Principle 3. Describe the need, not the fact, which you are addressing. It is about the person, not the person in care.
by: Dr. John S. Lyons
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Concept: The only way clinical outcomes can be used across a system of multiple interventions is if the clinical measure is independent of the treatment context. If the clinical measure is dependent on the treatment context then one can only measure episodes of care, and there are enormous challenges for interpreting clinical outcomes across treatment settings. For this reason a communimetric measure focuses on decontextualizing any active intervention.
There are a variety of ways to describe this process of deconstructing the impact of a treatment that exists only during the application of the treatment. For example, we might say that if an intervention is ‘masking’ the presence of a need, you describe the need — not the fact that you can mask it. Or you look at a person’s status before the application of an intervention, then ask: if the intervention were withdrawn, would that person return to their pre-intervention status?
Here are some examples of interventions that mask needs without necessarily resolving them:
- Locked detention stops youth from running but does not address runaway behavior.
- Psychotropic medication has a target symptom and one has to take the medication for the functional implications of that target symptom to be resolved.
- Having a service provider take a child to school makes sure that the child is in school but does not resolve a school attendance problem.
- 24 hour suicide watch does not resolve suicidal ideation or intention; it simply prevents a death outcome.
There are many similar examples, but they all have the same basic theme. To effectively communicate a person’s status in a helping intervention, it is absolutely essential to determine what the status of that person would be like if the help was not being provided.
Background: The origins of this characteristic come from one of the very first applications of the approach. The original communimetric measure was called the Severity of Psychiatric Illness (SPI), and it was used to model psychiatric emergency decision making. Child welfare in Illinois asked me to use the same methodology to model decisions to place youth in residential treatment center (RTC) in support of a community re-investment strategy. From a series of focus groups with system partners, I created the Childhood Severity of Psychiatric Illness (CSPI). The idea was to save money on RTCs and re-invest in community based care. But, a re-investment strategy takes 1-2 years to first save money and then to re-invest in a new interventions. The State had first tried this by asking RTCs to nominate step down candidates. Instead of identifying the best candidates for living in the community safely, RTCs tended to say “Don’t take Mary. Mary is doing great. You will disrupt Mary’s treatment.” Instead they were more likely to say “Take Johnny. We aren’t helping Johnny. Maybe you could?” So they identified precisely the wrong youth. After a tragic death outcome (a stepdown youth murdered his grandparents), the State revisited their strategy and that’s when I got involved. However, the only way their community re-investment strategy could work was if there were youth in residential treatment at the time that really didn’t need to be there, AND that these youth could be successfully returned to the community without intensive supports already in place (to allow the ramp-up of these community-based interventions using cost savings).
To answer the fundamental question of “Which youth are likely to succeed back in a community setting?” we did a review of more than 300 youth in residential care. In order to have meaningful results, we had to describe youth based on how they would be WITHOUT the residential intervention. Reviewers were trained to assess youth’s needs prior to placement and then look for evidence that these needs had actually been eliminated rather than simply addressed in care. This project had a profound impact on the Illinois system at the time and this was the origin of the third key characteristic of a communimetric measure.
Proof of Concept: Psychometric measures can be used only for monitoring the outcomes of episodes of care. This reality is entirely due to this third key characteristic. Using a measure of how someone is doing in residential treatment to guide a stepdown decision can be completely misleading. The stepdown decision should be based on a projection of how the individual might be if they were NOT in residential treatment. The CANS has been widely used as a cross systems decision support and outcome monitoring tool. The ANSA has begun to experience the same type of widespread use with adults. These two measures are among the only measures of functional status that reasonably can be used across systems to assess comparable outcomes.
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