Introduction to Person-Centered Planning: From Theory to Practice

Person-Centered Planning as a Tool for Systems Transformation

Making Recovery Real:Janis Tondora, Psy.D.New Jersey Psychiatric Rehabilitation Association Annual Conference, November 21, 2013

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2T. Tondora 12-4-09 for MASS PRAVideo clipThe Gestalt Project

Person First Makes a Differencehttp://www.youtube.com/watch?v=QficvVNIxTI&feature=youtu.be

What stood out for you in the clip and why?How did you feel emotionally MID-WAY through the clip? How did you feel at the end? What did you learn? And how might this relate to person-centered recovery planning?What if YOU were defined largely by ONE part of yourself a part you really struggle withmaybe an illness, maybe a difficult experience in your life. What if that was what others focused on most all the time? What would that be like?Are these the types of stories of the whole person that you tend to know about people you serve? If not, how can we use PCP to know people in different kids of ways?

3What stood out for you in the clip and why?How did you feel emotionally MID-WAY through the clip? How did you feel at the end? What did you learn? And how might this relate to person-centered recovery planning?What if YOU were defined largely by ONE part of yourself a part you really struggle withmaybe an illness, maybe a difficult experience in your life. What if that was what others focused on most all the time? What would that be like?Are these the types of stories of the whole person that you tend to know about people you serve? If not, how can we use PCP to know people in different kids of ways?

Questions for Consideration45What we hope for THEMWhat we value for US Compliance with treatmentDecreased symptoms/Clinical stabilityBetter judgmentIncreased InsightAccepts illnessFollows teams recommendationsDecreased hospitalizationAbstinentMotivatedIncreased functioningResidential StabilityHealthy relationships/socializationUse services regularly/engagementCognitive functioningRealistic expectationsAttends the job program/clubhouse, etc.Life worth livingA spiritual connection to God/others/selfA real job, financial independenceBeing a good momdaddaughterFriendsFunNatureMusicPetsA home to call my ownLoveintimacysexHaving hope for the futureJoyGiving backbeing neededLearningPeople with mental health and addictions issues generally want the exact same things in life as ALL people.

People want to thrive, not just survive

Recovery-oriented care challenges us to move past the maintenance of clinical stability to the true pursuit of RECOVERY! 6Beyond US and THEM7You keep talking about getting me in the drivers seat of my treatment and my life when half the time I am not even in the damn car! Person in Recovery as Quoted in CT DMHAS Recovery Practice Guidelines, 2005

In other words

Consumers demand it, public service systems endorse it, medical and professional programs are encouraged to teach it, and researchers investigate it. Yet, people struggle to understand exactly what It is and what It might look in practice.

Tondora et al., 2005, Implementation of Person-Centered Care and Planning: How Philosophy Can Inform Practice

Recovery-Oriented Carea fuzzy concept?

A Consumer and Family Driven System Recommendation 2.1

The plan of care will be at the core of the consumer-centered, recovery oriented systemProviders should develop customized plans in full partnership with consumers

PCRP Moves Recovery from Concept to Practice 99

The PLAN is a window of opportunity to promote CONCRETE recovery-practice change!

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A Passing fadflavor of the month?10The Person-Centered Train:Whos on Board?

IOMAACPJCAHOBazelon12National Perspective

ACACARFIt made such a huge difference to have my pastor there with me at my planning meeting. He knows me better than anyone else in the world and he had some great ideas for me.

I had been working on my recovery for years. Finally, it felt like I was also working on my LIFE!

When I have a voice in my own plan, I feel a responsibility to work it in my recovery.

First-Person Perspective14What exactly is PCRP?Person-centered planningis a collaborative process resulting in a recovery oriented care planis directed by persons in recovery in partnership with care providers and natural supporters

is reflected in the co-created written Recovery Plan which outlines the persons most valued recovery goals and how all will work together to achieve them14YES! In the experience of the persons served when we take stock of current planning practicesand in the written recovery plan itself

Is it REALLY any different?

Person-Centered Care Questionnaire: Tondora & Miller 2009http://www.ct.gov/dmhas/lib/dmhas/publications/PCCQprovider.pdfhttp://www.ct.gov/dmhas/lib/dmhas/publications/PCCQperson.pdfPerson is a partner in all planning activities/meetings; advance noticePerson has reasonable control over logistics (e.g., time, invitees, etc.)Person offered a written copyEducation/preparation regarding the process and what to expectLanguage as a key practiceRecognize the range of contributors to the planning process (e.g., peers, natural supporters).Value community inclusionWhile, not afterTrap of the one-stop shopDemonstrate a commitment to both outcomes and process; high expectations.Understand/support rights such as self-determination (e.g., role of advance directives; WRAP, etc.)

