Relating competency status to functional status at discharge in patients with chronic mental illness

This study assessed performance on a screening test of competency to consent to treatment, the Hopkins Competency Assessment Test (HCAT), in a population diagnosed with chronic mental illness, and examined the relationship between HCAT performance and functional status at discharge. We hypothesized that patients with chronic mental illness who failed the HCAT would also have problems in performing activities of daily living at the time of discharge. Forty-three patients on a short-stay psychiatric service were administered the following screening tests: (1) Mini-Mental State Exam (MMSE), on admission; (2) the HCAT, approximately four to five days after admission; (3) At discharge, the Milwaukee Evaluation of Daily Living Skills (MEDLS), and the Occupational Therapy Task Observation Scale (OTTOS). Analyses included correlation between the competency measure HCAT and the functional measures; sensitivity, specificity, and positive and negative predictive values of the HCAT score; and odds ratio and chi-square analysis. The HCAT was highly correlated with the MEDLS and OTTOS. The HCAT was not sensitive in identifying impairment on either functional measure, but when patients failed the HCAT, they were likely to be functionally impaired at discharge. The negative predictive value of the HCAT was greater than the positive predictive value. Patients who failed HCAT were significantly more likely to have an MMSE score lower than 27 and less than 12 years of school. Seven of forty-three (16.3%) patients failed a screening measure of competency, indicating that there is a subgroup of chronically mentally ill patients who may not understand issues of informed consent. Patients who failed the HCAT were more likely to be functionally impaired at discharge. Cognitive impairment and low education are important factors in failure to pass competency screening. Competency screening along with screening for cognitive impairment can be useful in identifying patients at risk for poor functional status at discharge.