Smmit White Paper:  

"First Steps and Beyond: Incorporating Shared Decision Making in Massachusetts
Mental Health Services, Report and Recommendations from the 2009 Summit "

Issue Brief on the the White Paper  

BLUEPRINT
 Recommended first steps to incorporate SDM in Massachusetts' mental health services
include the following:
1. Call to Action: Policy Leaders Send a Clear Message that SDM is Critical to High
Quality Care
2. Establish a Multi-Stakeholder SDM Task Force, and Seek Funding for It
3. Create a SDM Website for Massachusetts
4. Conduct a Series of Stakeholder Needs Assessments
5. Develop a Workforce Training Strategy
6. Formalize the Role of the Peer Specialist in Providing Decision Support
7. Address Risk/Liability Concerns, and Propose Legislation
8. Address Racial and Ethnic Factors in SDM

1. Call to Action: Policy Leaders Send a Clear Message that SDM is Critical to High
Quality Care
When a significant systemic change is necessary, policy leaders such as the DMH Commissioner
and State Medical Director must express their personal commitment to that change. Leadership
should establish this commitment by sending clear and consistent messages to stakeholders that
SDM is critical to high quality mental health care. In addition, leadership should formally
announce that SDM implementation is a major objective and highlight the existing projects that
already fit within this objective.
An initial letter should explain why DMH is pursuing a SDM initiative; it should outline short
term and long term expectations for the initiative; and it should describe what is expected of
 stakeholders. It is also important to acknowledge the challenges posed by the current financial
climate, and the challenges that present with any large scale transformation. In its initiation and
implementation of SDM across the service delivery system, DMH should embrace organizational
change principles such as modeling, observational learning, and reminding staff that they have
the competence to achieve this goal.

2. Establish a Multi-Stakeholder SDM Task Force, and Seek Funding for It
Organizing the SDM initiative will require the time and resources of many people. The authors
have personally agreed to commit their time and resources to the SDM initiative. In addition,
DMH, through its Research Centers of Excellence and other avenues, should seek grant funding
to support the SDM Initiative.
A SDM task force should be established and include policy leaders, early practitioners of SDM,
mental health consumer and family members, and other stakeholder representatives. Several
members could be drawn directly from the group of summit attendees. The authors will also
identify key opinion leaders - highly respected stakeholders who have influence over their peers’
opinions and actions - to seek their buy-in and support for developing the task force. Leadership
should educate and discuss with the opinion leaders the SDM initiative, either through formal
meetings and presentations, or through more informal communications.
The task force should meet regularly to share information on important SDM developments,
problems and opportunities; to develop mutually informed SDM strategies; and to support the
implementation of SDM throughout the system. Task force discussions and deliberations should
include not only face to face meetings, but also teleconferences, webinars, discussions on
networking websites, and/or other online community building tools.
A successful model for this task force approach is the Transformation Committee
("TRANSCOM"), whose goal has been to develop and implement mental health peer services in
Massachusetts. TRANSCOM's membership has included representatives from several consumer
lead organizations, the Association for Behavioral Health ("ABH"), state agencies, and managed
care organizations. TRANSCOM first developed mission and vision statements and work plans,
and it later became a subcommittee of the Mental Health State Planning Council. Ultimately,
TRANSCOM assisted the consumer-run Transformation Center in developing the Massachusetts
certified peer specialist training. Members helped DMH and MBHP codify the role of the
certified peer specialist in various services, and they nurtured the development of the peer-lead,
DMH-funded "Recovery Learning Community" model.

3. Create a SDM Website for Massachusetts
A website established specifically for Massachusetts mental health SDM activities on the DMH
internet site as well as CQI’s website. CQI's website, www.cqi-mass.org, currently includes a
summary of last year's SDM summit; this section could be enhanced to provide key SDM
information and updates to Massachusetts stakeholders, including:
  this White Paper and the results of other related proceedings;
 a summary of SDM-related research and demonstration projects that have been taking
place in Massachusetts, including the use of CommonGround;
 a SDM bibliography and literature reviews;
 links to other key websites, including SAMHSA's SDM website
(http://mentalhealth.samhsa.gov/consumersurvivor/shared.asp).

