Project GREAT: Bringing Consumerism to Mental Health Education and Services Department of Psychiatry and Health Behavior Medical College of Georgia, Augusta, GA

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Project GREAT Bringing Consumerism to Mental
Health Education and ServicesDepartment of
Psychiatry and Health BehaviorMedical College of
Georgia, Augusta, GA

• Gareth Fenley, MSW
• Certified Peer Specialist
• Alex Mabe, PhD
• Professor and Chief of Psychology
• Joseph S. Ricci, PhD Administrative Director

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the mental health delivery system is fragmented
and in disarray.
Source New Freedom Commission on Mental Health
(2003). Achieving the promise Transforming
mental health care in America. Final Report. DHHS
Pub No. SMA-03-3832, Rockville, MD.
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Mental Illness Affects People in the Prime of
Their Lives
Half of the lifetime cases of mental illness
begin by age 15 and three-quarters by age 24
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About half of Americans will meet criteria for a
DSM-IV Disorder in their lifetime.
Kessler, et al., 2005
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Use of Mental Health Services- Adults
Between 2001 and 2003, 60 percent of individuals
with a mental disorder got no treatment
National Comorbidty Survey Replication Study-
Wang et al., 2005
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Use of Mental Health Services- Serious Mental
Illness

• 55 percent stated that they had not received
  services because they did not need it.

National Comorbidty Survey Study- Kessler et
al., 2001
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Use of Mental Health Services

• Delays in making treatment contact range from 6-8
  years for mood disorders and 6-23 years for
  anxiety disorders.
• 10 dropout by the 5th visit, 18 by the 10th
  visit, 20 by the 25th visit.

National Comorbidty Survey Replication Study-
Wang et al., 2005
National Comorbidty Survey Study- Edlund et
al., 2002
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Medication Regimen Adherence

• Noncompliance rates well over 50 for most
  medication treatments of major psychiatric
  disorders often not detected by the provider.

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Access to High Quality Care
In the National Comorbidity Study 78.2 of mood
disorders and 95.9 among nonaffective psychoses
did not receive minimally adequate mental health
treatment

• Wang, Berglund, Kessler, 2000

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Have Psychiatrists Become Medication Managers?

• From 1987 to 1997
• Percent of patients receiving medications
  doubled.
• Average number of visits declined from 12.6 to
  8.7.

• Olfson et al., 2002

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Traditional Psychiatric Care
Case Vignette
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Stigma

• Surgeon Generals Report on Mental Health of
  1999,
• despite unprecedented knowledge gained in just
  the past three decades about brain and human
  behavior, mental health is often an afterthought
  and illnesses of the mind remain shrouded in fear
  and misunderstanding.

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Stigma

• National survey data indicate that 75 percent of
  the public views individuals with mental illness
  as dangerous.
• This negative view has been influenced by
  negative images of psychosis, poor social skills,
  poor personal appearance.
• Stigma is worse for schizophrenia versus
  depression.

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Stigma- Mental Health Care

• People with mental illness often internalize
  negative attitudes toward those with mental
  illness, resulting in reluctance to seek and/or
  maintain adequate mental health care.

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Recovery and Project GREAT
Houses by an unnamed child from Vienna
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Buzz Aldrin - Astronaut
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represents a convergence of data and theory and
a consumer-driven movement that all clearly point
to the enormous benefits of giving individuals a
sense of self-determination in their own health
and well-being.
The Recovery Model of mental health care
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The Recovery Model

• Transcends the exclusive focus on symptom
  reduction that marks the traditional medical
  model.
• Instills hope while emphasizing a non-linear
  process of recovery that includes setback and
  challenges.
• Recognizes that people living with mental illness
  have strengths, goals, and dreams to be honored.
• Emphasizes holistic and individualized care.
• Defines recovery as what the patient does.

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The Recovery Model

• Insists that health care is to be collaborative.
• It is a partnership, more like midwifery than
  surgery, but perhaps characterized best in the
  words of The Home Depot,

You can do it. We can help. Used with
permission of Larry Davidson, Ph.D. Davidson, L.
(2007, January). Recovery and serious mental
illness What it is and how to promote it.
Presentation at the Medical College of Georgia
Psychiatry Grand Rounds (January 11, 2007).
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The Essence of the Recovery Model of Mental
Health Care

• Self-Determination
• Self-Efficacy
• Support

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Diane Arbus - Photographer
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Project G.R.E.A.T.(Georgia Recovery-Based
Educational Approach to Treatment)

• System transformation to a Recovery model of care
  through teaching and dissemination.
• Funded by the Georgia Department of Human
  Resources, Division of Mental Health,
  Developmental Disabilities, and Addictive
  Diseases with special assistance by the Carter
  Center in Atlanta.

