FARS, CFARS & MGAF-R: What do you want to know about them FARS, CFARS & MGAF-R: What do you want to know about them? How can they help you do your work? John C. Ward, Jr., Ph.D. 2005 FCCMH/FLAPRA Conference “Mission Possible: Inspiring Hope and Recovery” September 14, 2005

“Recovery is organic… measured as a functional process…not an event !” “Not everything that counts can be counted… and, not everything that can be counted, counts.” Albert Einstein

Important Internet Addresses: http://www.dcf.state.fl.us/mentalhealth/links.shtml Department of Children and Families (DCF) information on performance measures including FARS/CFARS & MGAF-R http://www.dcf.state.fl.us/publications/policies.shtml Department of Children and Families (DCF) publications including Mental Health/Substance Abuse Data Pamphlet (CFP 155-2) under revision http://outcomes.fmhi.usf.edu Louis de la Parte Florida Mental Health Institute’s outcome measures website including FARS & CFARS information, user manuals, forms and FARS/CFARS Web-based Training and Certification Program…all free! (except charge for CEC’s)

Can we do this in 115 minutes? 10 minutes: Global Assessment - MGAF-R 5 minutes: Multi-Domain Functional Assessment 10 minutes: Description of FARS/CFARS 20 minutes: Guidelines for determining problem severity ratings for FARS or CFARS 10 minutes: FARS& CFARS Web Training Program 20 minutes: Using FARS or CFARS assessments to develop Individualized Treatment Plans 20 minutes: Using FARS or CFARS assessments to develop Agency Level Quality Assurance/ Quality Improvement Reports 20 minutes: Discussion, Questions and Answers

“Global” Functional Assessment In 1987, the Global Assessment of Functioning (GAF) was published by the American Psychiatric Association in the DSM III-R (derived from older GAS) Single score from 1 to 100 Divided into groups of ten score ranges Mixed functional and behavioral descriptors related to mental health symptoms, work, relationships, etc. for each block of ten points

Why the MGAF-R ? Concerns about inter rater reliability of the GAF led to development of the Modified GAF, which included descriptive anchors to increase reliability of GAF rating - Caldecot-Hazard, S. & Hall R. (1995) In 2004, the Florida “DCF Functional Assessment Workgroup” revised the MGAF “anchors” to align with DSM – IV resulting in the “MGAF-R” In, 2005, Florida DCF required the MGAF-R “global” rating in lieu of the Multi-domain Functional Assessment Rating Scale (FARS) for evaluating adults who receive DCF contracted “Medication Only” mental health services

To arrive at an MGAF-R rating, first conduct a clinical interview and fill out the top of the MGAF-R form… Modified Global Assessment of Functioning – Revised (MGAF-R) Name of person being evaluated (Optional: required only if needed SSN of person being Evaluated: (Required) by your agency or copy is retained ___ ______/___ ___ ___/___ ___ ___ in paper clinical record, please print): Provider Agency Tax ID (Required): (last)_________(first)______(mi)__ _______________________ Date of Birth (Required) : Date of Assessment (Required): ______/_____/_____ _______/_______/_______ mm dd yyyy mm dd yyyy Gender: (Required) Male Female

…then, begin with the list of functional criteria from the bottom of the form… 10 Immediate Danger from Serious Neglect or Self-Injurious Behavior Group A Criteria: -Serious suicidal act with clear expectation of death (e.g., stabbing, shooting, hanging, or serious over dose with no one present) -Frequent severe violence or self-mutilation -Extreme manic excitement, or extreme agitation and impulsivity (e.g., wild screaming, ripping the stuffing out of a bed mattress) -Persistent inability to maintain minimal personal hygiene -Urgent/emergency admission to present psychiatric hospital -In acute, severe danger due to medical problems (e.g., severe anorexia or bulimia with heart or kidney problems) 8-10 1-2 of the criteria in Group A 4-7 3-4 of the criteria in Group A 1-3 5-6 of the criteria in Group A

