Treatment BY
DAVID
Plans J. KNESPER,
for M.D., AND
Mental DEREK
Health MILLER,
The authors present a methodfor the development of standardprocess criteriafor the care of defined subpopulations ofpsychiatric patients using a twodimensional problem category system to describe patients. Patient subpopulations, described by both a traditional psychopathological problem cluster and a less traditional psychosocial problem cluster, are matched to a list ofproblem-solving services to develop a model treatment plan. The authors present this method for developing standard treatment plans as an alternative to APA ‘s Model Criteria Sets.
MORE EFFECTIVE AND COMPREHENSIVE quality assurance programs require both accountability and professional standards from mental health professionals. APA endorses this concept (1). Subsumed under quality assurance are quality records, admission certification, peer review, utilization review, medical audit, and medical care evaluation studies, as well as other basic and often overlapping elements. These elements are emphasized in the accountability requirements of Professional Standards Review Organizations (PSRO), the Joint Commission on Accreditation of Hospitals (JCAH), third-party payers, state mental health codes, and other legal precedents (2-7). The basic elements of quality assurance demand the establishment of standards of cane, a review of treatment procedures, and a review of the utilization of services rendered. In order to meet these demands, sets of basic criteria for quality care need to be developed. The comparison ofthe care a patient actually neceives to standard criteria of care then becomes possible. APA’s Model Criteria Sets (MCS) (8) is a major contribution toward the development of standard criteria for quality cane. The MCS is not a final, ultimate product; rather, it serves as a stimulus and aid to local mental health programs that wish to adopt or modify the MCS or to develop alternatives. This paper will present an alternative model for the development of standard criteria of care that we be-
The 48104. gator,
tute, ment
authors are with the University of Michigan, Ann Arbor, Dr. Knesper is Instructor ofPsychiatry and Research Department of Psychiatry and Mental Health Research
and Dr. Miller of Psychiatry.
is Professor
and
Associate
Chairman,
Mich. InvestiInsti-
Depart-
Care M.D.
lieve to be less constricting than those previously reported. Psychopathology provides an insufficient descniptive basis for the planning of adequate clinical care. A complementary set of psychosocial problem categories have to be developed, as well as adequate patient records that make clean the interaction between psychosocial problems and the psychopathological state of the individual as it varies through the treatment process.
GENERAL
METHOD
The primary tools of classification and systematization are used for the development of standard cniteria of cane. Classification is a necessary first step in an underdeveloped area; systematization creates a single framework from a relatively unassembled collection of scientific knowledge, clinical practice, professional judgment, and currently accepted theory. The process of separating and conceptualizing vanous dimensions that are necessary for the development of adequate criteria of care is not new. The process is facilitated if the following four dimensions are considered: 1. Thepatient’s description. This is organized information that identifies, describes, and characterizes the patient in clear, well-understood terms. 2. The patient’s problems. This describes the paient’s psychological, social, and biological incapacities as perceived by himself or others. Treatment is indicated when these problems result in a potential, relative, or permanent exclusion from valued work, play, on family life. 3. Problem-solving services. These are the basic, active intervention techniques that are required for problem solution or change. They include preventive, diagnostic, therapeutic. supportive, and rehabilitative methods. 4. Treatment plan. This is a systematic, goal-oriented program of problem-solving services. It is based on the description of the patient and his problem charactenistics, is specific to solving identified psychological, social, and biological problems, and is directed toward the goals of problem change and improvement. The specificity of problem-solving services is multi-determined by clinical research, professional consensus, and other recognized criteria. These four dimensions will be shown to provide a method for developing treatment plans and thus for es-
Am
J Psychiatry
133:!,
January
1976
45
TREATMENT
PLANS
tablishing standard criteria of care for a specific problem on group of problems. The concept of the patient’s problem is used to develop a unique categorization that distinguishes a set of traditional psychopathological problems from a set of psychosocial problems in mental illness. The concept of problem-solving services is used to develop an example categorization scheme of these services. These concepts provide a mechanism for the development of four types of treatment plans. We call the first of these nondiffenential, nonindividualized treatment plans. The words nondifferential’ and ‘nonindividualized’ may seem to connote a nonprofessional attitude toward treatment planning because professional attention is actually focused on planning a unique program of problem-solving services for a particular patient. However, placing a patient in an inpatient or outpatient treatment facility should automatically dictate a standard program of services. Thus a patient with problems of sufficient severity to necessitate psychiatric hospitalization receives dietary, hotel, laboratory. environmental, and other inpatient services provided by a relatively fixed number of staff. The nature of these services is dictated typically by the constraints of resources and by a general treatment approach that is assumed to be applicable to a specific characteristic of all patients-for example, an age group. In addition. these services are given within the context ofa general philosophy oftneatment. The nondifferential, nonindividualized treatment plan provides the backdrop against which more specific, differential, and individualized treatment plans for solving problems occur. The more specific treatment plans can be categonized into three groups: differential, individualized treatment plans for solving routine problems; differential, individualized treatment plans for solving special problems; and differential, individualized treatment plans for clinical research. In this paper we will review this approach to treatment planning and elaborate on the method specifically as it is applied to the development of one concrete example: a differential, individualized treatment plan for the solution of routine problems for an adolescent patient. ‘ ‘
‘
‘
‘
PROBLEM
DESCRIPTION
It is generally agreed that a crucial element in velopment of a treatment plan is a description patient’s problems. However, there is no consensus to the nature of the categorization scheme for problems. Treatment decisions are inadequate problems are clearly defined and the etiological planation for the problems is clarified. Adequate apeutic intervention may treat causes as well as toms, and a decision to ignore one or the other
46
Am J
P.s’yc/ziatrs
/33:1
,
January
1976
the deof the as these unless exthensympshould
