Transcript Slide 1

2010 Psychosocial Rehabilitation Conference
Ottawa, Ontario
September 22,2010
Phoenix Residential Society
• Who we are?
▫ Carole Eaton – Executive Director
▫ Michael F. Seiferling – Research Assistant
• The Program
▫ Phoenix Apartment Living Services (P.A.L.S.)
Introduction
• The History
▫ Paradigm shift in mental health services (1990)
▫ Journey of critical self-reflection
▫ The “BACKLASH”
▫ Forging ahead into the forest alone
The Forest
▲The
assessment
▲The program
assessment
▲The program
assessment
▲The
assessment
The NEEDS Assessment
• Intended to assess the extent to which the
intervention is needed
• Examines the implication of the circumstances for
the design of the program
• Defines what services are needed and how they
might be delivered?
The NEEDS Assessment
• What is the level of need among the client
groups?
• What are the staffs needs regarding training?
• What service areas come up most frequently?
The NEEDS Assessment - Clients
• Used Multnomah Community Abilities Scale
• Developed by a group of community workers
• Widely used in many formal health settings
(primarily community based settings)
Is both...
• Functional Assessment
▫ Clinical tool
• Outcome measure
▫ Research tool
Who Is It For?
MCAS Snapshot
NEEDS Assessment - Clients
Level of Disability
MCAS Scores
• 40 = inpatients
High(1747)
10%
Med(4862)
21%
Low (63+)
69%
• 50-60 = high level
of support
• 60 = lower intensity
outpatient care
Individual Item Results for Groups
6.00
5.00
4.00
3.00
2.00
1.00
0.00
PALS -1
PALS - 2
Summary of Findings - Clients
• Two distinct groups appear
• PALS 1 – much higher functioning
• PALS 2 – more emphasis on rehabilitation
NEEDS Assessment - Staff
• Staff should be ‘recovery focused’
• What is staff’s knowledge of recovery?
• What does this mean for the training of our staff?
The Recovery Knowledge Inventory
• 20 questions that group into four factors
• Roles and Responsibilities – risk-taking,
decision-making, responsibility of clients and
staff
• Non-linearity of Recovery Process – role of the
illness and symptom management and nonlinearity of the process
The Recovery Knowledge Inventory
• Roles of Peers and Self-Definition – person’s
activities in defining an identity, moving beyond
the role of a mental patient
• Expectations regarding recovery – including
those most effected by the illness
Comparison of RKI Scores
5.0
4.5
4.3
4.0
4.0
4.3
3.9
3.5
3.5
3.5
3.0
3.0
2.8
2.5
Phoenix
Connecticut
2.0
1.5
1.0
0.5
0.0
Roles and Responsibilities in
Recovery
Non-linearity of Recovery
Process
Role of Self-definition and
Peers in Recovery
Expectations Regarding
Recovery
NEED Assessment - Staff
Reasonable
understanding of
recovery
Scores comparable to
other Region
× Non-linearity of
Recovery
Focus on Motivational
Enhancement Therapy
× Expectations
regarding recovery
Rapp and Gorscha
Strengths Model
Program Theory Assessment
• Involves describing the program theory in explicit
and detailed form
• Various approaches are then used to examine how
reasonable, feasible, ethical and otherwise
appropriate it is
Program Theory Assessment
• Main Theories, treatment modalities
▫ Reality Therapy/Choice Theory
▫ Psychiatric Rehabilitation
• Specific Program guidelines
▫ Best Practices
 Clinical Competencies
▫ Evidence Based Practices/Guidelines/Standards
Program Theory Assessment
• Goals of the Program
▫ To assist individuals with serious and persistent
mental illness to live as independently as possible in
the community
▫ Promote greater self-reliance and an enhanced
quality of life
▫ To build on the existing strengths of the person, to
improve skills and increase supports.
Case Management Models
ACT/ICM
•
•
•
•
•
1:10 caseload
High outreach
24 hour accessibility
Emphasis on skill training
High degree of direct service
provision and frequency of
contact
• Occurs in community
• SMI high service users
Strengths/Rehabilitation
•
•
•
•
•
1:20-30 caseload
Moderate outreach
No 24 hour accessibility
Emphasis on skills training
Moderate degree of direct
service and frequency of
contact
• Mainly occurs in community
• SMI
Evidence based ingredients for CM
1. CM should deliver as much of the help as possible
2. Natural community resources are primary partners
3. Work is in the community
4. Individual and team case management works
5. Case managers have primary responsibility for a
person’s services
Evidence based ingredients for CM
6. Case Managers can be Para-professionals
7. Case loads should allow for high frequency of
contact
8. CM should be time-unlimited
9. People need access 24-7
10. CM should foster choice
Caseload size
• Research does suggest that a caseload of
20:1 - 30:1 ratio may work provided that the
people receiving services are:
▫ more stable and independent or
▫ the caseloads are compromised of people
normally distributed in terms of severity
Frequency of Contact
• It has been stated that “the strongest predictor of
successful engagement [is] frequency of contact”
• Frequency of contact has been identified as more
important that total hours of service, suggesting
that “brief visits may be more valuable then less
frequent but longer visits”
Frequency of Contact
• A good average to strive for people who are typical of
involvement with ACT/ICM programs is 11 contacts
per month (2-3 contacts per week)
• It is suggested that phone contact may also be used as
a supplement to face to face contact
• The quality of contact may play a mitigating role on
determining client outcomes. In other words, there
must be a strong helping relationship present in
