Speakers' Presentations - Day Two
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Day Two - Thursday, 4 October 2007
Stream Six - Information Utility
Paper 26: Building the evidence base for mental health staff working with mental health consumers with ‘high and complex' needs
Jeff Symonds RPN, MHSc., Mental Health Nurse Consultant, Waikato District Health Board, NEW ZEALAND
When working in today's mental health services, clinical staff are often challenged with how to achieve an evidence base approach for people who have long-term serious psychiatric and social disability, often substance and alcohol abuse, lack of motivation, apathy and ongoing risk issues. This presentation demonstrates an electronic clinical (ECR) care planning approach which uses a nationally ratified risk assessment model, a clinician's subjective risk opinion and clinical rating scales such as the Health of the Nations Outcomes Scale (HoNOS) and the Personal and Social Performance Scale (PSP). Using this ECR care planning approach helps staff to identify, measure and prioritise a broad range of concerns/protective factors, and implement interventions that are able to be monitored and measured into treatment/recovery planning. Staff also see how these key elements work to complement each other and the potential to combine respective training programmes.The use of this combined approach as described above is able to be easily used by staff and has direct relevancy to care planning. This model is applicable for use in community and inpatient settings and arguably takes a broader perspective than simply focusing on risk or clinical factors when working with mental health consumers with high and complex needs.
Paper 27: Clinical outcome scale (Health of the Nation Outcome Scale - HoNOS) and independent clinician versus clinician team ratings
Julie Porter, NUM: Education and Research, Charters Towers Rehabilitation Unit, AUSTRALIA
There has been a recent trend to encourage routine outcome measurement and needs assessment as an aid to decision making in clinical practice and patient care. Standardised instruments (including the Health of the Nation Outcome Scale (HoNOS), Life Skills Profile (LSP), and the Mental Health Inventory (MHI) have been developed which measure clinical symptoms of disorders such as schizophrenia, and wider health related quality of life and consumer needs. Such measures may usefully be applied to aid the recognition of psychosocial problems and to monitor the course of consumers' progress over time. These measures might also be used to help clinicians to make decisions about treatment and to assess subsequent therapeutic impact. (Gilbody et al). Coombs et al examined the impact of training and clinical experience on the inter-rater reliability (IRR) of the HoNOS. There was no significant difference (SD) between post- and pre-training IRR scores. There was no SD between nurses and the comparison group, characterised by non-clinical work experience in a mental health setting. All four groups achieved adequate IRR. (Coombs et al 2002). There is however limited research investigating single rater outcomes versus ratings conducted as a group during the clinical review process. This study will assess the reliability of individual clinician's ratings compared with ratings conducted as a component of the clinical review process by the clinical team. It will provide evidence of the benefits of using group collaboration for HoNOS collection. Utilising observations of all clinicians with the opportunity for discussion during the review process promotes recognition of aspects that may otherwise have not been considered, thereby enhancing the consumer's pathway to recovery.
Paper 28: Using MH-SMART information in service quality circles: Are three Cs good enough?
Dr David Turner. MH-SMART Utilisation Facilitator, Waitemata District Health Board, NEW ZEALAND
Learning objective: To provide a useful framework by which data can be organised into information. One of the primary aims of MH-SMART is to promote quality in mental health services. Quality may be defined as; are we doing what we should be doing with the desired effect set against standard expectations? The task for services is to therefore develop ways in which to answer some of these questions. With the richness and accessibility to MH-SMART information afforded by electronic information systems within our District Health Board, the challenge was to establish ways in which such information could be meaningfully used by clinicians and service leaders. A framework of three related, but separate activities was developed: Counting, looking for Change and making Comparisons.This paper will present examples of how a mental health service for older adults has utilised this framework as a basis for organising their information. This resulted in different conversations about the meaning of quality that was fed back into a quality improvement cycle. It is not so much the numbers that are collected that lead to quality improvements; it is the way in which these numbers are used. This paper suggests one simple, but effective framework that facilitates the organisation of information in such a way that services can begin to answer questions about the quality of their service. It is however, the initial steps in a journey to developing routine quality conversations. The use of the 3C's framework may be enough to present data as information. However, to complete the journey through knowledge and wisdom may require more attention.
Paper 29: Making HoNOS clinically useful: A brief strategy for making HoNOS (CA) useful in the multidisciplinary team setting.
Malcolm Stewart Ph.D, Professional Leader - Psychology, Counties Manukau District Health Board, Auckland, NEW ZEALAND
The validity of data and the ultimate sustainability of routine collection of standard measures in mental health services arguably depends more on the demonstrated utility of the measures for service users and clinicians than most other factors. However, even when services are routinely collecting standard measures, the multidisciplinary teams (MDTs) often do not develop ways of utilising these data to support decision making. This paper describes a brief strategy that has been developed to assist MDTs to efficiently and effectively use the HoNOS (Health of the Nation Outcome Scale) family of measures in team discussions concerning individual service users. Used in this way the HoNOS can, in combination with other information and perspectives, potentially make for broader, more recovery-oriented and solution-focused MDT discussions without prolonging these discussions unduly. The strategy applies equally to HoNOSCA, HoNOS, and HoNOS 65+. The strategy will be presented as it is usually introduced in training to clinical teams. There will also be discussion of the implementation of this strategy in MDT settings. Use of this strategy may benefit service users and clinicians by integrating the use of HoNOS data into clinical decision making and also by assisting to improve communication within some MDTs.
Paper 30: Making the most of outcome measurement
This presentation does not represent an official position of the Department of Human Services. Copyright in this presentation (including content and design) is owned by the State of Victoria or used under licence. You may make limited copies of this presentation in accordance with the Copyright Act 1968 (Cth), including copies for research, study, criticism, review or news reporting. You may not publish, reproduce, adapt, modify, communicate or otherwise use any part of this presentation (in particular for commercial purposes).
Peter Woods and Angie Hunter, Department of Human Services, Victoria, AUSTRALIA
Learning objectives:
1. Overview of the data systems in Victoria including the opportunities outcome measurement has provided to review and enhance.
