How a point-of-care dashboard facilitates co-production of health care and health for and with individuals with psychotic disorders: a mixed-methods case study.

BACKGROUND: Individuals with psychotic disorders experience widespread treatment failures and risk early death. Sweden's largest department specializing in psychotic disorders sought to improve patients' health by developing a point-of-care dashboard to support joint planning and co-production of care. The dashboard was tested for 18 months and included more than 400 patients at two outpatient clinics. METHODS: This study evaluates the dashboard by addressing two questions: 1) Can differences in health-related outcome measures be attributed to the use of the dashboard? 2) How did the case managers experience the accessibility, use, and usefulness of the dashboard for co-producing care with individuals with psychotic disorders? This mixed-method case study used both Patient-Reported Outcome Measures (PROM) and data from a focus group interview with case managers. Data collection and analysis were framed by the Clinical Adoption Meta Model (CAMM) phases: i) accessibility, ii) system use, iii) behavior, and iv) clinical outcomes. The PROM used was the 12-item World Health Organization Disability Assessment Schedule (WHODAS 2.0), which assesses functional impairment and disability. Patients at clinics using the dashboard were matched with patients at clinics not using the dashboard. PROM data were compared using non-parametric statistics due to skewness in distribution. The focus group included five case managers who had experience using the dashboard with patients. RESULTS: Compared to patients from clinics that did not use the dashboard, patients from clinics that did use the dashboard improved significantly overall (p = 0.045) and in the domain self-care (p = 0.041). Focus group participants reported that the dashboard supported data feedback-informed care and a proactive stance related to changes in patients' health. The dashboard helped users identify critical changes and enabled joint planning and evaluation. CONCLUSION: Dashboard use was related to better patient health (WHODAS scores) when compared with matched patients from clinics that did not use the dashboard. In addition, case managers had a positive experience using the dashboard. Dashboard use might have lowered the risk for missing critical changes in patients' health while increasing the ability to proactively address needs. Future studies should investigate how to enhance patient co-production through use of supportive technologies.

Using Complexity Assessment to Inform the Development and Deployment of a Digital Dashboard for Schizophrenia Care: Case Study.

BACKGROUND: Health care is becoming more complex. For an increasing number of individuals, interacting with health care means addressing more than just one illness or disorder, engaging in more than one treatment, and interacting with more than one care provider. Individuals with severe mental illnesses such as schizophrenia are disproportionately affected by this complexity. Characteristic symptoms can make it harder to establish and maintain relationships. Treatment failure is common even where there is access to effective treatments, increasing suicide risk. Knowledge of complex adaptive systems has been increasingly recognized as useful in understanding and developing health care. A complex adaptive system is a collection of interconnected agents with the freedom to act based on their own internalized rules, affecting each other. In a complex health care system, relevant feedback is crucial in enabling continuous learning and improvement on all levels. New technology has potential, but the failure rate of technology projects in health care is high, arguably due to complexity. The Nonadoption, Abandonment, and challenges to Scale-up, Spread, and Sustainability (NASSS) framework and complexity assessment tool (NASSS-CAT) have been developed specifically to help identify and manage complexity in technology-related development projects in health care. OBJECTIVE: This study aimed to use a pilot version of the NASSS-CAT instrument to inform the development and deployment of a point-of-care dashboard supporting schizophrenia care in west Sweden. Specifically, we report on the complexity profile of the project, stakeholders' experiences with using NASSS-CAT, and practical implications. METHODS: We used complexity assessment to structure data collection and feedback sessions with stakeholders, thereby informing an emergent approach to the development and deployment of the point-of-care dashboard. We also performed a thematic analysis, drawing on observations and documents related to stakeholders' use of the NASSS-CAT to describe their views on its usefulness. RESULTS: Application of the NASSS framework revealed different types of complexity across multiple domains, including the condition, technology, value proposition, organizational tasks and pathways, and wider system. Stakeholders perceived the NASSS-CAT tool as useful in gaining perspective and new insights, covering areas that might otherwise have been neglected. Practical implications derived from feedback sessions with managers and developers are described. CONCLUSIONS: This case study shows how stakeholders can identify and plan to address complexities during the introduction of a technological solution. Our findings suggest that NASSS-CAT can bring participants a greater understanding of complexities in digitalization projects in general.

