Recovery Model Recovery Model Interventions TrainingInterventions Training

Patricia Kovars, MS, MFT II, AuditorPatricia Kovars, MS, MFT II, AuditorCounty of Orange, Health Care Agency County of Orange, Health Care Agency

Authority and Quality Improvement Authority and Quality Improvement Services (AQIS) Services (AQIS)

pkovars@ochca.compkovars@ochca.com

CURRENT PRACTICECURRENT PRACTICE

•What do you typically do with What do you typically do with your clients?your clients?

•Any shift in your current practice Any shift in your current practice toward the Recovery Model?toward the Recovery Model?

Training Training Objective:Objective:

• To assist clinicians in the practical To assist clinicians in the practical application of the Recovery Model in application of the Recovery Model in working with severe mentally ill personsworking with severe mentally ill persons

• To strengthen clinical interventions in To strengthen clinical interventions in addition to providing CMSaddition to providing CMS

• To improve clinical skill and To improve clinical skill and documentationdocumentation

RECOVERY RECOVERY MODELMODELWhat is the Recovery Model?What is the Recovery Model?

A process of change through which A process of change through which individuals improve their health and individuals improve their health and wellness, live a self-directed life, and strive wellness, live a self-directed life, and strive to reach their full potential. –Substance to reach their full potential. –Substance Abuse and Mental Health Services Abuse and Mental Health Services Administration (SAMHSA, Dec 2011)Administration (SAMHSA, Dec 2011)

A holistic process: bio-physico-psycho-A holistic process: bio-physico-psycho-socio-culturo-spiritedsocio-culturo-spirited

County of Orange County of Orange

Vision StatementVision Statement Everyone (regardless of sex, race, color, Everyone (regardless of sex, race, color,

ethnicity, national origin, language, ability, ethnicity, national origin, language, ability, religion, sexual orientation) with a mental illness religion, sexual orientation) with a mental illness and/or addictive disorder will recover…mental and/or addictive disorder will recover…mental illnesses can be prevented or managed…are illnesses can be prevented or managed…are detected early and…everyone with a mental detected early and…everyone with a mental illness at any stage of life has access to effective illness at any stage of life has access to effective treatment and supports, which are essentials for treatment and supports, which are essentials for living, working, learning, and participating fully living, working, learning, and participating fully in our community.—Dr Clayton Chauin our community.—Dr Clayton Chau

What am I doing to What am I doing to help help my clients get my clients get better?better?Moving beyond a role of case Moving beyond a role of case

management:management: The clinician takes responsibility The clinician takes responsibility forfor a client a client

by determining the needs, plan, services, by determining the needs, plan, services, and monitors the services delivered. Case and monitors the services delivered. Case management that evolved in the 70’s and management that evolved in the 70’s and 80’s has not been successful for treating 80’s has not been successful for treating severe mentally ill persons. (Marshall, BMJ, severe mentally ill persons. (Marshall, BMJ, 1995: Case Management a Disastrous 1995: Case Management a Disastrous Mistake: editorial, Lancet, 1995)Mistake: editorial, Lancet, 1995)

What is an What is an intervention?intervention?

• InterventionIntervention:: Any outside process Any outside process that hasthat has the effect of modifying an the effect of modifying an individual’s behavior, cognition, or individual’s behavior, cognition, or emotional state. (Encyclopedia of emotional state. (Encyclopedia of Mental Disorders)Mental Disorders)

What do Recovery Model What do Recovery Model interventions look like?interventions look like?

RECOVERY ZONE(Stay in the zone)

NEGLECT RECOVERY ZONE CONTROL

Neglect--Recovery Zone--Neglect--Recovery Zone--ControlControl

• NeglectNeglect=Letting the client do what =Letting the client do what he/she wantshe/she wants

• ControlControl=Getting the client to do what =Getting the client to do what you wantyou want

• RecoveryRecovery ZoneZone=The midpoint, common =The midpoint, common ground, happy medium (Patricia Deegan)ground, happy medium (Patricia Deegan)

Recovery as a Recovery as a Journey Journey

of the Heart of the Heart (article) Patricia (article) Patricia Deegan, 1996Deegan, 1996

““Our greatest challenge is to find a Our greatest challenge is to find a way to refuse to be dehumanized in way to refuse to be dehumanized in the age of managed profit, and to be the age of managed profit, and to be bold and brave and daring enough to bold and brave and daring enough to remain human hearted while working remain human hearted while working

in the human services.” in the human services.”