2. Understanding of ROMP and QUATRO achievements.
3. Exploration of how outcome measurement has been used in quality improvement activities.
4. Exploration for future outcome measurement activities in Victoria.
Outcome measurement was implemented across all area based and specialist clinical services in Victoria in 2002-03. The diverse governance structures in Victoria have resulted in considerable variation in practice and reporting capabilities with limited access for reports by clinicians and managers until quite recently. The Reporting on Outcome Measurement Project (ROMP) (2005 - 07) has made significant advances in the provision of detailed service-level outcome measurement reports for clinical services. Three geographical QUATRO clusters have worked with clinicians and consumer/carer consultants to encourage clinical utility of outcome measurement. Learnings from ROMP and QUATRO and other jurisdiction's experience has informed the development of a new state-wide approach funded by Quality through Outcomes Agreement. QUATRO VIC will be staffed by clinicians and consumer/carer consultants and will provide targeted interventions with managers to promote utilisation of outcome measurement aggregate data for service improvement as well as work with clinical teams to embed outcome measurement in clinical practice. A web-based aggregate reporting framework building on the success of ROMP will also be established. Along with significant system enhancements being deployed from 1 July 2007, Victorian services will be in a strong position to address the real world application challenges outcome measurement presents.
Stream Seven - Implementation Experiences
Paper 31: Magic Mushroom Seeds
Chris Hickson, Social Worker and Lucy Laphen (co-presenter), Psychiatric Nursing and NGO background, Capital and Coast District Health Board, NEW ZEALAND
Please note: Some aspects of this presentation were spoken to and therefore do not appear in the presentation. Readers are very welcome to contact any of the "three witches" for further consultation. For those who may enquire about the nature of "the lights going out" this was due to major developments at a national level and, for a time, there was a sense of being left in the dark.
The Regional Rangatahi Adolescent Inpatient Service [CCDHB] was selected to trial a paper collection of HoNOSCA data which began in July '05 following the four day training of three staff. In brief I will describe our subjective experience of this undertaking.
Resistance was expected from staff in introducing this ‘mandatory' new cultural norm, perhaps magnified once it was dubbed the ‘Three Witches of Eastwick'. The witches set off enthusiastically to begin monthly training sessions, trained five staff and planned to enlighten all clinicians to this magical practice of sowing HoNOSCA seeds. The collection began and norms emerged.
Then training stopped! The witches were bemused. Darkness engulfed the unit. Witches and goblins quibbled over the magic seeds, obviously mushroom seeds! Growing so fast we couldn't pick them! "Why should we?" "You do it, I did it last time." "There's not mushroom in my day for this BS". Fertiliser rained. Sow mushroom seeds, collect mushrooms, SELL mushrooms! Suddenly ... a light turned on ... a booming voice called over the land, "What have you done with the mushrooms (information)?" The witches knew the magic mushrooms needed to be seen and sold and made a make-shift basket to show them. Some saw the mushrooms as valuable, "Wow it's all been worth it, I can see now why we grew mushrooms." Then suddenly a Wizard appeared and promised the witches a new glorious basket for October 1st and gave the witches training material to teach others to sow and cultivate their MAGIC MUSHROOM SEEDS.Hope was restored!
Paper 32: Implementation of mental health NOCC data feedback systems
Dean Lewin, Principle Project Officer, Mental Health Branch, Queensland Health, AUSTRALIA
Although there has been considerable investment in the collection of mental health data, there has been comparatively little emphasis on establishment of the feedback mechanisms for service providers to support the provision of quality mental health services. Queensland recognised this early in the state-wide implementation of the NOCC National Outcomes and Casemix Collection protocols (NOCC) and developed a collection system and associated reporting tools that enable the utilisation of NOCC information to support and improve service delivery. This paper will outline the feedback systems and processes that have been implemented in Queensland including:
• Consumer and clinician level: Clinical Profile reports within the Outcomes Information System (OIS) that graphically display NOCC data for a single collection occasion.
• Treating Team level: Clinical History reports within the OIS that can display a series of NOCC collection occasions.
• Service level: Service Profile reports within the OIS that display, based on the parameters chosen by the user, matched summary level NOCC data to inform service providers, team leaders and service managers.
• State Level: of ad-hoc data requests accessible through crystal reports to inform researchers and policy planners, as well as by use of the Decision Support System (DSS) data-cubes that allow local and state information managers to interrogate the NOCC data.
The paper will summarise the key features of the NOCC feedback mechanisms available to users in Queensland and explore developments underway to incorporate these feature into a state-wide integrated mental health clinical information system.
Paper 33: Implementing MH-SMART at Waikato 1: An operational perspective
David Ireland, MH-SMART Site Co-ordinator, Mental Health and Addictions Service, Health Waikato, NEW ZEALAND
The implementation of routine outcome measurement throughout New Zealand is a significant part of the overall national Mental Health Information Strategy. The benefits and use of outcome measurement are reliant upon a robust and sustainable implementation across all spheres of implementation, including but not limited to, training and education, information systems development and reporting. The aim of the presentation is to provide an overview of the issues and barriers identified and resolved during the initial implementation of routine outcome measurement within Health Waikato. This includes training, systems development, managerial buy in and clinical buy in. To share experiences and lessons learnt during the process so far and to provide recommendations about the future sustainability of routine outcome measurement.
Paper 34: Implementing HoNOS in the Waikato II: Practitioner's perspective
John Fitzgerald, Karma Galyer and Philippa Thomas, The Psychology Centre, Hamilton, NEW ZEALAND
Despite public demands for greater transparency and accountability within our public health systems, and increasing emphasis on the duty of care relationship between clinicians and their clients, the formal monitoring of clinical change and outcomes remains a vexed question. Since 2005 many governmental providers of mental health services in New Zealand have been attempting to address these concerns through the routine collection of data from the HoNOS suite of measures.
This paper reports on the experiences of one provider, Health Waikato, as it has worked through the implementation process. In particular, we present the keystones, impediments, issues and recommendations from the perspective of the clinicians, those who have completed the HoNOS measures. Data for this presentation is drawn from an anonymous survey of staff, focus groups and key informant interviews, and an analysis of the archival information held by the provider. These data are used to illustrate impediments to implementation gleaned from the literature, and to generate additional discussion points. Key issues covered include the adequacy of support systems, resourcing, leadership, clinical utility, and broader service evaluation. We finish by providing recommendations which may go some way to allaying concerns expressed by clinical staff.
