John S. Lyons, Ph.D. University of Ottawa Children’s Hospital of Eastern Ontario
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Transcript of John S. Lyons, Ph.D. University of Ottawa Children’s Hospital of Eastern Ontario
Building a System one Child/Family at a Time: Total Clinical Outcomes Management and
Treatment Planning
John S. Lyons, Ph.D.University of OttawaChildren’s Hospital of Eastern Ontario
Three essential problems
Fundamental misunderstanding of the nature of our business
Our business is complex System expertise is not resident
among those with the most contact with the people we serve
Understanding our Marketplace:The Hierarchy of Offerings
I. CommoditiesII. ProductsIII. ServicesIV. ExperiencesV. Transformations
- Gilmore & Pine, 1997
Challenges in the Human Service System
Many different adults in the lives of the people we serve
Each has a different perspective and, therefore, different agendas, goals, and objectives
Honest people, honestly representing different perspectives will disagree
This creates the potential for conflict
So what’s our problem? You can’t manage what you don’t measure
You need good information to make good decisions
You can try to fake it. You can rely on intuition. But even
good intuition is limited as a management strategy
Collecting information is measurement
Example problems with managing transformations as services
Focus on finding people and getting them to show up rather than finding people you can help, helping them and then finding some one else
Assessment used to justify service receipt rather than to understand and communicate
An hour is an hour is an hour—time valued equivalently over an episode
Supervision as enforcement rather than teaching
The Philsophy: Total Clinical Outcomes Management (TCOM) Total means that it is embedded in all
activities with individual & families as full partners.
Clinical means the focus is on health, well-being, and functioning.
Outcomes means the measures are relevant to decisions about approach or proposed impact of interventions.
Management means that this information is used in all aspects of managing the system from individual family planning to supervision to program and system operations.
Managing Tension is the Key to Creating an Effective System of Care
Philosophy—always return to the shared vision. In the mental health system the shared vision are the people we serve
Strategy—represent the shared vision and communicate it throughout the system with a standard language/assessment
Tactics—activities that promote the philosophy at all the levels of the system simultaneously
The Troubles IThe Troubles I ’’ve seenve seen……....
People are more honest with researchers than People are more honest with researchers than cliniciansclinicians
Substance abusing girls Substance abusing girls ‘‘self esteemself esteem’’ plummets with plummets with treatmenttreatment
Clinical factors donClinical factors don’’t predict service utilizationt predict service utilization Method matters with consumer satisfactionMethod matters with consumer satisfaction Consumer & Providers use assessment for advocacy Consumer & Providers use assessment for advocacy
rather than accuracyrather than accuracy Measures developed for research do not translate Measures developed for research do not translate
well into service delivery applications well into service delivery applications
The Strategy: CANS and ANSASix Key Characteristics of a Communimetric Tool
Items are included because they might impact care planning
Level of items translate immediately into action levels
It is about the individual not about the individual in care
Consider culture and development It is agnostic as to etiology—it is about the
‘what’ not about the ‘why’ The 30 day window is to remind us to keep
assessments relevant and ‘fresh’
CHILD AND ADOLESCENT NEEDS AND STRENGTHS (CANS-MH)Use with manual dated 1/5/08PROBLEM PRESENTATION 0 1 2 3 NA 1. Psychosis 2. Attention Deficit/Impulse 3. Depression/Anxiety 4. Oppositional Behavior 5. Antisocial Behavior 6. Substance Abuse 7. Adjustment to Trauma 8. Attachment RISK BEHAVIORS 0 1 2 3 U 9. Danger to Self 10. Danger to Others 11. Other Self Harm 12. Elopement 13. Sexually Abusive Behavior 14. Social Behavior 15. Crime/Delinquency FUNCTIONING 0 1 2 3 U16. Intellectual/Developmental 17. Physical/Medical 18. Sleep 19. Family 20. School Achievement 21. School Behavior 22. School Attendance 23. Sexual Development
Other Self HarmThis rating includes issues of recklessness, engaging in unsafe behaviors that are putting the child or youth in jeopardy of physical harm.. A rating of 2 or 3 would indicate the need for a safety plan.
0 No evidence of behaviors other than suicide or self-mutilation that place the youth at risk of physical harm.
1 History of behavior other than suicide or self-mutilation that places youth at risk of physical harm. This includes reckless and risk-taking behavior that may endanger the youth.
2 Engaged in behavior other than suicide or self-mutilation that places him/her in danger of physical harm. This includes reckless behavior or intentional risk-taking behavior.
3 Engaged in behavior other than suicide or self-mutilation that places him/her at immediate risk of death. This includes reckless behavior or intentional
risk-taking behavior.
CAREGIVER NEEDS & STRENGTHS 0 1 2 3 U NA28. Physical/Behavioral Health 29. Supervision 30. Involvement 31. Knowledge 32. Organization 33. Resources 34. Residential Stability 35. Safety STRENGTHS 0 1 2 3 U NA36. Family 37. Interpersonal 38. Relationship Permanence 39. Educational 40. Vocational 41. Well-being 42. Optimism 43. Spiritual/Religious 44. Talents/Interests 45. Inclusion 46. Resiliency 47. Resourcefulness
Talent/InterestsThis rating should be based broadly on any talent, creative or artistic skill a child or adolescent may have including art, theatre, music, athletics, etc.
