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TheDLA-20–Finally…aUsefulFunctionalAssessment

ScottJ.Westbrock,MSW,LICSW

JaneR.King,PsyD,LP

This is an informational session about the DLA-20. Following this session, you will not be certified to use the DLA-20. Therefore the full instrument cannot be distributed.

FocusonFunctioning:BetterCompliance&Outcomes

•  Stateandfederalfundingagencieshavechangedlawsandstandardsthataffectfundingforservicesprovided.

•  Howcanwecomplywithstate/federalregulationswhenbillingMedicalAssistance,Medicareora3rdPartyPayer?

–  Establishmedicalnecessity–  Makerehabilitationyourtreatmentgoal

andoutcomesmeasurable•  Bothrequirementscanbeaddressedifyou

focusonclientassessedneeds:–  Havingtherighttoolsmakesiteasier–  Measureimpactofsymptomseverityon

ADLs:Mild,Moderate,Severe,ExtremelySevere.

–  Tieassessedneedstoobjectives!

MedicalNecessity&Rehabilitation•  Appropriatelyqualifiedpractitioneridentifies&targetsclinicallyappropriateservicesandinterventionsatappropriateintensityandduration

•  AsdirectedbyanIndividualizedServicePlan•  Designedtoimprovefunctioningandsymptomsorpreventtheirworsening

•  Asbaseduponassessedneedsandanapproveddiagnosis. Source:BillSchmelter,Ph.D.MTMTeamConsultant TracerModelofReviewfromanAuditor’sPerspective

FunctionalAssessmentWants•  Stateandprogramadministrators:

–  Academic,clinicalandbehavioralhealthassessmentsthatjustifyrehabilitativeservicesandsupportindividualrecovery.

•  Providers:–  Assessmenttoolsthatdrivedecisionsoneffective

treatmentoptionsandhelpdeterminegoals.–  Decisionsabouthowtoaddressserioussymptoms

andimpairedLevelsofFunctioningrequirespecificLevelsofCarethatareevidence-basedandtiedtolengthsofstaythatcanberoutinelyreviewedtoensureprogresstowardoutcomes.

TheDLA-20FunctionalAssessment

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TheDailyLivingActivites-20(DLA-20)•  DevelopedbyWillaPresmanes,M.Ed.,M.A.

–  MAinCommunity&OrganizationalPsychology,Statistics–  M.Ed.InCounselingPsychology

•  JCAHOconfirmedfacevalidity(1998)•  CARFcurrentlyliststhetoolforapproveduse•  SEMHMRawardedtheDD/MR(formoderate-severediagnoses)version

asvalidoutcomes(2002)•  TheNationalCouncilhassupportedimplementationforover13years.•  SpecificallypointedoutbyLindaRosenbergduringheropeningkeynote

atNATCON2017!•  ApprovedbyDHStobeusedastheFAforCCBHCsinMinnesota

TheDLA-20•  Identifiesmedicallynecessarydata:currentandco-

occurringsymptoms–LevelofFunctioning.•  Reliablyidentifiesdailylivingandprimaryhealth

problems,stresses.•  Accuratelytargetstreatmentinterventionsin

appropriatelevelsofcare.•  Recordsdataforprescribingmedications.•  Usefulformeasuringchangeoverrepeatedmeasures,

andistime-sensitive.•  Validforreportingoutcomestoindividuals,providers,

payersandadministrators.

Signsandsymptomsofmentalillnessarenotthesolefocusofmedical

necessity–theimpactonleveloffunctioningindailylivingcorrelateswithintensityofcare

neededtoeffectchange.

HowDoesItWork?

Discussing,Anchoring&Scoring

HowitWorks….•  25-30minute,onepagesummaryfunctionalassessment•  Designedtobeanobjectivetoolforusebytraineddirect-carestaff•  20specificdailylivingactivitieswhereclientsmaydemonstrate

variousimpairments–  Nutrition,money,hygiene,productivity

•  Levelofimpairmentforeachtypeofactivityisratedona7-pointscale(1-7)–  Lowernumbersindicatemoresevereimpairment–  A“7”indicatesacompleteabsenceofimpairmentforthatactivity

•  Measuresaremonitoredforchangeovertime–repeatadministrationsevery3-6months.

