Transcript Presentation by Dr. John Ward on use of FARS,CFARS and …

FARS, CFARS & MGAF-R:
What do you want to know
about them?
How can they help you do your
work?
John C. Ward, Jr., Ph.D.
2005 FCCMH/FLAPRA Conference
“Mission Possible: Inspiring Hope and
Recovery”
September 14, 2005
“Not everything that
counts can be
counted…
and,
not everything that can be
counted,
counts.”
Albert Einstein
“Recovery is
organic…
measured as
a functional
process…not
an event !”
Important Internet Addresses:
• http://www.dcf.state.fl.us/mentalhealth/links.shtml
Department of Children and Families (DCF)
information on performance measures including
FARS/CFARS & MGAF-R
• http://www.dcf.state.fl.us/publications/policies.shtml
Department of Children and Families (DCF)
publications including Mental Health/Substance
Abuse Data Pamphlet (CFP 155-2) under revision
• http://outcomes.fmhi.usf.edu
Louis de la Parte Florida Mental Health Institute’s
outcome measures website including FARS &
CFARS information, user manuals, forms and
FARS/CFARS Web-based Training and Certification
Program…all free! (except charge for CEC’s)
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Can we do this in 115 minutes?
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10 minutes: Global Assessment - MGAF-R
5 minutes: Multi-Domain Functional Assessment
10 minutes: Description of FARS/CFARS
20 minutes: Guidelines for determining problem
severity ratings for FARS or CFARS
10 minutes: FARS& CFARS Web Training Program
20 minutes: Using FARS or CFARS assessments
to develop Individualized Treatment Plans
20 minutes: Using FARS or CFARS assessments
to develop Agency Level Quality Assurance/
Quality Improvement Reports
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20 minutes: Discussion, Questions and Answers
“Global” Functional Assessment
• In 1987, the Global Assessment of Functioning
(GAF) was published by the American
Psychiatric Association in the DSM III-R (derived
from older GAS)
• Single score from 1 to 100
• Divided into groups of ten score ranges
• Mixed functional and behavioral descriptors
related to mental health symptoms, work,
relationships, etc. for each block of ten points
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Why the MGAF-R ?
• Concerns about inter rater reliability of the GAF led to
development of the Modified GAF, which included
descriptive anchors to increase reliability of GAF rating
- Caldecot-Hazard, S. & Hall R. (1995)
• In 2004, the Florida “DCF Functional Assessment
Workgroup” revised the MGAF “anchors” to align with
DSM – IV resulting in the “MGAF-R”
• In, 2005, Florida DCF required the MGAF-R “global”
rating in lieu of the Multi-domain Functional
Assessment Rating Scale (FARS) for evaluating adults
who receive DCF contracted “Medication Only” mental
health services
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To arrive at an MGAF-R rating, first
conduct a clinical interview and fill out
the top of the MGAF-R form…
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Modified Global Assessment of Functioning – Revised (MGAF-R)
Name of person being evaluated
(Optional: required only if needed SSN of person being Evaluated: (Required)
by your agency or copy is retained
___ ______/___ ___ ___/___ ___ ___
in paper clinical record, please print):
Provider Agency Tax ID (Required):
(last)_________(first)______(mi)__
_______________________
Date of Birth (Required) :
______/_____/_____
mm
dd
yyyy
Gender: (Required) Male
Female
Date of Assessment (Required):
_______/_______/_______
mm
dd
yyyy
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…then, begin with the list of functional
criteria from the bottom of the form…
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Immediate Danger from Serious Neglect or Self-Injurious Behavior
Group A Criteria: -Serious suicidal act with clear expectation of death
(e.g., stabbing, shooting, hanging, or serious over
dose with no one present)
-Frequent severe violence or self-mutilation
-Extreme manic excitement, or extreme agitation and
impulsivity (e.g., wild screaming, ripping the stuffing
out of a bed mattress)
-Persistent inability to maintain minimal personal
hygiene
-Urgent/emergency admission to present psychiatric
hospital
-In acute, severe danger due to medical problems (e.g.,
severe anorexia or bulimia with heart or kidney problems)
8-10 1-2 of the criteria in Group A
4-7 3-4 of the criteria in Group A
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1-3 5-6 of the criteria in Group A
…work your way up the criterion lists…
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20 Suffering from Neglect or in Danger of Hurting Self or Others
Group B Criteria: -Suicide attempts without clear expectation of death
(e.g., mild overdose or scratching wrists with people
around)
-Some severe violence or self-mutilating behaviors
-Severe manic excitement, or severe agitation and
impulsivity
-Occasionally fails to maintain minimum personal hygiene
(e.g., diarrhea due to laxatives, or smearing feces)
-Urgent/emergency admission to the present psychiatric
hospital
-In physical danger due to medical problems (e.g., severe
anorexia or bulimia and some spontaneous vomiting or
extensive laxative/diuretic/diet pill use, but without
serious heart or kidney problems or severe dehydration and
disorientation)
18-20
1-2 of the criteria in Group B
14-17
3-4 of the criteria in Group B
11-13
5-6 of the criteria in Group B
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…until you find criteria that fits your
interview and mental status findings…
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Inability to Function in Almost All Areas
Group D Criteria: -Serious impairment with work, school or housework if a
housewife or househusband (e.g., …)
-Frequent problems with the law (e.g., …)
-Serious impairment in relationships with friends (e.g., …)
-Serious impairment in judgment (including …)
-Serious impairment in thinking (including …)
-Serious impairment in mood (including …)
»
(and the list goes on…)
Group C Criteria:
-EITHER Suicidal Preoccupation or frank suicidal ideation
with preparation
-OR behavior considerably influenced by delusions (etc.)
