EVALUATION OF A 4 WEEK REHABILITATION ASSESSMENT PROGRAM AT ST VINCENT’S MENTAL HEALTH COMMUNITY CARE UNITS: MENTAL HEALTH CONSUMERS’ AND CLINICIANS’ PERSPECTIVES
Jodie Key 1, Corinne Owens1, Michael Wilson1 & Melissa Petrakis1,2
1
St Vincent’s Mental Health Service, Melbourne, Australia
2
Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
ABSTRACT Background: Some consumers with a mental illness benefit from intensive residential-based rehabilitation in a community setting. A 4-week Rehabilitation Review Program (RRP) has been introduced at a community care unit (CCU) to identify areas of need for rehabilitation. Aims: To share a qualitative evaluation seeking consumer and clinician perspectives on the RRP process. Methods: Interviews were conducted with a purposive sample of consumers who participated in the RRP. Online surveys were sent to multidisciplinary referring and CCU clinicians. A thematic analysis was conducted. Results: Consumers reported the RRP was useful to judge goodness of “fit” for the setting; however that the process was somewhat overwhelming, and both the rational and process could be clearer. Clinicians reported the process assisted with clinical decision-making, and enhanced role satisfaction, yet was repetitive. Conclusions: Implications are that the process of the RRP could benefit from revision in order to more fully embrace recovery principles.
Correspondence: Jodie Key Acting Senior Clinician, Occupational Therapist, Footbridge CCU, St Vincent’s Mental Health Service 540 Napier Street, North Fitzroy VIC 3068 t: +61 3 9481 5644 | f: +61 3 9481 4193
[email protected]
BACKGROUND Community care units (CCUs) were initiated in 1996 as part of a shift in mental health care from large institutions to community based treatment. CCUs ‘provide medium to long-term accommodation, clinical care and rehabilitation’ (DHS, 2007). The guidelines set out by the Department of Health about the role of CCUs are broad so that individual services can create a program that suits their consumers and catchment area profile (DHS, 2007). The evaluator discovered through consultation with a number of Victorian based CCUs that each program runs quite differently. Although each adheres with the departmental guidelines, they 1
vary in the way they assess consumers’ rehabilitation needs and suitability for the intensive rehabilitation program offered (DHS, 2007). A review of the literature shows there to be a wealth of knowledge published about the principles of recovery oriented practice; engagement, supporting self-determination and hope with consumers who suffer with enduring mental illness (Rapp & Goscha, 2006; Slade, 2009; Department of Health Victoria, 2011). The purpose of the helping relationship in which consumers and clinicians enter is to enable ‘the conditions in which people have the agency to determine their own options’ (Department of Health Victoria, 2011, p. 9). However little research has been conducted specifically on CCUs and how it is that their program supports consumers through their recovery journey. The evaluator discovered through consultation with a number of Victorian based CCUs that each program runs quite differently. Although each adheres with the Departmental guidelines, they vary in the way they assess consumers’ rehabilitation needs and suitability for the intensive program (DHS, 2007). An action research study by Leighton (2005) found that a UK based residential rehabilitation service revised its assessment procedures to include a society-centred approach rather than an individualised approach. This program did also revise its referral process to include admission criteria; age, mental state and a particular focus on the consumers’ motivation as ‘a key factor within successful rehabilitation’ (p.337). Munro et al. (2007) describes the model of the residential based service delivery offered in Queensland as being based on a case-management model, similar to the Footbridge CCU. However the study did not go into detail about referral or assessment processes and how it is decided who receives the service and who does not. Munro (2007) describes the occupational therapy (OT) role primarily as one of assessment, which functions as “assisting the referral process” (p.262). The study also gathered a consumers’ view on the benefits of CCU (Munro, et al., 2007, p. 260): It’s a lot better than being in hospital. They give you more freedom and they also are there when you feel that you need help. CCU is a temporary place so people like me can get better and they help you get on track when you live in the community A study by Trauer et al. (2001) found that consumers residing at CCUs showed minimal changes in their mental health symptoms but transitioning from institutional care (12 months post) to this environment improved their “quality of life in relation to their ‘living environment’ (p.419). There is strong evidence around what interventions and facilities should be provided in longterm