Mental Health Transformation Grant

My Health, My Choice, My Life Program Evaluation Report January 2013 Submitted by: Centerstone Research Institute

This report is based upon information gathered at baseline and discharge interviews and reflects data gathered using three instruments: 1) the National Outcomes Measurement System (NOMS), 2) the Health and Self-Management Questionnaire (HSMQ), and 3) the Recovery Assessment Scale (RAS).

*This word cloud was generated from letters written to Commissioner Varney by My Health, My Choice, My Life participants after completing the program. This Word Cloud gives greater prominence to words that appeared more frequently in these letters.

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Data Used For this analysis, participants responses on three assessment tools were used: NOMS, Health and Self-Management Questionnaire, and the Recovery Assessment Scale. Some of the following graphs will include information from intake assessments only, while most will include information from a matched pairs analysis. Matched pairs can be defined as participants that completed the intake and discharge interviews. Throughout this report, the data that are missing (i.e. the participant refused to answer or did not know the answer) are not included in the matched pairs analysis. Thus, there may be some variation on the number of participants responses from question to question. NOMS: The NOMS are completed by all participants at intake and discharge. If a participant is unable to complete the discharge interview (i.e. cannot be located, refuses to participate, etc.) an administrative discharge is completed for that participant. Participants with administrative discharges are not included in the matched pairs analyses.
Assessment Intake Discharge Admin Discharge Matched Pairs Missing, Refused, Dont Know Total 404 300 73 300 31

Health and Self-Managmement Questionnaire: The HSMQ is completed by participants at intake and discharge. There is no administrative discharge for this assessment. Some participants did not complete the discharge assessment because they could not be located or refused to participate in the discharge interview.
Assessment Intake Discharge Matched Pairs Missing, Refused, Dont Know Total 396 296 296 4

Recovery Assessment Scale: The RAS is completed by participants at intake and discharge. There is no administrative discharge for this assessment. Some participants did not complete the discharge assessment because they could not be located or refused to participate in the discharge interview.
Assessment Intake Discharge Matched Pairs Missing, Refused, Dont Know Total 412 297 297 3

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Demographics Race, gender, and age statistics My Health, My Life, My Choice demographics mirror the state of Tennessees demographics across the population with 80% White, 19% Black, ~1% Native American, Hispanic, Asian, or Alaskan 1. Fifty-nine percent of participants are women, almost 41% are male and < 1% transgender. The average age of participants is 46 years with the largest cluster of men and women falling into the 50 to 59-year-old category. From NOMS data:
164 Total 3 133 White 0 29 Black 2 Race Native Amer Hispanic Asian Alaskan 0 1 3 3 1 1 2 1 1 1 1 50 100 Frequency 150 13 20 47 188 235

Male Female Transgender

200

250

80 Frequency 60 40 20 0 19 or under 20-29 30-39 40-49 6 7 35 18 0 1 27 48 45 21 1 1

73 51 38 19 0 50-59 0 60-69 8 2 0 0 1 0 over 90

70-79

Age Group

http://quickfacts.census.gov

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Functioning Responses are coded so that larger numbers represent better outcomes. Overall participants report statistically significant improvements between baseline and discharge in functioning, to include controlling their own lives, getting along with their families, dealing with crisis and experiencing fewer symptoms that interfere with their daily lives. Significance .000 (highly significant) .000(highly significant) .000(highly significant) .000(highly significant) .001(highly significant) .000(highly significant) .000(highly significant) .001(highly significant) .000(highly significant) Question/Response a. How would you rate your overall health right now? b. I deal effectively with daily problems. c. I am able to control my life. d. I am able to deal with crisis. e. I am getting along with my family. f. I do well in social situations. g. I do well in school and/or work. h. My housing situation is satisfactory. i. My symptoms are not bothering me.

5.00 4.00 3.00 2.00 1.00 .00

Baseline Discharge

Mental Health Status Participants responses indicate statistically significant improvements between baseline and discharge in their mental health status to include feeling less nervous, less hopeless, and less depressed. Responses are coded so that larger numbers represent better outcomes (i.e., more nervousness yields a low score and less nervousness yields a high score). Significance Question/Response During the past 30 days, about how often did you feel.. .000(highly significant ) Nervous? .000(highly significant) Hopeless? .000(highly significant) Restless or fidgety? .000(highly significant) So depressed that nothing could cheer you up? .000(highly significant) That everything was an effort? .000(highly significant) Feel worthless?

