Researchers Test Outcomes-Based Treatment Plan on Older Adults with Mental Health Issues in New Hampshire
From 1998 to 2000, researchers at the New Hampshire-Dartmouth Psychiatric Research Center under the direction of Stephen J. Bartels, M.D., M.S., tested the Outcomes-Based Treatment Plan.
The plan is a guided assessment and treatment planning toolkit designed to be used by nonphysician clinicians in community mental health and home care settings to improve the care of older people with mental disorders.
Researchers tested the Outcomes-Based Treatment Plan by comparing results for older adults with whom the plan was used (the intervention group) to those who received usual care (the comparison group).
Forty-four clinicians and 100 clients from 13 sites in New England participated in the study. The project was part of the Robert Wood Johnson Foundation (RWJF) Home Care Research Initiative national program (for more information see Grant Results).
- Researchers found that at baseline, routine evaluation and treatment planning practices lacked attention to key domains such as substance abuse, suicide risk or dangerous behaviors and caregiver burden or risk of neglect or abuse.
- The use of the Outcomes-Based Treatment Plan was associated with a significant increase in the assessment of symptoms, functioning, supports and safety. On average, clinicians using the toolkit systematically assessed more than 90 percent of the symptom and functioning domains and more than 75 percent of the support/safety domains.
- The use of the Outcomes-Based Treatment Plan was associated with increased specificity in the treatment planning process.
The researchers helped the State of New Hampshire implement a modified form of the Outcomes-Based Treatment Plan in all mental health centers statewide.
RWJF supported this project with a grant of $299,486 from September 1998 to December 2000.
The care of older adults with mental health disorders is an increasingly serious public health challenge. One in four people over the age of 65 has a mental disorder (including Alzheimer's disease), according to researchers at the New Hampshire-Dartmouth Psychiatric Research Center, a public-academic liaison between the New Hampshire Division of Behavioral Health and the Dartmouth Medical School that focuses primarily on research related to services for people with severe mental illness.
Most older adults with mental disorders live in the community. They use far more health care services than do other older adults. As the number of people over the age of 65 grows it is expected to double by 2030, according to the U.S. Census Bureau home and community-based systems of care will face a major challenge in providing services. At the time of the grant, existing community mental health services for older people were inadequate and fragmented, as were outcome measures and systematic approaches to assessing their clinical needs and planning services for them.
In 1995, a task force of home health and mental health clinicians and consumers at the New Hampshire-Dartmouth Psychiatric Research Center developed the Outcomes-Based Treatment Plan, a guided assessment and treatment planning toolkit designed for use by nonphysician clinicians in community mental health and home care settings to improve the care of older people with mental disorders.
Supported by the state of New Hampshire, the plan is a comprehensive methodology to assess client status, improve treatment planning and evaluate the effectiveness of community and home care mental health services. It consists of a Summary Assessment Form, which covers symptoms (e.g., suicide risk and hostile and dangerous behaviors), functioning (e.g., health status and leisure activities) and support (e.g., caregiver burden and safety), and a toolkit. (For a detailed description of the Outcomes-Based Treatment Plan, see the Appendix.)
Researchers pilot tested the plan with clients and clinicians in New Hampshire, and then revised it. They felt, however, that more rigorous testing was necessary before the instrument could be used widely.
Researchers at the New Hampshire-Dartmouth Psychiatric Research Center tested the Outcomes-Based Treatment Plan by comparing results for older adults with whom the plan was used (the intervention group) to those who received usual care (the comparison group). Researchers compared the quality of clinical assessments, specificity of treatment plans and mental health outcomes. Their objectives were to test the ability of the Outcomes-Based Treatment Plan to:
- Produce more comprehensive and specific assessments of client mental health and functional status, and need for services.
- Result in a broader range of more specifically targeted services.
- Result in improved client outcomes.
Researchers finalized the Outcomes-Based Treatment Plan methodology (e.g., adding a Treatment Options Checklist and a Treatment Planning Guide and revising the Senior Outcomes Checklist; see the Appendix). Forty-four clinicians (26 from the intervention and 18 from the comparison group) and 100 clients age 60 and older (61 from the intervention and 39 from the comparison group) from 13 sites in New Hampshire, Massachusetts and Connecticut (eight community mental health centers and five home health agencies) participated in the study.
