Can a standardized needs assessment be used to improve the care of people with severe mental disorders? A pilot study of 'needs feedback'

Clients with long-term mental disabilities in a Swedish county—conditions of life, needs of support and unmet needs of service provided by the public health and social service sectors

Objective

The purpose of the study was to identify and describe conditions of life and needs of support and public service for clients with a mental disability in a Swedish county population.

Methods

Public health care and social service providers identified clients and completed a questionnaire concerning the clients’ conditions of life and their special needs. A consecutively recruited sample of clients completed a similar questionnaire.

Results

Totally, 1261 clients were identified. The prevalence of clients with mental disabilities was in the urban and rural areas, 6.4/1000 inhabitants and 4.5/1000 inhabitants, respectively. The most prevalent unmet need (42.9%) was to participate in social and scheduled activities. Almost half of the group was reported to need support in activities of daily living. Clients living in urban settings more often needed support with activities of daily living (P < 0.001), whereas clients living in rural settings more often needed support with job training (P < 0.001) or finding work (P < 0.01). Clients and psychiatric care providers reported the needs of the clients in the same areas; however, clients reported a fewer number of needs than did the care providers.

Conclusions

By using both psychiatric care and social service providers, effective case findings of clients with a mental disability were possible to achieve. In general, there was high agreement between psychiatric care providers and clients regarding the clients’ number of needs of support and their unmet needs of service. However, at the individual level, the agreement between client and psychiatric care providers was lower.

Traditions of research in community mental health care planning and care coordination: A systematic meta-narrative review of the literature

CONTEXT

In response to political and social factors over the last sixty years mental health systems internationally have endeavoured to transfer the delivery of care from hospitals into community settings. As a result, there has been increased emphasis on the need for better quality care planning and care coordination between hospital services, community services and patients and their informal carers. The aim of this systematic review of international research is to explore which interventions have proved more or less effective in promoting personalized, recovery oriented care planning and coordination for community mental health service users.

METHODS

A systematic meta-narrative review of research from 1990 to the present was undertaken. From an initial return of 3940 papers a total of 50 research articles fulfilled the inclusion criteria, including research from the UK, Australia and the USA.

FINDINGS

Three research traditions are identified consisting of (a) research that evaluates the effects of government policies on the organization, management and delivery of services; (b) evaluations of attempts to improve organizational and service delivery efficiency; (c) service-users and carers experiences of community mental health care coordination and planning and their involvement in research. The review found no seminal papers in terms of high citation rates, or papers that were consistently cited over time. The traditions of research in this topic area have formed reactively in response to frequent and often unpredictable policy changes, rather than proactively as a result of intrinsic academic or intellectual activity. This may explain the absence of seminal literature within the subject field. As a result, the research tradition within this specific area of mental health service delivery has a relatively short history, with no one dominant researcher or researchers, tradition or seminal studies amongst or across the three traditions identified.

CONCLUSIONS

The research findings reviewed suggests a gap has existed internationally over several decades between policy aspirations and service level interventions aimed at improving personalised care planning and coordination and the realities of everyday practices and experiences of service users and carers. Substantial barriers to involvement are created through poor information exchange and insufficient opportunities for care negotiation.

Cross-national comparative mixed-methods case study of recovery-focused mental health care planning and co-ordination: Collaborative Care Planning Project (COCAPP)

Background

Concerns about fragmented community mental health care have led to the development of the care programme approach in England and care and treatment planning in Wales. These systems require those people receiving mental health services to have a care co-ordinator, a written care plan and regular reviews of their care. Care planning and co-ordination should be recovery-focused and personalised, with people taking more control over their own support and treatment.

Objective(s)

We aimed to obtain the views and experiences of various stakeholders involved in community mental health care; to identify factors that facilitated, or acted as barriers to, personalised, collaborative and recovery-focused care planning and co-ordination; and to make suggestions for future research.

Design

A cross-national comparative mixed-methods study involving six NHS sites in England and Wales, including a meta-narrative synthesis of relevant policies and literature; a survey of recovery, empowerment and therapeutic relationships in service users (n = 449) and recovery in care co-ordinators (n = 201); embedded case studies involving interviews with service providers, service users and carers (n = 117); and a review of care plans (n = 33).

Review methods

A meta-narrative mapping method.