-OR serious impairment in communication (sometimes
incoherent, acts grossly inappropriately, OR profound
stuporous depression)
28-30
7 of the criteria in Group D
24-27
8 of the criteria in Group D
20-23
9 of the criteria in Group D
10
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1 of the criteria in Group C
…pick the number on the left margin that
matches the criteria you selected, enter
that rating in the space on the back page
of the form, and sign your name.
• Assigned MGAF-R Rating (Required): __________
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• Signature/Title of Person completing MGAF-R
(Required):_________________________________________
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What is “multi-domain”
functional assessment?
• A valid and reliable way to document
effectiveness of functioning separately
for Cognitive, Behavioral,
Physical/Medical, Interpersonal,
Social, and Role domains
• Based on information from face to face
clinical interviews that include mental
status exams, observed or self reported
symptoms, psychological testing
…and/or any other sources available
to the clinician or treatment team
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How do multi-domain functional
assessments help describe the
whole person?
• All People live, work, learn, meet needs
and experience quality of life on the
basis of functioning in cognitive,
physical, social, and role domains
• Need for and/or admission into
behavioral healthcare services generally
follows impaired functioning in one or
more domain (e.g., Baker Act Criteria)
• Discharge from treatment generally
follows restoration or improvement in
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functioning in those domains
How are multi-domain functional
assessments used ?
• At Individual level, to develop treatment
plans by identifying and documenting problem
areas and potential assets of functioning at
admission…and, to evaluate and monitor
progress during treatment and at discharge
• At Agency level, aggregates of ratings help
monitor Quality Assurance and Quality
Improvement goals in programs and services
• At District level, assessment of service
recipients helps plan for needed services
• At State level, data aggregates help describe
service outcomes for legislative reports 14
Why ‘Functional’ Scales In Florida ?
• 1) Florida’s Governance and Accountability Act
was passed in 1994.
• 2) DCF (then HRS) was advised they would be
one of the first budget entities under the
Governor’s budget office to be asked to develop
performance measures
• 2) In 1993, FMHI was asked to assist “District 7”
in developing and piloting performance measures
• “Florida Council” asked FMHI to consider
including functional assessment Instruments as
part of that process
• FMHI looked at CCAR but had to make many
revisions…resulting in…
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The Functional Assessment
Rating Scales
TM
TM
John C. Ward, Jr., Ph.D.
Michael G. Dow, Ph.D.
John C. Ward, Jr., Ph.D.
Michael G. Dow, Ph.D.
Teri L. Saunders, M.S.
Shawn C. Halls, M.A.
Kathy F. Penner, M.A.
Kristina A. Musante, B.A.
Ray T. Berry, B.A.
Natalie Sachs-Ericsson, Ph.D.
