Washington State Study
Only 5.7% – 12.5% of adults achieve meaningful improvement in their psychological and social functioning after receiving treatment (WSIPP report 2008)
Poor results are corroborated statewide
Washington State Institute for Public Policy (WSIPP) was directed by the 2001 Washington State legislature to conduct long-term outcomes studies of clients of the Washington State public mental health system. In 2008, WSIPP reported the results of a 4-year study on 39,039 clients of the Washington State public mental health system. Based upon their analysis of Global Assessment of Functioning scale scores, the Institute report concluded that “5.7 to 12.5 percent of consumers in the study cohort [cohort: the group of individuals who are the subjects of a study] had a meaningful improvement in GAF scores during the period of service.” Significantly, the Institute stated, “Improvement levels did not appear to be related to utilization patterns.” In other words, those who received regular services did no better than those who received intermittent services.
Update on Outcome Reporting in the Washington State Mental Health System
I. The JLARC report
In 2000, the Washington State Joint Legislative Audit and Review Committee produced a report entitled Mental Health System Performance Audit analyzing the Washington State Mental Health System.* This report had been requested by the Washington State Legislature. The report noted that “Legislative enactments in 1995 directed the MHD to streamline process-oriented oversight activities and focus on consumer and system outcomes.” In other words, the legislative intention to have a mental health system that tracks consumer outcomes has been in place for at least 18 years.
Among the “major findings” of the JLARC report were the following:
The MHD has made efforts to streamline burdensome activities to promote system accountability. However, these accountability activities are focused on processes of service, rather than on outcomes of service. There is almost no information collected on a statewide basis on client or system outcomes. (p. 3)
Because of the lack of statewide outcome data, comparisons of the effectiveness of services provided by RSNs and providers are impossible. (p. 3)
Legislative enactments in 1995 directed the MHD to streamline process-oriented oversight activities and focus on consumer and system outcomes…. However, while efforts have been made to streamline accountability activities, these activities focus on processes of care rather than outcomes of care. We believe the MHD should focus its accountability efforts on outcomes and negotiate with HCFA to do so as well by replacing current process-oriented accountability activities with an approach that is outcome-based. (p. 15)
JLARC called for
(2) Accountability of efficient and effective services through statewide standards for monitoring and reporting of information that bears directly on system and client outcomes…” (p. 16)
… the MHD collects almost no information on client or system outcomes. Therefore, it is not possible to make any comparisons of service effectiveness: (e.g., did the services provided have a positive effect on the clients served?) Nor is it possible to relate service effectiveness to service efficiency. (p. 19)
The recommendations of JLARC led to the passage of legislation that entered into law in the form of RCW 71.24.015, where it states that the intent of the legislature is to have a mental health system that uses “practices that are evidence-based, research-based, consensus-based, or, where these do not exist, promising or emerging best practices, which provide for…(3) Accountability of efficient and effective services through state-of-the-art outcome and performance measures and statewide standards for monitoring client and system outcomes, performance, and reporting of client and system outcome information. These processes shall be designed so as to maximize the use of available resources for direct care of people with a mental illness and to assure uniform data collection across the state.”
Also, 71.24.805 states the legislature’s support for “replacing process-oriented accountability activities with a uniform statewide outcome measurement system; and using outcome information to identify and provide incentives for best practices in the provision of public mental health services.” (emphasis added)
It is clear that the legislature wants to have statewide outcome measures in place that would allow the state to determine which practices are leading to the most mental health gain for clients of the mental health system.