Paper 35: Practice makes perfect: A practical approach to embedding mental health information collection and use in clinical, service and organisational development
Laurie Hakiwai, National NGO Co-ordinator, Te Pou, NEW ZEALAND
For the last two years, District Health Boards in New Zealand have been collecting and using mental health information. Now that the initial excitement is over, how do we ensure mental health information collection continues, our understanding increases and it is part of daily practice? To address this, the information programme within Te Pou, New Zealand's national centre of research, information and workforce development, has developed a framework that includes key structures, processes and activities which support sustainability. It is also using this approach as the planning framework for its work with, and amongst District Health Boards.
This work shop/poster aims to support team leaders, clinical advisors, service managers and quality coordinators to understand the key components of this framework. With a focus on how it can be utilised to give practical support in workforce development, yearly planning and service growth.
Stream Eight - Using Outcomes with a Consumer/Clinician Focus
Paper 36: The utility of outcomes information in predicting the occurrence of clinical incidents during CAMHS treatment
Renae Kurth and Brett McDermott, Mater Child and Youth Mental Health Service, AUSTRALIA
Learning objectives:
• Increase knowledge of research into clinical incidents in child and youth mental health treatment.
• Increase knowledge of outcomes information collected during CAMHS treatment and learn how outcomes information may be applied to predicting the occurence of clinical incidents and enhancing client care. Background: Clinical incidents present numerous challenges to child and adolescent mental health service (CAMHS) delivery. Clinical incidents occur frequently in CAMHS inpatient settings, threatening staff and patient safety, and affecting resource management. Furthermore, youth involved in clinical incidents experience worse treatment outcomes and longer hospital admissions. Accurate prediction of clinical incidents before their onset could facilitate their prevention and, ultimately, enhance service delivery and client care. This study evaluated the utility of Australian CAMHS mandated outcome measures in predicting the occurrence of clinical incidents in youth mental health treatment. A case control study was conducted using archival database information. The sample consisted of 72 patients. Of these, 36 patients were involved in clinical incidents and 36 were case controls, matched on age, gender, intensity of treatment setting, and availability of clinician-rated outcomes information. Outcome information completed at intake included the consumer or carer rated SDQ and the clinician-rated HoNOSCA. At intake, patients who went on to have clinical incidents differed significantly from their matched controls on clinician ratings of disruptive-antisocial behaviour, substance abuse problems, self-harm, scholastic-language problems, problems with family life and relationships, overall behaviour problems and total difficulties, and parent ratings of conduct problems. Using combined outcome measure scores at intake, the majority of patients were correctly classified as being involved in a subsequent clinical incident or not. Outcome information at intake may be useful in predicting the occurrence of clinical incidents during the course of mental health treatment.
Paper 37: The journey of consumer participation and outcome measures. (Paper Unavailable)
Glenn Moorey, Community Mental Health Practitioner, Central and Upper Great Southern Mental Health Service, AUSTRALIA
This presentation will focus on the consumer and clinician's experience of engaging a collaborative assessment and management plan though tools such as Health of The Nation Outcome Scale (HoNOS), Life Skills Program (LSP) and the Kessler b10+ (self report questionnaire). The involvement of the consumer in assessment, planning and management is essential. It is a key element in better outcomes and continued engagement with mental health services. Allowing transparent services demystifies the process of mental health services which in turn encourages stakeholders to better engage on a more positive level.
The involvement of the consumer has been a process that asked three questions:
1) What services does mental health provide?
2) How do we measure the level and type of services mental health services provide?
3) How does the consumer measure the outcomes of the mental health services and give feedback as to the effectiveness?
This presentation will show data over a sample of Great Southern Mental Health and the journey of one consumer through the engagement of mental health services.
Paper 38: Using outcome measures to improve clinical practice
Peter Jeffrey, MH-OAT Coordinator, Greater Western Area Health Service (GWAHS), NSW, AUSTRALIA
The presentation will demonstrate how increasing clinician compliance and accuracy with outcome measures improves clinical practice within mental health services. Through targeted training and ongoing clinician support, there have been improvements in completion rates and quality of documentation and outcome measures. The framework for this process is the MH-OAT (Mental Health Outcome & Assessment Tool) initiative mandated by NSW Department of Health. The process followed in GWAHS involved regular file audits to assess compliance and quality of documentation and the level of outcome measure completions. Regular reports are generated for feedback to managers and clinicians to inform and validate their efforts with the completion of the outcome measures.
The use of outcome measures has multiple benefits:
1. A pointer for clinical planning and intervention.
2. A point of reference to gauge improvement or decline.
3. A challenge to reconsider decisions.
4. Using outcome measures to reinforce clinical impressions.
5. Ammunition to argue for increased (or question) resources.
The challenge is to convince clinicians to accept and understand the benefits of using outcome measures. This is to their own and their clients' benefit in the processes of assessment, care planning, relapse prevention and discharge.
Paper 39: A trial of outcome measures reports designed specifically for consumers
Professor Tom Trauer and Glenda Pedwell, Project Manager, St Vincent's Hospital, Mental Health Service, Melbourne, AUSTRALIA
Learning objectives:
1. Attendees will see new outcome reports designed specifically for consumers.
2. Attendees will be learning the experiences of clinicians in using these reports with their consumers. Increasing consumer expectations for access to information has been a growing trend across the healthcare sector. In the mental health sector, outcome measures are a rich source of information for potential use by consumers and clinicians to track the consumer's progress. However, graphical reports designed for clinicians have only recently become available and some clinicians are seeing these for the first time. Currently available standard consumer reports were designed with service providers in mind; anecdotal reports indicate that it is extremely rare for clients to be provided with graphical reports that track their outcome measure ratings over time. We report a trial of outcome reports designed specifically for consumers. We designed these reports with input from consumers; they are printed in colour and run directly from the outcome measures database. We recruited two adult continuing care teams in Melbourne; each was willing and able to participate in the project, had the requisite information technology infrastructure, and agreed to the investigators attending their weekly meetings over the course of the two month study period. During that time clinicians were routinely provided with the new reports based on the most recent outcomes assessments in advance of their next appointment with the consumer, and asked to give them to the consumer, with whom they should discuss them. We report the mainly qualitative findings based on clinicians' reported experiences. The provision of outcomes reports to the consumers themselves is an important extension of routine outcome measurement.
