Masterclass
Dr Miranda Wolpert
USING PATIENT REPORTED
OUTCOMES IN CLINICAL
CONVERSATIONS
Timetable
10.30 -11 am- welcome, introductions and agreeing goals
11- 12: Overview
12- 12.30 Using Assessment measures (Kelsie)
12.30-1.30 Lunch
1.30- 2.45 Using Progress tracking (Lily)
2.45- 3.15pm Tea/coffee
3.15- 4.00 Using Feedback (Lily)
Overview
TASK
KEY MEASURES (parent and/or child )
START *
Agree key problems
Agree key goals and/or focus on general
wellbeing
Agree intervention approach to try
Agree measures to use repeatedly
General assessment measures:
•
SDQ
•
RCADS
(Clinician Care Planning Tool)
GBO/CORS
ONGOING
Undertake intervention
Review Progress
Review Experience
Continue to consider options in light of above
One or more of short specific symptom scales for:
•
Out of control behaviour
•
Depression
•
Panic
•
Separation anxiety
•
General anxiety
•
Social anxiety
•
PTSD
•
OCD
If none of the above suitable use
•
Impact scale
At end of meeting: SRS or Feedback (PREM)
REVIEW
Review progress more generally
Review experience overall
Re-complete original assessment:
•
SDQ
•
RCADS
CHI ESQ (PREM)
Attendees’ level of
confidence in the use and
interpretation of PROMs
Confidence with regards to
interpreting PROM data?
Confidence in the use of PROMs?
15
16
13
14
11
12
10
8
6
6
4
2
2
0
1
2
3
4
5
20
18
16
14
12
10
8
6
4
2
0
19
12
9
6
1
1
2
3
4
5
Attendees’ use of PROMs with
young people
How many young people do you use
PROMs on a session by session basis
with?
How many young people do you use
PROMs with?
13
14
12
13
35
11
10
10
25
8
20
6
15
4
10
2
5
0
0
None
Few
Most
All
31
30
12
3
None
Few
Most
1
All
Some common challenges to
using PROMs noted by
attendees
• Time pressure
• Amount of paperwork generated
• Integrating PROMs into the therapeutic
conversation
• Lack of confidence
• Making it relevant to the client/ knowing
which ones to use
• Evidence of their impact
Some advantages to using
PROMs noted by attendees.
•
•
•
•
•
Identify and monitor difficulties
Provide evidence of change/ progress
Provide focus for the work
Evaluating intervention and/ or service
Can be helpful in improving practice
Some reasons given for not
using PROMs on a session by
session basis
•
•
•
•
•
•
•
Time pressures
Not appropriate for the child/young person
Client refused to complete them
Only recently available/ started
Not part of service structure/ plan
Lack of confidence
Unsure of usefulness
Why bother?
Views of members of VIK Young Minds: Session by session monitoring is important for children and young people
because...
1.
It gives us a shared understanding of where we’re starting from
2.
It gives us a shared understanding of where we’re heading to
3.
It gives us a shared understanding of how we’re going to get there
4.
It means if we go off track or get a bit lost along the way, we can both figure out how to find the way back again.
5.
It makes us feel like there is a point to our therapy
6.
It supports us to feel more in control of its direction – to understand when things are working, when things are
not and what we can do about it.
7.
It enables us to get a more in-depth understanding of what we’re feeling, why we’re feeling it and what we can
do about it.
8.
It gives us hope that we can make progress, recover and achieve our goals.
9.
Makes us feel like this is more of a shared experience between us and the clinician... like we’re in this together.
10. We both need to work on the therapy together – sharing our different forms of experience and expertise –
PROMs help make the balance of power more equal.
Impact
• There is evidence that use of PROMS can
• Improve clinicians ability to detect worsening
of symptoms (Lambert, 2010)
• Provides information that may have otherwise
been missed (Worthen & Lambert, 2007)
• Reduce drop out (e.g. Miller et al. 2006)
• Increase speed to reach good outcomes
(Lambert et al. 2005)
• More regular feedback improves outcomes
(Bickman et al 2011)
Dangers
•
•
•
•
•
Tick box exercise
Gets in way
Mis judgements
Detracts from meaningful discussions
Focuses on negatives
Our beliefs
• Outcome measures + poor practice is still
poor practice
• Outcome measures + good practice may
help
Dos and Donts
Context of shared decision
making
1. Young people and those working with them agree key problems
and goals together.
2. Those working with young people support them to understand
the options available.
3. Young people and those working with them agree which options
to try.
