Using the Resident Assessment Instrument-Mental Health (RAI-MH) to Determine Levels of Care for Individuals with Serious Mental Illness

Clinical Predictors of Delayed Discharges in Inpatient Mental Health Settings Across Ontario

Delayed discharges constitute an ongoing issue in psychiatric facilities. This study examined clinical predictors of 30-day delayed discharges in all designated inpatient mental health units within Ontario, Canada. Data for 76,184 inpatient episodes were obtained from 68 psychiatric facilities between 2011 and 2013. Risk factors for delayed discharges were analyzed using multivariate logistic regression. Indicators of functional, social, and cognitive impairment positively predicted delayed discharges, while symptoms of mental illness were inversely related. Policy makers and mental health care practitioners may utilize early predictors of delayed discharges to introduce treatment interventions and policies that reduce the risk of delays in mental health settings.

The interRAI Suite of Mental Health Assessment Instruments: An Integrated System for the Continuum of Care

The lives of persons living with mental illness are affected by psychological, biological, social, economic, and environmental factors over the life course. It is therefore unlikely that simple preventive strategies, clinical treatments, therapeutic interventions, or policy options will succeed as singular solutions for the challenges of mental illness. Persons living with mental illness receive services and supports in multiple settings across the health care continuum that are often fragmented, uncoordinated, and inadequately responsive. Appropriate assessment is an important tool that health systems must deploy to respond to the strengths, preferences, and needs of persons with mental illness. However, standard approaches are often focused on measurement of psychiatric symptoms without taking a broader perspective to address issues like growth, development, and aging; physical health and disability; social relationships; economic resources; housing; substance use; involvement with criminal justice; stigma; and recovery. Using conglomerations of instruments to cover more domains is impractical, inconsistent, and incomplete while posing considerable assessment burden. interRAI mental health instruments were developed by a network of over 100 researchers, clinicians, and policy experts from over 35 nations. This includes assessment systems for adults in inpatient psychiatry, community mental health, emergency departments, mobile crisis teams, and long-term care settings, as well as a screening system for police officers. A similar set of instruments is available for child/youth mental health. The instruments form an integrated mental health information system because they share a common assessment language, conceptual basis, clinical emphasis, data collection approach, data elements, and care planning protocols. The key applications of these instruments include care planning, outcome measurement, quality improvement, and resource allocation. The composition of these instruments and psychometric properties are reviewed, and examples related to homeless are used to illustrate the various applications of these assessment systems.

The use of a brief mental health screener to enhance the ability of police officers to identify persons with serious mental disorders

Police agencies in Canada and elsewhere have received much criticism over how they respond to persons with serious mental disorders. The adequacy of training provided to police officers on mental health issues and in particular on recognizing indicators of serious mental disorders has been a major concern. This paper describes the process that led to the development of a new brief mental health screener (interRAI Brief Mental Health Screener, BMHS) designed to assist police officers to better identify persons with serious mental disorders. The interRAI BMHS was developed in collaboration with interRAI, an international, not-for-profit consortium of researchers. The government of Ontario had previously partnered with interRAI to develop and implement the Resident Assessment Instrument for Mental Health (RAI-MH), the assessment system mandated for use on all persons admitted into inpatient psychiatric care in the province. Core items on the interRAI BMHS were obtained through analysis (N=41,019) of RAI-MH data together with input from representatives from health care, police services, and patient groups. Two police services in southwestern Ontario completed forms (N=235) on persons thought to have a mental disorder. Patient records were later accessed to determine patient disposition. The use of summary and inferential statistics revealed that the variables significantly associated with being taken to hospital by police included performing a self-injurious act in the past 30days, and others being concerned over the person's risk for self-injury. Variables significantly associated with being admitted included abnormal thought process, delusions, and hallucinations. The results of the study indicate that the 14-variable algorithm used to construct the interRAI BMHS is a good predictor of who was most likely to be taken to hospital by police officers and who was most likely to be admitted. The instrument is an effective means of capturing and standardizing police officer observations enabling them to provide more and better quality information to emergency department (ED) staff. Teaching police officers to use the form constitutes enhanced training on major indicators of serious mental disorders. Further, given that items on the interRAI BMHS are written in the language of the health system, language acts as common currency between police officers and ED staff laying the foundation for a more collaborative approach between the systems.

ALC status in in-patient mental health settings: Evidence based on the Ontario Mental Health Reporting System

This article examines the characteristics associated with Alternate Level of Care (ALC) status in mental health in-patient units across Ontario. Using assessment information from the Resident Assessment Instrument-Mental Health, the prevalence of ALC episodes, resource utilization associated with ALC, and demographic and diagnostic characteristics of ALC patients are examined. The effective management of ALC patients should be an important priority for all stakeholders involved in mental health services delivery in Canada.