be manifest. Unfortunately. diagnostic labels for mental problems have limited utility, and their use often aggravates actual problem solution. A traditional mental illness category may say nothing about etiology and may in no way assist the definition of specific thenapeutic interventions. Psychiatric diagnoses may be quite irrelevant in indicating therapeutic interventions (912). In addition, except for the broadest of categories, conventional clinical methods for establishing psychiatric diagnoses are of low reliability ( I 3-16); however, once these labels are attached to an individual, they are difficult to change and have disadvantageous social consequences (17, 18). The ambiguity of traditional psychiatric nosology has sufficiently disguised the problems of mental illness as to make them refractory to solution, given our present tools (19, 20). However, sufficient evidence does not yet exist for the total abandonment of a traditional approach. and broad nosological categories are one determinant in the development of our treatment planning method. Another approach to patient description makes use of psychosocial problem categories. Many professionals feel that the application of the physical illness model to behavioral and mental illness is frequently inappropriate because it results in a concept that the ongin of the illness is concealed totally within the individual. Many origins may be social or experiential. With this focus, Bahn (2 1 ) produced a strong argument for a classification scheme for psychosocial disorders. The use of both a psychopathological and a psychosocial category scheme has been recommended in child psychiatry. A three-dimensional classification system for mental disorders using clinical psychiatric problems, intellectual level, and associated etiological factors as appropriate measurements has been suggested (22). Similarly. the addition of psychosocial etiological factors as yet another dimension has resuited in a four-dimensional classification model for childhood illnesses (23). We assume that a broad global psychopathological category is necessary but insufficient to define differential treatments for mental illness. The broad psychopathological categories must be complemented by one on more categories from a global set of psychosocial problem categories. Appendix 1 lists psychopathological problem categonies adapted from standard sources (24, 25). Appendix 2 is a proposed list of psychosocial problem categories. A patient is described by at least one category from each list; therefore, treatments are matched to a combination of problems taken from each of the two sets. For example. a treatment plan could be developed for a patient described as being both schizophrenic and dangerous to self, or any ofthe many other problem combinations. Our use of the concept of problems must be distinguished from the use of the problem-oriented record. The problem-oriented record, in its present form, requires the use of highly specific and particular prob-
DAVID
lems (26). Therefore, the patient may be described by a long list of problems not necessarily derived from a standard classification scheme. In contrast to this, we use a small number of global psychosocial categories as a classification scheme for psychosocial disorders.
DESCRIPTION
OF SERVICES
Langsley and Le Baron (27) have shown that there considerable variation in the length of stay of patients in different mental health care facilities. Much of this variation must result from different practices, services. and treatment plans. This phenomenon. of course. makes it incumbent upon a mental health care facility to state explicitly what treatment services it offers and what the expected length of service application to a particular problem or group of problems will be. This avoids the umbrella term services nendered. With this in mind, a simplified categorization of services is presented in appendix 3. Treatment plans are developed by matching services to at least one problem from the list of psychopathological problems and one problem from the list of psychosocial problems. This is followed by a combination of the problems, each of which is associated with a specific list of services. is
‘ ‘
‘ ‘
TREATMENT
I.
KNESPER
AND
DEREK
MILLER
research. Clinical research must be complemented, not encumbered, by standard treatment plans. Once a protocol of services for clinical research on a specific problem has been developed and standandly approved, the deviations from the standard treatment plans of types 1-3 must bejustified by the researchers and such organizations as a human subjects review committee and a quality assurance committee. These treatment plans are, by definition, unique. Further elaboration will be limited to the development of type 2 treatment plans because these are usually the first conceptually difficult treatment plans to be developed by a quality assurance program. We recommend that this type as well as others be further differentiated according to the broad age groups of children, adolescents, young adults, older adults, and eldeny adults. An example of a treatment plan for a patient described as adolescent, schizophrenic, and dangerous to self is presented in table 1. Several aspects of the treatment plan deserve specific discussion. First, the services were taken from a relatively short list; therefore, the specific services for the patient described are few. This is the procedure of choice. Long lists of many services resulting in very
TABLE 1 Differential, Individualized Treatment lems for an Adolescent Patient
Plans for Solving Routine
Prob-
PLANS Treatment
We propose the following four types of treatment plans: Type 1. Nondifferential, nonindividualized. A patient described only as a psychiatric inpatient would receive such services as diet, routine laboratory studies, and a therapeutic environment. These services are given to all inpatients without substantial exception. They may vary from institution to institution and sometimes between different programs within one setting. Type 2. Differential, individualized for solving routine problems. This is illustrated in table I by a treatment plan for an adolescent patient who is both schizophrenic and dangerous to self. Here, as in types 3 and 4 (discussed below), the concept ofdifferential assignment of services and individualization is based on a defined subpopulation of patients. Individualization to the level ofthe single patient is left to the professional. Tvpe 3. Differential, individualized for solving special problems. These are treatment plans that are unique and very specific because the problem requires a mobilization of special resources that must be used with great precision. Resource mobilization is often reinforced by policy statements and legal intervention. Examples of such special problems would be the chronically suicidal patient, the violent patient in the emergency room, and the firesetter on an inpatient ward. Type 4. Differential, individualized for clinical
Plan,
by Pro blem Categories
Item
Schizophrenic
Required services
family psychosocial evaluation
protective
neurological
neurological
(present 100%
Disorder
Dangerous
to Self care
in of all
cases)
Frequent
consultation
services
(present in more than ofall
5#{216}C7
cases)
consultation
anticholinergics major tranquilizers
individual psychotherapy
group/family
change
in legal
status
psychotherapy
Infrequent services (present in less than 50% of all cases)
psychological testing minor tranquilizers lithium carbonate
Rare
convulsive
services
(absent ofall
social
minor tranquilizers sedatives
services
service
convulsive
service
in 95% cases)
Am
J Psychiatry
/33:1,
January
/976
47
TREATMENT
PLANS
