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The Urgent Consultation Clinic of the Ottawa HospitalGeneral Campus: Implementation and Outcome Eval

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... M.H.A., John Kowal, Ph.D., Mary-Clare Royle, M.D. ... (Posavac & Carey, 1993) Develop and improve programs. Identify program outcomes. Report to funders ... – PowerPoint PPT presentation

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Title: The Urgent Consultation Clinic of the Ottawa HospitalGeneral Campus: Implementation and Outcome Eval


1
The Urgent Consultation Clinic of the Ottawa
Hospital-General Campus Implementation and
Outcome Evaluation Frameworks J. Robert
Swenson, M.D., Colleen MacPhee, M.H.A.,John
Kowal, Ph.D., Mary-Clare Royle, M.D., Katharine
Gillis, M.D., Tim Aubry, Ph.D.University of
Ottawa Centre for Research on Community
ServicesJune 2007 - National SHARED Care
Conference
2
Objectives
  • Framework of our program evaluation
  • Orientation to the outcome evaluation of the UCC
  • Evaluation design
  • Clinician rating measures
  • Outcome Questionnaire
  • Other self-report measures
  • Procedures
  • Preliminary Results

3
Program Definition
  • A more or less coherent system of inputs,
    activities, outputs, and outcomes that have been
    organized to address specific needs and resolve
    particular problems of a given population
  • e.g., Urgent Care Clinic

4
Program Evaluation Definition
  • The systematic collection of information
    about the activities, characteristics, and
    outcomes of programs to make judgements about the
    program, to improve program effectiveness, or to
    inform decisions about future programming

5
Make-Up of a Program
PROGRAM MISSION
PROGRAM PROCESSES
PROGRAM OUTCOMES
NEEDS
INPUTS
INITIAL OUTCOMES
INTERMEDIATE OUTCOMES
GOALS OBJECTIVES
ACTIVITIES
VALUES PRINCIPLES
OUTPUTS
LONGER-TERM OUTCOMES
RELATIONSHIP TO THE THREE MAIN TYPES OF PROGRAM
EVALUATION
NEEDS ASSESSMENT
IMPLEMENTATION / PROCESS EVALUATION
IMPACT / OUTCOME EVALUATION
6
Purposes of Program Evaluation(Posavac Carey,
1993)
  • Develop and improve programs
  • Identify program outcomes
  • Report to funders
  • Help qualify for accreditation
  • Respond to requests for information

7
The Ottawa Hospital Urgent Consultation Clinic
(UCC)
  • Interdisciplinary program providing short-term
    outpatient mental health services.
  • Patients referred from Psychiatric Emergency
    Services and Medical/Surgical Services and
    Psychiatric Inpatient Services.
  • UCC team Psychiatry, Psychology, Nursing, and
    Social Work
  • Services provided psychodiagnostic assessments,
    medication management, short-term psychotherapy,
    and liaison with community mental health
    services.

8
The Ottawa Hospital Urgent Consultation Clinic
Program Logic Model
ASSUMPTION An interdisciplinary Urgent
Consultation Clinic (UCC) mental health team as
part of a comprehensive range of intensive-level
psychiatric services at The Ottawa Hospital (TOH)
will result in improved access to, and quality
of, psychiatric care for outpatients with mental
health problems
GOAL To demonstrate that this Urgent
Consultation Clinic model improves quality of
mental health care.
  • ACTIVITIES
  • Referrals are screened for acuity and
    appropriate level of intervention to determine
    suitable services
  • Psychiatry
  • Psychodiagnostic assessment
  • Medication review and management
  • Short-term psychotherapy and psycho-education
  • Resident training
  • Psychiatric Nursing
  • Assessment
  • Management of patients with co-morbid mental
    health and physical problems
  • Symptom and medication monitoring
  • Counselling and psycho-education
  • Psychiatric Social Work
  • Assessment
  • Individual and family therapy
  • OBJECTIVES
  • To provide short-term outpatient mental health
    services for patients referred by
  • Psychiatric emergency services (PES)
  • Medical/surgical services
  • Emergency services
  • Inpatient psychiatry
  • To improve patients mental health and quality
    of life
  • OUTPUTS
  • of patients referred
  • of patient assessments
  • of patients seen in follow-up counseling or
    therapy
  • of follow-up counseling or therapy sessions
  • of patients seen for medication management
  • of patients referred to the Acute Partial
    Hospitalization Program
  • of patients referred to a community-based
    mental health professionals
  • of patients discharged to family physician
  • SHORT-TERM OUTCOMES
  • Patients
  • Increased patient access to mental health
    programs and services
  • Increased knowledge of mental health issues
  • Improved participation in patient-centered
    treatment plan
  • Increased psycho-social support
  • Increased knowledge of adaptive coping skills
    and strategies
  • Program
  • Improved triage system for incoming referrals
  • INPUTS
  • UCC Team
  • Psychiatry (2.5
  • FTE)
  • Residents (1.3 FTE)
  • Social work (0.5 FTE)
  • Nursing (2.0 FTE)
  • Psychology (0.3 FTE)
  • Resident (0.1 FTE)
  • Support staff (1.5 FTE)
  • Office space and equipment
  • LONG-TERM OUTCOMES
  • Patients
  • Decreased severity of mental health problems
  • Improved functioning
  • Increased coping skills and strategies
  • Improved quality of life
  • Increased satisfaction with acute mental health
    services
  • Mental Health Practitioners
  • Enhanced training for psychiatry and psychology
    residents in the provision of acute mental health
    services


