Utilizing Outcome Measures to understand clinical activity and improve service interventions

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Utilizing Outcome Measures to understand clinical
activity and improve service interventions

• Sandra Keppich-Arnold
• Alfred Psychiatry
• BAYSIDE HEALTH

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Informing clinical utility and activity

• Consumer / clinician perception informing
  consumer need
• Capacity to collaborate in care and treatment
• Demand and service issues
• - trends and intervention prompts to inform
  service planning and design

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The journey..

• Establishing an (aged psychiatry)
• Hospital Substitution Service in 1999 post
  MHCASC
• Need to evaluate outcomes
• Elected HoNOS, BARTEL and MMSE
• Outcomes identified scores predicting admission
  triggers at assessment

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The AMHOCN journey - AGED

• HoNOS over 65
• LSP (community)
• Basis 32 (community)
• Focus of Care (community)
• RUG ADL (inpatient)

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Experiences from APMHS services

• Inpatient HoNOS target at discharge
• Care planning using HoNOS
• Discharge planning in community
• Case Load monitoring
• Dependency levels
• BASIS 32 feedback of trends

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Caulfield Aged Psychiatric Service

• Reports to CGMC / Aged Care and Rehabilitation
  Program
• Established links and relationships with Alfred
  (Bayside) Adult Mental Health Service
• Aged Psychiatry Service consisting of
• 15 Bed Psycho-geriatric Assessment Unit
• 30 bed Psycho-geriatric nursing home
• Community Team
• Memory Clinic (sub-acute funding)

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Caulfield Experiences

• Embedding OM activity into clinical processes to
  challenge clinical activity at admission, review
  and identify potential for discharge

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Life in an APS service

• Mobile Aged Psychiatry provides a range of
  services
• from intake and referral, assessment, acute
  treatment,
• case management, support and clinical consultancy
• services.
• The perspective is
• the front and back door to services
• manage high volume clients
• significant levels of risk
• highly reactive environment

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Challenges to Mental Health service delivery at
CGMC 2001 - 02

• Referrals to PGAT (N 550 CL)
• Case Loads - 350
• Client mix (case management) - 80 functional
  illness 20 organic (dementia)
• Inpatient admission diagnosis- 80 functional
  mix with extended LOS/multiple admissions
  medical co-morbidity (CL) /seeking OOA
• Clinician role of monitoring in community vs.
  treatment and therapeutic
• Staff dissatisfaction

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Back in 2002..

• No consistent understanding of core business
• Ongoing demand for access with poor exit criteria
  and processes
• No local agreement as to acceptable case loads.
• No definition of case management
• Case loads monitored not managed
• Review processes haphazard.

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Level of Community Intervention (July 02)

• Audit of 60 CC files in the community identified
• 2 multi-disciplinary input into clinical care
• 2 had evidence of therapy type interventions
• 45 clients had no active follow up of treatment
  advice given to GP
• 60 had received no face to face contact in the
  four weeks previous to audit

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The plan to change was based on

• Belief that all clinicians were working to
  achieve positive outcomes
• The workload was unremitting - so a need to
  control the flow through better management
  processes (intake assessment)
• Safe turnover is the key to effective management
  of the volume

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Priority interventions

• Identify what was core business
• Maximize resources for these activities
• Establish consumer orientated planning and
  service provision
• Streamline processes utilizing existing
  bureaucratic systems
• Identifying which tools could support clinical
  decision making processes for entry, treatment
  and exit.

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Maximizing Resources

• Establishing targeted programs in the context of
  demographics.
• Assessment and treatment
• Consultation Liaison Psychiatry
• Recovery
• All underpinned with rigorous audit clinical
  supervision processes to maintain management
  focus - attention to activity and identifying the
  content of the intervention

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Process of change

• To develop specific programs and methods of
  work to meet the diverse needs of clients
  requiring a special approach
• Utilise OM to guide clinical interventions rather
  than rely on clinician opinion

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Making the change - key strategies

• Establish defined Intake/Exit criteria.
• Strengthening clinical review processes with a
  focus on OM
• Linking HoNOS to case load burden
• Monitoring performance through audit, case load
  monitoring, KPIs

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Case Load Measurement

• APS is diverse so whilst it is not just about
  numbers the nature of work (acute
  care/intake/continuing care) we decided to cap
  case loads regardless of dependency
• Some rules existed - contact less than monthly -
  move to consultation models
• HoNOS less than 4 plan ensure recovery talk! -
  this in itself might shift the focus of care and
  identify issues previously not identified.

