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Engagement, Activation and Recovery-oriented Practice
The Role of the New Behavioral Health Workforce in Whole Health Care with Elizabeth Whitney, RTP Technical Assistance Lead Advocates for Human Potential, Inc. August 7, 2105 Intro Self Background in community behavioral health We all know that behavioral health is essential to overall health For many of us we know this intuitively; and we also know it anecdotally from the work we do with individuals and families For those in the audience who are quality managers, administrators, academics we know this through exploring and describing trends in populations of clients; in many cases, data is telling us that this is true Increasingly, policies, healthcare system designs, and funding mechanisms are reflective of this reality
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fail to take prescribed meds
40% of general population lacks skills, knowledge, and confidence to manage personal healthcare. fail to take prescribed meds skip appointments return to hospital soon after discharge And yet... 40% of people lack skills, knowledge and confidence to manage own healthcare Objectives for this workshop - Today, want to talk with you about approaches for effectively engaging people in services and helping them become active in their use of services and ability to care for themselves Increasingly, behavioral health administrators and providers recognize the imperative for engaging individuals in order to provide high quality and cost-effective services. Recovery practices provide an established framework for meaningful engagement, activation and for promoting self-direction. From Issue brief: Numerous studies have associated patient activation with positive health-related behaviors, experience of care, improved health outcomes, and reduced health care costs (Westat, 2013). Hibbard, Greene & Overton (2013) have identified several core elements of activation, including symptom self-management, shared decision making, collaboration with health care providers, and navigation of the provider system. and then will introduce you to a host of resources that are available to you - mostly free of charge - for training Because of their lived experience, peer providers are especially effective in activation. Engagement is especially important for long term conditions (diabetes, high blood pressure, behavioral health conditions). Impact of these figures on people with behavioral health conditions…. Hibbard, J. et al. (2004). Development of the Patient Activation Measure (PAM): Conceptualizing and Measuring Activation in Patients and Consumers. Health Service Research, 39(4 pt 1),
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Georgia’s Story I would like to introduce you to Georgia; she will help us apply some of the concepts from today Georgia is the single mother of two young children under 5. She works as a clerk at package delivery store. She has a long history of depression and was hospitalized after her second child was born. For years, she has enjoyed a few beers after work and on weekends. Recently she met a man she enjoys spending time with. When he visits he brings oxycodone. Georgia finds it relieves stress and pain of being on her feet all day and running after two kids every evening. Georgia’s weight is increasing and she has started oversleeping and missing some work. The past few weeks she has started asking her boyfriend for more oxycodone, thinking it might help the pain of her increasing depression. This week the neighbors called saying her kids were playing in the street. Georgia had been passed out on the couch.
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What are some of the challenges and stressors that Georgia is facing?
Physically demanding work Adequate pay? Single mother of two Depression Gaining weight Alcohol misuse Opiate use New relationship Could (and should) ask what her strengths likely are….
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At the same time…. 2006 study found that adults receiving behavioral health treatment in the public system die decades prematurely due to preventable conditions. Cardiovascular disease is associated with the largest number of deaths. Some of the other reasons for premature death are poverty, homelessness, unemployment, side effect of psychotropic medications, social isolation, trauma and discrimination. (Parks, Svendsen, Singer, & Foti, 2006) Behavioral health treatment, services, and recovery supports are widely available. But many people do not access them. There are increasing financial incentives, technology, apps, and myriad resources that promote wellness and self-care activities. But many people ignore them. Some people who use medical and behavioral health treatment and services are not considered partners in their own care. … at a huge cost.
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Let’s put this in more personal terms. Let’s think about Georgia again….
We don’t know how willing she might be right now to engage in services, but let’s say she reaches out Maybe she calls a primary care physician who focuses on her weight and prescribes an antidepressant – totally missing the substance issues. Maybe she convinces him she needs a pain killer, too. But let’s say she reaches out to a substance use or mental health clinic and it’s 3 months for an initial, non-emergency appointment and assessment. Let’s say she actually waits and even shows up for the appointment. She meets with a clinician. POPCORN: What happens when if she calls YOUR organization? Is she immediately screened out based on ability to pay or other factors What is the wait time like? What is the follow up to her if she has to wait a week or more? Are support options available in the mean time? Is scheduling flexible or does she have to take time off work to come in? What about day care? Can she choose the person she sees, e.g. male/female, culture/race? Once she’s in the door, what happens? Are their set rules – such as no drinking 24 hours before an appointment Required UAs? A structured program available? Individual flexibility? Will someone help Georgia attend to her health and weight concerns at the same time? Georgia’s Story
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How would YOU approach engaging Georgia in services?