II. First DSHS Public Disclosure Request
In February of 2013, a request was made to DSHS, asking what statewide mental health outcome measures were currently in place. DSHS responded with links to several documents (see Appendix A). From these documents a list of 40 outcomes currently being measured was compiled. The measures are:
1. Access to health and behavioral care
2. State hospital inpatient evaluations
3. Percent of mental health consumers receiving a service within 7 days after discharge
4. Youth and adult arrests
5. Children, youth and adults who are homeless or whose residences are very unstable
6. Working age adults who are employed
7. Youth receiving diploma or GED
8. Adults attending training, technical or college
9. Voter registration rates among persons with mental illness
10. Emergency room visits classified as “inappropriate”
11. Mortality rates, crude and age-adjusted
12. Consumer participation in treatment, for DSHS clients using mental health services from
13. Level of coordination with other agencies, for DSHS clients using mental health services
14. System investment ratio: Proportion of resources spent on community-based services
15. Use of evidence-based and promising interventions and practices
16. Mental health treatment penetration
17. Mental health outpatient treatment within 30 days after a mental health inpatient stay
18. Mental health outpatient treatment within 30 days after release from Washington State
19. Consumers receiving peer services, clubhouse services, and youth and family support
20. Youth and adults with co-occurring substance use who receive chemical dependency services
21. Feeling accepted by the community among persons with mental health problems, for DSHS
clients using mental health services from the RSNs
22. Number of adult Medicaid consumers who receive OP services from RSNs
23. Number of youth Medicaid consumers who receive OP services from RSNs
24. % adult Medicaid consumers seen in MH system within 7 days post-discharge from IP services
25. % youth Medicaid consumers seen in MH system within 7 days post-discharge from IP services
26. % adult Medicaid consumers who receive an intake within 14 days of request
27. % youth Medicaid consumers who receive an intake within 14 days of request
28. Number of adult Non-Medicaid consumers who receive OP services from RSNs
29. Number of youth Non-Medicaid consumers who receive OP services from RSNs
30. % ITA detentions done in community hospitals or E&Ts v. State Hospitals
31. L&I Claims Filed at State Psychiatric Hospitals
32. Restraint Incidents Per 1,000 Patient Days
33. Seclusion Incidents Per 1,000 Patient Days
34. Western RSN average daily utilization of state hospital civil beds
35. Eastern RSN average daily utilization of state hospital civil beds
36. Number of children waiting more than 30 days for admission to CLIP
37. % served in pre-release engagement services in the ORCSP program
38. Funds spent to transition individuals from jails to community settings
39. Number of children receiving services in the Wraparound pilots
40. % contracts with completed risk assessments and monitoring plans
As can be seen from this list, most of these are essentially process oriented measures. Only a few might be considered client outcome oriented and none of them could be used to, as stated in RCW 71.24.805, “to identify and provide incentives for best practices.”
DSHS does client surveys regarding how satisfied clients are with their service but this is not the same thing, particularly when the real concern is for the seriously mentally ill category, who are not likely to be highly represented on such a survey.
III. Second DSHS Public Disclosure Request
Following the receipt of DSHS’s reply to the first request, a second request was made for any statewide outcome measures (test, scales, etc) currently in place that measure client improvement or decline in terms of the symptoms of the psychiatric disorder for which the client are being treated (and the reduction or increase in the severity of those symptoms) or a somewhat more general assessment such as the Global Assessment of Functioning or a similar instrument.
DSHS replied that
“We have conducted a diligent search for any responsive documents across different parts of the Department. The Department does not collect information from treatment providers to directly measure and individual’s improvement or decline in terms of the psychiatric disorder for which they are being treated.”
In short, legislative intent that has been in place since 1995 is to date not realized in the form of any outcome reporting that would allow the state to know whether current mental health treatments are truly benefitting clients of the Washington State Mental Health System or to compare treatments and procedures offered by one provider or RSN with those of another to determine what are the best practices.
CCHR has, however, done its own investigation of mental health outcomes in King County and Washington State and found them to be uniformly disappointing.
Request for Public Records ID # 201302-PRR-552
The Department of Social and Health Services (Department) received a public records request from you by email on 2/19/2013. Your request was sent to Behavioral Health and Recovery, and referred to me for a response.
We are providing you with links to related Department publications and or reports as follows:
• Core Metrics – behavioral health measures can be found starting page 1.3a (or page 17 of the PDF) http://www.dshs.wa.gov/ppa/PMdocuse.shtml
• Governor’s GMAP
• DSHS Research & Data Analysis Mental Health Transformation Project – statewide performance report
• 2013 DSHS Performance Measures, Data and Research Document
We have attached here an Excel file of the most recent Results through Performance Management System (RPM) reported to the Office of Financial Management (OFM).
The Washington State Institute for Public Policy http://www.wsipp.wa.gov, a state research institution, and The Washington Institute for Mental Health Research & Training http://depts.washington.edu/washinst/ have both published reports on mental health outcomes. Their websites may provide you with additional information.
You also requested any documents reporting the results of any analysis of statewide mental health outcomes (using the current uniform statewide outcome measurement system) comparing the Regional Support Networks (RSNs) and providers to determine the relative effectiveness of mental health services provided by the various RSNs and providers.
The RSN administrators are responsible for outcomes in the RSNs. The Department need only produce its own records in response to your request. If you want information on outcome reports held by the RSNs, you would need to contact each individual RSN administrator. We are providing you with the link to the list of RSN administrators.
Finally, you may want to utilize the link below for additional information on RSN services.
We believe that this information is responsive to what you requested. If you believe that we have misinterpreted your request, have any questions or need additional information, please feel free to contact me …. Thank you.
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