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2020 – 04 – Tools

When you start to consider how to implement trauma informed care practices into your practice, there are a few things that must be addressed. One of the most important is that we need to make sure that we are considering all parts of the client experience. This means that it’s important that everyone who interacts with clients are informed and are actively engaged in their role of shaping the client experience. This includes everyone from therapists to front desk staff. The mentality of “That’s not my client” or “I just answer the phones” can be extremely damaging to the client experience.

Environments Matter

Focusing on trauma informed care practices requires that we look at the entire experience of how our clients interact with our services. It is not enough to only focus on our therapeutic model that we use with clients. Instead, we must increase our awareness of the whole client experience beyond the therapeutic session. For example, have you ever thought about what it’s like to call your clinic to make an appointment? Or what is it like to sit in your lobby?

Here are a few examples of questions to ask yourself:

  • Consider your furniture in the lobby. Is there enough seating? Are there dedicated spaces for families to sit together? What about the colors? Are they soft and peaceful or are they filled with busy patterns?
  • Is there adequate lighting in the parking lot after dark?
  • What kind of signs do you have in your lobby? Are they welcoming and affirming?
  • Is there artwork in the lobby to make the environment feel warm and peaceful? Or does the space feel empty and cold like a medical clinic?
  • Do you have music playing in the lobby? What kind? Is it sensitive and appropriate to clients who may have experienced trauma?
  • Do you and your those you work with have protocols around trauma appropriate ways to respond to a crisis? Do you have an internal safety protocol?
  • Do you offer water or snacks for families while they wait in the lobby?

Experience Mapping

Now, these are just some examples of ideas of common ways that organizations have found to make their environments more trauma-informed based on client feedback. However, these might not work for you and your space. In order to really understand what will work, you have to first collect information from your clients about their experience.

A common way to holistically assess client experiences is called experience mapping (also known as journey mapping). The foundation of experience mapping is that you purposefully focus on EACH stage of the client’s experience, rather than just when you are directly working with them. While the key stages will be unique depending on the type of need and service, there are several common stages to consider:

  1. Need Identification. This is usually the first stage, which happens before the client decides to receive care. In this stage, the client recognizes that they have a need (or a professional recommends some type of behavioral health service or treatment). Considerations during this stage include – What do clients find online when they search for information about you, your organization, or competitors? What do others say about you, your organization, or what clients should expect? This may come from a friend or family member, or from whoever referred/recommended the treatment (such as a primary care physician or social worker). This part of the client’s journey is important because even though you are not directly interacting with the client, it sets the stage for what they should expect.

 

  1. Scheduling or Access. Whether clients are being admitted to a behavioral health facility inpatient program, scheduling outpatient appointments, or seeking to be part of existing services such as group therapy sessions, their actual first step with you or your organization is initiating some type of scheduling process. This is so important because it is their first direct impression. Considerations include how easy it is to find the right contact information, their experience during a phone call or email, how quickly they are able to get a first appointment scheduled, and managing paperwork/billing requirements prior to their first visit, and being prepared for what to expect. It’s not uncommon for clients to say that they tried contacting several behavioral health providers, but never made it past this stage. Either their call was not returned, the person who answered the phone was not helpful, or the appointment was scheduled weeks out and not in a timing appropriate for their needs. Not only can this cause you or your organization to lose clients, but it also results in clients sometimes arriving for their first visit already frustrated and with negative emotions.

 

  1. First Visit or Assessment. When clients first begin treatment or therapy, their anxiety is often times at an all-time high. They are unsure what to expect and if this will truly help. Therefore, the beginning stages of their therapy and treatment need to be very clear in setting expectations moving forward, and in making sure that they feel understood and listened to. Considerations during this stage include: How were the clients greeted upon their arrive and made to feel welcome? How well did the client feel listened to and understood? To what extent is the client confident in the care plan moving forward? If any decisions need to be made about treatment, how was the client helped to make these decisions and what resources were provided? Setting expectations early in the process is critical to all services, and particularly to trauma-informed care. This can include asking patients directly what is most important to them, their preferences during treatment, and assessing any triggers that could impact future care.