Results

Quantitative and qualitative data were analysed within and across sites using inferential statistics, correlations and the framework method. Our study found significant differences for scores on therapeutic relationships related to positive collaboration and clinician input. We also found significant differences between sites on recovery scores for care co-ordinators related to diversity of treatment options and life goals. This suggests that perceptions relating to how recovery-focused care planning works in practice are variable across sites. Interviews found great variance in the experiences of care planning and the understanding of recovery and personalisation within and across sites, with some differences between England and Wales. Care plans were seen as largely irrelevant by service users, who rarely consulted them. Care co-ordinators saw them as both useful records and also an inflexible administrative burden that restricted time with service users. Service users valued their relationships with care co-ordinators and saw this as being central to their recovery. Carers reported varying levels of involvement in care planning. Risk was a significant concern for workers but this appeared to be rarely discussed with service users, who were often unaware of the content of risk assessments.

Limitations

Limitations include a relatively low response rate of between 9% and 19% for the survey and a moderate level of missing data on one measure. For the interviews, there may have been an element of self-selection or inherent biases that were not immediately apparent to the researchers.

Conclusions

The administrative elements of care co-ordination reduce opportunities for recovery-focused and personalised work. There were few shared understandings of recovery, which may limit shared goals. Conversations on risk appeared to be neglected and assessments kept from service users. A reluctance to engage in dialogue about risk management may work against opportunities for positive risk-taking as part of recovery-focused work.

Future work

Research should be commissioned to investigate innovative approaches to maximising staff contact time with service users and carers; enabling shared decision-making in risk assessments; and promoting training designed to enable personalised, recovery-focused care co-ordination.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Information needs, care difficulties, and coping strategies in families of people with mental illness

Objective:

To determine information needs, care difficulties, and coping mechanisms of family members of people with mental illness.

Methods:

In this descriptive cross-sectional study, the study sample consisted of the families of 134 patients who were treated in the Psychiatric Unit of Cumhuriyet University Training and Research Hospital in Sivas, Turkey between January and May 2011. Data was collected by a questionnaire and analysed descriptively, and by chi-square testing.

Results:

It was determined that 79.1% of family members were knowledgeable of the patients’ illness. It was found that they experienced difficulties in communicating with the patient, and in ensuring drug compliance and anger management and that they used psychological and social coping strategies.

Conclusion:

Our results indicate that access to medical information on its own is not sufficient for carers of people with mental illness, and the necessity of developing positive attitudes when dealing with the illness and its symptoms. We recommend that nurses and other health professionals offer long term support and consultation programs to family members.

An examination of the needs of older patients with chronic mental illness in public mental health services

OBJECTIVES

To describe the needs of patients aged 50 years and over with chronic mental illness being case managed within a public mental health service, and to determine factors that influence these needs.

METHOD

Patients were recruited from community-based Adult Mental Health (AMH) teams and Specialist Mental Health Services for Older People (SMHSOP) teams. Eligibility criteria included a diagnosis of schizophrenia or mood disorder. Patient, carer and key worker interviews were carried out using the Camberwell Assessment of Need for the Elderly (CANE).

RESULTS

Of 183 eligible patients, 97 (mean age of 66.4 years) participated, of whom 63 were managed by AMH teams and 34 by SMHSOP teams. The majority (52%) had a diagnosis of schizophrenia, particularly those managed by AMH (71%). Patients self-rated fewer needs overall on the CANE than their key workers or the researcher, and also rated a higher proportion of their needs being met (83%) than the key worker (77%) or researcher (76%). From each perspective, over 80% of psychiatric and around 95% of identified medical needs were being met. The majority of social needs were unmet, with patients reporting only 42%, and key workers only 33%, met needs. The key unmet social needs were company, daily activities and having a close confidant. Key workers, patients and researchers rated SMHSOP service delivery to have significantly less unmet needs.

CONCLUSIONS

The social needs of older patients with chronic mental illness require greater attention by public mental health services.

Individual unmet needs for care: are they sensitive as outcome criterion for the effectiveness of mental health services interventions?

BACKGROUND

Mental health interventions should demonstrate an effect on patients' functioning as well as his/her needs, in particular on unmet needs whose assessment depends on the perspective of either the patient or the clinician. However, individual met and unmet needs appear to change over time, qualitatively and quantitatively, raising questions about their sensitivity to change and about the association between level of needs and treatment.

METHODS

Data on baseline and follow-up need assessment in community mental health services in four European countries in the context of a cluster randomised trial on a novel mental health service intervention were used, which involved 102 clinicians with key worker roles and 320 patients with schizophrenia or related psychotic disorders. Need assessment was performed with the Camberwell assessment of needs short appraisal schedule (CANSAS) among patients as well as clinicians. Focus is the sensitivity to change in unmet needs over time as well as the concordance between patient and clinician ratings and their relationship with treatment condition.