The resource group method in severe mental illness: study protocol for a randomized controlled trial and a qualitative multiple case study.

BACKGROUND: The resource group method provides a structure to facilitate patients' empowerment and recovery processes, and to systematically engage significant others in treatment and care. A patient chooses members of a resource group (RG) that will work together on fulfilling patients' recovery plan. By adopting shared decision-making processes and stimulating collaboration of different support systems, a broad and continuous support of patients' chosen goals and wishes is preserved and problem solving and communication skills of the RG members are addressed. OBJECTIVE: The objectives of this study are (1) to establish the effectiveness of the RG method in increasing empowerment in patients with severe mental illnesses (SMI) in the Netherlands; (2) to investigate the cost-effectiveness and cost utility of the RG method; and (3) to qualitatively explore its dynamics and processes. METHODS/DESIGN: This multisite randomized controlled trial will compare the effects of the RG-method integrated in Flexible Assertive Community Treatment (FACT) (90 patients) with those of standard FACT (90 patients). Baseline assessments and 9-month and 18-month follow-up assessments will be conducted in face-to-face home visits. The primary outcome measure, empowerment, will be assessed using the Netherlands Empowerment List (NEL). The secondary outcomes will be quality of life (MANSA); personal, community and clinical recovery (I.ROC); general, social and community functioning (WHODAS 2.0); general psychopathological signs and symptoms (BSI-18); and societal costs (TiC-P). An economic evaluation of the cost-effectiveness and cost utility of the RG method will also be conducted. A qualitative multiple case-study will be added to collect patients', RG members' and professionals' perspectives by in-depth interviews, observations and focus groups. DISCUSSION: This trial will be the first to study the effects of the RG method on empowerment in patients with SMI. By combining clinical-effectiveness data with an economic evaluation and in-depth qualitative information from primary stakeholders, it will provide a detailed overview of the RG method as a mean of improving care for patients with SMI.Trial registration The study has been registered in the Dutch Trial Register, identifier: NTR6737, September 2017.

Durability of the efficacy of integrated care in schizophrenia: a five-year randomized controlled study.

OBJECTIVE: The aim of the study was to evaluate the durability of efficacy of the Integrated Care (IC) program in a Swedish context. The IC program is a person-centered flexible assertive community treatment approach delivered through a novel mechanism: a resource group clinical microsystem for each patient. METHODS: All patients with schizophrenia in a Gothenburg urban-sector catchment area were randomly assigned to either the IC or the Rational Rehabilitation (RR) programs. Sixty-six patients were interviewed and assessed by independent interviewers before treatment, after treatment (24 months), and at follow-up (five years). Analysis was by intention to treat. RESULTS: At the five-year follow-up, significant improvements were noted in social functioning and consumer satisfaction in the IC group (N=35) compared with the RR group (N=31). No patients were lost to services in either program. CONCLUSIONS: The major finding was the durability of efficacy of the IC program.

Resource Group Assertive Community Treatment (RACT) as a Tool of Empowerment for Clients with Severe Mental Illness: A Meta-Analysis.