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Project G.R.E.A.T.The Team

• Peter F. Buckley, MD
• Gareth Fenley, MSW
• P. Alex Mabe, PhD
• Scott A. Peebles, PhD

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Project G.R.E.A.T.The Goals

• To transform an academic department into a
  Recovery Model program.
• To disseminate the Recovery Model to mental
  health agencies and medical schools throughout
  Georgia and beyond.

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Project G.R.E.A.T.The Challenges

• If it aint broke, dont fix it attitude.
• Fears that the Recovery Model would infringe on
  the best practices in traditional care.
• Time constraints.
• Stigmatizing attitudes.
• No administrative precedent for a Certified Peer
  Specialist.
• No consumer presence on hospital/clinic advisory
  boards.

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Tom Harrell - Jazz Musician
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Project Great Defining and Refining as we go.

• Phase I Bringing on a Certified Peer Specialist.

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A Peer Specialist or Peer Support Specialist

• Manages his or her own life with mental illness
• Provides mental health services to others with
  mental illness (peers)

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Winning against Ongoing Challenges

• The peer specialist
• May have been disabled by the most severe
  diagnoses (schizophrenia, PTSD, etc.)
• May also be in recovery from co-occurring
  substance abuse
• May experience continuing symptoms of mental
  illness

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The Peer Specialists Role

• Part of a multidisciplinary team
• Does not treat symptoms
• Offers role modeling and teaching about Recovery

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The Georgia Certified Peer Specialist (CPS)
Program

• High school diploma or GED required
• Competitive admissions process
• Two-week training
• Certification exam
• Continuing education

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Peer Support in Georgia

• First ever rewarded with Medicaid reimbursement
• Has trained residents of 13 US states and Canada
• 300 Georgians certified
• The leading curriculum for peer specialist
  training internationally

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Project GREAT and the CPS Project

• Intimately linked from the beginning
• Hiring a CPS to join the MCG staff was planned
  from the outset
• Several CPSs collaborated to advise MCG on a
  Steering Committee and in focus groups during the
  creation of the plan

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Institutional Barriers

• Obtaining administrative clearance to hire the
  CPS took a year after grant funding began
• CPS credential is not recognized by MCG hospital
  administration
• CPS is unable to view medical records or access
  scheduling system
• CPS has hospital privileges similar to a
  volunteer but is full-time paid staff expected to
  collaborate with clinical treatment teams

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Opportunities and Challenges

• Faculty, staff, and residents at all levels have
  welcomed the CPS
• Expressed attitudes toward CPS on team have been
  positive
• A handful of MDs have made most of the referrals
  (mostly inpatients who may be difficult to follow
  up with as outpatients)
• Many providers have expressed willingness to
  refer to CPS services, but puzzlement over how
  the process works

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Dr. Kay Redfield Jamison- Psychologist, Scientist
and Author
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Project Great Defining and Refining as we go.

• Phase II Developing a Behavioral Health
  Advisory Council

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Lunatics Running The Asylum? (Is there a place
for PFCC in Mental Health?)

• Psychiatric patients are traditionally seen as
  unable to collaborate in their own care due to
  mental impairment
• Many family members have been encouraged to
  surrender care decisions entirely to
  professionals and even to consider some loved
  ones dead

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Patient and Family Advisors in Mental Health
Unique Challenges

• Physical logistics (locked units, unmarked
  locations)
• Procedural logistics (heightened confidentiality,
  separate and often lesser insurance benefits)
• Funding
• STIGMA
• Affecting patients
• Affecting families
• Affecting care providers

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MCGs Commitment

• Vision To be a national leader in patient and
  family centered teaching, research and care
• PFCC inaugurated in childrens medical center
• MCG featured in PBS series Remaking American
  Medicine
• Under leadership of VP Patricia Sodomka, FACHE,
  expanding PFCC to entire MCG enterprise
• Top Level Departmental Leadership has attended
  meeting and supported the enterprise.

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MCGs Behavioral Health Advisory Council

• Patient and family members referred by clinicians
• Active participation by psychiatry faculty,
  staff, and administrators
• CPS Serves as the Facilitator
• Meets monthly.
• Minutes and policy recommendations distributed to
  all members of the council and targeted faculty,
  staff, and administrators.

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Topics Tackled by the Council

• Billing procedures
• Reminder calls and letters
• Interior decoration/renovation
• Involving kids in policy making
• Transition to tobacco free campus
• Inpatient programming/volunteering
• Patient and family info leaflet
• Feedback on patient and family experiences

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Sigmund Freud Psychiatrist, Scientist
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Project Great Defining and Refining as we go.

• Phase III Developing workshops to immerse
  psychology and psychiatry faculty and students in
  the Recovery Model of Mental Health Care.

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Workshop I Knowledge, Attitudes, and Behavior

• Active learning is more effective.
• Expose the learner to individuals with mental
  illness that promote a more positive sense of
  what patients can do for themselves.
• Build the case from relevant and empirically
  supported data.
• Provide useable tools.
• Teach skills, not just knowledge.

