Community Programs Office of Quality Management Tom Bleecker, Ph.D. Nathaniel Israel, Ph.D. Monica Rose, Ph.D. Deborah Sherwood, Ph.D. 8/20/2013
Adult Needs & Strengths Assessment (ANSA) Domains Behavioral Health Needs: Psychosis, Depression, Anxiety, Adjustment to Trauma, Impulse Control, Interpersonal Problems, Substance Use Life Domain Functioning: Physical/Medical, Family Functioning, Living Skills, Social Functioning, Residential Stability, Employment Risks: Danger to Self, Danger to Others, Self-Injurious Behavior, Grave Disability, Exploitation, Criminal Behavior Strengths: Optimism, Community Connection, Spiritual/Religious, Involvement in Recovery/Motivation for Treatment Other: Cultural Stress, Medication Adherence NEEDS are rated as follows: 0 = no evidence , no need for action 1 = mild degree of the dimension, need for watchful waiting to see whether action is needed 2 = moderate degree of the dimension, need for action 3 = severe, profound, dangerous, or disabling level, need for immediate or intensive action STRENGTHS are rated as follows: 0 = a significant strength that is present 1 = a moderate level of the strength is present 2 = a mild level of the strength is present 3 = the strength is not present . 2
Behavioral Health & Life Domain Functioning 100% Clients Overall Behavioral Health Top Behavioral Health Needs : 90% Needs 80% Depression (70%) 1. 70.0% 70% 59.0% Anxiety (59%) 2. 60% 50% 38.8% Adjustment to Trauma (39%) 3. 40% 31.5% 30.1% 24.5% 30% 20% 10% 0% Psychosis Depression Anxiety Adj to Impulse Interpers Trauma Control Probs Percent Actionable N=11,297 Top Life Domain Functioning Needs: 100% 1. Residential Stability (46%) Clients Overall Life Domain 90% Functioning 2. Social Functioning (45%) 80% 70% 3. Family Functioning (44%) 60% 45.4% 45.7% 50% 43.5% 40% 32.9% 29.7% 27.9% Top Life Domain Functioning Needs by Age: 30% 20% - Age 18 to 25: Family Functioning (55%) 10% 0% - Age 26 to 59: Residential Stability (48%) - Age 60 & above: Physical/Medical (48%) N=11,297 Percent Actionable 3
Risks & Strengths Risks 100% Clients Overall Risks Twice as many clients were rated with an 90% 80% actionable level of need on “Danger to Self” (21%) 70% compared to all other risks. 60% 50% Risks and Gender 40% Twice as many Males (12%) than Females (5%) were 30% 20.8% 20% rated with an actionable level of need on Criminal 8.6% 9.2% 6.2% 5.2% 4.7% 10% Behavior risk. Conversely, twice as many 0% Females (7%) than Males (3%) were rated with Danger to Self Danger to Grave Self-Inj. Exploitation Criminal Others Disabilities Behavior Behavior an actionable level of need on Exploitation Percent Actionable N=11,297 100% Clients Overall Strengths Strengths 90% Community Connection* (32%) was rated 80% 70% the lowest overall client strength. 60.6% 60% The developer of the ANSA suggests that 46.1% 50% 36.6% Community Connection is the most important 40% 31.9% 30% strength in terms of recovery. 20% 10% 0% *Community Connection: An individual’s level of Optimism Community Spiritual/Religious Involve in Recovery Connection involvement in the cultural aspects of his community Percent Actionable N=11,297 (e.g. community group activities or informal networks) 4
Medication Compliance, Cultural Stress, & Substance Use 100% Substance Use Medication Compliance, Cultural Stress, & Substance Use More than half of clients (57%) were 90% rated with Substance Use as an actionable need 80% (21% of this group used alcohol/drug daily) 70% 57.4% 60% Substance Use and Ethnicity 50% African American clients (71%) had the highest 40% proportion of clients with an actionable need on 30% Substance Use followed by White clients (68%) Latino clients (56%), and Asian clients (26%). 15.7% 20% 13.8% 10% 0% Medication Compliance Medication Cultural Stress Substance Use About 16% of clients had an actionable need Compliance related to Medication Compliance. Percent Actionable N=11,297 Cultural Stress Overall, 14% of clients were rated with an actionable need related to Cultural Stress; however the proportion of Asian (28%) & Latino (23%) clients with a need related to Cultural Stress was 3 times higher than it was for White clients (6%). 5
Association between Treatment Level of Care and ANSA Actionable Needs 10 Average Number of Actionable Needs at Intake by Level of Care 9 8.3 Total Needs 8 7.4 Behavioral Health Needs 7 Life Domain Functioning 6 5.1 Risks 5 4.0 4 3.5 3.2 3.2 2.8 3 2.1 2 1.1 1.0 1 0.3 0 Outpatient Services Intensive Case Management Residential Services N=813 N=2,785 N=7,679 Level of Care 6
Client Improvement Over Time Number of client episodes with at least 2 ANSAs: 9,297 Number showing reliable improvement in at least one domain: 6,395 (68.8%) Number showing reliable improvement by Domain: • Behavioral Health Domain: 3,142 (33.8%) • Life Domain Functioning: 2,793 (30.0%) • Risks Domain: 2,851 (30.7%) • Strengths Domain: 3,441 (37.0%) Behavioral Health Needs Items : Psychosis, Depression, Anxiety, Adjustment to Trauma, Impulse Control, Interpersonal Problems, Substance Abuse Life Domain Functioning Items : Physical/Medical, Family Functioning, Living Skills, Social Functioning, Residential Stability, Employment Risks Items : Danger to self, Danger to Others, Gravely Disabled, Exploitation, Criminal Behavior, Self Injurious Behavior Strengths Items : Optimism, Community Connection, Spiritual/Religious, Involvement with Recovery 7
Nathaniel Israel, Ph.D. Office of Quality Management 2013. 08.07 v2.2
Background Have tools in place to understand clinical and functional improvement at the client, program, and system levels In the past two fiscal years, used these tools to benchmark system performance and to understand performance in relation to best practice Moving from description to evidence-informed, collaborative action 9
% Clients Who Improve 100 90 80 70 High Quality System 60 50 Program 40 30 Current Performance in SF 20 10 0 *Each diamond represents a Children’s Behavioral Health program 10
Problem High-quality, effective care is the exception, not the norm Effectiveness of care often depends on whether a client gets the ‘right’ clinician in the ‘right’ agency Strong belief from many providers that they are able to effectively treat some clients and some conditions How do we build on this to facilitate more effective practice? 11
Method Use ways of formulating decisions which are already accessible to clinicians (clinical formulation) Add in structured clinical data (CANS) to help select important concerns and orient decision-making Construct a program-wide clinical formulation based on the data Use these pieces of data to better understand and disseminate what practices are effective in our local context 12
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Putting Practices Together Is this site effective at addressing this Need? List approaches (general framework and specific practices) used by each site with evidence of promising practices Look for common practices across sites Look for unique practices at sites Identify context considerations which may influence practice (age, language, culture, setting) 15
Integration and Learning Existing System-wide Initiatives Trauma-Informed System Performance Contracting Existing Forums for Practice Conversations SuperUser Calls, Provider Meetings, CYF Executive Leadership Affinity Groups How was this practice developed, taught, sustained? Dissemination and Training Champions Learning must translate into practice change 16
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