Real-world evaluation of the Resident Assessment Instrument-Mental Health assessment system

Primary care for individuals with serious mental illness (PriSMI): protocol for a convergent mixed methods study

INTRODUCTION

People with serious mental illness (SMI) have poor health outcomes, in part because of inequitable access to quality health services. Primary care is well suited to coordinate and manage care for this population; however, providers may feel ill-equipped to do so and patients may not have the support and resources required to coordinate their care. We lack a strong understanding of prevention and management of chronic disease in primary care among people with SMI as well as the context-specific barriers that exist at the patient, provider and system levels. This mixed methods study will answer three research questions: (1) How do primary care services received by people living with SMI differ from those received by the general population? (2) What are the experiences of people with SMI in accessing and receiving chronic disease prevention and management in primary care? (3) What are the experiences of primary care providers in caring for individuals with SMI?

METHODS AND ANALYSIS

We will conduct a concurrent mixed methods study in Ontario and British Columbia, Canada, including quantitative analyses of linked administrative data and in-depth qualitative interviews with people living with SMI and primary care providers. By comparing across two provinces, each with varying degrees of mental health service investment and different primary care models, results will shed light on individual and system-level factors that facilitate or impede quality preventive and chronic disease care for people with SMI in the primary care setting.

ETHICS AND DISSEMINATION

This study was approved by the University of Ottawa Research Ethics Board and partner institutions. An integrated knowledge translation approach brings together researchers, providers, policymakers, decision-makers, patient and caregiver partners and knowledge users. Working with this team, we will develop policy-relevant recommendations for improvements to primary care systems that will better support providers and reduce health inequities.

A Predictive Model for Estimating Risk of Harm and Aggression in Inpatient Mental Health Clinics

Serious mental illness is a major risk factor for aggression and violence. The present study aimed to develop and test an algorithm to predict inpatient aggressions that involve a risk of harm to self or others. This work is based on a retrospective study aimed to investigate the prediction of risk of harm and aggressions at St. Joseph's Healthcare Hamilton, between 2016 and 2017. An analysis of the risk factors most strongly associated with harmful incidents is, followed by the description of the process involved in the development of a predictive model which estimates the risk of harm. The efficiency of the model developed is finally evaluated, showing an overall accuracy of 75%: the specificity to identify episodes considered not at risk of harm is equal to 91.85%, whereas the sensitivity to identify episodes considered harmful is equal to 28.57%. The model proposed can be seen as a seminal project towards the development of a more comprehensive, precise and effective tool capable to predict the risk of harm in the inpatient setting.

An Examination of the Performance of the interRAI Risk of Harm to Others Clinical Assessment Protocol (RHO CAP) in Inpatient Mental Health Settings

We study violence risk prediction at St. Joseph's Healthcare Hamilton. Data from January 2016 to December 2017 have been anonymized and collected, for a total of 870 episodes of inpatient aggressions perpetrated by 337 patients. We examine the predictive performance of a clinical indicator embedded in a mandatory assessment tool for psychiatric facilities in Ontario, the Resident Assessment Instrument for Mental Health (RAI-MH): the Risk of Harm to Others Clinical Assessment Protocol (RHO CAP). The RHO CAP's performance is studied among two groups of patients. Moreover, an analysis of the most important risk factors associated with harmful incidents is presented. The RHO CAP has demonstrated a better performance in discriminating which patients were more at risk to commit some type of aggression than at identifying the risk of harm among those who will commit aggression.