9
UCC Outcome Evaluation Questions
  • Do patients experience a decrease in the severity
    of their mental health problems over the course
    of receiving UCC services?
  • Do patients experience an improvement in
    functioning over the course of receiving UCC
    services?
  • Do patients experience an improvement in their
    quality of life over the course of receiving UCC
    services?
  • Are patients satisfied with UCC services?

10
Clinician Rating Measures
11
Threshold Assessment Grid(Slade, Powell, Rosen
Strathdee, 2000)
  • Assesses the severity of mental health problems
  • Ratings obtained on 7 domains in 3 areas
  • Safety (intentional unintentional)
  • Risk (from to others)
  • Needs Disabilities (survival, psychological
    social difficulties)
  • Response alternatives range from none (0) to very
    severe (4)
  • Total scores obtained by summing scores across
    domains
  • Cut-off total score of 5 or more or at least 2
    moderates
  • Good psychometric properties

12
Global Assessment of Functioning(Spitzer,
Gibbon, Williams Endicott, 1994)
  • Overall Psychosocial Functioning
  • psychological symptoms, occupational social
    functioning
  • 100-point single-item rating scale
  • Values range from 1 (poorest functioning) to 100
    (highest functioning)
  • Cut-off points
  • Reasonably good psychometric properties

13
Patient Self-Report Measures
14
Outcome Questionnaire(Lambert, 1996)
  • 45 item version most commonly used
  • Educational level sixth grade
  • Symptom distress, interpersonal relations, social
    role
  • Response alternatives - Never (0) to Almost
    Always (4)
  • OQ-45 5 minutes
  • Total score ranges from 0 to 180 on the OQ-45

15
Outcome Questionnaire Items (Lambert, 1996)
  • Symptom Distress
  • My heart pounds too much
  • Interpersonal Relations
  • I am satisfied with my relationships with
    others
  • Social Role
  • I feel stressed at work / school

16
Outcome Questionnaire (Lambert et al., 1996)
Strengths
  • Brief and simple
  • Good psychometric properties
  • Sensitive to changes
  • Economical
  • Measures multiple dimensions of well- being
  • Identifies difficulties found in wide range of
    mental disorders
  • Useful for clinicians and administrators

17
Outcome Questionnaire(Lambert, 1996)
Scoring Interpretation
  • Total (addition of items)
  • Critical items (8,11,26,32,44)
  • Cut-off scores OQ-45 64
  • Clinical change OQ-45 14 or more

18
(No Transcript)
19
Possible Outcomes Based on OQ-45 Scores
64 ----------------------------------------------
--------------------------------------------------
------
20
Comparison of Client Scores on the OQ-45F at
Intake to the Scores of Normative Samples(OQ
Measures, LLC, 2004)
  • Undergraduate students (n 235)
    42.15
  • Community residents (n 815)
    45.19
  • EAP clients (n 441)
    73.61
  • University counselling centre (n 486)
    75.16
  • Medical Clinic (n166)
    80.92
  • CLSC II (n70)
    81.80
  • Outpatient clinics (n 342) 83.09
  • Community mental health centre (n100)
    86.07
  • CLSC I (n174)
    87.41
  • Inpatient clinics (n 207)
    88.80
  • Psychiatric Day Hospital Programme (n 158)
    104.15

