Using Clinical Systems Mentorship (CSM) in Adherence Work<br />Adherence Workshop<br />Kigali, 2009<br />
What is mentorship?<br />
Similarities and differences<br />Supervising<br />Managing<br />Mentoring<br />Advising<br />
The Learner- Centered Model<br />Mentee role<br /> Active partner<br />Mentor role<br />Facilitator<br />Learning process<...
So to recap…<br />Mentorship is relational, an interpersonal process<br />Mentorship occurs in a context<br />Space: a sys...
In your work….<br />Can you name some mentor/mentee pairs?<br />
Adherence advisor and onsite counselor<br />Adherence advisor and onsite MDT<br />Adherence advisor and expert client<br /...
Moving on to CSM<br />
Clinical Systems Mentorship (CSM)<br />CSM is the name of an integrated methodology developed by ICAP <br />Broadens the r...
Goals of CSM<br />The goals of the CSM methodology are to <br />Implement high quality programs<br />Build capacity to sus...
Where did it come from?<br />Derivative of:<br />Mentorship methodology<br />Communities of practice methodology (Wenger)<...
In short,<br />It is a way of thinking about things, a strategy for doing them, and ensuring you are doing them effectivel...
Continuity Care Model<br />
CSM: Three general principles<br />Data and data-based problem identification and remediation, with local ownership and te...
CSM: First general principle<br />The foundation of CSM is the process of continuous data-driven assessment, intervention,...
Define measures of quality: SOCs<br />Measure<br />Assess measures<br />Design and implement intervention<br />Prioritize ...
Second general principle:  Skillsets<br />Microskills (traditional mentorship skills)<br />Interpersonal, communication, f...
Third general principle: Stages of Development<br />Needs at start up are different than they are later, after longer func...
Developing patient-level capability<br />Developing district- and national-level capability<br />Assess and improve implem...
CSM: Summary of general principles<br />Data and data-based problem identification and remediation, with local ownership, ...
Applying CSM to Adherence<br />
First principle:  Data driven QI<br />Develop a model of care (MOC) with goals and standards (SOC)<br />Devise strategies ...
Developing a MOC:  Adherence in HIV C&T<br />Adherence measured/assessed<br />Adherence monitored<br />Adherence happens<b...
Goals and objectives: Points on adherence support model<br />To strengthen the continuum of adherence<br />To measure/asse...
Five key components of the MOC<br />Appointment systems (priority)<br />Integrated tracking and tracing systems<br />Adher...
Note: There are two levels<br />Individual level<br />Assessment of individual adherence and planning specific interventio...
Creating SOCs<br />Utilize components of the MOC<br />Set targets<br />
Root cause analysis:  Prioritize Key Issues<br />	After measures have been assessed, the team can identify their site prio...
Problems that can be easily fixed
Long term issues that need to be addressed but may take more time</li></li></ul><li>For priority problems…<br />Brainstorm...
Example: Assessing Measures<br />
Proposed Analysis<br />
Example: Assessing Measures<br />
Proposed Analysis<br />
Main idea<br />Measurement is pointless unless you USE the data for monitoring and intervention planning<br />
Third principle: Context<br />Adherence challenges change over time and targets and expectations, as well as interventions...
A Social Model of Adherence for sub-Saharan Africa<br />Ware and Bangsberg PLoS Medicine (in press)<br />Adherence<br />fu...
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Clinical Systems Mentorship and Adherence: The ICAP Approach

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Clinical Systems Mentorship and Adherence: The ICAP Approach

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

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