How do you feel this will work for you. Switch Sides – and repeat! SEEMS BEST WAY TO ELLICIT PRACTICE IS TO GIVE CASES AND SEE HOW THEY WOULD GET GOAL OUT OF THE CLIENT?? INTERACTIVE DISCUSSION: Patient’s Care Goals (chronic and preventive) Patient’s Self Management Tools: Patient’s barriers to care: Team Goals

Report Out How might you incorporate this approach into your daily practice? How do you envision this working in your clinic?