A System to Implement a Standard Assessment Protocol, Treatment Planning Guidelines, and System of Outcome Measurement to Serve Older Adults with Mental Disorders

Developed by the NH-Dartmouth Psychiatric Research Center
(Contact Stephen J. Bartels or Keith M. Miles - 603-271-5747)

Description of the OBTP Intervention: The Outcomes-Based Treatment Planning System (OBTP) is a new methodology designed to increase the quality of home and community-based care of older persons with mental disorders, by substantially improving the clinical tools and practices of the clinicians who serve them. The Outcomes-Based Treatment Planning System (OBTP) is an ambitious effort to design, assist and structure the process of mental health assessment, treatment planning, and measurement of outcomes for the older adult consumer.

The new methodology consists of a comprehensive, integrated, step-by-step system to assess client needs, plan services and treatment, and measure outcomes of treatment at regular intervals. The system consists of specific tools designed for use with this population by mental health clinicians. The OBTP system was initially conceived and developed by the NH-Dartmouth Psychiatric Research Center with a task force of clinicians, consumers, administrators, and researchers in New Hampshire in 1995-96.

Over the years, the New Hampshire-Dartmouth Psychiatric Research Center’s Aging Services Division has revised, pilot tested, and refined the OBTP methodology, working with clinicians from the ten community mental health centers in New Hampshire and several mental health and home health agencies in Connecticut and Massachusetts.   The primary goal of the OBTP innovation is to improve the quality of mental health care for older adults using a clinically relevant and user-friendly approach, which incorporates the most appropriate instruments, guidelines, and related tools.

The OBTP consists of two documents - An OBTP Summary Assessment Form and an OBTP Toolkit (See Attachments A and B).   Within these two documents, the OBTP system is made up of several parts, all of which are conceptually and structurally linked to form a complete system:

• Assessment Domains – The OBTP addresses 18 domains relevant to the older adult requiring mental health services. These represent the areas deemed most important in defining the quality of life of older adults with mental disorders. The OBTP system asks the clinician to review client needs in each of these areas on a quarterly basis. These domains are broadly defined as Symptom, Functioning and Support domains and address specific areas.  
• Sample Screening Questions - Each domain contains screening questions for use by clinicians assessing the client’s strengths and weaknesses. These questions were selected as being the best available to identify potential problems where care and services are needed.   The questions are meant to give the clinician guidance in how to initially address each domain but are not required if the clinician has other standard questions he/she uses. If a problem is suggested, the clinician then turns to…
• Domain-specific formal rating instruments and scales - In each domain, there are instruments available in an accompanying OBTP Toolkit which the clinician is urged to use to measure severity of need in those areas where observation, responses to screening questions or other collateral information suggest a problem. After using the appropriate scale to assess the severity of the problem, the clinician completes….
• Quarterly Summary Rating Scales - In each domain there is a summary rating scale to measure overall severity in that domain, using client or family interview information, observations, and scores on formal rating instruments. These are completed each quarter. After rating the severity, the clinician decides whether this domain is a….
• Service Planning Target - After problem severity has been determined in a domain, the clinician, in consultation with the client, determines if this domain should be a service-planning target. If so, it is checked on the Summary Assessment, initiating service planning. The Clinician then turns to… 
• OBTP Treatment Options Checklist – This is a list of service and treatment options available to address the problem in each domain.   It is designed to help the clinician identify and quickly track the services and interventions provided to consumers on a quarterly basis. For additional help in service planning, the Clinician can also refer in the OBTP Toolkit to the…
• OBTP Treatment Planning Guide – Once Service Planning Targets are identified, the clinician may opt to consult the OBTP Treatment Planning Guide in the Toolkit. This Guide provides a listing of potential interventions and services in each domain, and a summary of recommended evidence-based treatments and protocols in each domain, as offered by authoritative sources and summarized by the PRC. Once treatment options are identified, the clinician can then prepare the…
• OBTP Treatment Plan – To record and describe service activities, an optional Treatment Plan is also included in the OBTP Toolkit. This form is related to the assessment by associating treatments planned to service planning targets. A domain that has been indicated as a service-planning target in the OBTP Assessment is addressed in the treatment plan. Since agencies often prefer or are required to use their own treatment plan, this component is optional. To elicit consumer feedback about their health status, the clinician turns to the …
• Senior Outcomes Checklist (SOC-12) – The SOC-12 is a self-report questionnaire to be completed by the consumer. It is based upon the SF 12, and includes several questions to assess the client's perception of the value of services. The information collected from the SOC-10 is used to inform the development of the treatment plan, and as a way to obtain feedback from the consumer about the client’s health status and assess how helpful services have been. This can be used as often as the clinician finds useful but at least annually.