Mean Score

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5.00

Mean Score

4.00 3.00 2.00 1.00 .00 Feel Nervous Feel Hopeless Feel Restless Feel Depressed Everything Effort Feel Worthless

Baseline Discharge

Alcohol and Tobacco Use There was no significant differences in tobacco use from baseline to discharge and only a modest statistical difference in alcohol consumption (P = 0.034).
1.50 Mean Score 1.00 .50 .00 Tobacco Use Alcohol Use 1.20 1.02
Baseline Discharge

.18

.09

Drug Use Almost everyone reported zero drug use at baseline therefore statistical tests cannot be used to examine this section. The Military Family and Deployment and Violence and Trauma sections are not included in this analysis owing to the small number of participants reporting involvement in the military or issues with violence and/or trauma. Stability in Housing There were no statistical differences between baseline and discharge in any of the housing stability parameters.
1.20 1.00 1.14 .82
Baseline Discharge

Mean Score

.80 .60 .40 .20 .00 Nights Homeless Nights Hospital Nights Detox Nights Jail .35 .11 .37 .11 .05 .00

.09

.03

Times ER

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Living Circumstances Most participants owned or rented their home, some lived with someone else or in a group home. Only 3 participants were homeless.
140 120 Baseline Discharge

Frequency

100 80 60 40 20 0 Owned/rented Someone else's place Group home Transitional living facility Homeless Detox

Education and Employment The following three charts represent baseline data for education and employment. No statistically significant differences were observed between baseline and discharge. Most of the participants were not enrolled in an educational program and about 75% have a high school education or greater, 25% have less than a 12th grade education.

Enrolled in Educational Program

250 217 200 153 Frequency 150 100 50 2 0 Not Enrolled Parttime Fulltime 8 5 1 4 5 0
Females Males Transgender

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Educational Attainment
Graduate Level Bachelor's Some College Vocational Training 12th Grade Less than 12th 0 1 0 0 0 5 0 2 10 20 30 40 3 Transgender Males Females

7 7 8 27 29 7

78 79 40 41 50 60 70 80 90 Frequency

Employment
Other Unem Not Looking Unem Retired Unem Vol Unem Disabled Unem Looking Employed Part Employed Full 0 0 0 0 0 1 2 0 0 6 8 7 13 20 40 60 80 100 120 140 Frequency 17 20 3 6 8 14 96 133 4 3 23 36 Transgender Male Female

Additional Employment Questions Paid at or Above Min Wage?

Frequency 40 20 0 Yes No 28 29 3 6 Baseline Discharge

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Paid Directly?
Frequency 50 0 Yes No 29 31 2 4 Baseline

Could Anyone Have Applied For Their Job?

Frequenc y 20 0 Yes No 18 17 12 17 Baseline

Arrest Summary (unpaired samples)- Sslight decrease in number of arrests observed between Baseline & Discharge. Assessment N Arrests Percentage Baseline 404 4 0.99 Discharge 300 2 0.66

Perception of Care Most program participants agreed or strongly agreed that staff believe in them; provide them with opportunities to have a voice; and staff made sure that they understand their rights. Participants also perceived that staff respect them, helped them obtain the information that they need and participants reported that they would recommend My Health, My Life, My Choice to friends and family members. Look-up table for graph below a. Staff here believe I can grow, change and recover. b. I felt free to complain. c. I was given information about my rights. d. Staff encourage me to take responsibility for how I live my life. e. Staff told me what side effects to watch out for. f. Staff respect my wishes about who is and who is not to be given information about my treatment. g. Staff were sensitive to my cultural background (race, religion, language, etc.) h. Staff helped me obtain the information I needed so that I could take charge of managing my illness. i. I was encouraged to use consumer run programs (support groups, drop-in centers, crisis phone line, etc.) j. I felt comfortable asking questions about my treatment and medication. k, I, not staff, decided my treatment goals. l. I like the services I received here m. If I had other choices, I would still get services from this agency n. I would recommend this agency to a friend or family member.

