1. 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

2. THANK YOU!
Stacey
Michael
Lorin

4. 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

5. Supportive Relationship Autonomy Listening for Change Talk

6. 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

7. Debrief

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

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

10. 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!!!

11. 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.

12. 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

13. 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!

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

15. 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.

16. Thank you for your time!
Please complete the survey, we really, really, really, take it to heart!
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