Chair Massage Flier

Happy Holidays!

Chair Massage Clinic for Clients

In January we will begin offering a monthly chair massage clinic at each of our two locations. Clients will be able to sign-up for a 15-minute chair massage with a skilled LMT. In her practice, the massage therapist states that she "meets each individual with presence and compassion, giving her/him a session that responds to their unique needs and offering him/her tools to support positive shifts in their lives outside of the session." The massage therapist practices nurturing relaxation massage, mindful deep tissue massage, and energy work. She draws upon her experience with meditation, Yoga, and ayurveda.

Massage is thought to be especially beneficial for clients with mental illness. In a 2005 pilot study using interview data before and self-report instruments after completing a brief program of complementary therapy accompany ongoing pyshcotherapy, the study found that the integration of complementary therapies into community mental health practice holds promise for enhancing mental health outcomes and improving quality of life for long-term users of mental health services (J Altern Complement Med. 2005 Jun;11(3):569-74).

Personal Journal/ Reflection for the New Year

Today's art therapy activity was designed to enable clients to create their own lunch bag journal in which to put reflections for the new year. They created their journals using four paper lunch bags folded in half. Clients were encouraged to decorate them using any materials that are provided, including handmade paper, ribbons, tiny envelopes, washi tape, markers, pencils, stencils, collage, etc.

Clients were reminded that this is the time of year when people usually make annual resolutions. They were encouraged to reflect on challenges they may have had this year and what they would like to make as goals for the upcoming year. Below please find images of the journals created during today's art therapy class.

 

 

 

2013 Christmas Tree Decorated by Clients

Chronic Disease Self-Management Series

Choosing a Yoga Instructor

While we already have one Yoga instructor who is delightful and offers perfect practice for our clients, Health & Wellness is presently expanding its Yoga offerings to another site. So, we are in the process of interviewing candidates to fill the new Yoga instructor postion. We've made some observations during this process that we thought we would share with readers who may also be expanding programming for their behavioral health clients.

Most important to the Health & Wellness team is that the new Yoga instructor be skillful at his/her craft. The instructor should be well-versed in providing Yoga practice to all ages and ability levels. Further, the instructor must be sensitive to the individual clients' abilities and needs. For instance, the instructor ought to be able to teach both floor and chair Yoga simultaneously as many of our clients are older and may lack the flexibility and coordination needed for floor Yoga.

Another important feature of our new Yoga instructor, we've decided, is that he/she should not practice only Yin Yoga, or a style that is largely cerebral--or too much in the head. We've found that this style when offered exclusively can exacerbate psychiatric symptoms. Our clients do better when there is nearly constant movement and physical activity rather than only mental processing.

And finally, our clients need music! Some interviewees have stated that they offer a chant in the beginning of class but provide no other music during their practices. We've found that our clients respond well to music, which, again, enables them to focus on being grounded, present and responsive to their surroundings.  Music protects against perseveration of psychiatric symptomology as well.

So for what it's worth, we offer these observations on choosing a Yoga practitioner for an integrated services program.   

Writing Retreat

The inaugural Health & Wellness writing retreat was held Saturday December 7. Ten clients participated in the retreat. Poems about faces and masks were read and clients wrote poems and prose about the same. Clients began the afternoon with a warm up exercise, writing in a free-association style. Then clients were provided prompts including tangible masks to touch and use as inspiration for two free writing exercises. Most clients shared their writing with the group by reading their poems and prose aloud. Below please find one participant's writing:

 

"Many faces have I. Sometimes I feel happy and wear a smiling face with a gaping grin and teeth aglow. Other times I feel sad and wear a frowning face with terse lips and sagging ends. Perhaps my most well-worn face, however, is the puzzler with a concentrated gaze and a near smerk."

December 1-7 | National Handwashing Awareness Week

With the flu season upon us, it is more important than ever that we practice good hand hygiene. The Centers for Disease Control say that handwashing is the single most effective way to prevent the transmission of disease. Below please find the four principles of hand awareness:

The 4 Principles of Hand Awareness

1. Wash your hands when they are dirty and BEFORE eating
2. DO NOT cough into your hands
3. DO NOT sneeze into your hands
4. Above all, DO NOT put your fingers into your eyes, nose or mouth

(Source: http://www.henrythehand.com/healthful-tips/weekly-healthful-tips/comprehensive-flu-prevention-campaign/)

Fresh Air Group (Smoking Cessation Class)

Self Symbol

In this art therapy excercise, clients were directed to choose a personal symbol that they can draw from for strength. Clients were asked to imagine a symbol that would represent himself/herself. If the idea of a symbol seemed too abstract, they were encouraged to think of an iconic image such as the Empire State Building, or a logo, trademark, or branding idea such as evident in an advertising campaign. Clients were then directed to draw their personal symbol on paper. Copies of each symbol were made by the art therapy intern who provided them to everyone in the group. Clients therefore would wind up with a stack of images, one for each member of the group. Clients were then directed to cut out the symbols and make an individual collage with the group’s symbols. Clients were given plenty of time to share their distinct collages with the group. Collages were then hung in the main area of the day treatment program for all to enjoy.

