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Collaborative Care Management
Training Double Tree Hotel
October 13, 2017
rmhp.org 2
Wi-Fi
Network Name: att
Password: rocky
rmhp.org
Announcements
3
CME Credits In-person participants can claim these at the registration table
Ask Me
Microphones
Material
Welcome
Need help?
Find a staff member with a red Ask Me ribbon
Please hold your questions
until a staff member hands you a microphone
Material can be located at rmhpcommunity.org under
todays date in the calendar
Thank you for being here today!
4
What’s in Your Packet?
• Agenda
• Action Planning Guide
• Evaluation Form
• Patient Centered Observation
Form- MA/Nurse
• Patient Centered Observation
Form- Clinician version
• Stages of Change Visual
• Motivational Interviewing
Statements/Questions
• Adverse Childhood Experience
(ACE) Questionnaire
Team Approaches to Communication
and Efficiency: Critical skills
Larry Mauksch, M.Ed
Clinical Professor Emeritus Department of Family Medicine
University of Washington
Editor, Families, Systems, and Health
Disclosures
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Receive consultation fees and honoraria for consultation
and training provided to academic and health care
organizations with a focus on communication, teamwork,
competency assessment, self management support
Co-owner of MedFAD.com, a competency assessment
software company
Objectives
Define two critical skills that primary care teams can use to optimize quality of care and time management
Learn to use a communication assessment tool
Plan how to incorporate skills into a team approach to care.
Observation Form Purpose
and Training
The value
• Structures vision
• Creates and standardizes vocabulary
Primarily for formative assessment and to strengthen the “observer self” (mindfulness)
Online training: www.pcof.us
PCOF Use
Behavior in either of the columns to the right of thick vertical line is in the competent range
Observers mark accurately and avoid giving the benefit of the doubt
Feedback is best:
When solicited
Specific, rather than
general
Curious, not judgmental
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Relationship Communication and Efficiency: Creating a Clinical Model from a Lit Review
Mauksch et al, 2008, Arch of Intern Med, 168 (13) 1387-1395
Ongoing influence
Rapport and Relationship
Mindfulness
Topic Tracking
Empathic response to
cues
Sequential
1. Upfront collaborative
agenda setting
2. Hypothesis testing and
understanding the patient perspective
3. Co-creating
a plan
SMS: problem solving
EEE: Polite Interruption Mauksch. Questioning a Taboo…, JAMA. 2017 March 14th
Excuse yourself (acknowledge and/or apologize)
Empathize with the problem that is being cut off
Explain why you are interrupting
• Planning time use
• Finishing an important topic (topic tracking)
• Stopping to explore an important cue
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Interruption: Important cue
Mr. Fredricks, forgive me for stopping you. You just said
something about wondering if your thigh pain was in your
bones and perhaps serious. Can we go back to that?
It sounds like you have some important concerns that I want
understand further.
EEE: Polite Interruption Mauksch. Questioning a Taboo…, JAMA. 2017 March 14th
Excuse yourself (acknowledge and/or apologize)
Empathize with the problem that is being cut off
Explain why you are interrupting
• Planning time use
• Finishing an important topic (topic tracking)
• Stopping to explore an important cue Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Relationship Communication and Efficiency Mauksch et al, July 14 2008, Arch of Intern Med
Ongoing influence
Rapport and Relationship
Mindfulness
Topic Tracking
Empathic response to
cues
Sequential
1. Upfront collaborative agenda setting
Visit Organization
Agenda collision
Acute
Chronic HM / Preventive
Self Management
Support
Care Management
Upfront Collaborative Agenda Setting Brock, Mauksch, et al. JGIM, Nov, 2011; Mauksch et al, Fam, Syst,
Health, 2001 Identifies patient’s priorities
Organizes the visit
Decreases chance that patients or providers will introduce “oh by the way” items
Screens for mental disorders
Facilitates shared decisions about time use between acute, chronic, and health maintenance care
Does not lengthen the visit; protects time for planning
Decreases clinician anxiety
Agenda Creation
Avoid premature diving by patient or yourself
When needed interrupt the patient or yourself:
Acknowledge, Empathize
Share reasoning
If the list is greater than three items,
the patient is screen positive for depression or anxiety
Ask, “what is most important”
• Listen (feel) for the most important concern
Orient the patient:
“I know you are here to talk about ____. Before we get into_____ is there something else important to addresses today? Making a list will
help us make the best use of time”.
Diving or Agenda Setting
Old
What are we doing today?
How are you?
What can I do for you?
What is going on?
