Clinical Systems Mentorship and Adherence: The ICAP Approach

USING CLINICAL SYSTEMS MENTORSHIP (CSM) IN ADHERENCE WORKAdherence Workshop

Kigali, 2009

What is mentorship?

Similarities and differences

Supervising Managing Mentoring Advising

The Learner- Centered Model

Mentee role Active partner

Mentor role Facilitator

Learning process Self-directed, responsible for own learning

Relationship Length Goal determined, but has a beginning, middle, end

Focus Process oriented, critical reflection and application

Mutability Dynamic, developmental, changes over time and with

development

So to recap…

Mentorship is relational, an interpersonal process

Mentorship occurs in a context Space: a system Theme: a programme Time: stages of development

Mentorship skills CAN and SHOULD be used by supervisors and advisors

In your work….

Can you name some mentor/mentee pairs?

Adherence advisor and onsite counselor Adherence advisor and onsite MDT Adherence advisor and expert client Adherence advisor and ICAP MDT Adherence advisor and DHT Adherence advisor and patient Adherence advisor and partners (CBO, govt,

NGO, etc)

Moving on to CSM

Clinical Systems Mentorship (CSM)

CSM is the name of an integrated methodology developed by ICAP Broadens the relational principles of clinical

mentorship to the context of public health programming and health systems strengthening.

It adds specific “macro”skills related to implementation, quality, and capacity building

Goals of CSM

The goals of the CSM methodology are to Implement high quality programs Build capacity to sustain these programs

Where did it come from?

Derivative of: Mentorship methodology Communities of practice methodology

(Wenger) Diffusion of innovations methodology

(Rogers) Appreciative inquiry methodology

(Cooperrider) Whole team learning (Engenderhealth) CQI methodology

In short,

It is a way of thinking about things, a strategy for doing them, and ensuring you are doing them effectively.

Continuity Care Model

CSM: Three general principles

Data and data-based problem identification and remediation, with local ownership and team participation, are fundamental (QI,QA)

Specific skillsets are necessary (microskills and macroskills)

Strategies change according to context and stage of development

CSM: First general principle

The foundation of CSM is the process of continuous data-driven assessment, intervention, and re-assessment Measurability is key Using data for problem remediation is key Those involved in service delivery (TEAMS)

lead this process increasingly over time

This is also known as Quality Improvement (QI) or Quality Assurance (QA)

Define measures of quality: SOCs

Measure

Assess measures

Prioritize problem

areas

Design and implement

intervention

Second general principle: Skillsets Microskills (traditional mentorship skills)

Interpersonal, communication, facilitation, teaching

TEAMS are fundamental

Macroskills Specific, content based, task oriented

Third general principle: Stages of Development

Needs at start up are different than they are later, after longer functioning.

Expectations change Indicators for quality may be different Targets for quality may be different

Goal 1: Implement high quality care

Goal 2: Build capacity

Sit

e S

tart

-up

Sit

e M

atu

rity

Assess and

Build Capacity

Time

Assess and improve

implementation

Assess and improve quality

Developing district- and national-level capability

Developing patient-level capability

Are you doing what you think you are doing?

How well?Is it sustainable?

CSM: Summary of general principles

1. Data and data-based problem identification and remediation, with local ownership, are fundamental (QI,QA)

2. Specific skillsets are necessary3. Strategies change according to context

and stage of development

Applying CSM to Adherence

First principle: Data driven QI

Develop a model of care (MOC) with goals and standards (SOC)

Devise strategies for implementation Implement Evaluate

Developing a MOC: Adherence in HIV C&T

Home

Clinic

Clinic

Clinic

Testing

Home

Patient entry into care

Counseling

Adherence happens

Adherence measured/assessed

Adherence monitored

Adherence intervention

Adherence happens

Adherence measured/assessed

Adherence monitored

Counseling

Goals and objectives: Points on adherence support model

To strengthen the continuum of adherence To measure/assess adherence: Shekinah

will discuss this To monitor adherence (use measures): I will

discuss now To intervene in care delivery and receipt of

care: Cross-cutting to working sessions To ensure interventions are effective:

