H. Stephen Leff

Assessing behavioral health outcomes in outpatient programs: reliability and validity of the BASIS-32.

The Behavior and Symptom Identification Scale (BASIS-32) was developed to assess mental health outcomes among patients with severe illness treated on inpatient programs. However, its applicability and utility to those treated in outpatient programs has not been determined. The objective of this study was to assess reliability, validity, and sensitivity to change of the BASIS-32 among mental health consumers treated in outpatient programs. A total of 407 outpatients completed the BASIS-32 and the Short Form Health Status Profile (SF-36) at the beginning of a treatment episode and again 30 to 90 days later. Outpatients reported less difficulty at intake than did inpatients, and the BASIS-32 detected statistically significant changes 30 to 90 days after beginning outpatient treatment. Factor structure and construct validity were partially confirmed on this sample of outpatient consumers. Analyses of data from a wide range of facilities and samples would add to validation efforts and to further refinement of the BASIS-32.

Clinical factors associated with employment among people with severe mental illness: Findings from the employment intervention demonstration program

Research has shown that supported employment programs are effective in helping psychiatric outpatients achieve vocational outcomes, yet not all program participants are able to realize their employment goals. This study used 24 months of longitudinal data from a multisite study of supported employment interventions to examine the relationship of patient clinical factors to employment outcomes. Multivariate random regression analysis indicated that, even when controlling for an extensive series of demographic, study condition (experimental versus control), and work history covariates, clinical factors were associated with individuals’ ability to achieve competitive jobs and to work 40 or more hours per month. Poor self-rated functioning, negative psychiatric symptoms, and recent hospitalizations were most consistently associated with failure to achieve these employment outcomes. These findings suggest ways that providers can tailor supported employment programs to achieve success with a diverse array of clinical subpopulations.

Demographic Characteristics and Employment Among People with Severe Mental Illness in a Multisite Study

People with psychiatric disabilities experience disproportionately high rates of unemployment. As research evidence is mounting regarding effective vocational programs, interest is growing in identifying subgroup variations. Data from a multisite research and demonstration program were analyzed to identify demographic characteristics associated with employment outcomes, after adjusting for the effects of program, services, and study site. Longitudinal analyses found that people with more recent work history, younger age, and higher education were more likely to achieve competitive employment and to work more hours per month, while race and gender effects varied by employment outcome. Results provide strong evidence of demographic subgroup variation and need.

Quality Measures for Mental Health Care: Results from a National Inventory

The National Inventory of Mental Health Quality Measures was funded by the Agency for Healthcare Research and Quality to (1) inventory process measures for assessing the quality of mental health care; (2) identify clinical, administrative, and quality domains where measures have been developed; and (3) identify areas where further research and development is needed. Among the 86 measures identified, most evaluated treatment of major mental disorders, for example, schizophrenia (24 percent) and major depression (21 percent). A small proportion focused on children (8 percent) or the elderly (9 percent). Domains of quality included treatment appropriateness (65 percent), continuity (26 percent), access (26 percent), coordination (13 percent), detection (12 percent), and prevention (6 percent). Few measures were evaluated for reliability (12 percent) or validity (3 percent). Measures imposing a lower burden were more likely to be in use (chi 2 = 4.41, p = .036). Further measures are needed to assess care for several priority clinical and demographic groups. Research should focus on measure validity, reliability, and implementation costs. In order to foster quality improvement activities and use of common measures and specifications for mental health care, the inventory of quality measures will be made available at www.challiance.org/cqaimh.

The employment intervention demonstration program: major findings and policy implications.

This article summarizes the published results of the Employment Intervention Demonstration Program (EIDP), a federally-funded, multi-site study examining the effectiveness of supported employment programs for 1273 unemployed individuals with psychiatric disabilities in the U.S. Findings confirm the effectiveness of supported employment across different models, program locations, and participant populations. The studys results are discussed in the context of public policies designed to encourage return to work for those with a severe mental illness.

Toward a national consumer survey: evaluation of the CABHS and MHSIP instruments.