Tell me about your ear pain.
New
What is on your list of concerns today?
In addition to your ear pain is there something else?
Let’s make a list of your concerns and then figure out how to make the best use of our time?
Agenda Setting
Missteps and corrections
• Interrupt your self: “ I am getting ahead of myself”
Provider diving
• Interrupt with an apology, empathy, and reason
• “I apologize for interrupting. Your sleep is a concern but before we talk about it, is there something else?”
Patient diving
• Orient: “Lets plan the use of time before we use it”
No orientation to purpose of agenda setting
Relationship Communication and Efficiency Mauksch et al, July 14 2008, Arch of Intern Med
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Ongoing influence
Rapport and Relationship
Mindfulness
Topic Tracking
Empathic response to
cues
Sequential
1. Upfront collaborative agenda setting
2. Hypothesis testing and understanding the patient
perspective
Explore the Patient Perspective When:
Promoting self management and behavior
change
Detecting clues about thoughts
or feelings
Family or cultural influences are
suspected
Psychosocial factors may be
present
There are unexplained
medical symptoms
You sense distrust in the health
system
Desired change does not occur
Contemplating a major health care decision
Discussing palliative care
(PalCOF)
Exploring Patient Perspective:
Core Skills and attitudes
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
• Curiosity
• Empathy
• Remembering, when patients do not do something, there is always a reason
• Cultural humility
Attitudes
• Reflective listing
• Open ended, focused questions
Skills
Relationship Communication and Efficiency Mauksch et al, July 14 2008, Arch of Intern Med
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Ongoing influence
Rapport and Relationship
Mindfulness
Topic Tracking
Empathic response to
cues
Sequential
1. Upfront collaborative
agenda setting
2. Hypothesis testing and
understanding the patient perspective
3.
Co-creating
a plan
Co-creating a Plan
Assess patient’s preferred
decision role
State clinical issue / decision
to be made
Describe options
Discuss pros and cons
Discuss uncertainties
Assess patient understanding
Ask for patient preferences
Resolve decision
differences
Plan respects patient goals and values
Closing the visit
Questions
Teachback
After visit summary
Combine Teachback and AVS and share the screen
Links to Online Training
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Patient Centered Observation Form (PCOF)
www.pcof.us
Palliative Care Observation Form (PalCOF)
www.palcof.com
Family Centered Observation Form (FCOF)
https://sites.google.com/view/fcof
Practice Reflection and
Commitment to Change Tool JOUR OF CONTIN EDUC IN HEALTH PROFESSIONS, 35(3):166–175, 2015
The most useful information for me was:
This highlighted the following gap in my practice:
FILL IN ONE OR MORE OF THE PRACTICE CHANGE OPTIONS BELOW
I will change my current practice in the
following way:
Barriers I anticipate:
What changes to my current practice am
I considering? What would enable me to
change
What confirmed my current practice? What supports my current
practice?
I am not convinced there is a need to change my current practice because:
BREAK
A team Approach for Self-management
Support and Building a Collaborative
Care Plan
Larry Mauksch, M.Ed
Consultant and Trainer
Clinical professor Emeritus
Department of Family Medicine
University of Washington
Editor, Families, Systems and Health
Objectives
Define key problem solving skills used when integrating self management support in primary care by care managers and others
Evaluate EHR design to support a team approach to self management support
Create a flexible team approach for integration of self management support
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Transdisciplinary Functions and Roles in Primary Care
Role
Function
PCP Nurse Medical
Assistant
Pharm Behavioral
health
Care
Management
Relationship 5 5 5 5 5 5
Agenda setting
and activation
4 3 5 2 4 4
Self management-
simple
4 3 4 3 2 2
Self management-
complex
3 4 2 3 4 5
Primary care
counseling
3 4 1 2 5 4
Plan confirmation
and care
integration
3 4 4 3 4 5
Proactive follow-up
and stepped care
3 5 4 3 3 4
Intensity: 5 =always; 4= often; 3 = periodic; 2 = support; 1 = reinforce and connect Larry Mauksch, M.Ed UW Family Medicine
Stages of Activation Hibbard et al Health Services Research 2007, 42(4) 1443-63
Level of activation (age 45 or older, 2.9 chronic conditions)
diabetes, HTN, lung, cholesterol, arthritis, heart
Percent
(cumulative)
May be overwhelmed and unprepared to
play an active role in their own health
12
May lack knowledge and confidence
about self management
29
(41)
Taking action but may lack confidence
and skill to support self management
37
(78)
Mastered self management but may not
maintain behaviors at times of stress
22
The Patient’s Path
MA/
RN/BH
CM
Warm greeting,
elicits agenda, activates patient,
may provide HBC
MD
ARNP
PA
Makes connection,
elicits and negotiates agenda,
provides care, promotes
self management
MA/RN BH
CM
Elicits questions, provides education,
navigation
F/U support,
Behavior change counseling
Patient uses
e-planning/
scheduler
Front
Office
Greets patient, introduces form or
acknowledges
e-plan receipt
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Visit Organization
Agenda collision
Acute
Chronic HM /
Preventive
Self Management
Support
Care Plan
During Agenda Setting
Plan the use of time before using time
• Upfront collaborative agenda setting
• “Something else”
Self management support
• Begins upstream from clinician encounter
• Ask patients about health goals
• If care plan exists, check on progress
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Behavior Change and
Goal Setting
Provider
Determined
Patient Determined
Goal Disease Can be from a larger
domain
Pros Helps with disease
management
Builds patient
investment
Cons Greater resistance
(contemplation)
Requires more
patience, may not
be disease focused
at first
Goal Setting
Which part of this would you like to work on?
