Transcript Slide 1

Are Consumer Held Routine Outcome
Measures the Next Step?
Psychiatry
Dr Roderick McKay
June 2013
Disclaimer
• Material presented does not represent the
views of the National Mental Health
Information Development Expert Advisory
Group, or any other organisation
……….but informed by the shared
experience and expertise of many
Why Routine Outcome
Measurement?
Goals may include:
• To improve care
• Through improving services and policy
• Through improving direct care
Key components of routine outcome
measurement in Australian specialist mental
health services
ADMISSION
REVIEW
DISCHARGE
Outcome measure(s)
Outcome measure(s)
Outcome measure(s)
Broader
information
systems(e.g.,
decision support
tools)
. ., their care
Other data about the consumer and
.
Data linkage
(Adapted from McKay, Coombs and Pirkis 2012)
Why routine outcome measures?
Building evidence of impact on
outcomes of ROM
if feedback is provided
• Carina Knaup, Markus Koesters, Dorothea Schoefer, Thomas
Becker and Bernd Puschner Effect of feedback of treatment
outcome in specialist mental healthcare: meta-analysis. The British
Journal of Psychiatry 2009 195: 15-22
• Feedback requires familiarity with the measures, or their
interpretation
– By both sharing the information
Two of the measures used in
Australia
• Health of the Nation Outcome Scales
– Collection of 12 clinician rated scales
– Covers common problems in symptoms and
function found in consumers of mental health
services
– 0 to 4 rating against glossary on each scale
• Score of 2 or above clinically significant (Burgess et al
2009)
– Possible Total scores 0-48
The HoNOS scales
1. Overactivity, aggression
2. Non-accidental self-injury
3. Problem drinking or drug-taking
4. Cognitive problems
5. Physical illness or disability problems
6. Problems associated with hallucinations or delusions
7. Problems with depressed mood
8. Other mental and behavioural problem
9. Problems with relationships
10. Problems with activities of daily living
11. Problems with living conditions
12. Problems with occupation and activities
HoNOS glossary extract
(from www.amhocn.org)
Kessler 10
• Consumer rated measure
• 10 items focussed on psychological
distress
• Possible scores 10 to 50 rated over 4
weeks or 3 days
(from www.amhocn.org)
A good starting place to improving
care
• In clinical care is to consider how the measures
assist with the questions
– Have we adequately assessed the consumer?
– Has anything changed?
– Is there agreement between the consumer and clinician?
Using pattern recognition to move
beyond….
• Consumer A and consumer B both score
21 on the HoNOS
– What does that mean?
– They may have similar overall impairment, but
for very different reasons
• The scales provide further information
– That can be used with clinically informed
interpretation
Is there an adequate assessment?
(McKay and Coombs 2012)
Application depends on applying to the right questions at
the right time
Has anything changed?
Selectively focus on parts of the HoNOS can assist a longitudinal view
of a person presenting at a point in time
Is there agreement?
• Discussion of HoNOS scales at a point in time,
or total score compared with Kessler 10
(McKay and Coombs 2012)
Why consumer held routine
outcome measures?
Personal trial
Key issues in ROM in Australia
• Varied familiarity with measures, esp by
senior clinicians
• Concerns re inconsistent focus upon rating
accuracy by clinicians
• Limited engagement with
consumers/carers around clinician rated
measures
• Limited offering of consumer rated
measures
• Only covers contact of people with public
clinical specialised services
Why consumer held ROM?
• Encourage more consistent rating by clinicians
• Consistent with recovery orientation
• Overcome data linkage issues for individual consumers
using different services
• Open alternate options for data linkage to answer
questions that cannot be answered currently
• Force some critical thinking regarding
– What everyone should be familiar with
– What are critical factors to ‘report’
Mental health care is becoming
more complex
• There are increasing numbers of providers of
mental health care
–
–
–
–
Specialised clinical mental health service
(NGO operated) Specialised mental health service
GP
Private psychiatrist
• Many consumers have more than one provider
of mental health care
• …..and may want to monitor their own mental
health outcomes (including with their carer or
parent)
• ...and many people with mental illness do not
seek assistance
Communicating between sectors, and over time
Service A
Service B
Service C
Consumer
Key reasons for consumer held outcome measures
•
•
Need to be told by all consumers, potential consumers, their carers, and those professionals who
support them
May be
– So I can understand
o my mental health better
o What mental health professionals think of my mental health
o what influences my mental health
– So I can communicate about
o How I feel about my mental health
o How my perspectives are similar and different to your perspectives
o My goals in relationship to my mental health and life
–
So you can partner with me in regaining the ability to achieve my goals
o Not tell me how to ‘get better’
Key components of consumer held routine
outcome measurement
FIRST MEASURE
REVIEW
Outcome measure(s)
Outcome measure(s)
REVIEW
Outcome measure(s)
. ., their care and experiences
Other data and knowledge about the consumer and
.