4. Conduct a Series of Stakeholder Needs Assessments and Demonstration Projects
Participants at the SDM summit agreed that a series of in-depth needs assessments should be
conducted in preparation for the establishment of SDM in Massachusetts. A needs assessment is
a systematic exploration of the way things are (opinions, attitudes, practices, etc) and the way
they should be. The results of a needs assessment can lay the foundation for developing the
initiative's goals and objectives.
At a minimum, needs assessments of two target audiences should be conducted: providers and
clients. The general goals of these needs assessments should include the following:
 To identify existing supports and barriers to SDM for each group;
 To identify methods for minimizing barriers and maximizing supports for SDM;
 To maximize the opportunity to create a proposal for change that is as tailored as possible
to the specific needs of each group.
a. Needs Assessment and Demonstration Projects Targeting Mental Health Providers
Summit participants offered the following specific recommendations with regard to a needs
assessment targeting mental health providers:
 The provider needs assessment should review the current practices and capacity of
agencies to provide administrative oversight of their services through policies, incentives,
and accountability.
 The assessment should evaluate the capacity of supervisors to provide a consistent
message regarding SDM.
 Because the goal and challenge is to transform the overall culture of providers, it will be
important to assess the existing level of staff knowledge, attitudes and skills around SDM
implementation and use.
 Academic detailing is the face-to-face education of prescribers, designed to improve their
prescription practices. Academic detailing has shown demonstrated success in changing
prescribing patterns. The provider needs assessment should evaluate the feasibility of
implementing a program of academic detailing for psychiatrists to promote SDM.
In order to facilitate the adoption of SDM among providers, several issues must be addressed.
Providers have reported that their three most often reported facilitators to using SDM have
been: provider motivation, positive impact on the clinical process, and positive impact on
patient outcomes.  Facilitating continuing medical education for current physicians as well
as introducing SDM into the medical school curriculum for future physicians will be
 important. However, we know from the organizational change literature that education and
training are necessary, but not sufficient components of changing a system.44 Therefore,
implementation should include promoting a culture of recovery and inclusion, a recognition
of the value that prescribers bring to the process of SDM, as well as developing DMH as a
learning organization rooted in the extensive use of data and ongoing change, improvement,
and innovation. Specific recommendations include promoting pilot projects such as the polypharmacy reduction
initiative, to show feasibility and positive impact on the clinical process as well as demonstrate
that SDM does not have to be restricted to certain select clients or to certain psychosocial
variables. Demonstration and expansion of successful projects like CommonGround can show
that decision support tools facilitate the provider-client conversation without taking up extra
time.
b. Needs Assessment Targeting Mental Health Clients
Summit participants offered the following specific recommendations with regard to a needs
assessment targeting mental health clients:
 The client needs assessment should evaluate the extent to which clients wish to
participate in services/treatment decision making, and the ways in which they wish to be
involved.
 Results of the assessment should be sorted to determine how client preferences may vary
relative to the following:
o by category of client (e.g. race/ethnicity, age, gender)
o by the type of decision (e.g. medication, vocational support, therapist)
 The assessment should evaluate which kinds of general and specific decision supports are
best for helping people with mental illness to identify their needs and preferences
regarding various treatment options. The assessment should seek to determine which
decision supports are easiest and most likely to be utilized by clients, and which ones will
help clients make high quality decisions.
 The assessment should seek to understand how decision supports can best be utilized to
remove some of the anxiety people often feel when faced with difficult decisions.
 The assessment should help to determine the role certified peer specialists can play in
providing decision support (see #6 below).
Stakeholders should leverage existing resources and work with interested researchers to conduct
these needs assessments.

5. Develop a Workforce Training Strategy
After appropriate needs assessments are conducted and analyzed, a comprehensive workforce
training strategy should be developed to prepare providers for the implementation of SDM. As
described above, the provider needs assessment should assess workers’ knowledge, skills and
attitudes regarding SDM, along with their willingness to change their practice patterns. Training
in the practice of SDM should be tailored to specific providers according to their level of access
to information about service options, the experiences they have had working with consumers,
and the team culture within which they work.
Different types of providers (e.g. psychiatrists, peer specialists, social workers) working in
different types of environments (e.g. clinics, clubhouses, Programs for Assertive Community
Treatment ["PACT"] teams) will have different training needs. Customized focus groups and
informal meeting sessions should supplement the needs assessment to determine the most critical
training needs for each provider group, and for providers overall.
A key finding from the 2009 SDM summit was that SDM has never been incorporated into
training for behavioral health providers. Similarly, pre-service training rarely contains content on
involving clients in treatment decisions. SDM training should be interactive and should target the
lowest-paid least-trained staff, which often have the most contact with consumers. The feasibility
of incorporating SDM into medical education curricula should be given careful consideration.
Once implemented, all training programs should be evaluated for effectiveness.
Finally, mental health providers, like consumers, should have access to decision support tools
that are easy to use. To ensure that resources are used efficiently, efforts to develop decision
support tools for providers should be coordinated to avoid duplication.