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180 160 140 120 Frequency 100 80 60 40 20 0 a b

Strongly Agree

Agree

Undecided

Disagree

Strongly Disagree

f g h i Question Reference

Social Connectedness Participants reported statistically significant improvements between baseline and discharge in all data elements measured within the social connectedness indicator, specifically participants improved in their ability to form friendships, enjoy people, belong in the community and accept support from their families.
Belong in Community .000 Support from Family .000

Friendships Significance .004

Enjoy People .000

4.30 4.20 4.10 Frequency 4.00 3.90 3.80 3.70 3.60 3.50 3.96

4.21 4.15 4.03 3.89 3.76 3.86 4.13

Baseline Discharge

Friendships

Enjoy People

Belong in Community Support from Family

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Health and Self Management Questionnaire Disease Diagnoses Participants most commonly reported depression, anxiety, high cholesterol, bipolar, schizophrenia and arthritis when asked about their diagnosis. Less commonly they reported substance abuse, heart disease and cancer. *Includes baseline data only

Schizophrenia Bipolar Subst Abuse Anxiety Depression Cancer Arthritis Heart Disease Other Lung Disease Bronch Emph COPD Asthma Obesity High Cholesterol High Blood Pressure Type I Diab Type II Diab 0 50 10 60 0 49 68 25 15 45

84 118

170 205

96

77 130 136

100 Frequency

150

200

250

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Disease Treatment Participants had received treatment for the diseases they reported however frequencies of treatment were lower on almost every disease reported. *Includes baseline data only

Schizophrenia Bipolar Subst Abuse Anxiety Depression Cancer Arthritis Heart Disease Other Lung Disease Bronch Emph COPD Asthma Obesity High Cholesterol High Blood Pressure Type I Diab Type II Diab 0 50 10 52 44 1 37 55 22 13 33

78 111

156 192

71

112 123

100 Frequency

150

200

250

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Disease Diagnoses by Gender (Baseline)

82 70 0 Bipolar 3 Subst Abuse 0 Anxiety 3 Depression 3 Cancer 0 Arthritis 0 Heart Disease Other Lung Disease Bronch Emph COPD Asthma 0 Obesity 0 High Cholesterol 0 High Blood Pressure Type I Diab 0 Type II Diab 0 Totals 6 0 50 100 150 200 250 300 350 400 450 Frequency 289 404 40 67 104 141 0 10 7 91 146 38 106 0 2 1 0 28 65 0 47 80 15 35 61 117 10 20 150 232 127 195 42 29 87 118 Transgender Male Female

Schizophrenia

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Marital Status (Baseline). Most of the participants were unmarried.

Frequency 400 200 0 Married Yes Marital Status Married No 53 342

Health Insurance Benefits (Baseline). Participants primarily have Tennessee Medicaid and Medicare for their insurance provider.

Other Insurance Veteran Benefits Has SSI Private Insurance No Insurance Has Medicare Has TennCare 0 8

12

12 20 32 108 170 20 40 60 80 100 120 140 160 180

Frequency

Primary Care Physician Program participants reported a highly statistically significant increase in connections with a primary care provider between baseline and discharge (P < 0.001).
.90 .85 .80 .75 .70 .65 Baseline Discharge

Mean

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Health and Limitations Current Health: Uniformly participants reported improvement in how they felt when intake responses were compared to discharge responses. Question: In general, would you say your health is:
150 Frequency 100 50 0 Poor Fair Good Very Good Excellent 40 23 96 67 85 42 51 Baseline Discharge 37

110

25

Statistical Test (P = .001) Relative Health Assessment (General Health)

Discharge Baseline

Much better now than one year ago Somewhat better now than one year ago About the same as one year ago Somewhat worse than one year ago Much worse than one year ago 0 16 18 20 40 60 28 37 59 50

85 65

82 110

80

100

120

Frequency

Statistical Test (P = .001)

Health Limitations on Activities Statistical tests found significant differences between baseline and discharge in four of the questions in the chart below (identified by asterick). Table of statistical significance (P-values). * = statistically significant. Vigorous Moderate Activities Activities 0.153 0.007* Lifting Things 0.026* Stair Climbing 0.518 One Stair 0.235 Bending over 0.041* Walk One Mile 0.312 Walk Several Blocks 0.114 Walk One Block 0.012* BathingDressing 0.079