How would you approach engaging Georgia in your service system? Say the kids playing in the street was a wake up call and she calls your agency…. POPCORN: Are there common approaches to treatment, services and even recovery supports that you think might hinder the process of recovery from mental health or addiction disorders for some people…..? What does your organization do to welcome people like Georgia? What can the CLINICIAN do to help Georgia connect with and receive benefit from treatment and services. What happens in our interactions with Georgia? What would happen to her in your service? How long is your wait? What outreach might be available? Do peers have a role here? How? What peer services might be available in your area? How would you hook Georgia up with them?
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Create dependency Discourage self-care Ignore preferences Do not encourage healthy behaviors Lead to fragmented care Some traditional practices in behavioral health MAY…. Not always be supportive of recovery oriented practices or approaches.
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What if we….. Truly collaborated WITH her on a plan that “fits” her needs and preferences, rather than simply expecting her to adhere to our plans for her?
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What if we….. Addressed the whole person… …not just the diagnosis?
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8 Dimensions of Wellness
SAMHSA’s 8 Dimensions of Wellness Image source: SAMHSA Wellness Home Page
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Science has rendered untenable the artificial division of people into parts, particularly mental and physical parts. Recovery-oriented practice is powerful because it focuses on real people, real lives, and the important social and economic context of personal change. A 2014 report from the American Academy of Family Physicians noted that; One-half of primary care patients have a mental or behavioral diagnosis or symptoms that are significantly disabling every medical problem has a psychosocial dimension most personal care plans require substantial health behavior change… …a whole person orientation simply cannot be imagined without including the behavioral together with the physical.” (American Academy of Family Physicians, 2014)
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Whole Health Personal spending burden Individual engagement
Population spending burden Individual engagement Community engagement Preventive services Care access Patient safety Evidence-based care Care match with patient goals Life expectancy Well-being Obesity Addictive behavior Unintended pregnancy Healthy communities Healthy People Care Quality Lower Cost Engaged People Source: (Committee on Core Metrics for Better Health at Lower Cost, 2015)
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Now, we are focusing on preparing, equipping, and supporting people in taking care of their own behavioral health needs, and themselves, while remaining in the community.
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A growing body of evidence demonstrates that people who are more actively involved in their health care experience better health outcomes and incur lower costs. Health Affairs, 2013 Engagement in self-care involves activating people to manage their own conditions, their own care, and their own lives. Engagement in care typically means connecting people with needed behavioral health care.
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Informed, empowered people
And tend to … Make informed and personally relevant decisions about treatment and care Follow through with treatment and self- care regimens Experience fewer adverse events Have knowledge, skills, and confidence to better manage their own health and health care Make healthy lifestyle choices Make informed and personally relevant decisions about treatment and care Follow through with treatment and self-care regimens Experience fewer adverse events This in a nutshell is recovery…. PIX: Unknown artist 'Bell's Bar Weightlifter', 1950s, American Folk art, Milwaukee Museum
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SAMHSA’s Vison for Recovery to Practice
Through education, training, and resources the Recovery to Practice (RTP) program supports the expansion and integration of recovery-oriented behavioral health care delivered through multiple service settings. Recovery to Practice (RTP) is a workforce development initiative that focuses on integrating recovery into behavioral health care through multiple disciplines and service settings. The overarching goal is to improve the competence and skill of the behavioral health workforce, and to transform concepts of recovery-oriented practice into concrete behavioral guidelines and clinical interventions based on those practices.
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4 Major Dimensions That Support a Life in Recovery
Health Purpose Home Community The efforts of the Substance Abuse and Mental Health Services Administration (SAMHSA) have helped to clarify the characteristics and meaning of recovery in everyday life, as well as its fundamental importance to everyone with a mental health or substance use condition. SAMHA’s definition of recovery focuses on 4 major dimensions that support a life in recovery: Health: overcoming or managing one’s disease(s) or symptoms—for example, abstaining from use of alcohol, illicit drugs, and non-prescribed medications if one has a substance use problem—and for everyone in recovery, making informed, healthy choices that support physical and emotional wellbeing. Home: a stable and safe place to live; Purpose: meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income and resources to participate in society; and Community: relationships and social networks that provide support, friendship, love, and hope.