detailed treatment plans would best be avoided so as to facilitate communication and understanding and promote later meaningful evaluation of the plan’s effectiveness. Furthermore, a major purpose of specifying the treatment services is to detail only the critical elements of active treatment to which the greatest amount of therapeutic value is attributed. The type 2 treatment plan is complemented by the existence of a type I treatment plan, which serves as a backdrop and avoids needless repetition of information in the other types of treatment plans. The breakdown of services into a required category (see table 1) allows for placement within the treatment plan of services judged to be necessary in the treatment process. The breakdown of services into a rare category calls attention to services that may be hazardous in the treatment process and that, if used. would require considerable written explanation and justification in the patient’s medical record. The breakdown of services into frequent and infrequent categories penmits necessary clinical discretion. The percents that may be attached to these permit a mental health cane facility to follow aggregate trends in the care of defined patient subpopulations and to intervene to reverse undesirable trends in service delivery. This can avoid Unnecessary “punitive’ actions against individual clinicians who of necessity must deviate from inflexible and restrictive standards. By limiting the possibility of unnecessary constriction of treatment options, an atmosphere of cooperation is permitted that has the potential for producing meaningful attempts to evaluate the effectiveness of particular treatment plans. ‘
DISCUSSION
A quality assurance or review committee can either develop its own model treatment plans or modify or adopt existing treatment plans. After a set of treatment plans is adopted, deviations from model treatment can be detected by a nonphysician chart reviewer. For the method presented here, the patient charts would be reviewed by the physician reviewers of the committee when services categorized as required have not been provided on when services categorized as rare have been provided. Physician review also occurs when services that fall outside of the services recommended for a particular patient subpopulation have been provided. In addition. physician reviewers will need penodically to review selected charts from patients who neceive services categorized as infrequent. In no case does any physician review imply substandard care; it implies only a need for explanation and justification to peers. In addition to their use to detect deviations, model treatment plans also serve an educational function when they are made available to clinicians. Therefore, the term model treatment plan’ is used in preference to model criteria set’ because the model may serve as a flexible guideline for individual clinicians planning the cane of a single patient. Because the model plan is not an exhaustive description ofservices, clinical judgment and therapeutic innovation are permitted. ‘ ‘
‘ ‘
We would emphasize that this method depends on a mental health care facility’s adopting or developing and periodically updating both the model treatment plans and the categorizations of problems and services. Techniques applicable to the evaluation of treatment plans were discussed by Donabedian (28). It must be pointed out that an approach to quality assurance based on ‘laundry lists’ of services matched to problems has been criticized as being relevant only to improving the process of care and possibly irrelevant to improving the outcome of care (29). ‘
We advocate a two-dimensional system using psychopathological problems and psychosocial problems for describing a patient. We also point out the need for another dimension, that is of a measurement of seventy. Service assignment and treatment depend on not only the presence of a problem but also its severity. The example treatment plan in table 1 was written as though there were no interaction between the two categonies ofpnoblems. Services were assigned to each category separately and then to the two categories combined. It is probable that the services assigned to a patient described simultaneously by a psychopathological and a psychosocial problem would be different from those assigned to a patient described by each category separately. When several problems, each of which has assigned services, are combined to form one treatment plan, it is possible that a service required for one problem is infrequent or rare for another problem. This conflict can be resolved during the development of model plans as it occurs. The forum in which this conflict resolution takes place might be a quality assurance committee.
48
Am
J Psychiatry
/33:1
,
January
/976
‘
‘
‘
The method for the development of treatment plans presented here produces the appearance of a static quality both for patients and for patient care. Obviously people are sensitive to stress. and an individual’s perception of and reaction to actual or potential stress may produce a different cluster of psychopathological or psychosocial problems over time. These changes may demand equivalent changes in treatment plans; therefore, there is no assumption that any one plan is unchangeable for the duration of treatment. The vide a nosis, view. treatment
treatment plan method method fonjustification admission certification, Each ofthese procedures plan.
In order admission diagnostic the method who listed
illustrated here can proof the problem. or diagand continued stay necan be part ofa type 1
to certify the need for admission, general criteria that are not specific to a particular label can be developed. This is essentially reported by Pinsker and Richman (30), I 1 indications for admission to an inpatient
DAVID
psychiatric facility. For example, ‘suicidal or destructive behavior is an immediate threat,” “treatment which cannot be initiated or continued unless in a su‘
12.
127:759-763, Akiskal HS,
pression. 13.
pervised setting,” and “no alternative resources available at time ofadmission” are three indications for admission. This approach defines the purpose of psychiatric hospitalization and distinguishes it from the purpose of establishing a diagnosis or problem statement. Pinsker and Richman also reported a similar method for continued stay review. The justification of a diagnosis is also pant of a type I treatment plan. This can be done by specifying the mmimum information required to be recorded in the patient record to categorize any patient into a subpopulation of patients with similar problems. Patient records that establish a base of minimum necessary information have been described: the records of Elpens and Chapman (31) and Spitzer and Endicott (32) are good examples. Unfortunately, these records use a highly standardized checklist-type format most suitable for automated information systems and less suitable for day-to-day use by clinical professionals. However, with modification such records can be made more congenial to multiple users. Last, one important ground rule deserves reemphasis. Quality assurance is a local phenomenon requining local initiation and support. Good clinical practice has variation, there are many acceptable paths to the same result, and professional variation is wedded to innovation and improved clinical performance. For these reasons we have presented a method with only guideline examples. With its consideration should come rethinking, modifications, and (perhaps) anothen, better method that makes more sense in another geographical area.
14.
Arch
Stengel
2.
Medical 3. Decker 4. 5.
Care in the Hospital. Chicago, B, Bonner P: PSRO: Organization
US
Department
Professional ville, Md.
6. Gayer rights, can
atnc 7.
of Health,
Standards HEW, 1974
KD: Elements treatment and Hospital
Association
Services
J: Counts,
state
and
PSRO
Am
Program
17.
E: Classification
sis. BrJ Kitsuse
18.
and
Rosenhan 257. 1973
19. Szasz 20. 2 1. 22.
23.
24.
on Administration
Hospital.