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Health Limitations on Activities

Bathing-Dressing Walk One Block Walk Several Blocks Walk One Mile Bending over One Stair Stair Climbing Lifting Things Moderate Activities Vigorous Activities .00 .50 1.00 1.50 Frequency 1.86 1.79 2.00 2.50 3.00 2.84 2.78 2.68 2.57 2.41 2.32 2.17 2.11 2.37 2.27 2.55 2.50 2.10 2.13 2.54 2.45 2.48 2.36

Discharge Baseline

Statistical Tests Limitations as a result of physical and emotional health (paired samples). Program participants reported fewer physical and emotional limitations associated with performing at work and they reported accomplishing more.
Reduced Work Time-Physical (P = 0.004) 250 204 200 Frequency 150 Frequency 111 100 50 0 Baseline Discharge 82 175 Yes No 180 160 140 120 100 80 60 40 20 0 Baseline Discharge 153 133 118 No 168 Yes

Accomplish Less-Physical (P = 0.001)

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Limited Work-Physical (P = 0.012)

200 Frequency 150 100 50 0 Baseline Discharge 137 149 111 175 Yes No

Difficulty Performing-Physical (P = 0.023)

200 Frequency 150 100 50 0 Baseline Discharge 105 181 123 Yes 162 No

Reduced Work Time-Emotional (P < 0.001) 250 200 Frequency 150 100 50 0 Baseline Discharge 123 81 162 205 Yes No

Accomplish Less-Emotional (P = 0.005)

200 Frequency 150 100 50 0 Baseline Discharge 141 144 111 175 Yes No

Limited Work-Emotional (P < 0.001) 250 200 216 169 117 70 Yes No

Frequency

150 100 50 0

Baseline

Discharge

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Physical and emotional interference with social activities Question: During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors or groups? Statistically significant improvement was observed between baseline and discharge where physical health or emotional problems interfered less with normal activities with family and friends. Statistical Test (P < 0.001).
200 Frequency 150 100 50 0 Not at all Slightly Moderately Quite a bit Extremely 119 69 72 36 22 39 22 23 16 154 Baseline Discharge

Question: How much bodily pain have you had during the past 4 weeks? Participants reported less bodily pain at discharge than at baseline. Statistical Test (P < .001).
100 Frequency 80 60 40 20 0 None Very Mild Mild Moderate Severe Very Severe 35 76 95 Baseline 44 56 54 53 44 43 35 23 14

Question: During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? Pain interfered with normal work less at discharge when compared to responses collected at baseline. Statistical Test (P = .002).
200 Frequency 150 100 50 0 Not at all Slightly Moderately Quite a bit Extremely 123 143 61 68 46 Baseline Discharge 30 40 38 16 7

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Participants reported more pep, less nervousness, more feelings of peacefulness, more energy, more happiness and a better outlook in general when baseline responses were compared with discharge responses. Statistical Test: (P < 0.001).
40.000 38.000 Mean 36.000 34.000 32.000 30.000 Baseline Discharge

Question: During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)? Physical or emotional problems less often interfered with social activities when responses from baseline were compared to discharge. Statistical Test (P < 0.001).
160 140 120 100 80 60 40 20 0 143 109 75 55 40 49 33 15 11 19 13 9 All of the time Baseline Discharge

Frequency

None of the A little of the Some of the A good bit of Most of the time time time the time time

Statistical Test: (P < 0.001). Participants perception of their own health improved significantly between baseline interview and discharge interview where participants perceived themselves healthier and their outlook in general became more positive.
40.000
Mean

35.000 30.000 Baseline Discharge

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Symptoms Participants reported statistically significant improvements when baseline responses were compared with discharge responses. Participants reported being less affected by fatigue, pain, shortness of breath, stress, and sleep problems. Statistical Test (P < 0.001).

Affected by Fatigue
150 Frequency 100 52 50 0 None Some Moderate Considerable 69 82 116 82 59 33 17 36

Baseline

25

Severe

Statistical Test (P = 0.004).

Affected by Pain
150 Frequency 100 50 0 None Some Moderate Considerable 83 97 73 87 57 46 27 23

Baseline Discharge

45

33

Severe

Statistical Test (P = 0.011).