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Recovery in Behavioral Health
A colleague and advocate of recovery-oriented approaches in behavioral health, Ron Manderschied, described recovery as one of the most powerful words in our behavioral health lexicon --- Because it creates real lives; it promotes future hope; it can even open key doors to enlightened and dramatic care reforms. The promise and actuality of recovery are transforming the mental health and substance use landscape in ways almost unimaginable just a decade ago. People with lived experience of recovery have fostered this vision, and been the early pioneers in defining recovery-oriented practice …. And SAMHSA has made the vision an everyday reality for many. Historically, persons with serious mental illnesses and serious substance use conditions were widely assumed by community members, by SOME professionals, and even by themselves to be in a permanent state of chronic illness--a state of defeat. Even though people have been known to recover since long before the moral therapy movement of the 1700’s, persistent negative stereotypes and shame led many people who did recover to conceal this fact. These negative and limiting concepts persisted broadly even into the early 2000s. And….. despite evidence to the contrary …. they still persist in some areas today. Recovery is not a journey alone. Other people: peers in recovery, family members, friends, providers and supportive communities are fellow travelers on a person's road to recovery. Reference column in Boston Globe re secrecy and use of methadone… A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.
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10 Components of Recovery in Behavioral Health
SAMHSA’s 10 Components of Recovery in Behavioral Health In 2011, SAMHSA released a new working definition of recovery and a set of guiding principles. The revised working definition and principles incorporate aspects of recovery from addiction that were missing from the first set of SAMHA dimensions of recovery and underscore that an individual may be in recovery from a mental disorder, a substance use disorder, or both. The 4 major dimensions [home, health, purpose, community] and these 10 components of recovery in behavioral health form a strong structure and foundation for developing recovery oriented lives, building recovery-oriented services and systems. To help the field incorporate these principles, and to help the behavioral health workforce bridge from where we have been to where we are going, SAMHSA initiated the Recovery to Practice initiative.
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The initial phase of the RTP initiative was launched in 2011 and focused on working with 6 professional disciplines to create discipline-based curricula that promoted the understanding and uptake of recovery principles and practices. These are the six disciplines that developed RTP Curriculum: American Psychiatric Association with American Assn of Community Psychiatrists NAADAC – the association for addiction professionals Council on Social Work education International Association of peer specialists American psychological association American Psychiatric Nurses Association. Each discipline had latitude to use the language and frameworks that made most sense for their membership. Each discipline developed ways to integrate the curricula into their discipline’s professional development activities, including academic preparation, residency education, continuing education events, certificate programs, and certification procedures. To a large degree the curricula are in the public domain. Each association has a webpage dedicated to Recovery to Practice. [just google RTP and the association name] And you can find information about each of these curriculum on those websites.
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People with mental health and substance use conditions have been – and still are – subject to prejudice and discrimination. Reducing and eliminating prejudice and discrimination is necessary for people to live full, meaningful, and self-determined lives in the communities of their choice. There are core messages that run through these curricula and in fact, underpin all recovery-oriented practices. The first is an understanding that people with behavioral health conditions have been – and many still are – subject to prejudice and discrimination. Yet we also have fundamental human rights and restoring these rights is necessary to live full, meaningful, and self-determined lives in our communities of choice. July 2015 Paolo del Vecchio (Dain/Davidson) Bringing Recovery to Practice: Improving Provider Competencies and Promoting Positive Outcomes Paolo del Vecchio, M.S.W., xPaolo del Vecchio
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Importance of person-first language
Learning from perspective of people in recovery Centrality of autonomy, self-determination, and choice With this history of discrimination has come a high degree of pessimism in prognosis. People with serious mental illness simply did not get better and often required life-long care. We nkow this is not true. One of the things that communicates discrimination and pessimism is language. Language is powerful and communicates assumptions and expectations on many levels. Person-first language is an important first step in restoring ‘personhood’ to individuals. In the recent decade or so, we have begun to invite people with lived experience to the table – in policy, research, service providers, and yes, as colleagues. The field is beginning to understand that what we have valuable insights into what works and what does not – and why. We know that with personhood goes self agency – autonomy, self-determination, and choice are central in the life of each of us, including those of us living in recovery.
