Transcript Improving the Quality of Mental Health Care

Improving the Quality of
Mental Health Care:
Can Ireland Cross the
Quality Chasm?
Harold Alan Pincus, MD
Professor and Vice Chair, Department of Psychiatry
Co - Director, Irving Institute for Clinical and Translational Research
Columbia University
Director of Quality and Outcomes Research
NewYork-Presbyterian Hospital
Senior Scientist, RAND Corporation
Improving Mental Health Services Conference
Dublin, Ireland- 10.21.2015
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Questions
•
•
•
•
Why is the quality of mental health care such a big deal?
How is the quality of care measured?
What types of measures are used?
How are measures developed and what criteria are applied
in choosing measures?
• What strategies are applied in using quality measures to
improve the quality of patient care?
• What are the challenges and risks in quality measurement?
• How might it affect you, the settings you work in and your
patients as Mental Health Reform is implemented in
Ireland?
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Ireland Mental Health Division
Service Priorities
• Ensure the views of service users are central to the
design and delivery of services
• Deliver timely, clinically effective and standardised
safe services
• Design integrated evidence based, recovery
focused services
• Promote the mental health of the population
including reducing loss of life by suicide
• Enable the provision of services by trained and
engaged staff as well as fit for purpose infrastructure
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A Reality Check
• How do YOU choose a doctor for yourself, your
family, your Mom and Dad?
• How do YOU choose a mental health provider for
yourself or suggest one for a friend or a family
member?
• How do YOU determine whether you, your family,
your Mom and Dad are receiving high quality
medical care?
• High quality mental health care?
• What DATA do you examine to answer these
questions?
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To Err Is Human:
Building A Safer Health System
First Report
Committee on
Quality of Health Care
in America
To order: www.nap.edu
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Crossing the Quality Chasm
“Quality problems occur typically
not because of failure of goodwill,
knowledge, effort or resources
devoted to health care, but because
of fundamental shortcomings in the
ways care is organized”
Only 55% chance of getting
appropriate care
The American health care delivery
system is in need of fundamental
change. The current care systems
cannot do the job.
Trying harder will not work:
Changing systems of care will!
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Six Aims For Improvement
• Safe
• Timely
• Effective
• Efficient
• Patient-centered
• Equitable
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Ten Rules for Achieving the Aims
Old Rules
1. Care is based on visits.
2. Professional autonomy
drives variability.
3. Professionals control
care.
4. Information is a record.
5. Decisions are based
upon training and
experience.
New Rules
1. Care is based upon
continuous healing
relationships.
2. Care is customized to
patient needs and
values.
3. The patient is the
source of control.
4. Knowledge is shared
and information flows
freely.
5. Decision making is
evidence-based.
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Ten Rules for Achieving the Aims
Old Rules
6. “Do no harm” is an
individual clinician
responsibility.
7. Secrecy is necessary.
8. The system reacts to
needs.
9. Cost reduction is
sought.
10. Preference for
professional roles over
the system.
New Rules
6. Safety is a system
responsibility.
7. Transparency is
necessary.
8. Needs are anticipated.
9. Waste is continuously
decreased (for all).
10. Cooperation among
clinicians is a priority
(Health care is a team
sport).
