Needs-based planning: evaluation of a level-of-care planning model

Rural citizen-patient priorities for healthcare in British Columbia, Canada: findings from a mixed methods study

BACKGROUND

The challenge of including citizen-patient voices in healthcare planning is exacerbated in rural communities by regional variation in priorities and a historical lack of attention to rural healthcare needs. This paper aims to address this deficit by presenting findings from a mixed methods study to understand rural patient and community priorities for healthcare.

METHODS

We conducted a provincial survey of rural citizens-patients across British Columbia, Canada to understand their most pressing healthcare needs, supplemented by semi-structured interviews. Survey and interview participants were asked to articulate, in their own words, their communities' most pressing healthcare needs, to explain the importance of these priorities to their communities, and to offer possible solutions to address these challenges. Open-text survey responses and interview data were analyzed thematically to elicit priorities of the data and their significance to answer the research questions.

RESULTS

We received 1,287 survey responses from rural citizens-patients across BC, 1,158 of which were considered complete. We conducted nine telephone interviews with rural citizens-patients. Participants stressed the importance of local access to care, including emergency services, maternity care, seniors care, specialist services and mental health and substance use care. A lack of access to primary care services was the most pronounced gap. Inadequate local health services presented geographic, financial and social barriers to accessing care, led to feelings of vulnerability among rural patients, resulted in treatment avoidance, and deterred community growth.

CONCLUSIONS

Two essential prongs of an integration framework for the inclusion of citizen-patient voices in healthcare planning include merging patient priorities with population needs and system-embedded accountability for the inclusion of patient and community priorities.

Expanding the use of the ASAM CriteriaTM to make mental health level of care placements

Purpose

Despite the prevalence of co-occurring mental health and substance use disorders, the assessment and placement processes for each often remain separate. The purpose of this paper is to describe an expanded use of the American Society of Addiction Medicine (ASAM) CriteriaTM to make placements into substance use, co-occurring, and mental health treatment.

Design/methodology/approach

A rationale for the development of two new domains (Domain 7, substance use and Domain 8, independent living skills) and preliminary data supporting the use of the ASAM CriteriaTM as a placement process for all types of behavioral health issues will be provided.

Findings

Dimension 3 and Domains 7 and 8 were correlated with selected clinical indices in the expected direction (Dimension 3: depression (F (4, 4650)=202.092, p<0.001), medication usage (F (4, 4,637)=174.254, p<0.001), and psychotic symptoms (F (4, 4,561)=62.954, p<0.001); Domain 7: alcohol use (F (4, 4,458)=213.786, p<0.001) and drug use (F (4, 4,471)=611.491, p<0.001); and Domain 8: functional impairment (F (4, 3,927)=815.646, p<0.001) and number of “high needs” (F (4, 3,927)=737.568, p<0.001).

Research limitations/implications

The limitations of this research included a lack of inter-rater reliability data and less established intake assessments.

Practical implications

This single placement approach for clients seeking behavioral health services can create a more efficient, person-centered intake experience.

Originality/value

This paper suggests that it is possible to deploy a single assessment and placement approach for all types of behavioral health issues.

Supported accommodation for people with severe mental illness: a review

The authors describe the main forms of supported accommodation available to people with mental health problems in the UK. They address the questions of who needs supported accommodation and how people may be selected for the differing types of unit. Historical trends and policy in this area are reviewed and the general research evidence and evidence of cost-effectiveness are considered. A ‘total system’ approach to assessing accommodation need in a locality is advocated. The authors also consider key quality issues that should be addressed for supported accommodation to be effective.

Applying a Bauhaus design approach to conceptualize an integrated system of mental health care: Lessons from a large urban hospital

We have applied a Bauhaus design lens to inform a visual conceptual framework for a rational mental health care system. We believe that Canada’s healthcare system can often be fragmented and does not always allow for service delivery to easily meet patient care needs. Within our proposed framework, the form of services provided follows patient- and healthcare-centred needs. The framework is also informed by the ethics and values of social responsibility, population health, and principles of quality of care. We review evidence for this framework (based on need, acuity, risk, service intensity, and provider level) and describe patient care pathways from intake/triage to three patient-centred tiers of care: (1) primary care (low needs), (2) acute ambulatory transitional care (moderate needs), and (3) acute hospital and complex care (high needs). Within each tier, various models of care are organized from low to high service intensity as informed by reports from the British Columbia Ministry of Health and the World Health Organization. We hope that our model may help to better conceptualize and organize our mental health care system and help providers clarify roles, responsibilities, and accountabilities to improve quality of care.