The interRAI Suite of Mental Health Assessment Instruments: An Integrated System for the Continuum of Care

The lives of persons living with mental illness are affected by psychological, biological, social, economic, and environmental factors over the life course. It is therefore unlikely that simple preventive strategies, clinical treatments, therapeutic interventions, or policy options will succeed as singular solutions for the challenges of mental illness. Persons living with mental illness receive services and supports in multiple settings across the health care continuum that are often fragmented, uncoordinated, and inadequately responsive. Appropriate assessment is an important tool that health systems must deploy to respond to the strengths, preferences, and needs of persons with mental illness. However, standard approaches are often focused on measurement of psychiatric symptoms without taking a broader perspective to address issues like growth, development, and aging; physical health and disability; social relationships; economic resources; housing; substance use; involvement with criminal justice; stigma; and recovery. Using conglomerations of instruments to cover more domains is impractical, inconsistent, and incomplete while posing considerable assessment burden. interRAI mental health instruments were developed by a network of over 100 researchers, clinicians, and policy experts from over 35 nations. This includes assessment systems for adults in inpatient psychiatry, community mental health, emergency departments, mobile crisis teams, and long-term care settings, as well as a screening system for police officers. A similar set of instruments is available for child/youth mental health. The instruments form an integrated mental health information system because they share a common assessment language, conceptual basis, clinical emphasis, data collection approach, data elements, and care planning protocols. The key applications of these instruments include care planning, outcome measurement, quality improvement, and resource allocation. The composition of these instruments and psychometric properties are reviewed, and examples related to homeless are used to illustrate the various applications of these assessment systems.

Patient-reported outcome measurements (PROMs) and provider assessment in mental health: a systematic review of the context of implementation

Purpose

To review and integrate the vast amount of literature yielded by recent growing interest in patient-reported outcome measurement and routine outcome measures (PROMs/ROMs), in order to suggest options and improvements for implementation. PROMs are the systematic assessment of service users’ health using standardized self-report measures. Specifically, for ROMs, it includes routine provider or caretaker assessment measures. Both are administered to ascertain routinely, the impact of treatment in mental health settings and to improve care. A review is needed because of the large differences in setting, conceptualization, practice and implementation. Here, we examine the different major projects worldwide.

Data sources

Psych INFO and PubMed including Medline, Biomed Central, EMBASE Psychiatry and Elsevier Science’s Direct.

Study selection

We conducted a systematized review of the literature published from 2000 to 2018 on the implementation and sustainability of PROMs and ROMs in mental health services for adults.

Data extraction, synthesis and Results

We described and characterized the programs in different countries worldwide. We identified 103 articles that met the inclusion criteria, representing over 80 PROMs/ROMs initiatives in 15 countries. National policy and structure of mental health services were found to be major factors in implementation. We discuss the great variability in PROMs/ROMs models in different countries, making suggestions for their streamlining and improvement.

Conclusion

We extracted valuable information on the different characteristics of the numerous PROMs/ROMs initiatives worldwide. However, in the absence of a strong nationwide policy effort and support, implementation seems scattered and irregular. Thus, development of the implementation of PROMs/ROMs is left to groups of enthusiastic clinicians and researchers, making sustainability problematic.

Homelessness at discharge and its impact on psychiatric readmission and physician follow-up: a population-based cohort study

AIMS

A significant proportion of adults who are admitted to psychiatric hospitals are homeless, yet little is known about their outcomes after a psychiatric hospitalisation discharge. The aim of this study was to assess the impact of being homeless at the time of psychiatric hospitalisation discharge on psychiatric hospital readmission, mental health-related emergency department (ED) visits and physician-based outpatient care.

METHODS

This was a population-based cohort study using health administrative databases. All patients discharged from a psychiatric hospitalisation in Ontario, Canada, between 1 April 2011 and 31 March 2014 (N = 91 028) were included and categorised as homeless or non-homeless at the time of discharge. Psychiatric hospitalisation readmission rates, mental health-related ED visits and physician-based outpatient care were measured within 30 days following hospital discharge.

RESULTS

There were 2052 (2.3%) adults identified as homeless at discharge. Homeless individuals at discharge were significantly more likely to have a readmission within 30 days following discharge (17.1 v. 9.8%; aHR = 1.43 (95% CI 1.26-1.63)) and to have an ED visit (27.2 v. 11.6%; aHR = 1.87 (95% CI 1.68-2.0)). Homeless individuals were also over 50% less likely to have a psychiatrist visit (aHR = 0.46 (95% CI 0.40-0.53)).

