1. Self-Management for Persons with SMI in a Behavioral Health Home Jaspreet S. Brar, MD, PhD Senior Fellow, Department of Psychiatry, WPIC & Community Care Behavioral Health, Pittsburgh, PA & Suzanne Daub, MSW, LCSW Senior Director of Physical Health / Behavioral Health Integration Community Care Behavioral Health, Pittsburgh, PA Collaborative Family Healthcare Association 16 th Annual Conference October 16-18, 2014 Washington, DC U.S.A. Session #: A2a October 17, 2014

2. Faculty Disclosure Please include ONE of the following statements: We have not had any relevant financial relationships during the past 12 months.

3. Learning Objectives At the conclusion of this session, the participant will be able to: 1.Identify the similarities and differences between two models of behavioral health homes. 2.List the central component’s of the Wellness Coaching model used by Community Care Behavioral Health 3.Discuss the structure of Self-Management in the Wellness Coaching Model, including the roles of the Wellness Coach and the Person-In-Care 4.Learn of web-based Self-Management Resources

4. Bibliography / Reference Lorig, K., Holman, H., Sobel, D., Laurent, D., Gonzalez, V., 2012, Living a Healthy Life with Chronic Conditions: Self-Management of Heart Disease, Arthritis, Diabetes, Depression, Asthma, Bronchitis, Emphysema and Other Physical and Mental Health Conditions. Fourth Edition. Bull Publishing Company, Boulder, CO. Bartels S, Desilets R. Health Promotion Programs for People with Serious Mental Illness (Prepared by the Dartmouth Health Promotion Research Team). Washington, D.C. SAMHSA-HRSA Center for Integrated Health Solutions. January 2012. Mrazek, P. J., & Ritchie, G. F. (2012). Becoming a Preventionist: Making Prevention Part of Your Mental Health Practice; A Continuing Education Course. Alexandria, VA: National Association of State Mental Health Program Directors (NASMHPD). Reardon, C., 2010. Integrating Behavioral Health and Primary Care - The Person- Centered Healthcare Home. Social Work Today, Vol. 10 No. 1 P. 14. Swarbrick, M. (2010). Peer Wellness Coaching Supervisor Manual. Freehold, NJ: Collaborative Support Programs of New Jersey, Institute for Wellness and Recovery Initiatives.

5. Learning Assessment A learning assessment is required for CE credit. A question and answer period will be conducted at the end of this presentation.

6. Health Homes: A One Stop Shop Superb Access to Care Patient Engage- ment in Care Clinical Infor- mation Systems Care Coor- dination Team Care Patient Feedback Publicly Available Infor- mation Triple Aim: Improve Outcomes, Reduce Cost, Improve Patient Experience

7. Health Homes: A Vehicle for Integrating Care Patient-Centered Medical Home (PCOM) – Moving from physician-centered care to involving all members of the healthcare team (“Reinvent Primary Care”) – Patient at the center of care Embedding behavioral health services in medical settings – Behavioral Health Consultant Behavioral Health Homes (BHH) – Improving the capacity of behavioral health settings to support physical health challenges – CCBH model: Use of a Wellness Coach / Health Navigator

8. The Community Care Experience  Initially 2 agencies in North Central PA in 2009  11 agency added in 2013 (PCORI), 10 additional in 2014  Wellness Nurse at each agency  Wellness coaching training for nurses and case managers  Used the IHI’s Learning Collaborative model for implementation  Population-based care + Use of a disease registry  Outcomes monitoring  Case conferences to support best practices  Self Management resources

9. Components of the Community Care Model  Wellness Coaches  Nurse  Case Manager  Peer Specialist  Wellness Coaching training  Self Management Toolkits  Member Registry  Key Pharmacy and BH data  Tiers 1 and 2  Development of connections with Primary Care  Support of Psychiatrists