Chicago.
hospitals.
and
the
Rutter
RL:
Psychiatric
to the family
syndromes
background.
in children
clinical
DF: drug
1 1 . Baldessanini sus affective
Importance
effects. Arch Ri: Frequency
Ill,
I 1-13.
night
disorders
from
method. DL:
Social
On
being
Problems
sane
1944-1968.
behavior:
problems
9:247-257.
in insane
places.
of the mentally
of
1962 Science
179:250-
ill: “treatment”
or so-
M, Lebovici of mental
S. Eisenberg
disorders
L. et al: A tn-axial
in childhood:
an
Q
classifica-
international
study.
I
American
Psychiatric
Association:
of Mental
Diagnostic
Disorders.
2nd
ed.
and
Statistical
Washington.
DC.
APA.
1968 25.
Group
for
orders
in
posed
the
Advancement
Childhood:
Ryback
27.
Mental Health Langsley DG,
RS:
28.
local standards 1974 Donabedian A:
Mem 29.
Report
The
Fund
of Psychiatry:
Theoretical
Classification.
26.
Problem
of
62. New Oriented
treatment. the
H, Richman
in
RL.
mated
I:
the
state
care.
ofthe
art.
psychiatric
integrated
records.
of
131:1358-1362,
of medical
Association in a General
An
case
and
1974 a survey
Milbank
1966
A: Reviewing
Endicott
psychiatric
Pro-
Psychiatry
Hospital
care.
Institute Hospital.
JR. Chapman RL: Management information services. Administration in Mental Health.
12-25 Spitzer
a
1966
& Stratton, guidelines:
I Psychiatry
quality
assurance: 1974
GAP,
Record
suppl):166-206,
Dis-
and
York,
Grune review
Am
Evaluating
44 (July
Pathological
Considerations
Care. New York, Le Baron GI: Peer
Brook RH: Quality ical Staff 3: 15-26,
31. Elpers health
Arch
on
Med-
Presented AdministraChicago.
Ill.
for mental fall. 1973, pp
group
of forms
Gen
Psychiatry
for
auto-
24:540-.
1971
of
APPENDIX
I
Psychopathological
1974
ProhIen
their
on
J
of
1967 yen-
Psychiatry
sick,
2.
Categories
(includes testing,
no diagnosis, diagnosis border, worried but
denot
etc.)
Situational
and
environmental
457,
in prediction
18:119-126, of schizophrenia
term experimental
ferred,
relation
36:450-
Am
I . Nondiagnostic
to treatment.
and
diagnosis
Gen Psychiatry of diagnoses
2 1:601-
of Psychi-
Am J Orthopsychiatry of psychiatric
WHO
Rock-
1966 10. Klein
Bull
in de-
Child Psychol Psychiatry 10:41-61, 1969 Rutter M, Schaffer D, Shepherd M: An evaluation ofthe proposal for multi-axial classification of child psychiatric disorders. Psychol Med 3:244-250, 1973
547,
Am I Psychiatry 129:74-80, 1972 8. American Psychiatric Association, Ad Hoc Committee PSROs: Model Criteria Sets. Washington, DC, APA. 1974
9. Jenkins
disorders.
107:887-908. 1961 reaction to deviant
TS: Commitment
Manual
Re-
Office
1975
cial restraint? J Nerv Ment Dis 125:293-307, 1957 Szasz TS: The classification of ‘ ‘ mental illness. ‘ ‘ Psychiatr 33:77-101, 1959 Bahn AK: Need for a classification scheme for the psychosocial disorders. Public Health Rep 80:79-82, 1965 tion
1973 Accreditation 1972 Manual.
research
32:285-305,
ofmental
Psychiatry II: Societal
theory
for
Peer
Overview
MILLER
Ward CH: The psychiatric nomenclature: reasons for diagnostic disagreement. Arch Gen Psychiatry 7:198-205, 1962 16. Kreitman N: The reliability ofpsychiatnic assessment: an analy-
32.
Welfare,
Program
J
treatment; modalities, patients’ plans. Presented at the Amen-
Institute
in a General
Robitscher
acts).
AHA, 1972 for Regional
Education.
of active discharge
(off
Publishing Co. of Hospitals: Chicago. JCAH,
Review:
of recent
at the American Hospital tion of Psychiatric Services Nov 11-13, 1974
statement on peer review in psychiatry 130:381-385. 1973 Hospital Association: Quality Assurance
view. Cambridge, Mass, Ballinger Joint Commission on Accreditation Manual for Psychiatric Facilities.
WT:
Psychiatry
DEREK
15.
REFERENCES
Psychiatry American
Gen
AND
663, 1960 Beck AT, Ward CH, Mendelson M, et al: Reliability of psychiatnc diagnoses: 2. A study ofconsistency ofclinicaljudgments and ratings. AmJ Psychiatry 119:351-357, 1962
30. Pinsker
I . Position
1970 McKinney
J. KNESPER
reactive
3.
Developmental
4.
Personality
disorders
culturally 5. Neurotic
determined disorders
neurotic
6. Psychotic
disorders
(responses
to specific
events) deviations
depressive
syndromes
Am
(includes
learning
(includes
borderline,
behavior (includes
patterns) neurotic
disorders)
schizoid,
depression
and
and
reaction)
of childhood
J Psychiatry
133:!,
and/or
Januar’
adolescence
/976
49
TREATMENT
PLANS
Schizophrenic disorders 8. Major affective disorders (excludes neurotic depression) 9. Psychophysiological disorders 10. Brain syndromes-acute (includes intoxication) I I Brain syndromes-chronic (excludes mental retardation but includes epilepsy, even if episodic) 7.
.
12.
Mental
retardation
Social Other
system
Special Pathophysiological EEG Neuropsychological testing Special radiological studies Other Psychological Special
APPENDIX Proposed I 2.
.
2#{149}
Psychosocial
Suffering Behavior
5. 6. 7.
8. 9. 10.
