Level of Care Assessments - A Systematic Review of Measures Appropriate for Emergency Departments
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Level of Care Assessments: Systematic Review of Measures Review of Measures Appropriate For E D t t Emergency Depar tments Tonia L Nicholls PhD Tonia L. Nicholls, PhD Johann Brink, MB ChB BA Hons FCPsych(SA) FRCPC Karen Chu, BA Michelle Pritchard MPH Michelle Pritchard, MPH Denise Bradshaw, MSW Connie Coniglio, Ed.D RPsych BC Quality Forum 2015
Transcript of Level of Care Assessments - A Systematic Review of Measures Appropriate for Emergency Departments
Level of Care Assessments: Systematic
Review of MeasuresReview of Measures Appropriate For
E D t tEmergency Departments
Tonia L Nicholls PhDTonia L. Nicholls, PhDJohann Brink, MB ChB BA HonsFCPsych(SA) FRCPC Karen Chu, BAMichelle Pritchard MPHMichelle Pritchard, MPHDenise Bradshaw, MSWConnie Coniglio, Ed.D RPsych
BC Quality Forum 2015
Overview
k d d i l• Background and Rationale
• Method ‐ Systematic Review
• Intervention• Intervention
– Level of Care Utilization System (AACP, 1996)
– Implementationp
• Next steps
• Challenges and Lessons learned
Level of Care Assessment Measures
Problemh dd d l ll f l• Persons with severe addiction and mental illness frequently
cycle between health, social, and criminal justice agencies with little therapeutic benefit and considerable health, social, pand economic costs.
Police
Emergency Departments
Courts/Jails
ForensicsHomeless Shelters
Level of Care Assessment Measures• 40% of homeless mentally ill in Vancouver have had contact with FPSC
(Nijdam‐Jones, Nicholls, Crocker, & Roy, under review)
Context• In order to provide for the immediate and long‐term health
needs of seriously addicted and mentally ill individuals in BC, PHSA was given responsibility to develop a provincial model forPHSA was given responsibility to develop a provincial model for clinical pathways that articulates a continuum of care.
Emergency DepartmentsEmergency Departments
Acute and longer term stabilization & treatment unitstreatment units
Tertiary beds
Boarding homes
Level of Care Assessment Measures
Community ACT & mental health teams
Challenge
h b f d di d i• In the absence of standardized assessment or systematic evaluations it is difficult to identify which individuals are appropriate for these services and to develop an appropriate pp p p pp ptreatment plan (e.g., Webster, Martin, Brink, Nicholls, & Desmarais, 2004)
• In December 2013, a Clinical Leadership Group recommended the implementation of an assessment tool to guide placementthe implementation of an assessment tool to guide placement decisions along this continuum based on level of risk and need.
• >40 years of research demonstrates the value of integrating systematic, structured measures to defend against the limitations of human decision making
Level of Care Assessment Measures
structured measures to defend against the limitations of human decision making
Measurement
S i i d k• Systematic review was undertaken (Nicholls, Chu, & Brink, under review):
1. Identify measures that can inform level of care decisions
2. That are appropriate for use with seriously mentally ill and substance involved individuals with complex behavioural challengesbehavioural challenges
3. Review the quality of available measures
4. Suitability for use in EDs across BC health authoritiesy
Level of Care Assessment Measures
MethodsMethods
Database Search termsAll
resultsResults relevant to inclusion criteria
Experts / Citations Vancouver Coastal Health LOCUS 1 1Experts / Citations Vancouver Coastal Health - LOCUS 1 1RVH Review MacFarlane et al. - CCAR 1 1References for LOCUS- TRAG 1 1
Phone calls w authors TRAG authors - ANSA 1 1PsycINFO Triag* & psychiatr* & ER 38 1PsycINFO Triag* & psychiatr* & ER 38 1
Decision making & emergency department & psychiatr* 32 0Triag* & psychiatr* & level of care 5 1Level of care & decision making & psychiatr* 13 0
Medline T i * & hi t * & ER 10 0Medline Triag* & psychiatr* & ER 10 0Decision making & emergency department & psychiatr* 37 0Triag* & psychiatr* & decision making 16 1Triag* & psychiatr* & emergency room 97 0
Google Scholar Decision making & le el of care & mental health 0 1Google Scholar Decision making & level of care & mental health 0 1
TOTAL measures 8
Level of Care Assessment Measures
ResultsResults
• Our review identified eight tools: • six were quickly eliminated:
(1) RAI‐MH: does not satisfy our objectives (e.g., too comprehensive, lacked decision‐making supports for bed utilization and level of care in emergency psychiatric services)(2) i RAI ESP i l (li l i f dil il bl )(2) interRAI ESP: very new; commercial (little info readily available)(3) CCAR: authors advise not appropriate for EDs; up to 45 mins(4) CTRS: published 1984; little information; little uptake (5) MHTRS: single table for tx acuity (mins‐hrs to triage in ED)(6) TRAG: the Texas workgroup who developed this are now using ANSA
