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Service Delivery Innovation Profile

Shared Decisionmaking Tools Plus Peer Support Lead to More Efficient and Effective Mental Health Consultations and High Satisfaction


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Snapshot

Summary

A program known as CommonGround uses paper-based and computerized decision support tools and peer specialists to help mental health clients identify treatment preferences and effectively communicate them to clinicians. Before meeting with a clinician, clients spend roughly 30 minutes working through a decision support tool that generates a consultation report and self-management suggestions for reference during the subsequent 15-minute consultation. The clinician and the client review the report and access additional decision aids to address specific concerns. Peer specialists are available to assist with completion of the initial tool and to help the client access additional information or complete other decision aids after the visit. The program has proven easy for people diagnosed with mental illness to use; has led to frequent use of shared decisionmaking between clinician and patients; and has increased the effectiveness and efficiency of consultations, leading to high levels of satisfaction among clients. Ongoing studies are evaluating the program's impact on clinical outcomes.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation analysis of use of the program and the shared decisionmaking approach (including analysis of 98 audiotaped transcripts from clinic visits), feedback from clinician and client focus groups on the efficiency and effectiveness of consultations, and the results from client surveys exploring various aspects of their satisfaction with the program.
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Developing Organizations

Pat Deegan, PhD & Associates
Pat Deegan, PhD & Associates is located in Byfield, MA.end do

Use By Other Organizations

As of June 2013, this program is currently being used by 72 organizations (including state hospitals, public sector outpatient clinics, peer centers, and assertive community treatment teams) in Kansas, Pennsylvania, Massachusetts, California, Indiana, and Oregon; 20 of these organizations use the Web-based software program, while 52 use the paper-based tools only.

Date First Implemented

2006
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Patient Population

Vulnerable Populations > Mentally illend pp

Problem Addressed

Shared decisionmaking—the collaboration between patients and caregivers in reaching an agreement about a health care decision—can be useful when medical evidence does not suggest a clearly optimal treatment option,1 as frequently occurs with patients suffering from mental illness. Yet few mental health practices offer shared decisionmaking to patients.
  • Potential benefits of shared decision making in mental health: In shared decisionmaking, the caregiver provides information about the possible outcomes of various treatment options, encourages the patient to consider aspects of each option that are personally important, and encourages the patient to fully participate in decisions about medical care.1 Shared decisionmaking processes often make sense with patients suffering from mental health issues, because a medication's effectiveness for a given individual is often uncertain, and risk profiles of equally efficacious medications can vary widely.2 Shared decisionmaking allows the clinician and the mental health client to identify both nonpharmacological strategies and medical therapies to improve wellness.2
  • Failure to offer shared decisionmaking in mental health care: Conventional models of mental health care often do not focus on shared decisionmaking.2 Rather, most mental health care focuses on encouraging client compliance with a physician-determined medication regimen.2 One barrier to shared decisionmaking may be the brevity of visits, which typically last 15 minutes; the clinician may find it difficult to answer all client questions or embark upon a nuanced exploration of treatment risks and benefits during such a short visit.3 A second barrier may relate to a clinician not viewing the patient as being capable of participating in decision making. However, research clearly shows that even individuals with major mental disorders are fully competent to participate in shared decisionmaking and to provide informed consent.3
  • Unrealized benefits of decision support tools: Decision support tools can facilitate shared decisionmaking by increasing patients’ knowledge about their conditions and treatment options, reducing decisional conflict, improving visit efficiency, and prompting better adherence to treatment regimens that reflect patient preferences.2,4 Yet few mental health providers currently offer such tools to patients.

