Presentation given by Steve Lauriks from Amsterdam Public Health Service, The Netherlands at the FEANTSA/HABITACT seminar "Tackling homelessness as a social investment for the future: Looking at the bigger picture", 12th June 2013, Amsterdam

1. Self Sufficiency MatrixSelf Sufficiency Matrix
Comprehensive and reliable screening in Dutch Public Mental Health
Care
S. Lauriks, T. Fassaert, M. de Wit, M. Buster, and S. van de Weerd

2. Self Sufficiency MatrixSelf Sufficiency Matrix
Comprehensive and reliable screening in Dutch Public Mental Health
Care
S. Lauriks, T. Fassaert, M. de Wit, M. Buster, and S. van de Weerd

3. Introduction
 Self Sufficiency is the realization of an acceptable level of
functioning either by oneself or by adequately organizing care
 Clients of PMHC are often
characterized by not actively
seeking help or not having their care needs met by regular
services: limitations in self sufficiency
 The Dutch PMHC-system offers
multidisciplinary care to clients that
cope with psychosocial and socio-
economic problems

4. The SSM (Dutch version)
 The Dutch version of the Self Sufficiency Matrix (SSM-D)
distinguishes 5 levels of self sufficiency (columns)
Acute problem, Not, Barely, Adequately, Completely
 The SSM-D assesses a persons’ level of self sufficiency on 11
domains (rows)
Income, Day-time activities, Housing, Domestic relations, Mental health, Physical
health, Addiction, Daily life skills, Social network, Community participation, Judiciary
 For each level of self sufficiency, domain-specific criteria are
specified (cells)
1 acute problem 2 not self sufficient 3 barely self sufficient 4 adequately self sufficient 5 completely self sufficient
Income No income, high and
increasing debts.
Inadequate income and/or
spontaneous or
inappropriate spending,
increasing debts.
Can meet basic needs with
income; appropriate spending; if
there are debts, they are stable;
Income management/ budget
control by a third party.
Meets basic needs without receiving
social security benefits; manages
his/her debts without assistance
and they are decreasing.
Income is sufficient, well managed;
has income and is able to save.

5. Development
 Pearce et al. (1996): Economic self sufficiency standard
 The Snohomish county self sufficiency taskforce (2004): First
SSM based on ROMA outcomes standards
 Arizona and Utah (a.o.) (2006): State-specific adaptations of
SSM
– Adaptations of the SSM vary in number of domains.
– Number of levels of self sufficiency and formulation of domain-specific criteria
remains consistent
 Public Health Service Amsterdam (2010): First Dutch
adaptation of SSM (SSM-D)
– The SSM-D was developed with feedback and input from professionals,
policymakers, and researchers from the field of PMHC

6. Psychometric properties
Internal consistency
Group: 2686 clients Young adults office & Central Access Point
PMHC
Method: Principal Component Analysis (PCA)
Results: ■ One construct: self-sufficiency
■ No redundant (unnecessary) domains
Inter-rater reliability
Group: 2 social workers screened 20 clients & 36 professionals each
rated 3 fictitious cases
Method: Correlations, % exact agreement, Kappa
Results: ■ High correlations between raters
■ Exact agreement smaller
■ Access to information is of primary importance
Fassaert T, Lauriks S, van de Weerd S, de Wit M, Buster M (2013) Ontwikkeling en betrouwbaarheid van de Zelfredzaamheid-
Matrix. Tijdschrift voor Gezondheidswetenschappen 91(3): 169-177

7. Psychometric properties
Construct validity
Group: 81 clients Youth ACT & 86 clients with SMI in Long-term outpatient
treatment
Method: Screening with SSM-D & HoNOS (ACT-group) and SSM-D & CANSAS
(SMI-group). Correlations between overall and domain scores
Results: ■ Strong correlations between
overall scores
■ Strong correlations between
domains with related subscales
In addition
■ SSM-D was able to discriminate
between both study-populations.
Fassaert T, Lauriks S, van de Weerd S, Buster M, de Wit M. Psychometric properties of the Dutch version of
the Self-Sufficiency Matrix (SSM-D). Submitted to Community Mental Health Journal

8. Application – Decision Support Tool for PMHC access
Purpose
Transparency in the professional decision to grant/deny
access to PMHC at the Central Access Point in Amsterdam
Method
 Screeners at the CAP perform an interview, decide on the
access to PMHC, and score the SSM-D for 612 clients
 SSM-D predictors of the professional decision are analyzed
with logistic regression modeling in one half of the research
group (N1)
 Cut-off points with optimal sensitivity and specificity are
analyzed with ROC-curves of decisions in the other half of
the research group (N2)

