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Clinical Systems Mentorship and Adherence: The ICAP Approach
 

Clinical Systems Mentorship and Adherence: The ICAP Approach

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

    • Using Clinical Systems Mentorship (CSM) in Adherence Work
      Adherence Workshop
      Kigali, 2009
    • What is mentorship?
    • Similarities and differences
      Supervising
      Managing
      Mentoring
      Advising
    • 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
    • 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
    • In your work….
      Can you name some mentor/mentee pairs?
    • 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)
    • Moving on to CSM
    • 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
    • Goals of CSM
      The goals of the CSM methodology are to
      Implement high quality programs
      Build capacity to sustain these programs
    • 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
    • In short,
      It is a way of thinking about things, a strategy for doing them, and ensuring you are doing them effectively.
    • Continuity Care Model
    • 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
    • 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)
    • Define measures of quality: SOCs
      Measure
      Assess measures
      Design and implement intervention
      Prioritize problem areas
    • Second general principle: Skillsets
      Microskills (traditional mentorship skills)
      Interpersonal, communication, facilitation, teaching
      TEAMS are fundamental
      Macroskills
      Specific, content based, task oriented
    • 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
    • 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
    • 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
    • Applying CSM to Adherence
    • First principle: Data driven QI
      Develop a model of care (MOC) with goals and standards (SOC)
      Devise strategies for implementation
      Implement
      Evaluate
    • 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
    • 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
    • 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
    • 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
    • Creating SOCs
      Utilize components of the MOC
      Set targets
    • 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
      • Problems that can be easily fixed
      • 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
    • Example: Assessing Measures
    • Proposed Analysis
    • Example: Assessing Measures
    • Proposed Analysis
    • Main idea
      Measurement is pointless unless you USE the data for monitoring and intervention planning
    • 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
    • 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
    • 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