Collaborative Care Management Training - · PDF file• Motivational Interviewing ... share the screen . Links to Online Training Larry Mauksch, M.Ed University of Washington Department

Collaborative Care Management

Training Double Tree Hotel

October 13, 2017

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What’s in Your Packet?

• Agenda

• Action Planning Guide

• Evaluation Form

• Patient Centered Observation

Form- MA/Nurse

• Patient Centered Observation

Form- Clinician version

• Stages of Change Visual

• Motivational Interviewing

Statements/Questions

• Adverse Childhood Experience

(ACE) Questionnaire

Team Approaches to Communication

and Efficiency: Critical skills

Larry Mauksch, M.Ed

Clinical Professor Emeritus Department of Family Medicine

University of Washington

Editor, Families, Systems, and Health

Disclosures

Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Receive consultation fees and honoraria for consultation

and training provided to academic and health care

organizations with a focus on communication, teamwork,

competency assessment, self management support

Co-owner of MedFAD.com, a competency assessment

software company

Objectives

Define two critical skills that primary care teams can use to optimize quality of care and time management

Learn to use a communication assessment tool

Plan how to incorporate skills into a team approach to care.

Observation Form Purpose

and Training

The value

• Structures vision

• Creates and standardizes vocabulary

Primarily for formative assessment and to strengthen the “observer self” (mindfulness)

Online training: www.pcof.us

http://www.pcof.us

PCOF Use

Behavior in either of the columns to the right of thick vertical line is in the competent range

Observers mark accurately and avoid giving the benefit of the doubt

Feedback is best:

When solicited

Specific, rather than

general

Curious, not judgmental


Relationship Communication and Efficiency: Creating a Clinical Model from a Lit Review

Mauksch et al, 2008, Arch of Intern Med, 168 (13) 1387-1395

Ongoing influence

Rapport and Relationship

Mindfulness

Topic Tracking

Empathic response to

cues

Sequential

1. Upfront collaborative

agenda setting

2. Hypothesis testing and

understanding the patient perspective

3. Co-creating

a plan

SMS: problem solving

EEE: Polite Interruption Mauksch. Questioning a Taboo…, JAMA. 2017 March 14th

Excuse yourself (acknowledge and/or apologize)

Empathize with the problem that is being cut off

Explain why you are interrupting

• Planning time use

• Finishing an important topic (topic tracking)

• Stopping to explore an important cue


Interruption: Important cue

Mr. Fredricks, forgive me for stopping you. You just said

something about wondering if your thigh pain was in your

bones and perhaps serious. Can we go back to that?

It sounds like you have some important concerns that I want

understand further.

EEE: Polite Interruption Mauksch. Questioning a Taboo…, JAMA. 2017 March 14th

Excuse yourself (acknowledge and/or apologize)

Empathize with the problem that is being cut off

Explain why you are interrupting

• Planning time use

• Finishing an important topic (topic tracking)

• Stopping to explore an important cue Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Relationship Communication and Efficiency Mauksch et al, July 14 2008, Arch of Intern Med

Ongoing influence


Mindfulness

Topic Tracking


cues

Sequential

1. Upfront collaborative agenda setting

Visit Organization

Agenda collision

Acute

Chronic HM / Preventive

Self Management

Support

Care Management

Upfront Collaborative Agenda Setting Brock, Mauksch, et al. JGIM, Nov, 2011; Mauksch et al, Fam, Syst,

Health, 2001 Identifies patient’s priorities

Organizes the visit

Decreases chance that patients or providers will introduce “oh by the way” items

Screens for mental disorders

Facilitates shared decisions about time use between acute, chronic, and health maintenance care

Does not lengthen the visit; protects time for planning

Decreases clinician anxiety

Agenda Creation

Avoid premature diving by patient or yourself

When needed interrupt the patient or yourself:

Acknowledge, Empathize

Share reasoning

If the list is greater than three items,

the patient is screen positive for depression or anxiety

Ask, “what is most important”

• Listen (feel) for the most important concern

Orient the patient:

“I know you are here to talk about ____. Before we get into_____ is there something else important to addresses today? Making a list will

help us make the best use of time”.

Diving or Agenda Setting

Old

What are we doing today?

How are you?

What can I do for you?

What is going on?

Tell me about your ear pain.

New

What is on your list of concerns today?

In addition to your ear pain is there something else?

