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Health Status and Outcomes in Mental Health
The overarching aims of the Victorian Outcome Measurement Project
are to:
- Ensure that the mental health sector undertakes continuous
quality improvement.
- Enable consumer health status to be monitored by consumers
and clinicians.
- Enable the comparison of services.
- Foster an ethos of routine outcome measurement.
- Provide the basis for the ongoing development of health status
and outcome measurement.
Criteria
for a Suite of Measures
The development of the suite of outcome measures proposed for adult
clinical services has been informed by consultation with the reference
group, analysis of the relevant literature and Commonwealth studies.
The preferred approach is a multi-dimensional one where combinations
of inputs, outputs and outcomes are considered to create a picture
of service performance.
Measures need to meet the following criteria:
Acceptability-acceptable to consumers and carers, being
culturally-appropriate, non-intrusive, non-stigmatising and confidential.
Compatibility-compatible with the relevant legislation,
the National Mental Health Standards and Victorian policy.
Economy-as few measures as possible, each measure included
in the suite has a clearly defined purpose and overlap is avoided
or minimised.
Feasibility-compatible with routine clinical practice without
imposing an unnecessary burden upon consumers, carers, clinicians
or managers.
Adequate coverage-covers both community-based and inpatient
services and is not restricted on the basis of diagnosis.
Continuity-able to inform practice and review and to provide
an opportunity for the comparison of outcomes over time.
Integration-the inter-relationship with current data collection
and monitoring mechanisms is clearly defined and duplication is
avoided or minimised.
Aggregation-supports the aggregation of data and the comparison
of service effectiveness at various levels-individual, service provider,
statewide.
Overview
of Proposed Measures
Based on the above criteria a suite of measures proposed for Adult
Mental Health Services has been developed. The measures relate to
both consumer and service outcomes.
The table below shows the type and focus of the proposed measures.
A detailed description of each measure follows in the next section.
| Type of measure |
Domain |
Focus |
Data collection instrument/mechanism |
| Adult MH consumer outcomes |
Health outcome |
Health status, severity and change over time |
12-item HoNOS scale with total score. |
| |
|
Health status, change over time and consumer
participation |
Self-rating tool-for example Mental Health
Inventory or BASIS-32 |
| |
Psycho-social functioning |
Level of disability of client population |
16-item version of Life Skills Profile (LSP) |
| |
Aim of treatment |
Aim of treatment intervention |
Focus of Care rating |
| |
Client attributes |
De-identified clinical and socio-demographic
data |
Existing PRISM/RAPID data |
| Adult MH service outcomes |
Service activity |
Quantitative measures documenting key parameters
of service delivery (for example utilisation, throughput) |
Key Performance Indicators (KPIs) derived from
existing Minimum Data Set and other indicators under development. |
| |
Evidence of service responsiveness |
Responsiveness to client need |
Indicators under development |
| |
Evidence of integrated service |
Service components work in unison, facilitating
continuity of care |
Indicators under development; may include:
· Time between referral and initial appointment.
· Time between discharge from inpatient service and first appointment
at community-based service |
| |
Satisfaction |
Consumer satisfaction |
Annual survey |
| |
|
Carer satisfaction |
Annual survey |
Health
Outcome Measure (Clinician-Rated)
Health of the Nation Outcome Scales (HoNOS)-version 4 (1996)
was developed by the Royal College of Psychiatrists in London. HoNOS
comprises a set of 12 clinician-rated items, each assessing an important
issue commonly encountered by clients. These include both clinical
problems such as depressed mood, hallucinations and delusions, as
well as social aspects of clients' functioning such as living conditions
and relationships.
Rationale
HoNOS was chosen because of its brevity, sensitivity to change and
because it does not rely on a diagnosis. The instrument was designed
for use with persons with a mental illness, and it covers a range
of domains (behaviour, impairment, symptoms and social problems).
Its psychometric properties are satisfactory and HoNOS can be supported
by information systems.
Health
Outcome Measure (Rated by Self or Carer)
Two instruments will be trialed. These are the Mental Health Inventory
(MHI) and the Behaviour and Symptom Identification Scale (BASIS-32).
Rationale
The advantages of self-rating by consumers include:
- Consumers are an expert regarding their own mental health.
- Active involvement in health monitoring.
- Consumer rating may reveal information of which the clinician
was not aware.
- A dual perspective in tracking 'change over time'.
Psycho-Social
Functioning
The original Life Skills Profile (Rosen et al, 1989: Parker
et al, 1991) is a 39-item scale measuring psycho-social functioning
and can serve to indicate the level of client disability. The focus
of the instrument is upon the client's general functioning over
the three months prior to the rating. An abbreviated version of
the Life Skills Profile (LSP-16) comprising 16 items was developed
as part of the MH-CASC project. It is proposed that this abbreviated
scale be used in Victoria.
Rationale
In order to interpret the extent of clinical change in a client
population it is important to understand the overall level of disability
of the population concerned. This will be probed by gauging the
psycho-social functioning of clients. Because of its focus upon
general functioning (and because it excludes crises) the LSP complements
the HoNOS (where raters are asked to rate the most serious problem
encountered in the rating period). The tools further complement
each other as the LSP excels in long term non-acute settings whereas
the HoNOS more readily shows change in acute settings.
Aim
of Treatment
Focus of Care: Clinicians are asked to identify which of
four types of focus best described the care provided to the patient
over the period rated. The four types of focus, and their definitions,
are as follows:
| Focus of Care Rating |
Description |
| Acute |
Short term reduction in severity of symptoms and/or personal
distress associated with recent onset or exacerbation of psychiatric
disorder. |
| Functional gain |
Improve personal, social or occupational functioning or promote
psychosocial adaptation in a patient with impairment arising
from a psychiatric disorder. |
| Intensive extended |
Prevent or minimise further deterioration and reduce risk
of harm in a patient who has a stable pattern of severe symptoms/frequent
relapses/severe inability to function independently, and is
judged to require care over an indefinite period. |
| Maintenance |
Maintain level of functioning, minimise deterioration or prevent
relapse where the patient has stabilised and functions relatively
independently. |
Rationale
The Focus of Care is intended for use in community-based services
only. It classifies the consumer's primary need for treatment and
will be recorded at each contact, enabling a month-by-month comparison
of community episodes according to their focus of care.
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