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Navigating the Outcome Morass

• Factors in the Selection of the Daily Living
  Assessment-20
• (DLA-20)
• Lance R. Heffer, PsyD

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Outcomes and Behavioral Health

• Outcome has moved from a largely academic
  pursuit of the nature of psychotherapy to a more
  general context
• Narrow focus on circumscribed symptoms pure
• pathology within a pure technique
• Focus on client variables, therapist
  variables and the
• interaction
• Problems in generalizing
• Subject samples
• Setting

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The Larger ContextCommunity Mental health
Movement Emphasis on serious and persistent
conditions versus neurotic disorders.
Programming that include intensive levels of
intervention (day programs, / 24-7)
Recovery Movement (Presidents Commission)
Emphasis on Consumer involvement
Integration Independence (choice)Economic
Private sector abuses of the 80s and 90s
(proliferation of private psychiatric
facilities) Expanding behavioral health
benefits Constricted health budgets
Utilization Review (medical necessity)
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Large Context (cont.)These factors have
combined to press for the need to demonstrate
outcomes not only for psychotherapy but also for
programmatic ancillary or related services
(TRP, residential, case management, etc.)The
problem becomes What is it we measure and what
are the elements of successful outcome
Criterion Measurement Problem
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Symptoms and FunctionalitySymptoms are an
expression of a disease entityFunctionality
is the degree to which an individual is limited
in the real world by that symptom and/or
diagnosable entity Real world can be
best conceptualized as ones ability to
love (manage relationships) and work
(generativity of some kind) and the day-
to-day expectations necessary to sustain those
primary activities (maintain personal safety,
self-care, utilize community resources,
collaborate with care providers, etc.)
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Symptoms and Functionality (cont.)The emphasis
on symptoms is understandably driven by the DSM
IV (American Psychiatric Association)Physicians
intervene primarily at the molecular or tissue
level (psycho-pharmacology)Non medical
professionals historically have contributed to
the overemphasis on symptomatology due to
graduate school curriculaBoth kinds of
providers work on symptoms from different
perspectives but none-the-less narrow the view of
the person and negatively affects a broader, more
complete outcomeWe all know that there are
people with virulent symptomatology that function
well in the world (Monk). Conversely those with
relatively low symptomatology can have serious or
even pervasive impairments in their ability to
navigate the demands of life.
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Where are We ?Our current efforts largely
lack cohesiveness but We do have a general
appreciation for the interaction of
symptoms interaction of symptoms and
functionality but our outcomes are
generally program specific (Mult Nomah)
Some outcomes need to be symptom-driven
Inpatient, crisis stabilization, more
intense levels of drug programming
(BPRS) We routinely incorporate consumer
feedback We have macro outcomes with
meaning (hospitalization rates, reduced
legal involvement, school attendance etc.) But
Our outcomes are not linked in a coherent
way with the obvious differences in
medical and non-medical service delivery
(Medical Necessity)
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What to do?The single common denominator for
everyservice in behavioral health is the Five
Point Axis Diagnosis, regardless of
disability(MH, MR/DD, SA)While Axis I is
largely a compendium of symptoms, Axis V is the
Global Assessment of Functioning (GAF)
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Problems with the GAF Notoriously unreliable
due to Lack of focus in graduate programs
Historically viewed in a derisive manner by
clinicians Vulnerability to
legal/economic factors
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Willa Presmanes Med, MADuring Communicares
reorganization Ms. Presmanes became aware to us
through David Lloyd, our consultant.Ms.
Presmanes work over the past twenty-years has
been in researching a cross-walk through
functional assessment to provide valid, reliable
GAFIn extensive studies she and her
collaborator (R. Scott PhD) were able to distill
20 functional elements.
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DLA-20Twenty item scale across all significant
areas offunctioningSeparate forms (similar
functional domains) for Adult mental Health,
Substance Abuse, Youth Mental Health and
MR/DDTime efficient (6 10 minutes) for
administrationScoring easy and mathematically
elegantPost training reliability coefficients
within and across professional discipline .80
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Benefits of the DLA-20Allows coherent structure
of levels of care that includefunctionality as
well as symptom and risk.Rooted in routine
clinical practice for all consumers (diagnosis)
Allows easy access to individual outcomes
(change in GAF. Pre-post) (in fact individual
change scores for domains as well
aggregate)Leads to a coherent utilization
management system Entry / Exit criteria
Programmatic Individual
providerSignificant increment to the
demonstration of medical necessity The Golden
Thread
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The Golden ThreadLinks initial assessment
(DLA-20) toTreatment Planning Leads to a
more rational division of labor (medical
focuses on symptoms and non- medical on the
limitations created by the symptoms)
Assists providers and consumers to select
most exigent of limitations Subsequent
documentation to the plan (progress
notations)
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SummaryCommunicare status and initial
experience (outliers)Willa Presmanes
Contact information requirements
Willa.Presmanes_at_gmail.comRecommend contact with
Ms. Presmanes and strong consideration of the
DLA-20 derivedGAF as central outcome.