Paper 40: Consumer, carer and clinician collaboration: The Western QUATRO Project
Jennifer Black and Tania Lewis, Department of Human Services, Victoria, AUSTRALIA
The Western QUATRO Project set out to influence the practice and culture around the use of outcome measures by mental health services, with the emphasis being on consumer and carer participation in the outcome measurement process. The QUATRO team included three clinicians and a consumer and carer consultant. Team members share their personal experiences of being part of a unique team and discuss some of the challenges involved in the project. They will outline the innovative practices which have resulted from the project. The collaborative nature of the project saw the contribution of Consumer and Carer Consultants and clinicians valued and applied to provide the impetus for some innovative practices. They, together with the project team, have become agents of change within the mental health sector.
The presentation will outline some of the achievements that have resulted from this collaborative and innovative process including:
• Consumer and Carer Consultant Workshop and ongoing consultation and networking opportunities.
• Consumer and Carer Consultant Training Workshops.
• Consumer and carer consultant participation in developing promotional materials including a brochure, flyer, poster and flipper card.
• Collaboration with AMHOCN (Australian Mental Health Outcomes and Classification Network) to produce training materials (clinician) to be used nationally. This includes the planning and production of a training DVD featuring consumers, carers and clinicians from the Western Cluster.
• Ongoing support for consumer and carer consultants to be involved in the training of clinicians in relation to the meaningful use of outcome measurement.
• Involvement in consumer and carer forums nationally.
Stream Nine - Ways of Measuring Other Important Things
Paper 41: The routine collection of data on outcomes by Australian private hospitals with psychiatric beds
Allen Morris-Yates, Liaison Manager, Australian Mental Health Ouctomes and Classification Network, AUSTRALIA
Since 2002 almost all private hospitals with psychiatric beds in Australia have been routinely collecting and reporting a nationally agreed suite of clinical measures and related data for the purposes of monitoring, evaluating and improving the quality of and effectiveness of care. This work is directly comparable with similar activities being undertaken in public sector specialist mental health services. For purposes of analysis and reporting, the clinical measures data collected under the agreed Outcome Measures Protocol (OMP) is linked with data collected under the Hospitals Casemix Protocol (HCP). Participating hospitals submit both the OMP and linked HCP data to a Centralised Data Management Service (CDMS). The CDMS is operated by the Australian Medical Association (AMA) under an agreement for services, with funding from participating private hospitals, private health insurance funds and the Australian government. Responsibility for the governance of the CDMS rests with all stakeholders participating in the Private Mental Health Alliance, including the National Network of Private Sector Consumers and Carers, the AMA and the RANZCP, the Australian Private Hospitals Association, the Australian Health Insurance Association and the Australian government. The OMP and HCP data submitted by hospitals is used in a number of different ways. Standard quarterly reports are routinely prepared and provided to participating hospitals and private health insurance funds. The reports include detailed statistical analyses of patients' clinical status at admission to and discharge from episodes of care, with the results being stratified by mental health diagnostic groups. These analyses clearly indicate that the majority of patients admitted to private hospitals are acutely unwell with their symptomatic problems usually also having a significant impact on their social and role functioning. By discharge, both clinician ratings and patient self-assessments indicate large (effect size > 1.0) improvements in clinical status for the majority of patients.
Paper 42: How can we build appropriate and sound mental health outcomes systems? Overview of key principles
Dr Paul Duignan, Clinical Psychologist, Mental Health Consultant, NEW ZEALAND
Defining, measuring, attributing, reporting on, and being accountable for outcomes in mental health have come of age. Wherever we look we find mounting advocacy for more accountability for outcomes and the development of various outcomes measurement systems. This inaugural Australasian Mental Health Outcomes Conference is part of this international trend. The combination of evidence-based practice in health sciences and the movement to manage for outcomes/results in the public sector is driving interest in this area. Mental health is only one of the many sectors where this pressure is being felt. In spite of the level of interest in outcomes, the underlying concepts on which sound outcomes systems should be based are often not well understood. As a consequence, outcomes systems are sometimes built badly and often they meet resistance from stakeholders because of a lack of clarity about whether they are assuming attribution (proof that a player actually changed an outcome) and the related issue of accountability (holding particular players to account for changes in outcomes). All stakeholders should be clear about how these issues can be best dealt with in outcomes systems. Such awareness increases the chances that good outcomes systems will be introduced which stakeholders are likely to accept as fair and transparent. This presentation will provide an overview of general principles of how to build good outcomes systems; the link between outcomes monitoring and more one-off evaluations; and the issues of measurement, attribution and accountability. In addition, software visualisation of high-level (not individual patient level) sector and organisational outcomes will be discussed.
Paper 43: Evaluating efforts in mental health promotion: RCTs and beyond
Janet L Fanslow, PhD, Senior Lecturer; University of Auckland, NEW ZEALAND
Aim: to outline community level evaluation tools that will enhance our ability to promote mental health at the community level.
Background: While appropriate provision of mental health treatment and recovery services remain a bedrock for improving mental health outcomes, factors such as reducing social isolation, eliminating violence and abuse, and increasing economic participation are also key components of promoting positive mental health. Tackling these issues requires community participation on a broader scale, and the effects of intervention techniques such as advocacy, legislation and social marketing can be more diffuse, and harder to measure. The purpose of this presentation is to initiate discussion on ways we might measure aspects of community readiness to engage on issues relevant to mental health promotion, and describe evaluation methods that can help document positive shifts in whole communities. Conclusion: Positive change at the community level is achievable, but requires enhancement of the techniques and tools we have available. Energetic discussion, action and measurement on these issues will improve our ability to create the mentally healthy society we strive for.
Paper 44: The Population and outcomes based research and evaluation framework of North Metro CAMHS in Western Australia
Marg Jones, Western Australia Health Department, Mental Health Division, AUSTRALIA
Describe the population and outcomes based research and evaluation framework under development in North Metropolitan CAMHS in Western Australia, and its indicated use by clinicians, managers and researchers.North Metropolitan Area CAMHS in WA has, in conjunction with a strategic planning process, established a research and evaluation programme to inform future planning.