“What would you like to do to improve your health?”
“If you were going to change one thing about managing your health, what would it be?”
“If you woke up tomorrow morning and one thing changed in how you managed your health, what would it be?”
Collaborative Goal-
setting
Offer a variety of choices
Listen to what the patient wants
Go with the patient’s choice
ONE goal at a time
What are the key
components of a
health behavior
care plan to send
home with the
patient ? Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Action Planning
• What I will do:
• How often?
• When?
• Potential barriers?
• How will I overcome these barriers?
My Ongoing Action Steps
Patient Centered Problem Solving
What can help increase confidence?
Confidence- 1(low) to 10(high)
Barriers?
When?
How often?
Focus the activity (biking)
Name an activity (exercise)
Brainstorm activities (different ways)
Name the goal (wt loss)
Meet the patient where s/he is and hone
Review Patient Centered Observation Form (PCOF):
Clinician version:
Self management support
MA/Nurse Version:
Self management support
and
Self management follow up Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Assist with Action Planning
Things I can do to help reach this goal:
a.
b.
c.
d.
Confidence Ruler
1 2 3 4 5 6 7 8 9 10
Not Somewhat Very
Confident Confident Confident
Increase Confidence
What would it take to make your confidence a ____?
•(1 higher than their current rating)
Arrange follow-up
Would it be OK if Christine calls you next week to see how this is going?
PCCP Chart review Chunchu, Mauksch, et al. Fam, Syst, Health, 2012, September
PCCP
51 yrs; 60%F
Controls
55 yrs; 40% F
Goal documented 96 % 43 %
Ongoing activity 89 34
Specific activity 78 41
How often 68 07
When 68 07
Barriers 75 01
Confidence 71 00
What can help with confidence 53 00
Patient Centered Problem Solving
What can help increase confidence?
Confidence- 1(low) to 10(high)
Barriers?
When?
How often?
Focus the activity (biking)
Name an activity (exercise)
Brainstorm activities (different ways)
Name the goal (wt loss)
Meet the patient where s/he is and hone
Additional Thoughts:
• Collaborative Care Plans
• Stepped Team Involvement,
• EHR Modification,
• Motivational Interviewing vs
Problem solving
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
For any patient who is working on
self management
Weave it into the discussion
•Most patients with chronic illnesses
•Patients with whom you discuss health risk behaviors, eg, diet, alcohol, exercise
•Patients who need help with simple behavior changes, eg., remembering to take Rx
Phases of Teamwork and
Planning
Planning (Huddles)
Action (The provision of care)
Debriefing (Reviewing the experience, celebrating success, and planning change and learning)
Work Flow Options
MA/RN/CM/BH establishes goal and plan
MA/RN/CM/BH establishes goal, part of plan, PCP finishes
MA/RN/CM/BH establishes goal, PCP completes plan
MA/RN/CM/BH establishes goal and completes plan
MA integrates progress check into agenda setting at subsequent visits or on the phone
Primary Care Team Building Activities Fiscella, Mauksch, et al Improving Care Teams’ Functioning:
Recommendations from Team Science. 2017.