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Evidence-Based Planned Care Model
Community
Health System
Resources and Policies
Health Care Organization
SelfManagement
Support
Delivery
System
Design
Decision
Support
Clinical
Information
Systems
Productive Interactions
Patient-Centered
Informed, Empowered
Patient and Family
Timely and
Efficient
Coordinated
EvidenceBased and Safe
Prepared, Proactive
Practice Team
Improved Outcomes
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Published 2006
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INSTITUTE OF MEDICINE
Committee on Developing Evidence-Based Standards
for Psychosocial Interventions for Mental Disorders
Published 2015
INSTITUTE OF MEDICINE
“Crossing the Quality Chasm”
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Follow-up after Hospitalization for Mental
Illness within 7 Days (HMOs only) 2003-2012
(NCQA October 2013)
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Top Ten Most Common Medicaid
Readmissions
1. Septicemia (except in labor) — $319 million (17,600 total readmissions)
2. Schizophrenia and other psychotic disorders — $302 million (35,800 total
readmissions)
3. Mood disorders — $286 million (41,600 total readmissions)
4. Congestive heart failure (nonhypertensive) — $273 million (18,800 total
readmissions)
5. Diabetes mellitus with complications — $251 million (23,700 total
readmissions)
6. Chronic obstructive pulmonary disease and bronchiectasis — $178 million
(16,400 total readmissions)
7. Alcohol-related disorders — $141 million (20,500 total readmissions)
8. Other complications of pregnancy — $122 million (21,500 total
readmissions)
9. Substance-related disorders — $103 million (15,200 total readmissions)
10. Early or threatened labor — $86 million (19,000 total readmissions)
* AHRQ Statistical Brief
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Antidepressant Medication Management:
Continuation Phase- HMO Means
Trends, 2002-2009
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Engagement of Alcohol and Other Drug
Dependence Treatment: HMO Means
Trends, 2004-2009
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Problem: Weak Measurement and
Improvement Infrastructure
• Clinical assessment and treatment practices not standardized
nor classified for use in administrative datasets
• Outcomes measurement not widely applied clinically despite
reliable and valid instruments (“measurement-based care”)
• Insufficient attention to development and use of performance
measures for improvement and accountability
• Inadequate investment in IT infrastructure (“MH informatics”)
• QI methods not yet permeating day-to-day operations
• Work force not trained in quality measures and improvement
• Policies do not incentivize quality/ efficiency
• Re-orient care toward patient-centered goals
Public Psychiatry Presentation
01.28.2015
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Ireland Mental Health Division
Service Priorities
• Ensure the views of service users are central
to the design and delivery of services
• Deliver timely, clinically effective and
standardised safe services
• Design integrated evidence based, recovery
focused services
• Promote the mental health of the population
including reducing loss of life by suicide
• Enable the provision of services by trained
and engaged staff as well as fit for purpose
infrastructure
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Preparing for the Future
Consumer Participation
Administrative/
Academic
Support
Standardize Practice Elements
– Clinical/Diagnostic Assessment
– Interventions
– IT Infrastructure
Develop Guidelines
– Evidence-Based
– Trustworthy
– Within/Across Disciplines
Measure Performance
– Can’t improve without measuring
– Across silos and levels
Improve Performance
– Learn
– Reward
Strengthen Evidence Base
– Validate Measures
– Evaluate effective QI strategies
– Translate from bench to bedside
to community
Clinical
Perspectives
Integrative Processes
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Standardize Practice Elements
• Clinical assessment
– Diagnoses (ICD/DSM)
– Clinical measures/Mental health “vital signs”
– Recovery-oriented goal setting/attainment
• Interventions
– Medications
– Psychotherapies and other psychosocial interventions
– Multi-Component/Team-Beased Interventions
• IT infrastructure
– Templates
– Coding/ICD 11
– New Technologies (eg, Natural Language Processing)
NIMH Meeting
07.14.2014
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Develop Trustworthy
Evidence-Based Guidelines
– BOGSAT Model
– Economic Model
– Evidence-Based Model
– Filling in the gaps?
NIMH Meeting
07.14.2014
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NIMH Meeting
07.14.2014
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How: Clinical Strategies
• Evidence-Based Practices
–
–
–
–
Specific interventions
Medications, psychotherapies, team-based, etc.
Appropriateness/fidelity assessment
Inter-professional training, supervision
• Measurement-Based Care (MBC)
– Clinical measures (e.g. HA1c, PHQ-9, MH “vital signs”)
– Systematic, consistent, longitudinal (“Ruthless Follow-Up”)
– Action-oriented/menus of reasonable options
• Person-Centeredness
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–
–
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Accessibility
Therapeutic alliance
Recovery orientation
Cultural competence
MED Behavioral Health WorkGroup Meeting
08.24.2015
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10 Key Organizational Practices
1. Population Management /Predictive Modeling *
2. Formal linkages with:
–
–
–
Primary Care
Substance Abuse
Social Services
3. Effective Teams/Communication*
4. Effective Implementation Strategies to Assure:
–
–
Access to Evidence-Based Psychosocial Services
Access to Evidence-Based Medication Strategies
5.
6.
7.
8.