ScoringtheDLA-20

•  Foreachofthe20dailylivingactivities,youwillassignascore(1-7)thatreflectstheclient’sLOFforpast30days.–  Itisa“snapshot”ofthepastmonthofyourclient’slife,basedonthe

generalpopulation–notcaseloadorotherswithsamedisorders.–  ScoringFunctionalSTRENGTHS

•  Astrengthmeansthat,comparedtotherestofthepopulation,client’sfunctioningiswithinnormallimits.

–  Scoretheseactivitiesas5,6,or7–  ScoringFunctionalCHALLENGES

•  Aweaknessmeansthat,comparedtotherestofthepopulation,client’sfunctioningisimpairedandnotwithinnormallimits

–  Scoretheseactivitiesas1,2,3,or4–  UsetheBenchmarkAnchors

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ScoringtheDLA-20•  Completedconcurrentlywithclient.

–  Usinginformationfromprevious30days–  Sumofall20scores–  Averagescores(total/20)–  Multiplyby10forEstimatedmGAF

•  Iffunctioningvariedinthelast30days,ratethelowestscore.•  Onceyoupickanumber,lookattheanchorbelowtomakesurea

lowerratingisnotmoreaccurate.•  Considerimpairmentsinfunctioningduetophysicallimitations

ANDthoseduetomentalimpairments.Donotconsiderenvironmentallimitationsorculturalnuances(e.g.“nojobsorschoolsorhousingavailable”-itisstillaproblem<=4).

ScoringtheDLA-20

•  Mustaddressatleast15items.All20arealwaysapplicable.

•  Thescoreisnotnecessarilycorrelatedwiththeclient’sself-reportedfunctioning—YOUhavetheanchors,theanswersheet:trustyourownassessmentofdatadescribedinanchorsdefiningstrengths&weaknesses.

PayAttentiontointegratedDLAHealth-CareIssuesinRED(e.g.,scores<=3)

1.  HealthPractices(mental,physical)2.  HousingStability,Maintenance3.  Communication(mentalstatus)4.  Safety(suicidal,homicidal)5.  ManagingTime6.  ManagingMoney7.  Nutrition8.  BetterProblemSolvingAround

Signs,Symptoms9.  FamilyRelationships10.  Alcohol/DrugUse

11.Leisure12.  CommunityResources13.  SocialNetwork14.  SexualHealth15.  Productivity16.  CopingSkills17.  BehaviorNorms18.  PersonalHygiene(inabilityto

careforbasicself-care,hygiene)19.  Grooming20.  Dress

DLA-20–1.HealthPracticesDLA-20ANCHORS

1-Extremelyseverefunctionalimpairment,needspervasivesupports

2–Severefunctionalimpairment,needsextensivesupports

3–Seriousimpairmentwithserioussymptoms;intensesupports

4–Moderateimpairment;routine,frequentsupportforDLA

5–WNL/StrengthMildfunctionalimpairment,intermittentsupport

6–WNL/StrengthIntermittentmildimpairment,needslowlevelsupports

7–WNL/StrengthOptimalindependencewithnosupport

HealthPractices:1–Rateindependentself-careforphysicalhealth(PH)andmentalhealth(MH),includingmanagingmoods,medications,illnessmanagement

Evidenceofdangertoself/othersduetoMH;Noself-care,evidenceofbreaksinreality,requirespervasiveinterventions(e.g.:multipleorlengthystaysincrisis,jail)

Markedlimitationsinself-care&mayhavephysicalcomplications,extensivehelpforveryseverementalimpairments,concernfordangertoself/others

Limitedself-care&compliance,seriousimpairmentsinmoods,symptoms,mentalstatus,maybephysicalissuespromptingcontinuoushelpforhealthcare.

Marginalself-careandcompliancewithhealthissuesorprescriptions,managingmoodsismoderateproblem;requiresscheduledlowlevelmentalhealthassistance.