The aim of the current meta-analysis was to explore the effectiveness of the method here labeled Resource Group Assertive Community Treatment (RACT) for clients with psychiatric diagnoses as compared to standard care during the period 2001 - 2011. Included in the meta-analysis were 17 studies comprising a total of 2263 clients, 1291 men and 972 women, with a weighted mean age of 45.44 years. The diagnoses of 86 % of the clients were within the psychotic spectrum while 14 % had other psychiatric diagnoses. There were six randomized controlled trials and eleven observational studies. The studies spanned between 12 and 60 months, and 10 of them lasted 24 months. The results indicated a large effect-size for the "grand total measure" (Cohen´s d = 0.80). The study comprised three outcome variables: Symptoms, Functioning, and Well-being. With regard to Symptoms, a medium effect for both randomized controlled trials and non-randomized studies was found, whereas Functioning showed large effects for both types of design. Concerning Well-being both large and medium effects were evident. The conclusions of the meta-analysis were that the treatment of clients with Resource Group Assertive Community Treatment yields positive effects for clients with psychoses and that the method may be of use for clients within the entire psychiatric spectrum.

The self-assessment Global Quality of Life scale: Reliability and construct validity.

Abstract Objective. The aim was to establish psychometric properties of the Global Quality of Life Scale (GQL) for people with severe mental illness. Methods. GQL is a stand-alone visual analogue scale included in "The Quality Star", a minimal platform for clinical follow-up and efficiency documentation of mental health services in eight dimensions widely used in Sweden. Validating instruments included MANSA, Inventory of Problem and Solutions, Consumer Satisfaction Rating Scale, Perceived Global Distress, health screening using UKU-Side Effect Rating Scale, GAF, and Perceived Global Burden (for next of kin). Test-retest reliability of the GQL was examined between ratings at quarterly intervals during 1 year. Results. There were three main results: test-retest reliability at quarterly intervals was very satisfactory, concurrent validity with the initial item of life satisfaction scale of MANSA, "Life as a whole", was demonstrated and finally content validity was clarified by associations with a number of validating measures from several contexts in three studies. Conclusion. GQL have acceptable psychometric properties and is valid for serious mental ill persons. Its use as easy-to-use instrument for screening of perceived global quality of life was supported.

Naturalistic studies--researching the everyday clinical world.

During the last decade, a vast amount of research has been produced concerning the efficacy of different pharmacological and psychological treatments in psychiatry for various diagnoses. This movement towards evidence-based practices has aimed at grounding clinical practice in evidence derived from research, to optimize outcomes. Such developments should translate into the successful management of seriously mentally ill persons, allowing them to remain safely and productively in their communities rather than in more restrictive settings. Treatment regimens grounded in evidence are well behind the deinstitutionalization of mentally ill persons, which has sometimes even led to their reinstitutionalization in unfavorable settings (jails, nursing homes, etc.) and unsafe living conditions (shelters, streets).

Self-reported consumer satisfaction in mental health services: validation of a self-rating version of the UKU-Consumer Satisfaction Rating Scale.

The UKU-Consumer Satisfaction Rating Scale (UKU-ConSat) for the evaluation of consumer satisfaction in mental health services was constructed for assessments by independent professional interviewers. In the present study, a patient self-reported version of the scale is validated against the original version. The Spearman's rank correlation between single items, subscores and the total of the original scale and the self-assessment version was found to be good. Another main finding was an acceptable unidimensionality of the self-rating version of the UKU-Consumer Satisfaction rating scale, evaluated by a Mokken analysis. Furthermore, the internal consistency by Cronbach's alpha was found to be satisfactory. The results show that the patient self-rating version is psychometrically sound and therefore suitable for use in ordinary clinical practice. Being a part of a concept for continuous quality control and development in mental health services, the self-rating version of the UKU-ConSat promotes an open collaborative dialogue between professionals and users. A further advantage is that it saves professional time.

The clinical strategies implementation scale to measure implementation of treatment in mental health services.

