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NECCCD Mar 13 2017

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Peter Cornish

on 26 April 2017

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Transcript of NECCCD Mar 13 2017

Stepped Care Research
Research Questions
Online stepped care
is very new
Canada has an opportunity to lead the world:
While stepped care has been studied in the UK and Netherlands...
And online care has been studied in Australia...
No-one has studied
online stepped care
Next Steps
CoP: Gov of NL; Eastern Health Region (NL); UNB; George Washington University
Other Collaborators?
Funding awarded: $50k (NL Dept of Health
Other funding: eHIPP CIHR proposal submitted for $1.4 million

Challenges facing Stakeholders
Increasing demand
Long waiting lists
Indigenization & internationalization
Increasing media attention on "mental health crisis"
False positive referrals
Stigma -> "pass the hot potato"
Stepped Care 2.0
Community of practice model.
System of delivering and monitoring programs, while promoting student centricity, autonomy & empowerment.
Online components to meet clients where they are in change process.
Most effective yet least resource intensive intervention is offered first.
Care is only stepped up to the next level with evidence or prediction of program failure.
!
Step 1 Watchful Waiting
TAO
Online Therapy (USER) - U of R
Monitoring built into programs

Step 4: Therapist-Assisted E-Mental Health
Step 2: Self-Help
Step 3: Face-to-Face Psycho-education
Counselling prep courses (Mood 101)
Cognitive Skills Workshops
Mindfulness Skills Training
Daily Meditationj Sessions
OQ45 weekly
Study Skills clinics
Learning to Learn credit
course
Regular campus community mental health screenings
Plan: Mental health first aid training; Mindfulness in the curriculum; Healthy Campus Community Direction
Mood Management Apps
Wellness Tracker
Mindfulness Apps
Cyberpsych
OQ45 monitoring weekly
Stepped Care for Mental Health
Treatment Intensity
Intake - resolve or refer to next appropriate step
OQ45, CCAPS, ORS/SRS used to monitor mental health during waiting period
Alerts
Reliable change - progress or deterioration
Step 5: Group Therapy
With process element
Anxiety, depression, interpersonal, harm reduction, chronic illness
OQ45 every 3, 5 and 7th sessions
ORS/SRS every session
Step 6: Individual Counselling
Brief individual counselling or therapy
In-house or community referral
In-house: bursts of therapy (once every 2-4 weeks)
Designed to bridge through to community treatment
OQ-45 every 1st, 3rd and 9th sessions; SRS/ORS ea session
Step 7: Psychiatric Consultation
Fee for service
Initial assessments only
Consultations for physicians, counselling team, Emergency Dept.
Referrals to community care
OQ45 monthly
Step 8: Referral to Community
Long-term outpatient psychiatric care (1.5 year wait)
Psychotherapy - Terrace Clinic (10-18 month wait)
Crisis - Mobile Crisis Team; Crisis Line, Psychiatric Inpatient Hosp.
Mental Health Nurse Case Manager coordinates pathways to community
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http://www.cyberpsyc.com/
http://www.counseling.ufl.edu/cwc/tao
Discussion

Do you think the model could be adapted for other mental health programs?
Applications in Primary Care settings?
Other tertiary care settings?
Other thoughts, comments?


Stepped Care 2.0:
A Framework for Rapid Access & Improved Outcomes
Peter Cornish
Memorial University of Newfoundland


Stepped Care 2.0 for Integrated Primary Care
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2
3
4
5
6
7
8
http://www.cyberpsyc.com/
http://www.counseling.ufl.edu/cwc/tao
Step 1:
Walk-in Consult / Single Session Therapy Appr.
Online Therapy USER
TAO-Connect
10-15 minutes therapist support via web each week
BHM-20 monitoring built into programs