Difficulties
with
personal
APPENDIX
relationships,
behavior,
3 Categorization
PATIENT
PROBLEM-DIAGNOSING
Pathophysiological Medical Neurological Surgical Other Psychosocial Family
50
Categories
or so-
cial performance-at home Difficulties with personal relationships, behavior, or social performance-at work or school Difficulties with personal relationships, behavior, or social performance-in the community Behavior leading to conflict with the law-actual or potential Drug abuse-alcohol Drug abuse-other than alcohol Cannot care for self and has inadequate social support
Simplified
of
Problem-Solving
Services
SERVICES
Consultation
Genetic
Psychopharmacological Anticholinergics
Antidepressants Lithium carbonate Major tranquilizers Minor tranquilizers Sedatives Stimulants Other Social Arrangements to care for patient’s Change in legal status Change in living arrangements Financial assistance and/or hospital Link-up with other agency Other
Protective
/33:1,
January
Studies
PROBLEM-SOLVING SERVICES (includes prevention) Psychotherapeutic Family behavioral, expressive, or supportive therapy Group behavioral, expressive. or supportive therapy Individual behavioral, expressive, or supportive therapy Marital/conjoint behavioral, expressive, or supportive therapy
Other
J Psychiatry
and Biological
PATIENT
Con vu/site Evaluation
Am
Testing
Other
from subjective psychological symptoms actually or potentially dangerous to self actually or potentially dangerous to others
3. Behavior 4.
Problem
Evaluations
1976
Care
family
expenses
DAVID
Plans J. KNESPER,
for M.D., AND
Mental DEREK
Health MILLER,
The authors present a methodfor the development of standardprocess criteriafor the care of defined subpopulations ofpsychiatric patients using a twodimensional problem category system to describe patients. Patient subpopulations, described by both a traditional psychopathological problem cluster and a less traditional psychosocial problem cluster, are matched to a list ofproblem-solving services to develop a model treatment plan. The authors present this method for developing standard treatment plans as an alternative to APA ‘s Model Criteria Sets.
MORE EFFECTIVE AND COMPREHENSIVE quality assurance programs require both accountability and professional standards from mental health professionals. APA endorses this concept (1). Subsumed under quality assurance are quality records, admission certification, peer review, utilization review, medical audit, and medical care evaluation studies, as well as other basic and often overlapping elements. These elements are emphasized in the accountability requirements of Professional Standards Review Organizations (PSRO), the Joint Commission on Accreditation of Hospitals (JCAH), third-party payers, state mental health codes, and other legal precedents (2-7). The basic elements of quality assurance demand the establishment of standards of cane, a review of treatment procedures, and a review of the utilization of services rendered. In order to meet these demands, sets of basic criteria for quality care need to be developed. The comparison ofthe care a patient actually neceives to standard criteria of care then becomes possible. APA’s Model Criteria Sets (MCS) (8) is a major contribution toward the development of standard criteria for quality cane. The MCS is not a final, ultimate product; rather, it serves as a stimulus and aid to local mental health programs that wish to adopt or modify the MCS or to develop alternatives. This paper will present an alternative model for the development of standard criteria of care that we be-
The 48104. gator,
tute, ment
authors are with the University of Michigan, Ann Arbor, Dr. Knesper is Instructor ofPsychiatry and Research Department of Psychiatry and Mental Health Research
and Dr. Miller of Psychiatry.
is Professor
and
Associate
Chairman,
Mich. InvestiInsti-
Depart-
Care M.D.
lieve to be less constricting than those previously reported. Psychopathology provides an insufficient descniptive basis for the planning of adequate clinical care. A complementary set of psychosocial problem categories have to be developed, as well as adequate patient records that make clean the interaction between psychosocial problems and the psychopathological state of the individual as it varies through the treatment process.
GENERAL
METHOD
The primary tools of classification and systematization are used for the development of standard cniteria of cane. Classification is a necessary first step in an underdeveloped area; systematization creates a single framework from a relatively unassembled collection of scientific knowledge, clinical practice, professional judgment, and currently accepted theory. The process of separating and conceptualizing vanous dimensions that are necessary for the development of adequate criteria of care is not new. The process is facilitated if the following four dimensions are considered: 1. Thepatient’s description. This is organized information that identifies, describes, and characterizes the patient in clear, well-understood terms. 2. The patient’s problems. This describes the paient’s psychological, social, and biological incapacities as perceived by himself or others. Treatment is indicated when these problems result in a potential, relative, or permanent exclusion from valued work, play, on family life. 3. Problem-solving services. These are the basic, active intervention techniques that are required for problem solution or change. They include preventive, diagnostic, therapeutic. supportive, and rehabilitative methods. 4. Treatment plan. This is a systematic, goal-oriented program of problem-solving services. It is based on the description of the patient and his problem charactenistics, is specific to solving identified psychological, social, and biological problems, and is directed toward the goals of problem change and improvement. The specificity of problem-solving services is multi-determined by clinical research, professional consensus, and other recognized criteria. These four dimensions will be shown to provide a method for developing treatment plans and thus for es-
Am
J Psychiatry
133:!,
January
1976
45
TREATMENT
PLANS