Gender differences in the rate of restriction to room among Ontario forensic patients

Gender can have separate and interacting effects on mental health. Gender-based analysis provides insight into these effects on mental health, and it can provide evidence to inform policy and practice to meet these gender-specific needs among persons in forensic mental health settings. Both individual and facility-level characteristics play a role in restriction to room as a form of control intervention in forensic mental health. Understanding the gender differences associated with the factors that increase a person's risk of restriction to room can allow for more targeted interventions and provide insight into policies that will help reduce these types of control interventions.

Access to psychiatrists by French-speaking patients in Ontario hospitals: 2005 to 2013

There has been a limited amount of research suggesting that cultural and linguistic variables may affect access to health services, but no study has examined the access of French-speaking Canadians to psychiatrists. The present study used data from the Ontario Mental Health Reporting System to examine patterns of daily contact with psychiatrists in the first 3 days of admission to mental health facilities in Ontario. The results showed that after controlling for a broad range of covariates, French-speaking Ontarians were about one-third as likely to have daily contact with psychiatrists in that time period compared to English-speaking patients. These results were not explained by regional differences. Instead, they point to the possibility that language poses an important barrier to specific and highly specialized mental health services in this province.

Measuring the prevalence of current, severe symptoms of mental health problems in a canadian correctional population: implications for delivery of mental health services for inmates

This study measured the prevalence of current, severe symptoms of a mental health problem in an adult population of inmates in Ontario, Canada. The Resident Assessment Instrument-Mental Health was used to measure the prevalence of symptoms among a sample of 522 inmates. Propensity score weighting was used to adjust for nonrandom selection into the sample. Prevalence estimates were derived for the total inmate population, remand and sentenced, males and females, and Aboriginal and non-Aboriginal inmates. It is estimated that 41.1% of Ontario inmates will have at least one current, severe symptom of a mental health problem; of this group, 13.0%, will evidence two or more symptoms. The number of symptoms is strongly associated with presence of a psychiatric diagnosis and level of mental health care needs. Female (35.1%) and Aboriginal (18.7%) inmates are more likely to demonstrate two or more current, severe symptoms. Greater efforts must be made to bridge the gap between correctional and mental health care systems to ensure inmates in correctional facilities can access and receive appropriate mental health care services.

A care planning strategy for traumatic life events in community mental health and inpatient psychiatry based on the InterRAI assessment instruments

Clinical triggers from the Traumatic Life Events Clinical Assessment Protocol (CAP) identify individuals who might benefit from formal services or additional supports targeted towards trauma treatment. The Traumatic Life Events CAP identifies two groups who have experienced one or more potentially traumatic life events: (1) those who are in immediate danger due to current abuse/criminal victimization; (2) those who have experienced one or more traumatic events that evoked an intense sense of horror or fear. Descriptive analysis was conducted across psychiatric hospital and community-based mental health service settings to compare the two triggered groups to those without traumatic experiences (the not-triggered group). The Traumatic Life Events CAP identified subpopulations with unrecognized and untreated traumatic-stress-related symptoms, which are of great concern for those in community-based mental health services who are in immediate danger due to current abuse.

Moving forward: evaluating a curriculum for managing responsive behaviors in a geriatric psychiatry inpatient population

PURPOSE

The Gentle Persuasive Approaches (GPA) curriculum was developed as an adjunct to other educational initiatives that were part of Ontario, Canada's Alzheimer Strategy. GPA emphasizes that an individual's unique personal history has a direct application to the interpretation of and response to their behavior. It incorporates strategies into geriatric patient care to assist staff to respond effectively to verbal and physical expressions of need.

DESIGN AND METHODS

A pre- and postintervention approach was used to evaluate the effectiveness of GPA: (a) Staff Satisfaction Surveys immediately after GPA training and after 3 months, (b) risk event profiling to monitor aggressive behavior rates, (c) occupational health and safety records pre- and post-GPA training, and (d) Residential Assessment Instrument-Mental Health indicators pre- and post-GPA training.

RESULTS

Surveys revealed that GPA training significantly improved staff's response to challenging behaviors, understanding of how brain changes impact behavior, and learning strategies to respond to challenging behaviors. Specific body containment techniques were less employed on geriatric patients who experience responsive behaviors. Pre- and postphysical aggression rates declined over the 6-month period following GPA training. The training did not appear to impact occupational injury rates.

IMPLICATIONS

GPA appears to be a useful and positive approach for providing care to an inpatient geriatric psychiatry population. Specific body containment techniques may be less useful when employed with patients who have responsive behaviors. The program evaluation suggests that application of the GPA curriculum may be extended to patients with diagnoses other than dementia.