As Gail Kubrin, MD, a psychiatrist at Turtle Creek Valley Mental Health/Mental Retardation, Inc. walks to her office, she scans a computer printout of a Health Report from Margaret, a client who seems to be doing well: no suicidal thoughts, no problems with medication, a stable mood. Then a surprise: Margaret's goal for the session is to find out whether the medications she is taking would interfere with her becoming pregnant.
Raising personal issues can be hard for many clients. But since Turtle Creek turned to Shared Decision Making (SDM), its doctors and therapists are hearing a lot more important questions from clients who had been reticent in the past.
Before Turtle Creek opened its SDM center-only the second like it in the country-Kubrin shared Turtle Creek's recovery-oriented philosophy with clients and strove to make their sessions collaborative. A typical session began with a few minutes of conversation about the person's life, followed by a mental status exam, follow-up on any concerns and, if needed, a medication change.
The SDM process changes this process. Upon arrival, instead of sitting in a waiting room, Margaret enters the Decision Support Center, where a peer support specialist greets her, offering a healthy snack and beverage. Margaret then touches a screen to open a screen to open a computer program that lists her past and current medications, her “Power Statement”-a statement she prepared to identify what is most important in her life, so that her treatment team can recommend medication and supports needed to succeed in that area. She also makes notes on how she has been using her “Personal Medicine”-things that she does to make her feel good about herself and her life (like calling her sister, knitting sweaters for friends, and reading travel books).
Then she responds to prompts for additional information:
Symptoms since last visit
Severity of recent symptoms
Comparison of symptoms/severity at other recent visits
Use of medications and any side effects
Update medical status/status exam (the software records “problem” areas in red, to ensure these are readily seen and addressed by the psychiatrist during the visit.)
Questions for the doctor
Goal for the visit
SDM builds “a culture of recovery”
In March of 2008, Turtle Creek launched its SDM program using CommonGround, an innovative, peer-run, computer-based program developed by Pat Deegan & Associates (PDA). Designed to facilitate shared decision making between provider staff and consumers, the program has been described as an “amplifier” that helps consumers organize and express their concerns clearly. Community Care Behavioral Health (part of the insurance division of UPMC), the MBHO for Pennsylvania's Medicaid program in 36 Pennsylvania counties, worked with Allegheny County's Office of Behavioral Health to apply for and win “reinvestment” dollars for program funding from the state's HealthChoices program.
Then-Executive Director Judy Monahan-Grystar was clear about her reasons for implementing SDM at Turtle Creek. She sees decision support as “a plus for the consumer because it gives them a voice. And I think the traditional process has not allowed for that voice.” She says that the process “brings the team together around one set of goals”-the consumer's. The reasoning is shared by her successor, Fran Sheedy Bost.
Community Care, who had been working with PDA on a comprehensive recovery-focused initiative, saw SDM as a program that would make its commitment to recovery tangible throughout the provider network. James Schuster, MD, CMO, of Community Care describes it as “an intensive and expressive form of informed consent” that could help to spread a “culture of recovery” throughout provider organizations.
To support providers who were implementing SDM, Community Care designated several “recovery specialists” within the organization, trained them on the CommonGround system, and made them available to support providers, along with training and technical support from PDA.
Susan Preffer, coordinator for Turtle Creek's SDM program, explains that the problem with the typical doctor-client visits is that the client is mostly passive-answering questions, receiving advice, taking medication. It's a scenario that, over time, can make clients feel powerless.
“My biggest frustration,” says one, “was that doctors thought they knew what was best for me and I started believing [them].” Despite trying several different medications, the client says that “I just wasn't getting any better, and my life was falling apart.” As she used the tools, the client “learned that I have an important part to play in my own recovery, because this is about me, and what I think is important.”
The dynamic plays well with professionals, too. Kubrin reports that she no longer feels that she has to “fix” things for her clients. Instead, she senses that they are a team, shaped by client goals and supported by client resources. It's a more equal-and human-relationship.
In typical treatment settings, physicians review reports about a client made by other providers. But the CommonGround software changes all that. For the first time, “the physician sees a report about the client that is from the client's point of view,” says Darlene Karpaski, Turtle Creek's director of rehabilitation and decision support services. “Seeing a client using that report to talk to the doctor, who has the same document on his or her computer, is paradigm shifting.” Because resulting decisions are shared, clients are committed, secure in the knowledge that they can consider other strategies with their doctor if the chosen one doesn't work.