…work your way up the criterion lists… 20 Suffering from Neglect or in Danger of Hurting Self or Others Group B Criteria: -Suicide attempts without clear expectation of death (e.g., mild overdose or scratching wrists with people around) -Some severe violence or self-mutilating behaviors -Severe manic excitement, or severe agitation and impulsivity -Occasionally fails to maintain minimum personal hygiene (e.g., diarrhea due to laxatives, or smearing feces) -Urgent/emergency admission to the present psychiatric hospital -In physical danger due to medical problems (e.g., severe anorexia or bulimia and some spontaneous vomiting or extensive laxative/diuretic/diet pill use, but without serious heart or kidney problems or severe dehydration and disorientation) 18-20 1-2 of the criteria in Group B 14-17 3-4 of the criteria in Group B 11-13 5-6 of the criteria in Group B

…until you find criteria that fits your interview and mental status findings… 30 Inability to Function in Almost All Areas Group D Criteria: -Serious impairment with work, school or housework if a housewife or househusband (e.g., …) -Frequent problems with the law (e.g., …) -Serious impairment in relationships with friends (e.g., …) -Serious impairment in judgment (including …) -Serious impairment in thinking (including …) -Serious impairment in mood (including …) (and the list goes on…) Group C Criteria: -EITHER Suicidal Preoccupation or frank suicidal ideation with preparation -OR behavior considerably influenced by delusions (etc.) -OR serious impairment in communication (sometimes incoherent, acts grossly inappropriately, OR profound stuporous depression) 28-30 7 of the criteria in Group D 24-27 8 of the criteria in Group D 20-23 9 of the criteria in Group D 21 1 of the criteria in Group C

…pick the number on the left margin that matches the criteria you selected, enter that rating in the space on the back page of the form, and sign your name. Assigned MGAF-R Rating (Required): __________ Signature/Title of Person completing MGAF-R (Required):_________________________________________

What is “multi-domain” functional assessment? A valid and reliable way to document effectiveness of functioning separately for Cognitive, Behavioral, Physical/Medical, Interpersonal, Social, and Role domains Based on information from face to face clinical interviews that include mental status exams, observed or self reported symptoms, psychological testing …and/or any other sources available to the clinician or treatment team

How do multi-domain functional assessments help describe the whole person? All People live, work, learn, meet needs and experience quality of life on the basis of functioning in cognitive, physical, social, and role domains Need for and/or admission into behavioral healthcare services generally follows impaired functioning in one or more domain (e.g., Baker Act Criteria) Discharge from treatment generally follows restoration or improvement in functioning in those domains

How are multi-domain functional assessments used ? At Individual level, to develop treatment plans by identifying and documenting problem areas and potential assets of functioning at admission…and, to evaluate and monitor progress during treatment and at discharge At Agency level, aggregates of ratings help monitor Quality Assurance and Quality Improvement goals in programs and services At District level, assessment of service recipients helps plan for needed services At State level, data aggregates help describe service outcomes for legislative reports

Why ‘Functional’ Scales In Florida ? 1) Florida’s Governance and Accountability Act was passed in 1994. 2) DCF (then HRS) was advised they would be one of the first budget entities under the Governor’s budget office to be asked to develop performance measures 2) In 1993, FMHI was asked to assist “District 7” in developing and piloting performance measures “Florida Council” asked FMHI to consider including functional assessment Instruments as part of that process FMHI looked at CCAR but had to make many revisions…resulting in…

The Functional Assessment Rating Scales cfars TM TM John C. Ward, Jr., Ph.D. Michael G. Dow, Ph.D. John C. Ward, Jr., Ph.D. Michael G. Dow, Ph.D. Teri L. Saunders, M.S. Shawn C. Halls, M.A. Kathy F. Penner, M.A. Kristina A. Musante, B.A. Ray T. Berry, B.A. Natalie Sachs-Ericsson, Ph.D.

Functional Assessment Rating Scales CFARS Domains (Child & Adol) Depression Anxiety Hyper Activity Thought Process Cognitive Performance Medical/Physical Traumatic Stress Substance Use Interpersonal Relations Behavior In Home Setting Work or School ADL Functioning Socio-Legal Danger to Self Danger to Others Security Management Needs FARS Domains (Adults) Depression Anxiety Hyper Affect Thought Process Cognitive Performance Medical/Physical Traumatic Stress Substance Use Interpersonal Relations Family Relations Family Environment Work or School ADL Functioning Socio-Legal Ability to Care for Self Danger to Self Danger to Others Security Management Needs

