Person-Centered Planning:   From Policy to Practice to Evaluation

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A recovery-oriented system of care identifies and builds upon each person's assets, strengths, and areas of health and competence to support the person's efforts in managing his or her condition while regaining a meaningful, constructive sense of membership in the broader community.. . . . .

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Person-Centered Planning: From Policy to Practice to Evaluation

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1. Person-Centered Planning: From Policy to Practice to Evaluation Janis Tondora, Psy.D., Yale Program for Recovery and Community Health Daniel Wartenberg, Psy.D., M.P.H., Southwest Connecticut Mental Health System Joint National Conference June 2, 2005

2. A recovery-oriented system of care identifies and builds upon each person’s assets, strengths, and areas of health and competence to support the person’s efforts in managing his or her condition while regaining a meaningful, constructive sense of membership in the broader community.

4. Project Objectives: 1. To stimulate a dialogue on recovery between DMHAS leadership, providers, people in recovery, and their significant others 2. To develop a common understanding of the principles and dimensions of recovery and recovery-oriented services To use this understanding to inform statewide service development and strategic planning To promote accountability and the transfer of recovery principles to the daily practices of DMHAS providers Contributing Sources to Model: PIR, Advocacy Organizations, YPRCH, DMHAS staff and provider agencies, 2 RMHB, OOC Leadership, Policy #83, Lit reviews Overall model: Articulates a broad vision of recovery that involves a process of restoring or developing a positive and meaningful sense of identity apart from one’s condition and the limitations that might be imposed by that condition. “Recovery” as recovery is not understood as a static "end product or result”. It is neither “synonymous with cure” nor does it simply involve a return to a premorbid state. Rather, it is a life-long process that involves an indefinite number of incremental steps in various life domains – and people may move fluidly between the various dimensions over time – recovery is NOT assumed to be a linear process. 1. BEING SUPPORTED BY OTHERS - Recovery is not done alone. Becoming interdependent in one's community and having supportive others and role models, whether they be family members or friends, professionals, community members, or peers provides encouragement through the difficult times and to help celebrate the good. 2. RENEWING HOPE & COMMITMENT - Having a sense of hope and believing in the possibility of a renewed sense of self and purpose, accompanied by desire and motivation, is essential in recovery. This sense of hope may be derived spiritually and/or from others who believe in the potential of a person, even when he/she cannot believe in him/herself. 3. MEANINGFUL ACTIVITIES - Expanding and occupying normal, functional social roles (e.g., spouse, worker, student, taxpayer, friend, etc.) and making worthwhile contributions to a community of one’s choice is a cornerstone of recovery. 4. INCORPORATING ILLNESS - Often described as a first step to recovery, acknowledging and accepting the limitations imposed by one's illness helps one discover talents, gifts, and possibilities that allow a person to pursue and achieve life goals despite the presence of disability. 5. REDEFINING SELF - Perhaps the most overarching aspect of recovery, redefining self involves reconceptualizing mental illness as simply one aspect of a multi-dimensional identity rather than assuming a primary social role as "mental patient". 6. OVERCOMING STIGMA - People must recover from the social consequences and societal stigma as well as from the effects of the illness itself. Recovery involves developing resilience to stigma and/or actively fighting against it. 7. MANAGING SYMPTOMS - Although complete symptom remission is not necessary, being able to manage symptoms in some way is essential for recovery. Recovery involves periods of good and difficult times, setbacks and accomplishments, and times when symptoms may be more or less controlled. A shift occurs from simply receiving services to actively participating in and using treatments of one's choice to bring symptoms under some degree of control. 8. ASSUMING CONTROL- People must assume primary responsibility for their transformation from a disabled person to a person in recovery. Assuming control over one's life and treatment contributes to the redefined sense of self as an active, effective agent. Opportunities must be available for people to make choices and people must have options from which to choose. People must also be afforded opportunities to succeed and fail. EMPOWERMENT & CITIZENSHIP - As a sense of empowerment and control over one's life emerges, people in recovery begin to demand the same rights (e.g, the right to decide where to live, whom to love, how to spend one's time) and take on the same responsibilities (e.g., paying taxes, voting, volunteering) as other citizens. NOTE: PCC seen as one necessary vehicle through which to develop a recovery-oriented