residential mental health settings as indicated by a systematic review conducted by Taylor et al. (2009). There are few studies however that articulate the inner workings of how CCUs and residential services assess if a consumer would benefit from long-term rehabilitation or how clinicians utilise their skills to contribute to this decision-making process. Furthermore, there was no evidence found about how mental health consumers experience the process of being clinically assessed and accepted or not accepted into the program. The Footbridge CCU has been running its Rehabilitation Review Program (RRP) for approximately 8 years. According to managers past and present, the idea of creating an assessment bed arose from a need to look at suitability of consumers for the intensive recovery program that is offered at the CCU. Since its evolution, there has been no formal evaluation of its processes or how service users: consumers and clinicians perceive it. An action research study by Leighton (2005) found that a UK based residential rehabilitation service revised its assessment procedures to include a society-centred approach rather than an individualised approach. This program also revised its referral process to include 2
admission criteria; age, mental state and a particular focus on the consumers’ motivation as ‘a key factor within successful rehabilitation’ (p.337). There is a range of evidence highlighting the value of consumer participation in informing service development. The current report recognises the value of consumer perspective in creating a service that is more accessible and suited to consumers needs. The following evaluation gathers the consumers’ perspective along with the clinicians’ perspective on this program. Evaluation Questions What are the consumers’ perceptions of the RRP program? Do they find it helps with their recovery? Do the referring clinicians find RRP useful? Do the multidisciplinary team (MDT) of clinicians who complete the assessments find it helpful in gaining a greater understanding of the consumer? Do they find it a valuable use of their time?
METHODS Phase 1 – Consumer Interviews: Semi-structured interviews with consumers who have participated in the rehabilitation review program since 2010 till April 2012. Consumers were provided with a brief explanation of why the evaluation process was being conducted and were provided with an explanation around confidentiality. Ten consumers were approached, 7 participated and 3 consumers declined. Consumers were offered an opportunity to choose a pseudonym for reporting. Phase 2 – Consultation with Clinicians: Two online questionnaires distributed to clinicians of St V’s mental Health service: Clinicians who have referred to the program since 2010. Clinicians of the MDT who currently work at the CCU and participate in the rehabilitation review assessments. The questionnaire included closed, forced choice and open questions. There was a 23% response rate (5 of 22) of clinicians across the service who have referred to the RRP over the past 2 years. During the time of the survey, there was industrial action for nursing and allied staff that is likely to have affected the data collected. The qualitative data from the open-ended questions was coded using a qualitative thematic content analysis. Phase 3 – Documentation: Clinician Time use data – clinicians were asked to on a one-off occasion, document the time spent clinically (direct consumer contact and indirect i.e.: report writing, gathering history). This was also utilised as a proxy measure for engagement Referral documentation was reviewed (January 2010 – January 2012). RESULTS Consumers’ Perspective Consumers interviewed described the RRP as a way for the CCU staff to see if the consumer is “the right fit” for Footbridge: “to make sure you fit well at Footbridge.” – Tom 3
Consumers described their experience of the RRP as an invasion of their personal space and indicated they were overwhelmed by number of contacts with clinicians during this time: “Doing all the interviews. Some days I would have interviews with the doctors and OT’s and things, twice in a row” – Phillipa. Consumers reflected their experience of a lack of feedback from clinicians during the review period. “It would be nice if someone would go through the recommendations with me” – Jenny and “can’t remember recommendations or someone sitting down with me” – Michael Consumers indicated a lack of clarity or consumer involvement around the referral to the RRP. Some consumers agreed to participate in the program on advice of their case manager and loved ones. For others, they saw the program as an opportunity to secure accommodation: “The case manager and my dad thought it was a good opportunity to learn skills” Kelly and “my understanding was that I had nowhere else to go, and this was the first thing that came up” - Jenny. Another consumer stated: “Wasn’t explained. Referred from the St Vincent’s Hospital not from community case manager.” – Bobby