Clients had a diagnosis of a major psychiatric disorder and received mental health or home health services between May 1998 and May 2000. Four community mental health centers and three home health agencies served as intervention sites; four community mental health centers and two home health agencies served as comparison sites.
Researchers gathered data through two clinician phone interviews (at baseline and one year later), chart reviews of 100 clients (for the 12-month period before training in study procedures and at one year follow-up) and a brief consumer self-report of health status and satisfaction (the Senior Outcomes Checklist). Some 133 clients (83 intervention and 50 comparison) completed the Senior Outcomes Checklist at baseline and three months later (these included the 100 clients whose charts were reviewed plus new clients after May 1998). The researchers also began to develop a Web version of the Outcomes-Based Treatment Plan.
The researchers reported the following findings to RWJF:
- At baseline, routine evaluation and treatment planning practices lacked attention to key domains such as substance abuse, suicide risk or dangerous behaviors, and caregiver burden or risk of neglect or abuse. More than 40 percent of clinicians did not assess suicide risk, anxiety or substance abuse; and more than 75 percent of clinicians did not assess hostile or dangerous behaviors, caregiver burden, residential risk, safety or neglect and abuse.
- At baseline, rates of assessment found on chart review were lower than rates reported by clinicians during interviews. For example, clinician interviews showed suicide risk rates of 57.7 percent (intervention group) and 50.0 percent (comparison group), while chart reviews showed suicide risk rates of 36.1 percent (intervention group) and 28.2 percent (comparison group).
- The use of the Outcomes-Based Treatment Plan was associated with a significant increase in the assessment of symptoms, functioning, supports and safety. On average, clinicians using the toolkit systematically assessed more than 90 percent of the symptom and functioning domains and more than 75 percent of the support/safety domains, compared to 55 percent of the symptom and functioning domains and 27.1 percent of the support/safety domains before the intervention. The greatest gains in assessing symptoms were found for suicide risk, hostile and dangerous behaviors, memory, suspiciousness and hallucinations. The greatest gains in assessing function were found for health status, leisure activities and social skills.
- The use of the Outcomes-Based Treatment Plan was associated with increased specificity in the treatment planning process. Clients in the intervention group had more planned treatment actions after the intervention period (7.9) than those in the comparison group (1.56).
- Clients in the intervention group reported more improvement over time in their "overall sense of well-being" than those in the comparison group. However, researchers were unable to detect significant changes between the intervention and comparison groups on self-reported symptoms or functioning.
- Differences in chart reporting standards among sites influenced baseline rates of chart documentation.
- There were a relatively small number of clinicians studied, and there was an imbalance between intervention and comparison sites because fewer home health providers than mental health providers participated.
- The study compared the number of planned treatments between the intervention and comparison groups and units of service delivered, but it did not collect data on differences in services delivered. Researchers inferred that there was greater specificity and quality in services planned but did not assess the appropriateness of the final treatment selections or services.
- The period of time (three months) used to assess consumer outcomes may have been too short to show changes in symptoms and functioning.
In May 2000, the researchers helped the New Hampshire Division of Behavioral Health implement a modified form of the Outcomes-Based Treatment Plan in all mental health centers statewide.
Project staff made eight presentations and drafted two articles about the project. See the Bibliography for details.
- Providers must see assessment and treatment tools as a way to ultimately save time or improve their care without increasing paperwork. Project staff got buy-in from clinical administrators by showing them how filling out the toolkit forms would replace some existing paperwork. (Principal Investigator)
- Use ongoing, timely follow-up to maintain clinicians' interest in projects and monitor progress. Project staff communicated with clinicians regularly by phone and mail to maintain their interest and participation in the project and to monitor their progress. (Principal Investigator)
- Pay careful attention to project timing. In this project, training and startup activities coincided with summer vacation schedules, so that enrollment of consumers was slower than expected. (Principal Investigator)
- Compensate clinicians fairly for their time on research activities. In this project, all agencies received the same compensation, regardless of their performance. It would have been more effective to pay clinicians directly. (Principal Investigator)
AFTER THE GRANT
Researchers revised the Outcomes-Based Treatment Plan after this project concluded. They continue to work with the New Hampshire Division of Behavioral Health in the use of a modified form of the plan in the state's mental health centers. They are discussing plans with New Hampshire and other states to develop a computerized version of the toolkit with decision support capabilities. Development of a Web-based version of the plan is on hold, due to lack of funding. Three mental health centers in Connecticut that participated in the study continue to use the plan; centers in Philadelphia and Maine are pilot testing it; and several other states have expressed interest in replicating the plan.
