Outcome measurement Train the trainer workshop Day 2

1. Outcome measurement Train the trainer workshop Day 2 Aged Persons Mental Health Services

2. Housekeeping • Toilets • Morning and afternoon tea • Lunch • About mobile phones • Evaluation

3. National objectives • To build an informed mental health system where information is available to guide decisions at all levels to: • support clinicians in their treatment decisions • inform consumers about services they receive • help managers manage • inform policy makers in planning and paying for services

4. Child and Adolescent Adult Expert Advisory Australian Mental Health Expert Advisory Committee Outcomes and Classification Committee (including aged care, Network (AMHOCN) forensic mental health services) National governance and advisory structure AHMAC Mental Health Working Group – Australian Health Ministers Advisory Council NMHWG – National Mental Health Working Group National Mental Health Information Strategy Committee - ISC National Minimum Data Set Sub-committee Technical Specifications Drafting Group OPMHOEG – Older Persons Mental Health Outcomes Expert Group

5. Episodes, cases and collection occasions Course of illness Case 1 Case 2 Episode of Care I Setting = Inpatient Episode of Care II Setting = Ambulatory Episode of Care III Setting = Ambulatory Ward A Ward B MST CATT MST Continuing care . . . 91 days Intake to community Discharge from community Discharge from inpatient 91-day review Admission to inpatient Period of no care Intake to community Collection occasions

6. Outcome measure protocol for older persons mental health services - Victoria

7. Your local protocol • Is it completed? • Well on the way? • A distant vision?

8. Criteria for instrument selection • Acceptability • Compatibility • Economy • Feasibility • Adequate coverage • Continuity • Integration • Aggregation

9. Diagnosis • Principal diagnosis: • The principal diagnosis is the diagnosis established after study to be chiefly responsible for occasioning the patient or client’s care during the preceding period of care

10. Mental health legal status • Was the person treated on an involuntary basis (under the relevant mental health legislation) at some point during the preceding period of care?

11. The suite for APMHS • Health of the Nation Outcome Scales for Older Persons (HoNOS 65+) • Abbreviated Life Skills Profile (LSP-16) • Resource Utilisation Groups – Activities of Daily Living (RUG-ADL) • Focus of Care (FOC) • Behaviour and Symptom Identification Scale (BASIS-32)

12. Missing data As a generalrule of thumb there should be NO MISSING DATA from the clinician-completed outcome measures Missing items (scored as ‘9’) are assigned a value of zero in the Wellbeing Reporting Tool.

13. Health of the Nation Outcomes Scales for Older Persons - HoNOS 65+ • 12-item measure • Rating made by mental health professional • Not diagnosis-specific • Each rating point defined in glossary • Scores 0-4 (or ‘9’ for ‘not known’) • Takes into account all available information • Is a good indicator of severity • Outcomes can be derived by comparing ratings over time • Quick to rate once familiar with the glossary • OM rather than assessment tool: clinical depth traded off for ease of comparison • Timeframe = the most serious problem in last two weeks (excludes discharge in acute inpatient units = three days)

14. HoNOS 65+ scale structure • Behavioural disturbance • Non-accidental self-injury • Problem drinking or drug-taking • Cognitive problems • Physical illness or disability problems • Problems associated with hallucinations and delusions • Problems with depressive symptoms • Other mental and behavioural problems • Problems with relationships • Problems with activities of daily living • Problems with living conditions • Problems associated with occupation and activities

15. 1.Behavioural disturbance • Exclude: • Bizarre behaviours – rate in Scale 6 - • Problems with hallucinations and delusions Include: • Overactive, aggressive, disruptive, agitated, uncooperative, resistive behaviours due to any cause. Causes: dementia, alcohol, drugs, psychosis, delirium, depression

16. 2 Non-accidental self-injury Exclude: • Accidental self-injury due to: • Dementia • Severe learning disability • Exclude: • Illness or injury as a direct result of drug/alcohol - Why?: Cognitive problems are rated in Scale 4 Injury is rated in Scale 5 Why?: Lung cancer related to smoking or injury from drink driving is rated at Scale 5

17. 3 Problem drinking or drug taking Exclude: • Aggressive or destructive behaviour due to alcohol/substances • Exclude: • Illness or injury as a direct result of drug/alcohol Why?: AIDS from poor needle exchange or injury from drink driving is rated at Scale 5 Why?: Aggressive behaviours are rated in Scale 1

18. 4. Cognitive problems Include: • Problems of orientation, memory, language associated with any disorder • Exclude: • Temporary problems, hangovers associated with alcohol/substance use • rated in Scale 3 Types of disorders: dementia, learning disability, delirium, depression, schizophrenia

19. 5. Physical illness or disability problems • Include: • Side effects from medications, substance or alcohol use, physical disabilities resulting from accidents or self-harm associated with cognitive problems, drink driving accident Include: • Illness or disability from any cause that limits mobility, hearing, sight, or interferes with personal functioning Types of disorders: Rate pain here • Exclude: • Mental/memory problems – rate in Scale 4

