Transcript Assessing the Risk of Violence and Aggression

Violence and Aggression
Assessing the Risk of Violence and Aggression
Gary Chaimowitz
The HARM: The Development of a Nimble Violence
Risk Assessment Tool
Disclosure
Janssen
Sunovion
Learning Objectives
1.
Introduce a nimble implemented team based SPJ risk
management tool
2. Demonstrate how analytics can open up new avenues for risk
management, resource planning, quality improvement and
research
3. Amaze you
From 2006-2015, the HARM process successfully
guided our clinical team to manage areas of risk
•
A structured clinical judgment tool that guides the
assessor to formulate opinions regarding risk of
violence
•
Systematic and comprehensive with a focus on risk
management
•
Incorporates both historical/static and dynamic factors
in assessing risk as reflected in the literature
•
Nimble, easy to use and created to benefit the team
and with from inputs across multidisciplinary team
The Set Up…definitions
The Set Up…definitions
The Set Up…Quality Indicators
The Set Up….improving quality
The Set Up…data to outcomes
The Set Up….Data driven cognitive distortions
The Set Up…Quality Indicators
The Set Up
The Set Up
The Set Up…..the push back
The Set Up…Meetings
The Set Up…… Team meetings
So then…
Risk Assessment….generations
The Set Up…..
th
4
generation
The HARM (& AIS) advanced key areas for the team
Improved documentation
Improved communication
Reliability of Documentation
Improved discussions of risk
Monitored Change
Risk and Risk Management
The Aggressive Incidents Scale (AIS)
Key Components:
• Simple to use: enhance compliance
• Informs assessment of individual
• Simple to interpret: at a glance you could easily
surmise the degree of aggression displayed by patients
AIS – 9 Point Scale
Level
Incident
Description
9
Critical Incident – Possible Life and Death
Serious violent assault or sexual assault. The victim
requires medical attention.
8
Violent Unprovoked Assault
Impulsive interpersonal assault in which no apparent
precursors are identifiable
7
Violent Assault
Aggression involves physical contact with another person
6
Push/Shove
Clearly aggressive push or shove
5
Destruction of Property
Aggression directed at property
4
Improper Physical Contact
Behaviour not an assault but physical contact
inappropriate
3
Intimidating, Threatening, Personal Space Violated
Person’s body language or words are threatening in nature
2
Intimidating, Raised Voice
Person is verbally intimidating, possibly yelling and
possibly utilizing profanities
1
Rude, Argumentative
Person is being rude, argumentative, and possibly
challenging rules or staff’s authority
The Hamilton Anatomy of Risk Management
(HARM)
• A method of assessing risk
• SPJ tool that guides
the assessor to formulate opinions regarding risk of
violence
• The tool incorporates both static
and dynamic factors in assessing risk
• Helps identify potential victims
• Incorporates discussion about how to best manage risk
However, the lack of analytic capabilities meant lost
opportunities with the current HARM
Up until now, we have been unable to…
• Easily view individual patient performance over time
• Look at diagnosis, treatment patterns and outcome measures
across the practice
• Connect patient risk factors to treatment decision-making
both at an individual patient level as well as broadly across
patients
The development of the Electronic HARM (eHARM) now
enables the measurement of Mental Health Outcomes

The eHARM is the evolution of the original HARM process
 Accessible
research database derived through clinical practice
 Captures and charts Individual Patient Risk Management
outcomes over time
 Captures Aggregated outcomes which can inform service
planning or measure and evaluate outcomes for Risk and
Quality Management
e-HARM……
• A look at the tool
Home
HOME
 When a blank version of the HARM tool is opened, Unique
Patient ID, Hospital Name, and Patient Name should be
entered on the home page.
 Next, the save button should be selected and the file should
be saved to a general folder where all Patient HARM
entries are stored.
 Once saved, Unique Patient ID and Hospital name can no
longer be changed. Patient Name can always be edited.
New HARM Report
Patient Overview
Past Risk
Current Risk
Future Risk
Risk Management
Medications
New HARM
Report
Index Offenses and Prior Convictions
New HARM Report
Index Offenses and prior
convictions are indicated
by selecting check-boxes.
Aggressive Offenses/
Convictions will appear
in red when selected
Other
Offenses/Convictions
will appear in black when
selected
Unselected
Offenses/Convictions
will appear in grey.
Note that a red star indicates a mandatory field
Extra space is
provided for
additional details
Past gender and
victim targets must be
selected from dropdowns
Historical Risk Factors
New HARM
Report
Please indicate if any of the
following risk factors have
been a problem for the
individual or if any of the
following have been identified
in past assessments.
Research indicates that
certain conditions may carry
an elevated risk of violence
under certain conditions.
Please note these here.
