Dr Llew Lewis Consultant Psychiatrist Medical Lead Maintaining Adherence Programme (MAP) UK
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The Maintaining Adherence Programme
Practical use of psycho-education for schizophrenia and bipolar disorder
Dr Llew LewisConsultant Psychiatrist
Medical Lead Maintaining Adherence Programme (MAP) UKDeputy 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.
*Rummel-Kluge & Kissling. Curr Opin Psychiatry 2008; 21: 168–172*Mueser et al. Psychiatr Serv 2002;53:1272–1284; Mueser & McGurk. Lancet 2004; 363: 2063–2072
THE SOLUTIONTHE PROBLEMS
One year readmission rates = 45%
>50% of patients are non-compliant
Compliance programmes are lacking
Annual costs of 5 billion Euros in Germany
Frustrated patients, payers, carers and
healthcare providers
Clinical studies have demonstrated that psycho-education and wellness programmes significantly increase patient compliance and outcomes*
Benefits of Psycho-education
Patient knowledgeof disease
Therapeutic alliance
Self-managementof symptoms
Adherence to medication
Functional outcomes
Risk of relapse/hospitalization
Symptom severity
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Munich Compliance Program
1. “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.
2. 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..
3.Peer-to-peer psycho-education
4.Family-to-family psycho-education
5.Shared Decision Making:
•High quality information
•Collaborative partnership approach
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Cont..
7. Incentives for patients:
• Financial
• Pleasant lounge atmosphere for groups
• Good coffee
8. Reminder systems
9. Home treatment
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10.Wellness Elements:
• “Nordic Walking”, ”Coffee and Culture”
11.Depot clinic
12.Evaluation
13.Publication
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The Joint Working Agreement & funding arrangements
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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_082370
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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”o initial and 3 monthly formal review of risks associated
with poor adherence• Psycho-education for service users:
o Schizophrenia & Schizoaffective Disorder + Bi Polar Disorder
• Psycho-education for families & care giverso Peer to peer Psycho-education
• Reminder Service (telephone/text)• Shared Decision making approach• Wellness Activities
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A.Establishing the team
1. Identify the team• Experience in working with schizophrenia and bipolar
disorder • Not necessarily group facilitation nor education skills
2. Familiarise with content of modules
3. Challenge clinician beliefs and assumptions• “Patients wont understand the content”• “I don’t 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
5.Operational structure• Guidelines, paperwork, ipad data syching
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B. Identifying the patients
5. 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
6. Recruiting and consenting patients
7. Designing and equipping a “Recovery Lounge”
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C. Creating a process
8. Creating a process:a) Streamingb) Setting upc) Settling ind) Structuringe) Summationf) 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
1. "Welcome..how are you?"a. Needs to be time limited( especially in Bipolar
groups)
2. Recap:"what did we learn last week?"
3. "Any questions"
4. Make time to review any homework
5. 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 summarizea) Consolidate using participant language if possible
7. Questions and answers
8.Hand out materials…homework
9.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?
Retrospective evaluation to include: Resource use
Prospective evaluation to include: Resource use Clinical measures Patient satisfaction Staff satisfaction
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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