The research and evaluation programme framework has four components which are designed to support clinical practice: population mental disorder prevalence and morbidity data; efficacious evidence-based interventions; practice-based evidence (NOCC); and individual clinician support systems to assist in case formulation and decision-making. Population approaches to clinical services planning are required to ensure that the highest priority consumer populations are targeted for clinical service delivery. Clinical services are selected based on their relevance to the target populations and evidence base. By developing these first two components and linking these to the WA mental health information system database of National Outcomes Case Collections data (NOCC), clinicians, researchers and managers are able to assess the effectiveness of interventions, leading to the development of more effective, targeted interventions, and intervention processes more finely attuned to consumer needs.The WA Health Department Mental Health division has funded a project by CAMHS to establish the first two components above, aiming to set up an ongoing system of population database linkage tailored to CAMHS, a system of linking this to a review base of efficacious interventions, and the practice outcomes (NOCC data) recorded by the Mental Health Information System. This presentation will describe the progress of the research and evaluation framework to date, its proposed use, and the results of early trials of clinical utility, if available at that time.
Paper 45: Developing a tool to measure indigenous empowerment. (Paper Unavailable)
Melissa Haswell-Elkins and Rachael Wargent, North Queensland Health Equalities Promotion Unit, University of Queensland, Cairns, AUSTRALIA
Most mainstream measures of mental health typically focus on deficits, problems and clinical symptomatology. Concepts and pathways underlying these measures are based on Western psychiatric models to capture what is considered relevant to enable service providers to assess patients and evaluate outcomes consistent with this framework. While few people deny the importance of such aspects of mental illness, contemporary concepts of mental health care go further to engage with consumers to set their own goals, regain control, reclaim identity and ultimately recover. The consumer movement has increased consumer voice and influence on services, and consumer-rated measures are part of outcomes initiatives. In contrast to New Zealand, however, indigenous Australian consumers have had little involvement in the consumer movement. While exciting innovations (e.g., Hua Oranga) have brought Maori concepts of mental health into outcome measurement, less has been achieved to effectively capture indigenous Australian perspectives on mental health and well-being. This presentation will describe a tool to measure empowerment that emerged from descriptions of participants in an Aboriginal-developed empowerment intervention, the Family Well-Being Programme. People's accounts of moving from severe disempowerment and social and emotional suffering, towards personal psychological and group healing and participation in structural change were used to frame this tool. The tool is now being piloted within specific empowerment-oriented interventions addressing mental health, alcohol and suicide. By attending this session, participants will consider the importance of measuring empowerment as a mental health outcome and examine a research process toward developing such a measure with indigenous Australians.
Stream 10 - The Bright-eyed & Wise CAMHS & Older Persons
Paper 46: The Parent's Concerns Questionnaire (PCQ): A clinically useful assessment and outcome measure.
Dr. Stephen Matthey, Senior Clinical Psychologist, and Research Director for ICAMHS, Sydney South West Area Health Service, AUSTRALIA
Learning objectives:
1. To inform conference attendees about a recently developed assessment and outcome measure for parents concerned about their child's emotional/behavioural health.
2. To demonstrate the clinical usefulness of a simple scoring template for this PCQ which provides a clear English brief report detailing how many clients have improved, and in what areas.
3. To stimulate participants to think critically about the nature of traditional normative outcome measures and newer ipsative outcome measures. This presentation describes a parent-report measure (the PCQ) for parents concerned about their child's (infants to adolescents) emotional/behavioural health, including its psychometric properties, the scoring method, and the differences to more usual parent-report checklists. The PCQ is designed to be both useful clinically and for evaluation purposes. It has three sections: the first asks parents to nominate up to three situations or problems they would like to change by coming to the service. Associated with this are ratings for the frequency of situation occurrence, and degree of bother or stress associated with each situation for both parents and child. The second section asks about the parent-child interactional quality; the third section asks about the usual behaviours the parent does in response to common child difficulties. In addition, when the PCQ is used at the end (or follow-up) of a service the parents are asked to give their reason for any changes they report. The measure comes with an Excel file that provides a clear English report of how many clients have improved, and in which areas. The PCQ is used as the evaluation tool of choice in a number of parenting programs in Sydney, including some Triple P programmes. Clinicians often feel that evaluation tools are of more benefit to researchers than themselves. This PCQ stands out as an exception - not only do clinicians and service managers report it as being useful, but also clinicians find that it helps clients reflect on what they wish to achieve by coming to their service.
Paper 47: The HoNOSCA as a process and outcome tool for a health board CAMHS service
Steve Harvey and Gerard Dolan, Taranaki District Health Board, Taranaki,
NEW ZEALAND
Learning objectives:
1. To demonstrate the use of the HoNOSCA at a local level.
2. To review changes in overall functioning of clients who presented at a CAMHS service.
3. To identify factors impacting on treatment outcomes.The Health of the Nation Outcomes Scales for Children and Adolescents (HoNOSCA) is currently being rolled out as national outcome measure for children and adolescent mental health services within New Zealand. While this may have general policy utility it remains important to develop local initiatives to use the data from this scale to inform practice and service initiatives. The CAMHS service in Taranaki began to regularly use the HoNOSCA in July 2005 to rate the emotional and behaviour functioning of the young people referred to the service. These ratings were repeated at regular three month MDT follow ups and at discharge. The HoNOSCA provides an overall score as a measure of wellbeing/distress and to measure change arising from interventions. Observations show that interventions do result in general improvements in functioning. Additionally, scores from the subscales of emotional, family and social problems were analysed by presenting problem to explore the relationships among these concerns for clients presenting at Taranaki CAMHS over a nine month period. The results indicate that different presenting problems have varying outcome trajectories depending on social problems. These results suggest that more focussed interventions on social skills may address a group of clients whose progress appears impeded by outside social factors.
Paper 48: Routine HoNOS65+ collection in an acute psychogeriatric inpatient unit in New Zealand. (Paper Unavailable)
Gary Cheung, Psychogenatrician, Auckland District Health Board, NEW ZEALAND
HoNOS65+ was introduced as a routine outcome measure in our service as part of the New Zealand Mental Health Standard Measures of Assessment and Recovery Outcomes Initiative. The aim of this paper is to report the findings from the use of this tool in our acute psychogeriatric inpatient unit. This is a retrospective analysis of the HoNOS database from 2002 to 2005. Service users were classified into two groups: 1. organic disorders and 2. functional disorders according to their ICD-10 diagnoses. Statistical analysis was performed to compare the HoNOS65+ scores at admission and discharge within each group. There were 431 start episodes and 452 end episodes completed. However, only 130 of these episodes were matched and were usable in this analysis. 29 (21 per cent) service users with diagnoses of organic disorders and 101 (72 per cent) with diagnoses of functional disorders. The mean total HoNOS65+ score reduced significantly for both groups from admission (organic: 16.45, functional: 14.00) to discharge (organic: 12.34, functional: 8.76). For the organic group, significant improvement was observed in two (behaviour and symptoms) subscales; and for the functional group, significant improvement was observed in three (behaviour, impairment and symptoms) subscales. The findings support psychogeriatric inpatient treatment as an effective intervention for both organic and functional disorders. We identified a lack of improvement in the social subscale for both groups. The social subscale scores on admission were relatively low and the lack of improvement might be because specific interventions were not necessary during the inpatient episode. Further exploration of this subscale would be useful in clarifying whether there is a need to plan service development to address these aspects of service user care.
