The Ideal Clinician(s) – How Do We Find Him or Her? (Hint: Look at How They Were Trained) Leighton Y. Huey, MD Birnbaum/Blum Professor and Chair Department.

The Ideal Clinician(s) – How Do We Find Him or Her?

(Hint: Look at How They Were Trained)

Leighton Y. Huey, MD

Birnbaum/Blum Professor and Chair

Department of Psychiatry

University of Connecticut School of Medicine

No Recovery

Partial Recovery

Fully Recovered

Resources and Support Required

The Continuum of Recovery

Old Description

“Well Trained”• What does this mean?• Well trained in what?• How is “well trained” assessed?• ….and by whom?

“Bio-Psycho-Social”• What does this mean?

New Description

“Well-Trained” =Comprehensive Assessment, Treatment, and Follow-up

• Think in terms of multiple possibilities and narrow the choices as one gets to know the patient and the family

• Differential Diagnoses based on strong training in diagnostics

• Competent in Research Literacy• The approach to individuals with a First Episode vs.

the approach to individuals who have experienced multiple episodes – is there a difference?

“Well-Trained” continued…..

•Truly consider Biological, Psychological, Social Factors in the context of how the individual presents and what is ultimately desirable (con’t)

Comprehensive, Assessment, Treatment, and Follow-up (continued)

• BiologicalPhysical Health, Physical SymptomsHeredityPossible Contributing Factors to the

Clinical PresentationPossible endogenous factors contributing to

the clinical presentation (e.g. thyroid disorder, etc.)

Possible exogenous factors contributing to the clinical presentation (e.g., drugs, etc.)

New Description

• Psychological

State of mind of the individual and their family

Events impacting the presentation (e.g. trauma, incarceration, etc.)

Style of the individual

New Description• Social

Life circumstances (e.g. socioeconomic, living situation etc.)Level of FunctionSupportsLegalEducationalSpiritualOther

Prior Assessment and TreatmentResponse to Prior Treatment

Old Description

“Evidence Based”• What does this mean?• We want evidence, but what is the evidence?• How does a clinician take the evidence into account?• What compels a clinician to consider the evidence

and utilize it?• How broad is the application of the evidence?• When do we run out of evidence and have to rely on

common sense?

New Description (from Gray, 2004)

“Evidence-Based”

•Formulate the Question

•Search for Answers

•Appraise the Evidence

•Apply the Results to the Patient

•Assess the Outcome

“Evidence-Based” – (continued)

•Track Improvement and Outcomes

•A Form of Services Research Built Into the Multidisciplinary Effort (i.e. what works and what does not work)

New Description

Treatment Algorithims

• Integration of Biological, Psychological and Social approaches using only what is most appropriate, what is needed, and what the evidence tells us to do

• Tracking Outcomes, Quality of Life, Function

Old Description

“Culturally Competent” – What does this mean?

• Can only African Americans treat African Americans?• Can only Asian-Americans treat Asian-Americans?• Can only Hispanic-Americans treat Hispanic-

Americans?• Can only Caucasian-Americans treat Caucasian

Americans?• Can only First-Generation Americans treat First-

Generation Americans?• Can only Middle-Class Americans treat Middle Class

Americans?

• Can only women treat women?

• Can only children treat children? Etc.

• How about, for starters, we insist on just being competent?

New Description

“Culturally Competent”

•In providing care, clinicians must understand the beliefs that shape a person’s approach to health and illness

•Knowledge of customs and healing traditions in the design of treatment and interventions

Old Description

“Patient and Family Focused”

• What does this mean?• Does it really happen?• What is meant by “Focused”?• Is taking a history, doing an assessment,

coming up with a diagnosis, translate into “Patient and Family Focused”?

New Description

Shared Decision-Making

•A basic principle of treatment, i.e., a collaboration

Consumer/patient

Treating System

Family

•Setting the tone early at the first visit

New Description•Multidisciplinary in scope

•Conscious utilization in a cost-effective manner

•Use whatever resources are directly necessary for the individual and their family

LegalEducational

OccupationalSupports

Consumer/patient family

Psychology

Psychiatry

Social WorkNursing

Public health

Primary care

Old Description

“Transformation”

• What does this mean?

• “Transform” – like casting a magic wand and suddenly things are better?

• “Transform” – because this concept is used, it means we all agree on what the transformation should be?

New DescriptionTurn the System Upside Down

•Consumer/Patient and Family are the Center of the attention

But a caveat, if at the center , does this establish a dependent position unintentionally vs. shared decision making where the consumer/patient and family are part of the health care system?

vsPatient/Family

Patient/Family

Old Description

“Fee-for-Service”

• Fee for what service?

• Piece-work and therefore fragmented

• By definition, not comprehensive and not integrated

Old Description

“Capitation”

• Still not integrated, not comprehensive – covers only the medical health side

Old Description

“Carve-Out”

• Specialty services but still piece-work, not comprehensive or integrated

New Description

Need for New Economic Models

•Pay for Performance within a Quality Improvement, Cost-Effectiveness Paradigm

•Multidisciplinary a Requisite

•Outcomes and Follow-up Essential

•Fund Innovation Models

Enter the Annapolis Coalition

•Charged by SAMHSA to develop a National Strategic Plan on Workforce

•A broad-based, consensus-building national effort focusing on pre-professional and the established workforce in the context of Consumers/Patients and Families, Children, Information Technology, Dual Diagnosis, Rural Behavioral Health, Integration with Physical Health, etc.