Moderatelyself-sufficient,managesmoodsbutreliesonintermittent,someroutineassistanceorhomevisitsbyhelpingpersons,inprivateorself-helpresidences

Independentself-care,compliantwithtreatment,meds–minimalsupport,someassistanceokfromfamily,friends,otherhelpingpersons.

Optimallyindependentintakingcareofphysical&mentalstatus;makesgoodhealthcaredecisions,noassistanceneededinself-care.

DLA-20–10.Alcohol/DrugUseDLA-20ANCHORS

1-Extremelyseverefunctionalimpairment,needspervasivesupports

2–Severefunctionalimpairment,needsextensivesupports

3–Seriousimpairmentwithserioussymptoms;intensesupports

4–Moderateimpairment;routine,frequentsupportforDLA

5–WNL/StrengthMildfunctionalimpairment,intermittentsupport

6–WNL/StrengthIntermittentmildimpairment,needslowlevelsupports

7–WNL/StrengthOptimalindependencewithnosupport

Alcohol/DrugUse:10–Rateself-controlwithaddictivedrugsincludingcigarettes;ormaintenanceofalcohol/drugabstinence

Currentabuseordependenceleadingtoimminenthealthandsafetythreats–pervasivesubstanceabuse,noself-control

Currentabuseordependence,maydenysubstanceabuseproblem,doesnotparticipateintreatment;extremelylimitedself-control.

Currentabuseordependence,acknowledgesserioussubstanceabuseproblembutshowslimitedself-control,struggleswithtreatmentplan.

Currentmoderateproblemwithuse,dependence,compliantwithtreatment,moderatesuccessoveralcohol,cigarettes,drugs.

Nocurrentusebutrecenthistoryofabuse/dependence,adequatelyawareofrisksandseekinghelp,information,support,treatmenttocontinuouslysustainsuccess.

Safeuse,notsmokingorabstinentwithself-helpgroups.Mayhavehadhistoryofsubstanceabuse-relatedissue.

Nohistoryofsubstanceabuserelatedproblemsandoptimalself-controlwithsubstances.

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Quicklyidentifiesareasinneedofattention…

…andareasofstrength

mGAF

TrackingProgress

LookingGood!!! ReadytoDiscussDischarge!

DLA-20toMinnesota’sFunctionalAssessmentCross-Walk

DailyLivingActivities–20(DLA-20)

Minnesota’sFACrosswalk

HealthPractices MentalHealthSymptomsHousingStability,Maintenance HousingCommunication Self-CareandIndependentLivingSafety Self-CareandIndependentLivingManagingTime Vocational/Educational&Self-CareandInd.LivingManagingMoney FinancialNutrition Self-CareandIndependentLivingProblemSolving Self-CareandIndependentLivingFamilyRelationships Interpersonal(includingfamilyrelationships)Alcohol/DrugUse(IncludingTobacco) UseofDrugsandAlcoholLeisure Social(includinguseofleisuretime)CommunityResources MentalHealthServicesSocialNetwork Social(includinguseofleisuretime)Sexuality Self-CareandIndependentLivingProductivity Vocational,EducationalCopingSkills Self-CareandIndependentLivingBehaviorNorms Self-CareandIndependentLivingPersonalHygiene Self-CareandIndependentLivingGrooming Self-CareandIndependentLivingDress Self-CareandIndependentLiving*AddedCategoryalongwithInterpretiveSummary Other

Minnesota’sFunctionalAssessmenttoDLA-20Cross-Walk

Minnesota’sFARequirements

DLA-20Crosswalk

MentalHealthSymptoms HealthPracticesMentalHealthServices CommunityResourcesUseofDrugsandAlcohol Alcohol,DrugUse&TobaccoLegal BehaviorNormsVocational Productivity,ManagingTimeEducational Productivity,ManagingTimeSocial(includinguseofleisuretime) SocialNetwork/LeisureInterpersonal(includingfamilyrelationships) FamilyRelationships/SocialNetworkSelf-CareandIndependentLivingCapacity Communication,Safety,Nutrition,ProblemSolving,Coping

Skills,BehaviorNorms,Sexuality,PersonalHygiene,Grooming,Dress

Medical HealthPracticesDental HealthPracticesFinancial ManagingMoneyHousing HousingStability,MaintenanceTransportation CommunityResourcesOther *AddedCategoryalongwithInterpretiveSummary