Joint Commission Journal on Quality and Patient Safety
Huddles &
Debriefs
Team
Training
Peer
Coaching
Video
Creation
Role
Modeling
Coaching X X XX XX X
Cognition XX X X X X
Cooperation XX X X X XX
Coordination X X XX X X
Conflict X X X X XX
Communication X XX XX XX XX
Team Design Reflections
Team expansion is needed for ambivalent or pre-contemplative patients
•Nurse
•Care manager
•Behavioral health
•Extra medical assistant with extra training
Physicians need extra training for complex patients and close relationship with care manager functionality
Phone Follow Up
Collaborative Agenda setting
Highlight successes
Normalize struggles
Describe barriers
Revise plan
Schedule F/U Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Motivational Interviewing vs Problem
Solving ( Goals and action plans)
Time Evidence
Practicality Skill
learning
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
The Overlap:
Motivational Interviewing and
Goal Setting
• Collaborate on problem solving
• Drawing the patient out (evocation)
• Support the patient’s autonomy
Spirit of MI
• Open ended questions (what, how, tell me about)
• Affirmations (acknowledge effort and success)
• Reflect ( to avoid power struggles and promote patient exploration of an issue- video example)
• Summarize
OARS
Behavior Change Strategies Reported by
Top- and Bottom-Performing Clinicians Greene et al Ann Fam Med 2016 14 (2)
Strategy Top Clinicians (10) Bottom Clinicians (10)
Used mainly by Top clinicians
Emphasizing patient ownership 8 3
Partnering with patients 9 3
Identifying small steps 10 3
Scheduling frequent follow-up visits 7 3
Showing caring 5 1
Used by both groups
Reliance on team supports 10 7
Used mainly by bottom clinicians
Describing consequences of bad
health behaviors
2 8
Practice Reflection and Commitment to
Change Tool JOUR OF CONTIN EDUC IN HEALTH PROFESSIONS, 35(3):166–175, 2015
The most useful information for me was:
This highlighted the following gap in my practice:
FILL IN ONE OR MORE OF THE PRACTICE CHANGE OPTIONS BELOW
I will change my current practice in the
following way:
Barriers I anticipate:
What changes to my current practice am
I considering?
What would enable me to
change
What confirmed my current practice? What supports my current
practice?
I am not convinced there is a need to change my current practice because:
Skills Development: Objectives
Practice and assess use of self management support counseling skills
Evaluate ways to implement use of self management support in their respective settings.
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Patient Centered Problem Solving
What can help increase confidence?
Confidence- 1(low) to 10(high)
Barriers?
When?
How often?
Focus the activity (biking)
Name an activity (exercise)
Brainstorm activities (different ways)
Name the goal (wt loss)
Meet the patient where s/he is and hone
Pick something to change in
your life One person counsels
One person is the patient,
One person observes using PCOF
Everyone plays every role
Focus on a simple, real issue
Patient: Be ambitious
Counselor: restrain for success
Patient Centered Problem Solving
What can help increase confidence?
Confidence- 1(low) to 10(high)
Barriers?
When?
How often?
Focus the activity (biking)
Name an activity (exercise)
Brainstorm activities (different ways)
Name the goal (wt loss)
Meet the patient where s/he is and hone
TEAM COMMUNICATION
TRAINING
Team members reinforce use of communication
skills in one another
Shared learning of skills builds
team function
Mastering a Skill Domain
Practice
• Real situations
• Learned from expert: • description
• demonstration
Feedback
• Specific
• Sensitive
• Developmentally appropriate
Reflection
• Promotes analysis
• Synthesis
• Integration
Common Training Sequence
Introduction to PCOF
Group rating and discussion of C/B
Videos
Teamlet members
observe each other using extended
appointment slots
Groups meet to share learning and set goals
• Within teamlets
• Across teamlets
Recurrent observations and team meetings
for reinforcement
Do the cycle again to learn more skills and achieve more
goals
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
1) Skills on the PCOF
• Those done well
• Wonder about doing something differently
2) Overlap with Lean approach
• Going where the action is
• Value stream thinking- study the present, plan the future
• Standard work
• Raising skills to the ceiling of role capacity
• Work supported by coaching
• Reveal waste
• Change designed by folks who do the work
A Patient Centered Care Plan in an EHR:
Improving collaboration and engagement
2012, issue 3, Families, Systems and Health
Kavitha Chunchu, MD, Larry Mauksch,M.Ed.
