December 1st, 2010

Shared decision making embraces consumers

Shared decision making (SDM) is an interactive, collaborative process between consumers and their health care providers about decisions pertinent to the consumer’s treatment and services, according to the Substance Abuse and Mental Health Services Administration. The SDM model promotes self-determination and empowerment and enhances consumer involvement in health care. The Institute of Medicine cited consumer-centered care and approaches like SDM as a way to achieve better outcomes in mental health care and substance abuse in its 2006 report, “Crossing the Quality Chasm.”

SDM has gained traction in physical health care and is starting to make inroads in mental health care as a cornerstone of recovery-oriented services, says Jonathan Delman, J.D., M.P.H., D.Sc. (cand.), executive director of Mass.-based Consumer Quality Initiatives (CQI), an organization dedicated to mental health care improvement.

In June 2009, CQI and the Massachusetts Department of Mental Health (DMH) convened a policy summit in Waltham, Mass. to determine how SDM could be rolled out in the state system. The summit generated a white paper that was released this past August. With the summit and the white paper, Delman hopes to engage behavioral health leaders to get on board with incorporating SDM in mental health services. Recently, several DMH providers began using the white paper as a blueprint for delivering treatment to consumers consistent with the SDM approach, reports DMH spokesperson Anna Chinappi.

SDM achieves person-centered care by employing a secret weapon: decision support tools to help consumers work through treatment options. The tools are brochures, videos and interactive Web-based applications. CommonGround is one such application that helps consumers get the most out of medication management appointments.

The Massachusetts Behavioral Health Partnership adopted CommonGround and is in year three of a pilot program for medication management at two outpatient clinics, Advocates, Inc. in Framingham and the Edinburgh Center in Lexington. The clinic waiting rooms were converted into decision support centers where peer specialists help consumers step through the CommonGround online interface. Consumers emerge with a single-page health report that summarizes progress and concerns. They use the report as a prompt during the face-to-face with their prescriber.

“The CommonGround tool is designed to prepare consumers to have a conversation with the psychiatrist about their medication and whatever issues they want to address and reach a mutual plan,” says Anne Pelletier Parker, LICSW, vice president of network management and recovery initiatives at MBHP. When CQI surveyed consumers after their first CommonGround appointment, 68 percent felt the application helped them communicate better with their prescriber, Parker says.

One of the biggest benefits of SDM is helping consumers choose among “preference-sensitive” options, which are treatment options of equal efficacy whose only differentiator is how the consumer evaluates the risks and benefits.

“It’s hard to predict how antipsychotic medications will affect someone, but the side effects are well known,” says Delman, who has bipolar disorder. “If you get to express a preference between, say weight gain and sedation, you’re more likely to be prescribed a medication you’ll take.”

Additional SDM benefits include increased service satisfaction, decreased symptom burden and improved self-management and self-esteem as consumers become more active in treatment decisions.

Dartmouth Medical School professor Robert Drake, M.D., Ph.D., was an early proponent of SDM. He says that while all collaborative care models aim for a shared decision making ideal, they fall short of providing all the information consumers need in a structured, decision-supported process that also involves their social support network. At the Dartmouth-Hitchcock Medical Center, Drake says, women with early stage breast cancer are sent to the shared decision making center right after diagnosis to learn about their treatment options.

Proponents say there is no reason SDM can’t be applied to psychology as well as psychiatry, but there are few examples in practice. The theoretical model, says Paolo del Vecchio, M.S.W., SAMHSA’s director for consumer affairs, is for a provider or a decision aid to describe the various treatment modalities, risk/benefits, and costs for, say, cognitive behavioral therapy versus psychoanalysis versus medication for depression. Armed with the information, the consumer can make an informed decision with the provider about which approach to take.

This is far from today’s reality in which psychology is a “cottage industry,” Drake says, where providers hang out a shingle and treat whoever crosses their threshold in the modality they were trained in.

“But none of it is based on what’s best for you,” Drake says. “Its based on the chance of what door you walk through.”

For SDM to work in psychology, Delman says, a decision or question must be posed. This can stymie some therapists who are not trained – or inclined – to talk to consumers about choices.

“It’s hard for some providers to believe there are any options other than the one they believe in. That’s the mindset and it needs to be broken,” Delman says. “Because the doctor isn’t always right anymore. It doesn’t jive with person-centered care.”

A search of ClinicalTrials.gov revealed several New England-based decision aids in the works. The VA Medical Center at White River Junction, Vt. developed a 25-page booklet of treatment options for Posttraumatic Stress Disorder. UMass Boston in collaboration with the Foundation for Informed Medical Decision Making at Massachusetts General Hospital developed a DVD and booklet about coping with depression. Rhode Island Hospital and the Agency for Healthcare Research and Quality developed a Web-based decision aid to help women going through menopause make treatment choices.

Health insurance companies have expressed interest in applying SDM to their provider networks. They are interested for two reasons, says SAMHSA’s del Vecchio. First, to help increase the efficiency of the clinical encounter; second, to achieve better outcomes when people become more engaged in their treatment.

Drake says SDM won’t always lead to health care savings, if, for example, a consumer chooses therapy over medication for depression.

“Most people get offered medication first because in managed care, medication is cheaper,” Drake says. “But we ought to give people a choice and force insurance companies to pay for reasonable alternatives.”

By Nan Shnitzler

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