 

Below are some of the symbols and collages created by clients.

 

 

 

 

 

 

SoulCollage(c)

Today's art therapy class worked on SoulCollages(c). SoulCollaging is a technique used to enable clients to look inward and explore their inner wisdom. Click here to learn more. Below please find clients' SoulCollages.

Great American SmokeOut - November 21, 2013

In honor of National Smokeout Day, clients and staff created the following posters to display at our site. The Great American Smokeout is an annual social engineering event on the third Thursday of November by the American Cancer Society. The event encourages Americans, of whom 43.8 million smoke as of June 2013^[update], to stop tobacco smoking. The event challenges people to stop smoking cigarettes for 24 hours, hoping their decision not to smoke will last forever.

Recruitment of Clients

Scant attention has been afforded the practice of recruitment of clients to integrated service programs—those providing combined behavioral health care and primary care in one setting. What little research there is relates mainly to the recruitment of personnel (http://www.americanprogress.org/issues/2010/10/pdf/mentalhealth.pdf) and financial benefits of this new service delivery model. But there is much to be explored with respect to recruitment of clients, especially those with serious mental illness. This post explores the challenges (and delights) in the recruitment of such clients to one integrated service program in Western Massachusetts.

One area that has been given considerable attention by our program is advertising. It is challenging to reach the SMI population, even using multiple media outlets. Since the inception of our program, we have used print media, including a monthly newsletter and fliers for individual programs, as well as press releases, messages to email list-servs, and advertisements on Facebook and public access television. These  free or low-cost advertisement activities were carefully selected in an attempt to reach clients, caregivers and professionals working in the field who could make referrals. Of all of these methods, the one that has had the most impact is the printed monthly newsletter. Clients delight in seeing themselves in print, whether it is a photograph, their artwork or a poem submitted by one of them.

Gaining trust of clients has been a challenge. Historically, SMI clients have mistrust of health care professionals, and often for very good reason. Educating clients about the benefits of receiving health care for help alleviating debilitating symptoms has been one of our program’s main foci. In so doing, we often need to pay close attention to the idiosyncrasies of clients, being careful not to “trigger” past traumas. For example, we have learned that data collection may often need to be parceled out over time; we may not be able to collect all of the health behavior information that is required of clients during one visit. Care managers are especially attentive to this fact.

As an aside, I am often asked what is the difference between case management and care management.. The answer is that care management includes the addition of chronic disease management, health behavior change, and connections with expanded service offerings, including acute and community-based care. It also involves greater use of technology (i.e., telemedicine) and linking clients to a broad array of services including physical health providers”.

The care managers are the hub of activity at our integrated services program. All communication flows through them; they connect client, PCP, behavioral health clinicians and other ancillary (but important) staffs. Clients are informing us about their pleasure with their provider experiences and how this differs from what they have experienced elsewhere in their lives as they interfaced with the medical community.

For example, client "Joe" stopped by one of our care manager's offices. "I had asked him about the Integration program, about [his primary care provider], about how things are going for him," the care manager recounted. He replied, “She listens very well [and] she communicates what’s going on with me. She’s willing to help, which is a big, big thing. She considers everybody like a friend to her.”

The care manager added, "Joe" is the client the primary care provider saw last week on an acute visit, which resulted in a stream of emails and an “intervention” by all his providers to help him get through this rough patch of time.

This is a prime example of the positive experiences of all who are engaging in our integrated services program.

Providing plain English (or Spanish) explanations of al that is involved in participation in our program has also aided in recruitment. In order to participate in our integrated services program, clients must sign release of information forms so that medical information may be shared by all providers involved in a client’s care. This is sometimes a herculean task for staff to perform. Clients are often suspicious about providing consent for their individual providers to communicate with one another. Staff hear, “I don’t want my psychiatrist talking to my doctor,” for instance. Over time, we have found that what is especially reassuring for clients who express this feeling to hear is that our program requires all of the members of the team to talk to each other to make sure clients get the best care they can. And the only way we can do that is by asking clients to let us know that they understand this.