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Functional Assessment Rating Scales
• FARS Domains (Adults)
• Depression
Anxiety
Hyper Affect
• Thought Process
Cognitive Performance
Medical/Physical
Traumatic Stress
• Substance Use
• Interpersonal Relations
• Family Relations
• Family Environment
• Work or School
• ADL Functioning
• Socio-Legal
• Ability to Care for Self
• Danger to Self
Danger to Others
Security Management Needs
• CFARS Domains (Child & Adol)
• Depression
Anxiety
Hyper Activity
Thought Process
Cognitive Performance
Medical/Physical
Traumatic Stress
Substance Use
Interpersonal Relations
• Behavior In Home Setting
• Work or School
• ADL Functioning
• Socio-Legal
Danger to Self
Danger to Others
Security Management Needs
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Factor Scales & Clinical Scales
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FARS Domains (Adults)
Depression
Anxiety
Hyper Affect
Thought Process
Cognitive Performance
Medical/Physical
Traumatic Stress
Substance Use
Interpersonal Relations
Family Relations
Family Environment
Work or School
ADL Functioning
Socio-Legal
Ability to Care for Self
Danger to Self
Danger to Others
Security Management Needs
E
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D
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E
PS
R
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D
R
D
PS
R
PS
Factor Scales: D=Disability, E=Emotionality,
Clinical Scale groups from top: Diagnostic,
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CFARS Domains (Child & Adol)
Depression
E
Anxiety
E
Hyper Activity
R
Thought Process
D
Cognitive Performance
R
Medical/Physical
D
Traumatic Stress
E
Substance Use
PS
Interpersonal Relations
R
Behavior In Home Setting
R
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Work or School
ADL Functioning
Socio-Legal
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Danger to Self
PS
Danger to Others
R
Security Management Needs PS
R
D
PS
PS=Personal Safety, R=Relationships
(Ward, et al., 1999)
Co morbid, Psychosocial, & Risk
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(D. Moore/ FHP-2002…DCF may use in 2005)
FARS Problem Severity Ratings
Use the following 1 to 9 scale to rate the individual’s
current (within last 3 weeks) problem severity for each
functional domain listed below. Place your rating
number on the line to the right of the Domain name.
Also, using the list below each domain rating, place an
“X” mark next to the adjectives or phrases that describe
symptoms or assets. (Refer to FARS User’s Manual for
specific examples of use of this scale…available at
http://outcomes.fmhi.usf.edu)
• 1
No
Problem
2
3
Slight
Problem
4
5
Moderate
Problem
6
7
Severe
Problem
8
9
Extreme
Problem
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Are there any “principles” or special
instructions that help clinicians decide
what ratings to assign?
• The manuals discuss general guidelines that
include how “three basic treatment issues”
help decide how impaired functioning is in any
domain in addition to intensity or interference
from symptoms, words or phrases checked for
a domain (note: number of items checked not necessarily equal to a
problem severity rating of the same number, etc.)
• The manuals also include specific “anchors” to
assist in arriving at a problem severity rating
for each domain
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General Guidelines for Determining
Problem Severity Ratings
• . In general, severity ratings are associated with:
• 1) how immediate is the need for intervention (i.e.,
none, to some time in the future, to immediate, etc.),
or
• 2) how intrusive is the intervention that is needed
(i.e., ranging from need for normal or slightly more
than normal levels of interpersonal or social “support”,
to need for supportive medications with few side
effects, to need for major medications with serious
potential side effects, or need for external physical,
structural, or environmental controls, etc.), or
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General Guidelines for Determining
Problem Severity Ratings
• . 3) how does functioning in the rated domain impact
negatively on other domains (e.g., if impaired
functioning in the depression domain effects
interpersonal relationships, family relationships,
work or school functioning, and increases potential
for danger to self, etc. the depression domain would
be rated as more severe than if no other domains
were impacted by depressive functioning).
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Problem Severity Rating Anchors
• (Consider level of functioning within the past three weeks for each domain)
• 1 = No Problem
Functioning is consistently
average or better than what is typical for this person's
age, sex, and subculture. (i.e., functioning in this
domain is strong and may be an “asset” to call on to
improve functioning in other domains.)
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Problem Severity Rating Anchors
• 2 = Less than a Slight Problem
• 3 = Slight Problem Functioning in this range falls
short of typical for a person of this age, sex, and
subculture most of the time. That is, a problem in this
domain may be intermittent or may persist at a low
level. The problem or symptoms in this domain have
little or no impact on other domains or they may be
currently controlled by internal or external
interventions. The need for treatment in this domain
is not urgent but may require intervention in the future.
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Problem Severity Rating Anchors
• 4 = Slight to Moderate Problem
• 5 = Moderate Problem Functioning in this range is
clearly marginal or inadequate, not meeting the usual
expectations of a typical person of this age, sex, and
subculture. This means that the dysfunction or
problem in this domain may persist at a moderate
level or become severe on occasion. Problems in this
domain may be related to problems in other domains
and therapeutic intervention is required.
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Problem Severity Rating Anchors
• 6 = Moderate to Severe Problem
• 7 = Severe Problem Functioning in this range is
marked by obvious and consistent failures, never
meeting expectations for a typical person of this age,
sex, and subculture. The dysfunction or problem in
this domain may be chronic. It almost always extends
to other domains and generally interferes with
functioning in more than one other domain.