Prevalence of housing needs among inpatients: a 1 year audit of housing needs in the acute mental health unit in Tallaght Hospital

OBJECTIVE

There is a dearth of information relating to the prevalence of housing needs among psychiatric in-patients in Ireland. Most of the information we have to date emerged as a result of attempts to plan for the closure of old psychiatric hospitals and inappropriate community residences. This study sought to identify the prevalence of housing needs among in-patients in the acute psychiatric unit in Tallaght Hospital.

METHODS

Each week, over a 12-month period, nursing managers and/or key nurses who knew the patients well were asked for numerical data. Information was collected on the numbers of in-patients with accommodation needs, number of delayed discharges due to accommodation needs and number of discharges to homeless accommodation in the previous week.

RESULTS

On average, 38% of in-patients had accommodation related needs at any one time. Most (98%) of delayed discharges had accommodation related needs. Delayed discharge in-patients with accommodation needs accounted for 28% of all inpatients and for 72% of all inpatients with accommodation related needs.

CONCLUSIONS

Accommodation need among psychiatric in-patients is underreported. Housing need data should be routinely collected and effective interagency strategies developed to address housing needs.

The Use of the Addiction Severity Index Psychiatric Composite Scores to Predict Psychiatric Inpatient Admissions

The high prevalence of co-occurring mental health and substance use disorders indicates a need for integrated behavioral health treatment that addresses both types of disorder simultaneously. One component of this integrated treatment is the use of an assessment process that can concurrently identify the presence of each class of disorder. The Addiction Severity Index (ASI) has been extensively used and researched in the field of substance use disorders for over 30 years. The ASI has seven sections, including a section on substance use disorders and a section on psychiatric symptoms, making it a potential candidate for a co-occurring screen during intake. The following study utilized a receiver operating characteristic curve analysis to determine an optimal cutoff score on the ASI psychiatric composite score to identify which individuals seeking substance use disorder treatment were admitted to the Milwaukee County Behavioral Health Division's psychiatric hospital in the year subsequent to their ASI administration. Of the 19,320 individuals who completed an initial ASI in our system, 343 had an inpatient admission. The receiver operating characteristic curve was statistically significant, with an area under the curve of 0.75. A cutoff of 0.27 had a sensitivity of 0.77 and a specificity of 0.61, such that over 60% (11,963/19,320) of the sample was excluded. These results suggest that the ASI psychiatric composite score may be a useful initial screen to identify those with potential mental health problems/needs in a behavioral health system attempting to integrate addiction and mental health services.

Potential Effects of the Choice of Costing Perspective on Cost Estimates: An Example Based on 6 Early Psychosis Intervention Programs

OBJECTIVE

Because health care resources are constrained, decision-making processes often require clarifying the potential costs and savings associated with different options. This involves calculating a program's costs. The chosen costing perspective defines the costs to be considered and can ultimately influence decisions. Yet reviews of the literature suggest little attention has been paid to the perspective in economic evaluations. This article's purpose is to explore how the costing perspective can affect cost estimates.

METHOD

As a vehicle for our discussion, we use service use data for clients enrolled in 6 Ontario early psychosis intervention programs. Governmental and nongovernmental payer costing perspectives are considered. We examine annual costs associated with early psychosis intervention clients enrolled for ≤12 months versus those enrolled for >12 months. This also allows for an assessment of the impact that choice of time horizon can make on the results.

RESULTS

The difference in total between group cost for hospital, emergency room, and physicians is $2499; the >12-month group has relatively higher mean costs. When all governmental and nongovernmental costs are considered, there is a mean between-group cost difference of $1272, with lower mean costs for the >12-month group.

CONCLUSIONS

Although the Ministry of Health bears a large proportion of costs, other governmental agencies and the private sector can incur a sizeable share. This example demonstrates the potential importance of including other cost perspectives with the hospital sector in analyses as well as the impact of time horizon on cost estimates.