GRANT DETAILS & CONTACT INFORMATION
Research to Improve Home and Community-Based Mental Health Care for Older Persons
Dartmouth Medical School (Hanover, NH)
Dates: September 1998 to December 2000
Stephen J. Bartels, M.D., M.S.
Description of the Outcomes-Based Treatment Plan
The Outcomes-Based Treatment Plan consists of two documents: a summary assessment form and a toolkit. Within these two documents, the plan consists of several parts that are conceptually and structurally linked to form a complete system:
- Assessment Domains: This includes 22 domains relevant to older adults requiring mental health services that are important in defining their quality of life. They are broadly defined as symptom, functioning and support. The plan asks the clinician to review client needs in each of these areas each quarter.
- Sample Screening Questions: Each of the 22 domains contains screening questions for use by clinicians in assessing the client's strengths and weaknesses and to identify potential problems where care and services are needed. They are meant to give the clinician guidance in how to address each domain initially, but are not required if the clinician uses other standard questions.
- Domain-Specific Formal Rating Instruments and Scales: Each domain includes instruments to measure severity of need in areas where the screening questions suggest a problem.
- Quarterly Summary Rating Scales: Each domain includes a summary rating scale to measure overall severity, using client or family interview information, observations and scores on formal rating instruments. These are completed each quarter.
- Service Planning Targets: After problem severity has been determined in a domain, the clinician, in consultation with the client, determines if the domain should be a service planning target. If so, it is checked on the summary assessment, initiating service planning.
- Treatment Options Checklist*: This is a list of service and treatment options available for each domain. It is designed to help the clinician identify and quickly track the services and interventions provided to consumers on a quarterly basis.
- Treatment Planning Guide*: Once service planning targets are identified, the clinician may opt to consult the treatment planning guide in the toolkit. This provides a listing of potential interventions and services in each domain and a summary of recommended treatments and protocols in each domain, as offered by authoritative sources.
- Treatment Plan: The toolkit includes an optional treatment plan to record and describe service activities. This form is related to the assessment by associating treatments planned to service planning targets. A domain indicated as a service planning target in the assessment is addressed in the treatment plan.
- Senior Outcomes Checklist (SOC-10): The SOC-10 (now revised to include 12 items) is a self-report questionnaire based upon the Short Form 12 (a health assessment tool that measures physical health status, number of illnesses and self-perceived general health). It includes several questions to assess the client's perception of the value of services. The information collected from the SOC-10 is used to inform the development of the treatment plan, and to obtain feedback from the consumer about the client's health status and assess how helpful services have been.
*Researchers developed the Treatment Options Checklist and Treatment Planning Guide under the RWJF grant. The other components originated before the grant period.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Bartels SJ, Miles KM and Dums AR. "Improving Mental Health Assessment and Service Planning Practices for Older Adults: A Controlled Comparison Study." Mental Health Services Research, 7: 213223, 2005.
Bartels SJ, Miles KM and Dums AR. "A Guided Approach to Improving Community Treatment of Older Adults with Mental Disorders." Unpublished.
NH-Dartmouth Psychiatric Research Center, SOC-10: Baseline and Follow-up. June 1999.
NH-Dartmouth Psychiatric Research Center, SOC-12: Baseline and Follow-up. July 2000.
Report prepared by: Robert Crum
Reviewed by: Lori De Milto
Reviewed by: Molly McKaughan
Program Officer: Andrea Gerstenberger
Program Officer: James R. Knickman