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APY0010.1177/1039856214520794Australasian PsychiatryHolmes et al.
AP
Psychiatric services
Australasian Psychiatry
Alexander Holmes Associate Professor and Psychiatrist, Department of Psychiatry,) University of Melbourne, Melbourne,
VIC, Australia
Gail Bradley Senior Clinical Psychologist, Inner West Area Mental Health Service, Melbourne, VIC, Australia
Trevor Carslie Social Worker, Homeless Psychiatric Outreach Service, Inner West Area Mental Health Service, Melbourne,
VIC, Australia
Kate Lhuede Senior Occupational Therapist, Homeless Psychiatric Outreach Service, Inner West Area Mental Health Service,
Melbourne, VIC, Australia
Abstract
Objective: Performance indicators (PIs) aim to improve services by measuring key activities in a way that allows
comparison over time, between services and against benchmarks. This paper describes the development and imple-
mentation of Homeless Psychiatric Service PIs and explores their potential benefits and limitations.
Method: We collected descripton of quality service from key stakeholders. We identified eight key parameters, from
which PIs were developed and tested over a 12-month period.
Results: The use of the PIs led to increased awareness of the practice being measured. PIs were used to stimulate
practice changes. They played a positive role in team dynamics and were useful in clarifying team aims and identity.
The main challenge to their use was the burden of data collection and analysis.
Conclusion: Homeless service PIs can assist in determining how well the programs are performing in activities that
are relevant to clients and non clinical services for the homeless. With the movement of homeless clients away from
inner urban areas, homeless performance measures may aid teams to develop the capacity to work effectively with
homeless clients.
Keywords: benchmarking, homeless, homeless services, performance indicators, program planning, quality
P
erformance indicators (PIs) aim to improve ser- public mental health services. These were part of the
vices by measuring key activities in a way that ‘information infrastructure’ designed to encourage good
allows comparison over time, between services practice, inform about outcomes and value for money,
and against benchmarks. Within Australian public men- and contribute to state and national data.4 In broad
tal health, the focus to date has been on PIs applicable terms, these PIs are used to determine the degree that
over a wide range of services,1 yet the need to develop services are effective, responsive, continuous, appropri-
program-specific measures has been clearly articulated.2 ate, accessible, capable, efficient, safe and sustainable.4
Program-specific indicators measure activities that are PIs need to be observable, understandable, valid, rele-
more closely related to the key aims and objectives of the vant and efficient.5 An example of the current national
program, and have the advantage of promoting quality indicator is ’28-day readmissions to acute mental health
in their more specialised activities. Homeless Outreach units’, for which the threshold set at 15%.6
Psychiatric Services is one example of where specific
measures may have advantages. This paper describes the
development and implementation of homeless psychi-
atric service PIs and explores their potential benefits and Corresponding author:
limitations. Alex Holmes, Department of Psychiatry, University of
Melbourne, Royal Melbourne Hospital, Grattan Street,
The Second National Mental Health Plan3 stipulated the Parkville, Melbourne, VIC 3050, Australia.
development of performance indicators for Australian Email: acnh@unimelb.edu.au
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Australasian Psychiatry 22(2)
N or n: number
alternative16 (Does this person co-operate with health tion of approximately 180,000 persons. The catchment
services? Always = 4, Usually = 3, Rarely = 2 and Never included two male homeless shelters containing 120
=1). Assessment of an improved accommodation requires beds. During the year, no substantial changes occurred
‘ranking’ by accommodation type. The hierarchy used within mental health nor accommodation services.
was developed in reference to the definition of homeless During the initial implementation phase, concern was
used by the Australian Bureau of Statistics17 (1 = shelter- raised by participating clinicians regarding the burden of
less, 2 = emergency accommodation, 3 = single room the collection and recording of data, and the complexity
without amenities, 4 = transitional accommodation and of interpreting numerous PIs. In response, cognisant of
5 = stable and secure housing). the principle limiting the number of PIs, we removed the
two that were proving the most difficult to collect (com-
The benchmarks for the PIs were set with reference to
munication with family and collaborative casework).
what was known about the current performance, aspira-
tions for improvement and a judgement as to the limits Data was collected at entry and at discharge from the
of effectiveness. For example, prior to commencement service. When data was incomplete or unclear, neither
the number of referred patients whom were assessed was the numerator nor the denominator were entered.
