FAMILYORIENTED SERVICES Creating Systems Support for Change

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FAMILY-ORIENTED SERVICESCreating Systems
Support for Change
FAMILY INSTITUTE FOR EDUCATION, PRACTICE,
RESEARCH Thomas Jewell, Ph.D. University of
Rochester Medical Center Department of Psychiatry
(Psychology)
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GOOD NEWS FAMILY INTERVENTIONS WORK
BAD NEWS HAVING A GOOD INTERVENTION AVAILABLE
DOES NOT MEAN EVERYONE WILL USE IT
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WHY DONT STAFF USE THESE SKILLS OR
INTERVENTIONS?
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• Difficulty modifying professional duties
• Not included in performance evaluation systems or
  quality assurance measures
• Organizational Factors (Managed care)
• Time constraints due to increased workload
• Caseload Severity (SMI population)
• Low self-efficacy uncertainty
• Attitudes and beliefs of clinicians
• Attitudes and beliefs of families
• Attitudes and beliefs of clients/consumers
• Billing Issues
• Confidentiality Issues

Bernheim, 1989 Marsh, 1998 Thomas et al., 1999
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TRAINING ISSUES

• Family interventions can improve the lives of
  adults with psychiatric illnesses.
• Unfortunately, clinical teams in many real
  world settings do not regularly use
  research-based family intervention strategies
  with consumers.
• Why not?
• Didactic teaching alone (even by experts) is
  not enough.
• Insufficient attention is given to leadership,
  organizational, and team building issues when
  developing new programs.

Lehman et al., 1998 Corrigan McCracken, 1997
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Limitations of traditional staff training methods
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QUESTIONWhat do we need?

• ONE ANSWER A long-term training/supervision
  method that attends to administrative, staff,
  family and consumer needs while helping to
  enhance services and maintain improvements.

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FAMILY INSTITUTE FOR EDUCATION, RESEARCH,
PRACTICE
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Merge Dissemination-Training Models
McFarlane Toolkits
FAMILY INSTITUTE
Interactive Staff Training
Technical Assistance
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Interactive Staff Training Principles
University of Chicago - Center for Psychiatric
Rehabilitation
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Enhancing Family Services

• Teaching staff evidence-based family
  interventions for severe mental illness
• Teaching staff using an empirically-based
  training process (IST)

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Interactive Model of IST
PROCESS Organizational Component
CONTENT Family Interventions
Structure Program Committees Champions Team
Building Facilitating Team Problem
Solving Administrative Systems Quality
Assurance Depts.
Family Needs Assessments Joining Educational
Workshops Multiple Family Groups
I S T
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Working with Programs

• NOT here solely for didactic training.
• We assist staff with organizational issues
  involved in setting up, implementing, and
  maintaining a family services program.
• We assist administrators with supporting
  maintaining program improvements making them
  part of their system.

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Champions Own Words
Q Did you feel that your program staff had
control over the decisions being made in the
process?
A I think the team was quite enthusiastic about
the whole project feeling like this was unlike
going to a workshop or whatever, where you get a
lot of talk, but then you dont get a lot of help
actually implementing. I think that the staff
felt very positive that they were actually going
to be learning how to implement some of these
techniques in a way that we could really use in
the program with some of the really difficult
clients.
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Champions Own Words
Q Have the attitudes of other staff members
here changed at all, toward this project, over
time? A Yes, initially we were all, Another
meeting we didnt want to go to laughter and
rolling eyes. But as a result of learning about
the different modules and as a result of
implementing them, we look forward to seeing them
Consulting Team every month. We look forward
to the information theyre going to give us, and
to get some feedback on some questions we may
have. So yes, our attitude has definitely
changed.
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PHASE 1 Introduction to the System
1. Administrative support 2. Staff Needs/Barriers
Assessment 3. Identify program committee and
family services coordinator
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PHASE 2 Program Development
1. Participative decision making 2. Augment
knowledge of family programs 3. Socratic
questions about drafts
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PHASE 3 Program Implementation
1. Pilot the family program 2. Problem solve
program pitfalls
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PHASE 4 Program Maintenance
TONY SALERNO SLIDE

• User-friendly and controlled continuous
  performance improvement (PI)
• Revising paperwork, performance evaluations, peer
  coaching fidelity procedures, etc.
• 3. Administrative champion/liaison and family
  coordinator in place exit the system

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Program Maintenance Implementing User Friendly
Quality Improvement Programs
University of Rochester Medical Center Strong
Ties Community Support program
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Given the precious staff time and resources that
you have put into this training, what can your
agency do to maintain these programs innovations?
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Program Maintenance Strategies1. Program
Committees2. Competency Reviews3. Collegial
Coaching4. Performance appraisals 5. Employee
Recognition and Incentives
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Evidence Supporting IST Model

• Program changes are made during Implementation
  Phase
• Improved attitudes about specific treatment
• Increased perceptions of collegial support
• Decreased reports of emotional exhaustion

Corrigan et al., 1995 1996 1997
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SATISFACTION with IST
Staff Participants (N 41) Site N5
1 Strongly Disagree 2 Disagree 3
Somewhat Disagree 4 Somewhat Agree
5 Agree 6 Strongly Agree
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Nuts Bolts of Initiative

• Assemble Teams Prepare
• Technical Assistance Evaluation Teams
• Informational Forums/Sessions
• 8 during October November, 2002
• Assess Felt Need across NYS
• Statewide Selection of Counties/Sites
• Planning selection criteria
• Process issues being discussed
• County OMH NAMI-Affiliate endorsement
• Select Sites
• Provide Consultation Technical Assistance

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Build Collaborations

• Provider Organizations
• County Departments of Mental Health
• NYS Office of Mental Health
• University of Rochester Medical Center
• Conference of Local Mental Hygiene Directors
• NAMI - National, State, Local Affiliates
• State Psychiatric Facilities
• Mental Health Associations
• NYS Academic Institutions
• NYS Family Research Policy Workgroup
• International Leaders
• Individual staff members, families, clients

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PROGRESS?PROGRAM EVALUATION
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Many Levels for Evaluating Staff Training Programs

• Reaction (satisfying interesting?)
• Learning (learn new material?)
• Behavior (clinical programmatic changes?)
• Results (product target pop. benefits?)

