Clinical outcomes in mental health rehabilitation services

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1 Clinical outcomes in mental health rehabilitation services Dr Helen Killaspy Reader in Rehabilitation Psychiatry, UCL Chair, Faculty of Rehabilitation and Social Psychiatry, RCPsych

2 Outcomes, process and quality Policy assumes a positive association between service quality and clinical outcome (an assumption supported by very little evidence) Conflation of terms: Outcome - e.g. symptoms, length of admission, number (%) people readmitted, number (%) people re/gaining employment Process inputs e.g. number (%) people offered a physical health check, or a specific intervention (e.g. CBT) Quality - can include process and outcomes; includes experiences of/satisfaction with service

3 No health without mental health; a cross Government mental health outcomes strategy for people of all ages (DH, 2011) More people will have good mental health (outcome) More people with mental health problems will recover (outcome) More people with mental health problems will have good physical health (outcome) More people will have a positive experience of care and support (process) Fewer people will suffer avoidable harm (process) Fewer people will experience stigma and discrimination (process and outcome)

4 Principles when choosing outcome indicators and measures Data need to be: Available Collectable (brief measures, ideally free of copyright restrictions and fees) Meaningful (measures need to have good psychometric properties validity/reliability/sensitivity to change) Collatable (by data management systems that work!) Interpretable (by clinicians as well as performance depts) Useful at group and individual level Formattable so that results can be fed back in accessible form to staff and service users

5 Outcome indicators for PbR Likely to be recommended: Proportion of service users in each cluster who are on CPA p Proportion of service users on CPA who have had a review in the last 12 months p Proportion of service users with a crisis plan (limited to those on CPA) p Accommodation status (indicators of settled status and accommodation problems) o Intensity of care (bed days as a proportion of care days) p and o Completeness of ethnicity recording p Proportion of service users who have a valid ICD10 diagnosis recorded p Under consideration: Readmissions o Employment status o Duration of Untreated Psychosis p Waiting times p Delayed discharge p Admission rate p and o Average length of stay p

6 Outcome tools under consideration for PbR Clinician Reported Outcome Measure (CROM): HoNOS/Mental Health Clustering Tool For each cluster an assessment of statistically significant difference in rating between referral and review (or discharge) will be established using a total and 4 factor score % of service users that meet the criteria for improvement/deterioration Patient Reported Outcome Measure (PROM): Warwick & Edinburgh Mental Health Well Being Scale (7 item) Patient Reported Experience Measure (PREM): CQC service user survey questions (plus specific questions on Recovery) - Did you feel carefully listened to the last time you saw your NHS healthcare worker? - Do you have a telephone number to contact your mental health service out of hours? - Do you think your views were taken into account when deciding what was in your care plan? - How likely are you to recommend our services to friends and family if they needed similar care or treatment? (Likert scale 1-5)

7 The Warwick-Edinburgh Mental Well-being Scale (WEMWBS) Below are some statements about feelings and thoughts. Please tick the box that best describes your experience of each over the last 2 weeks. STATEMENTS None of the time Rarely Some of the time Often All of the time I ve been feeling optimistic about the future I ve been feeling useful I ve been feeling relaxed I ve been dealing with problems well I ve been thinking clearly I ve been feeling close to other people I ve been able to make up my own mind about things NHS Health Scotland, University of Warwick and University of Edinburgh, 2006, all rights reserved.

8 What might be a meaningful outcome in mental health rehabilitation? Improved symptoms? Improved functioning? Reduced challenging behaviours? Greater autonomy? Reduced admission length? Reduced readmissions? Fewer community placement breakdowns? Better quality of life? Better housing? Greater social inclusion? Better relationships? Engagement in activities/occupation? Better physical health?