0 This level indicates a child with significant creative/artistic strengths. A child/youth who receives a significant amount of personal benefit from activities surrounding a talent would be rated here.
1 This level indicates a child with a notable talent. For example, a youth who is involved in athletics or plays a musical instrument, etc. would be rated here.
2 This level indicates a child who has expressed interest in developing a specific talent or talents even if they have not developed that talent to date.
3 This level indicates a child with no known talents, interests, or hobbies.
Communication Measurement
Behaviors
Experiences
Assets
Relationships
Care
Planning
Traditional Psychometric
Measures
The Child and
Family
}
CANS Usage in the United States
States with CANS Presence:--Alaska --Kentucky --Montana --S. Carolina
--Arizona --Louisiana --N. Carolina --Washington
--California --Maine --N. Dakota
--Delaware --Michigan --Ohio
--Georgia --Minnesota --Pennsylvania
--Kansas --Missouri --Rhode Island
State-Wide CANS Usage:--Alabama --Iowa --New Jersey --Utah
--Colorado --Maryland --New York --Virginia
--Connecticut --Massachusetts --Nevada --W. Virginia
--Florida --Mississippi --Oregon --Wisconsin
--Indiana --Nebraska --Tennessee
--Illinois --New Hampshire --Texas
Family & Youth Program System
Decision Support
Care PlanningEffective practices
EBP’s
EligibilityStep-down
Resource ManagementRight-sizing
Outcome Monitoring
Service Transitions & Celebrations
Evaluation Provider ProfilesPerformance/ Contracting
Quality Improvement
Case ManagementIntegrated Care
Supervision
CQI/QAAccreditation
Program Redesign
TransformationBusiness Model
Design
TCOM Grid of Tactics TCOM Grid of Tactics
Services and Policy Research Perspective
Large databases are impressive but without clinical logic can be very misleading
Mental health is different than health care in terms of the information used to make decisions
Communimetric tools can be expected to have 100% use penetration
Figure 5.2 Survival analysis of time to placement disruption for children/youth whose placement matches CANS recommendations (Match=0), those whose placed is at a lower intensity than recommended (match=1) and those whose placement is more intensive than recommended (match=-1).
Figure 3. Comparison of Life Domain Functioning between CANS/CAYIT agreed referrals to residential treatment (Concordant)
and CANS referrals to lower levels of care who were placed in residential treatment (Discordant)
18.54
14.1013.22
14.98
12.8511.50
0
2
4
6
8
10
12
14
16
18
20
CAYIT CANS (p<.01) 1st Residential CANS 3-6 Mo. ResidentialCANS (p<.05)
Concordance
Discordance
Figure 2. Trauma Symptoms comparison between CANS/CAYIT agreed referrals to residential treatment and CANS referrals to lower levels of care who were placed in residential treatment (Discordant)
5.39
4.76
3.734.15
4.77
4.66
0
1
2
3
4
5
6
CAYIT CANS (p<.01) 1st Residential CANS 3-6 Mo. ResidentialCANS
Concordance
Discordance
Figure 4. Comparison of Emotional/Behavioral Needs between CANS/CAYIT agreed placements in residential treatment
(Concordant) and CANS referrals to lower levels of care who were placed in residential treatment (Discordant)
16.11
13.34 12.91
12.32 12.6312.29
0
2
4
6
8
10
12
14
16
18
20
CAYIT CANS (p<.01) 1st Residential CANS 3-6 Mo. ResidentialCANS
Concordance
Discordance
Figure 5. Comparison of high Risk Behaviors between CANS/CAYIT agreed placements in residential treatment (Concordant) and CANS
referrals to lower levels of care who were placed in residential treatment (Discordant)
14.13
10.459.419.66
9.00 8.44
0
2
4
6
8
10
12
14
16
CAYIT CANS (p<.01) 1st Residential CANS(p<.05)
3-6 Mo. ResidentialCANS
Concordance
Discordance
Prevalence of actionable needs on the Fire Setting item of the CANS by demographic characteristics.
N % Confidence IntervalGender Actionable of percentage
Female 2,063 0.87 (0.52 - 1.38)Male 2,092 1.82 (1.29 - 2.48)
Race/EthnicityAfrican American 2,002 1.38 (0.91 - 2.00)Non-Hispanic White 1,900 1.21 (0.77 - 1.81)Hispanic 233 2.15 (0.70 - 4.94)
Age0 to 3 years 1,698 0.0 (0.0 - 0.22)4 to 6 years 565 1.06 (0.39 - 2.30)7 to 9 years 451 1.55 (0.63 - 3.17)
10 to 13 years 554 3.43 (2.08 - 5.30)14 to 16 years 572 3.67 (2.29 - 5.56)17+ years 89 3.37 (0.70 - 9.54)
The relationship of trauma experiences to the likelihood of having an actionable fire setting behavior.
