Self Sufficiency Self Sufficiency MatrixMatrix

Comprehensive and reliable screening in Dutch Public Mental Health Care

S. Lauriks, T. Fassaert, M. de Wit, M. Buster, and S. van de Weerd

Self Sufficiency Self Sufficiency MatrixMatrix

Comprehensive and reliable screening in Dutch Public Mental Health Care

S. Lauriks, T. Fassaert, M. de Wit, M. Buster, and S. van de Weerd

Introduction

Self Sufficiency is the realization of an acceptable level of functioning either by oneself or by adequately organizing care

Clients of PMHC are often

characterized by not actively

seeking help or not having their care needs met by regular services: limitations in self sufficiency

The Dutch PMHC-system offers

multidisciplinary care to clients that

cope with psychosocial and socio-

economic problems

The SSM (Dutch version)

The Dutch version of the Self Sufficiency Matrix (SSM-D)

distinguishes 5 levels of self sufficiency (columns)Acute problem, Not, Barely, Adequately, Completely

The SSM-D assesses a persons’ level of self sufficiency on 11

domains (rows)Income, Day-time activities, Housing, Domestic relations, Mental health,

Physical health, Addiction, Daily life skills, Social network, Community participation,

Judiciary

For each level of self sufficiency, domain-specific criteria are

specified (cells)

1 acute problem 2 not self sufficient 3 barely self sufficient 4 adequately self sufficient 5 completely self sufficient

Income No income, high and increasing debts.

Inadequate income and/or spontaneous or inappropriate spending, increasing debts.

Can meet basic needs with income; appropriate spending; if there are debts, they are stable; Income management/ budget control by a third party.

Meets basic needs without receiving social security benefits; manages his/her debts without assistance and they are decreasing.

Income is sufficient, well managed; has income and is able to save.

Development Pearce et al. (1996): Economic self sufficiency standard

The Snohomish county self sufficiency taskforce (2004): First SSM based on ROMA outcomes standards

Arizona and Utah (a.o.) (2006): State-specific adaptations of SSM

– Adaptations of the SSM vary in number of domains.– Number of levels of self sufficiency and formulation of domain-specific criteria

remains consistent

Public Health Service Amsterdam (2010): First Dutch adaptation of SSM (SSM-D)

– The SSM-D was developed with feedback and input from professionals, policymakers, and researchers from the field of PMHC

Psychometric propertiesInternal consistencyGroup: 2686 clients Young adults office & Central Access Point

PMHC Method: Principal Component Analysis (PCA)

Results: ■ One construct: self-sufficiency■ No redundant (unnecessary) domains

Inter-rater reliabilityGroup: 2 social workers screened 20 clients & 36 professionals each

rated 3 fictitious casesMethod: Correlations, % exact agreement, Kappa

Results: ■ High correlations between raters■ Exact agreement smaller■ Access to information is of primary importance

Fassaert T, Lauriks S, van de Weerd S, de Wit M, Buster M (2013) Ontwikkeling en betrouwbaarheid van de Zelfredzaamheid-Matrix. Tijdschrift voor Gezondheidswetenschappen 91(3): 169-177

Psychometric properties

Construct validityGroup: 81 clients Youth ACT & 86 clients with SMI in Long-term outpatient

treatmentMethod: Screening with SSM-D & HoNOS (ACT-group) and SSM-D &

CANSAS (SMI-group). Correlations between overall and domain scores

Results: ■ Strong correlations between overall scores■ Strong correlations between domains with related subscalesIn addition■ SSM-D was able to discriminate between both study-populations.

Fassaert T, Lauriks S, van de Weerd S, Buster M, de Wit M. Psychometric properties of the Dutch version of the Self-Sufficiency Matrix (SSM-D). Submitted to Community Mental Health Journal

Application – Decision Support Tool for PMHC access

PurposeTransparency in the professional decision to grant/deny access to PMHC at the Central Access Point in Amsterdam

Method Screeners at the CAP perform an interview, decide on the

access to PMHC, and score the SSM-D for 612 clients

SSM-D predictors of the professional decision are analyzed with logistic regression modeling in one half of the research group (N1)

Cut-off points with optimal sensitivity and specificity are analyzed with ROC-curves of decisions in the other half of the research group (N2)

Application – Decision Support Tool for PMHC access

.0

.1

.2

.3

.4

.5

.6

.7

.8

.9

1.0

.0 .1 .2 .3 .4 .5 .6 .7 .8 .9 1.0

FALSE POSITIVE

TR

UE

PO

SIT

IVE

The DST based on weighted SSM-D domains is accurate and useful to promote transparency of the decision to allocate clients to PMHC.