Remeasure/reassess

Five key components of the MOC Appointment systems (priority) Integrated tracking and tracing systems Adherence counseling and

measurement/assessment (priority) Peer education/expert client programs Community linkages and referral

Note: There are two levels

Individual level Assessment of individual adherence and planning

specific interventions Counseling Support for individuals to disclose, how to integrate

adherence into life, etc Program level

Is the program as a whole supporting adherence adequately? SOCs Root cause analysis

Summation of individual level assessments and interventions become the program level SOCs

Creating SOCs

Utilize components of the MOC Set targets

Root cause analysis: Prioritize Key Issues

After measures have been assessed, the team can identify their site priorities:• The most important problems that must be

addressed• Problems that can be easily fixed• Long term issues that need to be addressed but

may take more time

For priority problems…

Brainstorming via asking “Why?” repeatedly

Can then eliminate the root cause, thereby solving the problem

Example: Assessing Measures

Result of measure of SOCPossible actions

Evaluate this month

Prioritize and evaluate next interval

On Target

ICAP Standards of Care for Adherence

Measureof SOC

2007

Patents on ART should be assessed for adherence to treatment at each follow-up clinic visit.

% of patients on ART assessed for adherence to care and treatment at follow-up visit

23/82=

28%

Result: 28% of patients have indication of adherence assessment on record in last interval

Why? Providers ask patients about adherence at every visit, but not in structured way

Why? Adherence questioning is usual patient care but providers do not document results

Why? Providers are in a rush and may only document the most significant non-adherence

Why? Because they don’t think it is necessary to document when patients are adherent

Problem: Providers do not routinely and consistently assess and document patient adherence

Mentorship Considerations: •Sensitize providers to assess patient adherence at every visit and to document both adherent and non-adherent results.•Implement standard adherence assessment questions or medication review for every patient on ART•Observe provider assessments and give feedback

Proposed Analysis

Example: Assessing Measures

Result of measure of SOCPossible actions

Evaluate this month

Prioritize and evaluate next interval

On Target

ICAP Standards of Care for Adherence

Measureof SOC

2008

Patients should be seen for scheduled appointments

% patients seen for scheduled follow-up clinic appointment

220/387

56.8%

Result: 56.8% of patients were seen for scheduled follow-up appointment in qtr.

Why? Attendance is not consistently documented – only appointments

Why? Sometimes patients are ticked or crossed when they come but other times, they are not

Why? There is no column in the attendance book to to indicated kept/missed appointments

Problem: Patient attendance is not routinely and consistently documented and matched with appointments

Mentorship Considerations: •Sensitize MDT on the importance of tracking patient attendance•Support development of appointment system to track patient attendance and missed appointments•Ensure that providers and reception understand appointment system and implement consistently•Plan strategies to create incentive for attendance at scheduled appointments•Develop plan to follow-up on patients who miss appointments

Proposed Analysis

Main idea

Measurement is pointless unless you USE the data for monitoring and intervention planning

Third principle: Context

Adherence challenges change over time and targets and expectations, as well as interventions, need to be flexible

Your role may change as district mentors might be your mentees over time

Social Structural:Patterns of Inequality,

e.g., stigma,gender inequality

Adherencefulfills

responsibility to helpers and

preserverelationshipsas a resource

Relationshipsas resources to

overcome economic

obstacles to adherence

Social Capital

Infrastructural:Few treatment sites

Distance to careCost/Availability of

Transportation

Cultural:Religious Beliefs

Respect for AuthorityImportance of

having children

Individual:HIV knowledge

Med side effectsCognitive function

Mental healthAlcohol Use

ResourceScarcity

ResourceScarcity

Improving Health

A Social Model of Adherence for sub-Saharan AfricaWare and Bangsberg PLoS Medicine (in press)

Goal 1: Implement high quality care

Goal 2: Build capacity

Sit

e S

tart

-up

Sit

e M

atu

rity

Assess and

Build Capacity

Time

Assess and improve

implementation

Assess and improve quality

Developing district- and national-level capability

Developing patient-level capability

Are you doing what you think you are doing?

How well?Is it sustainable?