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System of care includes access to treatment, medication, and recovery supports
Recovery takes place in a social context: community and social inclusion are key Principles of consumer and family-driven care embrace cultural competence Too often services and treatment have been insular, small worlds of programs, structures, and expectations that are separated from the broader community. We know that recovery LIVES in a social context. Being part of an accepting community and feeling “part of” is important for many of us. Few of us recovery in isolation of others. There can be no one-size fits all for recovery or recovery-oriented practice. For each of us, recovery is culturally-based and influenced. That is part of our richness. Finally, new approaches need new ways to think about outcomes. What does recovery look like? How can something so individual be measured and evaluated? There are essential themes here, each of which could be explored much more thoroughly ..it is worth holding on to these and using them as you think after this conference about what you can do to enhance recovery-orientation in your practice setting..
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Engagement in healthcare decision making
Engagement in self-care Engagement in treatment or services
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Stage-wise growth in activation
passive recipient of care basic knowledge about health and treatments skills and confidence to manage illness maintain positive health changes over time
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Taking an active role in my own health care is the most important thing that affects my health. I know what each of my prescribed medications does. I am confident that I will tell a doctor about concerns I have even when he or she doesn’t ask. I know how to prevent problems with my health. Insignia Health. Landro, L. New Vital Sign to Gauge: The patient’s Activation Level. Wall Street Journal. April 1, D1
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Practices that Can Support Engagement and Activation
Person-centered planning Inviting people to read doctor’s notes Use of peer coaches Tailoring support to activation levels Supporting people to manage their health: An introduction to patient activation, Judith Hibbard Helen Gilburt, May 2014; The King’s Fund
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Georgia’s Story Georgia has now been seeing an outpatient clinician, Jada, for two or three sessions. Jada feels that Georgia is opening up to her well. Georgia recently disclosed the extent of her drinking and oxycodone use and how depressed she is. However, Jada is concerned about Georgia’s depression and suggests she consult with an agency physician to consider medication. Jada wants to make the connection work – ASK: What are some steps Jada can take to ensure that a connection is made? Let’s say Georgia is at stage 2 of activation – aware of her issues and treatments, but you are not confident that she will bring these issues up or her other concerns on her own How would your approach change if she was more activated? she asks Georgia whether she is interested in going this direction and about healthcare resources she asks if she prefers to see a man or a woman calls the physician office with the client in the room to make sure the person is available POPCORN: Ask audience: what went well with this engagement? What else might you do?
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Patient (behavioral) Activation
Help people prepare for health care visits and ask questions Identify health-related goals that “fit” Plan do-able action steps to move toward goals Assist in daily management tasks Problem solving Provide social and emotional support and feedback Follow-up over time Patient (behavioral) Activation
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Asking questions is a skill!