Let’s make a list of your concerns and then figure out how to make the best use of our time?

Agenda Setting

Missteps and corrections

• Interrupt your self: “ I am getting ahead of myself”

Provider diving

• Interrupt with an apology, empathy, and reason

• “I apologize for interrupting. Your sleep is a concern but before we talk about it, is there something else?”

Patient diving

• Orient: “Lets plan the use of time before we use it”

No orientation to purpose of agenda setting



Ongoing influence


Mindfulness

Topic Tracking


cues

Sequential

1. Upfront collaborative agenda setting

2. Hypothesis testing and understanding the patient

perspective

Explore the Patient Perspective When:

Promoting self management and behavior

change

Detecting clues about thoughts

or feelings

Family or cultural influences are

suspected

Psychosocial factors may be

present

There are unexplained

medical symptoms

You sense distrust in the health

system

Desired change does not occur

Contemplating a major health care decision

Discussing palliative care

(PalCOF)

Exploring Patient Perspective:

Core Skills and attitudes


• Curiosity

• Empathy

• Remembering, when patients do not do something, there is always a reason

• Cultural humility

Attitudes

• Reflective listing

• Open ended, focused questions

Skills



Ongoing influence


Mindfulness

Topic Tracking


cues

Sequential

1. Upfront collaborative

agenda setting

2. Hypothesis testing and

understanding the patient perspective

3.

Co-creating

a plan

Co-creating a Plan

Assess patient’s preferred

decision role

State clinical issue / decision

to be made

Describe options

Discuss pros and cons

Discuss uncertainties

Assess patient understanding

Ask for patient preferences

Resolve decision

differences

Plan respects patient goals and values

Closing the visit

Questions

Teachback

After visit summary

Combine Teachback and AVS and share the screen

Links to Online Training


Patient Centered Observation Form (PCOF)

www.pcof.us

Palliative Care Observation Form (PalCOF)

www.palcof.com

Family Centered Observation Form (FCOF)

https://sites.google.com/view/fcof

http://www.pcof.us

http://www.palcof.com

https://sites.google.com/view/fcof

Practice Reflection and

Commitment to Change Tool JOUR OF CONTIN EDUC IN HEALTH PROFESSIONS, 35(3):166–175, 2015

The most useful information for me was:

This highlighted the following gap in my practice:

FILL IN ONE OR MORE OF THE PRACTICE CHANGE OPTIONS BELOW

I will change my current practice in the

following way:

Barriers I anticipate:

What changes to my current practice am

I considering? What would enable me to

change

What confirmed my current practice? What supports my current

practice?

I am not convinced there is a need to change my current practice because:

BREAK

A team Approach for Self-management

Support and Building a Collaborative

Care Plan

Larry Mauksch, M.Ed

Consultant and Trainer

Clinical professor Emeritus

Department of Family Medicine

University of Washington

Editor, Families, Systems and Health

Objectives

Define key problem solving skills used when integrating self management support in primary care by care managers and others

Evaluate EHR design to support a team approach to self management support

Create a flexible team approach for integration of self management support


Transdisciplinary Functions and Roles in Primary Care

Role

Function

PCP Nurse Medical

Assistant

Pharm Behavioral

health

Care

Management

Relationship 5 5 5 5 5 5

Agenda setting

and activation

4 3 5 2 4 4

Self management-

simple

4 3 4 3 2 2

Self management-

complex

3 4 2 3 4 5

Primary care

counseling

3 4 1 2 5 4

Plan confirmation

and care

integration

3 4 4 3 4 5

Proactive follow-up

and stepped care

3 5 4 3 3 4

Intensity: 5 =always; 4= often; 3 = periodic; 2 = support; 1 = reinforce and connect Larry Mauksch, M.Ed UW Family Medicine

Stages of Activation Hibbard et al Health Services Research 2007, 42(4) 1443-63

Level of activation (age 45 or older, 2.9 chronic conditions)

diabetes, HTN, lung, cholesterol, arthritis, heart

Percent

(cumulative)

May be overwhelmed and unprepared to

play an active role in their own health

12

May lack knowledge and confidence

about self management

29

(41)

Taking action but may lack confidence

and skill to support self management

37

(78)