CONCLUSION

Homeless adults are at higher risk of readmission and ED visits following discharge. They are also much less likely to receive post-discharge physician care. Efforts to improve access to services for this vulnerable population are required to reduce acute care service use and improve care continuity.

A latent class analysis of brief postpartum psychiatric hospital admissions

Almost 40% of postpartum psychiatric hospital admissions are brief, lasting 72h or less. We aimed to identify unique subgroups of women within this group to inform better intervention. All women in Ontario, Canada with a brief postpartum psychiatric admission (≤ 72h) (2007-2012)(N = 631) were studied using latent class analysis. We identified distinct subtypes of women and compared women within each subtype on post-discharge mental health indicators: physician visits, emergency department (ED) visits and readmissions. We identified four clinically distinct classes: (1)women with no diagnosed mental illness (2 years before delivery) (n = 179; 28.4% of the sample); (2)women with pre-existing history of severe mental illness (i.e. psychosis) (n = 161; 25.5%); (3)women with pre-existing history of non-psychotic mental illness (n = 211; 33.4%); and (4)adolescent rural-dwelling women with alcohol and substance use disorders (n = 80; 12.7%). In the 1 year post-discharge, women in classes 1-3 were more likely to have post-discharge physician visit than women in class 4 (p < 0.05) and were less likely to have a psychiatric ED visit (p < 0.05). Women in class 2 were most likely to be readmitted (p < 0.05). We identified clinically distinct subgroups of women with brief postpartum psychiatric admissions who may each benefit from differing targeted preventive strategies and post-discharge treatment planning.

Predicting psychiatric readmission: sex-specific models to predict 30-day readmission following acute psychiatric hospitalization

PURPOSE

Psychiatric readmission is a common negative outcome. Predictors of readmission may differ by sex. This study aimed to derive and internally validate sex-specific models to predict 30-day psychiatric readmission.

METHODS

We used population-level health administrative data to identify predictors of 30-day psychiatric readmission among women (n = 33,353) and men (n = 32,436) discharged from all psychiatric units in Ontario, Canada (2008-2011). Predictor variables included sociodemographics, health service utilization, and clinical characteristics. Using derivation data sets, multivariable logistic regression models were fit to determine optimal predictive models for each sex separately. Results were presented as adjusted odds ratios (aORs) and 95% confidence intervals (CI). The multivariable models were then applied in the internal validation data sets.

RESULTS

The 30-day readmission rates were 9.3% (women) and 9.1% (men). Many predictors were consistent between women and men. For women only, personality disorder (aOR 1.21, 95% CI 1.03-1.42) and positive symptom score (aOR 1.41, 95% CI 1.09-1.82 for score of 1 vs. 0; aOR 1.44, 95% CI 1.26-1.64 for ≥ 2 vs. 0) increased odds of readmission. For men only, self-care problems at admission (aOR 1.20, 95% CI 1.06-1.36) and discharge (aOR 1.44, 95% CI 1.26-1.64 for score of 1 vs. 0; aOR 1.79, 95% CI 1.17-2.74 for 2 vs. 0), and mild anxiety rating (score of 1 vs. 0: aOR 1.30, 95% CI 1.02-1.64, derivation model only) increased odds of readmission. Models had moderate discriminative ability in derivation and internal validation samples for both sexes (c-statistics 0.64-0.65).

CONCLUSIONS

Certain key predictors of psychiatric readmission differ by sex. This knowledge may help to reduce psychiatric hospital readmission rates by focusing interventions.