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Natalie Cole - Singer
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Jack Dreyfus Business Leader
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Eleanor Roosevelt Political Leader
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The Primacy of Choice and Personal
ResponsibilityExample of Data Provided

• Langer and Rodin (1976) a field study of
  nursing home residents.
• For one group it is stressed that their care and
  well-being is the responsibility of the staff.
• For the other group it is stressed that they are
  responsible for themselves.

Langer Rodin (1976) The effect of choice and
enhanced personal responsibility for the aged A
field experiment in an institutional setting. J
of Personality and Social Psychology, 34,
191-198.
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The Effects of Choice and Enhanced Responsibility

• Good care by the staff on behalf of the
  residents resulted in 71 becoming more
  debilitated.
• 93 of the residents given choice and
  responsibility increased in their functioning.

Langer Rodin (1976) The effect of choice and
enhanced personal responsibility for the aged A
field experiment in an institutional setting. J
of Personality and Social Psychology, 34,
191-198.
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Follow-Up Rodin and Langer - 1977

• 18 months later
• Those given choice and responsibility had a 15
  mortality rate.
• Those given care had a 30 mortality rate.

Rodin Langer (1977) Long-term effects of a
control-relevant intervention with the
institutionalized aged. J of Personality and
Social Psychology, 35, 897-902.
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Georgia Recovery Assessment Form
I. Individualized and Person-Centered Treatment
Plan (Goals and Objectives) Goal 1
__________________________________________________
__________________________________________________
__________________________________________________
________________________ New Patient/Family
Tasks ____________________________________________
________ ___________________________________
________________________________________
New Provider Tasks/Responsibility_________________
___________________________
__________________________________________________
_________________________ Goal 2
__________________________________________________
__________________________________________________
__________________________________________________
________________________ New Patient/Family
Tasks ____________________________________________
________ ___________________________________
________________________________________
New Provider Tasks/Responsibility_________________
___________________________
__________________________________________________
_________________________ Goal 3
__________________________________________________
__________________________________________________
__________________________________________________
________________________ New Patient/Family
Tasks ____________________________________________
________ ___________________________________
________________________________________
New Provider Tasks/Responsibility_________________
___________________________
__________________________________________________
_________________________
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Georgia Recovery Assessment Form - continued
II. List Personal Strengths for Patient related
to personal goals 1. 2. 3. III. Systems-based
Treatment Plan Is this individual/family
appropriate for referral for Peer Support
Services? (e.g., Peer Support Specialist,
Friendship Community Center, AA, NA, NAMI,
Parent-to-Parent, Bereaved Parents of America,
Health Grandparents Project of Augusta)
YES NO Would the patient like to participate
in Peer Support Services here at
MCG? YES NO Would any of the following
community support areas be appropriate for
consideration in your treatment planning (Please
circle appropriate services) Activities/Hobbies
Child Care Financial support Health
Care Housing Physical fitness Occupational/job
support School/Educational Support Spiritual/reli
gious support Substance Abuse Program
Transportation
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Monica Seles Tennis Champion
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Workshop II All about Attitudes

• Focused on reversing negative stereotypes
  regarding those individual living with mental
  illness.
• Provided real examples of individuals in
  recovery.
• Emphasized the stories and less so the
  principles.
• Hearing first hand from providers who have
  transformed their practice to the Recovery Model.

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Workshop II clips
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Ray Charles - Musician
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Project Great Defining and Refining as we go.

• Phase IV Putting the Recovery Model into
  Practice.

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Follow-Up Implementation of the Georgia Recovery
Assessment Form

• Working with PowerNote technical support to make
  sure that all psychiatry clinical notes have
  prompts to complete the three key Recovery-Based
  questions.

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Putting into Practice - More

• Putting the Certified Peer Specialist into the
  game.
• Keeping the fire under the Behavioral Health
  Advisory Council.
• Data Collection.
• Relaunching the GREAT Steering Committee.

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Preliminary Findings

• Workshop I Knowledge of Recovery significantly
  improved.
• Workshop II Attitudes regarding the
  capabilities of those with mental illness to
  actively participate in their care significantly
  improved.

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Lot Easier Said than Done

• Where are the referrals for the Certified Peer
  Specialist?
• Logistics of incorporating a Certified Peer
  Specialist into a traditional academic
  department.
• Getting administration to listen to the
  Behavioral Health Advisory Council
  recommendations.
• Changing practice habits is hard!

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Next Steps

• More data collection, including comparison
  academic site.
• Do a consumer needs assessment. Specific data
  need to move beyond contemplation of change.
• Identify Recovery Champions among our faculty and
  residents.
• Establish participative decision-making
  Establish faculty and resident focus groups.

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Dr. Patricia Deegan and Associates- Clinical
Psychologist, Author, and Co-Founder of the
National Empowerment Center Inc.