This article describes a study evaluating the Consumer Assessment of Behavioral Health Survey (CABHS) and the Mental Health Statistics Improvement Program (MHSIP) surveys. The purpose of the study was to provide data that could be used to develop recommendations for an improved instrument. Subjects were 3,443 adults in six behavioral health plans. The surveys did not differ significantly in response rate or consumer burden. Both surveys reliably assessed access to treatment and aspects of appropriateness and quality. The CABHS survey reliably assessed features of the insurance plan; the MHSIP survey reliably assessed treatment outcome. Analyses of comparable items suggested which survey items had greater validity. Results are discussed in terms of consistency with earlier research using these and other consumer surveys. Implications and recommendations for survey development, quality improvement, and national policy initiatives to evaluate health plan performance are presented.

Effects of co-occurring disorders on employment outcomes in a multisite randomized study of supported employment for people with severe mental illness.

Effects of co-occurring disorders on work outcomes were explored among individuals with severe mental illness who were participating in a multisite randomized study of supported employment. At seven sites, 1,273 people were randomly assigned to an experimental supported employment program or a control condition and followed for 2 years. Multivariate regression analysis examined work outcomes including earnings, hours worked, and competitive employment, as well as whether psychiatric disability was disclosed to coworkers and supervisors. Individuals with any comorbidity had lower earnings and were less likely to work competitively. Those with physical comorbidities had lower earnings, worked fewer hours, and were less likely to work competitively. Disclosure was more likely among those with both cognitive and physical comorbidities, as well as those with learning disabilities. Competitive employment was less likely among those with intellectual disability, visual impairment, and human immunodeficiency virus/acquired immuno-deficiency syndrome. The experimental condition was positively related to all outcomes except disclosure. The results suggest that, with some exceptions, comorbidities affect employment outcomes, requiring tailored services and supports to promote vocational success.

The effects of capitation on service access, adequacy, and appropriateness

The authors describe an evaluation of the influences on service access, adequacy, and appropriateness in four capitated public mental health programs. Access, adequacy, and appropriateness were higher than the fee for service programs, suggesting that the financial incentive in capitation was not a significant limiting factor. Access and adequacy were also limited by new program effects as well as by case manager and client preferences.

Effectiveness of supported employment for individuals with schizophrenia: Results of a multi-site, randomized trial

Background: Prior studies of supported employment efficacy for individuals with schizophrenia have yielded mixed results, with some finding poorer outcomes for those with this diagnosis and others finding no differences.Aims: This multi-site effectiveness trial examined the relative impact of diagnosis with schizophrenia and evidence-based practice supported employment on the likelihood of competitive employment.Method: At seven U.S. sites, 1,273 outpatients with severe mental illness were randomly assigned to either an experimental supported employment program or to a comparison/services as usual condition and followed for two years. Data collection involved semi-annual, in-person interviews, and weekly recording of all paid employment by vocational and research staff. Mixed-effects random regression analysis was used to examine the effects of study condition, schizophrenia diagnosis, and their interaction, on the likelihood of competitive employment.Results: Subjects in experimental group programs and t...

Implementing outcome systems: lessons from a test of the BASIS-32 and the SF-36.

With increasing pressure from third-party payers to assess client outcomes, clinical programs want to know how to implement outcome systems. This article focuses on practical and logistic questions involved in implementing an outcome assessment system in ambulatory behavioral healthcare settings. Study questions addressed outcome systems in general and the use of the Behavior and Symptom Identification Scale (BASIS-32) and the Short Form Health Status Profile (SF-36) in particular. General questions focused on obtaining provider buy-in, client consent and confidentiality, data collection methods, sampling, time points, maximizing client participation, clinical utility of outcome data, and resources needed for outcome assessment. Measure-specific questions focused on client acceptability of the instruments and applicability of measures to diverse populations. The article suggests several strategies for enhancing outcome assessment efforts and concludes that there remains a need for further understanding of ways to maximize the utility and value of outcome measurement.