9 Mental health rehabilitation services: indicators Number of admissions/discharges p Average length of stay (different for different components of rehab care pathway e.g. Low Secure Unit, High Dependency Unit, Community Rehabilitation Unit, Complex Care Unit) p and o Number of readmissions o Number (%) SUs who achieve successful (sustained) moveon to more independent settings o 65% will move on successfully over five years 10% will achieve independent living over 5 years (Killaspy et al., 2012) Number (%) and cost of out of area placements p Number (%) SUs participating in work, education, leisure o Number adverse/risk events p and o

10 Recommended outcome measures for mental health rehabilitation 42% of mental health rehabilitation units in England use standardised measures in their assessment process and 89% used them routinely after admission Wide range of tools used Faculty of Rehabilitation and Social Psychiatry recommend: HoNOS (multidimensional includes symptoms) CANSAS (needs) LSP and SFQ (social functioning) Recovery Star Quality Indicator for Rehabilitative Care (QuIRC)

11 Camberwell Assessment of Need Short Appraisal Scale Phelan et al., (1995) BJP, 167: ; Slade et al., (1996). SPPE, 31: Slade et al., (1998) Psych Med, 28: Assesses 22 domains 0=no problem (no need) 1=no/moderate problem due to help given (met need) 2=serious problem regardless of whether help given (unmet need) Staff, SU and carer versions available Good inter-rater reliability Clinicians do not need specific training Takes about 10 minutes Change in proportion of met: unmet needs over time gives a measure of service s performance Useful for care planning Food/diet Psychotic symptoms Accommodation Psychological distress Looking after the home Self-care Daytime activities Finances/budgeting Physical health Information about mh problems Safety to others Safety to self Company Welfare benefits Alcohol Substances Transport Relationships Sexual expression Literacy/numeracy/language Child care Telephone

12 Needs: CANSAS (Killaspy et al. Mental health needs of clients of rehabilitation services: a survey in one Trust. J. Men Health, 2008, 17: ) Mean Total N=141 High dependency inpatient unit n=27 Community rehabilitation unit n=44 Community residential care home n=50 Complex care inpatient unit n=20 Total needs Met needs Unmet needs

13 Social Function Questionnaire (Clifford and Morrison - unpublished) 40 items assess 5 domains: Self care Domestic skills Community skills Social skills Responsibility Each domain and overall score expressed as a mean: Developed for rehabilitation service users Already used routinely in some services Staff rated Do not need specific training Takes about 15 minutes Useful for care planning Good psychometrics

14 Social functioning: Life Skills Profile (Killaspy et al. Mental health needs of clients of rehabilitation services: a survey in one Trust. J. Men Health, 2008, 17: ) Total N=141 High dependency inpatient unit n=27 Community rehabilitation unit n=44 Community residential care home n=50 Complex care inpatient unit n=20 p (complex care vs other groups) Self care Mean (SD) 28 (6.0) 29 (5.9) 30 (5.6) 28 (7.0) 24 (5.0) Non turbulence Mean (SD) 41 (6.0) 40 (5.8) 41 (6.2) 41 (5.0) 38 (5.8) Social contact Mean (SD) 15 (4.0) 15 (3.5) 14 (4.0) 16 (4.4) 14 (3.2) Communication Mean (SD) 19 (3.0) 20 (3.0) 20 (3.1) 20 (3.0) 18 (3.3) Responsibility Mean (SD) 16 (3.0) 17 (2.9) 17 (2.5) 16 (3.3) 14 (3.0) <0.000 Total score Mean (SD) 120 (16.0) 121 (14.4) 122 (15.2) 121 (15.6) 108 (16) <0.001

15 Mental Health Recovery Star

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19 Summary Assessment of service quality and performance includes measures of process and clinical outcome As well as mandated outcomes and indicators, choose 1 or 2 further measures that are specific to specialty (process, outcome, quality) and conform to the ideal in terms of psychometrics, feasibility and usefulness Ensure clarity about processes for data collection, collation and reporting at organisation, service and team level (what, when, by whom) Ensure systems in place for regular feedback of data to clinicians and service users

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