1. Using Clinical Systems Mentorship (CSM) in Adherence Work Adherence Workshop Kigali, 2009

2. What is mentorship?

3. Similarities and differences Supervising Managing Mentoring Advising

5. 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

6. 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

7. In your work…. Can you name some mentor/mentee pairs?

8. 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)

9. Moving on to CSM

10. 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

11. Goals of CSM The goals of the CSM methodology are to Implement high quality programs Build capacity to sustain these programs

12. 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

13. In short, It is a way of thinking about things, a strategy for doing them, and ensuring you are doing them effectively.

14. Continuity Care Model

15. 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

16. 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)

17. Define measures of quality: SOCs Measure Assess measures Design and implement intervention Prioritize problem areas

18. Second general principle: Skillsets Microskills (traditional mentorship skills) Interpersonal, communication, facilitation, teaching TEAMS are fundamental Macroskills Specific, content based, task oriented

19. 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

20. 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

21. 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

22. Applying CSM to Adherence

23. First principle: Data driven QI Develop a model of care (MOC) with goals and standards (SOC) Devise strategies for implementation Implement Evaluate

24. 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

25. 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

26. 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

27. 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

28. Creating SOCs Utilize components of the MOC Set targets

31. Problems that can be easily fixed

33. Example: Assessing Measures

34. Proposed Analysis

35. Example: Assessing Measures

36. Proposed Analysis

37. Main idea Measurement is pointless unless you USE the data for monitoring and intervention planning

38. 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

39. 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

40. 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