15And how do all the pieces come together in the written recovery plan?

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RegulationsRequired PaperworkMedical NecessityComplianceCollaborativePerson-CenteredStrengths-basedTransparentand in a way that balances the spirit of person-centered care with the rigor required in clinical documentation?

and in a way that doesnt BURY us!!Apparently, Smiths desk just couldnt withstand the weight of the paperwork we piled on his desk.1819Meet Mr. GonzalezMr. Gonzalez, a 31-year-old married Puerto Rican man, is living with bipolar disorder and a co-occurring addiction to alcohol that he often uses to manage distressing symptoms. During a recent period of acute mania, Mr. Gonzalez was having increasingly volatile arguments with his wife in the presence of his two young sons. On one occasion, he pushed his wife across the room that prompted her to call the police. When the police arrived, Mr. Gonzalez was initially uncooperative and upset. After he calmed down, Mrs. Gonzalez agreed not to press charges, but insisted her husband leave the house and meet with his clinician the following morning. 19Mr. Gonzalez, a 31-year-old married Puerto Rican man, is living with bipolar disorder and a co-occurring addiction to alcohol that he often uses to manage distressing symptoms. During a recent period of acute mania, Mr. Gonzalez was having increasingly volatile arguments with his wife in the presence of his two young sons. On one such occasion, he pushed his wife across the room that prompted her to call the police. When the police arrived, Mr. Gonzalez was initially uncooperative and upset. After he calmed down, Mrs. Gonzalez agreed not to press charges, but insisted her husband leave the house and meet with his clinician the following morning.

20Meet Mr. Gonzalez (cont.)Mr. Gonzalezs wife is actively involved in his recovery and treatment, and she is open to reconciliation. However, she made it clear that he would not be allowed to live at home, or visit with his sons, until he gets control of himself. Upon visiting the Community Mental Health Center the following morning, Mr. Gonzalez tells his clinician repeatedly that his love for his family and his faith in God are the only things that keep him going when things are rough and he does not know what he will do without them. More than anything, he wants to be able to reunite with his family and be a good role model for his sons. He feels that the only person who understands this is the Center Peer Specialist with whom he has a close relationship.

20Mr. Gonzalezs wife is actively involved in his recovery and treatment, and she is open to reconciliation. However, she made it clear that he would not be allowed to live at home, or visit with his sons, until he gets control of himself. Upon visiting the Community Mental Health Center the following morning, Mr. Gonzalez tells his clinician repeatedly that his love for his family and his faith in God are the only things that keep him going when things are rough and he does not know what he will do without them. More than anything, he wants to be able to reunite with his family and be a good role model for his sons. He feels that the only person who understands this is the Center Peer Specialist with whom he has a close relationship.

Goal(s):Achieve and maintain clinical stability; reduce assaultive behavior; comply with medications; achieve abstinenceObjective(s):Patient will attend all scheduled groups in program; patient will meet with psychiatrist and take all meds as prescribed; patient will complete anger management program; patient will demonstrate increased insight re: clinical symptoms; patient will recognize role of substances in exacerbating aggressive behaviorServices(s): Psychiatrist will provide medication management; Social Worker will provide anger management groups; Nursing staff will monitor medication compliance; Psychologist will provide individual therapy Snapshot: A Traditional Treatment Plan 21Uh, excuse me 22Im here to return YOUR goals.You left them on MY recovery plan!

Comply with medsStop drinkingReduce aggressive behavior Increase insight22232323Recovery Goal: I want to get my family back. I dont want the kids to ever be afraid of me.

