MOVING FROM “WHAT’S THE MATTER WITH YOU” MEDICINE TO “WHAT MATTERS TO YOU”:

A PARADIGM SHIFT IN PHILOSOPHY OF CARE.

BEING A GOOD PSYCHIATRIST –What I Was Taught

• As clinicians we are the ones responsible for whether people “get better” or not

• Relieving people of their voices, unusual beliefs, anxiety, and depression is the core of good clinical care

and• Good clinical care is

the core of what it takes to foster recovery from severe mental illness

The Patient

OverOutcome

The “Zone ofDelusion”

FROM DEFINED ROLES FOR DOCTOR AND PATIENT

• Power imbalance

• Clinician responsibility

• “What’s the matter with you”

• Compliance• Constraint

TO A FOCUS ON BUILDING TRUST AND PARTNERSHIP

• Partnership• Shared

responsibility• Health

Behaviour• “What matters

to you”• Liberation

Kia Kaha: Manage

Better Feel Stronger A Mental Well-Being &

Self-Management Support Programme Offered by a Professional/Peer Team

in a Primary Healthcare Locality

ISPS - MSOP Conference Oct 2014

• 12-18% of those with Long-Term Conditions (LTCs) are likely to have severe Mental Health & Addiction (MH&A) conditions which significantly contributes to poor health outcomes and increased service utilisation.

• On the other hand, people with severe MH&A conditions will die on average 15-20 years younger, mostly as a result of poorly managed LTCs – CVD, Diabetes, Cancer etc.

• The presence of a comorbid MH&A condition in people with LTCs increases risk of admission by up to 3x, increases LOS up to 2x, and increases use of Outpatient Services by up to 2x.

• The presence of unmet psychosocial and cultural needs further adds to poor outcomes and increased service utilization.

Background

• Research has clearly demonstrated that identifying and meeting this MH&A need, and any associated psychosocial or cultural need, results in much improved outcomes and significantly reduced health service (secondary/tertiary) utilization.

Background (contd)

Aims• To achieve a 25% reduction in overall hospital and GP

utilisation for 125-150 individuals with LTCs, and co-existing severe MH&A issues engaged by 1 July 2014.

• This will be achieved by identifying and meeting mental health, addiction, and psychosocial needs; and building self-management skills of these individuals and their whanau. 

• We intend to do this by expanding our current Primary Mental Health service and introducing evidence-based interventions in an innovative way

Kia Kaha – Initial Concept

Patients with poorly managed LTCs

Screen for severe MH need

Engage using Flinders Care Planning

StanfordSME

Health Psychology

Not all of the high users seen identified themselves as having a “mental health issue”

What we identifed was high psychological distress and psychosocial complexity

Many were current CMHC pts but not well engaged, no focus on physical healthcare needs

Engagement was the biggest challenge (>50% fail rate)

We trialed the use of peer support workers to engage with the most hard to reach patients

Along the way, we recognised more and more the value of peer support as an “intervention” in itself

Initial Findings

Initial Findings

Some interesting themes emerged in the “stories” that sat behind these patients:

• Patient perspective – “no-one listens… sick of everyone telling me what to do… they don’t understand…”

• Clinic perspective – “no matter what we do they don’t change, they miss appointments – they don’t want to be well…”

Most of these people are disempowered and feeling hopeless BUT want their lives to be better, want to be well, and have been so grateful to be heard, and provided help in a way that works for them.

Dis-Engagement

De-Activation

Dis-Connection

Effect of Peer Outreach on Engagement

Peer specialist pilot starts

% m

akin

g fir

st a

ppoi

ntm

ent

Engagement

Activation

Connection

Kia Kaha – Change Package

2+ LTCs and 2+ EC admit past year

Flexible Peer and Professional Outreach

Patient Choice, Patient Voice

Self-Management

Peer Support

Health Psychology

Case Co-ordination

OUTCOME: Activated patient - Activated Services

Gender

Total cohort to date n=69

46% 54%

Age

Total cohort to date n=69

Number of participants

Ag

e g

rou

pin

g

Ethnicity

Total cohort to date n=69Number of participants

Eth

nic

gro

up

40

90

9

40

94

0

40

96

9

41

00

0

41

03

0

41

06

1

41

09

1

41

12

2

41

15

3

41

18

3

41

21

4

41

24

4

41

27

5

41

30

6

41

33

4

41

36

5

41

39

5

41

42

6

41

45

6

41

48

7

41

51

8

41

54

8

41

57

9

41

60

9

41

64

0

41

67

1

41

69

9

41

73

0

41

76

0

41

79

1

41

82

1

41

85

2

41

88

3

41

91

3

41

94

4

41

97

4

0

5

10

15

20

25

30

35

45% Reduction in Emergency Care Presentations for Participants enrolled

in Kia Kaha in 2013

Project commencesJuly 2013

Jun-

12

Jul-1

2

Aug-1

2

Sep-1

2

Oct-12

Nov-1

2

Dec-1

2

Jan-

13

Feb-

13

Mar

-13

Apr-1

3

May

-13

Jun-

13

Jul-1

3

Aug-1

3

Sep-1

3

Oct-13

Nov-1

3

Dec-1

3

Jan-

14

Feb-

14

Mar

-14

Apr-1

4

May

-14

Jun-

14

Jul-1

4

Aug-1

4

-

10

20

30

40

50

60

70

24% Reduction in GP visits for par-ticipants enrolled in Kia Kaha in

2013

Project commencesJuly 2013

Changes in GAD-7 score between initial assessment & exit from programme

Num

ber

of p

atie

nts

Significant Reduction in Generalised Anxiety Symptoms

Changes in PHQ-9 score between initial assessment & exit from programme

Significant Reduction in Depression Symptoms

Num

ber

of p

atie

nts

Systolic BP Diastolic BP Weight >100 kg Weight <100kg HbA1c0

20

40

60

80

100

120

140

160

Modest Reductions in Measures ofPhysical Health

Series 1 Series 2

Feedback from Patients & Whaanau

95% positive

“The programme is fricken awesome…it feels like I got my life back!”

“I’m much happier, much healthier, and not only that, I’m much freer –

and that’s what Kia Kaha is all about – better yourself, and get stronger!”

AcknowledgementsClinical Lead: Dr David Codyre

Project Manager: Jacqueline Schmidt-Busby

Improvement Advisor: Ian Hutchby

Project Team:

Health Psychologists – Pam Low, Leona Didsbury

Peer Specialists – Merle Samuels, Gary Sutcliffe