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Clinical Systems Mentorship and Adherence: The ICAP Approach
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Clinical Systems Mentorship and Adherence: The ICAP Approach

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  • 1. Using Clinical Systems Mentorship (CSM) in Adherence Work
    Adherence Workshop
    Kigali, 2009
  • 2. What is mentorship?
  • 3. Similarities and differences
    Supervising
    Managing
    Mentoring
    Advising
  • 4.
  • 5. The Learner- Centered Model
    Mentee role
    Active partner
    Mentor role
    Facilitator
    Learning process
    Self-directed, responsible for own learning
    Relationship Length
    Goal determined, but has a beginning, middle, end
    Focus
    Process oriented, critical reflection and application
    Mutability
    Dynamic, developmental, changes over time and with development
  • 6. So to recap…
    Mentorship is relational, an interpersonal process
    Mentorship occurs in a context
    Space: a system
    Theme: a programme
    Time: stages of development
    Mentorship skills CAN and SHOULD be used by supervisors and advisors
  • 7. In your work….
    Can you name some mentor/mentee pairs?
  • 8. Adherence advisor and onsite counselor
    Adherence advisor and onsite MDT
    Adherence advisor and expert client
    Adherence advisor and ICAP MDT
    Adherence advisor and DHT
    Adherence advisor and patient
    Adherence advisor and partners (CBO, govt, NGO, etc)
  • 9. Moving on to CSM
  • 10. Clinical Systems Mentorship (CSM)
    CSM is the name of an integrated methodology developed by ICAP
    Broadens the relational principles of clinical mentorship to the context of public health programming and health systems strengthening.
    It adds specific “macro”skillsrelated to implementation, quality, and capacity building
  • 11. Goals of CSM
    The goals of the CSM methodology are to
    Implement high quality programs
    Build capacity to sustain these programs
  • 12. Where did it come from?
    Derivative of:
    Mentorship methodology
    Communities of practice methodology (Wenger)
    Diffusion of innovations methodology (Rogers)
    Appreciative inquiry methodology (Cooperrider)
    Whole team learning (Engenderhealth)
    CQI methodology
  • 13. In short,
    It is a way of thinking about things, a strategy for doing them, and ensuring you are doing them effectively.
  • 14. Continuity Care Model
  • 15. CSM: Three general principles
    Data and data-based problem identification and remediation, with local ownership and team participation, are fundamental (QI,QA)
    Specific skillsets are necessary (microskills and macroskills)
    Strategies change according to context and stage of development
  • 16. CSM: First general principle
    The foundation of CSM is the process of continuous data-driven assessment, intervention, and re-assessment
    Measurability is key
    Using data for problem remediation is key
    Those involved in service delivery (TEAMS) lead this process increasingly over time
    This is also known as Quality Improvement (QI) or Quality Assurance (QA)
  • 17. Define measures of quality: SOCs
    Measure
    Assess measures
    Design and implement intervention
    Prioritize problem areas
  • 18. Second general principle: Skillsets
    Microskills (traditional mentorship skills)
    Interpersonal, communication, facilitation, teaching
    TEAMS are fundamental
    Macroskills
    Specific, content based, task oriented
  • 19. Third general principle: Stages of Development
    Needs at start up are different than they are later, after longer functioning.
    Expectations change
    Indicators for quality may be different
    Targets for quality may be different
  • 20. Developing patient-level capability
    Developing district- and national-level capability
    Assess and improve implementation
    Assess and Build Capacity
    Assess and improve quality
    Site Maturity
    Site Start-up
    Are you doing what you think you are doing?
    How well?
    Is it sustainable?
    Goal 1: Implement high quality care
    Goal 2: Build capacity
    Time
  • 21. CSM: Summary of general principles
    Data and data-based problem identification and remediation, with local ownership, are fundamental (QI,QA)
    Specific skillsets are necessary
    Strategies change according to context and stage of development
  • 22. Applying CSM to Adherence
  • 23. First principle: Data driven QI
    Develop a model of care (MOC) with goals and standards (SOC)
    Devise strategies for implementation
    Implement
    Evaluate
  • 24. Developing a MOC: Adherence in HIV C&T
    Adherence measured/assessed
    Adherence monitored
    Adherence happens
    Adherence intervention
    Testing
    Home
    Clinic
    Clinic
    Clinic
    Home
    Adherence monitored
    Adherence measured/assessed
    Adherence happens
    Counseling
    Patient entry into care
    Counseling
  • 25. Goals and objectives: Points on adherence support model
    To strengthen the continuum of adherence
    To measure/assess adherence: Shekinah will discuss this
    To monitor adherence (use measures): I will discuss now
    To intervene in care delivery and receipt of care: Cross-cutting to working sessions
    To ensure interventions are effective: Remeasure/reassess
  • 26. Five key components of the MOC
    Appointment systems (priority)
    Integrated tracking and tracing systems
    Adherence counseling and measurement/assessment (priority)
    Peer education/expert client programs
    Community linkages and referral
  • 27. Note: There are two levels
    Individual level
    Assessment of individual adherence and planning specific interventions
    Counseling
    Support for individuals to disclose, how to integrate adherence into life, etc
    Program level
    Is the program as a whole supporting adherence adequately?
    SOCs
    Root cause analysis
    Summation of individual level assessments and interventions become the program level SOCs
  • 28. Creating SOCs
    Utilize components of the MOC
    Set targets
  • 29.
  • 30. Root cause analysis: Prioritize Key Issues
    After measures have been assessed, the team can identify their site priorities:
    • The most important problems that must be addressed
    • 31. Problems that can be easily fixed
    • 32. Long term issues that need to be addressed but may take more time
  • For priority problems…
    Brainstorming via asking “Why?” repeatedly
    Can then eliminate the root cause, thereby solving the problem
  • 33. Example: Assessing Measures
  • 34. Proposed Analysis
  • 35. Example: Assessing Measures
  • 36. Proposed Analysis
  • 37. Main idea
    Measurement is pointless unless you USE the data for monitoring and intervention planning
  • 38. Third principle: Context
    Adherence challenges change over time and targets and expectations, as well as interventions, need to be flexible
    Your role may change as district mentors might be your mentees over time
  • 39. A Social Model of Adherence for sub-Saharan Africa
    Ware and Bangsberg PLoS Medicine (in press)
    Adherence
    fulfills responsibility to
    helpers and
    preserve
    relationships
    as a resource
    Relationships
    as resources to overcome economic obstacles to adherence
    Social Capital
    Improving Health
    Social Structural:
    Patterns of Inequality,
    e.g., stigma,
    gender inequality
    Individual:
    HIV knowledge
    Med side effects
    Cognitive function
    Mental health
    Alcohol Use
    Resource
    Scarcity
    Resource
    Scarcity
    Infrastructural:
    Few treatment sites
    Distance to care
    Cost/Availability of
    Transportation
    Cultural:
    Religious Beliefs
    Respect for Authority
    Importance of
    having children
  • 40. Developing patient-level capability
    Developing district- and national-level capability
    Assess and improve implementation
    Assess and Build Capacity
    Assess and improve quality
    Site Maturity
    Site Start-up
    Are you doing what you think you are doing?
    How well?
    Is it sustainable?
    Goal 1: Implement high quality care
    Goal 2: Build capacity
    Time

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