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1 Total Clinical Outcomes Management CANS Conference Nashville September, 2008
1
Total Clinical Outcomes Management
CANS Conference Nashville
September, 2008
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Workshop Overview
Background to TCOM Tensions and syndromes
The TCOM Framework
Keys to Successful Implementation
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Background 1980’s – quality initiatives
Focus on program services (not the individual child)
Movement toward articulating outcomes approach to care The Measurement & Management of Clinical Outcomes in Mental
Health (Lyons et al. 1997)
Total Clinical Outcomes Management (TCOM) Embed quality assurance and quality initiative into clinical service
« …the measurement and management of information regarding the characteristics of children and families is the single most important focus of managing treatment interventions at all levels of the system of care simultaneously »
Redressing the Emperor: Improving Our Children’s Public Mental Health System (Lyons, 2004), pg.100
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Challenges to the Child-Serving System Many different adults in the lives of our
children/youth Each has a different perspective and,
therefore, different agendas, goals, and objectives
Honest people, honestly representing different perspectives will disagree
This creates the inevitability of disagreements and potentially conflict
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Potential Solutions
If a primary challenge is ongoing disagreements then managing the child serving system is actually ongoing dispute resolution
The key principles of dispute resolution or conflict management are: Identify the shared vision Communicate about the shared vision
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Tensions
“Competing pressures arising from the incompatible or opposing goals and objectives that push or pull the system in opposite directions”
« They are structural aspects of the system that cannot be eliminated, but must be understood and managed »
Redressing the Emperor, Lyons 2004 (pg. 31 )
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System Level Tensions
Multiple Models Medical Model Social Model
Central vs Local Control Involvement of multiple state agencies/ministries and
levels of government Budget Silos vs Blended Funding
inpatient vs outpatient funding Agency and Service Delivery Boundaries
Integration with community service providers (inpatient vs group homes)
Insurance Model vs Biopsychosocial Model
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Program Level Tensions
Business Model vs Clinical Model Occupancy rate vs best interest of child/youth
Accountability vs Quality Improvement
Leadership Salaries vs Line Staff Salaries
Liability vs Learning Culture Environment Documentation driven by legalities vs clinical need
Clinician vs Administrator Tension Time allocation: Administrative Duties vs Clinical Duties
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Family and Child Level Tensions
The Unequal Information Tension
Parents vs Professionals – who cares more?
What youth want vs What Others Want for Them
Child Focus vs Family Focus
Parent Responsibility vs Parent Blame
Discipline expertise vs Team Consensus I’ve assessed this child, I know this child best.
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Syndromes
“ Habitual maladaptive patterns of behavior that have developed as a result of the historical, philosophical and contextual environment in which children’s public mental health has developed.”
Lyons, 2004
Syndromes develop in response to tensions.
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System Level Syndromes
The political dog walk Field of dreams What’s mine is mine but what’s your’s, well,
that’s negotiable
Example: “Not my job” – Level of supervision in group
homes
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Program Level Syndromes
Colonel Sander’s Syndrome Therapist Illusion Rose Reversal Public Funding as an Entitlement
Examples: “Rules are Rules” – no visitors for 24 hrs,
- lights out at 10:30 pm
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Child and Family Level Syndromes
Expert Syndrome Hammer-Nail Syndrome Happy Face Syndrome Ostrich Syndrome Fuzzy Pathogen Imagined Cure Endless Treatment
Example: “What is the appropriate bedtime for a 9 year old?” – Parents vs team Changing the CANS to reflect a personal view
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II. TCOM – the Framework
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Rethinking how we manage children’s services: Total Clinical Outcomes Management (TCOM)
The philosophy of TCOM is that the needs and strengths of the client/patient should drive the process of care.
The optimal means of achieving the goal of ‘uniform individuality’ is through the use of structured, evidence-based assessments.
Within the TCOM approach, standard assessment processes drive decision making at the individual child and family level, the program level, the hospital level, and ultimately, the system level.
The articulation of TCOM principles represents an important shift
in how services are managed.
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Rethinking how we manage children’s services: Total Clinical Outcomes Management (TCOM)
No longer are standardized clinical assessments the domain of research and evaluation only.
