Patient reported unmet needs

PATIENT - REPORTED UNMET NEED 1

********Date: 3-10-15*********

Student’s Name: Allen Sutton NPP

Setting: Outpatient Mental Health Office

Population Impacted: Mentally Ill Patients with Substance Abuse

and other comorbid illness

Capstone Advisor and Credentials: Dr Barbara

Turner , DUSON - Chairperson and Principle investigator

Committee Members and Credentials: Dr Louis Teitlebaum

Investigator

Dr Pending New Investigator

Statement of the Problem

Dual diagnosed patients affected by severe mental illness (MI),

substance abuse (SA), and other chronic comorbidities continue to

be the core demographic treated by outpatient mental health

clinics. The outpatient mental health clinics on Long Island

offers comprehensive mental health treatment which includes


individual therapy, psychoeducation and medication management.

Many private mental health clinics offer customized treatments

such as behavioral treatment, natural assisted detox for patients

that are dual diagnosis and medically guided maintenance. The

Garden City Outpatient Mental Health office of Doctor Louis

Teitlebaum , Board Certified Neuropsychiatrist and Psychiatric

Nurse Practitioner Allen Sutton , NPP are devoted to “effective

integrated treatment for people with severe mental illness”

citation . Their mission is the effective re-integration of

patients with severe mental illness into society and continuous

access to quality healthcare. This is accomplished

systematically by meeting patient needs and providing a

therapeutic alliance that encourage independent decision-making

and positive empowerment. The staff with in the clinical group

includes Psychiatrist, Nurse Practitioner , Psychologist and

Clinical Social Workers that believe in providing an understanding of

the concepts, principles and values inherent in everyday thinking about mental

health, psychiatric diagnoses and the theoretical drivers of mental health

policy, it can impact directly on the lives of people involved in all aspects

of mental health care . All individuals are referred from outside


sources such as local hospitals , mental health agencies,

detoxes, penal and EAP programs. The team is multidisciplinary

and each office are sole proprietors. The patients are referred

to the individual contractors for services within the group as

needed. Some patients prefer the fact that they have affiliation

with more than one provider within the group and others are

paranoid about someone outside their primary provider having

access to pertinent medical information. Effective communication

with schizophrenic patients is particularly important because

they are so easily overwhelmed by the external environment.

However, the signs and symptoms of schizophrenia vary

dramatically from person to person, both in pattern and severity.

(Harvard Letter , October 2011, p.) Getting to know the unmet

needs of patients allows providers to make decisions on effective

interventions. Mental health needs include broad domains of

health and social functioning.

There are few psychological therapies that have been

significantly researched and shown to be effective with

schizophrenia, but the leading one is called Cognitive Behavioral

Therapy (CBT) for Psychosis / Schizophrenia. While medications


can help minimize many of the “positive” symptoms – the voices,

delusions, etc. that are common with schizophrenia, even with the

medications many patients with severe symptoms are unable to

report what they perceive as unmet needs. CBT helps patients

develop skills to assess what is problematic in functioning in

the community and what unmet needs are associated. Unmet needs

are differentiated from met needs by the impact on their quality

of life (Phelan et al, 1995). Research has shown that mental

healthcare should be provided based on need and the goal of

improving quality of life. There are few psychological therapies

that have been significantly researched and shown to be effective

with schizophrenia, but the leading one is called Cognitive

Behavioral Therapy for Psychosis / Schizophrenia. While

medications can help minimize many of the “positive” symptoms –

the voices, delusions, etc. that is common with schizophrenia,

even with the medications many continue to have behavioral

problems.

The Assessment of Needs Questionnaire that can be completed

during normal psychiatric office visits can produce a wealth of

information important to identifying self-care deficits and unmet


needs. A previous study conducted by Slade et al. (2005)

researched the extent to which phone prompts, reminders,

increased contact and similar mental health interventions could

satisfy unmet needs and lead to quality of life improvement. The

expected results demonstrated that patients experienced both a

perceived quality of life improvement and a decrease in unmet

needs over the three months of this pilot study (Slade et al.,

2005). The intervention described here uses outpatient resources

to build on this knowledge base and test the validity of low-cost

patient self-assessment in improving perceived QOL for the out

patient population.

