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Measure Success Through DLA-20©

The Clinician & Consumer Instrument for Measuring Progress

Willa S. Presmanes, M.Ed., M.A.Outcomes Consultant

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WHY is measurement important in 2014?

1) CMS Medicaid RAC Audits

•Symptoms + DLAs =medical necessity

• Identify Strengths

•Weaknesses: problems for recovery

Focus Functioning

Focus Functioning

•Collaborate with client

•Person centered

• Identify Priorities

•Plan Meets needs

IPPIPP•Link goals to service notes

•Correct LOC

•Correct LOS

•Measureable progress

• Satisfaction +

TreatmentTreatment

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RAC Audit Findings: New Mexico Sept. 2013 Summary

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Newspapers: “The California Department of Health Care Services (DHCS) has temporarily suspended Medicaid

payments to 46 addiction treatment clinics, and 62 satellite counseling sites, due to credible allegations of Medicaid fraud or inappropriate billing by the clinics:

Providing services not deemed medically necessary (Our focus today).

Billing California’s Drug Medi-Cal (DMC) program for services that were not rendered.”

WHY is measurement important in 2014? Note: RAC audits last year in California

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Why Now? #2_ Let’s Review Medical Necessity:

• Appropriately Qualified Practitioner identifies & targets• Clinically Appropriate Services and Interventions

• At Appropriate Intensity and Duration

As Directed by an• Individualized Service Plan

Designed to• To Improve Functioning and Symptoms or Prevent their 

Worsening (our focus today)

Based on• Assessed Needs and an Approved Diagnosis

Source: Bill Schmelter, Ph.D. MTM Team ConsultantTracer Model of Review from an auditors’ perspective

(Recovery: Federal Register, Section 1905(a)(13) of the Act and 42 CFR § 440.130(d))

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“The Severity Index will be an essential specifier in all diagnostic categories. 

Assures that the individual does qualify for a mental disorder from definition and that it is a severe 

impairment. Assures, also, the clinician takes time in diagnosing. 

Replaces the Axis V GAF. “The Severity Index replaces GAF AND is based on functioning and not on the IQ, culture.

Why Now?#3 APA replaced DSMIV Axis V GAF: The Science of the DSM 5® With The

“Severity Index Across Time & Circumstances”

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EXAMINE HOW TO SCORE DSM 5® •USE DSMIV GAF!

The Severity Index Across Time & Circumstances

0 – No impairment – GAF 71 to 1001 – Mild impairment - GAF 61 to 702 – Moderate impairment – GAF 31 to 60

3 – Severe impairment – GAF 1 to 30

“Specifier must indicate level 1 or 2 or 3 before a diagnosis is validated as a mental disorder”

Why?#4_CMS TIES LOC TO NEEDS BASED ON FUNCTIONING

Severity Index 1_LOC 1 Severity Index 2_LOC 2 Severity Index 3_LOC 3

Needs minimal assistance with one or more ADLs of mobility (inside, outside, transferring, ambulation), personal care (dressing, bathing, continence), dietary (meal preparation, feeding), household maintenance (housework, shopping, laundry)

Needs moderate assistance with ADLs of mobility (inside, outside, transferring, ambulation), personal care (dressing, bathing, continence), dietary (meal preparation, feeding), household maintenance (housework, shopping, laundry)

Needs maximum assistance with ADLs of mobility (inside, outside, transferring, ambulation), personal care (dressing, bathing, continence), dietary (meal preparation, feeding), household maintenance (housework, shopping, laundry)

http://www.balancingincentiveprogram.org/resources/example‐core‐standardized‐assessment‐instruments‐level‐ii

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§ Encourage care coordination and primary care

§ Value-Based Purchasing

§ Accountable Care Organizations, Medical Homes

§ Bundled Payments

§ Link payments and outcomes

National Outcome Measures (NOMs):

“The NOMs for people receiving Adult SMI or Substance Use Disorder services will meet or exceed the benchmark in at least 4 of these 5 areas: Living Arrangements; Number of Arrests; Drug and Alcohol Use; Attendance at Self-Help Meetings; and Employment Status.” Note emphasis on functional DLAs

WHY?#5 CMS New Paradigm & NOMs

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1. Health Practices (Mental, Physical)

2. Housing Stability, Maintenance

3. Communication (mental status)

4. Safety (suicidal, homicidal)

5. Managing Time (sleep,prescriptions)

6. Managing Money

7. Nutrition(inc.diabetes,special diet)

8. Problem Solving around symptoms

9. Family Relationships

10. Alcohol/Drug Use (inc.Cigarettes)

11. Leisure

12. CommunityResources

13. Social Network (friends)

14. Sexual health

15. Productivity (work, school)

16. Coping Skills

17. Behavior (court orders)Norms

18. Personal Hygiene (inability to care for basic self care, hygiene)

19. Grooming

20. Dress

WHAT TO MEASURE?