Referring Clinician Perspectives The feedback was: “A useful and enlightening process – learning new things about the consumer.” Referring clinicians overall indicated the RRP to be a useful process despite the time intensity of the process. Clinicians indicated that involvement in team discussions with CCU staff was helpful: “I discovered things that I was not able to observe due to limitations of my role” - Martha. Of the clinicians who responded to the questionnaire, 100% stated they learned new information about the consumer they referred to the RRP. Clinicians indicated the reports assisted with clarification around clinical decision-making and interventions: “they were required to make a decision about the client returning home and this was obtained so very useful” - Henry. “…I was able to put supports in place and change the type of intervention used to engage with the consumer…” – Hilda. It was also articulated that there was repetition of information within the reports provided by the CCU MDT: Repetition of reported information “There was one report that seemed to repeat on what had already been said” - Martha. 100% of clinicians reported they perceived the OT report to be helpful, with 60% each the file review and psychology report to be helpful. The reports provided by Social work, Medical and nursing were rated at less than 10%. Footbridge MDT Perspective Within the Footbridge clinicians’ feedback, there were 5 key themes: RRP helps to gain a greater picture of the consumer. The RRP provided clinicians with an opportunity to engage with consumers: Peter – “build rapport while doing assessment” and develop an understanding how the consumer may engage in recovery oriented work: Meredith – “does give some picture as to the capacity of clients to participate in recovery”. Clinicians also indicated they found conceptualisation of the consumers’ presentation from other disciplines perspective useful: Dwayne –“Yes, greater understanding from various discipline's input”. One clinician stated that involvement in the RRP helped them to feel a valued part of the team. 4
Enhanced role satisfaction for clinicians – Clinicians described from a number of viewpoints, their enhanced role satisfaction in participating in the RRP. Clinicians indicated the opportunity to utilise assessment skills and their discipline specific expertise to be a positive of participating in the program: Matt –“I enjoy doing discipline specific work that the RRP allows me to do”. Clinicians also described the benefits of the program and engagement with the consumer. The clinicians described the benefit of being able to work with a range of consumers of varying presentations: Andy – “very challenging and all clients are so different with different issues to tackle - excellent for increasing skill” and Meredith – “It is rewarding getting to know and understand clients.” Clinician sensitivity to the consumers needs - clinicians’ expressed an awareness of the imposing nature of this review period onto the consumer. Clinicians articulated their observation of the challenges for some consumers to adapt to a new environment and program expectations: Dwayne – “The client needs at least that time frame to settle in to the environment”. Clinicians stated a need for flexibility around time frame to meet consumers needs rather than that of the teams: Jay – “it’s good to be able to extend or shorten according to individual circumstances” and Matt – “client is not very easily engaged or has other commitments that the review takes longer.” Time burden of the RRP and how this contradicts the recovery principles – The majority of clinicians expressed that they felt quite a pressure on them in terms of the time taken to complete the many tasks related to the RRP; engaging with the consumer, gathering history, writing the reports. Jay - “a lot of time and focus is spent on the report, not really getting a good sense of how the person is.” Within the feedback there was some indication from clinicians of their perception of the incongruence of the program constraints and the nature of clinical assessments with relation to how it fits with recovery principles: Pamela – “The identification of strengths is in line, the pacing isn't” and Meredith – “I think clinicians tend to focus on peoples weaknesses and illness. This does not reflect a person’s strengths or willingness to participate in the recovery program.” In comparison to the most commonly held view, one clinician felt there was adequate time in which to complete the RRP tasks: Meredith - “Too long. Can be done in 2 weeks.” A repetition of processes – Similar to the clinicians who referred to the program, the MDT identified a repetition of the information gathered between disciplines within reports: Dwayne –“Need to clarify each discipline area of assessment, seems that there is some double up at times” and Jay - “different disciplines write only their disciplinary findings to avoid repetition