What They Did

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Description of the Innovative Activity

Paper-based and computerized decision support tools and peer specialists help mental health clients identify treatment preferences and effectively communicate them to clinicians. Before meeting with a clinician, clients spend roughly 30 minutes working through a decision support tool that generates a consultation report and self-management suggestions for reference during the subsequent 15-minute consultation. The clinician and the client review the report and access additional decision aids to address specific concerns. Peer specialists are available to assist with completion of the initial tool and to help the client access additional information or complete other decision aids after the visit. Key elements of the approach include the following:
  • Program logistics: The clinic's waiting area is transformed into a peer-run decision support center, with semiprivate study carrels equipped with computers and headphones. Appointments are scheduled to accommodate 30 minutes of work in the center before meeting with the clinician.
  • Peer specialists to welcome and assist clients: Peer specialists (i.e., people on staff who are in recovery from a major mental disorder) welcome clients to the center, offer them a healthy snack and beverage, listen to their needs, provide emotional support if necessary, and help them access and use the decision support tool.
  • Computerized decision support tool/survey: Before each visit, clients typically use a touch-screen decision support tool to help them prepare for the consultation. (Clinics without computer access use a paper-based decision support tool.) The software presents information about mental illness recovery, plays video vignettes of people discussing how they achieved recovery, and emphasizes the importance of "personal medicines" (individualized nonpharmacological strategies that promote wellness). With assistance from the peer specialist if needed, clients also complete a survey about their symptoms and functioning, medication compliance, concerns related to psychiatric medicines (such as their impact on health), and goals related to medication use (known as the "power statement"). As of December 2009, 4,783 clients had used the software program. The output from this decision support system consists of two reports, outlined below:
    • Consultation report: Clients print a one-page summary report for reference during the consultation. The report helps clients organize their thoughts and concerns, thus allowing them to communicate more effectively with the clinician (who also receives an electronic version of the report). If desired, the client may choose to discuss the report's contents with the peer specialist before the clinician consultation.
    • Self-management suggestions: Based on the client’s responses, the computer software automatically generates self-management and recovery suggestions. For example, if a client indicates that he or she is struggling with sleep or hearing voices, the software will generate suggestions for self-care strategies. These strategies are printed on a personal medicine card for the client, and forwarded electronically to the clinician.
  • Joint client–clinician report review, including access to other support: During the 15-minute consultation, the client and the clinician review the report and the self-management suggestions, quickly honing in on specific concerns and overall progress. As part of this process, the clinician can access (via automatic prompts on his or her computer) other printable, topic-specific decision support tools and worksheets to help clients work through specific concerns. For example, tools may help clients list and rate the relative importance of the benefits and drawbacks of medical therapy and develop solutions to offset the drawbacks. Examples of available decision aids include the Ottawa Personal Decision Guide, the Agency for Healthcare Research and Quality (AHRQ) publication Antidepressant Medicines—A Guide for Adults With Depression, and tools developed by Pat Deegan, PhD & Associates. The system also provides links to nonindustry sponsored sources of information related to specific concerns the client may have.
  • Postappointment support from peer specialist: After the consultation, the client or clinician can request additional help from the peer specialist, typically with activities that could not be addressed during the visit due to time constraints. For example, the peer specialist can provide references or referrals to community resources, assist with completion of the additional decision support tools, help explore external Web sites, or create a medication reminder system.
  • Ongoing tracking of mental health status: Because surveys are completed at each visit, the software helps clients monitor their recovery. At subsequent visits, clients can use the software to track trends in symptoms, links between symptoms and medication use, and/or links between symptoms and substance use.

Context of the Innovation

Pat Deegan, PhD & Associates, a small company founded and operated by individuals in recovery from psychiatric disorders, develops innovative processes and technologies to support recovery from mental illness. Dr. Deegan believes that individuals with major mental illness have the right to receive person-centered care and, therefore, to receive unbiased information and participate in decisions regarding treatment. She developed CommonGround as a way to operationalize those values in everyday practice. Practice settings that have adopted CommonGround include public mental health clinics and state hospitals that serve patients with major mental disorders and co-occurring substance use disorders. These patients range in age from 18 to 65 years old, have typically been disabled for many years, and may have low literacy.

Did It Work?

