Shared Decision-Making in Mental Health Care - SAMHSA Store ...

71into treatment should still be involved in decision making about thetypes of treatment to be used for their illness and in the choice ofprovider (p. 112).The IOM strongly recommended the provision of decision support to all individuals—regardlessof legal or commitment status—by providing them with information,avoiding undermining their decision-making abilities, and appreciating the changingnature of consumer decision-making preferences. The IOM also recommended theuse of peer support services, especially for those individuals with impaired cognitionor diminished self-efficacy, as well as the use of advance directives.If involuntary or coercive treatment does occur, understanding and addressing thistreatment failure is essential. In the process, every effort at optimizing SDM shouldbe made. Accomplishing this vision will require changes in provider attitudes andbehavior as well as systems processes, and the active provision of decision supportsregardless of diagnosis and/or legal status. Significant redesign of current systems,and the adoption of practices and processes consistent with these values and rules,will be needed to remove system-level barriers to SDM. This redesign is intended toclearly identify the steps and processes necessary to provide services that meet theInstitute of Medicine’s six quality goals of being person-centered, safe, timely, efficient,effective, and equitable, and to engage and support service users in makingshared decisions about their recovery goals, objectives, and preferences for servicesand supports.System RedesignHistorically, service delivery has largely been organized around provider and/or systemconcerns. Administrative, regulatory, and payer demands, as well as professionalpriorities and traditions, have driven system design. Much of the organization ofcare has been based on traditional hierarchical relationships and provider authority.The result has often been far from person-centered care, or from supporting andpromoting SDM.The service delivery system’s values, priorities, organization, and functions may allbe barriers to SDM. Significant redesign is required to create and sustain the resourcesand supports necessary for SDM. Wagner’s chronic care model (Bodenheimer etal., 2002) has become a well-accepted framework to guide system redesign in thegeneral health care sector, and proposes community roles as well as those of providersand consumers required to support SDM. Figure 1 illustrates how the modelcan be adapted to mental health care. The CalMEND framework was developed bythe California Institute for Mental Health (www.CalMEND.org) to promote person-centeredapproaches and SDM. The diagram depicts the centrality of productiveinteractions—in essence, shared decisions—between consumers and providersas a key to realizing individuals’ recovery and wellness outcomes. The model alsoShared Decision-Making in Mental Health Care: Practice, Research, and Future Directions