20. 6. Problems associated with hallucinations and delusions Include: • Hallucinations and delusions or false beliefs irrespective of diagnosis • Include: • Odd and bizarre behaviour behaviour associated with hallucinations or delusions, false beliefs • Exclude: • Aggression, destruction, overactive behaviours attributed to hallucinations, delusion, false beliefs – Rate in Scale 1

21. 7. Problems with depressive symptoms • Exclude: • Suicidal ideation or attempts Exclude • Over activity or agitation WHY?: Aggressive, agitated behaviours are rated in Scale 1 WHY?: Self-harm is rated in Scale 2 • Exclude: • Delusions or hallucinations Why?: Delusions and hallucinations are rated in Scale 6

22. 8. Other mental and behavioural problems Rate only the most severe clinical problem that is not considered at scales 6 and 7 • Somatoform • Eating • Sleep • Sexual • Other • Phobic • Anxiety • Obsessive-compulsive • Stress • Dissociative

23. 9. Problems with relationships Problems associated with social relationships: Can be identified by: Patient, client, carers, family, others • Rate the most severe problem associated with: • Active/passive withdrawal from • Attempts to dominate • Destructive • Self-damaging • Non-supportive relationships

24. 10. Problems with activities of daily living Include: • Lack of motivation for using self-help opportunities • Exclude: • Lack of opportunities fro exercising intact abilities/skills Why? Rated in Scales 11 & 12 Why? This contributes to overall level of functioning Rate the overall level of functioning in ADLs Problems: BASICactivities of self-care: eating, dressing, toileting, showering etc COMPLEX activities: budgeting, public transport use, budgeting, bill paying, use of oven/microwave

25. 11. Problems with living conditions Rate: the older person’s usual accommodation • Rate: The overall severity of problems with: -Quality of living conditions/accommodation -Daily domestic routine Take into account the person’s preferences/degree of satisfaction Are the BASIC necessities met? YES! THEN - Does the environment contribute to maximising independence, minimise RISK, provide choice and opportunities to develop new skills and maintain old ones? • Exclude: • The level of disability – rated in Scale 10

26. 12. Problems associated with occupation and activities Rate: the older person’s usual situation • Rate: The overall problems with quality of daytime environment: Help to cope with disabilities? Any stigma, lack of qualified staff, supportive facilities • Access to – staff, day centres, elderly community groups/activities, equipment, bowls, day trips etc. • Exclude: • The level of disability – rated in Scale 10

27. HoNOS 65+ rating rules • Rate each item in order from 1 to 12 • Do not include information rated in an earlier item, minimal item overlap • Rate the most severe problem that has occurred over the previous two weeks [three days discharge acute inpatient unit] • Consider both the impact on behaviour and/or the degree of distress it causes • When in doubt, read the glossary

28. HoNOS 65+ scoring • Each item is scored: 0 = no problem 1 = sub-clinical problem 2 = mild problem 3 = moderate problem 4 = severe problem 9 = not known [0] Only use ‘9’ when you are genuinely unable to make a definitive rating

29. Importantvariations in rating guides

30. Sources of information The measures are not clinical interviews. Information should be gathered from: • The consumer • Direct observation • Information in the medical record • Information provided by other staff • Information provided by family and friends • Information provided by other agencies including general practitioner, housing, police and ambulance staff

31. From an alternative perspective

33. Measuring outcomes in aged persons MHS Training Vignette 1: Mr Nguyen Mr Nguyen is a 69-year-old man who arrived in Australia as a refugee following the Vietnam War. His wife died four years ago and he has remained living in their family home in inner Melbourne with his 19-year-old grandson Tran, who works full-time.

34. Training Vignette 1: Mr Nguyen (continued) • Tran contacted his grandfather’s GP after the neighbours expressed concern about Mr Nguyen’s behaviour. • The GP hadn’t seen Mr Nguyen for 18 months and had assumed he had moved. • Based on what Tran has told him, the GP has referred Mr Nguyen to the Aged Psychiatry Community Team for assessment. • Mr Nguyen understands very little English and speaks none. • From Tran you learn Mr Nguyen hasn’t left his house for 3-4 months, with food being provided by family members and some close neighbours. • The family had arranged for meals on wheels but Mr Nguyen just left them uneaten. • Tran does the banking, which consists of going to the bank each second Thursday, and withdrawing almost the total pension cheque in cash.

35. Mr Nguyen looks after the money and gives Tran the accounts that need to be paid, with directions and cash. • Mr Nguyen also insists on Tran buying the following items each week: rice, soap and tealeaves. • Tran is concerned because Mr Nguyen doesn’t use any of these items but stacks them in the sitting room. • There is so much of it that Tran has had to take some of the furniture into other rooms. • Mr Nguyen keeps the house really clean and tidy and he stacks all the papers, newspapers, cartons and containers in the spare room. • Tran has tried to throw some of it out but Mr Nguyen becomes very distressed and angry and then yells at Tran.