21
Patient Health Questionnaire (PHQ)(Spitzer,
Williams, Kroenke, et al., 1999)
  • Based on the PRIME-MD
  • Screen for most common groups of disorders (i.e.,
    depressive, anxiety, alcohol, somatoform, and
    eating disorders)
  • Additional categories problems with
    menstruation, pregnancy, childbirth, psychosocial
    stressors
  • 16 sub-sections questions range from past
    2-weeks to past 6-months
  • presence of distress (Y/N), intensity (not
    bothered, a little, a lot), frequency (not at
    all, several days, more than half of days, nearly
    every day), social/occupational impairment
  • very good psychometric properties

22
SF-12(Ware,1996)
  • Generic Health Measure
  • 12-items
  • Two scales (physical and mental health overall
    health-related quality of life)
  • Total score ranging from 0 (lowest level of
    health) to 100 (highest level of health)
  • Physical Mental Health Composite Scores
  • Good psychometric properties

23
SF-12
  • Flow Chart for Scoring
  • Enter data
  • Recode out-of-range item values as missing
  • Reverse score and/or recalibrate scores for four
    items
  • Compute raw scale scores
  • Transform raw scale scores to 0-100 scale

24
Satisfaction with Life Scale (Diener, Emmons,
Larsen, Griffin, 1985)
  • Global measure of subjective well-being
  • Cognitive appraisal of life situation
  • 5-item self-report measure
  • 7 response alternatives
  • Strongly Disagree to Strongly Agree
  • Total score ranging from 5 to 35
  • Very good psychometric properties

25
Client Satisfaction Questionnaire
  • Measures overall level of satisfaction with
    services
  • Use of 8-item version in study
  • Widely used allowing for comparison to other
    similar settings
  • Possible 4 response alternatives
  • 2 reflecting satisfaction
  • 2 reflecting disatisfaction
  • Very good psychometric properties

26
UCC Evaluation Methods
27
UCC Outcome Evaluation Design
28
UCC Outcome Evaluation Design
29
UCC Evaluation
  • Preliminary Results
  • (n31)

30
Baseline Characteristics(n31)
  • Age (yrs.)
  • Mean SD 36.9 12.1
  • Range 20 - 62
  • Sex
  • Female 11 (36)
  • Male 20 (64)
  • Language
  • English 29 (94)
  • French 2 (6)
  • Educational level1
  • Secondary 15 (56)
  • College 6 (22)
  • University 6 (22)
  • Employment status2
  • Full- or part-time 15 (52)
  • Unemployed 14 (48)
  • _________________________________________________
  • 1Date are missing for 4 participants.
  • 2Date are missing for 2 participants.

31
Referral Source and Follow-up
  • Participants
  • Variable n 31
  • _________________________________________________
  • Referral source
  • Psychiatric emergency services 5 (16)
  • Emergency department 7 (23)
  • Inpatient psychiatry 1 (3)
  • Medical/surgical services 18 (58)
  • Follow-up planned
  • Yes 9 (29)
  • No 22 (71)
  • _________________________________________________
  • seen on a single occasion and, referred to other
    mental health services

32
Baseline Clinical Characteristics(n31)
  • Psychiatric diagnosis
  • Axis I
  • Mood disorder 18 (58)
  • Adjustment disorder 1 (3)
  • Delerium 1 (3)
  • Schizophrenia 2 (6)
  • Axis II
  • Schizoid PD 1 (3)
  • Antisocial PD 3 (10)
  • Borderline PD 3 (10)
  • Narcissistic PD 2 (6)
  • Dependent PD 3 (10)
  • Concurrent condition 11 (36)
  • Psychological measures (mean SD)
  • Satisfaction with life scale 16.0 7.8
  • GAF 59.9 8.9
  • TAG 4.2 2.6

33
Future Directions
  • Recruit 150 participants
  • Examine outcomes over time (e.g., change in
    clinical status, quality of life, symptoms, etc.)
    based on patient and clinician ratings
  • Ascertain to what extent the UCC is being
    implemented as intended (e.g., time from referral
    to initial clinic visit, number of sessions,
    types of services provided, etc.)
  • Improve the quality of clinical services by
    integrating study results into clinical practice
  • Disseminate study findings to relevant
    stakeholders
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