order for any frequency of contact to be effective
Time-unlimited service
• It has been stated that ‘time-unlimited’ services are a
critical element for evidence based case management
• There has been some research which suggests that
successful transfers can be made to lower intensity
services
• The presents of informal social networks have been
considered an important factor for people moving on
Program Theory Assessment
• Other options
▫ Fidelity assessments for EBP
 Rapp and Goscha Strengths Case-Management
 SAMHSA Toolkits for Illness and Symptom
Management, IDDT, ACT
▫ Quality Review Tools
 Rapp and Goscha Strengths Case-Management
 MET Quality Review (MISC)
Program Process Assessment
• Examines how consistent the services actually
delivered are with the goals of the program
• If services are deliver to appropriate recipients
• Assess the extent to which a program is
implemented as intended and operating up to the
standards established for it
Program Process Assessment
• Key Questions…
Program Process Assessment
• We conducted…
Average Frequency of Contact
8.00
6.95
7.00
6.00
4.89
5.00
4.00
3.00
2.82
2.00
1.00
0.00
PALS -1
PHASS
PALS - 2
Program Process Findings
• Significant gaps in programming for community
clients (i.e. social, money management and
medication management)
• Frequency and Quality of contact needed to be
adjusted (higher needs clients were being under
served/need for MET)
• Sharper focus on how rehabilitation goals were
being developed and defined (i.e. Strengths
Model)
Program Impact Assessment
• Involves providing an estimate of the net effects of
a program
• Establishing the status of the program recipients
on relevant outcome measures and also
estimating what their status would have been
without the services
Program Impact Assessment
• Able to compare our program to other that have
used MCAS
• This comparison allows early estimation of
program impact
• Allows for more longer term applications to be
considered
Comparison
CMHEI On-going sample
PALS
• Intensive Community Support
Program (ACT/ICM)
• Several contacts per week
• Caseloads size – 17:1
• Age = 43.1 years
• Schizophrenia = 69.3%
• Mood Disorder = 28.4%
• Range (45-85)
• Intensive Community Support
Program
• Several contacts per week
• Caseload size - 13:1
• Age = 45 years
• Schizophrenia = 80%
• Mood/ Anxiety /other = 20%
• Range (32-80)
Comparison to other Regions
Oregon - Risk Pool
46
CMHEI - New client Mean (SD=9.6)
53.7
Oregon Mean (SD=9.7)
55.4
CMHEI On-going Mean (SD=9.0)
67
Total PALS (SD=9.34)
67.5
0
10
20
30
40
50
60
70
80
Comparison
• Competitive outcomes to ACT teams
• “Indictors” confirm scores
• Overall, very positive but..
Program Impact Assessment
• What about ‘Recovery’?
• MCAS measures ‘functional outcome’ but not
one’s sense of ‘recovery’
• Common misconception that these are directly
linked
Davidson explains…
The Vermont Study
Strauss-Carpenter Functioning Scale (n=168)
• Not in hospital in past year – 83%
• Meet with friends every week – 66%
• Had one or more close friends – 76%
• Displayed slight or no symptoms – 72%
• Led moderate to very full life – 76%
• Slight/no impairment in functioning – 55%
Mental Health Recovery Measure
• Based on research of the consumers views of recovery
• Developed for Adults with SMI who are receiving services
from
▫
▫
▫
▫
▫
criminal justice system
inpatient settings
outpatient service settings
peer-run programs
residential settings
• Correlations with
▫ Empowerment Scale
▫ Resilience Scale
▫ Community Living Scale
MHRM and subscales
PALS Comparison
86
85
84
MHRM Score
82
80
80
78.1
78
76
74
PALS
Normative Score
Phase II
Recovery and Functioning
• Compared MHRM and MCAS scores
• Found no/little correlation in scores
• MHRH scores hit ceiling so can’t be used for ongoing measurement
• Decided to move toward Strengths based goal
attainment as a ‘recovery measure’
Strengths Perspective
Implications - Outcomes
Functioning
Recovery
• The ‘Skills’ one need to live in
the community as
independently as possible
• Includes symptom
management
• Tends to determine ‘traditional’
outcomes in mental health
• Measured by the MCAS
• Requires knowledge in PSR
• Includes how much personal
satisfaction one has in their
lives
• Speaks more to how a person
accommodates/manages the
disability
• Can occur even with lower
functional scores
• Measured by Goal
Attainment
• Requires knowledge in MET
and Strength Assessment
Program Impact Assessment
• Next Steps…
The Efficiency Assessment
• Considers the relationship between the program
cost and its effectiveness
• This builds on good process and impact
assessments
• One of the most difficult areas
The Efficiency Assessment
• Early considerations…
Clinical Leadership Program
• Identifying skills within the agency and develop
and foster internal capacity
• Training provided in-house…
What we have learnt so far
• Program Evaluation is not as simple as identifying
an outcome measure
• Must address infrastructure issues along the way
(i.e. data management, training)
• Must be seen as part of a longer term plan
• Have a plan to deal with resistance
What’s ahead
• Strength's assessment which leads to consistent
goal attainment scaling
• Managing Data
• Additional tools
• Ability to clearly identify the impact of specific
interventions (i.e. peer support, Social Skills
Training)
Final Thoughts
• One program at a time!
• Don’t forget to plant all the trees
• Forests don’t grow in a day!!!
• Even small scale programs can start the process of
program evaluation
• Try, try, try…