Factor Scales & Clinical Scales FARS Domains (Adults) Depression E Anxiety E Hyper Affect D Thought Process D Cognitive Performance D Medical/Physical D Traumatic Stress E Substance Use PS Interpersonal Relations R Family Relations R Family Environment R Work or School R ADL Functioning D Socio-Legal R Ability to Care for Self D Danger to Self PS Danger to Others R Security Management Needs PS Factor Scales: D=Disability, E=Emotionality, Clinical Scale groups from top: Diagnostic, CFARS Domains (Child & Adol) Depression E Anxiety E Hyper Activity R Thought Process D Cognitive Performance R Medical/Physical D Traumatic Stress E Substance Use PS Interpersonal Relations R Behavior In Home Setting R Work or School R ADL Functioning D Socio-Legal PS Danger to Self PS Danger to Others R Security Management Needs PS PS=Personal Safety, R=Relationships (Ward, et al., 1999) Co morbid, Psychosocial, & Risk (D. Moore/ FHP-2002…DCF may use in 2005)

FARS Problem Severity Ratings Use the following 1 to 9 scale to rate the individual’s current (within last 3 weeks) problem severity for each functional domain listed below. Place your rating number on the line to the right of the Domain name. Also, using the list below each domain rating, place an “X” mark next to the adjectives or phrases that describe symptoms or assets. (Refer to FARS User’s Manual for specific examples of use of this scale…available at http://outcomes.fmhi.usf.edu) 1 2 3 4 5 6 7 8 9 No Slight Moderate Severe Extreme Problem Problem Problem Problem Problem

Are there any “principles” or special instructions that help clinicians decide what ratings to assign? The manuals discuss general guidelines that include how “three basic treatment issues” help decide how impaired functioning is in any domain in addition to intensity or interference from symptoms, words or phrases checked for a domain (note: number of items checked not necessarily equal to a problem severity rating of the same number, etc.) The manuals also include specific “anchors” to assist in arriving at a problem severity rating for each domain

General Guidelines for Determining Problem Severity Ratings . In general, severity ratings are associated with: 1) how immediate is the need for intervention (i.e., none, to some time in the future, to immediate, etc.), or 2) how intrusive is the intervention that is needed (i.e., ranging from need for normal or slightly more than normal levels of interpersonal or social “support”, to need for supportive medications with few side effects, to need for major medications with serious potential side effects, or need for external physical, structural, or environmental controls, etc.), or

General Guidelines for Determining Problem Severity Ratings . 3) how does functioning in the rated domain impact negatively on other domains (e.g., if impaired functioning in the depression domain effects interpersonal relationships, family relationships, work or school functioning, and increases potential for danger to self, etc. the depression domain would be rated as more severe than if no other domains were impacted by depressive functioning).

Problem Severity Rating Anchors (Consider level of functioning within the past three weeks for each domain) 1 = No Problem Functioning is consistently average or better than what is typical for this person's age, sex, and subculture. (i.e., functioning in this domain is strong and may be an “asset” to call on to improve functioning in other domains.)

Problem Severity Rating Anchors 2 = Less than a Slight Problem 3 = Slight Problem Functioning in this range falls short of typical for a person of this age, sex, and subculture most of the time. That is, a problem in this domain may be intermittent or may persist at a low level. The problem or symptoms in this domain have little or no impact on other domains or they may be currently controlled by internal or external interventions. The need for treatment in this domain is not urgent but may require intervention in the future.

Problem Severity Rating Anchors 4 = Slight to Moderate Problem 5 = Moderate Problem Functioning in this range is clearly marginal or inadequate, not meeting the usual expectations of a typical person of this age, sex, and subculture. This means that the dysfunction or problem in this domain may persist at a moderate level or become severe on occasion. Problems in this domain may be related to problems in other domains and therapeutic intervention is required.

Problem Severity Rating Anchors 6 = Moderate to Severe Problem 7 = Severe Problem Functioning in this range is marked by obvious and consistent failures, never meeting expectations for a typical person of this age, sex, and subculture. The dysfunction or problem in this domain may be chronic. It almost always extends to other domains and generally interferes with functioning in more than one other domain. Hospitalization or some other form of external control may be needed in addition to other therapeutic interventions).