Affected by Shortness of Breath

180 160 140 120 100 80 60 40 20 0 153 136

Baseline Discharge

Frequency

60

74 53 34 23 8 13 17 Severe

None

Some

Moderate

Considerable

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Statistical Test (P < 0.001).

Affected by Stress
100 80 Frequency 60 40 20 0 None Some Moderate Considerable 19 70 90 72 62 57 44 94

Baseline Discharge

37 26

Severe

Statistical Test (, P < 0.001).

Affected by Shortness of Breath

200 Frequency 150 100 60 50 0 None Some Moderate Considerable 136 153

Baseline Discharge

74 53 34 23 8 13 17 Severe

Smoking Statistical Test: There were no statistical differences in tobacco use between baseline and discharge. The chart below displays the distribution of reported use.

Tobacco Use
180 160 140 120 100 80 60 40 20 0 155 148 Baseline 93 73 10 Never Discharge

Frequency

5 Daily

Once or twice

Weekly

20

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Medicines Statistical Tests: There were no statistical differences in the number of medications taken between intake and discharge. However there were differences in the items on medication-related habits (see charts and statistics below). The trend was always toward improvement at discharge.

Forgot to Take Meds (P = 0.91)

200 178 181

Difficulty Remembering Meds (P = 0.58)

Yes No 200 183 190 Yes No

Frequency

a
150 107 100 50 0 Baseline Discharge 105

Frequency

150 102 100 50 0 Baseline Discharge 96

Stop Meds if Feeling Better (P = 0.03)

300

Stop Meds if Feeling Worse (P = 0.002)

300 Yes No 250 200 150 100 50 0 Baseline 61 35 Discharge 224 251 Yes No

Frequency

200 150 100 50 0 Baseline Discharge 50 34

There was a statistically significant difference between baseline and discharge in the number of prescribed medications taken (P = 0.007).

Number of Rx Meds
Mean of Rx Meds
5.8 5.6 5.4 5.2 5 Baseline Discharge 5.31 5.72

Frequency

250

235

252

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Medical Forms Question: How confident are you filling out medical forms by yourself? Statistical Test (P < 0.001).
150 Frequency 101 100 50 0 Not at all A little bit Somewhat Quite a bit Extremely 78 55 36 32 41 49 51 49 79 Baseline Discharge

Medical Care Statistical Tests: Only one behavior related to seeing a medical provider improved to a statistically significant level. Participants reported that they would more often prepare a list of questions for the primary care provider.

Prepare a List of Queations for Doctor (P = 0.025)

160 140 120 100 80 60 40 20 0 Baseline Discharge 100 90 80 70 60 50 40 30 20 10 0 Frequency

Ask Doctor Questions

Baseline Discharge

Discuss Related Personal Problems (P = 0.001)

100 90 80 70 60 50 40 30 20 10 0 Baseline Discharge

Frequency

Frequency

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Doctor and Emergency Room Visits Statistical Tests: There were no statistical differences between intake and discharge in number of visits to the doctor or emergency room. There were also no statistical trends in other items in this section (See charts below for frequency data).

Admitted to Hospital for NonYes psychiatric Reason

300 250 200 150 100 50 0 270 280 No 300 250 Frequency 200 150 100 50 0 Baseline Discharge

Admitted to Hospital for MH Reason

267 269

Yes No

Frequency

15

17 Baseline

18 Discharge

Admitted to ER for MH Reason

300 250 Frequency 200 150 100 50 0 Baseline Discharge 11 7 273 280

Yes No Frequency

300 250 200 150 100 50 0

Admitted to ER for Non-psychiatric Reason Yes

257 261 No

26 Baseline

25 Discharge

Admitted to Crisis Center for MH Yes or SA Tx

300 250 Frequency 200 150 100 50 0 Baseline Discharge 9 6 276 281 No Participants visited the doctors office or clinic for non-psychiatric reasons an average of 0.86 1.71 times per 6 months at baseline and 0.74 1.35 times per 6 months at discharge. The differences between means was not significant (P = 0.305).