Rather these assessments become key components in the
process of clinical service delivery.
Arbitrary lines between clinical operations and program evaluation are eliminated. They are the same thing.
Effective management, like good evaluation, requires accurate information, relevant to the objectives of the service.
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Total Clinical Outcomes Management
Total means that it is embedded in all activities with families as full partners.
Clinical means the focus is on child and family health, well-being, and functioning.
Outcomes means the measures are relevant to decisions about approach or proposed impact of interventions.
Management means that this information is used in all aspects of managing the system from individual family planning to supervision to program and system operations.
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Primary Tenet of TCOM The primary tenet of TCOM is that effective services in complex child
serving systems require a focus on a shared vision of the children and families receiving services.
Complex systems require the collaboration of multiple partners each with different mandates, agendas, and priorities.
The facilitation of communication among all system partners, including youth and families is necessary.
Despite differences, all partners share a commitment to serving children and families.
Accountability to the child and family is required between all partners at all levels
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Collaboration and Communication
Multiple Partners:Child / YouthFamilies
Educators Caregivers (foster parents, group home staff, respite)Health Care Providers
Case Managers Community Clinicians / Therapists
Child Welfare WorkersProbation Officers
AdministratorsAgencies / Hospitals / RTC’s / Jails /
Schools and School Boards Policy MakersFunding Sources (Government or Insurance)Courts
20Hierarchical Structure
Judge
Child Welfare Case Worker
Mental HealthCase Worker
Juvenile Justice Case Worker
Treatment ProvidersEducators
Youth’s Supporters
YouthYouth’s FamilyOthers
Decision making authority concentrated at the top
Decisions flow
downward
Complex and confusing webs of accountability
Characteristics of Accountability Networks in Traditional Child Serving Systems
“Traditional” child serving systems are multisystemic and involve a variety of stake-holders, each with their own priorities, needs, and funding streams. These stakeholders typically include:
Inform
ation
flows upward
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The” tighter” integration of stakeholders
Characteristics of Accountability Networks in Systems of Care
Systems of Care strive to replace traditional systems of hierarchical accountability with team-based and collaborative “circles of accountability” that are typically characterized by:
Judge
Youth
Child Welfare Case Worker
Juvenile Justice Case Worker
Treatment Providers
Youth’s Family
Mental HealthCase Worker
Educators
Youth’s Supporters
Others
An increase in “wraparound” sensibility
Flexible circular patterns of communication & accountability that are not constrained by formal structures
An increase in the importance
of collaboration, interdisciplinary
team work and group decision
making
A decrease in the
importanceof
authority determined
solely by rank
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Paradigm Shift
Shift in management of services Theoretical
Understanding the concepts and how they fit together Personal Conceptualization
How the theory fits with one’s own personal values / professional identity and role
Practice Integrating / translating theory into practice
Organizational Documentation, process
Articulation Language, terminology
Shift in vision My vision Shared vision
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My Vision
Judge
Child Welfare Case Worker
Juvenile Justice Case Worker
Treatment Providers Youth and Family
Mental HealthCase Worker
EducatorsYouth’s Supporters
Others
?
?
?
?
?
?
?
? -Budget
-Time
-Theory
-Scope of Practice
-Values / beliefs
Collaboration = Shared Vision
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Shared VisionJudge
Child Welfare Case Worker
Juvenile Justice Case Worker
Treatment Providers
Youth and Family
Mental HealthCase Worker
Educators
Youth’s Supporters
?
?
?
?
?
?
Shared Vision
Youth and Family
Care
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Understanding our Marketplace:The Hierarchy of Offerings
I. Commodities: raw materialsII. Products: mass produced from raw
materialsIII. Services: hiring someone to apply a productIV. Experiences: memoriesV. Transformations: opportunities for change
as a person or family
- Gilmore & Pine, 1997
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Further Challenge to the Child-Serving System We have been managing services not
transformations You cannot manage what you do not
measure We must manage transformational offerings
which requires that we measure the transformations.