Problem Severity Rating Anchors 8 = Severe to Extreme Problem 9 = Extreme Problem The highest level of the scale, suggesting the person's impaired functioning in this domain is creating a situation that is totally out of control, unacceptable, and/or potentially life-threatening. The need for external control or intervention is immediate.

Is training available for learning how to use the FARS and CFARS? Yes… the FARS & CFARS “Web-Based” Training and Certification Program is free and available at: http://outcomes.fmhi.usf.edu

If it’s helpful to talk about these scales in a group, why is FARS & CFARS training only available on the Internet Web-site? In the “beginning”, FMHI provided face-to-face trainings to help the state “ramp up” the implementation of FARS and CFARS That included training some staff in several DCF Districts and many clinical staff in several community mental health agencies to be “Certified FARS and/or CFARS Trainers”…some remain! That was in the 1990’s…way back in the last Century! Attrition rate of clinicians in the community programs makes it impractical for centralized face to face training

If it’s helpful to talk about these scales in a group, why is FARS & CFARS training only available on the Internet Web-site? The only realistic and cost effective alternative is web based Training and Certification that maintains a single minimum standard…permits existing trainers special access…and encourages agencies to emphasize importance to new clinical staff by providing up to date manuals, internet access & time to take the training…CEC applications indicate many use home computers at night to train & receive their official rater ID’s.

Important directions for FARS & CFARS Web-based Training and Certification Program 1) Manuals, forms, training & certification are free 2) Always start each session at: http://outcomes.fmhi.usf.edu 3) Download and read the September 2004 manual to understand the scales and learn how to arrive at the most reliable & accurate problem severity ratings 4) Read and follow detailed instructions in the manual to learn how to register and select a password for the web based training program, take the practice vignettes, take the certification test, and print a certificate with an official rater ID 5) Be sure to complete 2, 3, and 4 6) Direction #5 is the most important

Functional Assessment Rating Scales The Functional Assessment Outcomes Web Site (http://outcomes.fmhi.usf.edu) Functional Assessment Rating Scales The Functional Assessment Rating Scales – (FARS) for adult behavioral health functional assessment (John C.Ward, Jr., Ph.D. & Michael G. Dow, Ph.D., 1994, 1996, 1997, 1998) & (CFARS) for child or adolescent behavioral health functional assessment (J. Ward, M. Dow, T. Saunders, S. Halls, K. Musanta, K. Penner, R. Berry, & N. Sachs-Ericcsson, 1996, 1997, 1998) are ways of documenting and standardizing impressions from clinical evaluations or mental status exams that assess cognitive, social and role functioning. The FARS and CFARS (adapted from the Colorado Client Assessment Rating Scales - CCAR) were developed for use in Florida to evaluate the Florida Department of Children and Families (DCF) behavioral health outcomes for children and adults receiving state supported services.

…and just below that is: The FARS and CFARS links on the left side of this page take you to more information about these scales and free download of the FARS and CFARS user's manuals and forms. The manuals also include detailed instructions for registering and taking the free online training and certification programs for these instruments. Information about a consumer satisfaction measure developed by Dr. Dow and Dr. Ward (The Behavioral Healthcare Rating of Satisfaction - BHRS) is available at http://bhrs.fmhi.usf.edu.

Copyright 2000, 2005 - University of South Florida Contact information regarding the FARS and CFARS: John C. Ward, Jr., Ph.D.. Associate Professor Department of Mental Health, Law and Policy Louis De la Parte Florida Mental Health Institute and Department of Epidemiology and Biostatistics College of Public Health University of South Florida 13301 Bruce B. Downs Blvd. Tampa, FL 33612-3807 phone: (813) 974-1929 fax: (813) 974-9327 E-mail: ward@fmhi.usf.edu Copyright 2000, 2005 - University of South Florida

… other navigation links are on left side of the “Outcomes” page: HOME   Home FARS    FARS CFARS   CFARS FMHI Office 13301 Bruce B. Downs Boulevard Tampa Florida 33612 i Web design and interactive programming: John C. Ward, Jr., Ph.D Bart Mawoussi M.S. Sonnel Moreau M.S.

…when you click on the FARS link on the “Outcomes” page it takes you to the FARS page where you see these active links: Download the September 2004 FARS Manual Go to FARS Training and Certification Site (You must download and read this new manual before beginning your training...the manual has detailed instructions about registering for the online training, selecting your password, taking the training and printing your certificate.)