system in CT – a system that helps people to experience these various recovery dimension, s. As we saw earlier – traditional approaches to clinical treatment planning tend to over-emphasize – or ONLY emphasize – MANAGING SYMPTOMS, MAINTAINING ABSTINENCE, etc. PCC challenges providers to move far beyond these traditionally values goals to recognizes both the totality of the person and the importance of his/her life in the community – placing particular emphasis on empowerment, the role of “citizen”, involvement in meaningful activities, assuming control, etc… Project Objectives: 1. To stimulate a dialogue on recovery between DMHAS leadership, providers, people in recovery, and their significant others 2. To develop a common understanding of the principles and dimensions of recovery and recovery-oriented services To use this understanding to inform statewide service development and strategic planning To promote accountability and the transfer of recovery principles to the daily practices of DMHAS providers Contributing Sources to Model: PIR, Advocacy Organizations, YPRCH, DMHAS staff and provider agencies, 2 RMHB, OOC Leadership, Policy #83, Lit reviews Overall model: Articulates a broad vision of recovery that involves a process of restoring or developing a positive and meaningful sense of identity apart from one’s condition and the limitations that might be imposed by that condition. “Recovery” as recovery is not understood as a static "end product or result”. It is neither “synonymous with cure” nor does it simply involve a return to a premorbid state. Rather, it is a life-long process that involves an indefinite number of incremental steps in various life domains – and people may move fluidly between the various dimensions over time – recovery is NOT assumed to be a linear process. 1. BEING SUPPORTED BY OTHERS - Recovery is not done alone. Becoming interdependent in one's community and having supportive others and role models, whether they be family members or friends, professionals, community members, or peers provides encouragement through the difficult times and to help celebrate the good. 2. RENEWING HOPE & COMMITMENT - Having a sense of hope and believing in the possibility of a renewed sense of self and purpose, accompanied by desire and motivation, is essential in recovery. This sense of hope may be derived spiritually and/or from others who believe in the potential of a person, even when he/she cannot believe in him/herself. 3. MEANINGFUL ACTIVITIES - Expanding and occupying normal, functional social roles (e.g., spouse, worker, student, taxpayer, friend, etc.) and making worthwhile contributions to a community of one’s choice is a cornerstone of recovery. 4. INCORPORATING ILLNESS - Often described as a first step to recovery, acknowledging and accepting the limitations imposed by one's illness helps one discover talents, gifts, and possibilities that allow a person to pursue and achieve life goals despite the presence of disability. 5. REDEFINING SELF - Perhaps the most overarching aspect of recovery, redefining self involves reconceptualizing mental illness as simply one aspect of a multi-dimensional identity rather than assuming a primary social role as "mental patient". 6. OVERCOMING STIGMA - People must recover from the social consequences and societal stigma as well as from the effects of the illness itself. Recovery involves developing resilience to stigma and/or actively fighting against it. 7. MANAGING SYMPTOMS - Although complete symptom remission is not necessary, being able to manage symptoms in some way is essential for recovery. Recovery involves periods of good and difficult times, setbacks and accomplishments, and times when symptoms may be more or less controlled. A shift occurs from simply receiving services to actively participating in and using treatments of one's choice to bring symptoms under some degree of control. 8. ASSUMING CONTROL- People must assume primary responsibility for their transformation from a disabled person to a person in recovery. Assuming control over one's life and treatment contributes to the redefined sense of self as an active, effective agent. Opportunities must be available for people to make choices and people must have options from which to choose. People must also be afforded opportunities to succeed and fail. EMPOWERMENT & CITIZENSHIP - As a sense of empowerment and control over one's life emerges, people in recovery begin to demand the same rights (e.g, the right to decide where to live, whom to love, how to spend one's time) and take on the same responsibilities (e.g., paying taxes, voting, volunteering) as other citizens. NOTE: PCC seen as one necessary vehicle through which to develop a recovery-oriented system in CT – a system that helps people to experience these various recovery dimension, s. As we saw earlier – traditional approaches to clinical treatment planning tend to over-emphasize – or ONLY emphasize – MANAGING SYMPTOMS, MAINTAINING ABSTINENCE, etc. PCC challenges providers to move far beyond these traditionally values goals to recognizes both the totality of the person and the importance of his/her life in the community – placing particular emphasis on empowerment, the role of “citizen”, involvement in meaningful activities, assuming control, etc…