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Achieving Key Tenets
Maintaining the focus of assessments on children and families informs decision making at the five levels of the system the individual child and family level the program level the hospital / agency level the community level the full systems level
A central management strategy is used to ensure that all decisions are informed by an understanding of the needs and strengths of children and families. Assessments of needs and strengths of child and family (ie
CANS) needs to be embedded within the clinical service
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Child and Adolescent Needs and Strengths (CANS) Tool CSPI was developed CANS-MH builds on CSPI methodological approach
but with broader conceptualization Assessment Communication to team / system of care Decision support for service delivery Quality assurance monitoring
Retrospective / Prospective Reliability Validity
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Child and Adolescent Needs and Strengths: A Communimetric Measure Psychometric Communimetric
Fewer items required, shorter measure Immediate results, no need for scoring
Decision support focused Levels of need translate directly into action levels Measures are reliable at the item level Tool must be meaningful to the service delivery process All partners involved in communication process should be
involved in design of measure The value of the measure should be evaluated by its
communication utility
Common language for multidisciplinary settings
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Six Key Characteristics of a Communimetric Tool Items are included because they might impact
service planning Level of items translate immediately into action levels It is about the child not about the service Consider culture and development It is agnostic as to etiology—it is about the ‘what’ not
about the ‘why’ (2 exceptions: trauma and social behaviour)
The 30 day window is to remind us to keep assessments relevant and ‘fresh’
Numbers exist to add stories together=communimetrics
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CANS – A Communimetric MeasureAction Level Key
Needs: 0 - No Need1 - Watch/Prevent2 - Act3 - Act Immediately/Intensively
Strengths:0 - Centerpiece1 - Useful2 - Potential3 - None identified
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CANS Tools
Sector: Mental health, juvenile justice, developmental, Age: 0-5, YANSA, ANSA Comprehensive: Illinois, Indiana, New Jersey, New York,
Connecticut, Tennessee
Training Websites: Indiana
http://www.communimetrics.com/CansCentralIndiana/ New York
http://www.communimetrics.com/CansCentralNewYork/
Illinois http://www.dcfscansnu.com/
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CANS Implementation Tennessee: DCS Implementation of the CANS in child welfare system
All child welfare case workers have been trained in the CANS. They have developed four University partners at Centers for Excellence (e.g.
Vanderbilt, UT Memphis). These partners have become trainers and supervisors and monitor the quality of all assessments.
Agency: Choices Inc – Implemented TCOM approach in agencies in Indiana, Ohio, and Maryland.
They have embedded the CANS in their clinical management software system and use it for service planning, supervision, and program evaluation.
Instrumental in supporting Indiana and Maryland in adopting the CANS.
Indiana: FSSA Design and implement a cross-systems CANS version In the past years, partners from mental health, juvenile justice, child welfare, and
schools participated in the design phase. Now implemented in juvenile justice, child welfare and possibly medicaid A cross-systems web-management system was designed and implemented at that
time, too. More than 250 Super Users were created to facilitate the implementation process
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Steps to Transformation
Data (numbers)
Content
Information
Clinical Content
TCOM
The form - CANS
Tool
Framework
Transformation
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Family & Youth Program System
Decision Support
Service Planning
Effective practices
EBP’s
Eligibility
Step-down
Resource Management
Right-sizing
Outcome
Monitoring
Service Transitions & Celebrations
Evaluation Provider Profiles
Performance/ Contracting
Quality Improvement
Case Management
Integrated Care
Supervision
CQI/QA
Accreditation
Program Redesign
Transformation
Business Model Design
TCOM Grid of Activities TCOM Grid of Activities
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Service Planning
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Need Goal Plan of Action / InterventionsSignature /
Date
Suicide risk
Reviewed with: parents Agree? Y 6/10/06 Initial: JD
patient Agree? N
8/10/06 Initial: KB
Maintain patient safety
Goal met Goal /modified Goal active at d/c
- Put on d/c summary
• Standard Suicide Risk care plan
• Obtain assessment from past inpatient admission
• Explore safety risks / supervision in the home
• Evaluate personal coping mechanisms
MSmith RN