…the “Training and Certification” link on the FARS page takes you to the “secure” logon page: …where the top of the page says this: Welcome to the Functional Assessment Rating Scales (FARS) Training and Certification System. If you are one of the 4414 students already certified through the online FARS Rater Certification System, or if you are returning to complete your training, please enter your Social Security Number (do not use dashes or spaces) and Password below and click Login. You can retrieve your password if you have forgotten it by clicking on this link.

…and the middle of the logon page looks like this: Soc.Sec. # Password VeriSign Secured Login Verify >

…but, read on…some very important information is just below the logon boxes… If you have not previously registered as a student, please click here to register and select your password. If you have already registered as a CFARS or FARS student, you do not need to register again (just use the same password for this training session. If you register again, you may delete information about your previous training) . The registration process will require that you provide some personal information that will enable us to identify you as a certified FARS rater and to communicate important information in the future.

…forgot your password or want to see if your ssn is in the web database ? Click on the password retrieval link at the top of the logon page…it takes you: Password Lookup In order to retrieve your password, we will need your Social Security Number. Soc. Sec. # After clicking "Send Request," your password will be displayed in this window. If you require assistance, please send e-mail to Dr. John Ward (ward@fmhi.usf.edu) of the University of South Florida. Send Request

…after you enter your ssn without dashes or spaces on the password retrieval page, if you have previously registered or been registered by a certified trainer on the website, you will see this: Thank you for returning to the Functional Assessment Training and Certification System. Your password is supershrink. Use only the characters shown in boldface red. Please note that passwords are case-sensitive.

…when you “click here” to register on the logon page… New Student Registration The information you provide here will enable us to maintain your certification information and identify ways to improve the rater certification system in the future. The Louis de la Parte Florida Mental Health Institute is committed to safeguarding your information and respecting your privacy...Your personal information will be used to generate a unique rater certification number that you will use on each functional assessment that you submit. This rater certification number provides assurance of your successful completion of the training. The confidential information will be maintained in a database operated by the Florida Mental Health Institute. (* indicates a required entry - no dashes please)  

…right side of the Registration page: * Social Security Number: We will keep this information private.   Please enter your name as it should appear on your certificate:* First Name: * Last Name:  Please provide the following information regarding your current employer: * Company Name: Street Address: * City: * State: *Zip: * Telephone (No dashes, please.):* Your Email Address:  Demographic Information:  Gender: *  Education Information: Highest Level of Education:    * Specialty:  Degree Field/Major:  Note: Entering an incorrect value below may cause you to be unable to register as a student. Please do not enter or edit anything below unless you are a certified trainer. Certified Trainers Only: SSN [ ]

Click “Continue” to submit registration & go to this password selection page: Please supply a password in the boxes below. Certified trainers, please provide a password for your student. If you have returned to this page after supplying a password, then the passwords you supplied did not match. Please re-enter your password now. Supply Password Re-Type Password The password you select will be requested each time you login If you do forget the password, you will be able to retrieve it later.

After selecting a password, you go to your “Welcome…” page: Welcome, Sean Connery! (If you are not Sean Connery, click here.) While the training and certification program generally takes more than one hour to complete, It is not necessary to complete the training in one sitting. As you proceed through your training, the options displayed below will change depending on your current status. If you leave the training for any reason, simply log in again whenever you wish using the Social Security Number and password you supplied earlier. The login page will direct you here. Good luck! View Learning Objectives Begin, continue, or repeat the training vignettes Print Continuing Education Credits Application and Instructions (requires Adobe Reader 5.0 or newer). Get Adobe Reader

…the “training vignettes” link goes to: Instructions Please read the following vignette. You may need to scroll down to read it in its entirety. When you have finished, click here to complete the FARS for this vignette. You may also choose another vignette or go back to the previous page. Heather Heather is a twenty-five year old, single woman. She says she is “concerned about herself” because she has started feeling “anxious and tense” most of the time. She described herself as "…stressed out…I feel like my life is totally out of control. " She thinks that she first started feeling this way… etc.

