Behavioral Health Integration Complex Care Initiative SHARED CARE PLANNING Stacey Devenney, MA, CDP Kitsap Mental Health Services Michael Mabanglo, PhD, LCSW Lorin Scher, MD, UC Davis, School of Medicine

THANK YOU! Stacey Michael Lorin

Skilled Engagement Empathy Conveyance Open Ended Questions Reflective Listening Empathy Normalizing Acknowledging Affirming Reflective Listening Summarizing Exact Words Double sided reflection Open Ended Questions Conviction & Confidence

Supportive Relationship Autonomy Listening for Change Talk

Talk about a time when you or a family member were meeting with a clinician and they were not in sync with your treatments goals. What impact did that have on you or your loved one? Talk about a time when you were meeting with a clt/pt and you were were not in synch with their goal. What impact did that have on their treatment? 10 min

Debrief

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!!!

Developed collaboratively with the patient/client What a Shared Care Plan is not! Developed in isolation Written in “jargon” Developed separate from routines Identifies generalities Does not identify who will take action 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.

What a Shared Care Plan IS! 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 forms Standard Measures – ie PHQ9 Patient Centered Measures – crying less Care Team – anyone who has Action Steps Family, Patient, Pastor, Clinician other Natural Supports

EXERCISE #2 Choose a health behavior and goal you feel comfortable Break up into dyads (4-min intervals) Practicee: Discusses health behavior & goal 30 seconds Practicer: Elicits from Practicee Strengths, Barriers, Actions Steps, Care Team, Measure Back & Forth Now Switch Roles!

Debrief What went smoothly? What areas might you target for improvement?

Next Steps Think of an existing clt/pt and use your current plan or choose a shared care plan example and walk through how it might be effectively incorporated into your practice workflow. Conduct a Rapid Cycle PDSA Share your findings with your practice coach.

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