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Outcome Orientated Approaches Sami Timimi Tuesday, 3 September 13 Washing Machines and all that • • • Tuesday, 3 September 13 Quality control. Standardise all components. Remove the impact of human variation and fallibility. Predicting outcomes Patient/Extratherapeutic/Factors/(87%)/ Feedback/Effects/ //15A31%/ Treatment/Effects/ ///13%// Alliance/Effects/ ///////38A54%// Model/Technique. ............8%. Therapist/Effects/ /////////46A69%/ Duncan, B. (2010). On becoming a better therapist. Washington DC: American Psychological Association Tuesday, 3 September 13 Model/Technique/Delivered:/ Expectancy/Model/Technique/Delivered:/ Expectancy/Allegiance/ Rationale/Ritual/(General/Effects)/ //////////////30A?%/ / Key findings from research • Research finds therapy is effective for mental health problems in short and medium term. Poor long term outcomes. • • Extra-therapeutic factors such as social circumstances and Model or technique has a minimal impact on outcomes. motivation have biggest impact on outcomes • Quality of therapeutic alliance important. • Regular monitoring of progress and alliance improves outcomes (10 RCTs). Tuesday, 3 September 13 Move away from • A focus on a formal diagnosis. • A focus on ‘pathology’ and ‘dysfunction’ Blaming and/or berating people. • • Acting as the ‘expert’. • Encouraging dependency on services. • Using outcome measures as a ‘tick list’. Paperwork with no positive evidence. • Tuesday, 3 September 13 Move toward • De-centring importance of our treatments. Fostering meaningful therapeutic relations. • • Believe everyone is capable of change. • Using patient’s ideas about treatment. • Fostering patient autonomy. Appreciating the ‘messiness’ of mental health work. • • Encouraging clinician diversity. Tuesday, 3 September 13 Partners for Change Outcome Management Systems (PCOMS) • Norway couples therapy. Feedback v TAU; Both persons reliable or sig. change 50.5% v. 22.6%. FU v TAU-34.2% v. 18.4% Feedback sep./ divorce rate. • 2 independent US based studies. Feedback group doubled controls (10.4 vs. 5.1 points) Tuesday, 3 September 13 PCOMS in real clinical settings •Community Health and Counselling Services in Maine: Number of patients seen for more than one year from 655 (pre-PCOMS) to 321 (post-PCOMS). Number patients seen more than two years from 227 (pre-PCOMS) to 94 (post-PCOMS). ‘No Shows’ down by 30%. •Southwest Behavioral Health Services, Arizona: Average length of an episode of care in children’s’ services from 315 days to 188. Length of stay in adult 322 days to 158. No shows down by 47%. •Center for Family Service, Florida.‘. Using 40% fewer sessions to achieve program goals. ‘No shows’ down by 25%. Tuesday, 3 September 13 Adapted American Partners for Change Outcome Management systems (PCOMS) • Innovation award grant for Outcome Orientated Child and Adolescent Mental Health Services (OO-CAMHS) Jan 2011-Jan 2012. • Health and Education Innovation Clusters award for OO-AMHS elearning August 2011-June 2012. • Implementation grant award for OO-AMHS with NSPCC July 2012. • Whole service implementation across Lincolnshire CAMHS and a variety of accompanying projects locally, nationally, internationally. Tuesday, 3 September 13 Data comparison April-Oct. 2011 OO-CAMHS team Non-OO-CAMHS team 104 patients 168 patients • Over 2 years: 9% • Over 1 year: 28% 1% (1 pt.) • Tier 4: 7% • DNA: • Cancellation: 11% Tuesday, 3 September 13 • Over 2 years: • Over 1 year: • Tier 4: • DNA: • Cancellation: 34% 58% 9% (15 pt.) 11% 10% The problem of branding/commodifying Tuesday, 3 September 13 http://www.oocamhs.com Tuesday, 3 September 13 www.innovationforlearning.com/LPFT Tuesday, 3 September 13 Service Transformation Toolkit Tuesday, 3 September 13 QIPP case study Tuesday, 3 September 13 Peer reviewed and other publications and awards Tuesday, 3 September 13 What sort of service do you want? • Patient at the centre, involved in all decisions: A recovery and user empowering approach. • Challenge the dominance of models that are ‘expert’ led and emphasize the technical (e.g. medical model). • Sees mental health as part of social justice. Tackles stigma and celebrates diversity. • • Uses feedback throughout treatment in a way that is easy for busy clinicians to learn and use, achieves good outcomes, discharges nearly all, few in long term treatment, low rates of referral to tier 4/specialist services. Tuesday, 3 September 13 OO-CAMHS CORE principles • • • • CONSULTATION: pay attention to extra-therapeutic factors OUTCOME: Monitor outcome session-by-session. If no change by session 5, review with patient and MDT. RELATIONSHIP: Monitor the alliance session-bysession. ETHICS OF CARE: Develop a whole team