The Patient Centered Approach to Treating Patients Suffering with Schizophrenia and other Serious Mental Illnesses

Background -

One aspect of the mental health Access and Retention Initiative involves using transaction data to identify non-engaged patients. These patients may be defined as those having diagnoses including schizophrenia, schizoaffective disorder or bi-polar disorder and who, during the pre-pilot period missed 30% or more of their scheduled individual therapy appointments and/ or medication management follow-up appointments. Once these patients are identified, their provider staff will be identified and will pilot one or more strategies intended to improve patient engagement.

The purpose of this article is to outline some potential 'engagement improvement' strategies as a basis for pilot staff "self assessment" (i.e. where do individual pilot staff stand with regard to current use of the strategies), "strategy selection" (i.e. which strategies do the pilot staff believe might improve retention among their identified pilot cases) and "identification of training/ support" for strategy implementation. Since the no-show / cancellation rates for the selected 'non-engaged' pilot patients will have occurred in the context of current practice, site teams are encouraged to pilot strategies not currently in use or not consistently in use.

Person Centered Approach Engagement Strategy -

Of the strategies routinely discussed for improving the attendance of mental health patients (including those suffering with schizophrenia, schizoaffective disorder or bi-polar disorder), the person centered approach is probably the one most likely to generate a lasting change in patient level of engagement. However, it also involves the broadest and most significant change in practice for providers who do not currently embrace and use the approach. Also, since a meaningful person centered approach begins with the assessment and service plan, it is difficult to implement 'mid stream' for patients already in service for some time, unless there is willingness to revisit the assessment and plan.

While many provider organizations claim to embrace a person centered approach, a review of actual case records often does not support this. Many providers confuse Person Centeredness with "treating the patient respectfully" or "listing patient strengths" in the assessment. To gain a good understanding of the "Person Centered Approach" to actual practice, you are referred to the book, "Treatment Planning for Person -- Centered Care" by Doctors Neal Adams and Diane M. Grieder.

In a nutshell, the Person Centered Approach is ultimately about producing better outcomes and not about "being respectful" which is something that should be a 'given' in any orientation to service. Particularly germane to the topic of 'engagement' is the impact of person centered care on patient motivation. Ultimately, if the mental health treatment plan and the services provided offer little of inherent value to the patient, why would we expect engagement? If, in a patient's experience, the connection between what goes on in treatment or rehabilitative sessions and something of real value to the patient is weak or non-existent, the best we can hope for is blind compliance and not engagement.

While transitioning to a true person centered approach takes a significant commitment of time, training and process support, what follows are some key questions that can be asked about current practice that can help focus some immediate transition efforts.

1. Does the current clinical assessment identify meaningful patient strengths, preferences and personal goals, and do the patient and all staff currently working with the patient know what these are?

2. Does the assessment conclude with identified needs that are meaningful to the patient's personal goals and reasons for seeking treatment, and do they make sense to the patient.

3. Can the patient, without significant prompting, articulate the current goal(s) and objectives in his/her service plan?

4. Is there one integrated service plan, with relatively few current goals and objectives? (multiple plans and numerous goals/objectives are confusing to the patient and staff)

5. Can all staff that work with the patient know and articulate the current goal(s), objectives, and relevant patient strengths in the service plan (at least those that pertain to the intervention they are providing -- including group interventions)?

6. Do the patient's current service plan goals reflect (sound like) things the patient wants as opposed to things others (e.g. the provider) want for the patient?

7. Are the current objectives in the service plan meaningful, measurable changes in the patient's skills, functional capabilities, symptoms, etc that clearly relate to ultimate achievement of a goal of importance to a patient?

8. Does the patient believe the objectives in the service plan are achievable in a reasonable amount of time?

9. Where possible are the objectives stated in positive (hopeful) language as opposed to using the "dead man standard" (i.e. if a person died he/she would accomplish the objectives)?

10. Does the service plan mention specifically what patient strengths can be employed to help achieve a goal and associated objective(s)?

11. Does the service plan articulate the interventions (not just services) that are planned to help the patient achieve the objectives?

12. Do the patient and staff clearly understand how the interventions and services planned will help achieve the objectives?

Providers are generally familiar with the "Golden Thread" concept as it relates to documentation linkage and medical necessity. Person Centeredness, involved making that Golden Thread obvious and meaningful in the everyday patient-provider relationship. While the above questions by no means reflect the entire person centered process, they can be objectively applied to help assess the current level of person centered practice.