There is a real tendency for professionals working in integrated services programs treating SMI clients to lean on inducements as a way of gathering needed information, reducing no-shows etc. Our program staffs have resisted the urge to provide monetary inducements for our clients. While they do receive a grocery store gift card valued at $10 twice during the calendar year when they complete questionnaires, other inducements used are not of monetary form. For instance, one popular inducement for participation in the wellness activities offered by our program is the monthly raffle prize advertised in the newsletter. Items raffled off include a box of herbal tea, a one-month pass to the local YMCA, and a free book from the lending library. These are low-cost offerings that really appeal to clients and not only encourage them to be involved in our program but get them reading the monthly newsletter, which is chockfull of health and wellness information.  Another example of an inducement that is low-cost and not coercive is the giveaway of a bottle of water if clients participate in our regular walking groups during the summer months. This too is very appealing to clients and gets them involved in our regular walks.

Another important realization regarding recruitment of clients with SMI is that staff must have a willingness to experience regular distraction from the goal/directive at hand. Timing is everything and clients may not wish to engage at particular points. Or, as in the case of one recent client, crises may get in the way of recruitment activities. This client was scheduled to be enrolled in our program but presented with perseverance about his apparently lost food stamp card. Stating that he only had two cans of soup left in his cupboard, the need to locate his missing card was very great and he could not focus on the recruitment tasks at hand. Care managers connected this client with his residential and outreach support staff to help him locate the missing card or order a replacement. This meant that the care manager had to reschedule this client’s intake appointment. We take solace in the thought that assisting clients with pressing tasks at hand, instead of pushing forward with the recruitment activities, will engender them to our program and staffs and that they will likely return at a later point in time.

In a statement about distraction one manager said, “Perhaps what was most difficult for me to get used to working at my present job were the constant distractions and interruptions throughout my day. As a manager, I have always had an open-door approach to management, which, traditionally, has meant that I would be available to staff who had questions about their work or wished to schedule an impromptu meeting. Even on the busiest days in my former positions, never had I had as many interruptions throughout the day as I do now.

My first week on the job, I began to wonder if I was "going native." That is, the incessant interruptions with often bizarre story lines began to make me wonder if I would go insane. Initially, I felt like these interruptions were unnecessary and I would have to find a way to lessen them if I was going to get any "real" work done.

One year into my present position, I now regard the client interruptions with statements about "being half man- half woman," "there was a big, tall mean man at the institution," "I'm going to go to San Francisco with a waitress from Friendly's to get married," and-- perhaps my favorite question asked daily: "Can we use the treadwheel now?"-- as endearing representations of what goes on in the minds of people who are tormented by voices and feelings that they do not always understand. I now feel blessed to be able to assist clients with self-soothing and provide them with even momentary reassurance and understanding”.

Despite all of the above-named recruitment successes, we do experience rejection. There are clients for whom participation in our program is too overwhelming, too scary or too trauma-inducing. These clients are resistant to recruitment efforts and refuse enrollment into our program. For these clients we must accept that they are not ready for the kind of integrated service we provide. It is our hope that over time and, with greater exposure to our program, we may win them over too. Until then, we will press on.

Scribble Drawing Class II

There were four participants in today's scribble drawing class. The art therapy intern gave the following directive to clients, similar to the one she gave during the first scribble drawing class.

Directive: "Start by creating a scribble with eyes closed or open. Open your eyes and look at what is on the page. See if you can identify any concrete images in your scribble. Finish the drawing by coloring in shapes or adding new lines to create a finished drawing. When you are done, give the drawing a title. Share with the rest of the group how it made you feel. Were there any surprises or images that emerged?"

Two participants were late to the group, which threw things off a bit, said the art therapy intern. "I had to explain the exercise several times. One participant was glad to see others there and expressed being afraid that she would be the only one again.  The initial two participants had also been in the music group I went to and came because I had asked them to give it a try. One gave me a “high five” when I saw him again today."

The art therapy intern continued, one of the late participants "seems to have a lot of doubts about her skills that she expresses. (I’m not every good” or “my drawing wasn’t very good.”) She did, however, state that the last time she participated she brought the drawing home to her husband and said, “Look what I did!” She shared this with a smile and showing exuberance about creating the drawing. She choses a large sheet of paper and watercolor pencils and was hesitant to put the scribble on the page. “I don’t want to make a mistake,” she said, and continued by adding that she “doesn’t know what to do.” I encouraged her to do whatever she wants and not to think about it too much."