06/10/06
DJones CYC
08/10/06
SDoe SW
09/10/06
Dr.Lee PhD
09/10/06
Strengths: Community
Choir Talents / interests
SwimmingInterpersonal
Leadership
Ways to build on these strengths
1. Encourage regular daily physical exercise (yoga)
2. Maintain contact with swim team coach
3. Safety permitting, give short passes to attend choir practice
4. Give opportunity to explain goal group to new co-patients
5. Encourage phone calls to friends in community
Interdisciplinary Action PlanInterdisciplinary Action Plan
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Matching Needs to Evidence-Based Practices Trauma
SPARCS TF-CBT Parent-Child Psychotherapy
Oppositional Behavior Collaborative Problem Solving
Depression CBT
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Eligibility
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Decision models using the CANS
Profiles of actionable needs including patterns of ‘2’ and ‘3’ ratings rather than total scores with cut-offs
Supports decisions rather than makes them Evidence that CANS recommended level of
care associated with improved outcomes
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Figure 1. Functional Status Score comparing CANS/CAYIT agreed referrals to residential treatment with CANS referrals (Concordant) to lower levels of
care who were placed in residential treatment (Discordant)
28.5427.02
25.46 25.73
35.65
25.68
0
5
10
15
20
25
30
35
40
CAYIT CANS (p<.01) 1st Residential CANS(p<.05)
3-6 Mo. Residential CANS
Concordance
Discordance
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Resource Management
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44
45
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Service Transitions & Celebrations
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Service Transitions & Celebrations
Discharge from one program should be the starting assessment of the next.
Families tire of repeated and ceaseless assessments.
Sharing outcomes using structured assessments communicates differently than a ‘buddy-hug’ and ‘good job’.
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Program Evaluation
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Children’s Unit Program Review
What do we know about our children and families? Reviewed clinical and demographic information
on the children and families we served Literature Review
Trauma Phone Survey Formed a workgroup of staff who do
programming Retreat Day
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Key Demographics – Gender & Age
25%
75%
Male Female
19%
40%
41%
7 and under8 to 1011 to13
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Provider Profiling & Performance Contracting
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Overall CAPI
0.0
0.5
1.0
1.5
2.0
0 1.5 3 4.5 6 7.5 9 10.5 12
Months Since Admission
Ave
rage
Ite
m S
core
Overall CAPI
Albertina Kerr
Children's Farm Home
Christie School
ECC
EOAMTC
Parry Center
Riverbend Youth Center
SOASTC
EOPC/CAT
OSH
Scar/Jasper Mountain
Waverly
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Case Management, Integrated Care,Supervision
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Using Structured Assessments in Child and Family Teams Creates and documents a shared vision that is
directly translatable into action Provides a ‘navigator map’ to parents and other
caregivers Creates accountability for team decision-making Sets the stage for understanding outcomes and
effective resource management Either done in preparation for the team or in the team
meeting itself (useful for team building but can be time consuming)
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Admission Acuity – Top 5
2 or 3 3
1. Family Functioning 75% 34%
2. Educational Functioning 60% 37%
3. Peer Functioning 48% 15%
4. Aggressive behaviour - people 42% 13%
5. Impulsivity 38% 11%
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CANS Top 10 Needs
2 or 3 3
1. Treatment 93% 21%
2. Attention Deficit / Impulse Control 65% 12%
3. Emotional Control* 60% 20%
4. Danger to others 56% 6%
5. School behaviour 49% 18%
6. Oppositional behaviour 49% 5%
7. Sensory / stimulation sensitivities* 47% 0%
8. Education* 46% 15%
9. School Achievement 44% 18%
10. Family 43% 12%
* new item on CANS-MH 3.0
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CANS - Strengths 0’s and 1’s (Evident Strengths)
72% Relationship Permanence 67% Family 67% Optimism 60% Interpersonal 57% Cultural* 50% Life Skills* 42% Talents / Interests
2’s (Potential Strengths) 78% Wellbeing 57% Flexibility / adaptability to change* 53% Talents / Interests 50% Community Involvement* 50% Self Expression*
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QA/CQIAccreditationProgram Redesign
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Program Review Outcomes
Shifts in resources Increase in Social Work and Occupational
Therapy Resources Integration of OT into daily programming
Incorporation of new key concepts Trauma-informed care
Reinforced current philosophy Collaborative Problem Solving Key role of school
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Program Review Outcomes