Decision Support for Measurement-Based/Stepped Care
Care Management with Relentless Follow-Up*
Clinical Registries for Tracking and Coordination*
Recovery-Oriented, Shared Decision-making/Self
Management Tools and Services
9. Data-Driven Quality Measurement and Improvement*
10. Health Information Technology Support*
MED Behavioral Health WorkGroup Meeting
08.24.2015
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“Recovery”
• Recovery concept has attracted wide-spread interest over the
last decade
• Has become part of broader change and improvement
processes internationally (e.g., WHO, IIMHL)
• Complex concept
• Not necessarily symptomatic recovery
• Multiple domains of functioning
• Involves shared decision-making, respect, self esteem/self
stigma, individualized goal attainment
• Also housing, social supports, social services, criminal justice,
trauma domains
• Can be assessed at a programmatic and consumer level
• Ireland’s Advance Recovery Initiative/Recovery Context
Instrument (and similar efforts in other countries/IIMHL)
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Measure Performance
“You can’t improve what you don’t measure”- Deming
•
•
•
•
•
Standards v Clinical Measures v Quality Indicators
Improvement Measures
Accountability Measures
Descriptive Measures/Variation Analysis
Balancing Measures (eg, LOS/Follow Up)
“Not everything that counts can be counted, and not everything
that can be counted counts” – Einstein
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Dublin, Ireland- 10.21.2015
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Types of Measures
• Structure
– Are adequate personnel, training, facilities, QI infrastructure, IT
resources, policies, etc. available for providing care?
– The Joint Commission (facility accreditation)
• Process
– Are evidence-based processes of care delivered?
– Underuse, Overuse, Appropriateness, Fidelity
• Outcome
– Does care improve clinical outcomes?
• Patient Experience
– What do users and other stakeholders think about the system’s
structure, the care they have received, and their outcomes?
• Resource Use
– What/How much resources are expended for providing care?
– Are resources being used in an efficient way?
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Phases & Settings
•
•
•
•
•
•
•
•
•
Prevention
Screening/Follow-Up
Assessment
Acute Treatment
Chronic Treatment
Rehabilitation
Mental Health/Substance Abuse
“Non-Health” (social services, housing, etc)?
Accountability Across Settings/Providers
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“6 P” Conceptual Framework
Patient/User
Carer
Providers
Practices/Teams
Programs/Clinical
Organizations
Purchasers
(Local/National)
Populations
and Policies
• Enhance self-management/participation
• Link with community resources
• Evaluate preferences and change behaviors
• Improve knowledge/skills
• Provide decision support
• Link to specialty expertise and change behaviors
• Establish chronic care/MBC model; Reorganize practice
• Link with improved information systems
• Adapt to varying organizational contexts
• Enhance monitoring capacity for quality/outliers
• Develop provider/system incentives
• Link with improved information systems
• Educate regarding importance/impact of BH
• Develop plan incentives/monitoring capacity
• Use quality/value measures in purchasing decisions
• Engage community stakeholders; adapt models to local needs
• Develop community capacities
• Increase demand for quality care enhance policy advocacy
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Measure Development Process
•
•
•
•
•
•
•
•
Establishing an evidence base
Translating evidence to guidelines
Translating guidelines to measure concepts
Operationalizing concepts to measure
specifications (numerator/ denominator)
Testing for feasibility, reliability, validity
Choosing the “best” measures
Aligning measures across multiple programs
Stewardship/Updating measures over time
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Dublin, Ireland- 10.21.2015
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Components of Quality Measures
•
•
•
•
•
•
Numerator
Denominator
Exclusion criteria
Standardization
Risk adjustment
Benchmarks?
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Data Sources
• Administrative (e.g., Insurance Claims)
• Paper Chart Review
• EHR
– Specified Fields/Templates v NLP of Free Text
•
•
•
•
Longitudinal Registries (part of care)
Surveys (independent of care)
Patient Reported Outcomes
Systematic Qualitative Evaluation
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Choosing Indicators
• Explicit Criteria
• Scientific Acceptability
– Reliability
– Validity (proximal to outcomes)
•
•
•
•
Importance
Useability/Improvability
Feasibility
Other?
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Dublin, Ireland- 10.21.2015
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Using Indicators to Improve
Performance
• Learning
– Quality Improvement Techniques/Tools
– PDSA/Six Sigma/LEAN/Toyota
– US Institute for Healthcare Improvement
• Incentivizing
– Fear
– Shame
– $------$$$
– Pride?
