The Maintaining Adherence Programme Practical use of psycho-education for schizophrenia and bipolar disorder

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The Maintaining Adherence ProgrammePractical use
of psycho-education for schizophrenia and bipolar
disorder

• Dr Llew Lewis
• Consultant Psychiatrist
• Medical Lead Maintaining Adherence Programme
  (MAP) UK
• Deputy Medical Director
• South Essex Partnership Foundation University
  Trust
• (SEPT)
• June 2013

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Overview

1. Our organisations-partnership between SEPT and
   Janssen
2. The Munich Compliance Programme
3. Developing our model The Maintaining Adherence
   Programme (MAP)
4. Practical tips for psycho-education based on our
   experience in the MAP
5. Interim results

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South Essex Partnership University Foundation
Trust

• Integrated care including mental health, learning
  disability, social care, forensic and community
  health services
• 200 locations across Bedfordshire, Essex, Luton
  and Suffolk
• Employ approximately 7,000 people
• Serve a population of 2.5 million
• Annual turnover of approximately 350m

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The Munich Compliance Program

• Dr Werner Kissling and colleagues, Munich
• Recognised significant relapse rates in the year
  post discharge from hospital
• Non-adherence to treatment a factor
• Developed a model to address non-adherence

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Munich Compliance Program developed to address
low adherence and high readmission rates

• The impact of schizophrenia on healthcare budgets
  is substantial, typically between 1.5 and 3 of
  total national healthcare expenditures.

The Solution
The Problems
Clinical studies have demonstrated that
psycho-education and wellness programmes
significantly increase patient compliance and
outcomes
One year readmission rates 45
gt50 of patients are non-compliant
Benefits of Psycho-education
Compliance programmes are lacking
Therapeutic alliance
Self-managementof symptoms
Symptom severity
Annual costs of 5 billion Euros in Germany
Patient knowledgeof disease
Adherence to medication
Risk of relapse/hospitalization
Frustrated patients, payers, carers and
healthcare providers
Functional outcomes

• Rummel-Kluge Kissling. Curr Opin Psychiatry
  2008 21 168172
• Mueser et al. Psychiatr Serv 20025312721284
  Mueser McGurk. Lancet 2004 363 20632072

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Munich Compliance Program

• Differential diagnosis of non-adherence- a
  standardised approach to assessment of risk
  factors (at baseline and 3 monthly)
• Insight
• Drugs/alcohol
• Side effects
• Beliefs and attitudes to treatment
• Cognitive factors, carer support

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Cont.

• Psycho-education for all patients and relatives
• group setting, two facilitators
• 11-12 modules, manualised approach
• 1-2 hours per week
• Topics symptoms, diagnosis, treatments, early
  warning signs of relapse, crisis planning,
  drugs/alcohol, relationships, recovery

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Cont..

• Peer-to-peer psycho-education
• Family-to-family psycho-education
• Shared Decision Making
• High quality information
• Collaborative partnership approach

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Cont..

• Incentives for patients
• Financial
• Pleasant lounge atmosphere for groups
• Good coffee
• Reminder systems
• Home treatment

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• Wellness Elements
• Nordic Walking, Coffee and Culture
• Depot clinic
• Evaluation
• Publication

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The Joint Working Agreement funding arrangements
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The Maintaining Adherence ProgrammeObjectives
of the Project

• To partner with Janssen under a Joint Working
  agreement
• To translate and modify an Adherence model
  originally developed in Munich to a UK
  context-working with Dr. Werner Kissling
• To test the model within SEPT, an innovative
  mental health Trust in the south east of England.
• To produce an evaluation of the clinical and
  economic benefits and outcomes
• Department of Health Joint working guidelines 
  http//www.dh.gov.uk/en/Publicationsandstatistics/
  Publications/PublicationsPolicyAndGuidance/DH_0823
  70

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Why is this approach being considered?

• Despite advances in psychopharmacology and
  service innovations(UK National Service Framework
  1999), patients still relapse,
• Therefore, the aim is to
• Improve the quality of care and outcomes for
  people with diagnoses of schizophrenia,
  schizoaffective and bi-polar disorders through a
  focus on relapse prevention
• Improve productivity reduce overall resource
  usage in a climate of radical financial pressures

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Who is the MAP team?

• Consultant Psychiatrist (0,4 WTE)
• 3 WTE nursing staff (inc. 1 WTE team leader)
• 2 0,5 WTE occupational therapists
• Supported by
• Project management SEPT/Janssen)
• IT support (ipad data collection/synching with
  Trust data systems)

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What interventions does the UK model provide?

• Differential Diagnosis of non-adherence
• initial and 3 monthly formal review of risks
  associated with poor adherence
• Psycho-education for service users
• Schizophrenia Schizoaffective Disorder Bi
  Polar Disorder
• Psycho-education for families care givers
• Peer to peer Psycho-education
• Reminder Service (telephone/text)
• Shared Decision making approach
• Wellness Activities

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A.Establishing the team

• Identify the team
• Experience in working with schizophrenia and
  bipolar disorder
• Not necessarily group facilitation nor education
  skills
• Familiarise with content of modules
• Challenge clinician beliefs and assumptions
• Patients wont understand the content
• I dont understand the scientific/psychological
  models
• I have never facilitated a group

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cont

• 4. Role play
• Being the facilitator
• Learning how to facilitate in pairs
• Being a member of a group
• Enacting different scenarios or answering
  questions
• Getting used to using flip chart, writing on
  white board, operating the iPad
• Operational structure
• Guidelines, paperwork, ipad data syching