Short stay vs long stay postpartum psychiatric admissions: a population-based study

About 1-2/1000 of postpartum women require psychiatric admission. Length of stay is variable, and little is known about short postpartum admission. From all women in Ontario, Canada, with a psychiatric admission within 1 year postpartum (2007-2012) (n = 1702), we compared women with admissions <72 h to women with longer admissions on sociodemographics, clinical characteristics and post-discharge mental health service use. About 37% of admissions were <72 h. These women were more likely to be adolescents (11.7 vs 7.3%), less likely to be employed (16.6 vs 25.9%) compared to women with longer admissions, and fewer had a prior history of psychiatric admission (16.7 vs 59.0%). Index diagnoses of alcohol or substance use (12.5 vs 7.8%) and adjustment disorders (15.8 vs 6.3%) were more common in the short vs longer stay group; psychotic (5.8 vs 19.5%) and bipolar disorders (2.1 vs 14.2%) were less common. Women with short admission were at higher crude risk for ED revisit 7 days post-discharge (11.4 vs 4.9% OR2.52, 95% CI1.74-3.66) and at lower adjusted risk for readmission at 365 days post-discharge (19.5 vs 28.8%, aOR 0.63, 95% CI 0.46-0.85). Women with short stay postpartum admissions are a clinically distinct group that may benefit from targeted intervention.

Postpartum mental health of immigrant mothers by region of origin, time since immigration, and refugee status: a population-based study

Immigrant women are at high risk for postpartum mental disorders. The purpose of this study was to understand how rates of postpartum mental health contact differ among immigrant women by region of origin, time since immigration, and refugee status. We conducted a population-based cohort study of immigrant mothers in Ontario, Canada, with children born from 2008 to 2012 (N = 123,231). We compared risk for mental health contact (outpatient, emergency department, inpatient hospitalization) in the first postpartum year by region of origin, time since immigration, and refugee status, generating adjusted odds ratios (aOR) and 95% confidence intervals (CI). Immigrants from North Africa and the Middle East were more likely to have outpatient mental health contact than a referent group of immigrants from North America or Europe (aOR 1.07, 95% CI 1.01-1.14); those from East Asia and the Pacific, Southern Asia, and Sub-Saharan Africa were less likely (0.64, 0.61-0.68; 0.78, 0.74-0.83; 0.88, 0.81-0.94). Refugees were more likely to have contact than non-refugees (1.10, 1.04-1.15); those in Canada <5 years were less likely than longer-term immigrants (0.83, 0.79-0.87). Refugees were more likely to have an emergency department visit (1.81, 1.50-2.17) and a psychiatric hospitalization than non-refugees (1.78, 1.31-2.42). These findings have implications for targeted postpartum mental health service delivery targeting certain immigrant groups and particularly refugees.

The use of a brief mental health screener to enhance the ability of police officers to identify persons with serious mental disorders

Police agencies in Canada and elsewhere have received much criticism over how they respond to persons with serious mental disorders. The adequacy of training provided to police officers on mental health issues and in particular on recognizing indicators of serious mental disorders has been a major concern. This paper describes the process that led to the development of a new brief mental health screener (interRAI Brief Mental Health Screener, BMHS) designed to assist police officers to better identify persons with serious mental disorders. The interRAI BMHS was developed in collaboration with interRAI, an international, not-for-profit consortium of researchers. The government of Ontario had previously partnered with interRAI to develop and implement the Resident Assessment Instrument for Mental Health (RAI-MH), the assessment system mandated for use on all persons admitted into inpatient psychiatric care in the province. Core items on the interRAI BMHS were obtained through analysis (N=41,019) of RAI-MH data together with input from representatives from health care, police services, and patient groups. Two police services in southwestern Ontario completed forms (N=235) on persons thought to have a mental disorder. Patient records were later accessed to determine patient disposition. The use of summary and inferential statistics revealed that the variables significantly associated with being taken to hospital by police included performing a self-injurious act in the past 30days, and others being concerned over the person's risk for self-injury. Variables significantly associated with being admitted included abnormal thought process, delusions, and hallucinations. The results of the study indicate that the 14-variable algorithm used to construct the interRAI BMHS is a good predictor of who was most likely to be taken to hospital by police officers and who was most likely to be admitted. The instrument is an effective means of capturing and standardizing police officer observations enabling them to provide more and better quality information to emergency department (ED) staff. Teaching police officers to use the form constitutes enhanced training on major indicators of serious mental disorders. Further, given that items on the interRAI BMHS are written in the language of the health system, language acts as common currency between police officers and ED staff laying the foundation for a more collaborative approach between the systems.