Carol Charles, L.I.C.S.W, Valerie Ross, MS
Judy Pauwels, MD
Funded by Picker Institute and Gold Foundation
Engaging Patients In Collaborative Care Plans:
Communication Skills, EHR Applications,
Teamwork, and Training, May/June 2013
Family Practice Management
Larry Mauksch, M.Ed and Bertha Safford, MD
BREAK
Self-Management Support: Skill
Development
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
LUNCH 11:30 – 12:15 PM
• Understand core responsibilities of care managers as they pertain to behavioral health in primary care
• Practice applying principles and skills of motivational interviewing to increase patient engagement in care
• Increase confidence in managing difficult situations
– Trauma
– Suicidality
• Coordinating overall effort of the primary care team
• Ensuring effective communication among team members
• Offering brief counseling interventions to facilitate behavioral changes
Motivational Interviewing
Solution Focused Therapy
Problem Solving Therapy
Care Managers Behavioral Health Providers
Mild symptoms of depression, anxiety, PTSD, etc. (limited impairment in functioning)
Moderate to severe symptoms of depression, anxiety, PTSD, etc. (significant impairment in functioning)
Behavioral changes related to chronic disease management
Behavioral changes related to chronic disease management when they intersect significantly with MH problems or social/relational problems
Based on Jordan et al (2013)
General Duty Extension
Screen & assess for depression, anxiety, and substance use disorders * coordinated, co-located, or integrated
• Train front desk staff & MAs in how to administer screenings & talk to patients about them
• Develop workflows for screening
General Duty Extension
Facilitate patient follow-up with referrals made to behavioral health services * coordinated, co-located, or integrated
• Secure copies of release of information (ROI) forms for most common referrals
• Facilitate conversation with patients about importance of signing ROI
General Duty Extension
Provide patient education about common BH conditions and available treatments * coordinated, co-located, or integrated
• Support PCPs in using shared decision making aids in conversations with patients
General Duty Extension
Systematically track treatment response and monitor patients for changes in clinical symptoms and treatment side effects or complications * coordinated, co-located, or integrated
• Implement a BH registry
General Duty Extension
Support psychotropic medication management, focusing on treatment adherence monitoring, side effects, and effectiveness of treatment * coordinated, co-located, or integrated
• Develop meaningful measurements of progress (e.g. PHQ-9, GAD-7, FAQ-5)
Resist the “righting” reflex Understand your patient’s motivation Listen actively Empower
Open-ended questions Affirmations Reflective listening Summarization
Status Quo Change
Benefits
Costs
“Traumatic events, by definition, overwhelm our ability to cope. When the mind becomes flooded with emotion, a circuit breaker is thrown that allows us to survive the experience fairly intact, that is, without becoming psychotic or frying out one of the brain centers. The cost of this blown circuit is emotion frozen within the body. In other words, we often unconsciously stop feeling our trauma partway into it, like a movie that is still going after the sound has been turned off. We cannot heal until we move fully through that trauma, including all the feelings of the event.”
Susan Pease Bannitt (2012)
55% 95%
have experienced at least one trauma
to
• Alcoholism and alcohol abuse
• Chronic obstructive pulmonary disease (COPD)
• Depression
• Fetal death
• Health-related quality of life
• Illicit drug use
• Ischemic heart disease
• Poor work performance
• Financial stress
• Risk for intimate partner violence
• Multiple sexual partners
• Sexually transmitted diseases
• Smoking
• Suicide attempts
• Unintended pregnancies
• Early initiation of smoking
• Early initiation of sexual activity
• Adolescent pregnancy
• Risk for sexual violence
• Poor academic achievement
(CDC, 2016)
Trauma Physical health
problems
Trauma
Disrupted neurodevelopment
Physical health
problems
Physical deregulation
Trauma
Risky health behaviors
Physical health
problems
• More negative interactions with providers
• More negative perceptions of the healthcare system
Bassuk, Dawson, Perloff, & Weinreb (2001); Green, Kaltman, Chung, Holt, Jackson, & Dozier (2012)
• More negative interactions with providers
• More negative perceptions of the healthcare system
WHY? • Impairment in forming and maintaining trust in
relationships • Sensitivity to issues of power and authority
(Green et al., 2015)
• Invasive procedures
• Inflating a blood pressure cuff
• Power differentials between patient and provider
• Being confined in a small space
• Having arms restrained for minor procedures
• Removal or absence of clothing
• Medications with sedative side effects
• Sounds (e.g. ambulance siren, loud noises)
• Smells (e.g. latex gloves, rubbing alcohol)
(Veterans Affairs, 2002; SAMHSA, 2013)
• Irritability, hostility
• Demanding & present with many needs OR reluctant to discuss problems
• Problems with pain
– Poor tolerance of pain
– Poor perception of pain
– Chronic pain
(Trauma Committee at Institute for Family Health, 2015)
• Avoidance symptoms
– Repeatedly canceling appointments
– Avoiding telling providers about symptoms
• Dissociative symptoms
– Altered awareness/attention (“spacing out”)
– Flashbacks
– “Out of body experiences”
(Veterans Affairs, 2002)
(Fishbane, 2007)
• How can you support parents in preventing trauma experiences for their children?
