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  • 1. Deegan, Patricia E.
    et al.
    Rapp, Charles
    Holter, Mark
    University of Kansas.
    Riefer, Melody
    Best Practices: A Program to Support Shared Decision Making in an Outpatient Psychiatric Medication Clinic2008In: Psychiatric Services, ISSN 1075-2730, E-ISSN 1557-9700, Vol. 59, no 6, p. 603-605Article in journal (Refereed)
    Abstract [en]

    The Institute of Medicine ( 1 ) has found the quality chasm framework to be applicable to health care for people with mental health and substance use disorders, and it cites shared decision making as one of the top ten rules to guide the redesign of health care. Shared decision making has been defined as a collaborative process between a client and a practitioner, both of whom recognize one another as experts and work together to exchange information and clarify values in order to arrive at health care decisions ( 2 , 3 ).

    Decision aids for practitioners and clients have been developed in general health care to support the shared decision-making process ( 4 ). Decision aids are particularly helpful in reducing decisional conflict associated with making challenging choices in which there are benefits and risks associated with treatment or when empirical evidence is inconclusive or incomplete ( 5 ). Deegan and Drake ( 6 ) have argued that shared decision making and the use of decision aids related to medication management in psychiatry is an ethical imperative, is consistent with the long-standing tradition of building therapeutic alliances in treatment collaboration, and is a superior approach to medical paternalism and insistence on medication compliance.

    In this column, we describe a 12-month pilot program to begin to identify best practices for shared decision making in an outpatient psychiatric medication clinic. The primary intervention was the transformation of a typical waiting area in an urban, midwestern psychiatric medication clinic into a peer-run Decision Support Center (DSC). Services at the DSC included establishing peer-specialist protocols to support a welcoming environment, offering a healthy snack and beverage, assisting clients in completing a one-page computer-generated report for use in the medication consultation, giving clients access to health-related information via the Internet, providing informal peer support, and providing support with completing decision aids for helping clients address areas of decisional conflict related to medication use. Medication appointments were redefined to include 30 minutes of work in the DSC before meeting with a physician or nurse.

  • 2.
    Jones, Kristine
    et al.
    Nathan S. Kline Institute for Psychiatric Research.
    Colson, Paul W
    Charles P. Felton National Tuberculosis Center, NYC.
    Holter, Mark
    University of Michigan.
    Lin, Shang
    Nathan S. Kline Institute for Psychiatric Research.
    Valencia, Elie
    Parnassia Psychiatric Institute, The Netherlands.
    Susser, Ezra
    Columbia University, NYC.
    Wyatt, Richard J
    National Institute of Mental Health in Bethesda, Maryland.
    Cost-effectiveness of critical time intervention to reduce homelessness among persons with mental illness2003In: Psychiatric Services, ISSN 1075-2730, E-ISSN 1557-9700, Vol. 54, no 6, p. 884-890Article in journal (Refereed)
    Abstract [en]

    Objectives: Cost-effective programs are needed to assist homeless persons with severe mental illness in their transition from shelters to community living. The authors investigated the cost-effectiveness of the critical time intervention program, a time-limited adaptation of intensive case management, which has been shown to significantly reduce recurrent homelessness among men with severe mental illness. Methods: Ninety-six study participants recruited from a psychiatric program in a men's public shelter from 1991 to 1993 were randomly assigned to the critical time intervention program or to usual services. Costs and housing outcomes for the two groups were examined over 18 months. Results: Over the study period, the critical time intervention group and the usual services group incurred mean costs of $52,374 and $51,649, respectively, for acute care services, outpatient services, housing and shelter services, criminal justice services, and transfer income. During the same period, the critical time intervention group experienced significantly fewer homeless nights than the usual care group (32 nights versus 90 nights). For each willingness-to-pay value - the additional price society is willing to spend for an additional nonhomeless night - greater than $152, the critical time intervention group exhibited a significantly greater net housing stability benefit, indieating cost-effectiveness, compared with usual care. Conclusions: Although difficult to conduct, studies of the cost-effectiveness of community mental health programs can yield rich information for policy makers and program planners. The critical time intervention program is not only an effective method to reduce recurrent homelessness among persons with severe mental illness but also represents a cost-effective alternative to the status quo.

  • 3.
    Mowbray, Carol T
    et al.
    University of Michigan.
    Grazier, Kyle L
    University of Michigan.
    Holter, Mark
    University of Michigan.
    Managed behavioral health care in the public sector: Will it become the third shame of the states?2002In: Psychiatric Services, ISSN 1075-2730, E-ISSN 1557-9700, Vol. 53, no 2, p. 157-170Article in journal (Refereed)
    Abstract [en]

    Managed behavioral health care is increasingly being used in public mental health systems. While supporters cite potential benefits, critics describe dire consequences for individuals with serious, long-term mental illness. The situation has parallels with the major changes resulting from deinstitutionalization some four decades ago. Believing that analyzing history may prevent repeating some of its mistakes, the authors compare the antecedents, benefits, and negative effects of deinstitutionalization with those of the public-sector managed behavioral health care systems being developed today. Lessons learned from the earlier era include the need for careful general and technical planning; for assignment of responsibility, including monitoring, to the public sector; and for a focus on clients and the special needs generated by severe mental illnesses.