Mastered self management but may not

maintain behaviors at times of stress

22

The Patient’s Path

MA/

RN/BH

CM

Warm greeting,

elicits agenda, activates patient,

may provide HBC

MD

ARNP

PA

Makes connection,

elicits and negotiates agenda,

provides care, promotes

self management

MA/RN BH

CM

Elicits questions, provides education,

navigation

F/U support,

Behavior change counseling

Patient uses

e-planning/

scheduler

Front

Office

Greets patient, introduces form or

acknowledges

e-plan receipt


Visit Organization

Agenda collision

Acute

Chronic HM /

Preventive

Self Management

Support

Care Plan

During Agenda Setting

Plan the use of time before using time

• Upfront collaborative agenda setting

• “Something else”

Self management support

• Begins upstream from clinician encounter

• Ask patients about health goals

• If care plan exists, check on progress


Behavior Change and

Goal Setting

Provider

Determined

Patient Determined

Goal Disease Can be from a larger

domain

Pros Helps with disease

management

Builds patient

investment

Cons Greater resistance

(contemplation)

Requires more

patience, may not

be disease focused

at first

Goal Setting

Which part of this would you like to work on?

“What would you like to do to improve your health?”

“If you were going to change one thing about managing your health, what would it be?”

“If you woke up tomorrow morning and one thing changed in how you managed your health, what would it be?”

Collaborative Goal-

setting

Offer a variety of choices

Listen to what the patient wants

Go with the patient’s choice

ONE goal at a time

What are the key

components of a

health behavior

care plan to send

home with the

patient ? Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Action Planning

• What I will do:

• How often?

• When?

• Potential barriers?

• How will I overcome these barriers?

My Ongoing Action Steps

Patient Centered Problem Solving

What can help increase confidence?

Confidence- 1(low) to 10(high)

Barriers?

When?

How often?

Focus the activity (biking)

Name an activity (exercise)

Brainstorm activities (different ways)

Name the goal (wt loss)

Meet the patient where s/he is and hone

Review Patient Centered Observation Form (PCOF):

Clinician version:


MA/Nurse Version:


and

Self management follow up Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Assist with Action Planning

Things I can do to help reach this goal:

a.

b.

c.

d.

Confidence Ruler

1 2 3 4 5 6 7 8 9 10

Not Somewhat Very

Confident Confident Confident

Increase Confidence

What would it take to make your confidence a ____?

•(1 higher than their current rating)

Arrange follow-up

Would it be OK if Christine calls you next week to see how this is going?

PCCP Chart review Chunchu, Mauksch, et al. Fam, Syst, Health, 2012, September

PCCP

51 yrs; 60%F

Controls

55 yrs; 40% F

Goal documented 96 % 43 %

Ongoing activity 89 34

Specific activity 78 41

How often 68 07

When 68 07

Barriers 75 01

Confidence 71 00

What can help with confidence 53 00




Barriers?

When?

How often?






Additional Thoughts:

• Collaborative Care Plans

• Stepped Team Involvement,

• EHR Modification,

• Motivational Interviewing vs

Problem solving


For any patient who is working on

self management

Weave it into the discussion

•Most patients with chronic illnesses

•Patients with whom you discuss health risk behaviors, eg, diet, alcohol, exercise

•Patients who need help with simple behavior changes, eg., remembering to take Rx

Phases of Teamwork and

Planning

Planning (Huddles)

Action (The provision of care)

Debriefing (Reviewing the experience, celebrating success, and planning change and learning)

Work Flow Options

MA/RN/CM/BH establishes goal and plan

MA/RN/CM/BH establishes goal, part of plan, PCP finishes

MA/RN/CM/BH establishes goal, PCP completes plan

MA/RN/CM/BH establishes goal and completes plan

MA integrates progress check into agenda setting at subsequent visits or on the phone

Primary Care Team Building Activities Fiscella, Mauksch, et al Improving Care Teams’ Functioning:

Recommendations from Team Science. 2017.