tablishing standard criteria of care for a specific problem on group of problems. The concept of the patient’s problem is used to develop a unique categorization that distinguishes a set of traditional psychopathological problems from a set of psychosocial problems in mental illness. The concept of problem-solving services is used to develop an example categorization scheme of these services. These concepts provide a mechanism for the development of four types of treatment plans. We call the first of these nondiffenential, nonindividualized treatment plans. The words nondifferential’ and ‘nonindividualized’ may seem to connote a nonprofessional attitude toward treatment planning because professional attention is actually focused on planning a unique program of problem-solving services for a particular patient. However, placing a patient in an inpatient or outpatient treatment facility should automatically dictate a standard program of services. Thus a patient with problems of sufficient severity to necessitate psychiatric hospitalization receives dietary, hotel, laboratory. environmental, and other inpatient services provided by a relatively fixed number of staff. The nature of these services is dictated typically by the constraints of resources and by a general treatment approach that is assumed to be applicable to a specific characteristic of all patients-for example, an age group. In addition. these services are given within the context ofa general philosophy oftneatment. The nondifferential, nonindividualized treatment plan provides the backdrop against which more specific, differential, and individualized treatment plans for solving problems occur. The more specific treatment plans can be categonized into three groups: differential, individualized treatment plans for solving routine problems; differential, individualized treatment plans for solving special problems; and differential, individualized treatment plans for clinical research. In this paper we will review this approach to treatment planning and elaborate on the method specifically as it is applied to the development of one concrete example: a differential, individualized treatment plan for the solution of routine problems for an adolescent patient. ‘ ‘
‘
‘
‘
PROBLEM
DESCRIPTION
It is generally agreed that a crucial element in velopment of a treatment plan is a description patient’s problems. However, there is no consensus to the nature of the categorization scheme for problems. Treatment decisions are inadequate problems are clearly defined and the etiological planation for the problems is clarified. Adequate apeutic intervention may treat causes as well as toms, and a decision to ignore one or the other
46
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P.s’yc/ziatrs
/33:1
,
January
1976
the deof the as these unless exthensympshould
be manifest. Unfortunately. diagnostic labels for mental problems have limited utility, and their use often aggravates actual problem solution. A traditional mental illness category may say nothing about etiology and may in no way assist the definition of specific thenapeutic interventions. Psychiatric diagnoses may be quite irrelevant in indicating therapeutic interventions (912). In addition, except for the broadest of categories, conventional clinical methods for establishing psychiatric diagnoses are of low reliability ( I 3-16); however, once these labels are attached to an individual, they are difficult to change and have disadvantageous social consequences (17, 18). The ambiguity of traditional psychiatric nosology has sufficiently disguised the problems of mental illness as to make them refractory to solution, given our present tools (19, 20). However, sufficient evidence does not yet exist for the total abandonment of a traditional approach. and broad nosological categories are one determinant in the development of our treatment planning method. Another approach to patient description makes use of psychosocial problem categories. Many professionals feel that the application of the physical illness model to behavioral and mental illness is frequently inappropriate because it results in a concept that the ongin of the illness is concealed totally within the individual. Many origins may be social or experiential. With this focus, Bahn (2 1 ) produced a strong argument for a classification scheme for psychosocial disorders. The use of both a psychopathological and a psychosocial category scheme has been recommended in child psychiatry. A three-dimensional classification system for mental disorders using clinical psychiatric problems, intellectual level, and associated etiological factors as appropriate measurements has been suggested (22). Similarly. the addition of psychosocial etiological factors as yet another dimension has resuited in a four-dimensional classification model for childhood illnesses (23). We assume that a broad global psychopathological category is necessary but insufficient to define differential treatments for mental illness. The broad psychopathological categories must be complemented by one on more categories from a global set of psychosocial problem categories. Appendix 1 lists psychopathological problem categonies adapted from standard sources (24, 25). Appendix 2 is a proposed list of psychosocial problem categories. A patient is described by at least one category from each list; therefore, treatments are matched to a combination of problems taken from each of the two sets. For example. a treatment plan could be developed for a patient described as being both schizophrenic and dangerous to self, or any ofthe many other problem combinations. Our use of the concept of problems must be distinguished from the use of the problem-oriented record. The problem-oriented record, in its present form, requires the use of highly specific and particular prob-
DAVID
lems (26). Therefore, the patient may be described by a long list of problems not necessarily derived from a standard classification scheme. In contrast to this, we use a small number of global psychosocial categories as a classification scheme for psychosocial disorders.
DESCRIPTION
OF SERVICES
Langsley and Le Baron (27) have shown that there considerable variation in the length of stay of patients in different mental health care facilities. Much of this variation must result from different practices, services. and treatment plans. This phenomenon. of course. makes it incumbent upon a mental health care facility to state explicitly what treatment services it offers and what the expected length of service application to a particular problem or group of problems will be. This avoids the umbrella term services nendered. With this in mind, a simplified categorization of services is presented in appendix 3. Treatment plans are developed by matching services to at least one problem from the list of psychopathological problems and one problem from the list of psychosocial problems. This is followed by a combination of the problems, each of which is associated with a specific list of services. is
‘ ‘
‘ ‘
TREATMENT
I.