Paper 49: Investigating measures of disability profiling and their individual contribution to care planning and outcome analysis in CAMHS
Ms Gail Bowker, Manager and Dr Ashok Abhyankar (co-author/presenter) Consultant Psychiatrist, Top End Mental Health Services (TEMHS), AUSTRALIA
Learning objective: Participants should have an understanding of disability based care planning to achieve better outcomes in child and youth mental health. Disability profiling of clients engaged with CAMHS is a valuable component of care planning. Currently the HoNOSCA is utilised to qualitatively measure behaviours, impairments, symptoms and social functioning of children and adolescents with mental health problems, thus, providing a global measure of an individual's mental health status. However, the HoNOSCA does not provide a clear disability profile, as there is no delineation between the specific functional impairments relating to disability, in isolation from the specific impairments stemming from mental health issues. The International Classification of Functioning - Children & Youth (ICF-CY) offers a common framework for describing functioning and environment, including medical, social, educational and functional needs of children. The ICY-CF is utilised across varied disciplines as it localises the child's impairments on the levels of body, everyday functioning, involvement in life situations and environment; it quantifies the person-environment interaction essential for child development. This paper proposed to compare the HoNOSCA and ICF-CY profiles of 30 clinical cases. The aim was to determine their individual strengths and weaknesses in contributing to care plan development and outcome evaluation.
Paper 50: Finding hope where none could be found. (Paper Unavailable)
Sue Thomson, Community Mental Health Nurse, Waitemata District Health Board,
NEW ZEALAND
‘Wishes to die' and chronic dysthymia often fall into the ‘too hard' basket for clients and their clinicians. Experience leads many clinicians to believe that these wishes are based on entrenched thoughts and values which are difficult to change. The apparent lack of change in the clinical presentation over time and the difficulty demonstrating change by traditional measures of mood alone further reinforces this therapeutic nihilism. Consequently, both clients and their clinicians become reluctant to consider changes in their management, believing that recovery is hopeless. But do both groups have to think this way? What tools may the clinician have available to begin a conversation and therapeutic interaction about change and hope? This paper looks at three complex case studies of clients in a mental health service for older adults, with longstanding wishes to end their lives. The HoNOS65+ was used as a means to engage with both the clients and their clinicians to relook at change and initiate alternative management to enable a process whereby clients develop reasons for hope and a positive future. The outcomes in all three cases are outlined and discussed.
Stream Eleven - Thinking About Needs
Paper 51: Development and evaluation of a patient rated version of the Camberwell Assessment of Need Short Appraisal Schedule (CANSAS-P)
Professor Tom Trauer, St Vincent's Hospital, Mental Health Service, Melbourne, AUSTRALIA
Learning objectives:
1. Attendees will learn about a new form of the Camberwell Assessment of Need Short Appraisal Schedule (CANSAS-P) that has been developed specifically for self-completion by consumers.
2. Attendees will be able to evaluate the relative strengths of the CANSAS-P against previous forms. The comprehensive assessment of patients with severe mental illness includes the evaluation of needs, as this informs service planning, and levels of unmet need have been found to be associated with lower subjective quality of life. The Camberwell Assessment of Need is the most widely used instrument for this purpose. Existing forms of the instrument have not been particularly sensitive to the problems that consumers may face when completing complex self-assessment forms. We report the development and evaluation of a new, consumer-rated, short form (CANSAS-P). The CANSAS-P exhibited comparable detection of needs with its predecessor, better identification of domains that are problematic for clients to respond to, good test-retest reliability, especially for unmet needs, and generally positive evaluations by consumers. The assessment of consumer needs is important, and we recommend the CANSAS-P as the needs assessment measure of choice for self-assessment by consumers.
Paper 52: Context driven care planning (Use of ICD-10 Z Codes)
Dr Ashok Abhyankar, Consultant Psychiatrist and Ms Gail Bowker (co-author/presenter), Manager, Top End Mental Health Services (TEMHS), AUSTRALIA
Learning objective: Participants should have a good understanding of how Z Codes can be utilised for care planning and interagency collaboration. Children's mental health problems do not exist within a vacuum and can only be understood within a contextual framework. Whilst data pertaining to the Factors that Influence Health Status (FIHS) is routinely collected, this does not provide sufficient detail on contextual factors to adequately inform care planning. These contextual factors influence the direction and efficacy of treatment and are therefore essential to managed-care. ICD-10 Z Codes provide a way of quantifying the qualitative aspects of a young person's context. The purpose of this paper was to examine if common psychosocial stressors occur in child psychopathology, and if so, how are they related. It was hypothesised that specific psychosocial stressors would be associated with specific diagnostic categories. Furthermore, this study aimed to investigate how Z Codes could be utilised in care planning, secondary consultation, and in the development of policy initiatives in primary and secondary prevention.
Paper 53: Progress towards recovery: Multiple assessments using The CPS-50 and the CHR in a non-government organisation
R. Gedye, Equip, Auckland and C. Jordan, M. Fitch, N. Cowan and R. Belding, Institute of Information and Mathematical Sciences, Massey University, Auckland, NEW ZEALAND
Regular and comprehensive assessments are seen as a cornerstone of effective service provision in the recovery of individuals with major mental illness. In recognition of this the late Professor Ian Falloon and the Optimal Treatment Project group (OTP) developed a psychiatric assessment, the CPS-50 (Current Psychiatric State-50), that is quick to administer and can be used to monitor change across eight clinical scales, plus appendices that assess for service user disability and impairment. In addition, Professor Falloon developed a community health record (CHR) which focuses on a number of social domains including work, friendships and community tenure. Equip is a non-government agency working in community mental health in New Zealand which uses the CPS-50 and CHR to assess service user progress every six months. This presentation aims to investigate the overall progress of the Equip service user group as assessed by the CPS-50 and the CHR. Two hundred and fifty service users have been assessed using the CPS-50 and the CHR, and many service users have had multiple six month assessments. A statistical audit of these results is being undertaken. Relationships between the CPS-50 clinical scales and the CHR social domains will be examined. Further, relationships within and between service user groups based on assessment period, age and gender will also be presented. The contribution of regular and comprehensive assessments to further enhance service user recovery will be highlighted, as these relate to the individual service user, specific service user groups, assessment periods, and overall service user functioning.