Number of PercentTraumatic n Actionable None 1,061 0.49 (0.16 - 1.14)One 1,129 0.89 (0.43 - 1.62)Two 885 0.79 (0.32 - 1.62)Three 559 2.50 (1.38 - 4.17Four 296 1.35 (0.37 - 2.31)Five 151 3.97 (1.47 - 8.45)Six or more 119 8.40 (4.10 - 14.91)
Mental Health-Juvenile Justice Program CANS: Mental Health Needs percent of youth with actionable needs (2
or 3 ratings)
0
10
20
30
40
50
60
70
80
90
Psychs ADHD Dep Opp Antisoc Subab Trma
CANS InitialCANS 3-mo
Figure 1. Level of Need by Year for Admissions into Residential TreatmentN=2782
0
2
4
6
8
10
12
14
16
18
Beh/Emotion RiskBehaviors
Functioning Strengths
2003
2004
2005
2006
2007
Figure 6. Comparison of total score for RTC, CMO, and YCM initial assessments by year
0
5
10
15
20
25
30
35
40
2003 2004 2005 2006 2007
YCM
CMO
RTC
Figure 8. Average Improvement over the course of Residential Treatment by Year Note: higher score better improvement)
0
1
2
3
4
5
6
7
Beh/Emotion Risk Behavior Functioning
2003
2004
2005
2006
6
6.5
7
7.5
8
8.5
9
9.5
0 0.25 0.5 0.75 1 1.25 1.5 1.75 2
Year
TOT Scale
ALL YCM CMO TRH GRH PCR RES
Outcome Trajectories by program type in New Jersey
7
7.5
8
8.5
9
9.5
10
10.5
-1 -0.5 0 0.5 1 1.5 2
Years (vs Start Date)
Item
Ave
rage
(x
10)
TOT (ALL) YCM CMO TRH GRH PCR RES
Start
Hinge analysis of outcome trajectories prior to and after program initiation
Illinois Trajectories of Recovery before and after entering different types of Child Welfare Placements
5
6
7
8
9
10
11
-2 -1 0 1 2 3
Year
CA
NS
Ov
era
ll C
hil
d S
co
re
ALLILORFCFCSFCTLPGHRES
Percent of hospital admissions that were low risk by racial group Adapted from Rawal, et al, 2003
0%5%
10%15%20%25%
30%35%40%45%50%
1998 1999 2000 2001 2002
% o
f L
ow R
isk
Adm
issi
ons White
AfricanAmerican
Hispanic
Key Decision Support CSPI Indicators Sorted by Order of Importance in Predicting Psychiatric
Hospital Admission
If CSPI ItemRated as Start with 0 and
Suicide 2,3 Add 1
Judgment 2,3 Add 1
Danger to Others 2,3 Add 1
Depression 2,3 Add 1
Impulse/Hyperactivity 2,3 Add 1
Anger Control 3 Add 1
Psychosis 1,2,3 Add 1
Ratings of ‘2’ and ‘3’ are ‘actionable’ ratings, as compared to ratings of ‘0’ (no evidence) and ‘1’ (watchful waiting).
Change in Total CSPI Score by Intervention and Hospitalization Risk Level (FY06)
51.2
34.134.231.0
24.4
17.5
47.4
35.2
26.4
22.1 24.218.0
0
10
20
30
40
50
60
SASS Assessment End of SASSEpisode
Mea
n C
SP
I S
core
HOSP (high riskgroup)
ICT (high risk group)
HOSP (medium riskgroup)
ICT (medium riskgroup)
HOSP (low riskgroup)
ICT (low risk group)
“It is the reformer who is anxious for the reform, and not society, from which he should expect nothing better than opposition,
abhorrence and mortal persecution.”
Mahatma Ghandi
Cast of Characters: Late Adopters Columbo “If I act dumb maybe I can lower expectations and no
one will expect me to change” The Smartest Person in the Room “I already do this and have
for some time now so why should I change. What you are saying is no different from what I’ve already been doing”
The English Major “What exactly do you mean by this word…. I need clarity before I can change. You do realize that there are typos in this manual”
Nervous Nelly “We just aren’t quite ready to start doing this today….tomorrow doesn’t look good either”
The Philosopher “Do we really understand what this means…” or “isn’t it really much more complex than this….We need to think this through”
The Uber-Professional “This is not in my mandate, it would be unethical…..”
The Uber-Bureaucratic. “Let’s do it. We’ll start with a subcommittee to explore the feasibility of considering it through the larger committee…”
The Ostrich “If I don’t see it, it doesn’t exist….” The Slacker “If I just don’t do it maybe no one will notice”
Keys to Successful Implementation Take it a step at a time—planned incrementalism.
Implementation fatigue can drag change to a stop. Don’t get the approach confused with the
technology that supports it. Focus where the work starts—individual care
planning with children/youth and families. Transparent use creates reliability and validity Do not assume that training is an event. It is a
process. Reach out to others who use the approach. It is
designed as a mass collaboration.