Measuring Change: What's your commitment to, and motivation level for change?

Source: Understanding New York City's Mental Health Challenge

  • "At least one in five New Yorkers is likely to experience a mental health disorder in any given year."
  • "8% of NYC public high school students report attempting suicide."
  • "Each year, 1,800 deaths and upwards of 70,000 emergency room visits among adults aged 18 to 64 can be attributed to alcohol use."

  • "73,000 New York public high school students report feeling sad or hopeless each month."

  • "At any given time, over half a million adult New Yorkers are estimated to have depression, yet less than 40% report receiving care for it." 

---------------------

The prevalence of acute mental distress, chronic mental disorders and behavioral risks, as illustrated by data drawn from NYC, has been well-documented across the country. While statistics and research aggregate and frame these rates in orderly and understandable statements of facts and figures, let's not forget the ultimate risk and marker of impact is death and loss. The basic question remains -- How is it that, in an advanced and modern industrialized society, suicide remains a constant risk as a leading cause of death? How is it that unintentional deaths from drug overdoses and alcohol misuse continue to plague a fragmented care system focused on avoidable admission as its singular marker for change? The answer lies, in part, on the lack of an integrated delivery system that includes behavioral health, on a continued acute single factorial care model, and on our own motivation, or lack thereof, for change. During this search to improve our system of care, there is one constant fact to remember. When a patient chart is closed due to suicide or a preventable behavioral risk severely impacting health, such as uncontrolled diabetes, it is partly due to the lack of solution tools and supports available to the provider and the absence of an integrated care system that is able to act in a timely, coordinated and blended manner.

With the push for innovative care models focused on collaborative care and care management strategies, the re-tooling of clinical services and administrative processes must address gaps in care and reduce utilization of the most costly services, while at the same time achieving the desired patient outcomes inherent in the "Triple Aim". To measure these elements of a successful clinical change on behalf of the patient, let's move from the macro level of population health with its set of aggregated and manicured data to concrete clinical pathways of care. The focus must be on defining the detail-specific clinical treatment risks the provider is responsible for with patient engagement. We need to define  the supports and clinical re-tooling needed to transition the paradigm from acute medical care to integrated collaborated care.

Moving population health goals from the national lens to the local community level and patient-specific need is essential in understanding the needs for patient engagement and the provider's role in population health management and change. The development of an evidence practice center (EPC) in each care system is critical for mapping specific patient needs and risks; but, more importantly, it helps the provider understand where each patient fits into the landscape of risks and norms, as well as receptivity to a culturally relevant, evidence based practice. It is important to provide a communication platform for clinical and administrative guidance, and to maintain an exchange of timely information across care systems. Intelligently designed platforms are necessary to capture gaps in care, to flag risks before they escalate to acute care, and to accurately identify and measure the impact of defined clinical steps highlighted by the EPC. Protocols for engagement and treatment adherence are necessary tools to establish and ensure successful coordination across the delivery systems. Care coordination for a blended and collaborative treatment model requires the switch from an acute medical care paradigm to a true integrated care model that addresses the emotional, behavioral and social determinants that oftentimes play heavily in treatment adherence and risk. 

To help the clinical workforce take on this challenge of a model change, one must address the culture of the agency and its commitment to change. Patient engagement and our own understanding of a patient's motivation to engage in treatment is another key to meeting a patient's needs. For example, does the clinical staff understand that motivation for change comes in stages, and that it is critical to help a patient understand that self-motivation is critical in helping the individual actively engage in his/her own treatment? Training on how to assess and implement Motivational Interviewing (MI) is only one of the steps in this process. It is just as critical to understand how and when to use MI in the treatment of the complex chronic care patient.  

This brings us all back to the question: What is your own motivation for change? And, how are you using this concept and measuring it as a system or as a provider facing a substantial transition in the provision of care?

Read more here on prior Issue Briefs addressing integrated care.