RESULTS

At follow-up 294 patients (92%) had a full need assessment, while clinician rated needs were available for 302 patients (94%). Generally, the total number of met needs remained quite stable, but unmet needs decreased significantly over time, according to patients as well as to clinicians. Sensitivity to change of unmet needs is quite high: about two third of all unmet needs made a transition to no or met need, and more than half of all unmet needs at follow-up were new. Agreement between patient and clinician on unmet needs at baseline as well as follow-up was rather low, without any indication of a specific treatment effect.

CONCLUSIONS

Individual unmet needs appear to be quite sensitive to change over time but as yet less suitable as outcome criterion of treatment or specific interventions.

Health education needs of patients with schizophrenia and their relatives

The purpose of this study was to determine the health education needs of patients with schizophrenia and their relatives. A total of 80 patients and 80 relatives were included in the study. The data were collected using Descriptive Characteristics Questionnaire and Evaluation of Health Educational Needs Form. The subjects that patients and their relatives felt they had the greatest need to learn more about were general information about schizophrenia, coping with symptoms of schizophrenia, and communication and social relationships. It was determined that the patients' health education needs were affected by their employment status, income level, and longest place of residence, and their relatives' health education needs, by their marital status, degree of family relationship, educational level, income level, whether or not they were a member of an association or group, and whether or not they had received education about schizophrenia. On the basis of the health education needs identified by the patients with schizophrenia and their relatives, a health education program should be prepared.

Needs of people with severe mental illness

OBJECTIVE

This study reviews conceptual and methodological issues of needs for care among people with severe mental illness (SMI) and presents data on their prevalence, correlates and consequences for mental health care.

METHOD

Focus is on the definition of the concept of need as what people can benefit from and its measurement by means of two instruments, the Needs for Care Assessment (NCA) and the Camberwell Assessment of Needs (CAN).

RESULTS

The prevalence of needs among patients with SMI varies between 4 and 10, which appears to be rather unrelated to gender, age or education, but not to severity of symptoms, diagnosis or treatment setting. Important is the perspective of the beholder: patient and professional differ significantly from each other in the assessment of number of needs and their adequate fulfillment. One of two to four needs are unmet, in particular in the area of psychological distress, daily activities, social contacts and psychotic symptoms. Prevalence of unmet needs seems to be related to the system of mental health care and to socioeconomic circumstances as well: the less integrated and continuous care and the poorer the life situation, the more unmet needs.

CONCLUSION

Unmet needs are a strong predictor of less favourable health perceptions and a lower quality of life. Needs are to a certain extent changeable, and thus amenable by treatment or mental health interventions. The prevalence of (un)met needs should be an outcome criterion for the evaluation of mental health service systems and for cross-cultural comparison.

Reliability of the Camberwell assessment of need (Chinese version) for patients with schizophrenia at a daycare center of Taiwan

BACKGROUND

Despite its wide use in different cultures and languages, there has been no report about the Camberwell Assessment of Need (CAN) in Chinese patients.

METHOD

Forty-one Chinese chronic schizophrenic patients were interviewed to test the interrater reliability and test-retest reliability of the Chinese version of CAN.

RESULTS

The interrater reliability ranged from 0.82 to 0.98 when computed by intraclass correlations (ICC) for the numbers of needs and from 0.65 to 1.00 by Cohen's kappa coefficients for individual domain. The test-retest reliability was moderate to good for the numbers of needs (ICC=0.64-0.81), but varied when counted by Cohen's kappa coefficients for individual domain.

CONCLUSION

Although limited by the homogeneity and small sample size of the study group, this is the first trial of the CAN in Chinese culture. The satisfactory reliability and easy application make this instrument suitable for clinical use in Chinese culture.

Health needs assessment tools: Progress and potential

Objectives:Health needs has attracted the interest of policy-makers, health economists, and health professionals as modern health services try to satisfy individual and population health needs to optimize resource utilization. Health needs can be assessed by administering various types of survey or interview-based instruments. If health needs are to be satisfied in changing health agendas in developed and developing countries, it is essential to employ valid and reliable tools. Despite the importance of needs assessment, no comprehensive review of tools is currently available. We carried out a literature search to define and categorize existing health needs assessment tools.