6. Formalize the Role of the Peer Specialist in Providing Decision Support
Peer support not only improves the well-being of people with mental illness, but it also enables
mental health consumers to share information about different treatments. Through peer support
groups, many consumers have obtained reliable and useful information about medications.
Additionally, "peer specialists" are mental health consumers who utilize their experience of
mental health recovery to assist other consumers in articulating and reaching their personal
recovery goals. More specifically, the peer specialist works with other consumers on problem
solving, recovery/life goal setting, utilizing self-help recovery tools such as the Wellness
Recovery Action Plan ("WRAP"), skill building, and establishing self-help groups. "Certified"
peer specialists have gone through extensive training and passed an exam demonstrating their
knowledge of key competencies.
In Massachusetts, certified peer specialists are offered and funded through a variety of different
service delivery models, including PACT, day treatment programs, emergency service teams,
and community-based flexible support teams. Not only does the peer specialist work to inspire
clients, but also to guide and influence the perspectives of other treatment team members. Peer
specialists also operate independently of treatment teams, as staff of the consumer-run Recovery
Learning Communities.
Peers specialists are well-positioned to coach clients to actively participate in making treatment
decisions with their providers. In this role, a peer specialist could train consumers to use decision
support tools, provide direct assistance to consumers using decision supports, and coach
consumers in preparing for a treatment meeting. Beyond certification, a continuing education
course should be developed for peer specialists to learn to provide this specialized support.

7. Address Risk/Liability Concerns, and Propose Legislation
A model SDM system would provide clients and providers with access to correct, clear and
concise information that is easily retrieved and updated, as well as the resources necessary to
discuss relevant options without significantly draining provider resources. In addition, an SDM
system must include legislation that eliminates the paternalistic physician-based and patientbased
informed consent rules and replaces them with liability protection language that recognizes
the priority of autonomy and the responsibilities of provider and client as a partnership of equals.
Providers would no longer have to guess regarding their legal liability and they could improve
the health outcomes of their patients by enabling them to be more invested in their treatment
choice.46 Summit participants strongly encouraged the adoption of public policies to address
provider liability concerns. The major concern is that SDM will lead to more frequent negative
outcomes because clients may choose to forgo treatments such as medications or elect to take on
significant responsibilities of daily living, such as money management or employment.
In order to address these issues, the State of Washington passed a law in 2007 that recognizes
SDM as an evidence-supported activity that is likely to produce improved medical outcomes
through the use of decision aids and other decision supports. The law specifically contains
liability protection language, with a signed "acknowledgement of shared decision making"
document serving as prima facie of informed consent, reducing the potential liability for
providers. For more information about Washington's law, see Appendix A and
http://www.informedmedicaldecisions.org/pdfs/legislation.pdf. (Maine and Vermont are also
working on bills that will encourage SDM in medicine.)
Ultimately, when a provider and client collaborate in the treatment decision, they are prioritizing
patient autonomy over beneficence (provider taking action that serves the best interests of a
client). In instances of disagreement after discussion, the client’s preference should determine
the treatment, since the client has to live with the decision and its implications. By protecting
patient autonomy and acknowledging the importance of provider opinion and analysis, SDM
provides the most effective method of enabling providers to satisfy their ethical obligations to
clients. Stakeholders should explore all options to limiting liability for engaging in SDM.

8. Address Racial, Ethnic and Cultural Factors in SDM
Summit participants stated that a client's racial, ethnic and cultural background can affect his or
her views about particular health conditions and treatments. In several cultures, there is deep
stigma associated with seeking professional mental health services, and in particular the use of
psychiatric medication.47 Likewise, the extent to which clients desire involvement in treatment
decisions, and the relative appeal of specific decision supports, are likely to differ by racial,
ethnic and cultural groups.48 Cultural attitudes on the following factors will likely affect a client's
view on SDM:
 the role of family and friends in decision making
 the acceptable level of independence from the larger group
 the level of acceptance of the clinician as the "expert"
Every SDM initiative should take racial, ethnic and cultural identity and norms into account.