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Examine the DLA20: You will define current functioning (last 30 days), the full scope of ADLs, consumer strengths and weakness - does not replace the Severity Index or GAF score but reliably predicts the score and validates assessed needs for the treatment plan.

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• The DLA-20© is a 10 minute, one page summary functional assessment

• Designed to be an objective tool for use by trained direct-care staff

• 20 specific daily living activities where clients may demonstrate various impairments Examples: nutrition, managing money, hygiene,

productivity

• Level of impairment for each type of activity is rated on a seven-point scale (1 through 7) Lower numbers indicate more severe

impairment A “7” indicates complete absence of impairment

for that activity

• For each client, one DLA sheet can be used five times to track progress across repeated assessments (recommended: every 3 to 6 months)

How to measure? Daily Living Activities (DLA-20©) Functional Assessment

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Why DLA-20?Benefits of Measuring with the DLA-20 Consistent

Different people rate the same client similarly over same period

Sensitive Not all patients with the same illness

will be rated similarly

Relevant Ratings guide treatment focus

Service-driven Ratings determine amount of

appropriate services/levels of care

Outcome-driven Document true improvements over

time with repeated measures

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What outcomes can you expect? Linkages through Three Key Documents

• Linkages must be clear between serious symptomsthat impact daily living and assessed needs thatfocus on improving symptoms and functioningin 3 key documentsWe call this pulling the “Golden Thread” from the diagnostic

assessment (1) through to the individualized treatment plan (2) and finally to the progress notes (3)

Diagnostic Assessment Treatment Plan Progress Note‐Review

Describing signs and symptoms associated with diagnosis is not sufficient; must describe specific functional impairments

Symptom‐based plans are not enough; must include functionality‐based treatment goals

Progress reviews cannot be purely subjective; mustdocument specific and measurable improvements in functioning

©Willa S. Presmanes, MTM Services & NCCBH

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What Outcomes can you expect? The Golden Thread!

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What Outcomes can you expect?

STRENGTHS

Pull golden thread for all DLAs >=5

NEEDS:

Pull golden thread for all DLAs <=4

ASSETS? Examples

Independent, safe housingIndependent income

Working or Productive

Supportive family

No Alcohol/Drugs/Cigarettes

PRIORITIES:

What problems is the individual willing to work on? Pull golden thread for DLAs<=2 or lowest

scores and add comments

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What Outcomes to Expect? Sample prioritized goals to improve symptoms AND functioning using DLA-20low scores (assessed needs) & high scores (strengths) Client will reduce anxiety and hearing negative voices on scale from 6 to 2 so that she can be active outside of apartment, exercise, volunteer or work on regular routine, deal with divorce proceedings.

Client (25 yr. old) will journal sleep routine so exhaustion does not bring on negative voices of schizophrenia and so that she can do “normal things”, ex, meet others for coffee, talk.

Client wants better coping strategies to reduce depression and paranoia to a self report score 2 from 8 so that he can ride his bike and return to taking digital photographs.

“I want to feel less depressed” so that I am able to reduce cigarettes from 3 packs a day to 1 and reduce coffee from 5 pots a day to 2.

Client wants monthly visitation with daughters but must show courts her progress in reduction of uncontrolled anger and positive coping responses to symptoms of paranoid schizophrenia

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What outcomes can you expect? 10 programs in 10 states (N=186) saw statistically significant change scores last year w/Bipolar, Dual DSM

©Willa S. Presmanes, MTM Services

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What Outcomes

Can You Expect? Aggregated for programs

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Our goal was to bring focus: Why, What & How to Measure Results

• First: Why you need to measure NOW✓Medicaid Balancing Incentives✓ACA/CMS RAC audits ✓DSMV Severity Index✓CMS Levels Of Care✓NOMs (National Outcome Measures)✓Provider, Client collaboration & satisfaction

• Second: What to Measure?✓Symptoms impact Daily Living Activities✓Estimate Severity Index, GAF from DLA-20✓Use anchors to measure WNL reliably

• Third: What outcomes to expect:✓Pull the “Golden Thread”✓Use the DLA to design treatment plans & progress notes to ensure successful recovery✓20 possible outcomes: improved stability in housing, nutrition, schedules, family & peer relations, satisfied court results, work or school productivity, healthy moods, hygiene.

• Train Trainers: Ongoing! Track1) Acceptable range of errors; 2)

collaborate with client, 3) test reliability for training others

SUMMARY

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More Resources

•A free abstract of the original research article on Daily Living Activities Scale©, peer reviewed and published in Research on Social Work Practice is available at:http://www.thenationalcouncil.org/areas-of-expertise/dla-20-mental-

health-outcomes-measurement/

•Contact informationWilla S. Presmanes, M.Ed., M.A.

● E-mail: willa.presmanes@mtmservices.org Contracts available from NCBH.com E-mail: marian.bradley@mtmservices.org

● Phone: (919) 577-6770