 

  1. A unique part of behavioral health is that treatment can last weeks, months, years or really be never-ending. It’s important that clients feel listened to, respected, and understood throughout treatment. Considerations should include: How well is the client kept informed about their treatment progress and next steps? How well are the client’s unique needs met throughout treatment (this relates back to having their preferences and needs understood from the beginning, in the first visit/assessment stage). Is the client has questions or frustrations during treatment, where do they turn? This has major implications particularly for large organizations. Does the client have a way to voice their opinion or share their frustrations, and to have them resolved? If not, particularly in large organizations where they don’t regularly interact with leadership, they may take their frustrations straight to social media or to the organization’s leadership. Furthermore, client frustrations during treatment can lead to non-compliance or leaving the treatment/program altogether. It may be a simple fix or something that can be resolved, but if clients do not have a way to voice their concerns or have their problem resolved, you may never know about the problem in the first place, and are therefore unable to resolve it.

 

  1. Ending treatment/follow-up. A common challenge in any type of healthcare environment, including behavioral health, is that often times the last interaction clients or patients have with us is the bill that they receive at the end. But we don’t always take time to ensure clients have all of the tools that they need to succeed after treatment, or to follow-up to see how things are going. For patients with long-term challenges with addiction, this is actually one of the most important stages of their treatment. Ensuring they are well-connected to resources to help them managing their addiction long-term, and that they have support systems in place to be successful, is a critical step to promoting long-term success. Considerations during this stage include: How well does the client understand the long-term plan and next steps? In what ways can the client contact us if needs remain or questions arise? How well do we connect the client with resources that they will need to be successful? In what ways can we proactively reach out the clients have they have completed treatment to make sure they have everything that they need?

So here is an example of what a completed experience map might look like. It’s not so important what the map looks like – there are many types of experience maps and ways of visualizing the key steps in our clients’ experiences. What IS important is that the map is representative of their experience and that it is used to ensure each of the stages are understood and accounted for when we assess our clients needs and how well we are delivering trauma informed care.

Source: http://www.endeavormgmt.com/patient-experience

View the full presentation here: http://www.endeavormgmt.com/wp-content/uploads/2018/04/Behavioral-Health-Client-Experience-Management-Gelb.pdf

So how can you use these concepts when working with clients? There are several ways, depending on your role and resources.

  • In direct care, we can take time out of typical therapy or treatment sessions to examine the experience and talk to clients and what they need, asking specifically about each step that they experience. It is sometimes helpful to have someone else ask these questions, so clients are not hesitant to give both positive and negative feedback. Having a colleague or third party ask clients about their experiences and keep the feedback anonymous can be helpful
  • As leadership or when we are part of planning and decision-making, we can advocate for the client experience to ensure we are client-focused and not internally-focused. When we make decisions internally and talk about where the gaps are, we use these maps to ensure we are considering how all parts of the experience will be impacted through our decision. This may include playing devil’s advocate – such as “I understand this decision makes sense from our perspective, but let’s take a step back and consider how it will impact our clients.”

So now that we have that basic framework for using an framework to identify needs and opportunities throughout each stage of the journey the next question is HOW to obtain feedback from clients. I’d like to give you some practical tools to gather feedback from your clients. First, I want to emphasize that direct feedback from clients and families is always best. We’ve worked with organizations who spent a lot of time getting direct feedback from their clients to make improvements in certain programs, and then in other programs made changes based off of their own assumptions, and the results were very different. When we just go based off of our assumptions for what our clients want and need, we will probably get SOME things right – but miss other big things. Going off of our own assumptions is the antithesis of being a trauma-informed mental health professional. Instead, being able to genuinely listen to clients and receive their feedback (no matter how raw the feedback might be) and then make changes based on that feedback is the key to remaining open, accommodating, and sensitive to the lived experiences your clients bring when they walk through your doors.