A linear regression analysis study performed by Benaiges, Prat

and Adam (2012) analyzed three populations: individuals affected

by mental illness (MI), those affected by alcohol dependence and

individuals diagnosed with both. Of the three populations, the

dual-diagnosed SA/MI cohort exhibited the lowest quality-of-life

self-assessment; the addition of other chronic diagnoses would

probably make the situation more pronounced. A systematic review

by Meade & Sikkema (2005) further established strong correlative

linkages between MI and self-care deficits.


In HRQOL scholarship, there have been several different

methodologies suggested (Prince & Gerber, 2001; Lehman, Postrado,

& Rachuba, 1993; Yamada, 2007; Smith, Avis, & Assmann, 1999;

Visser, Oort, & A.G. Spranger, 2005; Achat, Kawachi, & Levine,

1998). One of these is M. Becker, R. Diamond, & F. Sainfort’s

(1993) discovery of a lacuna in the research concerning

measurements of quality of life. While previous measurements,

they argue, took into account what may happen in research

settings, they did not take into account clinical settings. Thus,

they set out to create a better measurement tool. A subjective,

self-report measure—The unmet needs questionnaire will be used

here in conjunction with the CDC measures in order to determine

pre-test and post-test differences. , The questionnaire’s main

thrust is subjective questions; the scale will include categories

of satisfaction instead of merely a scale of levels of

dissatisfaction in order to determine more accurately how

patients truly feel about their quality of life (See Appendix A).

Project Aims


Persons living with dual-diagnosed mental illness (MI),

substance abuse (SA), and other chronic medical diagnosis are a

vulnerable population in this country. Caregivers of psychiatric

patients know that giving more comprehensive mental health

treatment addresses the needs of the patients that are unmet.

The assessment of these needs is paramount in order to

provide tailored care to this population. Therefore the aim of

this project is to assess the self-reported unmet needs and

causative factors of self-care deficits among patients dually

diagnosed with mental illness, substance abuse, and chronic

medical issues being served by the Garden City Mental Health

Outpatient Clinic (GCMHOC).

Project Methods

This study will utilize a “pre- post-test” design and will

be limited to 50 patients served by the GCMHOC team. Inclusion

requirements are a mental disorder as specified by the criteria

of the Diagnostic and Statistical Manual 1st edition (DSM V, TR,

2014) with co morbid chronic medical illness and substance abuse


disorders. Men and women are equally eligible, between the ages

of 18–70.

The team members will use two instruments to measure

patients unmet needs. The HRQOL - Healthy Days Questionnaire

(CDC, 2012) is a broad multidimensional concept that includes

self-reported measures of physical and mental health that may

affect quality of life and combined with the second instrument

which is the Unmet Needs Questionnaire. The Unmet Needs

Questionnaire was developed by providers of the Garden City team

to determine the obstacles that impede access to health and human

services. The results of the surveys will provide opportunities

for providers to plan for tailored interventions.

Administering these instruments will take less than 30 minutes

during a regular psychiatric office visit. Using the data from

each patient, the providers will develop interventions tailored

to meet the needs of the patient. At the end of three months the

instruments will be re-administered to assess changes in

perceived unmet needs.


Recent federal policy changes endorse the use of

questionnaires to measure outcomes of specific impairment.

Data Collection Plan

Following IRB review the will administer the combined

instrument to their patients during a regularly scheduled

appointments. The assessment of their unmet needs will be

evaluated and plans for addressing the unmet needs will be

incorporated into the individual treatment plans of each patient.

At 3 months post assessment the instrument will be administered

once again to document changes in the perceived assessment of

unmet needs. Data will be analyzed and presented for assessment

of the utility of the instrument in helping patients address

their perceived unmet needs.