36. Mr Nguyen no longer sleeps in his bedroom but has taken to sitting on a stool in the passageway of the house each night. • Tran says he talks to himself a lot and won’t turn the lights out. This has been happening for the last two weeks. • Tran doesn’t want to be a part of any assessment because Mr Nguyen threatens to make him leave if Tran tries to interfere. • Tran is worried Mr Nguyen won’t talk to any interpreter that he doesn’t know. • Tran reports Mr Nguyen hasn’t lost any weight, but he has stopped drinking water out of the taps. • Instead, he takes water from the rusted-out water tank at the back of the house.

37. Measuring outcomes in aged persons MHS Training Vignette 2: Mrs Tilly

38. Case scenario • Mrs Tilly is an 82-year-old woman living in a community-based hostel in outer Melbourne. • Mrs Tilly has become increasingly irritable over the last two months and has hit several staff members, usually in the shower. • Two days ago she threw her glass and cutlery at another resident and cut his face.

39. Mrs Tilly has lived in the hostel for seven years and has always felt at home. • Four weeks ago Mrs Tilly had a ‘turn’ as described by the staff and was seen by her GP who found little, except for an elevated BP and some increased peripheral oedema, for which he increased her Atenolol. • Mrs Tilly denied any headaches or memory problems. • Over the past three weeks the staff report a decline in Mrs Tilly’s self-care, with her requiring almost full assist with washing, changing her clothes and general activities. • There is a note in the file about Mrs Tilly smelling of urine but there appears to be no follow-up.

40. Mrs Tilly has stopped going to her bowls, bingo and knitting groups and just wanders around the hostel. • The other residents report Mrs Tilly is up most of the night either banging about in her room or wandering up and down the passageway looking for her room. • Mrs Tilly is difficult to engage on assessment and appears vague, disorganised and her speech is somewhat slurred. • Her thoughts jump all over the place and she is very easily distracted. • It is difficult to assess her memory, as she cannot concentrate to complete a mini mental state examination.

41. Review of Mrs Tilly’s history reveals she has been seen by the Aged Care Assessment Team and given a high level approval for transfer to a nursing home called Happy Horizons in northern Victoria. • It appears that Mrs Tilly’s daughter Peg and family moved to northern Victoria some five years before and Peg has been trying to get Mrs Tilly to move there without success. • Mrs Tilly has been adamant about seeing out her days where she is close to her husband’s grave. • The Aged Care Assessment Team requested the GP do some follow up investigations given the short timeframe of decline in Mrs Tilly. • You obtain the results and it is apparent that Mrs Tilly has a urinary tract infection and is dehydrated.

42. Six months later • Now living in northern Victoria (five weeks). • Physically back to normal, sleeping all night. • Very occasionally ends up in someone else’s room. • MMSE – 28/30. • Is attending a great day program and knitting, playing bowls. • Will not see or speak to Peg; verbally threatens to cut her out of the will but sees the rest of the family. What score now?

43. Life Skills Profile-16

44. LSP - A non-technical instrument - originally designed to require little or no training • Key measure of function and disability in people with mental illness. • Complements the problem-based HoNOS. • Originally a 39-item scale; reduced to 16 items. • Brief; five minutes to rate. • Good inter-rater reliability. • Sensitive to change. • Focuses on the person's general functioning over the last three months; social relationships, day-to-day tasks etc • The LSP-16 is not a clinical interview • Take into account age, social and cultural context. • Do not rate the crisis or when the client was becoming ill.

45. Example of item structure 1) Does this person generally have any difficulty with initiating and responding to conversation? 0 No difficulty with conversation 1 Slight difficulty with conversation 2 Moderate difficulty with conversation 3 Extreme difficulty with conversation 2)Does this person generally withdraw from social contact? 0 Does not withdraw at all 1 Withdraws slightly 2 Withdraws moderately 3 Withdraws totally or near totally

46. Specific LSP-16 items • Item 6 - neglect their physical health? Not receiving treatment for a health condition, lead a generally healthy life style • Item 10 - behaviour related to medication adherence • Item 11 - attitude towards medication • Item 12 - cooperate with health services • Item 15 - deliberate intention

47. The LSP-16 subscales • Withdrawal • Antisocial behaviour • Self-care • Compliance

48. Focus of Care

49. Focus of Care • A 1-item tick box requiring the clinician to make a retrospective judgement about each consumer’s primary goal of care. • There are 4 choices: Acute, Functional Gain, Intensive Extended and Maintenance. • The FOC informs interpretation of OM data and contributes to casemix classification. • In APMHS, the FOC is collected in inpatient services (at discharge) and by community teams (at review and discharge).

50. Rating the Focus of Care • Single rating item to identify the main ‘focus of care’. • Assesses the primary goal of care. • Based on concept of ‘phase of illness’ in people with mental health disorders. • Rate main focus of care over whole episode - is therefore a retrospective measure • Measures categories - not rankings