4. Young people and those working with them review progress.
5. Young people and those working with them discuss options and
make any changes as necessary
RCADS
Revised Children’s Anxiety and Depression Scale (RCADS)
(http://www.childfirst.ucla.edu/RCADSGuide20110202.pdf)
Type of measure
Standardized norm based
Measures symptom
Measures anxiety and depression
Basic information:
47-item
Self- report
Parent report
Clinical bands by age and gender
Questions rated on a 4-point Likert-scale from 0 (“never”) to 3 (“always
RCADS
5 different sorts of problems
separation anxiety disorder (SAD),
social phobia (SP)
generalized anxiety disorder (GAD)
panic disorder (PD)
obsessive compulsive disorder (OCD)
major depressive disorder (MDD)
Total Anxiety Scale (sum of the 5 anxiety subscales)
Total Internalizing Scale (sum of all 6 subscales)
Strengths:
Well validated and well researched
Subscales for anxiety and depression which can be used alone also
Weaknesses:
Does not cover all types of problems
Not suitable for moderate to severe learning difficulty
put in example of actual questions and clinical band cut off scores
GOALS
Goal based outcomes (GBO) measure (Adapted from Law D. (2011) also http://www.corc.uk.net/)
Type of measure
idiographic /bespoke
Measures uniquely agreed goals
Clinical tool to aid focus and discussion
Basic information:
Collaboratively agree goals
Rate goals on 0-10 scale where 10 is completely at goal, 0 nowhere near
Covers :
How close service user feels is to reaching goal
Strengths:
Helps focus work on issues important to service user.
Weaknesses:
No norms so cannot compare across clients or services
The Current View Tool
• Not a diagnostic tool
• Does not replace a risk
assessment
Current Tool Problem Descriptions
Complexity Factors
• Rate whether
present/absent
• Diagnosable not
diagnosed
• Your view
Contextual Problems
• Environmental
factors
• External to the
Young person
• Additional to the
problems and
complexity
factors
Education/Employment/Training
Attendance difficulties
None
No problems noted. As rough guidance, around 1-2 days absence from school per month
should be considered as within normal limits.
Mild
Some definite problems. The CYP may be attending part-time or missing several lessons
(includes truanting, school refusal or suspension for any cause). As a rough guidance, 1 day of
absence per week might be considered here.
Moderate
Marked problems. The CYP may be attending infrequently, or is at high risk of exclusion or
dismissal. As a rough guidance, the child may be absent 2 days per week.
Severe
CYP is out of school the majority of the time (for reasons of truancy, exclusion or refusal) or
may be in a Pupil Referral Unit, expelled or not in Education, Employment or Training.
Attainment difficulties
None
No problems noted. The CYP will be attaining at the optimum age-appropriate level
moderated by that expected for their known abilities.
Mild
Some problems. For example, if the CYP is in school they may be well below the year level in
at least one subject, or have problems with work rate or timekeeping if in employment or
training.
Moderate
Significant problems. If at school they may fail key exams, or be below the year group in all
subjects. If in employment, they may have received formal warnings about their performance
and/or behaviour.
Severe
CYP has dropped out of education, employment or training.
Kelsie
Kelsie is a 15-year-old girl, she lives with her mother and two
biological siblings (boy aged 12 and girl aged 10).
Kelsie’s mother has a history of depression and often finds it difficult to
cope and look after the children. There is no extended family and no
support network so Kelsie has to take responsibility for her mother’s antidepressant medication regime. During her early childhood, Kelsie
witnessed domestic violence by her biological father, towards her mother.
Social Services were involved and she was briefly accommodated in a
foster placement. Her father left the household eight years ago, after
several periods of marital breakdown. The GP reports tha Kelsie says she
feels very sad all of the time and has trouble sleeping most nights. She
feels very alone and thinks it would be better if she wasn’t here anymore.
She says she has no actual plans to harm herself but admits to cutting her
arms on a regular basis and has now totally isolated herself from her
peers.
EXERCISE 1:
Decisions at referral
• Which measures would you choose to use for each of the possible
family members (if any)?
• How would you choose to deliver the questionnaires for each of the
possible family members?
SDQ
RCADS
Post out before session?
Child/Young Person only?
Mum only?
Dad only?
CYP and Parents?
?
Ask to complete over internet?
?
?
Administer by telephone?
?
?
Complete in waiting room?
?
?
Wait to give in-session?
?
?
SOME POSSIBLE OPTIONS:
EXERCISE 2:
First session – use of measures
•How you would explain why you would like the family to complete these
questionnaires
•How you might get the measures completed
SDQ
RCADS
Give measure(s) to family to complete in-session while you wait?
?
?
Administer whole measure(s) verbally in-session
with no discussion during administration?
?
?
Administer whole measure(s) verbally in-session
stopping to discuss individual items?
?
?
Administer measure(s) across several sessions?
?
?
Explain rationale for measure(s) but ask family to complete after session?
?
?
Give measure(s) for family to complete for next session?
?
?
SOME POSSIBLE OPTIONS:
EXERCISE 3:
Determining clinical significance
and Feeding back clinical
profiles
SOME IDEAS TO CONSIDER…ARE YOU TRYING TO:
-
Feedback all scale scores?
-
Feedback strengths first?
-
Feedback only the scores or items that stand out?
-
Check for other aspects of difficulties or strengths not covered by the measures?
-
Increase worry in the young person and/or parents?
-
Decrease worry in the young person and/or parents?
-
Reflect the young person’s or parent’s distress?
-
Give resilience or hope?
Feeding back a profile of scores that doesn’t fit with family’s expectations:
o worse than expected
o better than expected
o different difficulties than expected
Contact details
Corc@annafreud.org
Ebpu@annafreud.org
Websites
http://www.corc.uk.net
http://www.ucl.ac.uk/clinical-psychology/EBPU