In summary, the OBTP is meant to be used as a comprehensive and integrated system, with initial screening in multiple domains leading to the assessment and rating of problem severity and the identification of service planning targets. These targets in turn focus treatment planning, which is aided by the OBTP Treatment Planning Guide, and regularly modified by consumer feedback using a simple Senior Outcomes Checklist. 

The OBTP system also incorporates routine outcome measurement through quarterly reassessments and new ratings of each domain. The development of the OBTP system has been partially supported with State of New Hampshire Community Demonstration Program funds and was selected for testing in the Robert Wood Johnson Foundation's National Home and Community-based Care Initiative.

The OBTP system has been shown through the RWJ Initiative to be effective in increasing the range and depth of assessments, increasing the breadth of treatment options offered, and improving outcomes as perceived by consumers. It is now being implemented as the standard for all older adults receiving state supported mental health services in New Hampshire.

Next Steps: It is proposed to make the OBTP available to mental health clinicians nationwide, through a Web-based electronic application and database. This would enable an integrated clinical system for:

• Assessing the needs of older adults with mental illness.
• Giving guidance about services and guideline-based treatment appropriate to their needs
• Measuring the outcomes of such treatment to improve the quality of care.

We propose to develop an integrated, mental health application and database based upon this OBTP methodology utilizing the Internet.   This would allow mental health clinicians, provider agencies, and state mental health agencies throughout the country to securely access, via the internet and using a variety of access devices, an electronic client assessment protocol linked to standard severity rating scales, treatment planning instruments and guidelines, and outcome measurements which would fully inform and guide the clinician in their treatment of mental illness in older adults. 

Such a web-based system would make easily and widely accessible a needed set of uniform protocols and guidelines for assessing and treating older clients' needs. It would also allow tracking of client progress over time with standardized measures and progress reports. Finally, it would allow the aggregate analysis of treatment effectiveness by the type and intensity of the treatment, service, or medication used, and by client characteristics, such as age, gender or diagnosis.

With such a system, any clinician could utilize a hand-held or desktop computer to:

• Access screening questions for a variety of problem domains as he or she conducts a client assessment.
• Pull up on-screen helpful rating scales and instruments to explore in greater depth the problems suspected or reported by the client in each domain.
• Enter a rating of the severity of the client's problems in on-screen checkboxes.
• Access diagnostic possibilities suggested by the assessments made and problems reported.
• Check for the latest treatment guidelines and approaches using on-screen pull down menus and linked databases.
• Choose interventions from pull-down menus showing various treatment options for specific disorders, which are automatically entered into an electronic treatment plan.
• Refer to guidelines on evidence-based practices for each chosen problem area.
• Develop, enter, or update a client's treatment plan on-screen.
• Have a full client assessment profile and treatment plan printed at the end of the assessment session.
• Enter "ticklers" or reminders of scheduled next steps or needed actions to take.
• Update the treatment plan or enter progress notes electronically as needed.
• Allow the clinician or client to track progress graphically in each problem area, quickly viewing the client's history.
• Assess client's progress against progress of clients with similar diagnoses, characteristics.

• Examine clients' progress against the type, intensity, and cost of treatment and services to determine effectiveness for differing types of clients and diagnoses.
• Check the consistency with which differing interventions are being used by different clinicians.
• Compare the caseloads of different clinicians by client type and level of impairment.
• Check the appropriateness of the interventions used by agency clinicians for the problems identified.
• Facilitate and improve the training of new MH clinicians serving older adult using the standard protocol.

• Receive or develop automatic reports of the effectiveness of different interventions for different patients.
• Receive or develop reports comparing provider agencies by the types of interventions used and outcomes. achieved by type of patient, providing the information base for quality improvement efforts to upgrade clinical practices.
• Examine which provider agencies are providing which services at what cost.
• Receive or develop reports comparing need and risk levels represented by different provider agency populations.
• Utilize the aggregate information to develop expected standards for rates of improvement and efficacy of treatments.

• Having a uniform comprehensive protocol guiding their MH assessments and treatment, insuring that more complete care is provided.
• Having quick access and easy updates to the latest information and guidelines on standards of care for each of their problem areas.
• Being able to give their clinician feedback about their care and progress on a regular basis.
• Being able to track and review their progress over time.