  • 4.
    Salyers, Michelle P
    et al.
    Indiana University–Purdue University Indianapolis.
    Fukui, Sadaaki
    University of Kansas.
    Bonfils, Kelsey A
    Indiana University–Purdue University Indianapolis.
    Firmin, Ruth L
    Indiana University–Purdue University Indianapolis.
    Luther, Lauren
    Indiana University–Purdue University Indianapolis.
    Goscha, Rick
    University of Kansas.
    Rapp, Charles A
    University of Kansas.
    Holter, Mark
    University of Kansas.
    Consumer outcomes after implementing CommonGround as an approach to shared decision making2017In: Psychiatric Services, ISSN 1075-2730, E-ISSN 1557-9700, Vol. 68, no 3, p. 299-302Article in journal (Refereed)
    Abstract [en]

    Objective: The authors examined consumer outcomes before and after implementing CommonGround, a computerbased shared decision-making program. Methods: Consumers with severemental illness (N=167) were interviewed prior to implementation and 12 and 18 months later to assess changes in active treatment involvement, symptoms, and recovery-related attitudes. Providers also rated consumers on level of treatment involvement. Results: Most consumers used CommonGround at least once (67%), but few used the program regularly. Mixed-effects regression analyses showed improvement in self-reported symptoms and recovery attitudes. Self-reported treatment involvement did not change; however, for a subset of consumers with the same providers over time (N=83), the providers rated consumers as more active in treatment. Conclusions: This study adds to the growing literature on tools to support shared decision making, showing the potential benefits of CommonGround for improving recovery outcomes. More work is needed to better engage consumers in CommonGround and to test the approach with more rigorous methods.

  • 5.
    Salyers, Michelle P
    et al.
    Indiana University-Purdue University Indianapolis.
    Matthias, Marianne S
    Roudebush Veterans Affairs Medical Center, Indianapolis; Indiana University-Purdue University Indianapolis.
    Fukui, Sadaaki
    University of Kansas.
    Holter, Mark
    University of Kansas.
    Collins, Linda
    Roudebush Veterans Affairs Medical Center, Indianapolis.
    Rose, Nichole
    Indiana University-Purdue University Indianapolis.
    Thompson, John B.
    University of Kansas.
    Coffman, Melinda A
    University of Kansas.
    Torrey, William C
    Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
    A coding system to measure elements of shared decision making during psychiatric visits2012In: Psychiatric Services, ISSN 1075-2730, E-ISSN 1557-9700, Vol. 63, no 8, p. 779-784Article in journal (Refereed)
    Abstract [en]

    Objective: Shared decision making is widely recognized to facilitate effective health care. The purpose of this study was to assess the applicability and usefulness of a scale to measure the presence and extent of shared decision making in clinical decisions in psychiatric practice. Methods: A coding scheme assessing shared decision making in general medical settings was adapted to mental health settings, and a manual for using the scheme was created. Trained raters used the adapted scale to analyze 170 audio-recordings of medication check-up visits with either psychiatrists or nurse practitioners. The scale assessed the level of shared decision making based on the presence of nine specific elements. Interrater reliability was examined, and the frequency with which elements of shared decision making were observed was documented. The association between visit length and extent of shared decision making was also examined. Results: Interrater reliability among three raters on a subset of 20 recordings ranged from 67% to 100% agreement for the presence of each of the nine elements of shared decision making and 100% for the agreement between provider and consumer on decisions made. Of the 170 sessions, 128 (75%) included a clinical decision. Just over half of the decisions (53%) met minimum criteria for shared decision making. Shared decision making was not related to visit length after the analysis controlled for the complexity of the decision. Conclusions: The rating scale appears to reliably assess shared decision making in psychiatric practice and could be helpful for future research, training, and implementation efforts.

  • 6.
    Salyers, Michelle P.
    et al.
    Indiana University-Purdue University Indianapolis.
    Matthias, Marianne S.
    Indiana University-Purdue University Indianapolis.
    Fukui, Sadaaki
    University of Kansas.
    Holter, Mark
    University of Kansas.
    Collins, Linda
    Roudebush Veterans Affairs Medical Center, Indianapolis.
    Rose, Nichole
    Indiana University-Purdue University Indianapolis.
    Thompson, John Brandon
    University of Kansas.
    Coffman, Melinda A.
    University of Kansas.
    Torrey, William C.
    Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Dartmouth Psychiatric Research, Lebanon, New Hampshire.
    A Coding System to Measure Elements of Shared Decision Making During Psychiatric Visits2012In: Psychiatric Services, ISSN 1075-2730, E-ISSN 1557-9700, Vol. 63, no 8, p. 779-784Article in journal (Refereed)
    Abstract [en]

    Objective:Shared decision making is widely recognized to facilitate effective health care. The purpose of this study was to assess the applicability and usefulness of a scale to measure the presence and extent of shared decision making in clinical decisions in psychiatric practice.

    Methods:A coding scheme assessing shared decision making in general medical settings was adapted to mental health settings, and a manual for using the scheme was created. Trained raters used the adapted scale to analyze 170 audio-recordings of medication check-up visits with either psychiatrists or nurse practitioners. The scale assessed the level of shared decision making based on the presence of nine specific elements. Interrater reliability was examined, and the frequency with which elements of shared decision making were observed was documented. The association between visit length and extent of shared decision making was also examined.

    Results:Interrater reliability among three raters on a subset of 20 recordings ranged from 67% to 100% agreement for the presence of each of the nine elements of shared decision making and 100% for the agreement between provider and consumer on decisions made. Of the 170 sessions, 128 (75%) included a clinical decision. Just over half of the decisions (53%) met minimum criteria for shared decision making. Shared decision making was not related to visit length after the analysis controlled for the complexity of the decision.

    Conclusions:The rating scale appears to reliably assess shared decision making in psychiatric practice and could be helpful for future research, training, and implementation efforts. (Psychiatric Services 63:779–784, 2012; doi: 10.1176/appi.ps.201100496)

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