Step 5: Therapist-Assisted
E-Mental Health
Step 2: Informational
Online Self-Help
Mental Health Literacy Apps
Mood Management Apps
Mindfulness Apps
Fitness Trackers / Apps
ORS
Stepped Care 2.0 for Mental Health
Cost of
Intervention; Commitment level of stakeholders
Step 6: Intensive Group Therapy
Step 7: Intensive Flexible
Individual Cnslg/Therapy
Individual counseling or therapy only when group ruled out
5 min?
15 min?
30 min?
50 min?
Weekly, biweekly, monthly?
BHM20 each session
Fee for service
Initial assessments only
Consultations for physicians, counseling team, Emergency Dept.
Referrals to community care
Step 9: System Navigation / Acute /Tertiary Referral
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3
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5
6
7
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Rapid same-day
primary-care
consult - resolve or refer to next appropriate step
BHM-43 on first contact and BHM-20 for subsequent face-to-face sessions
ORS used to monitor mental health for online program
s
Alerts
Reliable change - progress or deterioration
Program Intensity
Student centricity / autonomy/self-advocacy / empowerment
Program Intensity
Client autonomy/self-advocacy /centricity / empowerment
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http://www.cyberpsyc.com/
http://www.counseling.ufl.edu/cwc/tao
Consultation-Based Activities
Cost of
Intervention;
Commitment
Level of
Stakeholders
Patient
Centricity
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9
Intensive peer-support
Intensive community case-management
Crisis - mobile crisis team; crisis line, psychiatric inpatient hosp.
Health system navigation
2 facilitators with process focus
BPD, anxiety, depression, interpersonal, harm reduction, chronic illness
Only offer groups which serve caseload
ORS/SRS every session
Step 4: Drop-
in Psychoeducation / Coaching / Peer Support
Step 3: Interactional
Online Self-Help
MindWell Take-5 30-day challenge
Memorial Meditates
Online Chat
Study Skills Coaching
Green Mindfulness
ORS before every contact
BHM-20 for on-site contacts
Drop-in online chat with counselors; Peer-to-peer chat
WellTrack
Breathing Room
The Desk
ORS
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Preliminary On-line Research
Outcomes better than treatment- as-usual
More accessible
More cost-effective
Has not been evaluated in the context of stepped care
Has only been studied with in-person (offline programming)
At least as effective as treatment as usual
Time & Energy Commitment Required of Students & Providers
Intake
Inform-
ational Online
Self-Help
Interactional
Online Self-
Help
Integrated Stepped Care for Mental Health at McGill?
High Student
Autonomy /
Self-advocacy
Therapist-
Assisted Online Intensive
Program
Intensive
Group
Therapy
Outpatient
Psychiatric Consultation
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2
3
4
5
6
7
8

Coaching on-
line / drop-in classes /
outreach
http://www.cyberpsyc.com/
http://www.counseling.ufl.edu/cwc/tao
Low Student
Autonomy /
Self-Advocacy
Intensive Tertiary / Acute Care
Intensive
Individual
Therapy
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Program Intensity
Student autonomy/self-advocacy
Healthy Campus Activities
Clinic-Based Activities

https://www.yourbreathingroom.com/Default.aspx?Site=MRU#start
https://thoughthelper.com/cbt/default.aspx
SOCAT
Step 8: Psychiatric Consultation
EXTRA SLIDES
END OF PRESENTATION

https://www.polleverywhere.com/my/polls
same
better
better
TAO overview
Why is TAO so effective?
Role Plays
Client at intake?
Stakeholder presentation (parent or student group)?
Conversation with reluctant colleague?
Workshop Outline
Now.
Wow!
How?

Parent or Student Group
insisting on traditional therapy
weekly
no cap
rumour that new model is simply cost cutting therapy on a shoestring
we expect more from elite institution
Reluctant Colleague or Trainee
I wasn't trained for this
My skills will be unused or wasted
Not best practice
What about the therapeutic relationship?!
Symptoms too severe
No other community options since students don't speak french
https://www.mywelltrack.com/
https://www.polleverywhere.com/
https://polleverywhere.com
https://polleverywhere.com/
https://polleverywhere.com
https://www.polleverywhere.com/
Stepped Care 2.0 for a Healthy Community
Wrap-Up
Why?
What are your pain points?
What are your
BOLD
ideas?
For a moment,
please
:
quell your liability fears
hang up your ethical standards hat...
Take risks...
What?
What could you change this year?
Aim for WOW!
How?
Who?
Group Activity:
Develop Change Management Plan
Identify stakeholders
Mobilize champions
Contain opponents
Secure resources
Promote the model
Report back:
Sales pitch to student union or administration