10. Wellness Coaching  Developed by Peggy Swarbrick, PhD at the CSPNJ Institute for Wellness and Recovery & UNDMJ  Help persons-in-care to identify strengths, needs and areas to improve, maintain or create  Clarify the person’s priorities  Establish a clear and specific goal (SMART goal)  Brainstorm action, steps and methods to support the person’s goal achievement  Set accountability, steps, including a time frame

11. What is Self-Management?  Carrying out health-promoting or (disease) risk-reducing activities and behaviors by persons with with chronic conditions  Self-management activities are:  Activities that people can do by themselves  Problem-based and Self-tailored  Self Management areas: Healthy WeightSmoking Cessation Physical ActivityTaking Medications Effectively PH/BH CareImproving Sleep Stress Reduction

12. Wellness Coach’s Role in Self-Management  Engage persons-in-care in an exploration of wellness and physical health.  Support person-in-care’s effort in identifying self- management goals (Physical Wellness Satisfaction Scale).

13. Case Manager’s Role in Self-Management  Review cognitive strategies  Involving information processing (i.e., learning, reasoning, problem-solving, and decision making)  Review behavioral strategies  The manner in which one functions and behaves  Tasks and strategies:  Must be doable  May involve modification of existing everyday tasks or learning new tasks  May address the specific area either directly or indirectly

14. Case Manager’s Role in Self-Management  Review strengths, needs, and barriers – Strengths: personal strengths for person-in-care Have control over practice of task or strategy? Enjoy the activity or past history? Can share experience with a friend or family member? Access to resources? – Needs: needs for person-in-care Needs additional information? Necessary tools? (weighing scale, pedometer, etc.) – Barriers: anticipated problems in carrying out tasks Not able to carry out the task/strategy?

15. Case Manager’s Role in Self-Management  Assist persons-in-care in identifying resources (more later)  Facilitate the use of these resources by persons-in-care  Explain the Web-based tools (Community Care’s Member Portal) and support its use  Support person-in-care’s efforts to carry out self- management strategies  Measure the effect of self-management on specific area(s)

16. What is the Role of the Person-In-Care?  Choose an area for self-management (7 areas)  Select one or more tasks or strategies presented by the case manager  Number of tasks or strategies can increase incrementally  Review the tasks or strategies with the case manager in order to understand how the task or strategy is practiced or carried out

17. Set a goal (S-M-A-R-T goal) – Example: I plan to lose 3 pounds of weight in the next month by walking 1 mile 3 times a week, cutting down sugars and reducing portion size Develop a plan to carry it out Implement the plan Monitor how the plan is working Adjust plan as needed What is the Role of the Person-In-Care?

18. Self-Management Resources  Other resources at the behavioral health provider’s facility  Resources at the area hospital(s)  Special consultation for example dietician or nutritionist  Local community centers, grocery stores, service clubs (i.e., Lions, Rotary, Kiwanis)  Parochial/faith-based organizations, churches, etc.

19. Self-Management Resources Flip-Charts and guides 1.Significance Significance/relevance of the specific area for self-management 2.Self-management tasks & strategies Cognitive, behavioral, and other strategies for self-management 3.Resources

20. Self Management Resources Steps of Hope  Self-management support and education http://www.ccbh.com/healthc hoices/educational/stepsofhop e/index.php http://www.ccbh.com/healthc hoices/educational/stepsofhop e/index.php  Recovery educational materials  Tobacco cessation materials  Weight management materials Wellness Resources  External websites http://www.ccbh.com/healthchoices/educ ational/wellness/index.php http://www.ccbh.com/healthchoices/educ ational/wellness/index.php  Healthy Weight & Physical Activity  Taking Medications Effectively  Improving Sleep  Quitting Smoking  Preventive Health Care  Stress Reduction  Diabetes, Hypertension, Dyslipidemia  COPD and Asthma  Hepatitis C and HIV  Traumatic Stress  Heart Disease and Stroke

21. Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!