Measuring patient reported outcomes will help improve progress in

achieving healthcare objectives set nationally. Analysis of unmet

needs data can help identify subgroups with relatively poor


perceived quality of life and help to guide interventions to

improve their situations (CDC, 2012).. Patient-reported measures

can help clinicians target interventions that will improve

patient outcomes of care.

Timeline

IRB review April 2014

Initiate first assessment August through October 2014

Administer second assessment November through January 2015

Data analysis February to April 2015

Evaluation Plan

Data will be entered into IBM SPSS v.20 (Chicago, IL).

CDC HRQOL Healthy Days Module: There are three variables of interest

in this module: general health, healthy days, and inability to

perform usual activities. Item 1, “Would you say that in general

your health is…” will be compared pre/post using Wilcoxon signed-

ranks test for paired, ordinal data. Unhealthy days are an

estimate of the overall number of days during the previous 30


days when the respondent felt that either his or her physical or

mental health was not good. To obtain this estimate, responses to

questions 2 and 3 are combined to calculate a summary index of

overall unhealthy days, with a logical maximum of 30 unhealthy

days. For example, a person who reports 4 physically unhealthy

days and 2 mentally unhealthy days is assigned a value of 6

unhealthy days, and someone who reports 30 physically unhealthy

days and 30 mentally unhealthy days is assigned the maximum of 30

unhealthy days. Healthy days are the positive complementary form

of unhealthy days. Healthy days estimate the number of recent

days when a person's physical and mental health was good (or

better) and is calculated by subtracting the number of unhealthy

days from 30 days. Item 4 “ During the past 30 days, for about

how many days did poor physical or mental health keep you from

doing your usual activities, such as self-care, work or

recreation? “ will be compare pre/post using a paired t-test.

The CDC HRQOL Activity Module contains items that address physical,

mental, or emotional problems or limitations the respondent may

have in daily life. Each item will be analyzed separately. Item

1, “Are you limited in any way in any activities because of any


impairment or health problem?” will be analyzed using a McNemar

test for paired categorical outcomes. Item 2 will be compared

using graphical display of the response to, “What is the MAJOR

impairment or health problem that limits your activities?” Item

3, “For HOW LONG have your activities been limited because of

your major impairment or health problem?” (In days), a paired t-

test will be conducted. Items 4 and 5 will be combined into one

item that addresses whether or not the individual needed help

from another person for personal care or routine needs. If a

respondent marks YES for either question, the combined item will

be scored as a YES. A McNemar test will be conducted to compare

proportion of individuals that needed help from another person at

pre and post.

CD HRQOL Healthy Days Symptom Module: There are five items that ask

the individual about the number of days in the past month that

s/he has dealt with lack of sleep, depression, anxiety, etc.

These items will be analyzed separately using paired t-tests.

Unmet Needs Questionnaire. An overall satisfaction score (averaging

12 items on general life satisfaction) will be compare at pre and


post using a paired t-test. Other items in the questionnaire will

be compared using McNemar (for dichotomous items) and Wilcoxon

signed-ranks test (for ordinal items).

Protected Health Information

All data collected is de-identified and annotated by a code

number. The patient’s name and associated number will be kept by

the office manager and not available to the members of the team

collecting the data. When the team conducts the second visit at 3

months the office manager will put the data collection

instruments in the patient’s folder with the code number on them.

Privacy, Data Storage and Confidentiality

The patient name and code number linkage will be destroyed upon

completion of the data collection. No PHI will be collected as

part of this project. During data collection the data will be

recorded on paper and kept in the patient file in locked cabinets

in the office file room; data will be destroyed at the completion

of the project.


References

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Colditz, G. (1998). Social

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Benaiges, I., Prat, G. & Adan, A. (2012). “Health related quality

of life in patients with dual

diagnosis: clinical correlates.” Health and Quality of

Life Outcomes. 10(106).