When you “click” on the “click here” button on the Training Vignette Page you go to scoring pages…one for each domain: Provide your rating for each FARS domain using the dropdown box below. Also, check any keywords you feel may be appropriate for this vignette. When you are finished entering all 18 ratings, click the button in the lower right labeled "Submit Ratings for Scoring." You may refer back to the text of the vignette which may be under this window. Use the "Next Domain" and "Previous Domain" links to navigate through the domains. You can skip domains or return to edit your ratings prior to submitting your ratings for scoring. Keep in mind that you cannot submit your ratings until you have supplied a rating for each domain. Depression Depressed mood Anhedonia Sad Hopeless Happy Lonely Sleep Problems Worthless << Previous Domain Next Domain >> V

…the bottom of the scoring page shows your ratings as you click on “Next Domain”… Depression 4 Anxiety 3 Hyper Affect 2 Thought Process 5 Cognitive Performance 6 Medical/Physical 6 Traumatic Stress 3 Substance Use 8 Interpersonal Relations 8 Family Relationships 6 Family Environment 6 Socio-Legal 4 Work/School 6 ADL Functioning 4 Ability to Care for Self 4 Danger to Self 3 Danger to Others 2 Security Mgmt Needs 5 Submit Ratings for Scoring

After you take at least two training vignettes and pass at least one, your welcome page looks like this: Welcome, Sean Connery! (If you are not Sean Connery, click here.) While the training and certification program generally takes more than one hour to complete, It is not necessary to complete the training in one sitting. As you proceed through your training, the options displayed below will change depending on your current status. If you leave the training for any reason, simply log in again whenever you wish using the Social Security Number and password you supplied earlier. The login page will direct you here. Good luck! View Learning Objectives Begin, continue, or repeat the training vignettes Begin, continue or repeat test vignettes Print Continuing Education Credits Application and Instructions (requires Adobe Reader 5.0 or newer). Get Adobe Reader

..and, after you pass a “test vignette” your “Welcome…” page looks like this: Welcome, Sean Connery! (If you are not Sean Connery, click here.) While the training and certification program generally takes more than one hour to complete, It is not necessary to complete the training in one sitting. As you proceed through your training, the options displayed below will change depending on your current status. If you leave the training for any reason, simply log in again whenever you wish using the Social Security Number and password you supplied earlier. The login page will direct you here. Good luck! View Learning Objectives View/Print your Certificate (Requires Adobe Reader 5.0 or newer) Begin, continue, or repeat the training vignettes Begin, continue or repeat test vignettes Print Continuing Education Credits Application and Instructions (requires Adobe Reader 5.0 or newer). Get Adobe Reader jward,ph.d.-usf/fmhi 2005

Sean Connery

You just completed the minimum amount of training & got a certificate (if you have the right version of Adobe), but… …if you want to get really good at using the scales to determine treatment needs and improve response to treatment for the people receiving your services, you should: keep manual open when you rate domains… share your assessments with the people you evaluate and get their feedback (unless prevented by your agency…but ask why!?) rate yourself on each of the domains…and, use the domains to plan and monitor treatment!

Using Completed FARS or CFARS Ratings to develop Individualized Treatment Plans & monitor functional change ? “Focus is on recovery as restoration of functioning rather than simply reduction of symptoms”

Basic Steps in Developing a Negotiated Individualized Treatment Plan Conduct Clinical Interview and assess mental status 2) complete “Admission” FARS/CFARS ratings & descriptors 3) Review completed FARS/CFARS with person assessed 4) Identify “Clinically Elevated” domains 5) Identify “Strength” Domains as personal assets that may help support/reinforce change

Basic Steps in Developing a Negotiated Individualized Treatment Plan (continued) 6) Describe Domain to be Addressed in Treatment Plan (include domain name, severity rating and “words/phrases” 7) Define goals for change in measurable terms 8) Devise an Action Plan with timelines 9) All parties sign the completed document

Ability/Care for Self x Danger to Self x Danger to Others x FARS Profile Ed Smith – 36yo married male No Slight Moderate Severe Extreme Problem Problem Problem Problem Problem 1 2 3 4 5 6 7 8 9 Depression x Anxiety x Hyper Affect x Thought Process x Cognitive Perf. x Medical/Physical x Traumatic Stress x Substance Use x Interpersonal Rel. x Family Relations x Family Environ. x Socio-Legal x Work or School x ADL Functioning x Ability/Care for Self x Danger to Self x Danger to Others x Security/Mngmt.Needs x

