Care Plans – Part 2

Health Home Staff TrainingService Model Developed with

Primary Care Development Corp

Objectives

• Staff will understand the link between the assessment, motivational interviewing techniques, and care planning.

• Staff will understand how to use basic motivational interviewing techniques in their everyday work with clients.

Agenda

• 9:30am Introduction and Recap from Last Training

• 9:35am Review Care Plan Workflow and Format

• 9:50am Motivational Interviewing and Care Planning

• 11:30am Close

Review Care Plan Workflow and Format

– Emphasize linking assessment work to care plan development

– Show how new format encourages proper writing of care plans

Standardized Care Plan Workflow

Intake

•Brief – Info gathering from Client•Assigned to CM•Reach out to provider & Client per Intake Workflow•Letter•Directory

Initial Comprehensive Assessment

•Client•Meet/Interview Client

•Providers•Case Conference w/ Providers/Proxy

•Assess documentation from Provider

•Identify needs w/ client•Use Motivational Interviewing Techniques

Care Plan Development

•Within first 30 days•Client Centered•Identifies strengths & challenges

•Client agrees to goal and interventions

•SMART Goals•Specific•Measureable•Achievable•Realistic/Relevant•Time Bound

What’s a Care Manager to Do?Can you still write a medically-focused, patient-

centered Care Plan within 30 days if you haven’t

received medical documentation or had a case

conference with the provider?

Yes…

• Client has still identified goals with you

• Conducting the Case Conference/obtaining the medical documentation is necessary to achieve the goal

• Interventions aimed at obtaining medical information are appropriate

No, if…

• You have not fully documented your attempts to obtain medical information/conduct the case conference.

• Client record MUST reflect multiple, progressive attempts to obtain information from medical providers THROUGH OUT the initial 30 days after admission.

• You must keep your supervisor informed of your progress (or lack thereof).

…but,

The Care Plan Process

Intake

Initial Assess-

ment1st Care

Plan

Re-Asses

Care Plan

Re-Assess

Care Plan

Re-Assess

Care Plan

What is Motivational Interviewing (MI)?

– A clinical method for helping people resolve ambivalence about change by bringing out internal motivation and commitment. This method is both client centered and directive. It was originally used with addicted populations and then effectively adapted for work with treatment adherence for people diagnosed with chronic illness.

– Motivational interviewing draws on tools and ideas already being used by many other fields and clinical methods. These elements are described in the venn diagram.

What is Motivational Interviewing (MI)?

What is Motivational Interviewing (MI)?

– The four elements of MI: We will review all four elements. We will focus on the most on the OARS Skills.

–MI Principals: RULE• Resist the righting reflex• Understand your clients motivation• Listen to your client• Empower your client

MI Spirit

• Collaboration – collaboration with the client is crucial to change. The client brings expertise on their life and insight into their motivations. The clinician brings expertise and a positive environment for change

• Evocation – The clinician is expected to evoke or draw out a clients reasons and possible methods for change. We acknowledge that there are many paths to change and we are expected to use information that our clients have given use to help them find their own path to change.

• Autonomy – At the end of the day, decision making is up to our clients. They will be the ones that choose how to live their lives and they are the ones who will bear the consequences. This does not mean that we simply agree with all of a client’s choices. Instead we help them to understand all of the possible consequences for any given choice, offer safer alternatives, and support. Ultimately, we reinforce that our clients ultimately make those choices for themselves.

Change Talk

– Change Talk• When clients discuss the change they want

in their own language• Change talk predicts action – people are

more likely to follow through with a plan for change, when it is something that they have spoken in their own words.• Many MI interventions are designed to elicit

and reinforce Change Talk

OARS

• Open-ended questions• Affirmations• Reflection• Summary

Open-ended question

• Cannot be answered with a yes or a no• Provide less biased data because the client is

telling you what is important and what is not• May give you information that you wouldn’t

have known to look for• Traps (Question answer trap – ratio of reflective

statements to questions should be 2 to 1 to avoid the interaction from becoming didactic. This leaves room for the client to continue leading the conversation, instead of waiting for the clinician to provide a solution) ?

• EXAMPLES:

Open-ended questionCLOSED QUESTIONS OPEN-ENDED QUESTIONS

Did you take your meds last night? Tell me about how taking your medication has been for the last week.

Have you been able to stay clean since I last saw you?

How has your crack use been since the last time I saw you?

Did you attend your last medical appointment

Tell me about how it was getting to your doctors appointment

Have you been using condoms? I’m wondering how it’s been trying to use condoms since our last conversation.

Have you been attending your GED classes How has it been getting to your GED classes?

How much and how often do you drink What are your drinking habits like

Affirmations• What are they? Positive reinforcement, statements of appreciation and

acknowledgment of the client’s strengths. Affirmations are strategically placed in the interview to help keep the client rooted in his/her strengths and resources.

• Why are they important?– A positive environment for change is one of the most important things we bring to our

clients (see MI Spirit).– Many times our clients come to us times when they have made many attempts to

change and have failed. Self-efficacy is one of the most significant indicators of self change. When we listen to our clients and draw out their success and bring them into light, we help to reinforce our clients self efficacy and improve their ability to move towards change talk.

• Pointers for creating affirmations instead of compliments– Avoid using “I.” Draw affirmations out of client’s own statements– Focus on descriptions rather than evaluations– Think about attending to non-problem areas– Think of supporting a competent view of the client instead of the deficient view of the

client

Summary

• What is a summary? A summary is a concise statement that summarizes a client’s statement and also guides the interview.

• Summaries are often used to do the following:• Collecting – used to gather information, confirm you have it right

and keep the conversation moving forward towards the goal.• Linking – these statements are used to link previously disclosed

information with newly disclosed information to highlight discrepancies and explore disconnections with the client (ie so I remember earlier that you said you want people to just leave you alone, and I also hear you saying now that you don’t really want to do the things that might accomplish that...”

• Transitioning – these questions move the discussion forward. These statements are often a bit longer and signal a shift towards the end of an interview or the setting of a goal.

OARS exercise

• OARS coding sheet exercise with video: http://www.youtube.com/watch?v=80XyNE89eCs

BNI – Brief Negotiated Interview

• Where did it come from – developed for use in the Emergency Room, for doctors and nurses to use. It is designed to use motivational interviewing methods to complete a quick task oriented interview

• The PACT version was made for non-clinician community health workers providing care management services in the field for HIV/AIDS patients who also suffered from mental health and substance abuse issues – similar to the types of patients you encounter through Health Homes. PACT is the Prevention and Access to Care and Treatment Project —supported by Partners In Health and Brigham and Women’s Hospital— that recruited and trained community health workers (CHWs) to work with Boston’s most vulnerable HIV/AIDS population.

• The PACT tool has been tested in the field and validated. It can be helpful when discussing care plan goals with clients

BNI – Brief Negotiated Interview

• Why are we looking at it? • Because it can be used to help guide the

creation of a care plan with a client.

BNI – Brief Negotiated Interview

• Take a minute to review the questions• Overview of each question – where do you see

OARS? Change talk? RULE? Collaboration, evocation, autonomy?

• Notes: KEY questions are “what do we do next” questions. The key question moves us from building motivation and discussing the issue to developing and implementing a plan for change. These questions determine what action will come next and solidifies the commitment to change, or describes the status of ambivalence. Ie “so where does that leave us” and “why not less”

Summary

• Motivational Interviewing provides us with useful skills for care planning with our clients. It helps us to help our clients create goals and objectives that they can successfully complete.

Final Discussion

– Staff experience doing role plays– Lessons learned– Q &A – Summary of main topics covered today

Close