Stream Twelve - Other national Collections
Paper 54: Knowing the People Planning (KPP). (Paper Unavailable)
Barry Welsh, Senior Advisor (Quality), Mental Health System Development, Population Health Directorate, Ministry of Health, NEW ZEALAND
Learning objectives:
1. Describe KPP.
2. Provide the rationale for KPP.
3. Show the significant improvements that have occurred both for consumers and the District Health Boards that have implemented KPP. Knowing the People Planning (KPP) is an innovative management tool designed to improve mental health service delivery processes for people who have used services for two years or more. KPP was developed jointly by the Ministry of Health, Auckland Uniservices, and South Island District Health Boards and their key stakeholders. KPP can demonstrate significant improvements in consumer outcomes. The Ministry of Health introduced ten sector wide health targets for the 2007/08 year. The research findings from implementing KPP directly influenced the choice of the mental health target that requires 90 -100 per cent of District Health Board's long-term consumers to have relapse prevention plans.
Paper 55: Mental health and addiction Key Performance Indicators for New Zealand
Ian McKenzie, General Manager, Mental Health Services, Counties Manukau District Health Board, NEW ZEALAND
The New Zealand Ministry of Health funded the development of a Key Performance Indicator framework for mental health and addiction services. The project was led by the Northern Region District Health Boards and took place during 2006 - 2007.
Development of the framework was informed by work carried out in Australia during 2005 and prior work in Canada. The framework was developed by a skilled group of sector representatives. Provider commitment to the project was on the basis that the framework would be used as a quality improvement tool. This commitment influenced the choice of indicators. The framework is comprised of nine domains (adopted from the Australian framework), sub-domains and a suite of first version indicators. this first version is intended to be a generic framework for use throughout the sector. It has been designed to provide high-level information that is applicable across populations. Later versions may target issues specific to specialist services and populations. The framework has been designed to enable services to learn about practices that lead to improved outcomes for service users. This learning will take place through provider-led benchmarking forums. The design group responsible for the framework's development has recommended that extensive testing and refinement is undertaken to maximise its utility as a quality improvement tool. Testing will take place during the next phase of the project. This paper presents the KPI framework, the process of its development, outcomes from the first phase of the project and implications for the sector.
Paper 56: PRIMHD: National integrated mental health system.
This paper is now outdated, please visit the NZHIS website instead
Christine Thorpe, Senior Advisor, National Information Systems, Health and Information Strategy and Policy, New Zealand Health Information Service, NEW ZEALAND
PRIMHD is the Project for the Integration of Mental Health Data.
PRIMHD will enable the integration of activity and outcomes information that can be used to assist the sector towards improved health outcomes for consumers.
During the past 10 months the sector has invested in the preparation of:
• a set of national information standards for the new national collection, and
• the development of business requirements.
We are now working towards a solution which supports these requirements.
PRIMHD will increase the value of mental health information because the collection will have both social and economic benefits over time. One of the priorities for PRIMHED is to shift the focus from information collection to information use.
Stream Thirteen - Extending Outcomes
Paper 57: Predictive aspects of outcomes measures in an Auckland therapeutic community.
Please Note: Any reference to the presentation, or use of the quotation from it, must be attributed to Odyssey House.
Alex Davidson, Research Analyst, Odyssey House, Auckland, NEW ZEALAND
Odyssey House (Auckland) treats 500 people yearly for addiction using the Therapeutic Community model. Funders seek information on how successful drug and alcohol treatment is. A modest proportion of clients ‘graduate', but there is little information on how many relapse. As for the majority who don't graduate, we need to know to what extent they improve in treatment.
The first of two outcomes measurement projects estimates improvement while still in treatment. Progress is measured by a model based on harm reduction criteria. Four domains are assessed:
• Decreased distress over drug and alcohol problems (instruments: depression and craving indexes).
• Effectiveness and efficiency of facilities and service delivery (indicators: occupancy rates, retention, waiting period before admission, staff support assessment).
• Client satisfaction increase across time (instrument: Client Satisfaction Survey).
• Assessment of four TC-related treatment domains (instruments: CAS and SAS tests).
The second project examines the post-treatment period. The graduate group of former clients was supplemented by a post-treatment group who left without formally graduating, but reached higher levels in treatment. Together they form the ‘Aftercare Service'. They are assessed monthly by a post-treatment questionnaire which measures seven domains representing five dimensions:
• Drug abuse: smoking, craving, substance use.
• Well-being: depression, suicidal ideation.
• Family reunification, reconciliation with partner/parents.
• Employment and earnings.
• Interaction with the criminal justice system.
Data from these two projects has made it possible to evaluate predictors of client success at the admission stage and early treatment stage. The results and implications of this evaluation for treatment are presented and discussed.
Paper 58: Supporting community-based recovery for adult users of mental health services: The Community Living Service.
Liz Stewart, Researcher, Counties Manukau District Health Board; Dean Emerson, Social Worker, Counties Manukau District Health Board; Andrea Williamson, Service Leader, Pathways Trust and Wiremu McClutchie, Consumer Representative, Community Living Service Improvement Group, NEW ZEALAND
In 2004 in the Counties Manukau District Health Board (CMDHB) region mental health services faced significant pressure. A shortage of community-based accommodation, living and support options meant a high level of inpatient occupancy, extended admissions and ongoing pressure on acute inpatient and crisis respite services. Service users faced difficulties in moving forward in their recovery. To address this, the Community Living Service (CLS) was set up to support adult mental health service users living within community settings. Six NGOs operate a strengths based CLS for referred service users, in partnership with a CMDHB clinical team, providing personalised support with accommodation, living skills, whanau/family connections, social isolation, employment or other aspirations. Innovative features of the CLS include a low one to eight staff/client ratio; use of a personalised flexifund and strengthening supportive community resources. A CLS Improvement Group of consumer, clinical and NGO representatives meets monthly to support effective implementation. Evaluation components include analysis of routine data, service user survey and interviews plus staff focus groups. Results from routine data include 38 per cent with improvements and 49 per cent with stability in housing outcomes. Many service users reported improvements in housing, respite and inpatient use and feelings of wellbeing and self belief. They expressed greater confidence about community living and moving forward in their recovery. Service benefits include improved operational processes, communication and collaboration between services and cost savings in mental health service expenditure. The CLS has supported adult service users to improve their quality of life, helped foster a ‘whole of person' approach in services and improved working relationships and understanding between clinical and community NGO services.