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Dublin, Ireland- 10.21.2015
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Using Indicators to Improve Quality
• Use at Clinical Level (Standardization)
– Measurement based, patient-centered care
-- Culture change (at all levels)
• Use at Organizational Level (Improvement)
– Audit/ profiling/ feed back
– PDSA/ checklists/ six sigma
– Reducing unwanted/inappropriate variation
• Use at Policy Level (Accountability)
–Public reporting
– P4P/Payment by Results/Value-Based Purchasing
– Shared Accountability
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Dublin, Ireland- 10.21.2015
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“Measurement should be used
for learning not judgment”
Don Berwick
Improving Mental Health Services Conference
Dublin, Ireland- 10.21.2015
Using Indicators to Improve Quality
• Use at Clinical Level (Standardization)
– Measurement based, patient-centered care
-- Culture change
• Use at Organizational Level (Improvement)
– Audit/ profiling/ feed back
– PDSA/ checklists/ six sigma
– Reducing unwanted/inappropriate variation
• Use at Policy Level (Accountability)
– Public reporting
– P4P/Payment by Results/Value-Based Purchasing
– Shared Accountability
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Dublin, Ireland- 10.21.2015
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National Program Evaluation of VA
Mental Health Services
A collaboration among RAND, Altarum
Institute, University of Pittsburgh and
Columbia University
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We Evaluated Quality by Examining the
Structure, Process, and Outcomes of Care
Structure of Care
What services are
available to veterans?
E.g.,
• – Type/level
Type/levelofofstaffing
staffing
• – How
many
patients
How many patients
can
can be served
be
served
– Hours
of operation
• – Hours
of
Provideroperation
workloads
• – Provider
workloads
Cost per workload
• Cost
unitper workload
– unit
Availability of
• Availability
of
evidence-based
evidence-based
practices
practices
Process of Care
What services do
veterans receive?
- Extent evidence-based
E.g.,
practices are
• Extent
evidence-based
implemented
practices are
- Frequency and timing of
implemented
services
• Frequency and timing
- Appropriate monitoring
offorservices
side effects
• Appropriate
monitoring for side
Improving Mental
effectsHealth Services Conference
Dublin, Ireland- 10.21.2015
Outcomes of Care
Does it make a
difference?
- Patient satisfaction
E.g.,
• Patient satisfaction
-• Functional
status
Quality of
life
-• Cost
Functional status
- Quality of life
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IOM Quality of Care Paradigm Drove the
Development of the Performance Indicators
Evidence
Guidelines
Performance
Indicators
Data Sources:
•Facility Surveys
•Administrative Data
•Medical Record Review
•Client Surveys
IOM Quality of Care Paradigm
Efficiency
Equity
Effectiveness
PatientTimeliness
Centeredness
Improving Mental Health Services Conference
Dublin, Ireland- 10.21.2015
Safety
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Performance Varied by VISN
Suicide: Assessment for suicidal ideation during the study
period
Physical exam: Physical exam within 30 days of NTE
Brief intervention: Brief intervention, specialty care, or
completed referral to specialty mental health during the study
period
Continuation phase anti-depressant (MDD): Filled
prescriptions for 180-day supply for an antidepressant in 180
days following NTE
Anti-psychotics (Schiz): Received anti-psychotics in 12
weeks following NTE
Medication lab tests: Those with an antipsychotic
prescription who received recommended lab blood
monitoring during the study period
Anti-depressant (MDD): Filled prescriptions for a 12-week
supply of an antidepressant in the 12 weeks following NTE
Anti-depressant [HEDIS] (MDD): Those with at least one
prescription who filled prescriptions for a 12-week supply of
an antidepressant in the 12 weeks following NTE
MHICM: ACT/MHICM during the study period with at least 2
inpatient discharges or 30 cumulative inpatient days
Housing and employment: Assessment within 30 days of
NTE (New Treatment Episode)
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Dublin, Ireland- 10.21.2015
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Using Indicators to Improve Quality
• Use at Clinical Level (Standardization)
– Measurement based, patient-centered care
-- Culture change/Care coordination
• Use at Organizational Level (Improvement)
– Audit/ profiling/ feed back
– PDSA/ checklists/ six sigma
– Reducing unwanted/inappropriate variation
• Use at Policy Level (Accountability)
–Public reporting
– P4P/Payment by Results/Value-Based Purchasing
– Shared Accountability
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Measurement-Based Care (MBC)
• Systematically apply appropriate clinical measures
– e.g. HA1c, PHQ-9, Vanderbilt Assessment Scales
– Create a measurement tool kit
• Assure consistent, longitudinal assessment
– “Ruthless” Follow-Up/Care Management
• Use action-oriented menu of evidence-based options
– Treatment intensification/“Stepped Care”
• Establish practice-based infrastructure
– Build IT/Registry Capacity
• Enhance Connectivity among Systems
– MH/PC/SUD/Social Services/Education