Joint Commission Journal on Quality and Patient Safety

Huddles &

Debriefs

Team

Training

Peer

Coaching

Video

Creation

Role

Modeling

Coaching X X XX XX X

Cognition XX X X X X

Cooperation XX X X X XX

Coordination X X XX X X

Conflict X X X X XX

Communication X XX XX XX XX

Team Design Reflections

Team expansion is needed for ambivalent or pre-contemplative patients

•Nurse

•Care manager

•Behavioral health

•Extra medical assistant with extra training

Physicians need extra training for complex patients and close relationship with care manager functionality

Phone Follow Up

Collaborative Agenda setting

Highlight successes

Normalize struggles

Describe barriers

Revise plan

Schedule F/U Larry Mauksch, M.Ed University of Washington Department of Family Medicine


Motivational Interviewing vs Problem

Solving ( Goals and action plans)

Time Evidence

Practicality Skill

learning


The Overlap:

Motivational Interviewing and

Goal Setting

• Collaborate on problem solving

• Drawing the patient out (evocation)

• Support the patient’s autonomy

Spirit of MI

• Open ended questions (what, how, tell me about)

• Affirmations (acknowledge effort and success)

• Reflect ( to avoid power struggles and promote patient exploration of an issue- video example)

• Summarize

OARS

Behavior Change Strategies Reported by

Top- and Bottom-Performing Clinicians Greene et al Ann Fam Med 2016 14 (2)

Strategy Top Clinicians (10) Bottom Clinicians (10)

Used mainly by Top clinicians

Emphasizing patient ownership 8 3

Partnering with patients 9 3

Identifying small steps 10 3

Scheduling frequent follow-up visits 7 3

Showing caring 5 1

Used by both groups

Reliance on team supports 10 7

Used mainly by bottom clinicians

Describing consequences of bad

health behaviors

2 8

Practice Reflection and Commitment to

Change Tool JOUR OF CONTIN EDUC IN HEALTH PROFESSIONS, 35(3):166–175, 2015

The most useful information for me was:

This highlighted the following gap in my practice:

FILL IN ONE OR MORE OF THE PRACTICE CHANGE OPTIONS BELOW

I will change my current practice in the

following way:

Barriers I anticipate:

What changes to my current practice am

I considering?

What would enable me to

change

What confirmed my current practice? What supports my current

practice?

I am not convinced there is a need to change my current practice because:

Skills Development: Objectives

Practice and assess use of self management support counseling skills

Evaluate ways to implement use of self management support in their respective settings.





Barriers?

When?

How often?






Pick something to change in

your life One person counsels

One person is the patient,

One person observes using PCOF

Everyone plays every role

Focus on a simple, real issue

Patient: Be ambitious

Counselor: restrain for success




Barriers?

When?

How often?






TEAM COMMUNICATION

TRAINING

Team members reinforce use of communication

skills in one another

Shared learning of skills builds

team function

Mastering a Skill Domain

Practice

• Real situations

• Learned from expert: • description

• demonstration

Feedback

• Specific

• Sensitive

• Developmentally appropriate

Reflection

• Promotes analysis

• Synthesis

• Integration

Common Training Sequence

Introduction to PCOF

Group rating and discussion of C/B

Videos

Teamlet members

observe each other using extended

appointment slots

Groups meet to share learning and set goals

• Within teamlets

• Across teamlets

Recurrent observations and team meetings

for reinforcement

Do the cycle again to learn more skills and achieve more

goals


1) Skills on the PCOF

• Those done well

• Wonder about doing something differently

2) Overlap with Lean approach

• Going where the action is

• Value stream thinking- study the present, plan the future

• Standard work

• Raising skills to the ceiling of role capacity

• Work supported by coaching

• Reveal waste

• Change designed by folks who do the work

A Patient Centered Care Plan in an EHR:

Improving collaboration and engagement

2012, issue 3, Families, Systems and Health

Kavitha Chunchu, MD, Larry Mauksch,M.Ed.

Carol Charles, L.I.C.S.W, Valerie Ross, MS

Judy Pauwels, MD

Funded by Picker Institute and Gold Foundation

Engaging Patients In Collaborative Care Plans:

Communication Skills, EHR Applications,

Teamwork, and Training, May/June 2013

Family Practice Management

Larry Mauksch, M.Ed and Bertha Safford, MD

BREAK

Self-Management Support: Skill

Development


LUNCH 11:30 – 12:15 PM

• Understand core responsibilities of care managers as they pertain to behavioral health in primary care

• Practice applying principles and skills of motivational interviewing to increase patient engagement in care

• Increase confidence in managing difficult situations

– Trauma

– Suicidality

• Coordinating overall effort of the primary care team

• Ensuring effective communication among team members

• Offering brief counseling interventions to facilitate behavioral changes

Motivational Interviewing

Solution Focused Therapy

Problem Solving Therapy

Care Managers Behavioral Health Providers

Mild symptoms of depression, anxiety, PTSD, etc. (limited impairment in functioning)