Douaihy, A.B., Jou, R.J., Gorske, T., & Salloum, I.M. (2003).

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Appendix 1

Healthy Days Core Module (CDC HRQOL-4)

1. Would you say that in general your health is:

a. Excellent 1

b. Very good 2

c. Good 3

d. Fair 4

e. Poor 5

f. Don’t know/Not sure 7

g. Refused 9

2. Now thinking about your physical health, which includes

physical illness and injury, how many days during the past

30 days was your physical health not good?

a. Number of Days ____


b. None _88___

c. Don’t know/Not sure _77___

d. Refused 99___

3. Now thinking about your mental health, which includes

stress, depression and problems with emotions, for how many

days during the past 30 days was your mental health not

good?

a. Number of Days ___

b. None _88___ If both Q2 and Q3 = “None,”

skip next question

c. Don’t know/ Not sure _77___

d. Refused _99___

4. During the past 30 days, for about how many days did poor

physical or mental health keep you from doing your usual

activities, such as self-care, work or recreation?



b. None __88__

Don’t know/Not sure __77__

d. Refused _99_

Healthy Days Symptoms Module

1. During the past 30 days, for about how many days did PAIN

make it hard for you to do your usual activities, such as

self-care, work or recreation?

a. Number of days ____

b. None 88__

Don’t know/Not sure __77__

d. Refused _99_


2. During the past 30 days, for about how many days have you

felt SAD, BLUE, or DEPRESSED?

a. Number of Days ___

b. None _88_

c. Don’t know/ Not sure __ 77__

d. Refused _ 99_


felt WORRIED, TENSE, OR ANXIOUS?


b. None __ 88__

c. Don’t know /Not sure _ 77___

d. Refused ___99_


felt you did NOT get ENOUGH REST or SLEEP?


b. None 88


c. Don’t know/Not sure 77

Refused 99


felt VERY HEALTHY AND FULL OF ENERGY?


b. None 88

c. Don’t know/Not sure 77

d. Refused 99

. Activity Limitations

These next questions are about physical, mental, or emotional

problems or limitations you

may have in your daily life.

1. Are you LIMITED in any way in any activities because of any

impairment or health problem?

a. Yes 1


b. No 2

Go to Q1 of Healthy Days Symptoms Module

Don't know/Not sure 7


Refused 9


2. What is the MAJOR impairment or health problem that limits

your activities?

a. Number of Days _ _

b. None 8 8 If both Q2 AND Q3 = "None", skip next question

Don't know/Not sure

7 7

Refused

9 9

a. Number of Days _ _

b. None

8 8


Don't know/Not sure

7 7

Refused

9 9

That is the MAJOR impairment or health problem that limits your

activities?

a. Arthritis/rheumatism

0 1

b. Back or neck problem

0 2

c. Fractures, bone/joint injury

0 3

d. Walking problem

0 4

e. Lung/breathing problem

0 5


f. Hearing problem

0 6

g. Eye/vision problem

0 7

h. Heart problem

0 8

i. Stroke problem

0 9

j. Hypertension/high blood pressure

1 0

k. Diabetes

1 1

l. Cancer

1 2

m. Depression/anxiety/emotional problem 1 3

n. Other impairment/problem

1 4


Don't know/Not sure

7

Refused

9

3. HOW LONG have your activities been limited because of your

major impairment or health problem?

b. Back or neck problem

0 2

c. Fractures, bone/joint injury

0 3

d. Walking problem

0 4

e. Lung/breathing problem

0 5


f. Hearing problem

0 6

g. Eye/vision problem

0 7

h. Heart problem

0 8

i. Stroke problem

0 9

j. Hypertension/high blood pressure

1 0

k. Diabetes

1 1

l. Cancer

1 2

m. Depression/anxiety/emotional problem

1 3


n. Other impairment/problem

1 4

Don't know/Not sure

9

Refused

7

Do Not Read. Code using respondent's unit of time.

