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Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011
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Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

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Page 1: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

Shared Decision Making: Partnering with People to Support Informed

Healthcare Decisions

Etta Mitchell, LMSWSeptember 23, 2011

Page 2: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

Wellness Focus

• Focused on the ‘whole person’- integrated physical and mental health care

• Learning to provide healthcare management, bringing together all domains of treatment to one cohesive resource.

Page 3: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

Critical Care

Page 4: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

This is Not About Statistics.It’s Personal!

• Freddie• Michael• Sue• Patty• Burt• Francis• Media• Shaylynn• David

Page 5: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

It’s Personal

Science—SufferingTreatment---Healing

Empirical Facts----HopePopulation Samples---Individuals

Statistical Problem---Me

Page 6: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

Typical Medical Intervention• Average appointment with a physician 15-20 minutes• Within an appointment, the physician must:– Establish a ‘therapeutic alliance’– Gather information- history, mental status, lab results, key

issues– Treatment Planning- safety, adherence, side effects,

general medical conditions– Establish a diagnosis and treatment goals- share

information with the individual, prescribe intervention– Action-referrals, order labs, complete documentation,

provide educational resources, determine follow up appointment.

Page 7: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

Consequences

• Frustration with care because people feel they do not have input into decisions that effect health and lifestyles

• Wasted resources on appointments not kept and prescriptions filled but not taken

• 1/3 of the people that enter into care, disengage.• Use of emergent care and crisis services increase

(Deegan, 2010)

Page 8: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

Medication Trap

Page 9: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

Substance Use Trap

Page 10: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

I know I need to but…..

Page 11: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

Shared Decision Making• A experience where clinicians and patients talk about what

is important to the individual and how it is impacted by healthcare challenges. They discuss the diagnosis and best evidence based treatment options. Recognizing that some medical choices are not as simple as ‘compliance’ and ‘non-compliance’, individuals are supported to think about the benefits and costs of all options. This leads to a consensus in the treatment plan, which is sometimes a compromise on both parts.

• Term first used in the ‘President's Commission for The Study of Ethical Problems in Medicine and Biomedical Research’ in 1998.

• Expanded to include mental and physical healthcare.

Page 12: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

• Pat Deegan & Associates

Page 13: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

Foundations of Shared Decision Making• The person is able to share what is most

important to them, their motivation for wellness.

“Working at the library is the most important thing to me right now. I need help to management my diabetes and depression so that I can be a good clerk.”

**This message should be personal and not about symptom abatement

• The person is informed about their diagnosis and possible treatments.

Page 14: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

Foundations of Shared Decision Making

• There is a change in the doctor-patient relationship. There are now to experts in the room.– The person is empowered to ask questions,

express concerns and disagreement, and engage in clinical discussions.

– The clinician learns to start conversations that promotes shared decision making, and expresses respect for the individual’s values, preferences, and right to choose.

Page 15: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

Foundations of Shared Decision Making

• A team approach to include the individual, friends and family members, social workers, therapists, CSSs, nurses, and other clinicians. Anyone that the individual identifies as a support!– Supplements the brief medical appointment• Educational materials and resources• Peer support• Decision aides• Support with decisional uncertainty

Page 16: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

How Can You Help?

• Assist the individual access information about the diagnosis that is clear and easy to read.

• Encourage them to develop questions to ask in the medical appointment- write them down.

• Support the individual to practice having difficult medical discussions- stating what is most important to them and knowing how to disagree or express concern.

Page 17: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

How Can You Help?

• Support them with decisional uncertainty

Many decision aides available:www.bcbs.com/betterknowledge/tec/www.Cochrane.orghttp://decisionaid.ohri.ca/decguide.htmlwww.informedmedicaldecisions.orghttp://effectivehealthcare.ahrg.govhttp://mentalhealth.samhsa.gov/consumersurvivor

Great work creating “Cool Tools”www.healthwise.net

Page 18: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

Decisional Aides

• Created by unbiased sources with unbiased content

• Peer support and recovery stories• Support groups• Booklets, articles, CD Rom• Worksheets to weigh benefits to risks-

Important to assign importance or value to each item

Page 19: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

Pat Deegan and Associates

Page 20: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

Non Compliance

• Compliance communicates a paternalistic stance regarding healthcare decisions

• Adherence is a personal and complicated decision, not an arbitrary one.