Moderate to severe symptoms of depression, anxiety, PTSD, etc. (significant impairment in functioning)

Behavioral changes related to chronic disease management

Behavioral changes related to chronic disease management when they intersect significantly with MH problems or social/relational problems

Based on Jordan et al (2013)

General Duty Extension

Screen & assess for depression, anxiety, and substance use disorders * coordinated, co-located, or integrated

• Train front desk staff & MAs in how to administer screenings & talk to patients about them

• Develop workflows for screening


Facilitate patient follow-up with referrals made to behavioral health services * coordinated, co-located, or integrated

• Secure copies of release of information (ROI) forms for most common referrals

• Facilitate conversation with patients about importance of signing ROI


Provide patient education about common BH conditions and available treatments * coordinated, co-located, or integrated

• Support PCPs in using shared decision making aids in conversations with patients


Systematically track treatment response and monitor patients for changes in clinical symptoms and treatment side effects or complications * coordinated, co-located, or integrated

• Implement a BH registry


Support psychotropic medication management, focusing on treatment adherence monitoring, side effects, and effectiveness of treatment * coordinated, co-located, or integrated

• Develop meaningful measurements of progress (e.g. PHQ-9, GAD-7, FAQ-5)

Resist the “righting” reflex Understand your patient’s motivation Listen actively Empower

Open-ended questions Affirmations Reflective listening Summarization

Status Quo Change

Benefits

Costs

“Traumatic events, by definition, overwhelm our ability to cope. When the mind becomes flooded with emotion, a circuit breaker is thrown that allows us to survive the experience fairly intact, that is, without becoming psychotic or frying out one of the brain centers. The cost of this blown circuit is emotion frozen within the body. In other words, we often unconsciously stop feeling our trauma partway into it, like a movie that is still going after the sound has been turned off. We cannot heal until we move fully through that trauma, including all the feelings of the event.”

Susan Pease Bannitt (2012)

55% 95%

have experienced at least one trauma

to

• Alcoholism and alcohol abuse

• Chronic obstructive pulmonary disease (COPD)

• Depression

• Fetal death

• Health-related quality of life

• Illicit drug use

• Ischemic heart disease

• Poor work performance

• Financial stress

• Risk for intimate partner violence

• Multiple sexual partners

• Sexually transmitted diseases

• Smoking

• Suicide attempts

• Unintended pregnancies

• Early initiation of smoking

• Early initiation of sexual activity

• Adolescent pregnancy

• Risk for sexual violence

• Poor academic achievement

(CDC, 2016)

Trauma Physical health

problems

Trauma

Disrupted neurodevelopment

Physical health

problems

Physical deregulation

Trauma

Risky health behaviors

Physical health

problems

• More negative interactions with providers

• More negative perceptions of the healthcare system

Bassuk, Dawson, Perloff, & Weinreb (2001); Green, Kaltman, Chung, Holt, Jackson, & Dozier (2012)

• More negative interactions with providers

• More negative perceptions of the healthcare system

WHY? • Impairment in forming and maintaining trust in

relationships • Sensitivity to issues of power and authority

(Green et al., 2015)

• Invasive procedures

• Inflating a blood pressure cuff

• Power differentials between patient and provider

• Being confined in a small space

• Having arms restrained for minor procedures

• Removal or absence of clothing

• Medications with sedative side effects

• Sounds (e.g. ambulance siren, loud noises)

• Smells (e.g. latex gloves, rubbing alcohol)

(Veterans Affairs, 2002; SAMHSA, 2013)

• Irritability, hostility

• Demanding & present with many needs OR reluctant to discuss problems

• Problems with pain

– Poor tolerance of pain

– Poor perception of pain

– Chronic pain

(Trauma Committee at Institute for Family Health, 2015)

• Avoidance symptoms

– Repeatedly canceling appointments

– Avoiding telling providers about symptoms

• Dissociative symptoms

– Altered awareness/attention (“spacing out”)

– Flashbacks

– “Out of body experiences”

(Veterans Affairs, 2002)

(Fishbane, 2007)

• How can you support parents in preventing trauma experiences for their children?

– Well child checks

– Behavioral issues addressed during visits

– Psychoeducation

– Collaboration with school system

– Interventions to meet social needs (e.g. housing, transportation, food security)

• How can you identify patients whose trauma histories may be impacting their health?