– Well child checks
– Behavioral issues addressed during visits
– Psychoeducation
– Collaboration with school system
– Interventions to meet social needs (e.g. housing, transportation, food security)
• How can you identify patients whose trauma histories may be impacting their health?
– Review charts of patients on the daily schedule
– Listen for red flags & risk factors during huddle
– Observe patients’ and family members’ nonverbal cues and patterns of behavior in the office
• Avoidant
• Dissociative
• Medically unexplained symptoms/somatization
• How can you include elements of trauma-informed care in your daily practice?
– Safety
– Trustworthiness & transparency
– Peer support
– Collaboration & mutuality
– Empowerment, voice, & choice
– Cultural, historical, & gender issues
– Understanding of nonlinear healing
– Respecting boundaries
(SAMHSA, 2013)
• How can you communicate trauma sensitivity in your practice?
– Trauma-related materials in waiting room
– Posters inviting patients to talk about trauma & needs in exam rooms
– Asking questions about trauma history & needs before/during exams
(SAMHSA, 2013)
• Ask yourself
– Why do people kill themselves?
– Is it ever acceptable to commit suicide?
– Can suicide be prevented?
– Do people who access care want to die?
– What are your individual professional responsibilities with a patient who is suicidal?
(Rudd, 2006)
• Be direct
• Be precise
• Establish a relationship
(Rudd, 2006)
• Suicide/completed suicide
• Suicide attempt with injuries
• Suicide attempt without injuries
• Instrumental suicide-related behavior
• Suicide threat
• Suicidal ideation
(O’Carroll et al, 1996)
• Suicide attempt vs. instrumental behavior vs. suicide threat
– Subjective/expressed intent
• “I’m going to shoot myself”
• “I wish I had died when I took those pills”
– Objective intent
• Preparation for death (e.g. letters to loved ones, organizing financial records, revising a will)
• Efforts to prevent discovery or rescue
(Rudd, 2006)
(Rudd, 2006)
Morbid Ruminations Suicidal Thoughts
Thoughts about death, dying, not wanting to
be alive
Thoughts of killing oneself
• Assessing a patient’s thinking
– Frequency
– Intensity
– Duration
– Specificity
(Rudd, 2006)
• Assessing frequency
– “How often do you think about killing yourself?”
– “What time of day do these thoughts usually occur?”
(Rudd, 2006)
• Assessing intensity
– “What exactly do you think about for that length of time?”
– “When you have those thoughts, how intense are they?” (scale 1-10)
(Rudd, 2006)
• Assessing duration
– “When you have these thoughts, how long do they last?”
(Rudd, 2006)
• Assessing specificity
– “How are you thinking about killing yourself?”
– “Do you have access to [method]?”
– “Have you made arrangements to get access to [method]?”
– “Have you thought about any other ways to kill yourself?”
(Rudd, 2006)
• Assessing specificity
– “What exactly do you think about for that length of time?”
– “Have you thought about when you might kill yourself?”
– “Have you thought about where you might kill yourself?”
– “Have you thought about taking steps to prevent anyone from finding you or stopping you?”
(Rudd, 2006)
• Assessing intent
– “Why do you want to die?”
– “Do you have any intention to act on your thoughts?” (scale 1-10)
– “Have you done anything in preparation for your death (e.g. rewriting your will, writing letters to loved ones, etc.)?”
– “Have you rehearsed your suicide in any way?”
(Rudd, 2006)
• Addressing chronic suicidality
– Differentiate between chronic course and acute episodes of suicidal thoughts & behavior
– Previous attempts heightened susceptibility to future suicidal crises
– Takes less to trigger a future suicidal crisis with more severe symptoms and more intent to die
(Rudd, 2006)
• Assessing protective factors
– “Even though you’ve had a really difficult time, something has kept you going. What are your reasons for living?”
– “Are you hopeful about the future?”
– “What would need to happen for you to be more hopeful about the future?”
– “What keeps you going in times like this?”
– “Whom do you rely on during difficult times?”
– “Has treatment been effective for you in the past?”