Hospitalization or some other form of external control
may be needed in addition to other therapeutic
interventions).
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Problem Severity Rating Anchors
• 8 = Severe to Extreme Problem
• 9 = Extreme Problem The highest level of the
scale, suggesting the person's impaired
functioning in this domain is creating a situation
that is totally out of control, unacceptable,
and/or potentially life-threatening. The need for
external control or intervention is immediate.
•
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Is training available for learning
how to use the FARS and
CFARS?
Yes… the FARS & CFARS
“Web-Based”
Training and Certification Program
is free and available at:
http://outcomes.fmhi.usf.edu
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If it’s helpful to talk about these scales in
a group, why is FARS & CFARS training
only available on the Internet Web-site?
• In the “beginning”, FMHI provided face-to-face
trainings to help the state “ramp up” the
implementation of FARS and CFARS
• That included training some staff in several DCF
Districts and many clinical staff in several community
mental health agencies to be “Certified FARS and/or
CFARS Trainers”…some remain!
• That was in the 1990’s…way back in the last Century!
• Attrition rate of clinicians in the community programs
makes it impractical for centralized face to face
training
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If it’s helpful to talk about these scales in
a group, why is FARS & CFARS training
only available on the Internet Web-site?
• The only realistic and cost effective alternative
is web based Training and Certification that
maintains a single minimum standard…permits
existing trainers special access…and
encourages agencies to emphasize importance
to new clinical staff by providing up to date
manuals, internet access & time to take the
training…CEC applications indicate many use
home computers at night to train & receive their
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official rater ID’s.
Important directions for FARS & CFARS Webbased Training and Certification Program
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1) Manuals, forms, training & certification are free
2) Always start each session at:
http://outcomes.fmhi.usf.edu
3) Download and read the September 2004 manual to
understand the scales and learn how to arrive at
the most reliable & accurate problem severity ratings
4) Read and follow detailed instructions in the manual
to learn how to register and select a password for
the web based training program, take the practice
vignettes, take the certification test, and print a
certificate with an official rater ID
5) Be sure to complete 2, 3, and 4
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6) Direction #5 is the most important
The Functional Assessment
Outcomes Web Site
(http://outcomes.fmhi.usf.edu)
Functional Assessment Rating Scales
The Functional Assessment Rating Scales – (FARS) for adult
behavioral health functional assessment (John C.Ward, Jr.,
Ph.D. & Michael G. Dow, Ph.D., 1994, 1996, 1997, 1998) &
(CFARS) for child or adolescent behavioral health functional
assessment (J. Ward, M. Dow, T. Saunders, S. Halls, K.
Musanta, K. Penner, R. Berry, & N. Sachs-Ericcsson, 1996,
1997, 1998) are ways of documenting and standardizing
impressions from clinical evaluations or mental status exams
that assess cognitive, social and role functioning. The FARS
and CFARS (adapted from the Colorado Client Assessment
Rating Scales - CCAR) were developed for use in Florida to
evaluate the Florida Department of Children and Families (DCF)
behavioral health outcomes for children and adults
receiving state supported services.
…and just below that is:
The FARS and CFARS links on the left side of this page
take you to more information about these scales and free
download of the FARS and CFARS user's manuals and
forms. The manuals also include detailed instructions for
registering and taking the free online training and
certification programs for these instruments.
Information about a consumer satisfaction measure
developed by Dr. Dow and Dr. Ward (The Behavioral
Healthcare Rating of Satisfaction - BHRS) is available at
http://bhrs.fmhi.usf.edu.
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Contact information regarding the FARS and CFARS:
John C. Ward, Jr., Ph.D..
Associate Professor
Department of Mental Health, Law and Policy
Louis De la Parte Florida Mental Health Institute
and
Department of Epidemiology and Biostatistics
College of Public Health
University of South Florida
13301 Bruce B. Downs Blvd.
Tampa, FL 33612-3807
phone: (813) 974-1929
fax: (813) 974-9327
E-mail: [email protected]
Copyright 2000, 2005 - University of South Florida
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… other navigation links are on left
side of the “Outcomes” page:
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HOME Home
FARS FARS
CFARS CFARS
FMHI Office
13301 Bruce B. Downs Boulevard
Tampa Florida
33612
i
Web design and interactive programming:
John C. Ward, Jr., Ph.D
Bart Mawoussi M.S.
Sonnel Moreau M.S.
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…when you click on the FARS
link on the “Outcomes” page it
takes you to the FARS page
where you see these active links:
• Download the September 2004 FARS Manual
Go to FARS Training and Certification Site
• (You must download and read this new manual
before beginning your training...the manual has
detailed instructions about registering for the
online training, selecting your password, taking
the training and printing your certificate.)