– Review charts of patients on the daily schedule

– Listen for red flags & risk factors during huddle

– Observe patients’ and family members’ nonverbal cues and patterns of behavior in the office

• Avoidant

• Dissociative

• Medically unexplained symptoms/somatization

• How can you include elements of trauma-informed care in your daily practice?

– Safety

– Trustworthiness & transparency

– Peer support

– Collaboration & mutuality

– Empowerment, voice, & choice

– Cultural, historical, & gender issues

– Understanding of nonlinear healing

– Respecting boundaries

(SAMHSA, 2013)

• How can you communicate trauma sensitivity in your practice?

– Trauma-related materials in waiting room

– Posters inviting patients to talk about trauma & needs in exam rooms

– Asking questions about trauma history & needs before/during exams

(SAMHSA, 2013)

• Ask yourself

– Why do people kill themselves?

– Is it ever acceptable to commit suicide?

– Can suicide be prevented?

– Do people who access care want to die?

– What are your individual professional responsibilities with a patient who is suicidal?

(Rudd, 2006)

• Be direct

• Be precise

• Establish a relationship

(Rudd, 2006)

• Suicide/completed suicide

• Suicide attempt with injuries

• Suicide attempt without injuries

• Instrumental suicide-related behavior

• Suicide threat

• Suicidal ideation

(O’Carroll et al, 1996)

• Suicide attempt vs. instrumental behavior vs. suicide threat

– Subjective/expressed intent

• “I’m going to shoot myself”

• “I wish I had died when I took those pills”

– Objective intent

• Preparation for death (e.g. letters to loved ones, organizing financial records, revising a will)

• Efforts to prevent discovery or rescue

(Rudd, 2006)

(Rudd, 2006)

Morbid Ruminations Suicidal Thoughts

Thoughts about death, dying, not wanting to

be alive

Thoughts of killing oneself

• Assessing a patient’s thinking

– Frequency

– Intensity

– Duration

– Specificity

(Rudd, 2006)

• Assessing frequency

– “How often do you think about killing yourself?”

– “What time of day do these thoughts usually occur?”

(Rudd, 2006)

• Assessing intensity

– “What exactly do you think about for that length of time?”

– “When you have those thoughts, how intense are they?” (scale 1-10)

(Rudd, 2006)

• Assessing duration

– “When you have these thoughts, how long do they last?”

(Rudd, 2006)

• Assessing specificity

– “How are you thinking about killing yourself?”

– “Do you have access to [method]?”

– “Have you made arrangements to get access to [method]?”

– “Have you thought about any other ways to kill yourself?”

(Rudd, 2006)

• Assessing specificity

– “What exactly do you think about for that length of time?”

– “Have you thought about when you might kill yourself?”

– “Have you thought about where you might kill yourself?”

– “Have you thought about taking steps to prevent anyone from finding you or stopping you?”

(Rudd, 2006)

• Assessing intent

– “Why do you want to die?”

– “Do you have any intention to act on your thoughts?” (scale 1-10)

– “Have you done anything in preparation for your death (e.g. rewriting your will, writing letters to loved ones, etc.)?”

– “Have you rehearsed your suicide in any way?”

(Rudd, 2006)

• Addressing chronic suicidality

– Differentiate between chronic course and acute episodes of suicidal thoughts & behavior

– Previous attempts heightened susceptibility to future suicidal crises

– Takes less to trigger a future suicidal crisis with more severe symptoms and more intent to die

(Rudd, 2006)

• Assessing protective factors

– “Even though you’ve had a really difficult time, something has kept you going. What are your reasons for living?”

– “Are you hopeful about the future?”

– “What would need to happen for you to be more hopeful about the future?”

– “What keeps you going in times like this?”

– “Whom do you rely on during difficult times?”

– “Has treatment been effective for you in the past?”