First lifetime psychiatric admission in the postpartum period: A population-based comparison to women with prior psychiatric admission

OBJECTIVES

To better understand women with a first lifetime psychiatric hospitalization in the postpartum period.

METHODS

We included all 1071 postpartum women in Ontario, Canada, with a psychiatric admission in the 1-year postpartum (2007-2012). We compared women with their first lifetime psychiatric admission to those with any prior psychiatric admission on demographic and clinical characteristics and on mental health physician visits, psychiatric emergency department (ED) revisits and psychiatric readmission within 1-year postdischarge.

RESULTS

Compared to women with prior admission, women with a first lifetime admission (n=537, 59%) were less likely to have psychotic disorders (14% vs. 25%) and had shorter lengths of stay (13.6+/-12.7 vs. 18.9+/-27.8days). Women with prior admission were at higher risk for ED revisits (44% vs. 32%, odds ratio=1.63, 95% confidence interval=1.26-2.09) and readmissions (32% vs. 24%, odds ratio=1.82, 95% confidence interval=1.39-2.38) by 1-year postdischarge versus women with first lifetime admission; differences were explained by clinical factors.

CONCLUSIONS

Although women with a first lifetime psychiatric admission postpartum have a favorable clinical course up to 1year after index admission versus women with any prior admission, 25% are readmitted with 1-year postdischarge, underscoring need for attention to this group.

Morbidity and mortality of women and men with intellectual and developmental disabilities newly initiating antipsychotic drugs

BACKGROUND

While up to 45% of individuals with intellectual and developmental disabilities (IDD) have a comorbid psychiatric disorder, and antipsychotics are commonly prescribed, gender differences in the safety of antipsychotics have rarely been studied in this population.

AIMS

To compare men and women with IDD on medical outcomes after antipsychotic initiation.

METHOD

Our population-based study in Ontario, Canada, compared 1457 women and 1951 men with IDD newly initiating antipsychotic medication on risk for diabetes mellitus, hypertension, venous thromboembolism, myocardial infarction, stroke and death, with up to 4 years of follow-up.

RESULTS

Women were older and more medically complex at baseline. Women had higher risks for venous thromboembolism (HR 1.72, 95% CI 1.15-2.59) and death (HR 1.46, 95% CI 1.02-2.10) in crude analyses; but only thromboembolism risk was greater for women after covariate adjustment (aHR 1.58, 95% CI 1.05-2.38).

CONCLUSIONS

Gender should be considered in decision-making around antipsychotic medications for individuals with IDD.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Antipsychotic drug use in pregnancy: high dimensional, propensity matched, population based cohort study

OBJECTIVE

To evaluate maternal medical and perinatal outcomes associated with antipsychotic drug use in pregnancy.

DESIGN

High dimensional propensity score (HDPS) matched cohort study.

SETTING

Multiple linked population health administrative databases in the entire province of Ontario, Canada.

PARTICIPANTS

Among women who delivered a singleton infant between 2003 and 2012, and who were eligible for provincially funded drug coverage, those with ≥ 2 consecutive prescriptions for an antipsychotic medication during pregnancy, at least one of which was filled in the first or second trimester, were selected. Of these antipsychotic drug users, 1021 were matched 1:1 with 1021 non-users by means of a HDPS algorithm.