Parent of child with fever Type of question Person with back pain “Why doesn’t she need antibiotics?” Reason “If surgery solves the problem, why wouldn’t I choose it?” “How is this different from 3 months ago when she got antibiotics?” Process “Do I need to choose one today?” “What should I do if the fever doesn’t go down?” Role “Before I choose one, what else do I need to know?” Alegría, M., Polo, A., Gao, S., Santana, L., Rothstein, D., Jimenez, A., Hunter, M.L., Mendieta, F., Oddo, V., Normand, S.L. (2008). Evaluation of a patient activation and empowerment intervention in mental health care. Med Care, 46(3), Copyright, The Right Question Institute, 2013
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Engagement in health care decision making
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Georgia’s Story Engagement in decision making
Dr. Sprando meets with Georgia. The doctor tells Georgia she has a serious clinical depression and that she needs medication to treat it. She quickly writes Georgia a prescription and provides her with a bunch of information about the medicine. She tells Georgia that she cannot drink while taking the medicine. Georgia agrees to try the medication and walks out of the office. Later, Jada, the counselor learns that Georgia did not fill the prescription or take the medication. POPCORN Ask audience: what went wrong in this attempt to engage the person in her healthcare? What might the physician have done differently [can then fill in gaps to their answers with some basic information about SDM]
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What intervenes? Person and clinician begin consultation
Person and clinician discuss medications Person leaves with a prescription Person makes decision about medication What intervenes? From Dr. Annie LeBlanc, PhD; Mayo Clinic
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Clinician preferences
Medical knowledge Years of education Practice experience Clinician preferences Breslin 2011 38
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Lifestyle preferences Own experiences
Expert on their life Personal health view Lifestyle preferences Own experiences Breslin 2011 39
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Making collaborative decisions that “fit”
Shared decision making is about “changing the conversation”. Making collaborative decisions that “fit” Client focused tools Provider focused tools Dialogue
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Person and clinician begin consultation
Person and clinician discuss medications Person leaves with a prescription Person makes decision about medication From Dr. Annie LeBlanc, PhD; Mayo Clinic
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Engagement in self-care
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Promoting self-care Invite in Explore understanding Provide information, education, and role modeling Connect self-care to personally- relevant goals Introduce peers who are experienced in self-care
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Georgia’s Story Georgia is uncomfortable with her weight and thinks that might be contributing to her depression and drinking. In one session, Jada and Georgia look at the internet together to see what they can find out about weight and depression. They find that obesity not only increases depression, but has a whole host of other health related issues as well. Georgia says – “You know, I want to be around to see my kids grow up. My grandma had high sugar and was miserable. I don’t think I want to go through what she went through.” Jada and Georgia talk together about a first steps – one thing Georgia could do to begin – just begin – attending to her health. Georgia mentioned that the recovery support center she has started to attend has an elliptical machine and a treadmill. Georgia suggests that she get on the machine for 5 minutes every day she is at the center. Jada agrees that would be an excellent start and offers Georgia a small calendar for the next 2 weeks where Georgia can write down what she does – or doesn’t do on the machines and also rate how she’s feeling that day. Georgia thinks it’s a reasonable place to start. Jada suggest that Georgia her in a week to let her know how it’s going.
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What worked well? What else could the clinician do?
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“Now I take it step by step
“Now I take it step by step. I have learned to hurry slowly and do it in stages and set partial goals when I have discovered that it makes sense … doing it by partial goals and making it manageable, then you get positive feedback that it’s going okay and then you don’t hit the wall. That’s my strategy, the strategy for success: partial goals and sensible goals and attainable goals, and that’s something I’ve learned to do in order to achieve things. When I have been able to deal with something that’s been a struggle and feel secure, I move on. Step by step, put things behind me.” “Now I take it step by step. I have learned to hurry slowly and do it in stages and set partial goals when I have discovered that it makes sense … doing it by partial goals and making it manageable, then you get positive feedback that it’s going okay and then you don’t hit the wall. That’s my strategy, the strategy for success: partial goals and sensible goals and attainable goals, and that’s something I’ve learned to do in order to achieve things. When I have been able to deal with something that’s been a struggle and feel secure, I move on. Step by step, put things behind me.”
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Objective Information Finding Voice Health Literacy
Practitioner Skills Building Skill Coaching Objective Information Finding Voice Health Literacy
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Example recovery practice competencies from CSWE
Prioritize client voice and right to self-determination. Recognize that individuals, their families and significant others are critical sources of support, resources, and information. Engage them with individuals’ consent. Assist individuals to integrate meaningful cultural and spiritual practices into recovery and wellness activities. See individuals’ lived experience with behavioral health conditions as triumphs and resiliency, rather than failures. All of these practices require us as clinicians to be intentional and aware in furthering our skills The Council on Social Work Education – a member of the original group of RTP disciplines not only developed curricula for use in their academic training of young professionals, but they have also been taking a close look at the structures and standards that guide social work practice through out the United States. They have developed a set of Advanced Social Work Practice Competencies in Mental Health Recovery which integrate recovery principles throughout the 10 Educational Policy and Accreditation Standards that describe the knowledge, skills and values required of social work professionals. Here you see some examples… you can get the full set of standards at the link identified. For the full set of CSWE Advanced Social Work Practice Competencies:
