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.