ethos. Teams are the drivers of change. Tuesday, 3 September 13 Consultation • Patient/extra-therapeutic = 40-87% variance of outcome. • Who is best placed to have a meaningful relationship with patient? Multi-agency consultation. • Are circumstances favourable for treatment? How stable is the extra-therapeutic context. • Is more than one agency working on same problem? Avoid duplication. Complex cases are often created. • Match clinician to patient from first appointment. • Avoid long term treatment with no discernible or measurable benefit. Tuesday, 3 September 13 Outcomes Tuesday, 3 September 13 Outcomes • Regular feedback can by itself improve outcomes. • PROM measure should be simple and feasible otherwise it won’t engage clinicians. • Keep a record of the outcome score session by session and plot a graph that is discussed at the beginning of each session. • If no improvement has occurred after 5 sessions discuss with the patient and/or their carer and/or the Multidisciplinary team, as up to 90% chance of no improvement in that treatment episode.. Tuesday, 3 September 13 Outcome Rating Scale Tuesday, 3 September 13 Relationship Tuesday, 3 September 13 Relationship • Alliance as rated by the patient strongest factor, from within treatment, associated with improved outcomes. • Use simple and feasible PROM measure. • From the first session create a culture of strong interest in patient feedback. • Building strong alliances is important particularly early in treatment. • Address and discuss alliance issues before the patient and/or their carer leave the session. Tuesday, 3 September 13 Ethics of care • Most ‘transformation’ projects fail at implementation and then maintenance phases. • Like patients, clinicians work better when they feel valued, listened to, and taken seriously. • Create culture that is interested in outcomes and values patients’ perspective. • Build strong culture of clinical feedback and supervision. • Be prepared to fail ‘successfully’ • Evidence base everything! Tuesday, 3 September 13 Feedback Tuesday, 3 September 13 Team/peer supervision • Cases for discussion. • Generate new ideas. • Encourage different perspectives. • Review outcome scores from first session. • Consider change of clinician. • Bring team data. • Celebrate team accomplishments. Tuesday, 3 September 13 5 Session clinic Tuesday, 3 September 13 Listening, respecting, resourcing Tuesday, 3 September 13 Learning from feedback • Local learning trumps model fidelity. • Data will support learning (Practice Based Evidence). • Supporting whole team implementation drives real change. • Assume everyone has resources. • Assume everyone can make good recovery. • Aim for discharge as soon as feasible. Tuesday, 3 September 13 Whole service implementation Tuesday, 3 September 13 Service reporting Templates NA/ Standard Criterion No. 1 Yes No ! ! Exceptions ! Is there evidence that another agency (e.g. social services) is involved in addressing the problems the patient is referred for? • If YES, have multi-agency discussions/consultations taken place? (Data source: patient record) 2 ! ! ! ! Is there evidence the Outcome Rating Scale (ORS) has been administered at each appointment and the score recorded for: a. The young person? ! b. Parent/carer? ! ! • If NO – is the reason for not using the ORS documented in the patient notes? Has a graph been used been used to plot the ORS scores so that client progress can be observed? (Data source: patient record/online database) ! ! ! ! ! ! ! ! ! 3 Is there evidence that Session Rating Scale (SRS) is being administered each appointment with: a. b. The young person? Parent/carer? Tuesday, 3 September 13 ! ! ! ! ! ! If NO – is the reason for not using the SRS documented in the patient notes? Is there evidence of SRS scores of 36 or below? • If YES, is there a record that this has been discussed with the person(s) who did the rating? • ! ! ! ! ! ! ! ! ! Successful transformations • Clinician buy in: easy to use, leadership, teams are the drivers of change. • Data integrity: Aim to get data. Focus in implementation phase of just getting back the data, that way you know clinicians are trying it. • Data management: Clear policies on who sees what and how it is used. In particular clinician specific data should not be available to managers in a position to hire and fire. Tuesday, 3 September 13 Learning from feedback • Local learning trumps model fidelity. • Data will support learning (Practice Based Evidence). • Supporting whole team implementation drives real change - use whole team data. • Everyone has resources. • Everyone can make good recovery. • Aim for discharge as soon as feasible. • Evaluate projects and developments as well as on-going team data. Tuesday, 3 September 13