(Rudd, 2006)
(Rudd, 2006)
Risk Level Description
Minimal No identifiable suicidal ideation
Mild Suicidal ideation of limited frequency, intensity, duration, and specificity
Moderate Frequent suicidal ideation with limited intensity and duration, some specificity in terms of plans, no associated intent
Severe Frequent, intense, and enduring suicidal ideation, specific plans, no subjective intent but some objective markers of intent
Extreme Frequent, intense, and enduring suicidal ideation, specific plans, clear subjective and objective intent
(Rudd, 2006)
Risk Level Indicated Response
Minimal
No changes in ongoing treatment Mild
Moderate Recurrent evaluation of need for hospitalization & treatment goals Increase in frequency of outpatient visits Active involvement of family Awareness of 24-hour crisis line services Frequent re-evaluation of risk Consideration of medication Telephone calls for monitoring
Severe Immediate evaluation for inpatient hospitalization
Extreme Hospitalization for stabilization
• Referring patients to BH services
– “I can understand why you’re so upset about XY&Z, and we can return to talking about that in a few minutes if you’d like. For the next 5 minutes, I need to ask you a few questions so we can create a plan for today.”
– “What have your previous experiences with therapists been like? Why did you stop going? How did you resolve issues trusting them? Do you believe treatment can help you?”
(Rudd, 2006)
Status Quo Change
Benefits
Costs
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Colorado Crisis Services Dale Wright LPC
Crisis Services Coordinator, Western
Colorado
Colorado’s Crisis Response System
GOALS
• Expand early access to support and services for individuals
and their families with behavioral health needs.
• Promote ongoing recovery through linkage with community
resources.
• Decrease the number of unnecessary involuntary civil
commitments, hospital emergency room visits, and jail stays.
• Increase the availability of community and natural supports to
prevent behavioral health crises.
Colorado’s Crisis Response System —
Key Service Components
• CRISIS HOTLINE / WARM LINE
• WALK-IN CENTERS / STABILIZATION UNITS
• MOBILE CARE
• RESPITE CARE
• MARKETING CAMPAIGN
Colorado’s Crisis Response System —
Key Service Components: Crisis line Services
CRISIS LINE 1-844-493-8255, including Text and Chat
• 24/7/365 support for anyone dealing with a self-defined
mental health, substance use, or emotional crisis. All calls are
connected to a mental health professional who provides
immediate support.
• Text is available 24/7/365 by texting TALK to 38255.
• Chat is available via the website 7 days a week from 4 p.m. to
midnight.
• Hotline is operated by Rocky Mountain Crisis Partners.
• Hotline was launched August 1, 2014.
Colorado’s Crisis Response System —
Key Service Components: Walk-in Center Services
CRISIS WALK-IN CENTERS / STABILIZATION UNITS
• The Walk-in Centers are open 24/7/365 and provide
screening, assessment, support, and linkage to resources.
• Centers are 27-65 designated by the State to accept
individuals on a mental health hold.
• Crisis Stabilization Units (CSU) provide crisis beds for up to
5 days, for either voluntary or involuntary treatment.
• Services are provided regardless of residency, legal status,
payer source/lack of payer source, or diagnosis. Prior
authorization is NOT needed for crisis stabilization services.
Colorado’s Crisis Response System —
Key Service Components: Walk-in Center Locations METRO DENVER REGION
• Westminster Walk-in Center
2551 W. 84th Avenue
Westminster, CO 80031
• Lakewood Walk-in Center
12055 W. 2nd Place
Lakewood, CO 80228
• Littleton Walk-in Center
6509 S. Santa Fe Drive
Littleton, CO 80120
• Boulder Walk-in Center
3180 Airport Road
Boulder, CO 80301
• Denver Walk-in Center
4353 E. Colfax Avenue
Denver, CO 80220
• Aurora Walk-in Center
2206 Victor Street
Aurora, CO 80045
NORTHEAST REGION
• Fort Collins Walk-in Center
1217 Riverside Ave
Fort Collins, CO 80524
• Greeley Walk-in Crisis Services
928 12th Street
Greeley, CO 80631
WESTERN SLOPE REGION
• Grand Junction Walk-in Center
515 28 3/4 Road
Grand Junction, CO 81501
SOUTHEAST REGION
• Pueblo Walk-in Center
1310 Chinook Lane
Pueblo, CO 81001
• Colorado Springs Walk-in Center
115 S. Parkside Drive
Colorado Springs, CO 80910
Colorado’s Crisis Response System —
Key Service Components: Mobile Services
MOBILE CARE
• Mobile Care is available 24/7/365, meeting the individual
wherever the crisis occurs.