The other piece is that direct feedback from your clients creates a motivation for change. Sharing with your team direct stories, quotes, data, or even short audio clips is so much more impactful than just saying that we need to change. One thing that can be particularly helpful is to record client feedback interviews (with client’s permission of course). Being able to share short 30-second audio clips with your team can make a huge difference in motivating them to implement changes. If you are not in upper management and have received barriers to change, this can also be particularly impactful as it could help motivate upper management to get on board with these changes.

For example, imagine trying to get your organization on board with implementing trauma-informed care practices and going into a staff meeting saying something like, “Our clients’ parents are choosing to not put their child into our intensive outpatient program because they live 3 hours away and can’t afford transportation costs to travel back and forth everyday.” The group might find it interesting, but it is still very cerebral. However, if you were to play an audio clip of a client’s parent in tears, explaining that their teenager is on the verge of committing suicide and is spiraling downward, but they can’t get him the help he needs because they cannot afford gas money to transport him to get him into treatment. Suddenly hearing it in the client’s voice and directly from the source makes the entire group stop and immediately discuss how they can fix this problem. So regardless of whether you have audio clips or not, the important thing is that you appeal to the emotional aspect of the clients’ need. It is not enough to just share clients’ stories. It takes a conscience thought around HOW you share their stories as it always makes a difference to incorporate the client’s direct words or voice when you are trying to make a change.

So here is an overview of a variety of practical tools to obtain direct feedback from your clients, and the tools towards the top are lower cost with the tools at the bottom being higher cost. Everyone here is in a direct role and has a different level of influence. You might be leading an initiative for trauma informed care and have a budget to do the higher cost research. Or, you might not have any role in managing the budget for this, and simply want to know what you can do on a daily basis. So this list will give you both of those options.

Observe

Observational feedback is feasible for anyone, in any role. It involved simply taking time to observe what is happening in your clinic and perhaps periodically asking for feedback. From a low-cost level, volunteering with a variety of service areas or providers will allow you to see what is happening, and where best practices or opportunities for improvement exist. In hospitals, a common tactic is executives spending a certain number of hours per week visiting client rooms and asking for feedback. If you’re providing in-home services, you could go with therapists or case managers to the appointments. The chair exercise is most relevant when services take place in a hospital or facility – and involves you literally “sitting” in each chair that the client would sit in – including the waiting room, therapy rooms, patient meeting rooms, etc. and observing what you see and what happens.

Collaborative Planning

This involves you working with other team members, or even clients themselves to create ideas for change. Bring together a group of team members or clients who have agreed to provide feedback, ideally from different areas of the journey, to discuss what you have seen, done, and know – and outline what needs to be changed. If you do have direct feedback from clients, it is helpful to incorporate this into your discussions. What do you know, or have you observed, that will help you plan ways to make the experience easier and better for your clients. If you don’t have this direct feedback, you can consider if your organization has patient satisfaction surveys, comment cards, or any other information that can help. What’s important here is making sure that you are accurately meeting the most important needs of clients, while at the same time collaboratively agreeing on what the internal team can do to help. What’s usually NOT successful is coming up with a load of new initiatives (such as – all patients will have phone calls returned within an hour) without getting input from the group about what is realistic and what can actually be delivered on.

Direct Feedback

Direct client feedback can take many forms. This can include focus groups, online surveys, or in-depth interviews. Some organizations even create patient/client advisory panels, which is a group of people who have agreed to provide their feedback and input as decisions are made.  In-depth interviews are helpful because they can capture both breadth and depth of information However, the downside is that these can be time-consuming, as each interview will probably take about an hour (remember, you are discussing each part of the client’s experience, so there is a lot to talk about!) It is also typical to pay an incentive for clients to participate because of the length of time requested from the client. However, some clients juts want to be part of helping to improve experiences for others, so don’t expect an incentive payment.

