Mark Payne Dallas Earnshaw Gary Burlingame NASHPD 4 TH National Summit May 1-3, 2005; Washington D.C.

1. Are your patients improving?Are your nurses competent to run groups?The Utah State Hospital—USH patient outcome and group competency program Mark Payne Dallas Earnshaw Gary Burlingame NASHPD 4TH National Summit May 1-3, 2005; Washington D.C.

7. SESSION OVERVIEW • Why did USH develop the group competency and outcome tracking program? • Brief overview of the program • How USH answered the question regarding patient outcomes • How USH answered the question regarding nurse competency in running groups

8. Why create the program? • Growing pressure from stakeholders to provide evidence that patients are improving—ROI • Growing reliance upon group treatments to meet the treatment plan objectives • Disparity in staff skill and experience (existing & new) in confidently and competently delivering group treatments

9. Overview of USH Group Competency & Outcome Tracking Program GROUP OUTCOME • Drivers: • Group Tx. for SPMI inpatients • is a primary modality • Group Tx. for SPMI is effective • or evidence-based Tx. • Group training of professional • is declining—staff skill deficits • Drivers: • Growing need to demonstrate • patient improvement • Unique challenges of outcome • assessment with SPMI • Providing clinicians with • feedback on patient outcomes

10. Overview of USH Group Competency & Outcome Tracking Program GROUP OUTCOME GROUP COMPETENCY PROGRAM: BASIC TRAINING IN GROUP SPECIALTY TRAINING IN GROUP TREATMENT • Hospital Wide • Unit Specific

11. Hospital Wide • Group Competency Committee • Group Coordinator Meetings • Coordinator Resource Manual • USH Group Manual • Group Programming • Training Conferences—MacKenzie • Group Consult Oversight

12. Overview of USH Group Competency & Outcome Tracking Program GROUP OUTCOME GROUP COMPETENCY PROGRAM: BASIC TRAINING IN GROUP SPECIALTY TRAINING IN GROUP TREATMENT • Hospital Wide • Unit Specific

13. Unit Specific • Group Coordinator collaborates with treatment teams • Group Programming • Group Consult Meetings • Shared coordinator resources • In-group observation/consultation

14. Overview of USH Group Competency & Outcome Tracking Program GROUP OUTCOME GROUP COMPETENCY PROGRAM: BASIC TRAINING IN GROUP SPECIALTY TRAINING IN GROUP TREATMENT

15. Specialty Training • Psychological Education Groups • Multifamily Groups • Cognitive Rehabilitation Groups • Basic RN Group Training

16. Evidence-based By-products • 4 articles & book chapters; 5 national presentations • Illustrative papers • Group Competency Program picked as Best Practice example in—International Journal of Group Psychotherapy-2002 • Training necessary to establish competency in psychiatric nurses in running PEG— International Journal of Group Psychotherapy—FOCUS ON LATER • Patterns of nurse competency in running groups—Journal of Psychosocial Nursing under review

17. Overview of USH Group Competency & Outcome Tracking Program GROUP OUTCOME • Multi source measures: • Adults • Brief Psychiatric • Rating Scale—BPRS • OQ 45 revised for SPMI • Children & Adolescents • Y-OQ

18. Overview of USH Group Competency & Outcome Tracking Program OUTCOME USH Data Infrastructure Training BPRS Research • Quality Resource dept • Psychology—BPRS • Social Work—OQ/YOQ • BPRS—UCLA anchor • OQ/Y-OQ staff, unit & • administration • E-chart indices • Meta-analysis • Implementation • Sensitivity • Predict ALS

19. Is this treatment working for this patient? Answering this requires: • Definition of how much change is required before patient can be considered improved—reliable change index (RCI) • Definition of success and failure—clinically significant change

20. Putting RCI & cut scores together to track individual patient change

21. OQ 30 Change in Admit Score

22. BPRS Subscales • AMOS structure equation modeling software • Population specific subscales • standardized scores for sub scales’ range

23. Clinical Feedback in Electronic Charting • Visually helpful • Highlights improvement and deterioration • (RCI and Cut Scores) • Automatically notifies clinical staff when patient deteriorates

24. Evidence-based By-products • 6 articles & book chapters, 3 international & national presentations • Illustrative research papers— • Predicting ALS—Psychiatric Services 2004 • BPRS Item Sensitivity—Psychological Services-under review • Meta analysis to guide in Instrument Selection and Application— Psychiatric Services 2005 • Guide to implementing outcome mgt.—Psychiatric Services 2005 • Establishing psychometric change indices for the Brief Psychiatric Rating Scale— current project

25. Psycho-educational group (PEG) treatment for the severely and persistently mentally ill—SPMI How much group training is necessary for RNs?

26. Literature Background • PEGs produce reliable effects with SPMI patients—esp. inpatients (Burlingame, MacKenzie & Strauss, 2004) • SPMI PEGs focus on disease management or skills (Murphy & Moller, 1998; Lieberman et al., 2001) • Last decade PEGs=preferred modality—esp. with inpatients (Taylor et al., 2001; Burlingame & Ridge, 2004)

27. Literature Background • Mental health training programs are decreasing emphasis on group treatments (Fuhriman & Burlingame, 2001; Cohen & Garret, 1995) • Nurses in particular report low confidence & competence in running treatment groups (Glotz, et al., 1994; Burlingame, et al., 2002)

28. Psycho-educational Groups—PEGS Skills Required to lead PEGs Mastery of specific group content Dimension 2 PEG specific Knowledge & Skills Dimension 1

29. Method • Twelve volunteer nurses were selected • Each nurse was initially assigned to either a self-instruction or a workshop group • Effectiveness of the training was measured by comparing pre- and post- results

30. Nurse Measures Dimension 1—PEG • PEG-Q—knowledge & skills (instructional methods, leadership, group dynamics, therapeutic properties, ethics & managing conflicts & problem patients) Dimension 2--Sym mgt. • SMQ—knowledge regarding content of group (memory/information processing, coping with symptoms, triggers, interpersonal distress, daily activities, symptom mgt techniques

31. Dimension 1—PEG Group Skills of Nurses Results Intensely Trained vs. Self-Instruction

32. Dimension 2—Symptom Mgt. Knowledge & Skills Results Intensely Trained vs. Self-Instruction

33. Comparing different methods of training nurses

34. Summary • Workshop = more in knowledge in running PEGs than self-instruction • Similar on symptom mgt • No differences between the workshop and peer supervision; both increased nurse knowledge & self-report skills • Anecdotally--Nurses report peer supervision provided more clinical knowledge and confidence—future study

35. Conclusions • Workshop produces more knowledge and skills than relying upon a self-instruction—may decrease resistance in running groups. • Explanations why workshop was equivalent to peer supervision • Workshop most effective training method • Effects of supervision not tapped by measures—confidence and clinical technique • Supervision may have hit a “ceiling” of knowledge

36. Where are we going? Outcome • Change metrics to assist clinicians with treatment planning and discharge • Unique characteristics of SPMI patients on extant outcome measures—factor analyses Group • Extension of nurse training to NEO • Increasing quality by common charting syst. • Introduction of evidence-based Txs.

37. For Further Information • Dallas Earnshaw: dearnshaw@utah.gov • Gary Burlingame: gary_burlingame@byu.edu