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Results

The program has proven easy for people diagnosed with mental illness to use, has led to frequent use of shared decisionmaking between clinicians and patients, and has increased clinicians' ability to identify whole health concerns. The program has also increased the effectiveness of consultations, leading to high levels of satisfaction among clinicians and patients. Ongoing studies are evaluating the program's impact on clinical outcomes.
  • Easy to use: Contrary to conventional wisdom that people with mental illness cannot use these types of shared decisionmaking tools, descriptive studies of CommonGround indicate that individuals with major mental illness do use the program, with one clinic finding that 90 percent of clients used the software.3
  • Frequent use of shared decisionmaking: Doctors who use CommonGround report entering into shared decisions with clients during 86.7 percent of consultations.3
  • Increases identification of whole health concerns: According to information provided in June 2011, when the program was used to address health and lifestyle behaviors, the most frequently discussed behaviors were sleep (89 percent) and diet (61 percent). The clinician and patient came to a shared decision addressing their whole health concerns 44 percent of the time.5
  • More effective communication and consultations, leading to high levels of satisfaction: Both clinicians and patients report that the program has enhanced the effectiveness of communication between them and of the overall consultation:
    • Positive feedback from clinicians: Clinicians believe the program has led to greater visit efficiency and effectiveness by facilitating client preparation and involvement in treatment discussions. Clinicians also report that the program helps improve their own shared decisionmaking skills, better understand their clients' lives, concerns and preferences, and focus more quickly on client concerns during the brief time available for the visit.6 In a number of cases, clinicians have found that clients are willing to disclose information via the computer that had not previously been discussed in face-to-face conversations.7
    • Positive feedback from clients: Clients report that the program helps to ensure that they cover all of their concerns during the visit, and that completing the tool leads to a sense of accomplishment. Some—notably those with acute psychosis—report that the program enabled them to better organize their thoughts and concerns before the appointment.6 In a survey asking clients to compare their office visits before and after program implementation, 77.6 percent reported an enhanced ability to discuss their concerns about medicines, 61.3 percent reported that the quality of their time with the doctor had improved, 59.8 percent reported being better able to identify "personal medicines," and 90.5 percent reported being satisfied overall with CommonGround.8

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation analysis of use of the program and the shared decisionmaking approach (including analysis of 98 audiotaped transcripts from clinic visits), feedback from clinician and client focus groups on the efficiency and effectiveness of consultations, and the results from client surveys exploring various aspects of their satisfaction with the program.

How They Did It

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Planning and Development Process

CommonGround typically entails an 11-step implementation plan, with multiple detailed substeps (more information on this process can be obtained from the program developer). A brief overview of selected major steps include the following:
  • Establishing leadership team: A team of physicians, clinic staff, and information technology personnel typically oversees program development and implementation.
  • Conducting readiness assessment: The team conducts an assessment to determine whether the organization is ready to adopt CommonGround, which requires a shift to a culture of shared decisionmaking.
  • Designating champion(s): The leadership team designates one or two champions (one of whom should be a senior staff person) to oversee the implementation within a particular site.
  • Hiring, training peer specialists: If no current employee can serve as a peer specialist, the organization hires and trains someone to serve in this role, which can either be a part-time or full-time position. The peer specialist attends an 8-hour onsite training session and receives a written job description.
  • Implementing hardware/software: The team arranges for the purchase of computer equipment (if needed), software, and study carrels, and for relevant individuals to receive training on the software.
  • Training medical staff: The medical staff participates in a 3-hour onsite training session to learn about the program. The clinicians learn to use the software, learn to read the clients' CommonGround report and incorporate it into their "exam," and learn to write a shared decision that meets fidelity standards.
  • Notifying clients: Those adopting the program send a letter to clients describing CommonGround and its availability to them going forward.

Resources Used and Skills Needed

  • Staffing: The program typically requires the hiring of one or more peer specialists to cover clinic hours.
  • Costs: Upfront development costs include the purchase of computers and fees associated with initial training. Ongoing costs include the salary and benefits of the peer specialist and a $2 monthly licensing fee per user.
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Funding Sources

Adopting clinics have either funded the program internally or obtained external grants to support it. In some instances, managed care companies have been willing to finance adoption of the program. In some states, peer staff can bill for their consultations, which helps to cover the costs of their compensation.end fs

Tools and Other Resources

Interested adopters can contact Pat Deegan for access to implementation and shared decisionmaking tools.

Information about CommonGround, including a 3-minute demonstration video, is available at
http://www.patdeegan.com/commonground.

The Ottawa Personal Decision Guide is available at http://decisionaid.ohri.ca/decguide.html.