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Linking clinical symptoms to response

• HoNOS score of 12 indicates high dependency
• HoNOS score of 10 - 12 high contact weighting
  (time consuming and significant workload)
• HoNOS score of 6 - 10 medium contact between
  weekly - fortnightly but with agency liaison
  support
• HoNOS score of 4 - 6 low contact and relatively
  stable - discharge planning

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Using HoNOS

• Score of HoNOS of 2 or more indicating clinical
  significance hence care planning indicated.
• Using HoNOS the symptoms drive the intervention
  frequency of contact rather than the frequency of
  contact driving the level of intensity.
• Case manager availability determined by
  evaluation of special interest activities and
  other demands.
• Fundamental agreement that first rank symptoms of
  scales 1 - 7 (behaviour or symptoms) must rate 4
  or above to prioritize interventions. If score
  not clinically significant focus on recovery with
  disability supports.

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Changes to date.

• Consistent models of case management offered
• Consumer focussed activity
• Tighter systems of support and review better
  informed
• Increased partnerships of care with others -
  across team collaboration as well as external
  agency supports
• Consistent and organised program activity reviews

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Results so far for MAPS Case Assessment
Management

• Average 2002 04 06
• Monthly discharge 10 30 28
• CM case loads/EFT 35 22 18
• Total Case Load 365 200 175

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Case Study

• 78 y.o lady with long standing schizophrenia
• Non compliant with all treatments and
  interventions
• Homeless
• Community concern
• Guardian involved and directing care planning
• Referred to MST

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Problems Interventions

• Behaviour Management
• - Pestering others - begging, agitated when not
  provided with means resulting in breaking
  property.
• Cognitive Problems
• - Initially assessed as high due to perceived
  disorientation, speech incoherent a Guardian
  appointed based on prior assessment
• Physical Health Problems
• - Recurrent UTI and chest infection

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Problems Interventions

• Hallucinations and Delusions
• Thought to be eccentric
• Problems with relationships
• - No supportive relationships evident or
  persisting
• Problems with Daily Living
• - Significant unable to self care
• Living Conditions
• - Homeless
• Occupation and Activities
• - Marked disability

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First Line interventions

• HOSPITALISATION CTO and revocation of
  guardianship
• Assess and understand cognition led to
  clinician awareness of level of psychoses
• Financial resource management to reduce risk
  of begging and assaultive behaviours
• Management of health issues linked to hygiene
  and housing
• DEPOT for compliance
• Linked to SRS for weekly shower and meals only
  progressively established relationship

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Recover focussed interventions

• Depot without CTO
• Establish secure housing
• Hygiene without MH team support and intervention
• Banking / cigarette management by self
• DEPOT for compliance
• Establish social relationships

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At 24 months

• SRS closed during period but secured housing in
  hostel
• Showering with supervision team still
  encouraging
• Buying from OP shop / managing clothes
• Managing cigarettes (10 / day) and attends bank 2
  x week to access allowance
• Making case worker coffee at weekly support visit
• CTO reviewed and revoked

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Recover focussed interventions

• Link with GP
• Change from depot to oral (wafers)
• Independent hygiene
• Establish engagement in social routines in hostel
• Fortnightly coffee out with case worker

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At 36 months

• Orals prescribed by GP
• Secure housing
• Social support group with case worker
• Participating in activities in hostel
• Hostel supervising hygiene
• The challenge is discharge..

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Case Study
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Can we routinely utilise these processes

• There are a range of clinical opportunities to
  explore the use of OMs
• This is not a replacement for clinical expertise
  but it does provide opportunity to reflect on
  clinical presentations institute care planning
  and further down the track I hope engage consumers

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Current service review at Alfred AMHS

• Community review data sets
• PDRS and CCU housing analysis using HoNOS and LSP
• Clinical review for continuing care driving
  intervention
• CCU and GP engagement
• Seclusion reductions projects using OCP and OM
  data to track and inform services of consumer
  profile and service responses.

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Thank You !