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TyingItAllTogether

TheGoldenThread

TheGoldenThread

TheGoldenThread(continued)TreatmentPlansarea*SNAP:Strengths,Needs,Assets,Priorities

–  STRENGTHS•  PullgoldenthreadforallDLAs>=5

–  AssessedNEEDS:•  PullgoldenthreadforallDLAs<=4

–  ASSETS?Examples•  Independent,safehousing•  Independentincome•  WorkingorProductive•  Supportivefamily•  NoAlcohol/Drugs/Cigarettes

–  PRIORITIES:•  Whatchallengeistheindividualwillingtoworkon?PullgoldenthreadforDLAs<=2orlowestscoresandaddcomments

TheGoldenThread(continued)Linkagesthrough3KeyDocuments

•  Linkagesmustbeclearbetweenserioussymptomsthatimpactdailylivingandassessedneedsthatfocusonimprovingsymptomsandfunctioningin3keydocuments.–  Thisiscalledpullingthe“GoldenThread”fromtheDiagnosticAssessment(1)throughtotheindividualizedtreatmentplan(2)andfinallytotheprogressnotes(3)DiagnosticAssessment TreatmentPlan ProgressNote-Review

Describingsignsandsymptomsassociatedwithdiagnosisisnotsufficient;mustalsodescribespecificfunctionalimpairments.

Symptom-basedplansarenotenough;mustincludefunctionality-basedtreatmentgoals.

Progressreviewscannotbepurelysubjective;mustdocumentspecificandmeasurableimprovementsinfunctioning

ServicePlanning

Goals

•  Definition:–  AGoalisageneralstatementofoutcomerelatedtoanidentifiedneedintheclinicalassessment.

–  Agoalstatementtakesaparticularidentifiedneedandanswersthequestion,“Whatdowe(clinicianandclient)wanttheoutcomeofourworktogethertobe,asweaddressthisidentifiedneed?”

Bill Schmelter PhD, Senior Clinical Consultant MTM Services & The National Council for Behavioral Health

CompliantMHGoalsthatneedmeasureableobjectives

Ø IwantthevoicestogoawayØ DecreaseuseofsubstancesØ ManagementalhealthandavoidhospitalizationsØ Reduceanxiety,socialphobia,clearcriminalrecordØ Beabletocopewithstress(i.e.,signs&symptoms)Ø Clientwillhavelessdepression,moreenergyØ Clientwillreportfewerhallucinations,delusions

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ServicePlanning:FromGoals…ComeSpecificObjectives

•  Objectivesareobservable&measurable(changesinsymptoms,behaviors,functioning,skills,knowledge,supportlevel.etc.)thatrelatetoachievementofthegoal,andareexpectedtoresultfromplannedinterventions.

•  Theassessmentshouldidentifythebaselinelevelsofsymptoms,functional/skilldeficitsandbehaviorsthatconstitutethebasisfortheidentifiedneeds.Objectivesarestatedchangesinthesebaselines.

Bill Schmelter PhD, Senior Clinical Consultant MTM Services & The National Council for Behavioral Health

Outcomes&Measures

DoTheyMatter,WhatDoTheyMean?

Dot:ACaseStudy

•  NationwideDLA-20CaseStudy–  StudiedeffectivenessofDLA-20trainings–  CaseStudypresentedaclientcasestudyasapretestandposttest

•  PretestgivenusingonlyGAFcriteria–  PretestAverageof36witharangeof26-46

•  TrainedontheDLA-20•  PosttestgivenusingDLA-20andanchors

–  PosttestAverageof25witharangeof23-28

WhatOutcomescanbeExpected?

10programsin10states(n=186)sawstatisticallysignificantchangescores.©WillaS.Presmanes,MTMServices

SCHRC’sProgress•  Initial1.5yearsafterimplementationofDLA-20

–  Overallimprovementinfunctioningof4.05%–  55.4%ofclientsdemonstratedanoverallimprovement–  Showedimprovementin19domains,with1domain(FamilyRelationships)remainingunchanged

•  October1,2017throughSeptember30,2018–  Overallimprovementinfunctioningof5.08%–  60.98%ofclientsdemonstratinganoverallimprovement–  Showedanimprovementin19domains,with1domain(Sexuality)decreasing.11points–a1.02%change.