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…the “Training and Certification”
link on the FARS page takes you to
the “secure” logon page:
…where the top of the page says this:
Welcome to the Functional Assessment Rating Scales
(FARS) Training and Certification System. If you are
one of the 4414 students already certified through the
online FARS Rater Certification System, or if you are
returning to complete your training, please enter your
Social Security Number (do not use dashes or spaces)
and Password below and click Login.
You can retrieve your password if you have forgotten it
by clicking on this link.
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…and the middle of the logon
page looks like this:
Soc.Sec. #
Password
Login
VeriSign
Secured
Verify >
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…but, read on…some very important
information is just below the logon
boxes…
• If you have not previously registered as a student,
please click here to register and select your
password. If you have already registered as a
CFARS or FARS student, you do not need to
register again (just use the same password for this
training session. If you register again, you may
delete information about your previous training) .
• The registration process will require that you provide
some personal information that will enable us to
identify you as a certified FARS rater and to
communicate important information in the future. 39
…forgot your password or want to see if
your ssn is in the web database ? Click
on the password retrieval link at the top
of the logon page…it takes you:
• Password Lookup
In order to retrieve your password, we will need your Social
Security Number.
•
Soc. Sec. #
Send Request
After clicking "Send Request," your password will be displayed in
this window.
• If you require assistance, please send e-mail to Dr. John Ward
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([email protected]) of the University of South Florida.
…after you enter your ssn without
dashes or spaces on the password
retrieval page, if you have previously
registered or been registered by a
certified trainer on the website, you
will see this:
• Thank you for returning to the Functional Assessment
Training and Certification System.
• Your password is supershrink. Use only the
characters shown in boldface red. Please note that
passwords are case-sensitive.
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…when you “click here” to register
on the logon page…
• New Student Registration
• The information you provide here will enable us to
maintain your certification information and identify
ways to improve the rater certification system in the
future. The Louis de la Parte Florida Mental Health
Institute is committed to safeguarding your information
and respecting your privacy...Your personal
information will be used to generate a unique rater
certification number that you will use on each
functional assessment that you submit. This rater
certification number provides assurance of your
successful completion of the training. The confidential
information will be maintained in a database operated
by the Florida Mental Health Institute.
• (* indicates a required entry - no dashes please) 42
…right side of the Registration page:
• * Social Security Number: We will keep this information private.
• Please enter your name as it should appear on your
certificate:* First Name:
* Last Name:
• Please provide the following information regarding
your current employer: * Company Name: Street
Address: * City: * State:
*Zip:
• * Telephone (No dashes, please.):* Your Email
Address:
• Demographic Information: Gender: *
• Education Information: Highest Level of
Education:
* Specialty:
Degree Field/Major:
• Note: Entering an incorrect value below may cause you to be
unable to register as a student. Please do not enter or edit
anything below unless you are a certified trainer.
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• Certified Trainers Only: SSN [
]
Click “Continue” to submit registration & go
to this password selection page:
• Please supply a password in the boxes below. Certified
trainers, please provide a password for your student. If you
have returned to this page after supplying a password, then the
passwords you supplied did not match. Please re-enter your
password now.
• Supply Password
• Re-Type Password
• The password you select will be requested each time you login
If you do forget the password, you will be able to retrieve it later.
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After selecting a password, you go to
your “Welcome…” page:
• Welcome, Sean Connery! (If you are not Sean Connery, click here.)
• While the training and certification program generally takes more
than one hour to complete, It is not necessary to complete the
training in one sitting. As you proceed through your training, the
options displayed below will change depending on your current
status. If you leave the training for any reason, simply log in again
whenever you wish using the Social Security Number and password
you supplied earlier. The login page will direct you here. Good luck!
• View Learning Objectives
• Begin, continue, or repeat the training vignettes
• Print Continuing Education Credits Application and Instructions
(requires Adobe Reader 5.0 or newer).
•
Get Adobe
•
Reader
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…the “training vignettes” link goes
to:
• Instructions
Please read the following vignette. You may need to
scroll down to read it in its entirety. When you have
finished, click here to complete the FARS for this
vignette. You may also choose another vignette or
go back to the previous page.
•
Heather
Heather is a twenty-five year old, single woman. She
says she is “concerned about herself” because she
has started feeling “anxious and tense” most of the
time. She described herself as "…stressed out…I feel
like my life is totally out of control. " She thinks that
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she first started feeling this way… etc.
When you “click” on the “click here” button
on the Training Vignette Page you go to
scoring pages…one for each domain:
• Provide your rating for each FARS domain using the dropdown box below.