MAIN OUTCOME MEASURES

The main maternal medical outcomes were gestational diabetes, hypertensive disorders of pregnancy, and venous thromboembolism. The main perinatal outcomes were preterm birth (<37 weeks), and a birth weight <3rd or >97th centile. Conditional Poisson regression analysis was used to generate rate ratios and 95% confidence intervals, adjusting for additionally prescribed non-antipsychotic psychotropic medications.

RESULTS

Compared with non-users, women prescribed an antipsychotic medication in pregnancy did not seem to be at higher risk of gestational diabetes (rate ratio 1.10 (95% CI 0.77 to 1.57)), hypertensive disorders of pregnancy (1.12 (0.70 to 1.78)), or venous thromboembolism (0.95 (0.40 to 2.27)). The preterm birth rate, though high among antipsychotic users (14.5%) and matched non-users (14.3%), was not relatively different (rate ratio 0.99 (0.78 to 1.26)). Neither birth weight <3rd centile or >97th centile was associated with antipsychotic drug use in pregnancy (rate ratios 1.21 (0.81 to 1.82) and 1.26 (0.69 to 2.29) respectively).

CONCLUSIONS

Antipsychotic drug use in pregnancy had minimal evident impact on important maternal medical and short term perinatal outcomes. However, the rate of adverse outcomes is high enough to warrant careful assessment of maternal and fetal wellbeing among women prescribed an antipsychotic drug in pregnancy.

READMIT: a clinical risk index to predict 30-day readmission after discharge from acute psychiatric units

Our aim was to create a clinically useful risk index, administered prior to discharge, for determining the probability of psychiatric readmission within 30 days of hospital discharge for general psychiatric inpatients. We used population-level sociodemographic and health administrative data to develop a predictive model for 30-day readmission among adults discharged from an acute psychiatric unit in Ontario, Canada (2008-2011), and converted the final model into a risk index system. We derived the predictive model in one-half of the sample (n = 32,749) and validated it in the other half of the sample (n = 32,750). Variables independently associated with 30-day readmission (forming the mnemonic READMIT) were: (R) Repeat admissions; (E) Emergent admissions (i.e. harm to self/others); (D) Diagnoses (psychosis, bipolar and/or personality disorder), and unplanned Discharge; (M) Medical comorbidity; (I) prior service use Intensity; and (T) Time in hospital. Each 1-point increase in READMIT score (range 0-41) increased the odds of 30-day readmission by 11% (odds ratio 1.11, 95% CI 1.10-1.12). The index had moderate discriminative capacity in both derivation (C-statistic = 0.631) and validation (C-statistic = 0.630) datasets. Determining risk of psychiatric readmission for individual patients is a critical step in efforts to address the potentially avoidable high rate of this negative outcome. The READMIT index provides a framework for identifying patients at high risk of 30-day readmission prior to discharge, and for the development, evaluation and delivery of interventions that can assist with optimizing the transition to community care for patients following psychiatric discharge.

Measuring the prevalence of current, severe symptoms of mental health problems in a canadian correctional population: implications for delivery of mental health services for inmates

This study measured the prevalence of current, severe symptoms of a mental health problem in an adult population of inmates in Ontario, Canada. The Resident Assessment Instrument-Mental Health was used to measure the prevalence of symptoms among a sample of 522 inmates. Propensity score weighting was used to adjust for nonrandom selection into the sample. Prevalence estimates were derived for the total inmate population, remand and sentenced, males and females, and Aboriginal and non-Aboriginal inmates. It is estimated that 41.1% of Ontario inmates will have at least one current, severe symptom of a mental health problem; of this group, 13.0%, will evidence two or more symptoms. The number of symptoms is strongly associated with presence of a psychiatric diagnosis and level of mental health care needs. Female (35.1%) and Aboriginal (18.7%) inmates are more likely to demonstrate two or more current, severe symptoms. Greater efforts must be made to bridge the gap between correctional and mental health care systems to ensure inmates in correctional facilities can access and receive appropriate mental health care services.