“Clinically Elevated” Domains Depression __6__ Depressed Mood Worthless Lonely Anhedonic Hopeless Sleep Problems Sad Happy Anti-Depression Meds

“Clinically Elevated” Domains Substance Use__5__ Alcohol Drug(s) Dependence Abuse Family History Cravings/Urges DUI Abstinent Med. Control Recovery Interfere w/Duties I.V. Drugs

“Clinically Elevated” Domains Work__4__ Absenteeism Poor Performance Attends School Dropped Out Learning Disabilities Seeking Employment Employed Doesn't Read/Write Tardiness Disabled Not Employed

“Clinically Elevated” Domains Danger to Self __4__ Suicidal Ideation Current Plan Recent Attempt Past Attempt Self-Injury Self-Mutilation

“Clinically Elevated” Domains Security/Management Needs __4___  Home w/o Supervision Suicide Watch Behavioral Contract Locked Unit Protection from Others Seclusion Home w/Supervision Run/Escape Risk Restraint Involuntary Exam /Commit

“Strength” Domains Medical / Physical__1__ Acute Illness Handicap or Perm. Dis. Good Health  CNS Disorder Chronic Illness Need Health Care  Pregnant Poor Nutrition Enuretic/Encopretic  Eating Disorder Seizures Stress-Related Illness 

“Strength” Domains Interpersonal Relationships__2__ Problems w/Friends Diff. Estab./Maintain Relationships Poor Social Skills Difficulty Maintaining Relationships Adequate Social Skills Supportive Relationships

“Strength” Domains Family Relationships__2__ No Contact with Family Poor Parenting Skills Supportive Family Difficulty with Partner Acting Out No Family Conflict w/Relative Difficulty with Child Difficulty with Parent

“Strength” Domains Family Environment__2__ Family Instability Separation Custody Problem Family Legal Problems Stable Home Divorce Single Parent Birth in Family Death in Family

Describe Domain to be Addressed “Moderate to Severe level of Depressive functioning as evidenced by FARS rating of 6 on Depression Domain & self report of depressed mood, feelings of worthlessness, sadness, loss of interest in most activities and sleep problems expressed as difficulty going to sleep and early awakening.

Define Goals for Change 1. I will learn the impact of negative thinking & negative self talk in people experiencing depressed mood and write 10 positive self statements to review with my therapist next Friday 2. By end of 30 days, I will increase my current rate of daily exercise from zero minutes per day to 30 minutes per day. (physical health is “strength”) 3. By end of 30 days, I will increase my sleep hours from current level of 3 hours average per night to at least 6 hours per night.

Describe Action Plan 1. I will attend Cognitive Therapy Group for Depression 3 sessions this week and meet with my Therapist on Friday at 3pm to discuss my positive self statement script. 2. I will plan with my wife for us to take a 30 minute walk after dinner each evening (supportive spouse is a “strength”. 3. Each night at bedtime for 30 days, I will review and practice the “good sleep hygiene” behavioral principles given to me by my therapist

Now…pick another “Clinically Elevated” Domain (e. g Now…pick another “Clinically Elevated” Domain (e.g., Danger to Self & Substance Use) and continue the process …

When something is used by clinicians and the people receiving services…it should also be used by the agency… So…how can an agency show that the procedures are important and also benefit from the information developed in the process?

Using Functional Assessments to develop Agency Level Quality Assurance/Quality Improvement Reports ?

Debate about value of Quality Assurance and the Evolution of Quality Management “From Quality Assurance to Total Quality Management” Carol M. Frattali American J. of Audiology – November 1991

QA QI Focused on Problem Solving Clinical Focus Externally Driven Delegated to a few Focused on Individuals Discipline focus Creates Defensiveness Effectiveness and Efficiency separate Focused on continuous improvement Focused on all activities Internally Driven Embraced by all Focused on work process Crosses disciplines Promotes Team Spirit Effectiveness and Efficiency integrated

However…QA is still important but should be expanded to include the QI Philosophy eg., JCAHO requires quality assurance mechanisms as the foundation from which to develop continuous quality improvement monitoring…and offer a ten-step QA process…

JCAHO 10-step Quality Assurance Process 1. Assign responsibility for monitoring and evaluation activities 2. Delineate the scope of care 3. Identify the most important aspects of care 4. Identify indicators for monitoring

5. Establish thresholds for the indicators that trigger evaluation 6. Collect and organize data for each indicator 7. Evaluate care when thresholds are reached to identify opportunities to improve care

8. Take action to improve care 9. Assess effectiveness of the action 10. Communicate results

Using FARS & CFARS Assessments in Quality Management …since I am not a QA expert, let’s first decide we want to…

easy

Using FARS & CFARS Assessments in Quality Management (cont.) …then, we will start with JCAHO Step 3.”Identify the most important aspects of care” …and pick a simple FARS example first…like “Admission to the agency is an important part of the clinical service provided by our agency.”