Also, check any keywords you feel may be appropriate for this vignette.
When you are finished entering all 18 ratings, click the button in the lower
right labeled "Submit Ratings for Scoring." You may refer back to the text of
the vignette which may be under this window.
• Use the "Next Domain" and "Previous Domain" links to navigate through the
domains. You can skip domains or return to edit your ratings prior to
submitting your ratings for scoring. Keep in mind that you cannot submit your
ratings until you have supplied a rating for each domain.
V
Depression
• Depressed mood
Anhedonia
• Happy
Lonely
• << Previous Domain
Sad
Sleep Problems
Hopeless
Worthless
Next Domain >>
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…the bottom of the scoring page shows
your ratings as you click on “Next
Domain”…
• Your Ratings
Depression
Hyper Affect
Cognitive Performance
Traumatic Stress
Interpersonal Relations
Family Environment
Work/School
Ability to Care for Self
Danger to Others
4
2
6
3
8
6
6
4
2
Anxiety
3
Thought Process
5
Medical/Physical
6
Substance Use
8
Family Relationships 6
Socio-Legal
4
ADL Functioning
4
Danger to Self
3
Security Mgmt Needs 5
Submit Ratings for Scoring
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After you take at least two training vignettes
and pass at least one, your welcome page
looks like this:
• Welcome, Sean Connery! (If you are not Sean Connery, click here.)
• While the training and certification program generally takes more
than one hour to complete, It is not necessary to complete the
training in one sitting. As you proceed through your training, the
options displayed below will change depending on your current
status. If you leave the training for any reason, simply log in again
whenever you wish using the Social Security Number and password
you supplied earlier. The login page will direct you here. Good luck!
• View Learning Objectives
Begin, continue, or repeat the training vignettes
Begin, continue or repeat test vignettes
• Print Continuing Education Credits Application and Instructions
(requires Adobe Reader 5.0 or newer).
•
Get Adobe
•
Reader
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..and, after you pass a “test vignette”
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Sean Connery
51
You just completed the minimum amount
of training & got a certificate (if you have the
right version of Adobe), but…
…if you want to get really good at using the
scales to determine treatment needs and
improve response to treatment for the people
receiving your services, you should:
• keep manual open when you rate domains…
• share your assessments with the people you
evaluate and get their feedback (unless
prevented by your agency…but ask why!?)
• rate yourself on each of the domains…and,
52
• use the domains to plan and monitor treatment!
Using Completed FARS or CFARS
Ratings to develop Individualized
Treatment Plans & monitor functional
change ?
“Focus is on
recovery as
restoration of
functioning
rather than
simply
reduction of
symptoms”
53
Basic Steps in Developing a
Negotiated Individualized
Treatment Plan
1) Conduct Clinical Interview and assess mental
status
2) complete “Admission” FARS/CFARS ratings &
descriptors
3) Review completed FARS/CFARS with person
assessed
4) Identify “Clinically Elevated” domains
5) Identify “Strength” Domains as personal assets
that may help support/reinforce change
Basic Steps in Developing a
Negotiated Individualized
Treatment Plan (continued)
6) Describe Domain to be Addressed in
Treatment Plan (include domain name,
severity rating and “words/phrases”
7) Define goals for change in measurable
terms
8) Devise an Action Plan with timelines
9) All parties sign the completed document
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FARS Profile
Ed Smith – 36yo
married male
No
Slight
Moderate Severe
Extreme
Problem Problem Problem Problem Problem
1
2
3
4
5
6
7
8
9
Depression
x
Anxiety
x
Hyper Affect
x
Thought Process
x
Cognitive Perf.
x
Medical/Physical
x
Traumatic Stress
x
Substance Use
x
Interpersonal Rel.
x
Family Relations
x
Family Environ.
x
Socio-Legal
x
Work or School
x
ADL Functioning
x
Ability/Care for Self
x
Danger to Self
x
Danger to Others
x
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Security/Mngmt.Needs
x
“Clinically Elevated” Domains
• Depression __6__
• Depressed Mood
Anhedonic
Sad
Worthless
Hopeless
Happy
Lonely
Sleep Problems
Anti-Depression Meds
57
“Clinically Elevated” Domains
• Substance Use__5__
• Alcohol
Drug(s)
• Family History
• Abstinent
Dependence Abuse
Cravings/Urges
Med. Control
• Interfere w/Duties
DUI
Recovery
I.V. Drugs
58
“Clinically Elevated” Domains
• Work__4__
•
•
•
•
•
•
Absenteeism
Poor Performance
Attends School Dropped Out
Learning Disabilities
Seeking Employment
Employed
Doesn't Read/Write
Tardiness
Disabled
Not Employed
59
“Clinically Elevated” Domains
• Danger to Self
__4__
• Suicidal Ideation
Current Plan
• Recent Attempt
Past Attempt
• Self-Injury
Self-Mutilation
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“Clinically Elevated” Domains
•
•
•
•
•
•
Security/Management Needs __4___
Home w/o Supervision
Suicide Watch
Behavioral Contract
Locked Unit
Protection from Others
Seclusion
Home w/Supervision
Run/Escape Risk
Restraint
Involuntary Exam /Commit
61
“Strength” Domains
•
•
•
•
•
•
•
Medical / Physical__1__
Acute Illness
Handicap or Perm. Dis.
