Transcript Identifying Social Work`s Role in Behavioral Health

Social Work’s Role in Behavioral Health Quality Improvement
Scott E. Provost, M.M., M.S.W.
Associate Director for Research
Center for Quality Assessment & Improvement in Mental Health
www.cqaimh.org
May 10, 2002
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Objectives
Learn about the status of quality assessment and
improvement in behavioral health
Review social work’s role in shaping quality
assessment and improvement in behavioral health
Identify new areas for social work education,
practice, and research that can influence the quality
of behavioral health care services
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Objective #1
 Learn about the status of quality assessment and
improvement in behavioral health
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Why Measure Quality?
 To facilitate oversight of health plans, hospitals & delivery
systems, and clinicians
 To encourage healthcare purchasing based on quality, not
just cost
 To increase market share, growth, and revenues
 To meet standards set by professional societies
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How is Quality Defined?
Quality can be defined as:
Conformance to Specifications
Value
Dependability
Responsiveness/timeliness
Authority/Consumer Empowerment
Empathy
Support/Follow-up Service
Psychological Impressions
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Quality and Evidence-Based Practice
 “The conscientious, explicit and judicious use of current
best evidence in making decisions about the care of
individual patients.” (Sackett, et al., 1996)
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Evidenced-Based Interventions
Adults
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Psychopharmacological Interventions
Assertive Community Treatment
Illness Self-Management
Supported Employment
Family Support Services
Integrated Dual Diagnosis Treatment
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Evidence-Based Interventions
Children
 Multi-systemic therapy
 Therapeutic foster care
 Family Involvement
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How is Quality Defined?
Quality represents the kind of care that maximizes
benefits and minimizes risks (Donabedian, 1980)
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Status of Quality Assessment and Improvement in
Behavioral Health
National Reports on Health Care Quality
Quality First: Better Health Care for All Americans, (President’s
Advisory Commission 1998)
To Err is Human (IOM, 2000)
Crossing the Quality Chasm (IOM, 2001)
Envisioning the National Health Care Quality Report (IOM,
2001)
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Status of Quality Assessment and Improvement in
Behavioral Health
Reports on Behavioral Health Care Quality
Managing Managed Care: Quality Improvement in
Behavioral Health (IOM, 2001)
U.S. Surgeon General’s Report on Mental Health (DHHS, 1999)
Report of the Surgeon General’s Conference on Children’s
Mental Health: A National Action Agenda (DHHS, 2000)
Mental Health: New Understanding, New Hope (WHO, 2001)
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Status of Quality Assessment and Improvement in
Behavioral Health
Quality of Care for Depression
Detection
One-third to one-half of patients with major depressive disorder are
properly recognized by primary care and other practitioners (AHCPR:
Depression in Primary Care: Volume 1. Detection & Diagnosis, 1993)
Medication Treatment
55.6-62.6% of individuals enrolled in participating health plans who
initiate treatment for major depression discontinue medication prior to 12
weeks (NCQA: Quality Compass, 2000)
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Status of Quality Assessment and Improvement in
Behavioral Health
Quality of Care for Schizophrenia
Medication Treatment
22.5% were given a dosage above 1,000 CPZ equivalents
15% were prescribed a dosage less than 300 CPZ equivalents
Lehman AF, et al., 1998 (N= 719 Individuals with Schizophrenia)
13.0% Dosed above PORT guidelines
23.3% Dosed below PORT guidelines
Leslie DL, Rosenheck RA, 2001 (N=34,925 VA Patients)
Family Services
40.8% of inpatients were offered or received a family service
Lehman AF, et al., 1998 (N= 719 Individuals with Schizophrenia)
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Status of Quality Assessment and Improvement in
Behavioral Health
Quality of Care for ADHD
About 50% of children with identified ADHD seen in real-world
practice settings receive care that conforms to American Academy
of Child & Adolescent Psychiatry Guidelines
Hoagwood K, et al. (2000)
47.3% of pediatric visits for psychiatric reasons involving stimulant
medications included any form of psychosocial intervention
Hoagwood K, et al. (2000)
68% of children receiving treatment for ADHD by a primary care
provider did not have any contact with a mental health specialist
Bussing R, et al. (1998)
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Status of Quality Assessment and Improvement in
Behavioral Health
Quality of Care for Panic Disorder
Fewer than 1 in 4 patients receives adequate pharmacotherapy and
only 1 in 8 received adequate psychotherapy
Roy-Byrne PR, et al. (Archives of General Psychiatry, 2001)
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Status of Quality Assessment and Improvement in
Behavioral Health
Follow-Up After Hospitalization for Mental
Illness
In a sample of 305,574 Medicare beneficiaries enrolled in
Medicare:
52.% received follow-up care
When stratified by race, the results were:
54% (Whites)
33.2% (Blacks)
Schneider EC, et al. (JAMA, 2002)
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Common Categories of Measures
Structure measures: “represent the relatively stable
characteristics of the providers of care, of the tools and
resources they have at their disposal, and of the physical and
organizational settings in which they work” (Donabedian, 1980)
Fidelity measures: are tools to evaluate whether or not
treatment programs are implemented according to a specified
manual or protocol.
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Common Categories of Measures
Outcome measures: are indicators of a patient’s health status,
i.e., medical and physiologic (biological, pathological,
behavioral) functional status and well-being (quality of life,
productivity, disability) habits or health risk states (Donabedian,
1980)
Process measures: assess the set of activities that go on within
and between patients and practitioners (Donabedian, 1980)
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How is a Quality Measure Defined?