5. Service Implications: Assuming Control

6. Infrastructure for Systems Transformation

7. “Person-Centered” Planning and Its Role in A Recovery-Oriented System Person-centered care and planning involves rethinking the traditional treatment process so that it is more responsive to consumers’ expressed capacities, needs, desires, and rights to self-determination.

8. But don’t we already do this? “If everybody’s doing it, how come nothing is getting done??” Joe Marrone, Institute for Community Inclusion “You keep talking about getting me in the ‘driver’s seat’ of my treatment and my life… when half the time I am not even in the darn car!” Person in Recovery (on her prior experiences of treatment planning)

9. Your current planning? Who is usually involved? How is the meeting organized, i.e., are there steps you take in developing the plan and goals? When does it occur? According to schedule… need? If according to need, what kinds of needs? What does the resulting document look like? What are the most common goals and objectives? Are they short-term/long-term… concrete/more global? How do you monitor that progress is made toward those goals and objectives? Who helps the person get there? Do people receive copies of their plans?

10. Person-centered care involves…

11. Key Principles and Practices

12. Key Principles and Practices

13. Recovery Institute Model CORE TRAINING AREAS: Motivational Interviewing Peer Support Cultural Competence Person-Centered Planning Persons in Recovery Core Clinical Skills

15. SWCMHS COE: Background and Early Steps Center-wide Recovery Steering Committee chaired by CEO Broad representation across diverse stakeholder groups

16. SWCMHS COE: Strategies and Process Conducting focus groups with agency leadership and COE stakeholders 1) to evaluate strengths and weaknesses of existing program 2) to assess capacities and consultation needs. Meeting regularly with agency senior leadership to address program development and systemic/organization issues – Shift from PCP to PCC… Conducting presentations and trainings on the evolving person-centered care program model for various COE stakeholders Participating in the PCC Steering Committee, and offering consultation and technical assistance as necessary to the group Co-facilitating individual planning meetings with providers and consumers Providing on-site consultation and 1:1 feedback sessions to supervisors and staff on COE program model and its implementation in the context of select pilot sites Drafting preliminary report summarizing lessons learned and recommendations

17. SWCMHS COE: Lessons Learned Key questions to consider early on: What is the point of entry in your specific agency? Where are the pockets of resistance? Who can be the champion and help you push the PCP agenda? How do you establish a committee around these current “champions” of the recovery movement? What are the best strategies for building consensus among the agency? What are the existing resources available for educational initiatives? How can persons in recovery be full partners in systems-change? Importance of prioritizing action steps to focus efforts: short-term; intermediate; and long-term objectives.

18. SWCMHS COE: Lessons Learned Importance of taking time to get to know the program prior to intervening or offering feedback. Need for flexibility in implementation (e.g. not trying to create a logistically impossible meeting with all parties at the table) Critical to focus not only on planning, but the broader scope of person-centered care. People are tempted to focus on producing a document, when what we are really advocating is a whole different way of interacting! Given the opportunity with one-on-one guidance from consultant…most clinicians embraced this approach. Keep momentum going, be prepared with follow-up steps, and focus, focus, focus! It is a given that there will be competing agendas and priorities.

19. SWCMHS COE: Lessons Learned Recovery cannot be an “add on” to existing services and supports. Rather, promoting recovery needs to be the overarching aim of all services and supports; otherwise, we need to ask why we are devoting scarce resources to them… Understand (and continuously challenge!) that current political/social pressures may have more to do with safety and containing costs than with promoting recovery – address “risk vs. safety” issue. Do not overlook organizational context and barriers while trying to “fix” individual providers… “When you pit a bad system against a good performer, the system always wins…(Rummler, 2004).

20. SWCMHS COE: Sustaining Momentum Once empowered, persons in recovery will push process forward Pilots Tickle List WRAP Language Take the time to work intensively with “organic groups” ARP – Automated Recovery Planner

21. The ARP: Automated Recovery Plan Incorporates Recovery Principles Encourages planning in multiple domains beyond symptom management Elicits consumer satisfaction which in turn drives formulation of plan Provides opportunity for prioritization Allows consumer to build a “recovery team” Utilizes a strengths-based model Prompts a recovery dialogue between the consumer and the provider Uses consumer-friendly language Specifies clear action steps and encourages all members of the team to contribute to those steps Supports Accreditation and Third-Party Billing Requirements Generates Aggregate Planning and Quality Improvement Data

22. SWCMHS COE: Partnerships as Key to Transformation Involve persons in recovery in all phases of the process; wherever possible, pay them for their time and contributions; create feedback loops to bring lessons/updates back to larger consumer audiences Ensure some degree of buy-in among ALL levels of clinical staff throughout the organization – including the CEO level Address concerns and utilize the talents of other providers in the network, e.g., community rehabilitation professionals Continuously provide feedback to the State Mental Health & Addictions agency re: systemic strengths and needs

23. SWCMHS COE: Partnerships as Key to Transformation Advocate to key funding & oversight bodies re: resource needs, e.g., Community Mental Health Strategy Board financed a “flexible-funding” component of the project Communicate with Advisory Boards; Regional Boards, Family Networks, etc. Continuously forge relationships with natural community stakeholders (e.g., Chambers of Commerce, Faith Communities, Realtor Associations, etc.) Explore opportunities for public/academic partnerships (e.g., DMHAS/Yale) to provide structure and dedicated time/resources for ongoing evaluation

24. Current & Next Steps: Collaborative Research & Evaluation NIH-funded R01, Culturally Responsive Person-Centered Care for Psychosis (PI: Larry Davidson, Ph.D.) Awarded to Connecticut DMHAS; carried out in collaboration with the Yale Program for Recovery and Community Health Overarching aim is to examine a model of person-centered care which incorporates much of what has been learned in recent years regarding the effectiveness of interventions such as self-directed wellness strategies, community integration programs, peer-support services, and collaborative treatment planning. Project targets the needs of people of color who are living with psychosis given that health disparities and clinical research and experience has shown that such individuals comprise one of the most disenfranchised populations in American medicine.

25. Person Centered Care… How do we get there? Clinical Staff

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