Cognition and the prediction of functioning in patients with a first treated episode of psychosis: a prospective study

Past research on the role of cognitive performance in predicting later psychosocial functioning for individuals with first treated episode of a psychotic disorder has yielded inconsistent results. Several factors have been suggested as determining the strength of any such relationship including the type of functioning measured, time of the cognitive assessment, covariates included and the use of global versus specific measures of cognitive functioning. In the current study, we examined the importance of these factors in a five year prospective study of individuals with first episode psychotic disorders. Just over 80% of the sample had a schizophrenia spectrum disorder. Cognitive assessments were carried out after initiation of treatment on 113 patients, and at one year for 79 patients. There was evidence that cognition predicted occupational functioning and use of a disability pension, but not a summary index of functioning or use of supervised housing, at follow-up. Overall I.Q. was a more consistent predictor than measures of specific cognitive functions, and there was evidence that cognition assessed after presentation for treatment, particularly after a year of treatment, was more predictive of later functioning than premorbid I.Q. Cognitive functioning, however, did not add to the prediction of outcomes beyond the level possible using past educational achievement or academic premorbid adjustment.

Distinctive trajectory groups of mental health functioning among assertive community treatment clients: an application of growth mixture modelling analysis

OBJECTIVE

Assertive community treatment (ACT) studies that have used conventional, statistical growth modelling methods have not examined different trajectories of outcomes or covariates that could influence different trajectories, even though heterogeneity in outcomes has been established in other research on severe mental illness. The purpose of our study was to examine the general trend in mental health functioning of ACT clients over a 2-year follow-up time period, to discover groups of ACT clients with distinctive longitudinal trajectories of mental health functioning, and to examine if some of the key sociodemographic and illness-related factors influence group membership.

METHOD

A 2-year, prospective, within-subjects study of 216 ACT clients within southern Ontario, collected functional outcome data at baseline and 12 and 24 months using the Colorado Client Assessment Record. Baseline covariates included sex, primary diagnosis, number of comorbidities, hospitalization history, and duration of illness. Growth mixture modelling (GMM) was used to examine trajectories.

RESULTS

Clinical staff assessments of ACT clients showed a statistically significant improvement in functioning and 84% achieved successful community tenure. GMM analysis identified 2 classes of ACT clients: class 1 (79.63% of clients) experienced lower and stable overall functioning, and class 2 (20.37%) showed a better baseline functioning score and improvement in the overall functioning over time. Class membership was predicted by the number of comorbidities and diagnosis.

CONCLUSIONS

Our study suggests general stability in overall functioning for the sampled ACT clients over 2 years, but significant heterogeneity in trajectories of functioning.

Patterns of out-of-home placement decision-making in child welfare

Out-of-home placement decision-making in child welfare is founded on the best interest of the child in the least restrictive setting. After a child is removed from home, however, little is known about the mechanism of placement decision-making. This study aims to systematically examine the patterns of out-of-home placement decisions made in a state's child welfare system by comparing two models of placement decision-making: a multidisciplinary team decision-making model and a clinically based decision support algorithm. Based on records of 7816 placement decisions representing 6096 children over a 4-year period, hierarchical log-linear modeling characterized concordance or agreement, and discordance or disagreement when comparing the two models and accounting for age-appropriate placement options. Children aged below 16 had an overall concordance rate of 55.7%, most apparent in the least restrictive (20.4%) and the most restrictive placement (18.4%). Older youth showed greater discordant distributions (62.9%). Log-linear analysis confirmed the overall robustness of concordance (odd ratios [ORs] range: 2.9-442.0), though discordance was most evident from small deviations from the decision support algorithm, such as one-level under-placement in group home (OR=5.3) and one-level over-placement in residential treatment center (OR=4.8). Concordance should be further explored using child-level clinical and placement stability outcomes. Discordance might be explained by dynamic factors such as availability of placements, caregiver preferences, or policy changes and could be justified by positive child-level outcomes. Empirical placement decision-making is critical to a child's journey in child welfare and should be continuously improved to effect positive child welfare outcomes.