Performance measures: “estimate the extent to which the
actions of a health care practitioner or provider conform to
practice guidelines, medical review criteria, or standards of
quality.” (Academy for Health Services Research & Health Policy)
Quality Measure: “A quantitative measure that can be used as
a guide to monitor and evaluate the quality of important
patient care and support service activities.” (JCAHO, 1989)
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Other commonly used terms
 Lever
 Metric
 Indicator
 Driver
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Domains of Quality*
Structure
Process
Outcomes
Institutions
Providers
Patients
Community
Financing
Prevention
Access
Assessment
Treatment
Coordination
Continuity
Safety
Symptoms
Functioning
Quality of Life
Satisfaction
Cost-Effectiveness
* Explorations in Quality Assessment & Monitoring: The Criteria and Standards of
Quality (Donabedian A, 1982)
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Ideal Properties of Performance Measures
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Objective
Based on scientific evidence
Not affect or distort results
Reliable
Valid
Standardized/Precisely Specified
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Timely Psychosocial Risk Factor Screening
Denominator:The total number of individuals admitted to an
inpatient psychiatric hospital over a 30-day period
Numerator:The number of individuals from the denominator
whose medical record documents a psychosocial screening
that address potential high risk areas including at least three
of the following five factors--stability of housing,
employment, dependent family members, treatment
compliance, and adequacy of self-care--recorded in the
admission note or progress note for the first three days of
hospitalization
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Timely Psychosocial Risk Factor Screening
The number of individuals from the denominator whose medical record
documents a psychosocial screening that address potential high risk areas
including at least three of the following five factors--stability of housing,
employment, dependent family members, treatment compliance, and
adequacy of self-care--recorded in the admission note or progress note for the
first three days of hospitalization
The total number of individuals admitted to an psychiatric hospital
during a 30-day period
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Quality Measures in Action
 Quality can be improved
without planning or effort
OR
 Quality can be improved
systematically using welltested methods and tools
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Uses of Performance Measurement
 Program Management
 Accountability
 Internal Quality Improvement
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Performance Measures & Balanced Scorecards
(Kaplan & Norton, 1996;2001)
Financial
Customer
Vision and Strategy
Internal Business
Processes
Learning and
Growth
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Balanced Scorecards for Nonprofit Organizations
(Kaplan & Norton, 2001)
Customer
Learning and
Growth
Mission
Internal Business
Processes
Financial
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Quality Improvement Action Steps
Define the Project
•Generate List of Potential Projects
•Organize Project Team
Diagnose the
Problem
•Analyze Existing Processes
•Construct Hypotheses/Theories
•Test Hypotheses/Theories
•Identify Root Causes
Address the
Problem
•Develop Remedies
•Design Interventions
•Overcome Barriers and Resistance
•Implement QI Interventions
Sustain Progress
•Evaluate Performance
•Monitor Progress
•Provide Feedback and Support
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Quality Improvement Action Steps
Plan
Act
Do
Check
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Objective #2
 Review social work’s role in shaping quality
assessment and improvement in behavioral health
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Understanding Social Work’s Role in Quality Improvement
Social
Workers
Teachers
Psychologists
Other
MH/SA
Counselors
Psychiatrists
Psychiatric
RNs
Primary
Care
Providers
Vocational
Counselors
Family/
Friends
Justice
System
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Understanding Social Work’s Role in Quality Improvement
Social Workers
Teachers
Case Manager
Psychiatrists
Psychiatric RNs
Psychologists
Other MH/SA Providers
Primary Care Providers
Vocational Counselors
Family/Friends
Justice System
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Understanding Social Work’s Role in Quality Improvement
Primary Care Provider
Social Worker
Community MH Center
Mediating Factors & Clinical Processes
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Clinical Social Work Skills
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Screening
Assessment
Case Management
Psychotherapy
Psychoeducation
Medication Facilitation
Family Education and Consultation
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Social Work Administration and Quality
Improvement
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Negotiation Skills
Program Evaluation
Information Technology
Organizational Design
Organizational Behavior
Operations Management
Industrial Quality Improvement
Multidisciplinary Collaboration
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Complexity of Social Work Administration
Delivery System
C
Facility A
Facility B
Social Work
Staff
Social Work
Staff
C
C
C
C
Facility C
Facility D
Social Work
Staff
C
C
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Social Work
Staff
C
C
C
C
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Objective #3
 Identify new areas for social work education,
practice, and research that can influence the
quality of behavioral health care services
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Trends in the Social Work Profession
Clinical Roles
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Performing Psychosocial Assessment
Reading Evidence-Based Reviews
Understanding Disease Management Practices
Continuing Education
Ongoing Supervision
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Trends in the Social Work Profession
Research
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Interventions Research
Effectiveness Research
Dissemination Research
Multidisciplinary Research
Process-Outcome Research
Quantitative “Epidemiological” Research
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Trends in the Social Work Profession
Education and Curriculum Issues
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Practice Guideline Development and Education
Continuous Quality Improvement and TQM
Organizational Behavior and Change
Operations Research and Management
Epidemiology/Statistics
Cross-Disciplinary Training
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Social Work’s Role in Behavioral Health Quality Improvement
Acknowledgements
 Richard C. Hermann, M.D., M.S.
 Massachusetts NASW Symposium 2002 Program
Committee
 AHRQ (R01-HS10303)
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