Paper 59: A holistic approach to outcome indicators of success within a non-government organisation (NGO
Rob Warriner, Director, Walsh Trust, NEW ZEALAND
WALSH Trust is a non-government organisation that, since 1988, has offered a range of mental health support services in West Auckland. Beginning with a single house offering supported accommodation, WALSH Trust, through a number of contracts, now offers housing and recovery services, mobile community support, training, peer support and supported employment services.
Since 2003 WALSH Trust has implemented a broad and holistic approach to the assessment of organisational outcomes. Philosopher Ken Wilber's four quadrant framework has underpinned the approach, integrating the examination of success across the organisation. These four quadrants are clients / staff (i.e. people), community, service development, and the organisation. This approach recognises that (for example) it would be impossible to aim to provide excellent services to clients if staff are unhappy with their working conditions. With respect to client outcome indicators, implicit in the framework is that the tools / approaches utilised will have both value and limitations. It was important that a range of approaches was adopted - which even then will likely fall short of a ‘total picture' of what is happening for a person, but can still provide a valuable, if blurry, "snapshot". This presentation will describe the framework and its introduction, the impact such an approach has had on organisational culture and work practices, and the tools and measures that have been utilised. Also discussed will be some of the challenges in implementing such a framework and the tools we use.
Stream Fourteen - Framework of Experience
Paper 60: Linking mental health information to best possible outcomes.
Pernilla Vis af Vivere, National Consumer Advisor, Te Pou, NEW ZEALAND
To encourage the development and use of mental health information to assist recovery through improvement of mental health services, findings of international research examining recovery from severe disorders will be discussed. Current expectations and statistics of the course and outcome of mental illness suggest recovery is but a commonly used word. The large number of consumers receiving invalids benefit is an indication that for many, mental disorders seem to be a long term, if not a life long issue. Does it have to be? Many studies have confirmed that high degrees and rates of recovery are possible, even from the most severe mental disorders, and that contributing factors to recovery are likely to be found outside of what is currently provided by mainstream services, as treatment as usual. By combining awareness of research examining high degrees and incidents of recovery, with the use of outcome measures and other mental health information, it is possible to monitor how well, or badly, service provision assists consumers best possible outcomes, and to inform policy and practise.
Paper 61: Art - Healing from the inside.
Garry De Foster, Marketing and Services, P.S. Survivors Incorporated, NEW ZEALAND
Key words: healing art, creative processes, holistic health
Learning objective: To reflect on the belief that human beings (whether considered mentally healthy or mentally disordered) perform creative activities by using the same faculties but the motives colours could be different, and yet equally healing. A comprehensive holistic model of care for people who have experienced major mental disorders must recognise the importance of body, mind, spirit and soul - the four parts which make human beings. The complexity of people's functioning when they experience mental disorders is much higher than in ‘mentally healthy' mates because the wholeness of the fourth-fold body (physical, etheric, astral and ‘I') is disjointed. No other known human activity can better harmonise those four parts as does art. Art (painting, drawing, sculpture, music, etc) therapies provide a sense of choice and self-control enabling the realisation of the soul's inner truths and this is the initiation for a powerful healing process. Life body, healthy emotions and feelings, higher self, consciousness and other vital premises of us (I), subtly involve the creative process of a performing art. The art is a spiritual vehicle which mobilises the nobilities of our consciousness and our higher self, and take us in to our inner world of imagination and emotion, vision and feeling, and activates our own healing resource which is crucial for the individual healing process. The healer is the person who performs art.
What is a helper's healing capacity in facilitating the healing process? It is his/her ability to find a way that one could take up a particular art activity that would participate in a healing process. This path is successful if servicing activity (do with and be with) is performed out of the knowledge that, in itself, it has enormous healing potential.
Paper 62: Nature of one's psychotic experience as the principle outcome measurement-related topic.
Borislav Dacic, Consultant and Julian McCusker Dixon, Project Manager, P.S. Survivors Incorporated, NEW ZEALAND
Learning objectives:
1. To highlight the importance of validation of the very nature of peoples' personal psychotic experience, which itself offers the road-sign to recovery.
2. To evaluate grounds for needed replacement of mental illness maintenance medical therapy with holistically facilitated, recovery-oriented healing therapies. Acceptance of the reality of a person's psychotic experience and its validation is the starting point in any genuinely recovery-oriented treatment. The great success in recovery achieved in experimental residential facilities in Diabasis, Berkeley, California (seventies); Kingsley Hall experiment in London and Soteria House in San Diego (sixties), almost not registered by bio-psychiatry, are virtually forgotten nowadays. John Wiere Perry, R. D. Laing and Dr Loren Mosher showed that people fully recover from psychosis when they are not treated by powerful and debilitating neuroleptic drugs. The human brain possesses capacities for healing and self-repairing beyond the dreams of researchers and science from only a few decades ago. If allowed and facilitated, the brain-body-spirit trinity, integrated nicely in our minds, is the way to recovery as the outcome. So-called "chronic schizophrenia" in our societies - where a person is medicated, distressed, hospitalised or persistently medicated for decades in community - is a cultural, social, economical and political outcome for a society that refuses to understand the healing nature of the phenomenon. "Dilemma is: whether to pursue the mental illness maintenance medical therapy with inescapable further health deterioration (both physical and mental) or to opt for a fully holistic approach in caring for people's well-being by facilitating innate healing processes that people already possess for their emotional, psychological, social and behavioural problems. Shall we maintain the slogan: "Recovery is not about destination in peoples' life but about their life journey?" The brain's psycho-linguistic and -semantic do not work that way. When clients and helpers share a common understanding and goal, their natural tendency is to cooperate in realising it.
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Page last updated: 1 March 2010