The association between income source and met need among community mental health service users in Ontario, Canada

We examined income source and match between recommended and received care among users of community mental health services. We conducted a secondary analysis of needs-based planning data on adults in Ontario community mental health programs from 2000 to 2002. The outcome was whether clients were severely underserved (yes/no) based on the match between level of care recommended and received. A logistic regression model investigated if income source predicted this outcome. 13% of clients were severely underserved. Over 40% were on public assistance and they had a higher risk of being severely undeserved than the others. Men were at greater risk. One aim of mental health reform is to increase access to care for vulnerable individuals. The finding that among users of community mental health services, individuals with public assistance income support are most vulnerable to being severely underserved should be considered by service planners and providers.

Examining the Effects of Enhanced Funding for Specialized Community Mental Health Programs on Continuity of Care

In this paper we examine the changes in continuity of care (CoC) likely to be affected by new system investments and the contributing factors. A mixed method approach was used. Decision-makers participated in two rounds of qualitative interviews. A 3-year cross-sectional quantitative data collection approach was used with clients and case managers. A main finding was that new system investments can improve CoC in terms of increased care access. However, it is not clear how other CoC dimensions will be affected. New funding can also have negative consequences related to the service models in which investments are made.

Gender differences in psychiatric diagnoses among inpatients with and without intellectual disabilities

There are few published studies on the relationship between gender and psychiatric disorders in individuals with intellectual disabilities. Adults (N = 1,971) with and without intellectual disabilities who received inpatient services for psychiatric diagnosis and clinical issues were examined. Among individuals with intellectual disabilities, women were more likely to have a diagnosis of mood disorder and sexual abuse history; men were more likely to have a substance abuse diagnosis, legal issues, and past destructive behavior. Gender difference patterns found for individuals with intellectual disabilities were similar to those of persons without intellectual disabilities, with the exception of eating disorder and psychotic disorder diagnoses. Gender issues should receive greater attention in intellectual disabilities inpatient care.

Prevalence and profile of people with co-occurring mental and substance use disorders within a comprehensive mental health system

OBJECTIVE

To examine the prevalence and profile of people with co-occurring mental and substance use disorders in relation to numerous demographic, diagnostic, and needs-related variables across a comprehensive system of mental health services using a standard methodology.

METHOD

Data were collected on cases (n = 9839) sampled from specialty tertiary inpatient, specialty outpatient, and community-based mental health programs. Status with respect to co-occurring disorders was based on recorded diagnosis of substance use disorder and the substance abuse measure within the Colorado Client Assessment Record. The demographic and needs profile was compared across groups with or without co-occurring disorders within each level of care.

RESULTS

Overall, the prevalence of co-occurring disorders was 18.5%, and highest among clients receiving specialty tertiary inpatient care (28%), and within selected subpopulations such as younger adults (55%) and those with personality disorders (34%). There were few differences between groups based on co-occurring disorders in the specialty inpatient programs. For outpatient and community settings, the clients with co-occurring disorders were distinguished by a more impaired and complex needs profile and more likely to be young, single, male, and of low education. Across all levels of care, having a co-occurring disorder was strongly associated with antisocial and challenging behaviour, legal involvement, and risk of suicide or self-harm.

CONCLUSION

The prevalence estimate of co-occurring disorders is likely representative of a multilevel system of care that serves a large, mixed urban and rural population. Results highlight the need to focus on specific subpopulations and sectors in pursuit of more integrated treatment and support for their mental health and addictions problems.

A comparison of patients with intellectual disability receiving specialised and general services in Ontario's psychiatric hospitals

BACKGROUND

Over the years, the closure of institutions has meant that individuals with intellectual disabilities (IDs) must access mainstream (i.e. general) mental health services. However, concern that general services may not adequately meet the needs of patients with ID and mental illness has led to the development and implementation of more specialised programmes. This study compares patients with ID receiving specialised services to patients with ID receiving general services in Ontario's tertiary mental healthcare system in terms of demographics, symptom profile, strengths and resources and clinical service needs.

METHOD

A secondary analysis of Colorado Client Assessment Record data collected from all tertiary psychiatric hospitals in the province was completed for all 371 inpatients with ID, from both specialised and general programmes.

RESULTS

Inpatients in specialised programmes were more likely to have a diagnosis of mood disorder and were less likely to have a substance abuse or psychotic disorder. Individuals receiving specialised services had higher ratings of challenging behaviour than those in more general programmes. The two groups did not differ significantly in terms of recommended level of care, although more inpatients from specialised programmes were rated as requiring Level 4 care than inpatients from general programmes.