KNESPER
AND
DEREK
MILLER
research. Clinical research must be complemented, not encumbered, by standard treatment plans. Once a protocol of services for clinical research on a specific problem has been developed and standandly approved, the deviations from the standard treatment plans of types 1-3 must bejustified by the researchers and such organizations as a human subjects review committee and a quality assurance committee. These treatment plans are, by definition, unique. Further elaboration will be limited to the development of type 2 treatment plans because these are usually the first conceptually difficult treatment plans to be developed by a quality assurance program. We recommend that this type as well as others be further differentiated according to the broad age groups of children, adolescents, young adults, older adults, and eldeny adults. An example of a treatment plan for a patient described as adolescent, schizophrenic, and dangerous to self is presented in table 1. Several aspects of the treatment plan deserve specific discussion. First, the services were taken from a relatively short list; therefore, the specific services for the patient described are few. This is the procedure of choice. Long lists of many services resulting in very
TABLE 1 Differential, Individualized Treatment lems for an Adolescent Patient
Plans for Solving Routine
Prob-
PLANS Treatment
We propose the following four types of treatment plans: Type 1. Nondifferential, nonindividualized. A patient described only as a psychiatric inpatient would receive such services as diet, routine laboratory studies, and a therapeutic environment. These services are given to all inpatients without substantial exception. They may vary from institution to institution and sometimes between different programs within one setting. Type 2. Differential, individualized for solving routine problems. This is illustrated in table I by a treatment plan for an adolescent patient who is both schizophrenic and dangerous to self. Here, as in types 3 and 4 (discussed below), the concept ofdifferential assignment of services and individualization is based on a defined subpopulation of patients. Individualization to the level ofthe single patient is left to the professional. Tvpe 3. Differential, individualized for solving special problems. These are treatment plans that are unique and very specific because the problem requires a mobilization of special resources that must be used with great precision. Resource mobilization is often reinforced by policy statements and legal intervention. Examples of such special problems would be the chronically suicidal patient, the violent patient in the emergency room, and the firesetter on an inpatient ward. Type 4. Differential, individualized for clinical
Plan,
by Pro blem Categories
Item
Schizophrenic
Required services
family psychosocial evaluation
protective
neurological
neurological
(present 100%
Disorder
Dangerous
to Self care
in of all
cases)
Frequent
consultation
services
(present in more than ofall
5#{216}C7
cases)
consultation
anticholinergics major tranquilizers
individual psychotherapy
group/family
change
in legal
status
psychotherapy
Infrequent services (present in less than 50% of all cases)
psychological testing minor tranquilizers lithium carbonate
Rare
convulsive
services
(absent ofall
social
minor tranquilizers sedatives
services
service
convulsive
service
in 95% cases)
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TREATMENT
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detailed treatment plans would best be avoided so as to facilitate communication and understanding and promote later meaningful evaluation of the plan’s effectiveness. Furthermore, a major purpose of specifying the treatment services is to detail only the critical elements of active treatment to which the greatest amount of therapeutic value is attributed. The type 2 treatment plan is complemented by the existence of a type I treatment plan, which serves as a backdrop and avoids needless repetition of information in the other types of treatment plans. The breakdown of services into a required category (see table 1) allows for placement within the treatment plan of services judged to be necessary in the treatment process. The breakdown of services into a rare category calls attention to services that may be hazardous in the treatment process and that, if used. would require considerable written explanation and justification in the patient’s medical record. The breakdown of services into frequent and infrequent categories penmits necessary clinical discretion. The percents that may be attached to these permit a mental health cane facility to follow aggregate trends in the care of defined patient subpopulations and to intervene to reverse undesirable trends in service delivery. This can avoid Unnecessary “punitive’ actions against individual clinicians who of necessity must deviate from inflexible and restrictive standards. By limiting the possibility of unnecessary constriction of treatment options, an atmosphere of cooperation is permitted that has the potential for producing meaningful attempts to evaluate the effectiveness of particular treatment plans. ‘
DISCUSSION
A quality assurance or review committee can either develop its own model treatment plans or modify or adopt existing treatment plans. After a set of treatment plans is adopted, deviations from model treatment can be detected by a nonphysician chart reviewer. For the method presented here, the patient charts would be reviewed by the physician reviewers of the committee when services categorized as required have not been provided on when services categorized as rare have been provided. Physician review also occurs when services that fall outside of the services recommended for a particular patient subpopulation have been provided. In addition. physician reviewers will need penodically to review selected charts from patients who neceive services categorized as infrequent. In no case does any physician review imply substandard care; it implies only a need for explanation and justification to peers. In addition to their use to detect deviations, model treatment plans also serve an educational function when they are made available to clinicians. Therefore, the term model treatment plan’ is used in preference to model criteria set’ because the model may serve as a flexible guideline for individual clinicians planning the cane of a single patient. Because the model plan is not an exhaustive description ofservices, clinical judgment and therapeutic innovation are permitted. ‘ ‘
‘ ‘
We would emphasize that this method depends on a mental health care facility’s adopting or developing and periodically updating both the model treatment plans and the categorizations of problems and services. Techniques applicable to the evaluation of treatment plans were discussed by Donabedian (28). It must be pointed out that an approach to quality assurance based on ‘laundry lists’ of services matched to problems has been criticized as being relevant only to improving the process of care and possibly irrelevant to improving the outcome of care (29). ‘
We advocate a two-dimensional system using psychopathological problems and psychosocial problems for describing a patient. We also point out the need for another dimension, that is of a measurement of seventy. Service assignment and treatment depend on not only the presence of a problem but also its severity. The example treatment plan in table 1 was written as though there were no interaction between the two categonies ofpnoblems. Services were assigned to each category separately and then to the two categories combined. It is probable that the services assigned to a patient described simultaneously by a psychopathological and a psychosocial problem would be different from those assigned to a patient described by each category separately. When several problems, each of which has assigned services, are combined to form one treatment plan, it is possible that a service required for one problem is infrequent or rare for another problem. This conflict can be resolved during the development of model plans as it occurs. The forum in which this conflict resolution takes place might be a quality assurance committee.
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/33:1
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‘
‘
‘
The method for the development of treatment plans presented here produces the appearance of a static quality both for patients and for patient care. Obviously people are sensitive to stress. and an individual’s perception of and reaction to actual or potential stress may produce a different cluster of psychopathological or psychosocial problems over time. These changes may demand equivalent changes in treatment plans; therefore, there is no assumption that any one plan is unchangeable for the duration of treatment. The vide a nosis, view. treatment
treatment plan method method fonjustification admission certification, Each ofthese procedures plan.
In order admission diagnostic the method who listed
illustrated here can proof the problem. or diagand continued stay necan be part ofa type 1
to certify the need for admission, general criteria that are not specific to a particular label can be developed. This is essentially reported by Pinsker and Richman (30), I 1 indications for admission to an inpatient
DAVID
psychiatric facility. For example, ‘suicidal or destructive behavior is an immediate threat,” “treatment which cannot be initiated or continued unless in a su‘
12.
127:759-763, Akiskal HS,
pression. 13.
pervised setting,” and “no alternative resources available at time ofadmission” are three indications for admission. This approach defines the purpose of psychiatric hospitalization and distinguishes it from the purpose of establishing a diagnosis or problem statement. Pinsker and Richman also reported a similar method for continued stay review. The justification of a diagnosis is also pant of a type I treatment plan. This can be done by specifying the mmimum information required to be recorded in the patient record to categorize any patient into a subpopulation of patients with similar problems. Patient records that establish a base of minimum necessary information have been described: the records of Elpens and Chapman (31) and Spitzer and Endicott (32) are good examples. Unfortunately, these records use a highly standardized checklist-type format most suitable for automated information systems and less suitable for day-to-day use by clinical professionals. However, with modification such records can be made more congenial to multiple users. Last, one important ground rule deserves reemphasis. Quality assurance is a local phenomenon requining local initiation and support. Good clinical practice has variation, there are many acceptable paths to the same result, and professional variation is wedded to innovation and improved clinical performance. For these reasons we have presented a method with only guideline examples. With its consideration should come rethinking, modifications, and (perhaps) anothen, better method that makes more sense in another geographical area.