• Incentivize Structures that Produce Outcomes
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Dublin, Ireland- 10.21.2015
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Evidence-Based Planned Care Model
Community
Health System
Resources and Policies
Health Care Organization
SelfManagement
Support
Delivery
System
Design
Decision
Support
Clinical
Information
Systems
Productive Interactions
Patient-Centered
Informed, Empowered
Patient and Family
Timely and
Efficient
Coordinated
EvidenceBased and Safe
Prepared, Proactive
Practice Team
Improved Outcomes
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Dublin, Ireland- 10.21.2015
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Person-Centered, Evidence-Based
Behavioral Health “Home”
• Patient-Centered Medical Home Standards as Base
• Formal Linkage to or Provision of Primary Care,
Preventive/Wellness, Substance Use and Social
Services
• Information Systems with Registry Functionality for
Measurement-Based Care
• Structures to Support Specific Evidence-Based
Practices (training, supervision, fidelity/outcomes
measurement)
– E.G., Medication Management, CBT, IPT, ExposureBased, ACT, Supported Employment
• Recovery-Oriented, Shared Decision-making Tools
and Services
MED Behavioral Health WorkGroup Meeting
08.24.2015
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Dublin, Ireland- 10.21.2015
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Shared Accountability
Breaking Down Silos
• Relatively simple concept
• Applies to all participants caring for a patient
• For example, PCP is jointly responsible for
assuring quality for both GH and BH care
• BHS is jointly responsible for assuring quality
for both BH and GH care
• The same applies to Med/Surg Health Plan
and BH Carveout
• Instantiated in training, practice, health plan
contracts, performance incentives……
……..And, ultimately, culture
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Issues in Quality Measurement
•
•
Adequacy of evidence base
Adequacy of data sources
– Documentation or Reality?
•
•
Costs of collection/monitoring
Determining benchmarks
– What rate is right?
•
Risk adjustment
– Cherry picking/skimming vs Penalizing low resource areas
•
Linking S-P-O
– e.g. Diabetes and ACCORD
•
Who is accountable for performance?
– Each of 6P’s vs Shared accountability
•
Patient-centered measures
–
•
Individual values/preferences vs Standardization
Measurement v. Improvement
– Are we really making a difference?
Improving Mental Health Services Conference
Dublin, Ireland- 10.21.2015
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International Models
• International Initiative for Mental Health
Leadership – Clinical Leaders Group
– 3 phase project
– Meeting last month in New York/Columbia
– Planning next phase
• Examples include:
–
–
–
–
–
US – Affordable Care Act
UK – benchmarking club
Netherlands – “MBHO” outcomes initiative
Sweden – Integrated into overall program
Recovery initiatives
Improving Mental Health Services Conference
Dublin, Ireland- 10.21.2015
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Ireland Mental Health Division
Service Priorities
• Ensure the views of service users are central
to the design and delivery of services
• Deliver timely, clinically effective and
standardised safe services
• Design integrated evidence based, recovery
focused services
• Promote the mental health of the population
including reducing loss of life by suicide
• Enable the provision of services by trained
and engaged staff as well as fit for purpose
infrastructure
Improving Mental Health Services Conference
Dublin, Ireland- 10.21.2015
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“Crossing the Quality Chasm”
NIMH Meeting
07.14.2014
56
NIMH Meeting
07.14.2014
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Back-Up Slides
• And leftovers
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IIMHL Clinical Leads Project
Aims
•
•
•
•
Develop framework for performance measures
Raise awareness of quality of care for mental health
Compare system performance across countries
Inform initiatives for transforming mental health services
Phase I
•
•
•
•
•
Compile indicators across countries (national or regional/ state/ provincial level)
Identify common (and differing) themes, methods and definitions
Describe how indicators developed and applied
Survey (programs)
Literature review (indicators)
Phase II
•
•
•
Develop overarching shared framework
Identify features of data sources/information systems
Reach consensus on indicator set
Phase III
•
Pilot indicator set and framework for cross country comparisons
Improving Mental Health Services Conference
Dublin, Ireland- 10.21.2015
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What we have learned
• There is a great deal of activity within and across countries related
to quality
• A large number of quality measures have been developed
• It is possible to obtain consensus on key quality measurement
concepts
• Operationalizing these concepts into usable measures is complex
(and doing so with comparability across healthcare
systems/countries is even more complex)
• Even when measures are developed they may not be effectively
employed
• Promising examples of impactful measurement approaches may
provide direction for the future
• Important gaps can be identified