CONCLUSIONS

In Ontario, inpatients in specialised and general programmes have similar overall levels of need but unique clinical profiles that should be taken into consideration when designing interventions for them.

Findings from A Comparison of Mental Health Services in Primary Care and Outpatient Mental Health Services

This project used the Colorado Client Assessment Record to compare individuals being seen by mental health teams in primary care with individuals being seen in outpatient services in the same community and to look at the implications for service delivery. While more individuals with a psychotic illness were seen in outpatient settings, many individuals seen in primary care had similar levels of need to those in outpatient clinics. Family physicians were more actively involved in the care of patients being seen in primary care. These findings suggest that a stronger role could be played by primary care in delivering mental health care, while differentiating which populations are best served in which setting.

A Population-based Needs Assessment for Mental Health Services

A needs assessment was done to objectively evaluate client need and determine gaps between these needs and the services provided by mental health services. The services included were standard case management, assertive case management and residential care across the Fraser Health Region in British Columbia, Canada. Assessments involved collection of data on current symptoms, functioning, and service use and needs. Results showed many specific areas where client needs were under met. A level-of-care planning model was applied to the data and results suggest that a high percentage of clients may be in fact receiving too high or too low a level of care for their needs. This method of performing a population-based needs assessment provided findings that have proved useful for planning purposes in order to ensure that community mental health services better match client need.

A service system planning model for individuals with serious mental illness

An institutional-based care system in mental health has been replaced by a network of community-based services with different levels of structure and support. This poses both an opportunity and a challenge to provide appropriate and effective care to persons with serious mental illnesses. This paper describes a simulation-based approach for mental health system planning, focused on hospital and residential service components that can be used as a decision support tool. A key feature of this approach is the ability to represent the current service configuration of psychiatric care and the client flow pattern within that framework. The strength of the simulation model is to help mental health service managers and planners visualize the interconnected nature of client flow in their mental health system and understand possible impacts of changes in arrival rates, service times, and bed capacity on overall system performance. The planning model will assist state mental health agencies to respond to requirements of the Olmstead decision to ensure that individuals with serious mental illness receive care in the least restrictive setting. Future plans for refining the model and its application to other service systems is discussed.

Consulting as a strategy for knowledge transfer

Academic researchers who work on health policy and health services are expected to transfer knowledge to decision makers. Decision makers often do not, however, regard academics' traditional ways of doing research and disseminating their findings as relevant or useful. This article argues that consulting can be a strategy for transferring knowledge between researchers and decision makers and is effective at promoting the "enlightenment" and "interactive" models of knowledge use. Based on three case studies, it develops a model of knowledge transfer-focused consulting that consists of six stages and four types of work. Finally, the article explores how knowledge is generated in consulting and identifies several classes of factors facilitating its use by decision makers.

Continuity of care: validation of a new self-report measure for individuals using mental health services

Continuity of care is a concern for individuals with persistent mental illness who need diverse services over time in response to multiple and changing needs. Efforts to study continuity have been hampered by lack of appropriate instruments. The Alberta Continuity of Services Scale--Mental Health is a newly developed, self-report scale that assesses continuity of care across settings and providers. This study examined the structure, reliability, and validity of the measure among users of community mental health programs. Findings were positive. Scores captured both positive and negative perceptions of care. Factor analyses elucidated 3 components of continuity--system access, interpersonal aspects, and care team function. Associations between the continuity scores and selected client and service use measures supported its validity. The tool holds promise for system monitoring, but would need refinements to create a shorter, conceptually clearer version. Also, performance among individuals with mild and very severe levels of mental illness needs to be evaluated.

Mental health program monitoring: towards simplifying a complex task

Finding measures that can assess areas of expected program impact, provide valid results, and be easily integrated into routine program practices is a significant challenge. This paper is intended to assist program staff by providing an accessible inventory of measures appropriate for routine monitoring of the status and outcome of individuals using mental health outpatient and community programs. The inventory is not exhaustive, but rather includes examples of solid measures for assessing outcomes in four key domains--symptoms, functioning, quality of life, and satisfaction. These can provide a core of information, to which measurement of more in-depth issues can be added to address specific concerns.