Outcomes focused service delivery: developing an academic-management partnership

Validation and implementation of the Australian Treatment Outcomes Profile in specialist drug and alcohol settings

INTRODUCTION AND AIMS

The measurement of clinical outcomes is an important, but lacking, component of drug and alcohol treatment in Australia. This study aimed to psychometrically validate the Treatment Outcomes Profile under Australian conditions, examining implementation and feasibility issues in three public opioid treatment program clinics in NSW.

DESIGN AND METHODS

The Treatment Outcomes Profile was modified to reflect Australian conditions and re-named the Australian Treatment Outcomes Profile (ATOP). The ATOP was introduced into the participating clinics and administered by clinic staff at 3-month intervals as part of routine clinical practice. Participants completed a research interview, consisting of the ATOP and a suite of 'gold standard' instruments assessing substance use and related health and welfare domains, in the 72 h following completion of a routine clinical ATOP. The researcher- and clinician-administered ATOPs were compared to assess interrater reliability, and the researcher-administered ATOP and 'gold standard' instruments were compared to assess concurrent validity. Implementation and feasibility issues were assessed using questionnaires and focus groups with clinician and clients.

RESULTS

The ATOP demonstrated acceptable concurrent validity and interrater reliability. It was well received by clients and clinicians, particularly for its ease of use, applicability and brevity.

CONCLUSIONS

The ATOP is a psychometrically valid instrument for the measurement of treatment outcomes in Australian opioid treatment populations and can feasibly be implemented as part of routine clinical practice in specialist opioid treatment program clinics. The role of the ATOP to measure outcomes in other drug and alcohol treatment modalities requires exploration.

Measuring outcomes in patients with depression or anxiety: an essential part of clinical practice

A wide range of instruments is available for ongoing assessment of clinical status and outcome in patients with depressive or anxiety disorders. However, few doctors use these instruments in managing their patients. As depression and anxiety are relapsing or chronic conditions and are often comorbid with other medical conditions, standard outcome measures should be incorporated into the management plans for all such patients.

Research priorities in mental health, Part 2: an evaluationof the current research effort against stakeholders' priorities

OBJECTIVE

To examine the current distribution of mental health research in Australia and compare this with the priorities of various stakeholder groups.

METHOD

A content analysis was carried out on a year's worth of published articles and a year's worth of competitive research grants. A questionnaire for stakeholders was developed in which respondents were asked to rate priorities for research using the same categories. Questionnaires were sent to mental health researchers,members of panels that evaluate mental health research grant applications,general practitioners, psychiatrists, clinical psychologists, mental health nurses, mental health consumer and carer advocates, and members of the National Mental Health Working Group.

RESULTS

Different groups of stakeholders tended to have differing perspectives on research priorities, with some major differences between committees that evaluate research grants and consumer and carer groups. Different stakeholder groups also tended to obtain their information about research from different sources. However, there were also a number of areas of agreement. When different research topics are considered,the following tended to be under-researched: affective disorders,suicide, primary care and community settings, prevention and promotion,evaluation of services, Aboriginal and Torres Strait Islander peoples,and socially and economically disadvantaged people.

CONCLUSIONS

It is of concern that committees that evaluate research are guided by different values from consumers and carers in setting priorities. Nevertheless, there is consensus across stakeholder groups that a number of areas should be a high priority.

Improving community-based services for older patients with depression: the benefits of an educational and service initiative

OBJECTIVE

The objective of this study was to report a quality improvement project for older patients with depression. The initiative focused on both clinical practice changes (improvement of medical, neurocognitive and behavioural assessment) and service development (greater continuity of care).

METHOD

After initial identification of key deficits, implementation of a service and educational initiative took place within a district mental health service. The service consisted of an inpatient unit, a specialized psychogeriatric service and two adult community mental health services. Mental health staff received education regarding the specific needs of older patients with depression and were provided with assessment materials, patient education and treatment aids. General practitioners participated in shared long-term management.

RESULTS

Following graded implementation, the management of 44 subjects (mean age = 65.4 years, 91% female) recruited over an 8-month period was reviewed. Compared with 99 subjects (mean age = 68.9 years, 69% female) from the earlier 12-month assessment phase, there were significant improvements in medical (43% to 92%), neurocognitive (37% to 84%) and behavioural (e.g. suicidal ideation: 78% to 100%) assessments. Similarly, relevant laboratory investigations (neuroimaging: 21% to 67%) and communication with general practitioners (73% to 97%) improved. The most change occurred in the adult community-based treatment services.

CONCLUSIONS

A coordinated management and educational initiative resulted in marked improvement in basic medical and psychiatric assessment and more integrated care. These changes did not require expansion of specialist services.

Better mental health services for young people: responsibility, partnerships and projects

OBJECTIVE

This paper argues that adolescent psychiatry is best linked with child psychiatry and opposes separate youth mental health programmes for 12-25-year-olds. It reports on the current status of services and considers how adult mental health services (AMHS) can improve services for young adults (18-25-year-olds).

METHOD

Factors in development, psychopathology, prevention, training and service systems are reviewed to suggest that current child and adolescent mental health service systems (CAMHS) are appropriate for 0-17-year-olds. Improvements in CAMHS are described from a Victorian perspective, including the model of specialist clinical programmes or teams for specific patient populations. Mechanisms are outlined for AMHS to better assist young adults from 18 to 25 years of age.

RESULTS

The model of clinical projects or clinical programme teams, developed in partnership with primary health and others, is a suitable vehicle to help AMHS to improve clinical services to their young adult populations. These may be funded from a variety of sources, including re-engineering existing service resources.

CONCLUSIONS

Such developments complement the work of specialist research units and build local competencies. More programme development and evaluation is needed, which will require the support of the College and State and Commonwealth Mental Health Branches.

Fifty years of medical specialisation: from foundation to fragmentation

The past 50 years of medicine have been dominated by revolutions in biological sciences and clinical therapeutics. No less dramatic have been changes in our healthcare systems, with medical specialisation playing a leading role. The middle of the century saw the rapid development of the teaching hospital as the centre of professional education, collegiate identity, medical specialisation and clinical research. By contrast, the past 20 years have seen dramatic shifts in response to the demands of a more diverse community.