14.
Arch
Stengel
2.
Medical 3. Decker 4. 5.
Care in the Hospital. Chicago, B, Bonner P: PSRO: Organization
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on Administration
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Rutter
RL:
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to the family
syndromes
background.
in children
clinical
DF: drug
1 1 . Baldessanini sus affective
Importance
effects. Arch Ri: Frequency
Ill,
I 1-13.
night
disorders
from
method. DL:
Social
On
being
Problems
sane
1944-1968.
behavior:
problems
9:247-257.
in insane
places.
of the mentally
of
1962 Science
179:250-
ill: “treatment”
or so-
M, Lebovici of mental
S. Eisenberg
disorders
L. et al: A tn-axial
in childhood:
an
Q
classifica-
international
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I
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APPENDIX
I
Psychopathological
1974
ProhIen
their
on
J
of
1967 yen-
Psychiatry
sick,
2.
Categories
(includes testing,
no diagnosis, diagnosis border, worried but
denot
etc.)
Situational
and
environmental
457,
in prediction
18:119-126, of schizophrenia
term experimental
ferred,
relation
36:450-
Am
I . Nondiagnostic
to treatment.
and
diagnosis
Gen Psychiatry of diagnoses
2 1:601-
of Psychi-
Am J Orthopsychiatry of psychiatric
WHO
Rock-
1966 10. Klein
Bull
in de-
Child Psychol Psychiatry 10:41-61, 1969 Rutter M, Schaffer D, Shepherd M: An evaluation ofthe proposal for multi-axial classification of child psychiatric disorders. Psychol Med 3:244-250, 1973
547,
Am I Psychiatry 129:74-80, 1972 8. American Psychiatric Association, Ad Hoc Committee PSROs: Model Criteria Sets. Washington, DC, APA. 1974
9. Jenkins
disorders.
107:887-908. 1961 reaction to deviant
TS: Commitment
Manual
Re-
Office
1975
cial restraint? J Nerv Ment Dis 125:293-307, 1957 Szasz TS: The classification of ‘ ‘ mental illness. ‘ ‘ Psychiatr 33:77-101, 1959 Bahn AK: Need for a classification scheme for the psychosocial disorders. Public Health Rep 80:79-82, 1965 tion
1973 Accreditation 1972 Manual.
research
32:285-305,
ofmental
Psychiatry II: Societal
theory
for
Peer
Overview
MILLER
Ward CH: The psychiatric nomenclature: reasons for diagnostic disagreement. Arch Gen Psychiatry 7:198-205, 1962 16. Kreitman N: The reliability ofpsychiatnic assessment: an analy-
32.
Welfare,
Program
J
treatment; modalities, patients’ plans. Presented at the Amen-
Institute
in a General
Robitscher
acts).
AHA, 1972 for Regional
Education.
of active discharge
(off
Publishing Co. of Hospitals: Chicago. JCAH,
Review:
of recent
at the American Hospital tion of Psychiatric Services Nov 11-13, 1974
statement on peer review in psychiatry 130:381-385. 1973 Hospital Association: Quality Assurance
view. Cambridge, Mass, Ballinger Joint Commission on Accreditation Manual for Psychiatric Facilities.
WT:
Psychiatry
DEREK
15.
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3.
Developmental
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Personality
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determined disorders
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6. Psychotic
disorders
(responses
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events) deviations
depressive
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J Psychiatry
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49
TREATMENT
PLANS
Schizophrenic disorders 8. Major affective disorders (excludes neurotic depression) 9. Psychophysiological disorders 10. Brain syndromes-acute (includes intoxication) I I Brain syndromes-chronic (excludes mental retardation but includes epilepsy, even if episodic) 7.
.
12.
Mental
retardation
Social Other
system
Special Pathophysiological EEG Neuropsychological testing Special radiological studies Other Psychological Special
APPENDIX Proposed I 2.
.
2#{149}
Psychosocial
Suffering Behavior
5. 6. 7.
8. 9. 10.
Difficulties
with
personal
APPENDIX
relationships,
behavior,
3 Categorization
PATIENT
PROBLEM-DIAGNOSING
Pathophysiological Medical Neurological Surgical Other Psychosocial Family
50
Categories
or so-
cial performance-at home Difficulties with personal relationships, behavior, or social performance-at work or school Difficulties with personal relationships, behavior, or social performance-in the community Behavior leading to conflict with the law-actual or potential Drug abuse-alcohol Drug abuse-other than alcohol Cannot care for self and has inadequate social support
Simplified
of
Problem-Solving
Services
SERVICES
Consultation
Genetic
Psychopharmacological Anticholinergics
Antidepressants Lithium carbonate Major tranquilizers Minor tranquilizers Sedatives Stimulants Other Social Arrangements to care for patient’s Change in legal status Change in living arrangements Financial assistance and/or hospital Link-up with other agency Other
Protective
/33:1,
January
Studies
PROBLEM-SOLVING SERVICES (includes prevention) Psychotherapeutic Family behavioral, expressive, or supportive therapy Group behavioral, expressive. or supportive therapy Individual behavioral, expressive, or supportive therapy Marital/conjoint behavioral, expressive, or supportive therapy
Other
J Psychiatry
and Biological
PATIENT
Con vu/site Evaluation
Am
Testing
Other
from subjective psychological symptoms actually or potentially dangerous to self actually or potentially dangerous to others
3. Behavior 4.
Problem
Evaluations
1976
Care
family
expenses