Page 21: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

Decisional Uncertainty with Medication

• People have several reasons for decisional uncertainty regarding medications:

Side effectsMeds unhelpful

Health ConcernsInteractions with other medications

Interactions with substance useNeed more support

ExplorationLogistics- co-pays and transportation

ConfusionBeliefsFears

Motivation

Page 22: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

Pat Deegan & Associates

Page 23: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

Antipsychotic Medication

• Questions often asked by consumers:• Which one will present the least risk for metabolic

dysregulation?• Will I gain weight and get diabetes?• Will it cause sexual dysfuntion?• Can I use alternative options such as vitamins,

psychotherapy, or watchful waiting?• What if I get pregnant?• What about hair loss or tremors?• What about sudden death?

• Be open to exploration, not dismissive

Page 24: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

Decisional Aide

Page 25: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

Yeah...but….

• People do not know enough to make informed medical decisions

• There is not enough time in the appointment.• I am not going to prescribe whatever patients

want!• What if people make the ‘wrong decisions’?

Listen, present options with facts, arrange for decisional support and peer support

Page 26: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

More Concerns

• People that say, “I don’t have a mental illness.”Avoid the power struggle! Build common ground by discussing what is important to them, how their life is impacted. It does not matter if they accept the label, focus on the impact of quality of life.

• People who are not able to make decisions for themselves.

• Help to create advance directives and proxy decision makers, in essence a good crisis plan.

• Not appropriate for emergencies, people without capacity- Alzheimers, intoxication, delirium

Page 27: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

Research • Has indicated that the decision making process for people with

mental health diagnoses do not differ from people with other major medical diagnoses. In fact, they express and increased desire to participate. (The MacArthur Treatment Competence Study, 1995)

• Shared Decision Making – Increases favorable health outcomes (Kaplan, Greenfield, & Ware, 1989)

– Empowers people to make decisions– Reduces anxiety– Promotes recovery– Increases adherence (Guadagnoli & Ward, 1998).– Leads to reduced demand for healthcare resources– Reduces medical cost DNKA rate, unused medications (Devine & Cook, 1983)

Page 28: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

Bottom Line

Page 29: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

BE THE DIFFERENCE

Page 30: Shared Decision Making: Partnering with People to Support Informed Healthcare Decisions Etta Mitchell, LMSW September 23, 2011.

ReferencesAdams, J., Drake, R.,& Wolford, G.(2007). Shared decision-making preferences of people with severe mental illness. Psychiatric Services 58, 1219–1221.

Devine, E. & Cook,T. (1983). A meta-analytic analysis of effects of psychoeducational interventions on length of postsurgical hospital stay. Nurs Res, 32 ,267-74.

Deegan, P. (2010). A description of a web application to support shared decision making. Psychiatric Rehabilitation Journal, 34(1):23-8.Deegan, P., & Drake, R. (2006). Shared decision making and medication management in the recovery process. Psychiatric Services, 57, 1636–1639.

Drake, R.., Deegan, P., & Rapp, C. (2010). The promise of shared decision making in mental health. Psychiatric Rehabilitation Journal, 34(1),7-13.

Drake, R., & Deegan, P. (2009). Shared decision making is an ethical imperative. PsychatricServ.60, 1007.Greenfield ,S., Kaplan, S., & Ware , J. (1985). Expanding patient involvement in care. Effects on patient outcomes. Ann Intern Med, 102, 520-

8.Greenfield ,S., Kaplan, S., & Ware J.(1988). Patients’ participation in medical care: effects on blood sugar control and quality of life in

diabetes. J Gen Intern Med, 3(5), 448-57.Grisso, T., Appelbaum, P., Mulvey, E., & Fletcher, K. (1995). The MacArthur treatment competence study. II: Measures of abilities related to

competence to consent to treatment. Law and Human Behavior, 19(2), 127-148.Guadagnoli, E., & Ward, P. (1998). Patient participation in decision-making. Soc Sci Med , 47(3), 329-39.Kaplan, S., Greenfield, S., & Ware, J. (1989). Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med

Care , 27, 110-27.Parks, J., Svendsen, D., Singer, P., Foti, M., & Mauer, B. (2006). Morbidity and Mortality in People with Serious Mental Illness. National

Association of State Mental Health Program, National Association of State Mental Health Program Directors, Medical Directors Council, Alexandria Virginia.

President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry (1998). "Quality First: Better Health Care for All Americans“

http://www.samhsa.gov/consumersurvivor/SDMWebinar/html/slide_001.html