This same participant didn’t get much completed by the end of class and wondered why she is slower than the rest. "She saw a bunny in her drawing with one angry eye and a baseball cap, big floppy ears and feet. I encourage her to take it home and work on it some more and bring it back to class next week," said the art therapy intern. 

Another participants also had difficulty with the exercise and was not sure how to identify images within the scribbles. He was polite and very quiet and reserved. He said, “I am not sure what I am supposed to do.” The art therapy intern said, "I worked with him a bit and told him what I was seeing in the drawing.  I showed him the outline of a whale that he had started and his face lit up and he exclaimed, “I saw that too!” This seemed to help him and he continued to quietly work on his drawing. He also has a difficult time finding a title and talking about his work."

While this participants does not title the work, he did talk a bit about the content. The rest of the group commented about his quality of work in the shading and he pointed out the “core” of the shape. "We compare it to the earth. There also seems to be fire, or veins in one of the shapes. We also notice that the scribbles on the bottom seem like water. He makes a comment about the core floating," concluded the art therapy intern. 
 

"The dynamics of the group were good. Everyone was engaged. The timing is still a challenge. It’s hard to give people enough time to create and then have time to process. I need to allow more time for processing of the drawings," the art therapy intern said in closing.

 

 

Case Management Reform - Abstract

Source: Professional Case Management

One Client's Integration Experience

The care managers are the hub of activity at our integrated services program. All communication flows through them; they connect patient, PCP, behavioral health clinicians and other ancillary (but important) staffs. Clients are informing us about their pleasure with their provider experiences and how this differs from what they have experienced elsewhere in their lives as they interfaced with the medical community.

For example, patient "Joe" stopped by one of our care manager's offices. "I had asked him about the Integration program, about Ellen, about how things are going for him," the care manager recounted. He replied, “She listens very well [and] she communicates what’s going on with me. She’s willing to help, which is a big, big thing. She considers everybody like a friend to her.”

The care manager added, "Joe" is the client/patient Ellen saw last week on an acute visit, which resulted in a stream of emails and an “intervention” by all his providers to help him get through this rough patch of time.

 

This is a prime example of the positive experiences of all who are engaging in our integrated services program.

 

 

Happy Halloween!

Writing Retreat

Scribble Drawing Class

Today's art therapy class was about scribble drawing. Clients were given the following instruction by the art therapy intern: "Start by creating a scribble with eyes closed or open. Open your eyes and look at what is on the page. See if you can see any concrete images in your scribble. Finish the drawing by coloring in shapes or adding new lines to create a finished drawing. When you are done, give the drawing a title. Share with the rest of the group how it made you feel. Were there any surprises or images that emerged?"

 

One client had a hard time starting the scribble and wanted to draw with eyes open. The art therapy intern demonstrated how she does a scribble drawing and then the client was able to do this on his own. She reported, "he was very excited to be in the group..." He titled his drawing, “Mountain Park Holyoke” because it reminded him of the colors and rides of Mountain Park. "It seemed like a happy memory for him," concluded the art therapy intern.

 

 

Baseline Evaluation

Provided below is information about baseline data (and preliminary six-month analysis) on the 85 patients currently enrolled in the CHD Health & Wellness integrated services program. With respect to demographics, the group is comprised of approximately 50% under age 45 and 50% over age 45. Sixty percent of the group is female and 38% of the group is male, with 2% reportedly trangendered. Half of the group is Caucasian and one-quarter each is Puerto Rican and African American.

As for functioning, 45% either agree or strongly agree that they are in "excellent health, very good or just good." CHD Health & Wellness patients report low rates of problem use with alcohol and a range of illicit drugs. Less than half of those enrolled report smoking tobacco less than weekly.

No patients report being homeless in the past 30 days. Ninety-five percent had not been admitted to a psychiatric hospital. In the past 30 days, 98% had not been admitted to a detoxification unit, none had been to jail, and 93% had not been admitted to an emergency room.

Two-thirds patients are currently permanently housed. Those who are not housed, include those living in someone else's house, in transitional living, or acute care.

With respect to social connectedness, over 70% of patients report being satisfied with their friendships; 78% have people with whom they do enjoyable things.

Health measures collected at baseline indicate that enrolled patients are at risk. The high rates of risk are for the following indicators: CO measure (46%), weight (4% underweight and 87% obese at risk). One-hundred percent of the enrollees are at risk regarding waist circumference. In addition, according to blood draw results, 78% of the population being served tested at risk for the indicator A1C and 43% tested at risk regarding Triglycerides.