Integration of key concepts into daily programming New schedule (chill time) Increased staff-parent collaboration
Retreat - Team Strengths based care Family centered care Trauma informed care
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Hospital Level
Sharing of clinical outcome data with various hospital teams Accountability, accreditation
Collaborated with other hospital services Emergency Department: Sharing information at individual
and program level Day treatment school program: Steps to Success Outreach services
Documentation Review – Electronic Knowledge Based Charting
Development of outcome management and tools for Consultation / Liaison team
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Community/Network Level
Development of outcomes management approach with CHEO Outreach services Outreach to rural communities
Partnerships with other sectors of care in our community Child Welfare, Youth Justice, Education, Community
Centres Building of stronger community partnerships with local
agencies Invite to discharge meetings
Collaborate with our Local Health Integration Network (LHIN)
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TransformationBusiness Model Design
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Figure 1. Level of Need by Year for Admissions into Residential TreatmentN=2782
0
2
4
6
8
10
12
14
16
18
Beh/Emotion RiskBehaviors
Functioning Strengths
2003
2004
2005
2006
2007
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Figure 6. Comparison of total score for RTC, CMO, and YCM initial assessments by year
0
5
10
15
20
25
30
35
40
2003 2004 2005 2006 2007
YCM
CMO
RTC
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Figure 8. Average Improvement over the course of Residential Treatment by Year Note: higher score better improvement)
0
1
2
3
4
5
6
7
Beh/Emotion Risk Behavior Functioning
2003
2004
2005
2006
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Redesigning Services for Children and Youth with Autism Provincial model in Ontario emphasizes
Intensive Behavioural Intervention (IBI) only Three funding streams for same children—
program, parent, Ministry No clear criteria to allow for flow through of
children through the system
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Impact of TCOM approaches
Reduction by 1/3 of children and youth placed in residential treatment in child welfare in Illinois
Improvement in psychiatric hospital decision-making and elimination of racial disparities
Identification of need for intensive community services in New York State
Expansion of TFC capacity and subsequent reduction in use of congregate care in Philadelphia
Expansion Transitional Living Program capacity in Illinois
Improved outcomes in Residential Treatment
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Family & Youth Program System
Decision Support
Service Planning
Effective practices
EBP’s
Eligibility
Step-down
Resource Management
Right-sizing
Outcome
Monitoring
Service Transitions & Celebrations
Evaluation Provider Profiles
Performance/ Contracting
Quality Improvement
Case Management
Integrated Care
Supervision
CQI/QA
Accreditation
Program Redesign
Transformation
Business Model Design
TCOM Grid of Activities TCOM Grid of Activities
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Implementing TCOM
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Key Aspects in Process of Introduction of TCOM
Resources Support from Administration
Commitment to vision Funds
Human Resources Training Workgroup Participation
Buy-In Mandate Clear direction from an administration that is stable over time Opportunity for involvement from all partners at all steps
Tailored to setting Clinically relevant and user friendly
Built in process for review
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Keys to Successful Implementation
Recognition of central role of needs and strengths Foster a culture that embraces change Introduce change in incremental steps Meaningful link to care important to secure buy-in. Select clinically meaningful outcome measures Minimize burden on patients, families and staff Share aggregate clinical data regularly Secure appropriate human and financial resources Common vision and long term commitment required Get started immediately following training
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Key Concepts for Change
Planned Incrementalism
Make sure tools are useful with individual children and families.
Make sure everyone actually uses the tools
Do not become institutionalized with your measures
Establish the objectives and mandate of each program.
Start basic. Easy to understand. Use graphs to show statistical information
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Keys Concepts for Change
Pilot. Nothing should ever be written in stone.
“Do not let resistors, obfuscators, nitpicking obstructionists or the nabobs of negativism block progress”.
Train administrators & evaluators in the use of tools.
Make decisions based on clinical information.
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