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

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The Maintaining Adherence Programme Practical use of psycho-education for schizophrenia and bipolar disorder Dr Llew Lewis Consultant Psychiatrist – PowerPoint PPT presentation

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


1
The Maintaining Adherence Programme Practical 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

2
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

3
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

4
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

5
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-management of symptoms
Symptom severity
Annual costs of 5 billion Euros in Germany
Patient knowledge of 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

6
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

7
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

8
Cont..
  • Peer-to-peer psycho-education
  • Family-to-family psycho-education
  • Shared Decision Making
  • High quality information
  • Collaborative partnership approach

9
Cont..
  • Incentives for patients
  • Financial
  • Pleasant lounge atmosphere for groups
  • Good coffee
  • Reminder systems
  • Home treatment

10
  • Wellness Elements
  • Nordic Walking, Coffee and Culture
  • Depot clinic
  • Evaluation
  • Publication

11
(No Transcript)
12
The Joint Working Agreement funding arrangements
13
The Maintaining Adherence Programme Objectives
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

14
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

15
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)

16
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

17
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

18
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

19
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

20
C. Creating a process
  • Creating a process
  • Streaming
  • Setting up
  • Settling in
  • Structuring
  • Summation
  • Skills

21
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)

22
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

23
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

24
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

25
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

26
Cont..
  • Participant and facilitator manuals
  • Pens and paper
  • Group "rules" and "expectations" displayed
  • Other resources leaflets for support groups,
    patient medication info leaflets,

27
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

28
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

29
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

30
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

31
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

32
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

33
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?"

34
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

35
f) Skills
  • Communication
  • Verbal and non verbal
  • Group facilitation techniques
  • Educative techniques
  • Clinical skills listening, empathising, limited
    disclosing
  • Customer service values into action

36
Beyond the group..
  • Operational staff
  • Wellbeing activities
  • Three monthly adherence review
  • Medical
  • Shared decision making
  • Urgent assessments and reviews

37
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

38
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
39
Recruitment summary
40
Demographics
41
Total number of MAP attendances (clients at 12
months post MAP entry)
42
Nature of MAP contacts (clients at 12 months
post MAP entry)
43
MARS score (medication adherence rating scale) -
baseline Vs most recent
44
Risk score (baseline Vs most recent)
45
Resource use in 12 months pre and 12 months post
MAP entry
46
Client and carer MAP experience questionnaires
47
Which parts of the program did you find most
helpful?
48
How well has the psychoeducation programme
helped your understanding of the following......?

49
Psychoeducation evaluation forms
50
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.

51
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

52
Thank you
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