“Navigating the Outcome Morass”

1. “Navigating the Outcome Morass” Factors in the Selection of the Daily Living Assessment-20 (DLA-20) Lance R. Heffer, PsyD

2. Outcome has moved from a largely academic pursuit of the nature of psychotherapy to a more general context: * Narrow focus on circumscribed symptoms: “pure pathology” within a “pure technique” * Focus on “client variables,” therapist variables” and the “interaction” * Problems in generalizing: * Subject samples * Setting Outcomes and Behavioral Health

3. “The Larger Context”Community Mental health Movement * Emphasis on serious and persistent conditions versus “neurotic” disorders. * Programming that include intensive levels of intervention (day programs, / 24-7) Recovery Movement (President’s Commission) * Emphasis on Consumer involvement * Integration * Independence (choice)Economic * Private sector abuses of the 80’s and 90’s (proliferation of private psychiatric facilities) * Expanding behavioral health benefits * Constricted health budgets * Utilization Review (medical necessity)

4. Large Context (cont.)These factors have combined to press for the need to demonstrate outcomes not only for psychotherapy but also for programmatic “ancillary” or related services (TRP, residential, case management, etc.)The problem becomes: “What is it we measure and what are the elements of successful outcome” – Criterion Measurement Problem

5. Symptoms and FunctionalitySymptoms are an expression of a disease entityFunctionality is the degree to which an individual is limited in the “real world” by that symptom and/or diagnosable entity * “Real world” can be best conceptualized as one’s ability to love (manage relationships) and work (generativity of some kind) and the day- to-day expectations necessary to sustain those primary activities (maintain personal safety, self-care, utilize community resources, collaborate with care providers, etc.)

6. Symptoms and Functionality (cont.)The emphasis on symptoms is understandably driven by the DSM IV (American Psychiatric Association)Physicians intervene primarily at the molecular or tissue level (psycho-pharmacology)Non medical professionals historically have contributed to the overemphasis on symptomatology due to graduate school curriculaBoth kinds of providers work on symptoms from different perspectives but none-the-less narrow the view of the person and negatively affects a broader, more complete outcomeWe all know that there are people with virulent symptomatology that function well in the world (Monk). Conversely those with relatively low symptomatology can have serious or even pervasive impairments in their ability to navigate the demands of life.

7. “Where are We ?”Our current efforts largely lack cohesiveness but * We do have a general appreciation for the interaction of symptoms interaction of symptoms and functionality but our outcomes are generally program specific (Mult Nomah) * Some outcomes need to be symptom-driven: Inpatient, crisis stabilization, more intense levels of drug programming (BPRS) * We routinely incorporate consumer feedback * We have “macro” outcomes with meaning: (hospitalization rates, reduced legal involvement, school attendance etc.) But: * Our outcomes are not linked in a coherent way with the obvious differences in medical and non-medical service delivery (Medical Necessity)

8. “What to do?”The single common denominator for everyservice in behavioral health is the Five Point Axis Diagnosis, regardless of disability(MH, MR/DD, SA)While Axis I is largely a compendium of symptoms, Axis V is the Global Assessment of Functioning (GAF)

9. “Problems with the GAF” Notoriously unreliable due to: * Lack of focus in graduate programs * Historically viewed in a derisive manner by clinicians * Vulnerability to legal/economic factors

10. Willa Presmanes Med, MADuring Communicare’s reorganization Ms. Presmanes became aware to us through David Lloyd, our consultant.Ms. Presmanes’ work over the past twenty-years has been in researching a “cross-walk” through functional assessment to provide valid, reliable GAFIn extensive studies she and her collaborator (R. Scott PhD) were able to distill 20 functional elements.

11. DLA-20Twenty item scale across all significant areas offunctioningSeparate forms (similar functional domains) for Adult mental Health, Substance Abuse, Youth Mental Health and MR/DDTime efficient (6 – 10 minutes) for administrationScoring easy and mathematically elegantPost training reliability coefficients within and across professional discipline + .80

12. Benefits of the DLA-20Allows coherent structure of levels of care that includefunctionality as well as symptom and risk.Rooted in routine clinical practice for all consumers (diagnosis) Allows easy access to individual outcomes (change in GAF. Pre-post) – (in fact individual change scores for domains as well aggregate)Leads to a coherent utilization management system * Entry / Exit criteria * Programmatic * Individual providerSignificant increment to the demonstration of medical necessity: “The Golden Thread”

13. The “Golden Thread”Links initial assessment (DLA-20) toTreatment Planning * Leads to a more “rational” division of labor (medical focuses on symptoms and non- medical on the limitations created by the symptoms) * Assists providers and consumers to select most exigent of limitations * Subsequent documentation to the plan (progress notations)

14. SummaryCommunicare status and initial experience (“outliers”)Willa Presmanes – * Contact information – requirementsWilla.Presmanes@gmail.comRecommend contact with Ms. Presmanes and strong consideration of the DLA-20 derivedGAF as central outcome.