Client journaling is another tactic that can be helpful as it allows you to ask clients to document their experiences throughout their visit, and then you can later review what they have written. In fact, some clinics are using flip cams as a budget-friendly, realistic way to share these videos of what to expect as a client. The unique thing is that clients actually record the videos themselves, so they are free of the marketing bias in which clients worry that the video does not realistically depict what to expect.

Monitoring Progress

Lastly, you will want to monitor how things are progressing. It’s not realistic to conduct direct research continually, so monitoring tools allow you to see how progress is being made, and where you need to focus improvement efforts. One of the most helpful ways to do this is through regular feedback surveys (or if this is not possible, even more simple is having comment cards and asking clients to fill these out regularly). A more technically advanced tool is a dashboard that allows everyone to regularly see the results in a way that clearly highlights high and low performing areas. For example, you might consider implementing a short feedback survey that can be automatically sent at certain stages of the journey – such as after the first appointment. These are sent via email and only contain 3-4 questions. The dashboard then can tracks the results. And what’s really cool is that you can create workflows to escalate problems for service recovery. For example, if someone has a problem with their first visit and indicates that on the survey, you can have it escalated to a designated person to call them and determine how to get it resolved. So before the client even moves on to their next step, or before they move to the point of submitting a complaint, you are able to fix the problem.

In sum, the idea of using an experience map to understand client experiences and promote the delivery of trauma-informed care is a  great foundational tool to start with. Or, you might be trying to solve a specific problem – such as if you are seeing in your client satisfaction surveys that certain areas are low but you don’t know why – this is where we can get to the bottom of WHY you are being rated low in specific areas. Questions are open-ended and allow for clients to tell their stories, to provide the detail that you can’t get through other tools. Because techniques such as individual interviews are 1-1, it’s also very private, which is helpful for situation in which clients don’t want to tell their stories to a group, like a focus group situation.

Other Considerations for Success

  • I won’t spend a lot of time on other tools but I do want to provide just a few things to think about if you or your organization decide to ask for client input on how to best improve their experiences and provide trauma-informed care.
  • First, determining who you want to participate in your research. What’s important is that your participants represent a variety of viewpoints and are not all people who are very happy with their experiences. Going to each team member and asking “who is your favorite family that we should ask to participate” is not going to give you the variety of information that you need.
  • The second consideration is that experience management can also include the experiences of those who refer to you (Hint: think about who most frequently recommends or refers others do you. Primary care physicians? Social workers? School counselors? Other organizations) As value-based healthcare has more of an influence, the ability to collaborate across organizations is increasingly important, and the best way to assess how you are doing here is to get feedback from referrers – also using an experience map just as you would for clients.
  • If you decide to obtain direct client feedback (which is the gold standard) tne thing that can be underestimated is the time and resources required to recruit for research participation. Especially if it is going to require a lot of time, such as a focus group or in-depth interview. We recommend providing an incentive payment for clients ($20-$50), and also considering using a third party who specializes in recruiting, if you do not have resources to do this internally. To make recruiting easier, conducting interviews via phone can be helpful as it is convenient for clients so they do not have to travel somewhere.
  • Make sure your questions cover all stages of the journey and ask both specific things, like what happened when you called to schedule your first appointment, as well as high level things, like what is the biggest thing you would change to improve the experience for clients.
  • When talking directly with clients, we recommend that the person asking questions is not employed by your organization, or is very far removed from client care. It’s common that clients worry if them sharing bad feedback will impact the services that they receive. It’s ideal that you are able to maintain anonymity and promise that their specific feedback will not be linked back to them. It’s also important to keep it conversational so that you can encourage them to share stories or examples. Some people like to take notes or audio record and type it later, but regardless of how you document the interview, it’s important to document the details – not just if the client was happy – but what happened and why they were happy.