1. Relationship
2. Treatment context
3. Patient variables
4. Techniques

Common Factors Research
Attending to readiness
Kopta's readiness & bond scales
Dose Response Research
Original dose response model
Good enough model
Multiple trajectories
Multiple Trajectories (Owen et. al.)
Original Dose Response Model, Michael Lambert
Good Enough Model (Barkham et al)
1. Expect well (well-being scale)
2. Feel well (symptoms scale)
3. Work well (life functioning scale)
Why at GW?
Video
Why hold back?
SC is not yet established as "best practice"
I'm afraid SC might increase liability.
What is your own readiness for change?
Staff readiness for change?
Administration readiness for change?
Student stakeholder readiness for change?
Choose 3-5
change targets
either your own or from the presentation this morning
Anticipate
pros
and
cons
of change
Encourage organic solutions
Encourage champions
Roll with resistance
Contain resistance
Responding to storming:
Demonstration Gillian & Peter

Moshe Talmon
Single Session
therapy principles
adapted for
SC 2.0

Primary Care
Open-ended
Focus on 1 problem
Focus on 1 solution
Write out plan
Invite direct contact if follow up needed
For developing therapeutic alliance
For managing treatment context
BHM Phase Measure acknowledges patients:
your center's foundational service model
Suggests session limits should be imposed
Suggests that session limits are
not
appropriate
BHM Well Being
BHM Symptoms
BHM Life Functioning
May be due to life functioning increases
May be due to well-being changes
May be due to exposure related symptom changes
early, late changers (75%)
worse before better (5%)
steady but slow (20%)
Suggests that
Phase model monitoring is important
Analytics has potential for predicting trajectories & informing stepping decisions
End of Presentation
Thank you!
Extra Slides
BHM-20
step 7
stepping
within
GW Implementation
James Prochaska
Michael Lambert
John Norcross
Mark Kopta
Scott Miller
Michael Lambert
Mark Kopta
your center's foundational service model
your center's foundational service model
Cost/program intensity
Autonomy/empowerment/patient-centeredness
Patient outcomes
Potential for EMR Analytics Organizing Principles
Outcomes
Cost/program intensity
Autonomy/empowerment/patient-centricity
Patient outcomes
Potential for EMR Analytics Organizing Principles
Intervention Cost & Intensity
or counseling
Time & Energy Commitment Required of Stakeholders
Walk-in
Consult / Single Session
Inform-
ational Online
Self-Help
Interactional
Online Self-
Help
Stepped Care 2.0 for Mental Health
High Client
Autonomy /
Self-advocacy
Therapist-
Assisted e-Mental Health
Intensive
Group
Therapy
Psychiatric Consultation
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2
3
4
5
6
7
8

Coaching
on-line /
drop-in peer support
http://www.cyberpsyc.com/
http://www.counseling.ufl.edu/cwc/tao
Low Client
Autonomy /
Self-Advocacy
System Navigation / Tertiary Referral
Intensive
Flexible Individual
Therapy
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Stepped Care Solutions
Portal/Dashboard
3-D analytics
Patient viewer
Provider viewer

Epidemiology
Stable (McMartin, Kingsbury, Dykxhoorn & Coleman, 2014)
Most students healthy
Peer or group work
Cost/program intensity
Autonomy/empowerment/patient-centricity
Patient outcomes
Potential for EMR Analytics Organizing Principles
Values
UBC Vision

UBC Commitments, Goals & Action - Student
Learning
Table Exercise: Mental Health Stepped Care
Provider Values
Accessible / Breadth / Rapid / Depth?
Autonomy / collaboration?
Serve / Empower?
Expert / Peer / Empowement?
Confidential / Go Public?
Evidence-based practice / practice-based evidence?
Clinic-based / Embedded / Distributed Care?
Best practices / Bold practices?
Others?
Thank you
Table Exercise: Stepped Care Features &
Functions
Table Exercise: Flexible care while preserving
our values
Healthy Communities Activities
Program Intensity
Student autonomy/self-advocacy /centricity / empowerment
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3
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8
http://www.cyberpsyc.com/
http://www.counseling.ufl.edu/cwc/tao
Healthy Campus Activities
Consultation-Based Activities
Cost of
Intervention;
Commitment
Level of
Stakeholders
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Stepped Care 2.0 for a Healthy Campus
Stepped 2.0 Adaptations Across North America
But
...
Early Outcomes
Early Outcomes
Completion rates almost triple that of average for online programming
MUN 30-Day Challenge
Full transcript