(Rudd, 2006)

(Rudd, 2006)

Risk Level Description

Minimal No identifiable suicidal ideation

Mild Suicidal ideation of limited frequency, intensity, duration, and specificity

Moderate Frequent suicidal ideation with limited intensity and duration, some specificity in terms of plans, no associated intent

Severe Frequent, intense, and enduring suicidal ideation, specific plans, no subjective intent but some objective markers of intent

Extreme Frequent, intense, and enduring suicidal ideation, specific plans, clear subjective and objective intent

(Rudd, 2006)

Risk Level Indicated Response

Minimal

No changes in ongoing treatment Mild

Moderate Recurrent evaluation of need for hospitalization & treatment goals Increase in frequency of outpatient visits Active involvement of family Awareness of 24-hour crisis line services Frequent re-evaluation of risk Consideration of medication Telephone calls for monitoring

Severe Immediate evaluation for inpatient hospitalization

Extreme Hospitalization for stabilization

• Referring patients to BH services

– “I can understand why you’re so upset about XY&Z, and we can return to talking about that in a few minutes if you’d like. For the next 5 minutes, I need to ask you a few questions so we can create a plan for today.”

– “What have your previous experiences with therapists been like? Why did you stop going? How did you resolve issues trusting them? Do you believe treatment can help you?”

(Rudd, 2006)

Status Quo Change

Benefits

Costs

BREAK

Colorado Crisis Services Dale Wright LPC

Crisis Services Coordinator, Western

Colorado

[email protected]

Colorado’s Crisis Response System

GOALS

• Expand early access to support and services for individuals

and their families with behavioral health needs.

• Promote ongoing recovery through linkage with community

resources.

• Decrease the number of unnecessary involuntary civil

commitments, hospital emergency room visits, and jail stays.

• Increase the availability of community and natural supports to

prevent behavioral health crises.

Colorado’s Crisis Response System —

Key Service Components

• CRISIS HOTLINE / WARM LINE

• WALK-IN CENTERS / STABILIZATION UNITS

• MOBILE CARE

• RESPITE CARE

• MARKETING CAMPAIGN


Key Service Components: Crisis line Services

CRISIS LINE 1-844-493-8255, including Text and Chat

• 24/7/365 support for anyone dealing with a self-defined

mental health, substance use, or emotional crisis. All calls are

connected to a mental health professional who provides

immediate support.

• Text is available 24/7/365 by texting TALK to 38255.

• Chat is available via the website 7 days a week from 4 p.m. to

midnight.

• Hotline is operated by Rocky Mountain Crisis Partners.

• Hotline was launched August 1, 2014.


Key Service Components: Walk-in Center Services

CRISIS WALK-IN CENTERS / STABILIZATION UNITS

• The Walk-in Centers are open 24/7/365 and provide

screening, assessment, support, and linkage to resources.

• Centers are 27-65 designated by the State to accept

individuals on a mental health hold.

• Crisis Stabilization Units (CSU) provide crisis beds for up to

5 days, for either voluntary or involuntary treatment.

• Services are provided regardless of residency, legal status,

payer source/lack of payer source, or diagnosis. Prior

authorization is NOT needed for crisis stabilization services.


Key Service Components: Walk-in Center Locations METRO DENVER REGION

• Westminster Walk-in Center

2551 W. 84th Avenue

Westminster, CO 80031

• Lakewood Walk-in Center

12055 W. 2nd Place

Lakewood, CO 80228

• Littleton Walk-in Center

6509 S. Santa Fe Drive

Littleton, CO 80120

• Boulder Walk-in Center

3180 Airport Road

Boulder, CO 80301

• Denver Walk-in Center

4353 E. Colfax Avenue

Denver, CO 80220

• Aurora Walk-in Center

2206 Victor Street

Aurora, CO 80045

NORTHEAST REGION

• Fort Collins Walk-in Center

1217 Riverside Ave

Fort Collins, CO 80524

• Greeley Walk-in Crisis Services

928 12th Street

Greeley, CO 80631

WESTERN SLOPE REGION

• Grand Junction Walk-in Center

515 28 3/4 Road

Grand Junction, CO 81501

SOUTHEAST REGION

• Pueblo Walk-in Center

1310 Chinook Lane

Pueblo, CO 81001

• Colorado Springs Walk-in Center

115 S. Parkside Drive

Colorado Springs, CO 80910


Key Service Components: Mobile Services

MOBILE CARE

• Mobile Care is available 24/7/365, meeting the individual

wherever the crisis occurs.

• Mobile Care can arrange for appropriate transport to needed

services for individuals in crisis, ensuring that transportation

options are safe and provided in the least restrictive manner

whenever possible.

• Mobile Care can be initiated by the Crisis Hotline; a mental

health professional may be sent out to provide a face-to-face

assessment.


Key Service Components: Respite Services

RESPITE CARE

• Respite Care provides stabilization and support and is often

peer managed.