Strengths to Draw Upon: Devoted father; motivated for change; supportive wife; Catholic faith and prayer are source of strength/comfort; positive connection to Center Peer Specialist; intelligent

Barriers Which Interfere: Acute symptoms of mania led to violence in the home; lack of coping strategies to manage distress from symptoms; abuse of alcohol escalates behavioral problems 242424Sample Short-Term Objective(s)

Within 30 days, Mr. Gonzalez will apply learned coping strategies to have a minimum of two successful visits with wife and children as reported by Mrs. Gonzalez in family therapy sessions. Services & Other Action Steps Center doc to provide med management to reduce irritability & acute manic sxPsychologist to provide family therapy sessions to discuss Mrs. Gonzalezs expectations and feelings re: future reunification Rehab Specialist to provide Communication and Coping Skills training to teach/coach skills that will foster successful visits with wife and childrenCenter chaplain to promote use of faith/daily prayer as a positive coping strategy to manage distressWellness Recovery Action Plan with Peer Specialist to promote daily wellness through the use of self-directed strategies A More Hopeful PropositionWe can balance person-centered approaches with medical necessity/regulations in creative ways to move forward in partnership with persons in recovery.We can create a plan that honors the person and satisfies the chart!In other words: PCP is not soft!

25What does all this mean for service users and their loved ones? PCRP is about making sure the services you receive help you achieve goals that are important to YOU!

Change is coming and YOU can be a part of it! Consider today an invitation to get involved26Systems Transformation:Lessons learned from the field

2727T. Tondora 12-4-09 for MASS PRA28LL # 1: Nothing about us, without us (REALLY!) Primacy of meaningful participation in ALL aspects of system from design to delivery to evaluation

Research showing we typically UNDERESTIMATE consumers desire to be involved (Chinman et al, 1999) NH exampleAnd that consumer involvement often has the single-most critical impact on recovery-oriented systems transformation28

http://www.yale.edu/PRCH/documents/toolkit.draft.3.5.11.pdfCT example 2930LL#2:Listen & Respond To Common ConcernsIf given choice, people will make BAD ones Payers wont let us do this; regs prohibit this The forms dont have the right fieldsConsumers arent interested/motivatedIt devalues clinical expertise; violates professional boundariesIts what the clubhouse doesLack of time/caseloads too highMy clients are sickerIt doesnt fit with focus on EBPsDont we already do ROC?

Is this whats on YOUR mind in your way??

A Word of CautionWe want to include you in this decision without letting you affect it.31PCRP is NOT an add-on or special new programAvoid initiative fatigueAvoid compartmentalizing task of transformationRehab and peers are often natural leaders but Change must be embedded across the organization as a whole!LL # 3: Be clear on what PCRP is NOT32Across ALL staff roles to avoid diffusion of responsibilityProgram developmentGovernance and committee structuresQI implicationsDesign of standardized assessments and EHRsHuman resource management even hiring practices!You Can Not Do Person-Centered Planning Without a Person-Centered SYSTEM

33The Person-Centered Plan as an Integrating Framework for Quality in a Changing Healthcare ClimateIncorporates EBPS, including IMR Informed by Stages of Change & MI MethodsEncourages Peer-Based ServicesMaximizes Self-Determination & ChoicePromotes Cultural ResponsivenessFocuses on Natural Supporters/Community Settings Respects Both Professional & Personal Wellness StrategiesConsistent w/ Standards of Fiscal & Regulatory Bodies, e.g., CMS, JCAHO, CARFDerived from a Comprehensive Assessment of Needs & StrengthsEmphasis on the Attainment of Meaningful OUTCOMES 34LL # 3: Be clear on what PCRP is NOTPCRP is NOT anti-clinical/anti-tx PCRP respects the value of clinical expertise but also emphasizes the value of lived experience There is a critical, but changed, role for practitionersproviders of hope assessment / formulationknowledge of the wide range of EBPs and emerging recovery/rehab practicesSkilled in practice of shared decision-making knowledge of the illness and possible solutionsteachers/trainers/coaches

34If the person is in the drivers seat of their care, where does that leave me?

PCRP is based on a model of PARTNERSHIP

Respects the persons right to be in the drivers seat but also recognizes the value of professional co-pilot(s) and natural supporters

LL # 3: Be clear on what PCRP is NOTPCRP is NOT only for people who are high-functioning or well on their way to recovery

Move beyond belief that some are too sick to engage in recoveryCommunicate a message of hope and a belief that life can be differentUnderstand sources of perceived resistance or lack of motivationFlex as needed/ be creative in how we listen to/solicit preferencesWA example or PCP research referralsDavidson, L, Harding, C., & Spaniol, L. (Eds). (2006). Recovery from severe mental illnesses: Research evidence and implications for practice.