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REIMBURSEMENTISSUES
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Family PsychoeducationNine Reimbursement
Reminders

• The reminders are based on general parameters for
  Medicaid-reimbursable services
• They cover many key areas that providers need to
  consider when providing and seeking reimbursement
  for Family Psychoeducation
• They are neither all-inclusive nor a substitute
  for careful review of Parts 587 and 588 of the
  outpatient regulations

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1 The Service Must Appear on the Programs
Operating Certificate

• Services other than required program services
  must be listed on the operating certificate
• Clinical support services are additional
  services for Adult Clinics and CDTs and must be
  listed on the operating certificate if utilized
  to provide Family Psychoeducation
• Listing additional services involves requesting
  an amended operating certificate from OMH

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2 The Service Must be Addressed in the
Recipients Treatment Plan

• Family Psychoeducation must be addressed in the
  recipients treatment or service plan
• Family Psychoeducation must relate to the
  recipients diagnosis, goals, objectives, and
  treatment

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3 The Service Provided Must be Consistent with
the Regulatory Definition

• In regulations, the two services that describe
  family education and support activities typical
  of Family Psychoeducation are clinical support
  services and psychiatric rehabilitation support
  services
• Whatever service is provided, it must meet the
  terms of its service definition

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Clinical Support Services Definition

• Services provided to collaterals, by at least one
  therapist, with or without recipients, for the
  purpose of providing resources and consultation
  for goal-oriented problem solving, assessment of
  treatment strategies, and provision of skill
  development to assist the recipient in the
  management of his or her illness

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Psychiatric Rehabilitation Support Services
Definition

• Consultation and technical assistance services
  provided to collaterals, by at least one
  therapist, with or without recipients. The
  purpose of this service is to enhance the
  capacity of the collateral to serve as a resource
  in assisting the recipient achieve or maintain
  his or her psychiatric rehabilitation goal

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4 Those Receiving Collateral Services Must Meet
the Definition of Collateral

• Clinical support services and psychiatric
  rehabilitation support services are services
  provided to collaterals
• Individuals receiving these services must meet
  the regulatory definition of collateral persons

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Collateral Persons Definition

• Members of the recipients family or household,
  or significant others who regularly interact with
  the recipient and are directly affected by or
  have the capability of affecting his or her
  condition and are identified in the treatment or
  psychiatric rehabilitation service plan as having
  a role in treatment and/or identified in the
  pre-admission notes as being necessary for
  participation in the evaluation and assessment of
  the recipient prior to admission

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5 The Service Must be Provided by a Member of
the Programs Staff

• Whatever service is provided, it must be provided
  by program staff
• Program staff could include a professional or
  non-professional member of the clinical staff, or
  an identified volunteer who is a member of the
  clinical staff.

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6 The Service Must be Provided inFace-to-Face
Interaction with Clinical Staff

• A reimbursable visit requires a face-to-face
  interaction between a recipient or collateral and
  clinical staff for the provision of service
• One outpatient visit, one collateral or group
  collateral visit, and one or more crisis visits
  per recipient may be reimbursed on any given day

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7 Regulatory Duration Requirements for Visits
Must be Met

• Collateral visits entail the provision of
  clinical support services of at least 30 minutes
• Group collateral visits entail the provision of
  clinical support services of a least 60 minutes
  but not more than two hours
• Psychiatric rehabilitation support services are
  required services for IPRTs, where visits of at
  least one hour and not more than five hours per
  recipient per day may be reimbursed

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More About Collateral Visits

• More than one of a recipients collaterals may be
  present, but no more than one collateral bill may
  be generated in a single session
• The recipient may or may not be present
• Concurrent recipient and collateral visits with
  the same therapist are not Medicaid-reimbursable
• Such visits may be held consecutively on the same
  day

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More About Group Collateral Visits

• Services involve more than one recipient and/or
  his or her collaterals in a group setting
• More than one of a recipients collaterals may be
  present, but no more than one collateral bill per
  recipient may be generated in a single session
• Recipients may or may not be present
• If recipients are also group participants, a
  group visit may be billed for each recipient
• Maximum number of individuals in a group is 12

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8 The Service Provided Must be Documented in
Progress Notes

• Documentation must include appropriate and timely
  progress notes

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9 The Case Record Must Include Required
Documentation

• The case record must include dates of all
  face-to-face contacts, types of services
  provided, and duration of contact
• Documentation must clearly substantiate services
  provided to the recipient and to the collateral
• Documentation must indicate that services are
  provided in accordance with the recipients
  treatment or service plan

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Research Program EvaluationUniversity of
Chicago, Center for Psychiatric Rehabilitation

• Context for Intervention
• Short-Term
• Intermediate
• Long-Term

OUTCOMES
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NYSOMHViews from the Field Office
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PANELDISCUSSIONQ A
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The End
PLEASE COMPLETE EVALUATIONS