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B. Identifying the patients

• Raising awareness
• Designing flyers
• Road-shows on wards, at CMHTs
• Developing referral criteria an admission to a
  ward, episode under CRHTT in the past 3 years
• Recruiting and consenting patients
• Designing and equipping a Recovery Lounge

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C. Creating a process

• Creating a process
• Streaming
• Setting up
• Settling in
• Structuring
• Summation
• Skills

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a) Streaming

• Be aware of differing chronicity of illness and
  functional/ cognitive abilities
• The presence of positive or negative symptoms
• Whether symptoms are controlled or not
• Differing social skills
• Use wellbeing activities or baseline assessments
  to form an opinion (MOCA)

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Negative symptoms/ lower Global Assessment
Functioning (GAF)

• Smaller groups (up to 5)
• Slower pace, more didactic, more repetition
• Adapt video clips..often shorter
• More active facilitation,
• Encouragement and positive feedback
• Take time to tease out symptoms and help
  participant relate content to experience

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Cont...

• May need to revisit content in one to ones
• E.g. Early warning signs identification and
  crisis planning...
• Be sensitive to educational attainment
• Participants may lack basic reading and writing
  skills
• May be ashamed, may not admit to deficits in a
  group...check this out beforehand

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Higher functioning/social skills

• Up to 8 manageable
• Often more engaged
• Ask challenging questions
• More likely to read materials and do inter-group
  tasks
• As group matures, the group facilitation becomes
  delegated empathic, supportive and encouraging
  of one another

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b) Setting up

• Soft incentives add value
• The "Recovery Lounge"
• Comfortable chairs, couches, temperature
• Refreshments, coffee, tea, water
• Toilet access
• iPad and TV connected
• Name labels

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Cont..

• Participant and facilitator manuals
• Pens and paper
• Group "rules" and "expectations" displayed
• Other resources leaflets for support groups,
  patient medication info leaflets,

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Flip charts and whiteboards

• Agenda and group structure
• Open questions referencing manual content
• Prompts for video and activities
• Whiteboard for recording group answers and using
  "own words"
• Ordering spontaneous responses into clear
  domains e.g. side effect types or classes of
  antipsychotics

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Prepare for surprises

• Ideally two facilitators
• If required one may have to leave the group with
  a participant if distressed to handover to
  another team member to contain
• Aim not to stop the group
• Managing distress well sends message facilitators
  can contain difficult scenarios- the group is safe

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c) Settling in

• Report to reception
• Customer care approach our values
• Positive hellos/goodbyes, common courtesies,
  keeping promises, active listening
• Offer refreshments
• Make introductions
• Remind each other of names
• Facilitators support informal social interactions

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d) Structuring/timing

• "Welcome..how are you?"
• Needs to be time limited( especially in Bipolar
  groups)
• Recap"what did we learn last week?"
• "Any questions"
• Make time to review any homework
• Introduce new topic aim to use open questions to
  gauge knowledge of the group

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For example

• What medications do you know?
• Use whiteboard to capture responses
• Facilitate as much from the group as possible.
• Arrange information into understandable groups
  like
• Antipsychotics, antidepressants, side effect
  medication
• Group quite possibly has experience of many
  different types

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Continued...

• Get the group to do the work
• Fill in the gaps at the end
• Encourage participation
• Acknowledge the lived experience and knowledge of
  the group
• Move away from didactic stance to collaborative
  participation

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Continued ...

• 6. Review, recap and summarize
• Consolidate using participant language if
  possible
• 7. Questions and answers
• Hand out materialshomework
• Feedback
• "How do you think the group went?"
• "Did we pitch it at the right level?"
• "What could we do better?"

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e)Summation

• Process notes
• Signposting as required
• To consultant clinic
• To review or booster sessions
• Shared decision making session
• One to one work on relapse signatures/ crisis
  planning
• "Choice and medication website
• www.choiceandmedication.org

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f) Skills

• Communication
• Verbal and non verbal
• Group facilitation techniques
• Educative techniques
• Clinical skills listening, empathising, limited
  disclosing
• Customer service values into action

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Beyond the group..

• Operational staff
• Wellbeing activities
• Three monthly adherence review
• Medical
• Shared decision making
• Urgent assessments and reviews

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principles

• Reminding linking back to group content to
  answer questions about
• The need for medication
• How medication works
• Dopamine and psychosis
• Types of medications/comparisons
• Identifying early warning signs
• Crisis plans

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How will we evaluate the MAP program?
Prospective evaluation to include Resource use
Clinical measures Patient satisfaction Staff
satisfaction
Retrospective evaluation to include Resource
use
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Recruitment summary
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Demographics
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Total number of MAP attendances (clients at 12
months post MAP entry)
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Nature of MAP contacts (clients at 12 months
post MAP entry)
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MARS score (medication adherence rating scale) -
baseline Vs most recent
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Risk score (baseline Vs most recent)
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Resource use in 12 months pre and 12 months post
MAP entry
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Client and carer MAP experience questionnaires
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Which parts of the program did you find most
helpful?
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How well has the psychoeducation programme
helped your understanding of the following......?

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Psychoeducation evaluation forms
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Staff feedback

• Staff interview participants were overwhelmingly
  positive about the MAP Program, describing many
  benefits from it for both patients and staff.
  Where potential improvements were identified,
  these related mainly to support for the service
  for administrative tasks and for appropriate
  referral of patients into and onward from the
  Program, and not to changes needed in the Program
  itself. However there was great willingness to
  learn from continuing feedback from patients and
  carers, to improve the Program if necessary.

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Summary

• MAP interventions in addition to usual care plan
• Psycho-education, reminder service, wellbeing
  components, SDM, rapid access to consultant if
  required
• 12 month Qualitative and economic evaluation
  promising
• Awaiting final evaluation

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Thank you