In the following section, outcomes at six-months for the 14 patients, who have matched intake and six-month data, are examined. There was a 14% increase in the number of patients who reported their overall health to be good or better than good at the six-month data point. Those who reported not being bothered by symptoms fell by 29%.

There were improvements in mental health symptoms having to do with feelings of hopelessness (30%), depression (50%), feeling like everything is an effort (25%), and worthlessness (25%). The number of patients feeling little or no nervousness, or restlessness dropped by 40% and 25%, respectively, at the six-month data point in the CHD Health & Wellness program.

There were improvements in the number of patients reporting less than weekly use of cannabis (7%) and prescription opioids (7%) and no change was noted in the number of patients using alcohol less than weekly.

Patients continue to report not being homeless at the six-month data point. There were no admissions to psychiatric hospitals, detoxification units, or incarceration same as program entry. The number of patients receiving school or job training increased by (300%) at the six-month data point yet there was a drop of 40% in those employed at six months.

Source: CAR, Evaluation Report, October 21, 2013

Meeting Meaningful Use Standards

Meaningful use standards. Our two FQHC partners implemented their EMRs, OCHIN-EPIC, with "go live" dates of March 1, 2013 and July 16, 2013, respectively. The Practice Teams are aware of the need to achieve meaningful use and a timeline is in place that should support the achievement of MU by December 2013.

The first FQHC is at the second year of Meaningful Use. This means that its providers use electronic prescribing for more than 40% of prescriptions, assess smoking status in more than 50% of patients, generate a visit summary for patients greater than 50% of the time and generate reminders for visits greater than 20% of the time.

The second FQHC reports that it is currently at Level 2 of the NCQA Primary Care Medical Home (PCMH) and has built into the EMR planning, the attainment of Levels 3 and 4 of PCMH, once staff are fully trained and system is fully implemented. CHC is already using e-prescribing (and does so for more than 40% of prescriptions), tobacco use is assessed for all patients over the age of 12 (and tobacco cessation counseling is available internally), visit summaries are generated in our current paper records (more than 50%), and reminders go out via phone for more than 70% of our patients. The FQHC purchased OCHIN/EPIC. EPIC is the product and OCHIN is the third party seller of the product. Staffs are currently being trained on the use of the product. Discussions are ongoing with CHD Health & Wellness regarding the interface between our EHR and their behavioral health electronic records.

CHD Health & Wellness had already planned to transition to a new electronic medical record (EMR) system called Profiler in advance of award of this grant. As such, other than staff meetings between IT staffs of CHD and the health centers, no additional costs for integration of the systems have been incurred as of yet.

Barriers to Accomplishments. Given constraints of the participating site’s EMRs, there are challenges to integrating the systems which require staff time to facilitate workarounds.

Actions to Overcome Difficulties. In an attempt to reduce as many workarounds as possible, considerable time and effort has been given to mapping out the workflows for staff so that administrative efficiencies may be realized. The original workflows continue to be updated by staff as the project unfolds. Recently, CHD Health & Wellness project manager, Dr. Higgins, began using the workflows as the basis for quality improvement meetings with care managers. During these meetings, staffs continue to identify ways in which to make data entry and EMR use more efficient. Dr. Higgins is also using PDSA analysis to improve efficiency and hopes to supply project funder with her findings at a later time.

CHD Health & Wellness's external evaluation team has developed a dashboard to support the regularly scheduled extraction of data from multiple systems. In July, 2013, the evaluator implemented the first quality assurance process to analyze and improve data extraction processes.

Integration in Practice

"I got word this afternoon that [one of CHD Health & Wellness's] patient's potassium levels were at a critical level," said our care manager. "The clinic nurse got a call from the lab. Meanwhile the endocrinologist called the [FQHC] to alert staffs after directing the patient to the ER. The RN who works with CHD Health & Wellness's PCP called over to CHD Health & Wellness to inform us (at the very same time I was notifying the [FQHC] via the EMR). I then faxed over to the RN the lab report that came to us (CHD Health & Wellness APRN had ordered the testing). Integration services at work!" proudly exclaimed the care manager.

This description of the complex work being provided by CHD Health & Wellness is a prime example of a truly integrated system. Not only are patients more likely to get the most appropriate care needed for their conditions, there is an increased likelihood that clients will willingly obtain medical care due to the increased familiarity of the integrated services team and the proximity of services being provided. For CHD Health & Wellness clients, onsite primary care demystifies the process of obtaining medical care. And as typified by the example provided by CHD Health & Wellness case manager, all team players can communicate with greater ease.