• Respite Care requires an assessment by a Crisis Clinician,

either through Mobile Care or at a Walk-in Center,; services

are up to 14 days.

• Services may include individual respite supports such as in-

home respite, peer supports, crisis apartments, or family-based

crisis homes.

BREAK

What is 2-1-1?

2-1-1 is a free, confidential, information and referral

service that helps people across the country find the

local resources they need.

2-1-1 is available in all 50 states, as well as in Puerto Rico and parts of

Canada. 90.6% of the U.S. population is covered by a 2-1-1 organization.

In 2016, 2-1-1s in the U.S. responded to nearly 13.4 million requests for

help.

In 2016, 2-1-1s answered calls equivalent to more than 10% of all

households.

2-1-1 resource databases maintain information on 942,130 agencies,

programs and services across the U.S.

The most prominent reasons for calling were housing, utilities

assistance, food/meals, and health care.

Western Colorado 2-1-1 is part of the Colorado 2-1-1 State

Collaborative. 100 % of the Colorado’s population in 64 counties has

access to 2-1-1.

Western CO 2-1-1 is one of 5 call centers in CO and serves 16

counties on the western slope.

Partnership between local governments, United

Ways and Hilltop with many funding sources

Contact Center located in Grand Junction

Open Monday- Friday 8-5

Available by phone, Email, App, Web Search, In

person at MCDHS Building (Limited hours)

(Chat coming soon!)

3 Full time Call Specialists, 1 Full time Resource

Specialist, 1 Healthy Communities Specialist

Partnerships

oLEAP

oEmergency Management/Disaster

Response

oFair and events- Health Fair, Senior Law

Day, Etc.

oPiton/Free Tax Preparation

oWestern Slope AHCM Project

Andrew

Katie

Sonia

Shonté

2016 Data o CO 2-1-1: 102,218 total contacts (phone, chat, text, email)

58,586 Website visits

oWC 2-1-1 : 7022 answered calls

7619 referrals given

8133 Website visits

oPopulation:

29% Seniors 30% Families 40% Adults under 60

oTop Presenting Needs:

Housing/Utilities- 20%

Income Supports and Assistance- 20%

Individual, Family, and Community Supports- 15%

Health Care- 12%

Food and Meals- 7%

2-1-1 connects people to health and

human services resources, such as:

oBasic Human Needs Resources

oPhysical and Mental Health Resources

oEmployment Supports

oSupport for Older Americans and

Persons with Disabilities

oSupport for Children, Youth and Families

oVolunteer opportunities and donations

2-1-1 is so much more than just giving out phone

numbers……

Caller Comments: “Every time I can't find what I need, I call 211. They are always able to find some resources when I can't.”

"It was there when I needed it.“

“I am extremely grateful. And was especially impressed with call back to ensure I was doing OK.”

“Very professional, helpful and a good resource.”

“I received "information and more” I am very pleased.”

“I am new to area and 211 really helped me navigate. It's a vital service to have especially for people relocating. 211 was my main info resource.”

Ways to contact 2-1-1: oBy simply dialing 211

oCalling our 1-800 #

oGoing online

(www.wc211.org)

oColorado211 App

oFacebook

All about that web…..

o The Database

o How to search for services

o Agency Profile Information

http://www.wc211.org/


Searching the 2-1-1 Database 1. Go on to www.wc211.org 2. Click on “Database Search” on the top right corner


3. You can search by Service Type…

4. Or by Keyword and Zip Code

Searching by Service Type allows you to search by a specific category

2-1-1 Database Client Exercise

1) An individual calls asking about legal services for themselves. They are going through a divorce and they do not know how to go through the process. They’re zip code is 81504. Using the database search, what resources are available to them?

2) An individual calls looking for food resources. They live in Clifton. They want to know where is the closest food pantry relative to their location. Using the database search, what is the closest food pantry to them?

3) A senior citizen calls from Orchard Mesa. They’re zip code is 81503. Winter season is coming soon and they notice that air is leaking through the windows and causing the temperature in her home to be uncomfortably cold. Using the database search, what resources are available to them?

As always, if you have any questions while using the database, contact an Information and Referral Specialist by

dialing 2-1-1.

Documents

Collaborative Care Management Training - · PDF file• Motivational Interviewing ... share the screen . Links to Online Training Larry Mauksch, M.Ed University of Washington Department