California’s recent mandates for child behavioral health providers to score CANS-50 and PSC-35s at 6-month intervals in their child serving programs is a landmark moment. This will create a lot of meaningful data that will allow revolutionary new care and planning, and has the potential to improve our child caring system by leaps and bounds.
There is much to do with these new tools, and I plan to blog a bit about how these tools integrate into clinical practice. If done well, these mandates are ones that providers will appreciate – since the scoring of these helpful tools will only help them do excellent work for the benefit of California’s children and families.
To integrate the PSC-35 and CANS-50 into clinical practice, it is first a good idea to note the differences between these two tools, and the different roles they will play in assessment, care planning, and outcomes tracking.
The PSC-35 – A tool with an integrated care background, useful for private parent insights, and psychometric validity
The PSC-35’s background is as a tool in integrated care: it is primarily used by pediatricians to screen their clientele for possible behavioral health problems, and to refer appropriately when the scores are high. One of the key features of this tool is that it is filled out by parents, and is meant to capture their vision of things. This is helpful, because research has shown that people can be more honest with a paper tool sometimes, and thus this pulls on this perspective in ways that can probably help the assessment and treatment planning that is going on in tandem. Further, the PSC-35’s questions are psychometrically valid, and the results are clustered into general information about the risk that the child has for psychopathology. Teams can use the results to gain an understanding of the parent’s view, and the information can be included in diagnostic formulations, as well as an indicator for progress on clinical changes in the client (i.e. how their symptoms are improving or not.)
There are limitations to the PSC-35, however, that limit is utility in community-based care. First, as stated, it is really a screening tool for physicians, and as such is meant to help non-mental health people identity mental health problems. However, in the behavioral health domain, you usually are being treated by mental health experts that don’t necessarily need this help identifying problems. In fact, the mental health information is being assessed as a part of routine care, and usually the PSC-35 is a little less than what a good mental health assessment is identifying. As such the PSC-35 might help inform a mental health assessment, but there is no need for screening here … we’re already at the end point of the referral. Second, as has been documented well for years, psychometric tools like the PSC-35 are not great for treatment planning, especially not in a community behavioral health setting, where measures of functioning, individual risks that extend beyond just simple symptoms, and caregiver capacity are fundamental to the work we do. The PSC-35 might give us some information like the client has a high amount of “externalizing” symptoms, but for questions such as if the client needs a family intervention or a school-based one … that is just not what psychometrics help us with.
Filling in the complete picture with the CANS-50: An established tool in community care for comprehensive assessment, treatment planning, tracking progress, and decision support
It is because the PSC-35 is limited in its approach, that it was a good idea for the state to also mandate the CANS-50 on a 6-month interval. The CANS-50 is a comprehensive “TCOM” tool that provides the building blocks of thorough assessment and treatment planning. The CANS-50 is filled out collaboratively, as a part of an integrated treatment planning process where all players are invited. It provides a concrete and objective way for broad teams (including school personnel, clinicians, the family, the client, natural supports, etc.) to agree on what needs to be worked on, and what strengths are available, then build a comprehensive plan, and monitor the implementation and success of the plan.
Because of the CANS-50’s comprehensive nature, you are able to use it to effectively understand the whole system of care: It is one tool that can measure outcomes in outpatient up through residential. People will find that clinical severity that is measured on the PSC-35 is not helpful to explain the differences between, say, a partial hospital and a day treatment program – because it measures narrowly based on psychometrically measurable symptoms, and many of the reasons behind level of care decisions simply cannot be found in that information. The CANS, in distinction, provides a means for seeing the broad needs and successes across a system of care.
But for any of this to work: you got to do it digitally
It is important to note that the PSC-35 and CANS together offer the most powerful fuel for real time clinical decision support. The PSC-35 has a research established cut-off for what constitutes “clinical” need. The CANS has the ability to break up a system of care into elemental units so that programs and levels of care can be modeled and analyzed. Together, evaluation of a child’s needs will be better than either working alone, and really great analytics can help for both planning individual care, as well as planning a better mental health system.
However, for this to be true, the two forms must be filled out digitally. If you have parents fill out the PSC-35 on paper, even if you type in the final score into a computer, you are losing tons of information that is necessary for real usefulness (besides the fact that you are making data-entry work for providers). Likewise, a CANS filled out in paper is perhaps a nice tool for structuring a planning meeting, but you completely miss out on the power of the tool to provide level of care decision support, identify treatment items, and all the rest. Unless these tools are plugged in, you are really just filling in a form, and you are not gaining their power to transform care.
This is just the beginning of the ways that the PSC-35 and CANS-50, when understood and well-integrated, can radically transform care of California’s children and families. Community Data Roundtable’s web-based DataPool outcomes application integrates the PSC-35 with the CANS-50 in ways designed to optimize their synergies. With reports, an algorithm engine, and a smooth worker-friendly interface for capturing the data for both tools, we believe the DataPool is the optimal tool for bringing California’s data vision to reality.