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)

Client –Level Formulation / Progress

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

Dashboards

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.

Integrating Total Clinical Outcome Management into Program Planning

1. Problem Identification

2. Problem Analysis

3. Plan Development

4. PlanImplementation

5. Plan Evaluation