Methods:We reviewed medical and social search engines for items containing specific health needs–related words to identify needs tools across a range of specialties. Papers were reviewed in terms of design, subject matter, psychometric features, and method of administration method.

Results:Thirty-one employed in 52 studies including cancer, mental health, palliative care, multiple sclerosis, and cardiovascular disease tools were identified.

Conclusions:This report summarizes available health needs instruments in a range of diseases to assist researchers in accessing health needs resources more easily and to encourage further research in this field.

The use of patient reported outcome measures in routine clinical practice: lack of impact or lack of theory?

This paper applies a theory-driven approach to explore why the use of patient-reported outcome (PRO) measures in clinical practice, in particular, health-related quality of life (HRQoL) instruments, has little or no apparent influence on clinical decision making. A theory-driven approach involves combining knowledge of whether and how an intervention works. It is argued that such an approach is currently lacking within the literature evaluating the effectiveness of feeding back HRQoL information to clinicians. The paper identifies a number of mechanisms that might give rise to the expected outcomes that are currently implicit within the design of the intervention and hypotheses specified within the trials evaluating the use of HRQoL measures in clinical practice. It then examines how far current clinical practice matches these mechanisms and in doing so, a number of possible explanations for the lack of impact of HRQoL on clinical decision making are reviewed. The influence of HRQoL information on clinical decision making depends on a large number of factors related to the design of the intervention, patients' and clinicians' desire to discuss HRQoL issues within the consultation and the legitimacy that clinicians give to HRQoL instruments. To date, knowledge of how the feedback of HRQoL information to clinicians might improve doctor-patient communication or clinical decision making has yet to sufficiently inform an assessment of whether these aspects of patient care are improved. The paper concludes by specifying how the feedback of HRQoL information to clinicians might be modified to maximise its impact on clinical decision making.

Systematic assessments of need and care planning in severe mental illness: cluster randomised controlled trial

BACKGROUND

Surveys have shown high levels of unmet need in representative samples of people with severe mental illness. Introducing standardised needs assessment into the care planning process might reduce these needs and improve outcome.

AIMS

To determine whether feedback from a standardised assessment of need enhances the effectiveness of care planning and whether exposing care coordinators to feedback on some patients improves their care of other patients.

METHOD

A single-blind, cluster randomised trial involving a within-cluster individually randomised arm: patients' needs were evaluated using the Cardinal Needs Schedule and the findings were fed back to their care coordinators under the care programme approach. A total of 304 patients were recruited from 72 care coordinators and 242 patients (79.6%) were reassessed at 12 months.

RESULTS

The only significant effect of the intervention was on patient satisfaction. Patients cluster-randomised to receive feedback were more satisfied than controls, but patients individually randomised to receive feedback were not.

CONCLUSIONS

Standardised needs assessment did not substantially enhance care planning in this trial. However, giving care coordinators some experience of feedback from a standardised assessment of need could improve satisfaction.

Nursing home care: changes after supervision

BACKGROUND

An intervention project was conducted in three nursing home wards in Sweden. Most patients had severe dementia. The intervention consisted of supervision for individualized and documented nursing care, based on multidimensional assessment.

AIM

To illuminate changes in carers' approach after the intervention.

METHODS

Several data collections were conducted across the intervention and consisted of nursing documentation, patient life stories as told by carers, video recorded interactions, stimulated recall interviews and a questionnaire. Both quantitative and qualitative methods were used in the analyses.

FINDINGS

The findings from the different methods mirrored each other and added to the credibility of the intervention. Communicated knowledge about patients improved in nursing documentation and also as told by carers. Carers were differently skilled in managing the complexity of nursing care situations before as well as after the intervention, but the intervention contributed to developing carers in 'confirming nursing care'. They also improved in their ability to verbalize reflections about their everyday life with patients with dementia.

CONCLUSION

Supervision made it possible for carers to share their lived experiences about their day-to-day life with patients, which could promote personal and professional development and thus improve care quality. It also appeared that a detailed assessment tool used as part of the nursing process contributed to seeing a patient as a real person behind a dementia surface.

Health care implications and space allocation of research published in nursing journals

PURPOSE

To examine how research is disseminated through nursing journals and to examine characteristics of published research.

DESIGN

A cross-sectional descriptive survey was conducted with manuscripts from 78 nursing journals that publish research.

METHOD

The final issue for 1999 was examined. Pairs of independent raters content-analyzed all research manuscripts.