New Description

• Multidisciplinary in scope utilizing a consciously cost-effective manner

The Annapolis Coalition on the Behavioral Health Workforce

Michael A. Hoge, MD

Chair, The Annapolis Coalition

Professor of Psychology (in Psychiatry)

Yale University School of Medicine

Neal Adams, MD, MPH

Director of Special Projects

California Institute for Mental Health

John A. Morris, MSW

Vice-Chair, The Annapolis Coalition

Senior Policy Consultant, Comprehensive Neuroscience, Inc.

Professor and Director of Health Policy Studies

Department of Neuropsychiatry & Behavioral Sciences

USC School of Medicine

Gail W. Stuart, PhD, APRN, BC, FAAN

Dean and Professor

Medical University of South Carolina

College of Nursing

Allen S. Daniels, EdD

Treasurer, Annapolis Coalition

President, Academic Behavioral Health Consortium

University of Cincinnati

Leighton Y. Huey, MD

Birnbaum/Blum Professor and Chair

Department of Psychiatry

University of Connecticut Health Center

Board of Directors

The Annapolis Coalition on the Behavioral Health Workforce

Steering Committee

Sue Bergeson

Vice President, DBSA

Depression and Bipolar Alliance

Larke N. Huang, PhD

Managing Research Scientist

American Institutes for Research

Joyce Burland, PhD

National Director

National Alliance for the Mentally Ill

NAMI Education, Training and Peer

Support Center

DJ Ida, PhD

Executive Director

National Asian American Pacific Islander

Mental Health Association

Joan M. Dodge, PhD

Georgetown University

National Technical Assistance Ctr

for Children’s Mental Health

Dennis Mohatt, PhD

Director, WICHE Mental Health

Program

Western Interstate Commission for

Higher Education

Michael Flaherty, PhD

Executive Director

IRETA/NEATTC

Oscar Morgan, PhD

Chief Operating Officer

National Mental Health Assoc.

Steve Gallon, PhD

Northwest Frontier ATTC

Oregon Health & Science Univ

The Annapolis Coalition on the Behavioral Health Workforce

David L. Shern, PhD

The Louis de la Parte Florida Mental

Health Institute

University of South Florda

Constance M. Horgan, ScD

Schneider Institute for Health Policy

Heller School for Social Policy and

Management

Brandeis University

Susan Storti, PhD

Addiction Technology Center of

New England

Brown University, Center for Alcohol

and Addiction Studies

Steering Committee (continued)

The Annapolis Coalition on the Behavioral Health Workforce

Edward L. Knight, PhD, CPRP

Vice President for Recovery Rehabilitation and Mutual Support

Daniel B. Fisher, MD, PhD

Executive Director, NEC

Wilma Townsend, MSW

WLT Consulting

Susan Bergeson, DBSA

Vice President

Depression and BiPolar Support Alliance

Vicki Cousins

Director, Office of Consumer Affairs

South Carolina Department of Mental Health

Paolo del Vecchio, MSW

Associate Director, Consumer Affairs

Center for Mental Health Services

Kaye Rote

Executive Director

Oklahoma Mental Health Consumer Council

Joyce Burland

Director of Education NAMI

Sandra Spencer

Executive Director

Federation of Families for Children’s Mental Health

Cynthia Wainscott

Vice Chair-North America

World Federation for Mental Health

Chair, National Mental Health Association

Mona Wasow

Clinical Professor of Social Work

School of Social Work

University of Wisconsin

Darlene Prettyman, RN

NAMI Board of Directors

NAMI

Consumer/Patient and Family Work Group Executive Committee

The Annapolis Coalition on the Behavioral Health Workforce

Consumer/Patient and Family Work Group Executive Committee

(continued)

Harriet P. Lefley, PhD, Professor

Department of Psychiatry

University of Miami School of Medicine

Joel Miller

Director, Policy Research Institute

NAMI

Ramiro Guevara

Director, Support, Technical Assistance, and Resource (STAR) Center

NAMI

New Description and Clinical Curriculum Reform

•Each discipline starts training by itself

•Build interdisciplinary seminars and clinical case conferences into the training experience focusing on the integration and coordination of care among disciplines

•Place multidisciplinary teams into clinical sites and have them function in the way they were trained

•Create Interdisciplinary Workgroups/Institutes to develop Innovation Models

•Study the Models and their Outcomes compared with treatment as usual

New DescriptionDeveloping a Strategy for Curriculum and Training Reform (Get Political!! Time for Return on Investment

•Identify Innovators

•Mobilize the Strength of the Respected National Advocacy Organizations to Work Together

•Press the Education and Training Establishments in each discipline to modify the way it educates and trains

•Focus on both pre-professional training and on the established workforce

•Develop funding systems that will drive and sustain innovation at the Federal and State Level