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WhyMeasureProgress?

•  MeasureorPerish•  OutcomesDrivetheValueEquation

Value-BasedPurchasing

•  Value-basedpurchasingispartofHealthCareReform.

•  Weneedtodemonstratethattheuseofoutcomemeasures(forexample,PHQ-9,DLA-20,etc.)increasesthequalityofcareanddemonstratescosteffectiveness.

OutcomeMeasurementTools

Teamsimproveandexcelbytrackingprogress•  PHQ-9–Depression•  GAD-7–Anxiety•  CAGE-AID–SubstanceAbuse•  AUDIT&AUDIT-C–SubstanceAbuse•  DLA-20

TheTripleAim

Reducepercapitahealthcarecosts Improvetheindividual’s

experience

Improvethehealthcareofthegeneralpopulation

“TheDLA-20hasshownthatoutcomesmeasurementandmonitoringhelppeoplewithmentalillnessmanagetheirtreatment,whichreducestheneedforspecialized,high-costservices.” LindaRosenberg,President&CEO

NationalCouncilforBehavioralHealthOperationalizingHealthReform,2013

CCBHC

CertifiedCommunityBehavioralHealthClinics•  1ofonly8statesinthecountryinafederaldemonstrationproject

•  July1,2017throughJune30,2019•  RedevelopingCommunityMentalHealthCentersintoIntegratedCareClinics

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CCBHC

•  Demonstratingacost-basedperdiemrateforbehavioralhealthservices

•  Demonstratinganintegratedmodelofcarethatincludes:–  Carecoordination–  Progressiveassessmentprocess–  Integratedassessmentandtreatmentplanning–  PrimaryCarescreenings

CCBHCinMN

•  6CCBHCs•  29servicelocations•  18counties

CCBHCinMN

•  InMinnesota,demonstratingservicesthatinclude:–  InitialEvaluationandComprehensiveEvaluation

–  IntegratedTreatmentPlan–  ExpandingFunctionalAssessmentbeyondjustrehabservices(ARMHS/CTSS)

–  TestingtheDLA-20(withanarrativesummary)forFunctionalAssessmentforadults

DLA-20inCCBHC

Earlycomments:•  Cantrackprogress•  Canshowclientsagraphofquantitativeprogress

•  Clarityforstaff•  Canbeusedasastructurefortreatmentplanning

DLA-20atDHS

•  TheDLA-20satisfiesthestatutoryrequirementforFunctionalAssessment

•  TestingtheuseoftheDLA-20forfunctionalassessmentforadultsinCCBHC

•  Willbegatheringdatato:–  Measureefficacyoftool–  Measureoutcomesforpersonsserved

•  WillanalyzedataandconsiderallowinguseofDLA-20beyondCCBHC

Conclusion

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TrendsfortheFuture•  Accountability

–  Bymeasuringoutcomesandcost•  PaymentReform

–  Incentivizingvalueandnotvolume•  Carecoordination

–  Managechronicconditions•  HealthInformationTechnology

–  EMR,HIEanddashboards•  Providerandhealthplanroles

–  Changing

BenefitsofMeasuringwiththeDLA-20•  Consistent

–  Differentpeopleratethesameclientsimilarlyoversameperiod•  Sensitive

–  Notallpatientswiththesameillnesswillberatedsimilarly•  Relevant

–  Ratingsguidetreatmentfocus•  Service-driven

–  Ratingsdetermineamountofappropriateservices/levelsofcare•  Outcome-driven

–  Documenttrueimprovementsovertimewithrepeatedmeasures

This marks the end of this session, please remember you are not certified to use the DLA-20. If you are interested, I would be happy to provide contact information.

Questions

ContactInformation

ScottJ.Westbrock,MSW,LICSWSouthCentralHumanRelationsCenterscottw@schrc.comJaneR.King,PsyD,LPMinnesotaDepartmentofHumanServicesjane.king@state.mn.us