9. Application – Decision Support Tool for PMHC access
.0
.1
.2
.3
.4
.5
.6
.7
.8
.9
1.0
.0 .1 .2 .3 .4 .5 .6 .7 .8 .9 1.0
FALSE POSITIVE
TRUEPOSITIVE
The DST based on weighted SSM-D
domains is accurate and useful to promote
transparency of the decision to allocate
clients to PMHC.
The information collected
with the SSM-D is useable
and relevant to the
professional and the
clinical care process.
Income 2
Day-time activities 2
Housing 1
Domestic relations 4
Mental health 3
Physical health 4
Addiction 2
Daily life skills 3
Social network 2
Community partipipation 2
Judiciary 4
Chance of True PMHC client PMHC Access Advice
0.97 Certain PMHC access
All domains are included in the model to
optimize predictive value

10. Purpose
Evaluation of progress of clients over time and effectiveness of
interventions
Example I
 100 clients referred at the CAP were offered
a social work intervention focused at
stabilization of socioeconomic problems
 SW’s scored the SSM-D at the first and
last meeting with the client
 Primary problematic domains at intake: Income, Day-time
activities and Housing
Application – Tracking client progress

11. Application – Tracking client progress
SSM-D scores at intake (T0) and last contact (T1)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Incom
e
D
ay-tim
e
act.
H
ousing
D
om
estic
rel.M
entalhealth
Phys.H
ealth
Addiction
D
aily
life
skillsSocialnetwork
C
om
m
.part.
Judiciary
SSM-D domains
%totalgroup
Completely
self sufficient
Adequately
self sufficient
Barely self
sufficient
Not self
sufficient
Acute problem
Significant higher scores at T1 on 8 SSM-D domains and the
SSM- D total score.

12. Example II
 121 clients of ‘Vulnerable Households’ intervention-team
 Case workers scored the SSM-D at intake, and at intermediary
or exit interview.
 Primary problematic domains at intake: Income and Day-time
activities
 Sig. proportion of group with secondary problems on Domestic
relations, Mental health, Daily life skills, Social network and/ or
Community participation
Application – Tracking client progress

13. Application – Tracking client progress
Progress on the SSM-D
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Incom
eD
ay-tim
e
activities
H
ousingD
om
estic
relations
M
entalhealth
Physicalhealth
Addiction
D
aily
life
skills
Socialnetwork
C
om
m
unity
partipipation
Judiciary
SSM-D domains
%oftheresearchgroup
Plus 4 levels
Plus 3 levels
Plus 2 levels
Plus 1 level
Stable
Minus 1 level
Minus 2 levels
Minus 3 levels
Significant differences between T0 and T1 on all SSM-D domains
and SSM-D total score

14. Application – Tracking client progress
The SSM-D seems an useful and feasible instrument to evaluate
clients over time and assess the effectiveness of interventions
But:
 Sensitivity to change of SSM-D
still needs to be determined
 Control group is needed for
evaluation of effectiveness
 Specific interventions – specific
outcomes? SSM-D provides
‘pixilated landscape picture’

15. Implementation

16. Amsterdam
 Public Health Service (GGD) – CAP
– Screening of homeless people, access to PMHC
 Municipal work and Welfare service (DWI)
– Identification of group at risk of social exclusion
 Community development service (DMO)
– Evaluation ‘Vulnerable households intervention’
Rotterdam
 Municipality of Rotterdam – Young adult office
– Screening and assessment of young adults without qualifications
Utrecht
 Public Health Service (GGD)
– Homeless management information system
The Hague
 Public Health Service (GGD) – Central Coordination Point
– Screening of homeless people, access to PMHC
– Homeless management information system
Implementation – 4 largest cities

17.  Additional domains for parents/ guardians
– Four domains to assess levels of self sufficiency with regard to care for (young)
children
 Assessment of sensitivity to change
– Pilot tests have been done but evidence for sensitivity to change is needed
 Accreditation of SSM-D as instrument for Routine Outcome
Monitoring
– Mental health care branch organizations and PMHC- financiers recognize SSM-D
as a feasible tool for ROM
 Development and dissemination of the SSM in the EU
– The SSM-D has recently been translated in English and the English website is
online
Future research and development

18. Future research and development

19.  One standard: truly achievable?
 Who are able to work with the SSM-D?
 SSM-D for underaged and elderly?
 OK for screening; OK for treatment planning?
 How does one set achievable goals for individuals?
 How do we set achievable goals for programs (financing)?
Implementation – issues to be ‘solved’

20. Steve Lauriks
Phone: +31 (0)622 728 596
E-mail: zrm@ggd.amsterdam.nl
Website: www.zelfredzaamheidmatrix.nl
www.selfsufficiencymatrix.org
Questions