OBJECTIVE: The authors describe the development of the Clinical Strategies Implementation Scale (CSI), an instrument designed to help providers measure the extent to which evidence-based strategies have been implemented in the treatment of persons with schizophrenia spectrum disorders. METHODS: Nine ordinal scales were devised to measure key aspects of treatment strategies that have been associated with clinical and social recovery from schizophrenia: goal- and problem-oriented assessment, medication strategies, assertive case management, mental health education, caregiver-based problem solving, living skills training, psychological strategies for residual problems, crisis prevention and intervention, and booster sessions. A study of interrater reliability was conducted with 15 trained raters from participating centers in Athens, Auckland, Bonn, Budapest, Gothenburg, and Tokyo who assessed 54 cases. Each treatment strategy was weighted according to its effect size in clinical trials. Correlation analyses were conducted to explore associations between the total CSI score and ratings of clinical, social, and caregiver outcomes each year over four years of continued treatment of 51 patients. RESULTS: Interrater reliability ranged from .93 to .99. Four annual total CSI ratings were significantly correlated with impairment, disability, functioning, work activity, and an index of recovery. Most correlations were stronger in years 3 and 4 than in years 1 and 2. CONCLUSIONS: Reliable and valid assessment of the implementation of evidence-based strategies in clinical practice is feasible. The quality of integrated program implementation may be associated with improved clinical and social recovery from schizophrenic disorders.

Implementation of evidence-based treatment for schizophrenic disorders: two-year outcome of an international field trial of optimal treatment.

According to clinical trials literature, every person with a schizophrenic disorder should be provided with the combination of optimal dose antipsychotics, strategies to educate himself and his carers to cope more efficiently with environmental stresses, cognitive-behavioural strategies to enhance work and social goals and reducing residual symptoms, and assertive home-based management to help prevent and resolve major social needs and crises, including recurrent episodes of symptoms. Despite strong scientific support for the routine implementation of these 'evidence-based' strategies, few services provide more than the pharmacotherapy component, and even this is seldom applied in the manner associated with the best results in the clinical trials. An international collaborative group, the Optimal Treatment Project (OTP), has been developed to promote the routine use of evidence-based strategies for schizophrenic disorders. A field trial was started to evaluate the benefits and costs of applying evidence-based strategies over a 5-year period. Centres have been set up in 18 countries. This paper summarises the outcome after 24 months of 'optimal' treatment in 603 cases who had reached this stage in their treatment by the end of 2002. On all measures the evidence-based OTP approach achieved more than double the benefits associated with current best practices. One half of recent cases had achieved full recovery from clinical and social morbidity. These advantages were even more striking in centres where a random-control design was used.

D(2)- and 5-HT(2) receptor occupancy in high-dose neuroleptic-treated patients.

Individual schizophrenic patients are sometimes reported to benefit from unusually high doses of neuroleptics. Such patients may have poor drug penetration into the brain or ultra-rapid metabolism. Alternately, very high doses may be required to induce occupancy of 5-HT(2) receptors, which have been suggested as mediators of atypical effects. Five schizophrenic patients treated with high doses of fluphenazine decanoate (100-250 mg/wk) and adjunct medications were examined with positron emission tomography and [(11)C]raclopride to measure D(2) receptor occupancy and [(11)C]NMSP to measure 5-HT(2) receptor occupancy. All patients were rated globally as 'markedly' to 'severely' ill and had high scores on all subscales of the Positive and Negative Syndrome Scale for schizophrenia. However, according to retrospective clinical evaluation, there was improved social function and reduced distress following high-dose treatment, an effect that deteriorated after previous explorative dose reduction. Extrapyramidal symptoms were modest. D(2) receptor occupancy was very high (89-97%). 5-HT(2) receptor occupancy was also high (76-105%). Plasma concentrations of fluphenazine were 5-37 nm. No patient had a cytochrome P450 CYP2D6 genotype associated with ultra-rapid drug metabolism. The findings suggest almost complete saturation of D(2) receptors, and do not support poor drug availability in the brain as the basis of the apparent high-dose requirement. The high 5-HT(2) receptor occupancy may have contributed to the apparent clinical improvement and modest degree of EPS. However, it is likely that the treatment used also induced occupancy of other neuroreceptors.