Title: Utilizing Outcome Measures to understand clinical activity and improve service interventions
1Utilizing Outcome Measures to understand clinical
activity and improve service interventions
- Sandra Keppich-Arnold
- Alfred Psychiatry
- BAYSIDE HEALTH
2Informing 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 -
3The 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
4The AMHOCN journey - AGED
- HoNOS over 65
- LSP (community)
- Basis 32 (community)
- Focus of Care (community)
- RUG ADL (inpatient)
5Experiences 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
6Caulfield 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)
7Caulfield Experiences
- Embedding OM activity into clinical processes to
challenge clinical activity at admission, review
and identify potential for discharge
8Life 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
9Challenges 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
10Back 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.
11Level 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
12The 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
13Priority 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.
14Maximizing 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
15Process 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
16Making 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
17Case 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.
18Linking 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
19Using 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.
20Changes 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
21Results 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
-
22Case 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
23Problems 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
24Problems 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
25First 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
26Recover 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
27At 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
28Recover 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
29At 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..
30Case Study
31Can 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
32Current 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.
33 Thank You !