Measuring strengths & recovery

Observations on the Mental Health Center of Denver

The Mental Health Center of Denver Private non-profit Mandate to serve the most ill:

Schizophrenia, Bipolar, Major Depression City of 500,000 in metro area of 2 million Serves 3,000 adults any point in time Turns away 2 for every 1 accepted

Services for adults

IntensiveVarious levels of clinical case management

Outpatient Psychiatric Rehabilitation

Supported Education & Supported Employment

Why Visit Denver? MHCD has established an

international reputation for being “recovery oriented”

We wanted to discover:How this had been achievedWhether we could do it in the North

West

How was it achieved?

Organisational structure & Philosophy Managerial practices

“Clinical” leadershipApproach to staff developmentEmployment practices

Recognition of the value and uses of data

Structure and Philosophy

Influence of vocational rehabilitationSeparate directorate represented at board

levelNot managed by clinical services

Centrality of the strengths and recovery model

Managerial Practices

Clear philosophy of care Relatively unbureaucratic approach Use of strengths approach with staff

For example in PDPs Performance evaluation through data Active stepped care

Employment practices

Employs large numbers of service users in multiple roles – some very high levelThis gives service users a very strong stake in

the organisation Emphasis on Individual Placement and

Support

Using and Valuing Data

Data expectations are clear and achievable

Strong IT department which employs statisticians

Data is used throughout the organisation to change practice

Defining Recovery

Recovery is a Multidimensional construct

Recovery means different things for different people

Consumers, Clinicians, Managers, other Stakeholders

These different viewpoints need to be captured in different ways

Measures of Recovery Recovery Markers Inventory (RMI) Recovery Measure by Consumer

(RMC) Recovery Needs Level (RNL) Promoting Recovery in Organizations

(PRO) The measures of recovery have been

extensively tested for reliability, sensitivity, and validity

Recovery Marker Inventory

Consists of a series of indicators usually associated with individual’s recovery Based on items derived from surveys of consumers

and staff Collected every other month on every consumer

in high case management teams, according to a predetermined criterion on outpatient consumers

Recovery Marker Inventory Dimensions Employment Education/training, Active/Growth orientation, Symptom interference, Engagement/role with service provider, Housing, Substance abuse (level of use & stages of

change).

Item difficulty for the Recovery Marker Inventory V2.1

• The easiest marker is reduction in symptom interference. In traditional treatment this will be primary goal.

• As the markers increase in difficulty that means that the number of consumers that get a high score in this marker decreases,

•For example, if a consumer has a high score in engagement/participation, they will also have a high score in active growth and symptom interference because these markers are easier to achieve for our consumers.

• The hardest marker of recovery for consumers to achieve is education. This means that most consumers who score high on education will score high on all other markers of recovery.

Changes in Recovery Markers Inventory based on Diagnosis

Estimated Changes in Recovery Marker Scores Over Time

3

3.5

4

4.5

5

5.5

Intake 6 12 18 24

Evaluation Period (Months)

Ab

ility

-to

-Rec

ove

r S

core HITT Mood and Other

CTT Mood and Other

OP Mood and Other

HITT Thought

CTT Thought

OP Thought

Recovery Measure by Consumer

Intended to measure the consumer’s perception of their Recovery Helps to understand whether what the clinician

observes matches how the consumer is feeling

Sometimes, the consumer fills it out with the help of the clinician, thus sparking new areas to explore together

Recovery Measure by Consumer Dimensions Active/growth orientation Hope Symptom’s interference Safety Social network

Order of Difficulty in RMC V3.0

The easiest domain is reduction in Symptom interference, (this was also our lowest indicator in the RMI).

As the domains increase in difficulty (move to the right), the number of consumers that get a high score decreases, For example, if a consumer has a high score in Hope they will

also have high scores in Active growth and Symptom interference because our consumers get higher scores in these items.

The hardest domain to achieve is Social networks. This means that consumers who score high on Social networks will score high on all other domains of recovery.

Recovery Needs Level

Helps to assign the right level of service to the consumers

The basic assumption being that consumers recover and their needs change over time.

Used at MHCD every 6 months in combination with their Individual Service Plan (ISP)

Recovery Needs Level

Measures criteria for service needs in 15 areas such as:

GAF Hospitalizations Lethality Co-Occurring Substance Abuse Case Management Needs

Recovery Needs Level

Completed by Primary Clinician in Electronic Record

Scored Electronically According to Algorithm

Four Levels of Service: High intensity case management with Residential

services High intensity case management Medium intensity case management Outpatient service

Promoting Recovery in MH Organizations (PRO) Sections for each type of staff that

interacts with our consumers (front-desk clinical, medical, case managers, rehabilitation)

Currently is being piloted at MHCD

The Feedback Loop

“At MHCD, we believe that evaluation is a critical component of system change.”

“We have a constant feedback loop about client’s recovery for clinicians, managers and directors, thereby providing data to assist in system transformation.”

(1) Recovery Marker Inventory (RMI)

(Longitudinal data to support clinical decision making)

(3) Recovery Measure by Consumer (RMC)

(Consumer’s perception of their own recovery)

(2) Promoting Recovery in Organizations (PRO)

(Consumer’s perceptions of how well specific programs and staff are

promoting recovery)

To what degree is RECOVERY

happening for consumers at MHCD

(Formative and summative evaluation of recovery)

Can be used as a “needs assessment” instrument in Recovery-Oriented Organizations

(4) Recovery Needs Level (RNL)(Appropriate level of services)

Four Measures of Recovery

Pros and Cons

The clinician rated measure has been very carefully developed, has good properties, and is easy to use

The service user rated measures is at an earlier stage of development

The Recovery needs inventory would need major modification