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Recovery Assessment Scale All of the 20 RAS questions showed statistically significant positive outcomes (P < .001 for all individual questions). Three Representative RAS Questions reflect highly statistically significant improvement when baseline (intake) interview responses are compared with discharge interview responses. Question A. I have my own plan for how to stay or become well B. Coping with my mental illness is no longer the main focus of my life C. My symptoms seem to be a problem for shorter periods of time each time they occur Higher scores represent better outcomes. Sig. .000 .000 .000

3.75 4.13 3.41 3.79 3.46 3.82 0 1 2 3 4 5

Baseline Discharge

Recovery Assessent Scale

Health Behaviors Survey: The Health Behaviors Survey is designed to assess the level to which the knowledge and skills gained during My Health, My Choice, My Life lead to behavioral changes that can be measured based upon participants self-report. This instrument asks participants to reflect on the past 4 weeks and is implemented at Intake and Discharge interviews. There were several statistically significant changes observed in health behaviors related to Eating Habits: paying attention to eating a variety of foods and serving sizes, eating foods lower in fat, reading labels, using the plate method in choosing foods, eating at the same time each day, eating more fruits and vegetables; Physical Activity: engaging in flexibility, strength and endurance activities. Participants also made statistically significant improvements in confidence related to making decisions, making an action plan, and brainstorming ideas. The bar chart below demonstrates examples of some of these improvements.

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EATING HABITS

Eating lower sodium foods Eating food lower in fat Paying attention to serving sizes 0 0.5 1 1.5 2 2.5 Discharge Intake

Servings of vegetables eaten Discharge Servings of fruit eaten 0 0.5 1 1.5 2 2.5 Intake

PHYSICAL ACTIVITY

Times per week engaged in endurance activities Times per week engaged in strengthening activities Times per week engaged in flexibility activities 0 0.5 1 1.5 2 2.5 3 Discharge Intake

CONFIDENCE

Brainstorming ideas Solving problems Making decisions 0 0.5 1 1.5 2 2.5 3 Discharge Intake

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Participants express high levels of satisfaction in their letters to the Commissioner. Participants completing the DSMP report that they learned information that helps them self manage their diabetes more effectively. They are also appreciative of learning how to increase their physical activity.

DSMP
Intellectual 12 Physical 11 Environmental 9 Social 4 Emotional 2 Spiritual 1 Occupational 0 Financial 0

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Similar to letters written by participants completing the Diabetes Self Management Program, the overall experience of the Chronic Disease and Self Management Program is very positive. Participants write about how they have improved their physical activity, have learned how to live healthier, eat healthier, and to have a more positive impression of themselves. Participants also attribute improvements in their social, emotional and environment to the CDSMP program experience.

CDSMP
Physical 69 Intellectual 64 Emotional 57 Environmental 41 Social 37 Spiritual 23 Occupational 4 Financial 1

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Fidelity Checklist Two fidelity checklists are completed by each peer wellness coach. Overall, the CDSMP is being implemented with acceptable fidelity. i. Version 1 (Old CDSMP Model)
Fidelity Checklist Version 1 (Old CDSMP Model) Session 1 Yes No Partial 151 1 1 153 Session 2 199 1 1 201 Session 3 190 0 2 192 Session 4 258 1 2 261 Session 5 180 1 1 182 Session 6 119 0 0 119

Fidelity Checklist Version 1 (Old CDSMP Model) Session 1 Yes No Partial 98.7% 0.7% 0.7% Session 2 99.0% 0.5% 0.5% Session 3 99.0% 0.0% 1.0% Session 4 98.9% 0.4% 0.8% Session 5 98.9% 0.5% 0.5% Session 6 100.0% 0.0% 0.0%

ii. Version 2 (2012 CDSMP Model)

Fidelity Checklist Version 2 (2012 CDSMP Model) Session 1 Yes No Partial 180 0 0 180 Session 2 204 4 2 210 Session 3 234 0 0 234 Session 4 249 4 0 253 Session 5 243 3 1 247 Session 6 119 0 0 119

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Fidelity Checklist Version 2 (2012 CDSMP Model) Session 1 Yes No Partial 100.0% 0.0% 0.0% Session 2 97.1% 1.9% 1.0% Session 3 100.0% 0.0% 0.0% Session 4 98.4% 1.6% 0.0% Session 5 98.4% 1.2% 0.4% Session 6 100.0% 0.0% 0.0%

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