a. Days 1 _ _

b. Weeks 2 _ _

c. Months 3 _ _

d. Years 4 _ _

Don't know/Not sure

7 7 7

Refused

9 9 9


4. Because of any impairment or health problem, do you need the

help of other persons with your PERSONAL CARE needs, such as

eating, bathing, dressing, or getting around the house?

a. Yes

1

b. No

2

Don't know/Not sure

7

Refused

9

5. Because of any impairment or health problem, do you need the

help of other persons in handling your ROUTINE needs, such

as everyday household chores, doing necessary business,

shopping, or getting around for other purposes?

a. Yes

1


b. No

2

Don't know/Not sure

7

Refused

9

This is the end of the Healthy Days Module (CDC HRQOL-14) Quality

of Life Assessment, thank you for your participation. If you have

any questions concerning the data generated by the questionnaire,

please feel free to contact Allen Sutton, NPP at 917 848 4558

Appendix B

Unmet Needs Questionnaire

1. How satisfied do you feel with access to healthcare from your

doctors?

a. Very satisfied


b. A little satisfied

c. Neither satisfied nor dissatisfied

d. A little dissatisfied

e. Very dissatisfied

2. How satisfied do you feel with your access to health-related

services in general?

a. Very satisfied





3. How satisfied do you feel with access to services related to

your mental health?

a. Very satisfied






4. How satisfied do you feel with the amount of access you have

to HIV/AIDS care?

a. Very satisfied





5. How satisfied do you feel with access to a Dentist,

Podiatrist, Neurologist or Ophthalmologist?

a. Very satisfied






6. During the past 30 days, how many appointments with your

primary care doctor have you missed?

If appointments were missed, why?

__________________________________________

a. 0

b. 1

c. 2

d. 3

e. 4

f. 5 or more

7. How satisfied do you feel with your pharmacy?

a. Very satisfied






Are your medications delivered?

Yes

No

8. During the past 30 days, what were your financial needs?

Answer more than one if applicable.

a. My finances provide an acceptable quality of life.

b. Over the past 30 days, I could have used additional money for

transportation.

c. Over the past 30 days, I could have used additional money for

food.

d. Over the past 30 days, I could have used additional money for

laundry and cleaning supplies.

e. Over the past 30 days, I could have used additional money for

clothing and personal cosmetic products, shelter,

furnishings or entertainment.

9. Do you have a winter jacket and water proof boots?


Yes

No

10. Over the past 30 days, have you had enough heat and hot water

in your apartment?

a. Plenty of heat and hot water

b. Acceptable amount of heat and hot water

c. Low amount of heat and hot water

d. No heat and hot water frequently

e. No heat in the last 30 days

11. How satisfied do you feel about the apartment where you live?

a. Very satisfied


c Neither satisfied or dissatisfied




Are you able to prepare meals in your apartment?

Yes

No

12. How satisfied do you feel with the relationships you have

with family, friends and significant others?

a. Very satisfied





13. During the past 30 days, how many days has your quality of

life been affected by substance abuse?

a. 0-3 days

b. 4-7 days


c. 8 -14 days

d. 15-21 days

e. 21+ days

Are you actively using Marijuana, Heroin, Crack, Cocaine, or K2?

Yes

No

Are you actively using Alcohol?

Yes

No

14. How satisfied do you feel with access to substance abuse

counseling or care?

a. Very satisfied






15. How satisfied do you feel with your level of education?

a. Very satisfied





Do you have a desire to go to school or work?

Yes

No

16. How satisfied do you feel with you level/type of employment?

a. Very satisfied






17. How satisfied do you feel with being able to do things for

yourself?

a. Very satisfied


c Neither satisfied nor dissatisfied



18. Over the past 30 days did you need support and did not get

it?

Yes

No

Please list any needs that you feel have been unmet.

1.

2.

3.


This is the end of the Unmet Needs Assessment, thank you for your

participation.

Patient reported unmet needs

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