DISCUSSION

Research studies comprised 241 (42.9%) of the manuscripts and 51.4% of the journal space. Many empirical studies omitted validity and reliability. Few manuscripts reported the date for completion of data collection, and fewer than one third contained the length of time from acceptance to publication.

CONCLUSIONS

Enhanced instrumentation reporting, shorter time from data collection to publication, and an increase in journal space devoted to research might enable nurses to make more cutting-edge clinical decisions.

Outcome measures and needs assessment tools for schizophrenia and related disorders

BACKGROUND

There has been a recent trend to encourage routine outcome measurement and needs assessment as an aid to decision making in clinical practice and patient care. Standardised instruments have been developed which measure clinical symptoms of disorders such as schizophrenia, wider health related quality of life and patients' needs. Such measures might usefully be applied to aid the recognition of psychosocial problems and to monitor the course of patients' progress over time in terms of disease severity and associated deficits in health related quality of life. They might also be used to help clinicians to make decisions about treatment and to assess subsequent therapeutic impact. Such an approach is not, however, without cost and the actual benefit of the adoption of routine outcome and needs assessment in the day-to-day care of those with schizophrenia remains unclear.

OBJECTIVES

To establish the value of the routine administration of outcome measures and needs assessment tools and the feedback they provide in improving the management and outcome of patients with schizophrenia and related disorders.

SEARCH STRATEGY

The reviewers undertook electronic searches of the British Nursing Index (1994 to Sept 1999), the Cochrane Library (Issue 2, 2002), the Cochrane Schizophrenia Group Trials Register (2002), EMBASE (1980-2002), MEDLINE (1966-2002), and PsycLIT (1887-2002), together with hand searches of key journals. References of all identified studies were searched for further trials, and the reviewers contacted authors of trials.

SELECTION CRITERIA

Randomised controlled trials comparing the feedback of routine standardised outcome measurement and needs assessment, to routine care for those with schizophrenia.

DATA COLLECTION AND ANALYSIS

Reviewers evaluated data independently. Studies which randomised clinicians or clinical teams (rather than individual patients) were considered to be the most robust. However only those which took account of potential clustering effects were considered further. Where possible and appropriate, risk ratios (RR) and their 95% confidence intervals (CI) were calculated. For continuous data Weighted Mean Differences (WMD) were calculated. Data were inspected for heterogeneity.

MAIN RESULTS

No randomised data were found which addressed the specified objectives. One unpublished and one ongoing trial was identified.

REVIEWER'S CONCLUSIONS

The routine use of outcomes measures and needs assessment tools is, as yet, unsupported by high quality evidence of clinical and cost effectiveness. Clinicians, patients and policy makers alike may wish to see randomised evidence before this strategy is routinely adopted.

Rehabilitation psychiatry

Rehabilitation services are changing across Britain. The focus of service developments appears to be in relation to community teams and assertive outreach. This leaves the question of which direction rehabilitation services are heading. As patients move into the community from long stay wards as part of the process of bed closures and resource transfer, rehabilitation services are left with changing patient characteristics. In addition, patient characteristics in rehabilitation vary between Trusts. This article explores and expands on these themes.

An assessment of the patients' needs in mental health education

AIM OF THE STUDY

The aim of this study was to identify the specific educational needs of Chinese patients with schizophrenia using a Chinese version of the Educational Needs Questionnaire.

BACKGROUND

Patient education provides adequate clinical information to patients, increases understanding of their illness condition and encourages their health-promoting behaviour. A full understanding and satisfaction of patient needs in relation to specific illness has played an important part in the development of an education programme for psychiatric patients. However, psychiatric patients' perceptions of their specific educational needs and whether or not these needs are being met have seldom been explored for the purposes of optimizing the effects of patient education programmes. This study served the purpose of assessing the learning needs of Chinese patients with schizophrenia in Hong Kong.

DESIGN

A cross-sectional survey was conducted in Hong Kong with 192 Chinese outpatients with schizophrenia. The principles for determining the equivalence of translated tools were applied to the development of the Chinese version of the questionnaire.

RESULTS

Patients gave high importance to gaining information about mental illness, strategies for improving social relationships and solving daily problems. Socioeconomic factors including education level and membership in a mutual support group correlated significantly with need importance and the unmet-need score. Length of illness negatively correlated with need importance, indicating the adverse effect of illness on patients' interests in fulfilling needs.

CONCLUSIONS

Assessment of mental health consumers' perceptions of their specific educational needs and tailoring patient educational curricula to the expressed needs appear essential. The importance of validity testing of a translated tool is also highlighted in this study.