The information collected with the SSM-D is useable and relevant to the professional and the clinical care process.

Income 2Day-time activities 2Housing 1Domestic relations 4Mental health 3Physical health 4Addiction 2Daily life skills 3Social network 2Community partipipation 2Judiciary 4

Chance of True PMHC client PMHC Access Advice

0.97 Certain PMHC access

All domains are included in the model to optimize predictive value

PurposeEvaluation of progress of clients over time and effectiveness of interventions

Example I 100 clients referred at the CAP were offered

a social work intervention focused at stabilization of socioeconomic problems

SW’s scored the SSM-D at the first and last meeting with the client

Primary problematic domains at intake: Income, Day-time activities and Housing

Application – Tracking client progress

Application – Tracking client progress

SSM-D scores at intake (T0) and last contact (T1)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

SSM-D domains

% t

ota

l gro

up

Completelyself sufficient

Adequatelyself sufficient

Barely selfsufficient

Not selfsufficient

Acute problem

Significant higher scores at T1 on 8 SSM-D domains and the SSM- D total score.

Example II 121 clients of ‘Vulnerable Households’ intervention-team

Case workers scored the SSM-D at intake, and at intermediary or exit interview.

Primary problematic domains at intake: Income and Day-time activities

Sig. proportion of group with secondary problems on Domestic relations, Mental health, Daily life skills, Social network and/ or Community participation

Application – Tracking client progress

Application – Tracking client progressProgress on the SSM-D

0%10%20%30%40%50%60%70%80%90%

100%

SSM-D domains

% o

f the

rese

arch

gro

up

Plus 4 levels

Plus 3 levels

Plus 2 levels

Plus 1 level

Stable

Minus 1 level

Minus 2 levels

Minus 3 levels

Significant differences between T0 and T1 on all SSM-D domains and SSM-D total score

Application – Tracking client progress

The SSM-D seems an useful and feasible instrument to evaluate clients over time and assess the effectiveness of interventions

But:

Sensitivity to change of SSM-D still needs to be determined

Control group is needed for evaluation of effectiveness

Specific interventions – specific outcomes? SSM-D provides ‘pixilated landscape picture’

Implementation

Amsterdam Public Health Service (GGD) – CAP

– Screening of homeless people, access to PMHC Municipal work and Welfare service (DWI)

– Identification of group at risk of social exclusion Community development service (DMO)

– Evaluation ‘Vulnerable households intervention’

Rotterdam Municipality of Rotterdam – Young adult office

– Screening and assessment of young adults without qualifications

Utrecht Public Health Service (GGD)

– Homeless management information system

The Hague Public Health Service (GGD) – Central Coordination Point

– Screening of homeless people, access to PMHC– Homeless management information system

Implementation – 4 largest cities

Additional domains for parents/ guardians– Four domains to assess levels of self sufficiency with regard to care for (young)

children

Assessment of sensitivity to change– Pilot tests have been done but evidence for sensitivity to change is needed

Accreditation of SSM-D as instrument for Routine Outcome Monitoring

– Mental health care branch organizations and PMHC- financiers recognize SSM-Das a feasible tool for ROM

Development and dissemination of the SSM in the EU– The SSM-D has recently been translated in English and the English website is

online

Future research and development

Future research and development

One standard: truly achievable? Who are able to work with the SSM-D? SSM-D for underaged and elderly? OK for screening; OK for treatment planning? How does one set achievable goals for individuals? How do we set achievable goals for programs (financing)?

Implementation – issues to be ‘solved’

Steve Lauriks

Phone: +31 (0)622 728 596

E-mail: zrm@ggd.amsterdam.nl

Website: www.zelfredzaamheidmatrix.nl

www.selfsufficiencymatrix.org

Questions