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Where can practitioners learn these skills and practices that help support recovery in behavioral health? There is a lot more available through RTP
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Recovery to Practices (RTP) Resources
American Psychological Association (APA) RTP resources American Psychiatric Association (APA) RTP resources International Association of Peer Supporters (iNAPS) RTP resources American Psychiatric Nurses Association (APNA) RTP resources NAADAC—the Association for Addiction Professionals RTP resources Council on Social Work Education (CSWE) RTP resources
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RTP Training Resources On Engagement
Topic Area Available Curricula Introduction/overview and fundamentals of recovery-oriented practice; applying recovery to behavioral health American Psychological Association American Psychiatric Association & American Association of Community Psychiatrists (AACP) iNAPS NAADAC CSWE Partnership and Engagement Person-Centered Planning & Shared Decision Making American Psychiatric Association &American Association of Community Psychiatrists (AACP) Health and Wellness
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NAADAC - the association of addiction professionals has develop a national training curriculum that will become a part of the national certification process for the addiction workforce. This recovery-oriented training curriculum is designed to: •Educate addiction professionals about a recovery-oriented model of care; •Educate addiction professionals about addiction recovery (and their specific role in promoting it); and •Teach competencies needed to integrate addiction recovery concepts into practice. The 30 hour Recovery to Practice (RTP) Certificate Program is designed to further hasten awareness, acceptance, and adoption of recovery-based practices in the delivery of addiction-related services and builds on SAMHSA’s definition and fundamental components of recovery. By obtaining this Certificate, addiction professionals are demonstrating to employers, third-party payers, and clients their advanced education in recovery-oriented concepts, skills, and practices. It is worth checking out! But wait, there’s more!
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Recovery to Practice Sample Resources
Recovery resources for addictions disorders Facilitating goal setting handout for clients/consumers Listening, persuading and supporting change tips sheet from the iNAPS Recovery to Practice Participant Workbook– v1 April 2014, Page 2-22, Module 2: The Complex Simplicity of Wellness Handouts and tools
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New Directions for RTP Promoting recovery practices in ALL behavioral health services and disciplines Multidisciplinary practice Integrated settings Diverse applications New resources The second phase of the RTP initiative moves away somewhat from discipline specific curricula and looks toward multidisciplinary and integrated services and settings. In this phase, we are positioned to support wide dissemination and uptake of recovery oriented practice and principles among professional provider organizations, agencies, training institutions, and other stakeholder groups. We continue with the overarching goal of improving the competence and skill of the behavioral health workforce and to transform general concepts of recovery into concrete and every-day practices and standards.
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Multidisciplinary Practice Manual and eLearning Module
Peer Specialist Manual and eLearning Module Multidisciplinary Practice Manual and eLearning Module WE have also been developing two new resources – Resource manuals are in development on Multidisciplinary applications and inter-professional collaboration And one for Peer specialists working with people experiencing homelessness Each of these manuals will be followed by an interactive eLearning module which will be developed next year
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RTP Training and Technical Assistance
Recovery-oriented Behavioral Healthcare Decision Support for Clinicians and Physicians One way we are doing this is through a webinar series which is presenting foundational information derived from the discipline-based curriculum and making it available to wider audiences. Each of these webinars will be recorded and archived for your future reference and use in training or professional development activities. We will continue with webinars next year. A second webinar series is in development and focuses on decision support for clinicians and physicians. We expect to make those webinars available soon.
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Coming up! August 10 – Peer Services: Creating an Environment for Success August 12 - Evidence-based Practice and Recovery-oriented Care August 17 – Building Recovery-oriented Systems August 19 – Whole Health and Recovery (part 1) August 26 - The Role of Medication and Shared Decision Making in Recovery August 31 - Partnership, Engagement and Person-Centered Care September 2 - RTP Applications: Incorporating Recovery-oriented Practice Competencies in Practitioner Training September 3 – Whole Health and Recovery (part 2) September 9 - Health Care Reform and Recovery Remember, there are a number of webinars coming up in the next few weeks. Please join us for as many as you can!
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Join Recovery to Practice!
If you are not receiving the RTP newsletter, please sign up at There have been some glitches with the RTP website so if you are not sure whether you’re signed up - have not received the recent newsletter that came out a week or so ago -- please sign up again using this address and we’ll make sure you are subscribed to RTP and receive upcoming newsletters and event notifications.
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Please provide feedback and comments by clicking on the Participation Evaluation link below in the link box. Thank you for attending today’s workshop.
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