The AHRQ publication entitled Antidepressant Medicines—A Guide for Adults With Depression is available at http://www.effectivehealthcare.ahrq.gov/ehc/products/7/10/AntidepressantsConsumerGuide.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

Adoption Considerations

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Getting Started with This Innovation

  • Assess organizational readiness for adoption: Because adopting CommonGround requires a willingness to promote a culture change within the institution, the organization should conduct a readiness assessment before implementation. This assessment includes an evaluation of the computer literacy of staff, access to Internet-enabled computers, willingness to hire peer staff, medical director interest, and experience with implementation of evidence-based practices.
  • Develop framework for employing peer staff: The institution must develop policies and procedures to support and guide use of peer staff, such as determining whether they will be allowed to access medical records.
  • Recognize as systemic intervention, and prepare accordingly: CommonGround involves clinicians, case managers, receptionists and peer staff, and therapists, and affects the treatment planning process and communication among caregivers and between caregivers and patients. This type of systemic intervention requires organizational leaders to define staff roles and to promote a culture that focuses on recovery and shared decisionmaking.
  • Avoid concurrent adoption of technologies: Do not implement this program simultaneously with the adoption of other electronic technologies (such as an electronic medical record), as the concurrent adoption of distinct technologies can often be highly disruptive for staff.

Sustaining This Innovation

  • Sustain focus via program champion: This individual can help staff learn to use the various features of the software and keep them focused on the value of shared decisionmaking. The program champion can also attend a monthly program webinar that provides training and technical support.
  • Review monthly data: Those adopting the program can tap into comparative data on software use and outcomes, thus allowing users to compare their own clinic’s experience with the program with that of others using it.

Use By Other Organizations

As of June 2013, this program is currently being used by 72 organizations (including state hospitals, public sector outpatient clinics, peer centers, and assertive community treatment teams) in Kansas, Pennsylvania, Massachusetts, California, Indiana, and Oregon; 20 of these organizations use the Web-based software program, while 52 use the paper-based tools only.

More Information

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Contact the Innovator

Patricia E. Deegan, PhD
Director
Pat Deegan, PhD & Associates LLC
17 Forest Street
Byfield, MA 01922
E-mail: pat@patdeegan.com

Innovator Disclosures

Dr. Deegan has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Deegan PE, Rapp C, Holter M, et al. Best practices: a program to support shared decision making in an outpatient psychiatric medication clinic. Psychiatr Serv. 2008;59(6):603-5. [PubMed] Available at: http://ps.psychiatryonline.org/article.aspx?articleid=99448.

Deegan PE, Drake RE. Shared decision making and medication management in the recovery process. Psychiatr Serv. 2006;57(11):1636-9. [PubMed]

Deegan PE. A Description of a Web Application to Support Recovery and Shared Decision Making in Psychiatric Medication Clinics. Unpublished manuscript.

Footnotes

1 Dartmouth-Hitchcock Medical Center. Center for Shared Decision-Making. About Shared Decision Making [Web site]. Available at: http://patients.dartmouth-hitchcock.org/shared_decision_making/about_shared_decision_making.html
2 Deegan PE, Drake RE. Shared decision making and medication management in the recovery process. Psychiatr Serv. 2006;57(11):1636-9. [PubMed]
3 Interview with Patricia Deegan, June 9, 2010.
4 O'Connor AM, Rostom A, Fiset V, et al. Decision aids for patients facing health treatment or screening decisions: systematic review. BMJ. 1999;319:731-4. [PubMed]
5 Hamera E, Pallikkathayil L, Baker D, et al. Descriptive study of shared decision making about lifestyle modifications with individuals who have psychiatric disabilities. J Am Psychiatr Nurses Assoc. 2010;16(5):280-7. [PubMed]
6 Deegan PE, Rapp C, Holter M, et al. Best practices: a program to support shared decision making in an outpatient psychiatric medication clinic. Psychiatr Serv. 2008;59(6):603-5. [PubMed] Available at: http://ps.psychiatryonline.org/article.aspx?articleid=99448
7 Goscha RJ. Finding Common Ground: Exploring the Experiences of Client Involvement in Medication Decisions Using a Shared Decision Making Model. Unpublished manuscript (doctoral dissertation).
8 Community Care Behavioral Health, Pittsburgh, PA. Unpublished data.
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: July 07, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 27, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: July 09, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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