Ask Ask yourself:yourself:

• Why did I choose to go into the Why did I choose to go into the helping profession?helping profession?

• What am I doing for self-care to What am I doing for self-care to prevent burnout?prevent burnout?

RECOVERY MODEL RECOVERY MODEL CONCEPTS:CONCEPTS:• HopeHope• Self-DirectionSelf-Direction• IndividualizedIndividualized• Person-CenteredPerson-Centered• EmpowermentEmpowerment• HolisiticHolisitic• Non-LinearNon-Linear• Strengths-BasedStrengths-Based• Peer supportPeer support• RespectRespect• ResponsibilityResponsibility

How do I apply How do I apply Recovery Model Recovery Model concepts to my concepts to my clients?clients? 2 Handouts:2 Handouts:

• Recovery Model Interventions for CliniciansRecovery Model Interventions for Clinicians ExerciseExercise: : Checkmark the ones that best fit Checkmark the ones that best fit

your clinical style and approach working in the your clinical style and approach working in the Recovery ModelRecovery Model

• Behaviors-InterventionsBehaviors-Interventions ExerciseExercise:: Circle at least one intervention that Circle at least one intervention that

you will use with a challenging client next you will use with a challenging client next sessionsession

What clinical What clinical interventions work best interventions work best with my client?with my client?

•SCHIZOPHRENIASCHIZOPHRENIA•BIPOLAR DISORDERBIPOLAR DISORDER•DEPRESSIONDEPRESSION

SCHIZOPHRENIASCHIZOPHRENIA

• PharmacotherapyPharmacotherapy-Widely accepted, but despite appropriate -Widely accepted, but despite appropriate levels of medication, 40% of Schizophrenic clients continue to levels of medication, 40% of Schizophrenic clients continue to experience residual psychotic symptoms. (Kane, 1996) There is experience residual psychotic symptoms. (Kane, 1996) There is a need for therapeutic interventions, as clients have difficulty a need for therapeutic interventions, as clients have difficulty with medication compliance and relapse rates are high.with medication compliance and relapse rates are high.

• PsychoeducationPsychoeducation-For both -For both familyfamily and client, aimed at and client, aimed at modifying the support network of the client. Hospitalizations modifying the support network of the client. Hospitalizations are caused by social/family reasons as much as they are for are caused by social/family reasons as much as they are for clinical reasons.clinical reasons.

• CBT For AcuteCBT For Acute SymptomsSymptoms-Examines client core beliefs and -Examines client core beliefs and coping strategies. CBT improves quality of life and mental coping strategies. CBT improves quality of life and mental state of both acute and chronic clients, and CBT especially state of both acute and chronic clients, and CBT especially helps with delusions. helps with delusions.

(What Works With Whom? Roth & Fonagy, 2005)(What Works With Whom? Roth & Fonagy, 2005)

BIPOLARBIPOLAR• PharmacotherapyPharmacotherapy-Lithium is effective in two thirds of Bipolar -Lithium is effective in two thirds of Bipolar

clients (Goodwin, 2002) and newer mood stabilizers are generally clients (Goodwin, 2002) and newer mood stabilizers are generally just as effective. (Moncrieff, 1995; Solomon et al., 1995) However, just as effective. (Moncrieff, 1995; Solomon et al., 1995) However, even with med compliance, 41-60% of clients still experience a even with med compliance, 41-60% of clients still experience a manic or depressive relapse over a 2 year follow-up. (Prien et al., manic or depressive relapse over a 2 year follow-up. (Prien et al., 1984) 25-50% of Bipolar clients are non-med compliant. (Prien & 1984) 25-50% of Bipolar clients are non-med compliant. (Prien & Potter, 1990)Potter, 1990)

• PsychoeducationPsychoeducation--Addressing marital, family and life stressors, Addressing marital, family and life stressors, managing indicators of relapse, and focusing on identifying the managing indicators of relapse, and focusing on identifying the prodromal (early) signs helps to reduce rates of relapse. prodromal (early) signs helps to reduce rates of relapse.