• Mobile Care can arrange for appropriate transport to needed
services for individuals in crisis, ensuring that transportation
options are safe and provided in the least restrictive manner
whenever possible.
• Mobile Care can be initiated by the Crisis Hotline; a mental
health professional may be sent out to provide a face-to-face
assessment.
Colorado’s Crisis Response System —
Key Service Components: Respite Services
RESPITE CARE
• Respite Care provides stabilization and support and is often
peer managed.
• Respite Care requires an assessment by a Crisis Clinician,
either through Mobile Care or at a Walk-in Center,; services
are up to 14 days.
• Services may include individual respite supports such as in-
home respite, peer supports, crisis apartments, or family-based
crisis homes.
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What is 2-1-1?
2-1-1 is a free, confidential, information and referral
service that helps people across the country find the
local resources they need.
2-1-1 is available in all 50 states, as well as in Puerto Rico and parts of
Canada. 90.6% of the U.S. population is covered by a 2-1-1 organization.
In 2016, 2-1-1s in the U.S. responded to nearly 13.4 million requests for
help.
In 2016, 2-1-1s answered calls equivalent to more than 10% of all
households.
2-1-1 resource databases maintain information on 942,130 agencies,
programs and services across the U.S.
The most prominent reasons for calling were housing, utilities
assistance, food/meals, and health care.
Western Colorado 2-1-1 is part of the Colorado 2-1-1 State
Collaborative. 100 % of the Colorado’s population in 64 counties has
access to 2-1-1.
Western CO 2-1-1 is one of 5 call centers in CO and serves 16
counties on the western slope.
Partnership between local governments, United
Ways and Hilltop with many funding sources
Contact Center located in Grand Junction
Open Monday- Friday 8-5
Available by phone, Email, App, Web Search, In
person at MCDHS Building (Limited hours)
(Chat coming soon!)
3 Full time Call Specialists, 1 Full time Resource
Specialist, 1 Healthy Communities Specialist
Partnerships
oLEAP
oEmergency Management/Disaster
Response
oFair and events- Health Fair, Senior Law
Day, Etc.
oPiton/Free Tax Preparation
oWestern Slope AHCM Project
Andrew
Katie
Sonia
Shonté
2016 Data o CO 2-1-1: 102,218 total contacts (phone, chat, text, email)
58,586 Website visits
oWC 2-1-1 : 7022 answered calls
7619 referrals given
8133 Website visits
oPopulation:
29% Seniors 30% Families 40% Adults under 60
oTop Presenting Needs:
Housing/Utilities- 20%
Income Supports and Assistance- 20%
Individual, Family, and Community Supports- 15%
Health Care- 12%
Food and Meals- 7%
2-1-1 connects people to health and
human services resources, such as:
oBasic Human Needs Resources
oPhysical and Mental Health Resources
oEmployment Supports
oSupport for Older Americans and
Persons with Disabilities
oSupport for Children, Youth and Families
oVolunteer opportunities and donations
2-1-1 is so much more than just giving out phone
numbers……
Caller Comments: “Every time I can't find what I need, I call 211. They are always able to find some resources when I can't.”
"It was there when I needed it.“
“I am extremely grateful. And was especially impressed with call back to ensure I was doing OK.”
“Very professional, helpful and a good resource.”
“I received "information and more” I am very pleased.”
“I am new to area and 211 really helped me navigate. It's a vital service to have especially for people relocating. 211 was my main info resource.”
Ways to contact 2-1-1: oBy simply dialing 211
oCalling our 1-800 #
oGoing online
(www.wc211.org)
oColorado211 App
oFacebook
All about that web…..
o The Database
o How to search for services
o Agency Profile Information
http://www.wc211.org/
Searching the 2-1-1 Database 1. Go on to www.wc211.org 2. Click on “Database Search” on the top right corner
3. You can search by Service Type…
4. Or by Keyword and Zip Code
Searching by Service Type allows you to search by a specific category
2-1-1 Database Client Exercise
1) An individual calls asking about legal services for themselves. They are going through a divorce and they do not know how to go through the process. They’re zip code is 81504. Using the database search, what resources are available to them?
2) An individual calls looking for food resources. They live in Clifton. They want to know where is the closest food pantry relative to their location. Using the database search, what is the closest food pantry to them?
3) A senior citizen calls from Orchard Mesa. They’re zip code is 81503. Winter season is coming soon and they notice that air is leaking through the windows and causing the temperature in her home to be uncomfortably cold. Using the database search, what resources are available to them?
As always, if you have any questions while using the database, contact an Information and Referral Specialist by
dialing 2-1-1.