< 50%. At the same time, the capacity to engage the dis- Numerators and denominators for each PI were calcu-
engaged was identified by three stakeholders: it is a key lated for each month, and then entered into a pre-
component of the Homeless Outreach Psychiatric formatted Excel spread sheet, which generated a
Service model.13 Setting the threshold at 70% reflected 12-month summary and graph (Figure 1). We presented
an expectation of improvement, balanced with the prac- and discussed the data at monthly team meetings, where
tical difficulty of finding homeless persons. we devised and implemented strategies related to
improving specific activities.
Overall, the activities recorded by the PIs occurred at levels
Implementing performance measures similar to established thresholds (Table 3). When changes
We collected data over a calendar year, for all of the cases occurred, they emerged over the course of the year. In the
referred to a homeless psychiatric service.13 This service first months, their primary impact was through an
covers the central business district and inner northern increased awareness of the practice being measured.
suburbs of Melbourne, Australia, comprising a popula- Subsequently, sub-optimal performance relative to the
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Figure 1. Homeless Psychiatric Service Performance Indicator: Improved engagement at discharge.
Table 3. Mean percentage and range of individual PIs over a 12-month period
arbitrary threshold (timeliness, active treatment or practices, having much in common with those applied
improved discharge accommodation) drew greater atten- in generic mental health services, place specific empha-
tion, leading to both analysis and practice change. For sis on access, engagement, continuity and interagency
example, exploration of the low levels of engagement at collaboration. When incorporated into a routine team
discharge revealed the impact of a precipitous unplanned process, homeless PIs can lead to practice change and
exit from an emergency accommodation. These exits were improved care.
instigated either by the client or the service, in response to
The PIs had a range of effects on the various stakehold-
particular behaviours. The team action was to become an
ers. In the client domain, accommodation at discharge
active participant in accommodation planning (coordi-
improved. Although the complex interplay between
nated by the housing worker) and to develop manage-
housing type, stability and mobility, and mental illness
ment plans, to deal with the behaviours associated with
precludes a comprehensive analysis of all potential
eviction. In time, fewer clients left the homeless setting
mechanisms for this finding, one is worth describing.
without follow-up care being arranged. Similar improve-
When information about individuals with a mental ill-
ments occurred in accommodation at discharge and suc-
ness is communicated to housing workers it changes
cessful discharge planning.
expectations and improves engagement, resulting in
Not all PIs improved over the year. Where early levels greater tolerance and more appropriate discharge plan-
were high (contact success), there was little scope for ning. Within the team, the PIs had a positive role in
improvement. For others, for example ‘engaged in active team dynamics. The monitoring of activities defined as
treatment’, initial improvements were not sustained. One ‘most important’ was seen as more meaningful and dem-
interpretation of this finding is that initial improvements onstrating gains for clients that enhanced team agency
relating to an increased focus on a function, but not sup- and identity. This support of group process is particu-
ported by effective change in method, will not be lasting. larly useful when working with homeless clients, whom
can be difficult and time consuming to work with, and
about whom pessimism and frustration are commonly
Discussion expressed.
We designed these PIs to measure activities identified as The major drawback of using PIs is the burden of collec-
important by those involved in the care of the homeless tion, analysis and use of data within cycles of quality
mentally ill, including the clients themselves. These improvement. A quantification of this effort was not
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13. Holmes A, Hodge M, Newton R, et al. Development of an inner urban homeless mental
Conclusion health service. Australas Psychiatry 2005; 13: 64–67.
Homeless service PIs can determine how well programs 14. Catholic Social Services. Summary report: Access to psychiatric care. Twelve months on.
are performing in activities that are relevant to clients and Report, 1995. Victoria: Catholic Social Services.
service providers within settings where there are home- 15. Human Rights and Equal Opportunity Commission. Human rights and mental illness.
less people. Using them can improve care and facilitate Report of the National Inquiry into the Human Rights of People with Mental Illness, 1993.
team morale. These measures may also be useful to non- 16. Rosen A, Hadzi-Pavlovic D and Parker G. The Life Skills Profile: A measure assessing
specialised teams, when working with homeless clients. function and disability in schizophrenia. Schizophr Bull 1989; 15: 325–337.
Thanks to Lisa Gibbs, of the University of Melbourne School of Population and Global Health, 18. Holmes AC, Hodge MA, Bradley G, et al. Accommodation history and continuity of care
for her advice and expertise in qualitative research methods. in patients with psychosis. Aust NZ J Psychiatry 2005; 39: 175–179.
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