Actualizing Our Vision: An Innovative Approach to Engaging Care Team Members in

PCMH Self-Management Support

Brian E. Sandoval, Psy.D. Juliette Cutts, Psy.D.Yakima Valley Farm Workers Clinic

Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.

Session # C3aOctober 17, 2014

Faculty Disclosure

• Brian Sandoval currently has or has had the following relevant financial relationships during the last 12 months:– Consultant, primarycareshrink.com

• Juliette Cutts has not had any relevant financial relationships during the past 12 months.

Learning Objectives

At the conclusion of this session, the participant will be able to:

• Describe how connecting training with organizational mission can differentiate “checking boxes” and true transformation

• Discuss how a multi-modal approach can empower patients and their providers to participate in patient-centered care.

• Identify strategies for leveraging Behavioral Health Consultants as well as data to drive transformative change

• Describe benefits and challenges of integrating elements of motivational interviewing into chronic disease management

Bibliography / Reference

1. Miller, W.R., Rollnick, S. (2012), Motivational Interviewing: Helping people change. Guilford Press: New York

2. Rosengren, D. B. (2009). Building motivational interviewing skills: A practitioner workbook. Guilford Press: New York.

3. National Standards for Diabetes Self-Management Education, 2011, Retrieved 8/22/14 from http://care.diabetesjournals.org/content/34/Supplement_1/S89.full – Need to incorporate

4. Self-Efficacy, Problem Solving, and Social-Environmental Support Are Associated With Diabetes Self-Management Behaviors, 2010. Retrieved 8/22/14 from http://care.diabetesjournals.org/content/33/4/751.full.pdf+html – Need to Incorporate

5. Stanford Patient Education Research Center, (Unpublished), Diabetes Self-Efficacy Scale. Retrieved 8/25/2014 from http://patienteducation.stanford.edu/research/sediabetes.html

Learning Assessment

• A learning assessment is required for CE credit.

• A question and answer period will be conducted at the end of this presentation.

Establishing a Clear Intention and Plan for Self-Management: From Accreditation to Transformation

• Leadership engagement• Starts with a concept!

• Collaboration with marketing

• Final product: “YVFWC Self-Management” – Operationalized our organization’s mission, vision,

and values into evidence-based communication skills (motivational interviewing or MI)

From Vision to Frontline• Ultimate goal: Culture change at YVFWC

– Create comprehensive, linked training programs for front desk/non-clinical and clinical staff

– Combine core MI content with mission-driven reflection and activities

– Initiate ongoing activities for staff engagement in enhancing self-management support

A Layered Approach: Fighting Scope Creep while Keeping It Integrated

YVFWC Vision, Mission, Values

Person Centered Communication skills

Self-Management skills

Motivational Interviewing skills

Person Centered Communication

• Setting a Solid Foundation for All Staff

• Connect General Communication Skills to our Vision, Mission, and Values

Self-Management Framework

ASK

PROVIDE

ASK

Putting Providers In the Patient’s Seat Made a Difference!

* Based on Miller & Rollnick, 2012,

Putting Training Into Practice: Accepting Reality while Steering to Transformation

• Shadow/observation of providers to understand workflows and demands

• Train relevant, “real life” MI skills amenable for PCP/nursing visits

• Train basic-level skills while recognizing those with more advanced skills

• Shorter, multimodal approach favored over day-long trainings

Putting Training Into Practice: Accepting Reality while Steering to Transformation

• Self Management Trainings to Drive NCQA Factor (2011) Achievement And Operational Design Processes– Documentation templates created to match clinical

training/NCQA factors

• Workflows Were Redesigned To Support Clinical Care Model And Self Management Philosophy– Risk-stratification protocols– Pre-visit prep– Huddles– Group visit model

Putting Training Into Practice: Working Towards Guidelines

• The Diabetes Self-Management Education Task Force Recommends “Creative, patient-centered experience-based delivery methods…for supporting informed decision-making and behavior change…” (p. S91)

• Research by King et al (2010) confirm the need to provide interventions that enhance problem-solving skills, increase self-efficacy, and increase patient engagement with community resources.

Training a Change Weary Team: Getting Real On the Road

• Be Careful What you Ask For– Listening to Feedback

• Creating Tools On The Road…Literally– Picture Based Action Plan

Self-Management Template Flow: The Plan

Major Concerns?

DM Pt’s flagged by MA during Pre-Visit Prep

YesRefer to RDDiet or Activity

Concerns

PCP to refer to BHC/RD as usual

Document SM Plan as part of visit

Yes

SM Plan in the last year?

Yes

No

Refer to RN/RD/BHC if available

Schedule F/U with PCP/RN/ RD/BHC Specifically for SM Plan

Yes Refer to BHCHx of MH issues?

No

Start by picking 1 pt/day to practice

Yes Refer to RNHx of non-

adherence, multi ED visits?

Self-Management Template Flow – Goal

Major Concerns? (BP/A1C)

Target Population Pt’s flagged by MA during Pre-Visit Prep

PCP to refer to BHC/RD as usual

Document SM Plan as part of visit

SM Plan in the last year?

Yes

No

Refer to RN/RD/BHC if available

Schedule F/U with PCP/RN/RD /BHC Specifically for SM Plan

MA gives Self-Efficacy Eval

< 5 on 2, 4, or 8 or MH issues?

Yes

Refer to RD

Refer to BHCYes

No

Return Self-Efficacy Eval to BHC

No

Tracking/Reporting

Current Process

Basic Process

At Risk Process

YesRefer to RN

< 5 on 5, 6, or 7 or hx of non-adherence, multi

ED visits

No

Did it work? Using Data to Measure Engagement

• Training session Feedback

• Huddle tracking for Self-Management

• Reporting structure for NCQA factor achievement

• PCHH workgroup feedback and ongoing PDSA cycles

Bumps in The Road and Other Tales of Implementation

• Successes• Connecting SM to organizational mission inspires

culture change!

• Training feedback overwhelmingly positive

• Lessons Learned• SM care models difficult to roll out when clinics have

drastically differing resources.• Timing, messaging, and constant PDSA important• Live training is impactful but takes considerable time

and consumes significant resources

Self-Management Template Flow:Reality

Target Population Pt’s flagged by MA during Pre-Visit Prep

Refer to RD Refer to BHCRefer to RN

Clinic Visit

What’s Next

• Increasing SM adoption for 3 NCQA conditions

• Enhancing SM to include all chronic conditions

• Development of ongoing training for existing staff / training protocol for new staff

• Performance monitoring - Maintaining and gaining ground

The Road Ahead

Keeping the Message Relevant and Present

Questions?

Session Evaluation

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!