• Family InterventionsFamily Interventions-Decreases marital/family stress and helps -Decreases marital/family stress and helps to reduce rates of relapse.to reduce rates of relapse.

• CBTCBT-Utilizes strategies for relapse prevention and management of -Utilizes strategies for relapse prevention and management of depressive symptoms. Both small and large studies indicate CBT depressive symptoms. Both small and large studies indicate CBT has good outcomes for Bipolar. CBT techniques help to stabilize has good outcomes for Bipolar. CBT techniques help to stabilize client lifestyle and help to manage the manic and depressive client lifestyle and help to manage the manic and depressive symptoms. (What Works With Whom? Roth & Fonagy, 2005)symptoms. (What Works With Whom? Roth & Fonagy, 2005)

DEPRESSIONDEPRESSION• PharmacotherapyPharmacotherapy-Tricyclics and SSRI’s are proven to be -Tricyclics and SSRI’s are proven to be

effective for severely depressed clients. Study by National effective for severely depressed clients. Study by National Institute of Mental Health (NIMH); Robins & Regier, 1991Institute of Mental Health (NIMH); Robins & Regier, 1991

• Interpersonal PsychotherapyInterpersonal Psychotherapy-There is a consensus of -There is a consensus of evidence that medication and therapy are evidence that medication and therapy are equally equally as as effective in the treatment of Depression. Common treatment effective in the treatment of Depression. Common treatment for Depression involves both medication and therapy.for Depression involves both medication and therapy.

• CBTCBT-Effective when delivered intensively with severely -Effective when delivered intensively with severely depressed clients. Most studies typically offer CBT in depressed clients. Most studies typically offer CBT in combination with other treatments such as: social skills combination with other treatments such as: social skills training, bibliotherapy, and relaxation training.training, bibliotherapy, and relaxation training.

• Relapse PreventionRelapse Prevention-Needed as there is an extremely high -Needed as there is an extremely high rate of relapse with all types of depression. (What Works rate of relapse with all types of depression. (What Works With Whom? Roth & Fonagy, 2005)With Whom? Roth & Fonagy, 2005)

DOCUMENTATIONDOCUMENTATION: How do I : How do I document billable clinical document billable clinical interventions in my treatment interventions in my treatment plans? plans? • To meet Medical Necessity an intervention must show that To meet Medical Necessity an intervention must show that it will significantly diminish the impairment or prevent a it will significantly diminish the impairment or prevent a

deterioration in an important area of life functioning.deterioration in an important area of life functioning.• InterventionsInterventions: Describe the specific activity, service, or : Describe the specific activity, service, or

treatment of the provider or other responsible person and treatment of the provider or other responsible person and the intended purpose or impact as it relates to the the intended purpose or impact as it relates to the objective (include specific behavior or skill).objective (include specific behavior or skill).

• Specify who will do what. Example: CC will…MD/RN will…Specify who will do what. Example: CC will…MD/RN will…Client will…Client will…

• Include: Include: frequency, amount, durationfrequency, amount, duration. Example: CC will . Example: CC will provide CBT to increase coping skills to improve provide CBT to increase coping skills to improve depressed mood and isolation: 1x week, 60 min, 12 depressed mood and isolation: 1x week, 60 min, 12 months.months.

How do I document How do I document billable clinical billable clinical

interventions in my interventions in my therapy notes?therapy notes?

Notes should include 5 key Notes should include 5 key elements: elements: •Who did you seeWho did you see•WhyWhy•Interventions-clinical, relevantInterventions-clinical, relevant•Response to the interventionsResponse to the interventions•PlanPlan

HANDOUTSHANDOUTS

•Medi-Cal Documentation Medi-Cal Documentation WordsWords

•Mental Health Services Mental Health Services •CFS Area 5 exampleCFS Area 5 example

CASE EXAMPLECASE EXAMPLE(Handout(Handout))

CASE EXAMPLE: STEVEN CASE EXAMPLE: STEVEN

• What interventions would work best with What interventions would work best with this type of client?this type of client?

• How would you work with this client?How would you work with this client?

EXERCISE: WRITE UP EXERCISE: WRITE UP OBJECTIVES-INTERVENTIONSOBJECTIVES-INTERVENTIONS PAGE AND THERAPY NOTEPAGE AND THERAPY NOTE

QUESTIONSQUESTIONS