of information.” A need for cohesive teamwork processes – Clinicians indicated the importance of having a coordinated and organised team process for the benefit of the RRP running smoothly. Peter – “could do with further improvement around getting all the team working at the same speed” and Matt – “It's handy if the co-ordinator is organised. It's very important to be proactive from the start to get all the assessments completed.” Parallel Themes Between Consumer And Clinicians’ Feedback Inconsistent views held by consumers and clinicians who refer and their understanding of the RRP’s purpose: Neil – Footbridge clinician - “may need further clarification for both clients and team members of its purpose”. Some clinicians who refer are able to communicate to the consumer the overarching principles of the program. Michael – consumer - “referred by C/M – “explained it is a place to live and improve myself”. There are also instances when the purpose of the referral and admission into the RRP is more related to an accommodation solution. Jenny – consumer - “my understanding was that I had no where else to go, and this was the first thing that came up.” 5
Clinician sensitivity to the burden placed on consumers: Clinicians showed an awareness of the burden placed on consumers with adapting to a new environment, in terms of the social challenges of sharing a unit that many have not previously experienced. Consumers indicated the difficulty of negotiating the physical environment of a shared unit, and a preference for staying in a single bedroom unit. Clinicians showed an awareness of the burden to consumers with the number of contacts throughout the review, describing finding it difficult to balance building rapport and gathering a depth of data to write the reports. CONCLUSIONS Effort should be made to for clinicians to vary the RRP according to the consumer’s individual needs. Consideration of the consumers prior responsibilities are ie: activities/study/ family commitments and what timeframe the RRP should reasonably be conducted based on the individual. A disproportionate amount of time is spent engaging the consumer compared with report writing. Consumers disliked being engaged in so many assessments; referring clinicians found the OT, psychology and file review to be the most valuable. For a more balanced approach it may be of use to narrow the types of assessments completed for a trial period, evaluate this and make changes as required Consumers are unclear of the purpose of the RRP. A second phase of evaluation should be conducted with pre-interviews of consumers to gather a picture of their understanding of the need for them to engage with the services offered and what it is that they view to be the benefit of the Footbridge CCU. Clinicians who conduct the RRP assessments must create an opportunity to provide feedback in a structured way to the consumers during the review period. Verbal and written feedback to the consumer should be provided. This feedback should amplify the person’s strengths, areas for improvement and reframe from using lots of medical jargon. This should be provided by the end of Week 2 by the coordinator.
REFERENCES Department of Health (2011) Framework for recovery orientated practice. Published by the Mental Health, Drugs and Regions Division, Victorian Government, Department of Health, Melbourne, Victoria Department of Human Services (DHS) (2007). Community Care (CCU) and secure extended care units (SECU). In: Victoria DHS, editor. Victoria: Mental Health Branch Metropolitan Health and Aged Care Services Division. p. 1-4. Hawthorne WB, Fals-Stewart W, Lohr JB. (1994). A treatment outcome study of community-based residential care. Hospital & Community Psychiatry, 45 (2):152-5. Leighton K. (2005). Practice development. Action research: the revision of services at one mental health rehabilitation unit in the north of England. Journal of Psychiatric & Mental Health Nursing, 12 (3), 372-9. Munro, J., Palmada, M., Russell, A., Taylor, P., Heir, B., McKay, J. and Lloyd, C. (2007) Queensland extended care services for people with severe mental illness and the role of occupational therapy. Australian Occupational Therapy Journal, 54, 257265. Rapp, C.A, Goscha, R.J. (2006). The Strengths Model of Case Management with People with Psychiatric Disabilities. New York: Oxford University Press. 6
Slade, M. (2009). 100 Ways to Support Recovery: A guide for mental health professionals, Rethink recovery series: volume 1, London, UK, May. Trauer T, Farhall J, Newton R, Cheung P. (2001). From long-stay psychiatric hospital to Community Care Unit: evaluation at 1 year. Social Psychiatry And Psychiatric Epidemiology, 36 (8), 416-9. Vandevooren J, Miller L, O'Reilly R. (2007). Outcomes in community-based residential treatment and rehabilitation for individuals with psychiatric disabilities: a retrospective study. Psychiatric Rehabilitation Journal, 30 (3):215-7.
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