…and then we go to JCAHO Step 4 …and then we go to JCAHO Step 4. which is “Identify indicators for monitoring…etc.” …“FARS evaluations are to be completed on all people admitted to services at this agency.”

…followed by JCAHO step 5 …followed by JCAHO step 5. which is “ Establish thresholds…that trigger evaluation…” which we might write as… …For a three month monitoring period, “95% of all people admitted for service to this agency will have Admission FARS evaluations completed within 10 days of their admission date.”

…and to JCAHO step 6:“ Collect and organize data for each indicator…” and 7: “Evaluate care when thresholds are reached…” …“Three months of monitoring shows that 90% of all people admitted for service to this agency had FARS Admission evaluations competed within 10 days of their admission date.”

…which takes us to Step 8. which is “Take actions to improve care…”, which could be… …”Meet (or send memo?) with all clinical supervisors to stress importance of having all people admitted to agency have a FARS evaluation completed within 10 days of admission to the agency.”

…and to Step 9. which is “Assess effectiveness of the action and document improvements…”, which could mean… …monitor admission evaluations for additional month to determine if intervention with clinical supervisors improved compliance with FARS 10 day assessment requirement.

…and finally to Step 10. which is “Communicate the results…”, which might be… …sending a memo to all clinical staff and supervisors and administrative and support staff thanking them for their efforts in achieving compliance with this critical aspect of care.

…or we might push a different button a little More complicated

…and do something like this …starting with the same statements we did for Step 3. but picking a different indicator for step 4.…. “People admitted for Crisis Stabilization services due to suicide precaution need treatment that will reduce risk of suicide before being discharged to less restrictive care.”

…and for step 5.….perhaps something like…. “For a 90 day period, 100% of people admitted for Crisis Stabilization services due to suicide precaution as documented by a FARS Danger to Self Rating of 4 or more will improve to a rating of 3 or less before being discharged to less restrictive care.”

Functional Assessment Rating Scale CSU/Inpatient QA Monitoring Report January 1 to April 30, 2005

But…before we get too complicated… the good news is that help is on the way for QA/QI reports that will be added to the DCF OneFamily web-based outcomes reporting system …more on that later!

What is planned for continued use of FARS and CFARS in Florida ?

DCF Functional Assessment Workgroup Recommendations (DCF Memorandum of Understanding) DCF will “study” multiple domains as “drivers” to better understand change reported in aggregated “single” score reports. Districts will not use functional change scores to evaluate individual agency contracts. Provider agency contracts will require use of relevant multiple domain scores in internal Quality Assurance (QA) programs, with QA reports available for examination by Districts as part of contract monitoring.

What is happening as we speak? The Functional Assessment Workgroup continues to assist DCF with monitoring implementation of the FARS to monitor outcomes for adults receiving state supported mental health services in contracted community behavioral healthcare programs and State Mental Hospitals. DCF added stakeholders to the workgroup - agencies that already use FARS to “statistically” monitor QA or Clinical Outcomes and who have experience in creating QA/QI and Clinical Monitoring Reports with FARS and CFARS data (e.g., Florida Health Partners/Health Options).

Staff at Florida State Hospital completed a six month FARS implementation pilot study comparing FARS with Multnomah Community Assessment Scale (MCAS) and Positive and Negative Symptom Scale (PANSS) data…the FARS will now replace PANSS and MCAS…and, As you know, DCF is currently operating OneFamily, a secure Internet outcomes reporting system for FARS and CFARS… that will soon include menus for statewide aggregate reports as well as individual provider agency QA/QI outcomes reports so providers and clinicians will have access to real-time FARS and CFARS data.

Thank you for your patience and attention… …now…does anyone have any questions?