Note that a red star indicates a mandatory field
For selected
historical risk
factors, details must
selected from a
drop-down list.
Current Risk Factors
New HARM
Report
For each selected risk factor, Status and Change must be
selected from a drop-down menu.
Research suggests that
one of the best predictors
of risk is one’s most
recent history. All of
these risk factors have
evidence supporting their
consideration in risk
assessment. Please
identify those relevant to
the person being
assessed.
Note that a red star indicates a mandatory field
Risk Management
All Current Risk Factors that ‘Need Improvement’ will be highlighted at the top
of the Risk Management Section
 Users should consider which management techniques are most appropriate
for each patient
(e.g. According to CPA clinical guidelines1, patients with Schizophrenia and
Med Non-Adherence risk should be considered for an LAI)
All drug related interventions can be identified
by selecting “Medication” under ‘Treatment
Plan / Intervention”. The subsequent section
will allow the entry of specific products.
Stressors/Destabilizers can be listed here
New HARM
Report
Any privileges can be
captured here
Throughout treatment, status and response
will be tracked in each HARM submission
The date of Next HARM Risk Assessment
must be entered here
Note that a red star indicates a mandatory field
1The Canadian Journal of Psychiatry, Clinical Practice Guidelines – Treatment of Schizophrenia. https://ww1.cpaapc.org/Publications/Clinical_Guidelines/schizophrenia/november2005/cjp-cpg-suppl1-05_full_spread.pdf
Patient Analytics
Patient Analytics – Risk Tracking
Patient Analytics
Select a Risk Factor and view how patient performance
has been tracking over time
AIS Totals
Either Clinical Likelihood of Violence
or Escape Risk can be selected here
eg. This patient’s ‘Med Non-Adherence’
performance has improved over the last 2
HARM entries
Short-term or Immediate can be
selected here.
Patient Risk
Analysis
Patient Analytics – AIS
Patient Analytics
View a total count of the AIS incidents that have
been tracked to this patient over the past 4 weeks
and over the past year.
AIS Totals
Patient Risk
Analysis
Note that a red star indicates a mandatory field
AIS totals are grouped by
level of severity
Aggregator
Patient Aggregator - Examples
33% of these 43 Patients are currently
enrolled in a Substance Abuse
Program
88% of these 43 patients have been
diagnosed with Schizophrenia Spectrum
and Other Psychotic Disorder
Patient Analytics – % Patients by Index Offense
Results can be filtered by All Patient Diagnoses or Primary
Diagnosis only.
Patient Analytics
-
Primary Diagnosis is the first diagnosis selected on the HARM form.
-
All Diagnoses include all 3 diagnoses selected on the HARM form.
Analytics by
Diagnosis
Analytics by
Risk Factor
Indicates the # of patients who have HARM
entries included in this graph’s analysis.
eg. Of the two patients included in this
analysis, both have Substance Related
Index Offenses.
Analytics by
Treatment
Patient Analytics – Average AIS Severity by Risk
Factor
This chart can be used to compare AIS Severity across patients with
different risk factors.
Analytics by
Diagnosis
Analytics by
Risk Factor
Analytics by
Treatment
Patient Analytics
These is a filter above this chart that can be used filter this chart to
show only patients with specific diagnoses.
Eg. Patients with Rule Adherence marked
as a risk factor have an average AIS
incident severity of 5.8.
We envision a future where data captured by the eHARM can
one day be used to transform psychiatric patient management
Data captured by the eHARM has the
potential to unlock a new understanding of
psychiatric patient risk. What if…
 We could monitor progress of all patients
using the HARM
 Have better understanding of what
mitigates risk for our patients
 Better understand the unique factors that
impact any individual’s risk
We envision a future where data captured by the eHARM can
one day be used to transform patient management
Data captured by the eHARM has the potential
to use inbuilt metrics to plan, fund and assign
programs and resources…the right care for the
right patient at the right time. What if…
 We knew which programs, services and
interventions actually reduced targeted
behaviours
 Could direct personalised care
 Knew which medications addressed risk factors
and reduced aggressive incidents
We envision a future where data captured by the eHARM can one day
be used to transform patient management
Data captured by the HARM has the
potential to use inbuilt metrics to aggregate
data over multiple services and programs
What if…
 Clinical activity directly created a rich
database
 We could easily conduct multi site research
 We were able to integrate clinical practice,
quality improvement and research with no
additional effort
The Possibilities….
Accessible research database
derived through clinical practice
Captures Individual Patient Risk
Management outcomes over time
Captures Aggregated outcomes
to inform service planning or
measure and evaluate outcomes
for Risk and QM
Thank you
[email protected]
[email protected]
[email protected]
905.522.1155 x35424
THE eHARM-GV