Risks Identified! Now What? :3/13/2009 Risks Identified! Now What? Maine Assembly on School-Based Heath Care Supported by W.K. Kellogg SBHC Policy Grant & Maine DHHS Teen & Young Adult Health Programs


Objectives :Objectives The Participant will be able to describe the opportunities and challenges of the Maine Behavioral Risk Assessment and intervention Pilot Project. The Participant will be able to articulate the principles of Motivational Interviewing and how they are put to use in helping students with behavioral health risks progress through the Stages of Change. The Participant will be able to design templates in Clinical fusion that can be used to record behavioral health risk data, and interventions and generate reports to demonstrate evidence-based interventions and student movement along the Stages of Change.


First we want to tell you WHY we came to do this Pilot. :First we want to tell you WHY we came to do this Pilot. Maine has performance – based contracting Maine School-Based Health Center funding sources wanted to see more improvements in behavioral health outcomes. Clinicians in SBHC’s in Maine wanted the same. Maine is a recipient of The WK Kellogg Foundation SBHC Policy Initiative. Kellogg promotes high quality care for common health risks across the network of state SBHC’s


Risks to be followed :Risks to be followed Tobacco Use Alcohol Use Other Substance Use Poor Nutrition Inadequate Physical Exercise Depression/Suicidality


Assessment Survey :Assessment Survey Are you doing a comprehensive risk assessment? What tools or methods of data collection do you use? Does the assessment include tobacco and alcohol use, depression/suicide, overweight and poor nutrition, lack of exercise and significant academic underachievement? Who is screened? All enrollees, all users, selected users? Who does the screening? NP, RN, Secretary, a mix? How are risks documented? How do you do follow-up? Are you having problems entering and using risk data with Clinical Fusion? Where have you found successes and where are the frustrations and barriers?


A Summary of the Findings from that Survey :A Summary of the Findings from that Survey Pre-contemplation was viewed as a discouraging dead-end. Training was needed in newer methods of negotiating change to be used consistently across programs. Help was needed in systemizing scheduling follow-up visits. Clinical Fusion’s ability to do reminders needed to be explored and maximized. Data collection tools were needed which would meet criteria for efficiency and uniformity.


Slide 7:Health Questionnaire


Evidence-Based Intervention :Evidence-Based Intervention Searching for the Clinical Guidelines National Guideline Clearing House Agency for Health Care Quality SAMSHA Cochrane Collaboration, etc. Reviewed the Literature for: Behavior Change Stages of Change Cognitive Dissonance The Transtheoretical Model of Change Health Risk Behaviors


MI Evidence Base :MI Evidence Base More than 60 Clinical Trials have been published and systematic efficacy reviews of MI have begun to appear See also Bibliography and Power Point presentation at www.motivationalinterview.org


STAGES OF CHANGE MODEL :STAGES OF CHANGE MODEL A model…not an intervention Assumes that individuals respond better to interventions tailored to match their stage of change. A method for evaluating treatment efficacy Motivation for change is an important predictor of treatment outcome.


Why Don’t People Change? :Why Don’t People Change? They don’t see/are in denial They don’t know They don’t know how They don’t care Make them see/confront Give them information Teach them skills Scare them/ shock them Some beliefs about change


Stages of Change :Stages of Change Precontemplation Contemplation Preparation Action Maintenance (Information) (Beginning Action) (Consistent Action) This is not a “how-to-do” model;it is a “how-to-think” model.


The evidence -base was sufficientWe had a local certified trainerWe had the fundingWe had willing clinicians :The evidence -base was sufficientWe had a local certified trainerWe had the fundingWe had willing clinicians Motivational Interviewing was the Intervention we would use


Motivational Interviewing :Motivational Interviewing (Miller/Rollnick 2002 p/25) It is a “client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence”


Principals of MI :Principals of MI Express Empathy Develop Discrepancy Roll with Resistance Support Self Efficacy


Express Empathy :Express Empathy Client-centered empathic counseling style Understand without judging. Accept without necessarily agreeing with or endorsing student’s viewpoint. Essential that the client feel understood, that the clinician can see how the client may have come to his point of view.


Roll with Resistance :Roll with Resistance Statements demonstrating resistance are not challenged Use Reflective Responses Shift Focus Reframe Agree With a Twist Emphasize Personal Choice Come Alongside


Develop Discrepancy :Develop Discrepancy Create and amplify discrepancy between present behavior broader goals and values. Acceptance and understanding are not enough. Motivational Interviewing is intentionally directive. Not done at the expense of the other MI principles. Be very careful here. This requires the most expertise!


Support Self-Efficacy :Support Self-Efficacy The student’s belief in the possibility of change is an important motivator The clinician’s belief in the student’s ability can become a self-fulfilling prophecy The student, not the clinician is responsible for choosing and carrying out change


Techniques Used in MI :Techniques Used in MI Open-Ended Questions Affirmations Reflections Amplified reflections Double sided reflection Summarizations. Expressing Empathy Rolling with Resistance Hang out with ambivalence Asking permission to transition in conversation Giving discrete feedback Emphasizing Developing Discrepancy Decisional Balance scales Recognizing Change talk Elicit change talk Reframing


Spirit of MI :Spirit of MI Miller,2004 MI is more than a set of techniques for doing counseling, it is a way of being with people. (Miller& Rollnick 2002)


Slide 22:Health Questionnaire


Slide 23:Health Risk Flow Sheet


ME SBHCs :ME SBHCs


Slide 25:Create Element Tables for drop-down choices. Custom Forms.


Slide 26:Custom Contact Form. Create Custom Folder and Questions.


Slide 27:Refining Questions: Set order of questions, default note, and default answer.


Slide 28:Setup Custom Contact Template.


Slide 29:Use Custom Contact Template.


Custom Forms :Custom Forms


Slide 31:Custom Reporting Restrict report answers to screen out default and/or NA answers.


Opportunities :Opportunities Brought together peer group of clinicians across a large state on multiple occasions to learn and process. CME’s and CEU’s added bonus. Clinicians report seeing teens feel more in control of their choices. Clinicians frustration reduced=They report less of the unrealistic feeling “I must help them see”! Data entry burden was kept to a minimum by making templates mimicking the paper forms Results reporting is centralized in Clinical Fusion. Consistently gathered risk assessment information.


: MI is not simple to master: Medical Model’s use of Forms and formal History –taking can run counter to the client-centered MI spirit Follow-up visits not reimbursed. EOB’s from insurance companies, sent home to parents can violate teen confidentiality. Data forms can still use tweaking. Reports take evaluator time to “build” , so they can be only run a couple of times a year. Most centers are still using manual reminder systems for follow-up. Challenges