37Competencyknowledge, skills and abilitiesProject Managementwork / business flowCulture Managementbehavior and attitudeLL # 4: Training is necessary, but not sufficientTransformation Change Model3838Initial trainingrecovery orientation as foundation followed by hands-on intensive skills-training in PCP Follow-up technical assistanceTo promote transfer to day-to-day work through remote plan consultations, co-facilitation of live tx team meetings, revision of forms/EHRs/planning structures/protocols Clinical Supervision specific to recovery principles and practicesQuality improvement efforts: focus on outcomes through chart reviews (new tools), pilot projects, learning collaborativesExecutive management commitment (and orientation to PCP)

Competencyknowledge, skills and abilitiesProject ManagementWork flow / business practiceCulture Managementbehavior and attitudeTransformation Change ModelLL # 5: Attend to (real) external barriersWhen you pit a bad system against a good performer, the system always wins (Rummler, 2004). 393940Many administrators DO feel stuck between a rock and a hard place as they struggle to reconcile (seemingly) competing tensions

LL # 5: Attend to (real) external barriersClinical gate keeping vs. direct accessEligibility criteria for voc servicesOffering copies of plansCompliance and billing issues

CT example of the RMS medical record and treatment plan Changing eligibility for supported employment Establishing policies around copies of plans

4041LL # 6: But, be prepared for red herrings While attention to organizational factors is important, sometimes this EXTERNAL focus can mask more complex change barriers

41People may resist change in subtle, and not-so-subtle ways!

4242LL # 6: Be prepared for red herrings Based on misunderstanding, or biases/assumptions?

Cant do PCP because we wont get paid for itWe arent allowed to give people a hard copy of their plan because our Medical Records department prohibits itPeer staff cant have access to confidential material

Make it possible, see what happens, then hold people accountable to deliver!4343T. Tondora 12-4-09 for MASS PRAPersonal storiesOutcomes dataValues imperativeFiscal benefits of systems transformationLL # 7: Different arguments appeal to different audiences 44At its core, recovery-oriented systems transformation is a VALUES-BASED imperative but there is a FISCAL case to be made as well!

Emerging research shows PCRP has a significant IMPACT on OUTCOMESgreater engagement in services as evidenced by reduced no-show rates & higher rates of medication adherence (Stanhope et al., 2013) Significant improvements in wide range of recovery outcomes, e.g., Sense of Community, positive coping, therapeutic relationship with primary practitioner; QOL, self-esteem, psychotic symptoms (Tondora et al, in press) What is the evidence behind PCRP?

New York Care Coordination Program*:43% decrease in emergency room visits per enrollee44% reduction in days spent in a hospital56% decrease in self harm among 51% reduction in harm to others*http://www.carecoordination.org/results.aspx45Emerging evaluation data shows PCRP is COST-EFFECTIVEComparison of Medicaid costs for Case Management and ACT populations in WYCCP counties to same populations in 6 comparison counties shows WNYCCP costs significantly LOWER in:inpatient services; outpatient services; and community support programs What is the evidence behind PCRP?

Enhanced employee satisfaction led to significant reductions in STAFF TURNOVER and re-training costs46Promote increasing accountability among providers and system as a whole Provide a road-map for trainees/providers who WANT to make changes, but are unsure which direction to move

Help prioritize state training & consultation objectives Implications for range of HR protocols, e.g., hiring decisions Educate consumers and families re: what they can/should expect from the system

LL # 8: Provide clarity in expectations47

Manuscript available for download at:www.ct.gov/dmhas/lib/dmhas/publications/practiceguidelines.pdf http://www.ct.gov/dmhas/lib/dmhas/publications/practiceguidelines.pdf48T. Tondora 12-4-09 for MASS PRAIs the system organized to perpetuate the status quoHow tolerant of risk/change is the system as a whole?How is the burden of risk shared across all stakeholders including PIR? Who is held accountable when things dont work out as planned?Just as in individual recovery, taking risks opens door to new opportunities! LL # 9: SOME risk IS necessary at individual and systems level

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Weve considered every potential risk except the risks of avoiding all risks.5051LL # 10: Plan thoughtfullydont be paralyzed by the pursuit of perfectionMany MH systems change efforts get derailed by perpetual efforts to help people get itWe dont think ourselves into a new way of acting, we act ourselves into a new way of thinking.*

Miller, K. (2009). Stop Complaining and Do It!: The three phases of any transformation. http://www.governing.com/column/stop-complaining-and-do-it

Sometimes you just have to dive in and do it/live it!!My challenge to you: What is ONE thing you might do different from this moment forward? 51We just need to stop accepting what is and start creating what should be

Dale DiLeoA Take Home Message:

For more information:

Janis Tondora: janis.tondora@yale.edu53