Good Health
CNS Disorder
Chronic Illness
Need Health Care
Pregnant
Poor Nutrition
Enuretic/Encopretic Eating Disorder
Seizures
Stress-Related Illness
62
“Strength” Domains
• Interpersonal Relationships__2__
•
•
•
•
•
•
Problems w/Friends
Diff. Estab./Maintain Relationships
Poor Social Skills
Difficulty Maintaining Relationships
Adequate Social Skills
Supportive Relationships
63
“Strength” Domains
• Family Relationships__2__
•
•
•
•
•
•
•
No Contact with Family
Poor Parenting Skills
Supportive Family
Difficulty with Partner
Acting Out
No Family Conflict w/Relative
Difficulty with Child Difficulty with Parent
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“Strength” Domains
• Family Environment__2__
•
•
•
•
•
Family Instability
Custody Problem
Stable Home
Single Parent
Death in Family
Separation
Family Legal Problems
Divorce
Birth in Family
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Describe Domain to be
Addressed
• “Moderate to Severe level of Depressive
functioning as evidenced by FARS rating of 6
on Depression Domain & self report of
depressed mood, feelings of worthlessness,
sadness, loss of interest in most activities
and sleep problems expressed as difficulty
going to sleep and early awakening.
66
Define Goals for Change
• 1. I will learn the impact of negative thinking &
negative self talk in people experiencing
depressed mood and write 10 positive self
statements to review with my therapist next
Friday
• 2. By end of 30 days, I will increase my current
rate of daily exercise from zero minutes per day
to 30 minutes per day. (physical health is
“strength”)
• 3. By end of 30 days, I will increase my sleep
hours from current level of 3 hours average per
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night to at least 6 hours per night.
Describe Action Plan
• 1. I will attend Cognitive Therapy Group for
Depression 3 sessions this week and meet with
my Therapist on Friday at 3pm to discuss my
positive self statement script.
• 2. I will plan with my wife for us to take a 30
minute walk after dinner each evening
(supportive spouse is a “strength”.
• 3. Each night at bedtime for 30 days, I will
review and practice the “good sleep hygiene”
behavioral principles given to me by my
therapist
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Now…pick another “Clinically
Elevated” Domain (e.g., Danger
to Self & Substance Use) and
continue the process …
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When something is used by
clinicians and the people
receiving services…it should
also be used by the agency…
• So…how can an agency show
that the procedures are important
and also benefit from the
information developed in the
process?
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Using Functional Assessments to
develop Agency Level Quality
Assurance/Quality Improvement
Reports ?
71
Debate about value of Quality
Assurance and the Evolution of
Quality Management
“From Quality Assurance to
Total Quality Management”
Carol M. Frattali
American J. of Audiology – November 1991
72
QA
• Focused on Problem
Solving
• Clinical Focus
• Externally Driven
• Delegated to a few
• Focused on Individuals
• Discipline focus
• Creates Defensiveness
• Effectiveness and
Efficiency separate
QI
• Focused on continuous
improvement
• Focused on all activities
• Internally Driven
• Embraced by all
• Focused on work process
• Crosses disciplines
• Promotes Team Spirit
• Effectiveness and
Efficiency integrated
73
However…QA is still important
but should be expanded to
include the QI Philosophy
• eg., JCAHO requires quality
assurance mechanisms as the
foundation from which to develop
continuous quality improvement
monitoring…and offer a ten-step
QA process…
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JCAHO 10-step Quality
Assurance Process
• 1. Assign responsibility for monitoring
and evaluation activities
• 2. Delineate the scope of care
• 3. Identify the most important aspects
of care
• 4. Identify indicators for monitoring
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5. Establish thresholds for the
indicators that trigger evaluation
• 6. Collect and organize data for each
indicator
• 7. Evaluate care when thresholds are
reached to identify opportunities to
improve care
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8. Take action to improve care
• 9. Assess effectiveness of the action
• 10. Communicate results
77
Using FARS & CFARS Assessments
in Quality Management
• …since I am not a QA expert, let’s
first decide we want to…
78
easy
79
Using FARS & CFARS Assessments
in Quality Management (cont.)