Level of Care Assessment Measures
• Two remaining measures: ANSA and LOCUS
Methods:Hierarchical
Empowering:Allows client and significant others to participate
dcriterion based
Person‐centred:Needs translate to services
Scientifically scrutinized: S d h i li bl lid i d bli i
analysisSound psychometrics: reliable, valid; peer reviewed publications
Quantifiable:Enhances communication
Flexible:Flexible:Adaptable in application; relevant across contexts
Comprehensive:Functioning (psychiatric/physical) risk recoveryFunctioning (psychiatric/physical), risk, recovery
Relevant: Explicitly informs needs; level of care/bed; placement pathway
Evidence‐informed:Evidence informed: Development reflects consideration of research literature
Efficient: Appropriately comprehensive, but brief; cost effective
Level of Care Assessment Measures
Appropriately comprehensive, but brief; cost effective
Suitable to ED:Concise < 15 mins; easy to use; doesn’t require extensive training
Results: LOCUSL l f C Utili ti S t
B k d
Level of Care Utilization System
Background• Developed by a task force of the American Association
f C it P hi t i t (AACP)of Community Psychiatrists (AACP) • following a 1995 review of existing patient placement practices & clinical experiences (Sowers et al., 2003).
• Released for field testing in May of 1996 (AACP, 1996; Sowers et al., 1999)
• Subsequently revised (AACP 1999 2009)Subsequently revised (AACP, 1999, 2009).
Level of Care Assessment Measures
Results: LOCUSLevel of Care Utilization System
Objectives• The LOCUS is used to translate an individual’s service needs
into a level of care
• Designed with 3 objectives in mind:1 Provide a system for assessment of service needs for adult clients1. Provide a system for assessment of service needs for adult clients,
based on six evaluation parameters;
2. Outline the spectrum of available services into six categories, taking into account available resources at each service level;into account available resources at each service level;
3. Offer a means of quantifying services in order to aid in appropriate placement determinations.
(AACP 2009)
Level of Care Assessment Measures
(AACP, 2009)
Results: LOCUS
Description
Level of Care Utilization System
Description
• A dynamic tool; repeated as needs change
• Six dimensions1. risk of harm (to self and others)
2. functional status
3. medical, addictive, and psychiatric co‐morbidity
4. recovery environment
a. level of stress
b. level of support
5 treatment and recovery history5. treatment and recovery history
• Each of these dimensions is rated on a five‐point scale
Level of Care Assessment Measures
S i• Scoring:
• ‐ Scores range 7 ‐35 • ‐ correspond to a level
of care recommendation
• ‐ However, manual allows for clinical over‐ridesrides • due to ambiguities
about extent to which a client
Level of Care Assessment Measures
might meet criteria
LOCUS Implementation
BCMHSUS developingTraining by LOCUS team to create HA knowledge experts
S t b 2014
BCMHSUS developing online training package for sustainability
Case studies adapted for BC and population
relevanceJ 2015September 2014
Winter 2014January 2015
Level of Care Assessment Measures
LOCUS Evaluation
Background
PHSA established a continuum of care with a primary goal to evaluate the extent toPHSA established a continuum of care with a primary goal to evaluate the extent to which the new beds are fulfilling their intended purpose by evaluating the effect of
the new SAMI beds on these health and safety outcomes.
Population & Pathway
Risk & Trajectories
Clinical & Psychosocial
Community Reintegration
(e.g., mental health and substance use
history, /
j(e.g. severity of crime, violence,
suicide,
yOutcomes
(e.g., psychiatric sx, cognitive
(e.g., transinstitutionaliz‐ation of health,
victimization/ trauma, crime)
victimization) functioning, quality of life)
social, and criminal justice agencies)
Level of Care Assessment Measures
Evaluation Design
Months0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Baseline Assessment Follow up 1 Follow up 2 Follow up 3 Follow up 4
Level of Care Assessment Measures
Challenges and L L d
• Handful of measures have promise
Lessons Learned
Handful of measures have promise • (ANSA‐A; LOCUS; interRAI ESP: Emergency Screener Psychiatry)
• No perfect measure that satisfies all criteria • lack of validation studies; particularly research of relevance to:
• EDs • population of concern (complex behavioral challenges –• population of concern (complex behavioral challenges violence, crime, suicide, persistent MI, substance abuse, homelessness)
• Canadian context• Canadian context
• LOCUS best fit using hierarchical criterion decision making
Level of Care Assessment Measures
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