(on record or in memories)
Data linkage (consumer opt in either/ both ways)
Service held routine outcome measurement systems
National interpretation
Web based
information to
assist
interpretation
and use
And we have no accepted mental health
‘Pulse, BP,ECG’
• What isn’t measured and understood across those who deliver and
receive healthcare isn’t accepted as important
• Pulse:
– current psychological distress
• BP:
– is that distress appropriate or over a crucial level, persistent or
unusual
• ECG
– What does expert evaluation show? (need to be understand the
report, even if cannot read the test itself or understand how it
works)
Maybe we aren’t so far from a psychological
‘pulse’
....if we communicate
•
•
Psychological distress
– Kessler 10 used in Australia
o Within some state mental health services
o By GPs to assist access to services
o By some psychologists
o For web based ‘self checks’, and some web based mental health services
o In studies of population health
But no agreement across users about how to communicate consistently about what it means
– How should you respond if you are told someone’s pulse is 100?
– How should you respond if you are told someone’s K10 is 30?
– How should you respond if you are told someone’s pulse is 60
– .....and temperature 40?
– How should you respond if you are told someone’s K10 is 10
– .....and have command hallucinations to harm someone?
Mental health BP
•
Could be the consistent plotting of psychological distress over time
Event 1
Then it becomes more complex
•
•
ECG, ECHO, Stress Test?
Different people with mental illnesses need
– different services,
– focussed on different aspects of a person health and function
Shared understanding by
whom?
From McKay, Coombs & Pirkis 2012
Then it becomes more complex
Aspects of Function
ICF: From WHO 2002
Aspects of Function
Emotional and
cognitive function,
physical health
Activity
capacities and
behaviour
Accommodation, Service
access and experience
Social inclusion,
occupational and
vocational inclusion
Recovery,
Quality of Life,
Which may vary by user
• eg What does a NUM, psychiatrist or
service manager need to know about the
function of consumers on the ward?
– ‘everything’
– One or two aspects of function?
• Relating to risk?
• Relating to ????
• And how does this relate to what a
consumer wants to know?
Personal trial
Need simple presentations that
everyone can understand
Need simple presentations that
everyone can understand
Need simple presentations that
everyone can understand
High level of
impairment
Significant
impairment
No significant
impairment
Areas of
possible
strength
Agitation↓↓
Cognition
Suicidal ideation
Services and
occupation
Relationships↓
Self care
Accommodation↑↑
Depression ↓
Physical health
Drug and alcohol
use ↓↓
Hallucinations or
delusions
Sleep
Arrows indicate change since previous review (↑=improvement
Communicating between sectors, and over time
Service A
Service B
BP, Pulse and ??
Service C
Consumer
Key reasons for consumer held outcome measures
•
•
Need to be told by all consumers, potential consumers, their carers, and those professionals who
support them
May be
– So I can understand
o my mental health better
o What mental health professionals think of my mental health
o what influences my mental health
– So I can communicate about
o How I feel about my mental health
o How my perspectives are similar and different to your perspectives
o My goals in relationship to my mental health and life
–
So you can partner with me in regaining the ability to achieve my goals
o Not tell me how to ‘get better’
Conclusions
• There are many obstacles to implementing
consumer held outcome measures
– Privacy, technology, consensus
• Mental Health needs to move to consumer held
outcome measurement because it should
– improve routine outcome measurement within specialised mental
health services
– assist the change in power balance within services required for
recovery to be a reality
– give consumers more of the information they need to maximise
their opportunity to recover
– help to move mental illness from being ‘some one else’s
business’
• (that I don’t understand, and hope I never have to)
Thank you
• References
– McKay T, Coombs T &Pirkis J. 2012 A framework for exploring
the potential of routine outcome measurement to improve
mental health care Australasian Psychiatry 20:127-133
– McKay R & Coombs 2012 T. An exploration of the ability of
routine outcome measurement to represent clinically
meaningful information regarding individual consumers
Australasian psychiatry 20:433-437
– World Health Organisation2002 Towards a Common Language
for Functioning, Disability and Health ICF