• …then, we will start with JCAHO Step
3.”Identify the most important aspects
of care”
• …and pick a simple FARS example
first…like “Admission to the agency is
an important part of the clinical
service provided by our agency.”
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…and then we go to JCAHO Step 4.
which is “Identify indicators for
monitoring…etc.”
• …“FARS evaluations are to be
completed on all people admitted to
services at this agency.”
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…followed by JCAHO step 5. which is
“ Establish thresholds…that trigger
evaluation…” which we might write
as…
• …For a three month monitoring
period, “95% of all people admitted for
service to this agency will have
Admission FARS evaluations
completed within 10 days of their
admission date.”
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…and to JCAHO step 6:“ Collect and
organize data for each indicator…” and
7: “Evaluate care when thresholds are
reached…”
• …“Three months of monitoring shows
that 90% of all people admitted for
service to this agency had FARS
Admission evaluations competed
within 10 days of their admission
date.”
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…which takes us to Step 8. which is
“Take actions to improve care…”, which
could be…
• …”Meet (or send memo?) with all
clinical supervisors to stress
importance of having all people
admitted to agency have a FARS
evaluation completed within 10 days
of admission to the agency.”
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…and to Step 9. which is “Assess
effectiveness of the action and
document improvements…”, which
could mean…
• …monitor admission evaluations for
additional month to determine if
intervention with clinical supervisors
improved compliance with FARS 10
day assessment requirement.
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…and finally to Step 10. which is
“Communicate the results…”, which
might be…
• …sending a memo to all clinical staff
and supervisors and administrative
and support staff thanking them for
their efforts in achieving compliance
with this critical aspect of care.
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• …or we might push a different button
a little
More
complicated
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…and do something like this
• …starting with the same statements
we did for Step 3. but picking a
different indicator for step 4.….
• “People admitted for Crisis
Stabilization services due to suicide
precaution need treatment that will
reduce risk of suicide before being
discharged to less restrictive care.”
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…and for step 5.….perhaps
something like….
• “For a 90 day period, 100% of people
admitted for Crisis Stabilization
services due to suicide precaution as
documented by a FARS Danger to
Self Rating of 4 or more will improve
to a rating of 3 or less before being
discharged to less restrictive care.”
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Functional Assessment Rating Scale
CSU/Inpatient QA Monitoring Report
January 1 to April 30, 2005
Admission (n=310)
Discharge (n=327)
9
8
7
6
5
4
3
2
1
Depress
Inpsn Rln
Fam Rln
Dngr Self
Security
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• But…before we get too
complicated…
• the good news is that help is on
the way for QA/QI reports that
will be added to the DCF
OneFamily web-based
outcomes reporting system
• …more on that later!
91
What is planned for continued use of
FARS and CFARS in Florida ?
92
DCF Functional Assessment
Workgroup Recommendations
(DCF Memorandum of Understanding)
• DCF will “study” multiple domains as “drivers”
to better understand change reported in
aggregated “single” score reports.
• Districts will not use functional change scores
to evaluate individual agency contracts.
• Provider agency contracts will require use of
relevant multiple domain scores in internal
Quality Assurance (QA) programs, with QA
reports available for examination by Districts
as part of contract monitoring.
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What is happening as we speak?
• The Functional Assessment Workgroup continues to
assist DCF with monitoring implementation of the
FARS to monitor outcomes for adults receiving state
supported mental health services in contracted
community behavioral healthcare programs and
State Mental Hospitals.
• DCF added stakeholders to the workgroup agencies that already use FARS to “statistically”
monitor QA or Clinical Outcomes and who have
experience in creating QA/QI and Clinical
Monitoring Reports with FARS and CFARS data
(e.g., Florida Health Partners/Health Options).
94
Staff at Florida State Hospital completed a six
month FARS implementation pilot study comparing
FARS with Multnomah Community Assessment
Scale (MCAS) and Positive and Negative
Symptom Scale (PANSS) data…the FARS will now
replace PANSS and MCAS…and,
• As you know, DCF is currently operating OneFamily,
a secure Internet outcomes reporting system for
FARS and CFARS…
• that will soon include menus for statewide
aggregate reports as well as individual provider
agency QA/QI outcomes reports so providers and
clinicians will have access to real-time FARS and
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CFARS data.
Thank you for your patience
and attention…
• …now…does anyone have
any questions?
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