• Significant investment in science, policy and infrastructure may be
needed to move the field ahead
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A large number of quality measures have been developed
• Over 650 were identified across 12
countries and 31 programs
• Covered 17 domains
• Multiple measures addressing the same or
similar concepts
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Promising examples of impactful measurement
approaches provide direction for the future
• US - Healthcare Reform (ACA)
• England - NHS Benchmarking Network
• Netherlands – Mandatory set of
performance indicators
• Canada – Mental Health Commission
• Scotland – Patient Safety Program MH –
Phase two measurement plan
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Promising examples of impactful
measurement approaches provide
direction for the future
• US - Healthcare Reform (ACA)
• England - NHS Benchmarking Network
→ All NHS Trusts/ Foundation Trusts in England/ Wales plus
some independent sector MH providers submitting data for
benchmarking purposes across domains of activity/ workforce/
finance/ safety/ and quality
• Canada - Mental Health Commission
→ Developed and will report on 63 indicators reflecting MH across
the lifespan for children and youth, adults, and seniors (different
settings, aspects of services and supports used by people with
mental illness )
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Dublin, Ireland- 10.21.2015
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Examples of Quality Reporting/Payment
Programs in ACA
•
•
•
•
•
•
National Quality Strategy
Core Hospital Safety Measures
Meaningful Use
Physicians Quality Reporting System
Value-Based Purchasing Modifier
Value Based Inpatient Psychiatry Quality
Reporting Program
• PhysicianCompare.Gov
• HospitalCompare.Gov
• NursingHomeCompare.Gov
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Care of mentally ill
faulted in report
US survey reviews patient follow-up; state
well below national average
Medicare data on hospitalcompare.gov
highlights poor performance of individual
hospitals
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England Benchmarking Project
Benchmarking service quality – illustrative example
Use of seclusion per 100,000 bed days - Improving
2013/14
Mean average =
198 per 100,000
bed days
• 2012/13
Mean seclusions
= 282
• London peer
group shown
© NHS Benchmarking Network 2014
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Dublin, Ireland- 10.21.2015
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Promising examples of impactful
measurement approaches provide
direction for the future (cont.)
• Scotland – Patient Safety Program MH – Phase
two measurement plan
→ National program to reduce harm by supporting MH staff to test,
gather real-time data and implement interventions (includes MH
outcomes, safety culture, balancing, and process measures)
• Netherlands – MH Outcomes Benchmarking
Institute (Stichting Benchmark GGZ)
→ Reduction of symptoms, Daily functioning, Quality of life, Risk by
different patient groups (adults-children/ youth, substance use, forensic
care etc.)
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Dublin, Ireland- 10.21.2015
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Important gaps can be identified
• Recovery-oriented quality measures
– Patient level
– Program level
•
•
•
•
Behavioral Health/ General Health Interface
Child and Adolescent
Substance Abuse
Outpatient/ ambulatory care
– Currently over-weighted to inpatient care
• Criminal Justice Interface
• Social Services Interface
• Outcomes quality indicators (not clinical instruments)
Improving Mental Health Services Conference
Dublin, Ireland- 10.21.2015
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Themes Going Forward in Developing
Behavioral Health Measures
•
•
•
•
•
•
•
•
•
Measurement-Based Care
Registries
Fidelity to Evidence-Based Practices
Integration of Behavioral and General Health
Care
Shared Accountability
Recovery- Based Care
Linkage with Social Services and Education
Predictive Modeling
Structural Measures for “Evidence-Based
Behavioral Health Care Homes”-Adapting PCMH
NIMH Meeting
07.14.2014
69
Significant investment in science, policy
and infrastructure is needed
• Expand evidence base for what is effective
for whom
• Improve reliability, validity and efficiency of
data sources (role of HIT)
• Implement routine use of clinical measures
(MH vital signs)-for measurement-based care
• Develop ontology for evidence-based
psychosocial interventions for capture in
administrative data
• Determining benchmarks-what rate is right?
• Identify agency to steward the development
and coordination of quality indicators?
Improving Mental Health Services Conference
Dublin, Ireland- 10.21.2015
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Measuring the Quality of Mental
Health Care
• Providing Resources And Stewardship
• Implementing Standardized, Longitudinal, ActionOriented Measurement
• Creating a Balanced Portfolio across Structure,
Process and Outcomes Measures
• Integrating Mental Health and General Health Care
• Expecting Evidence-Based Practices
• Applying Quality Improvement Tools
• Incorporating Health Information Technology
• Setting Benchmarks, Comparisons, and Accountability
• Investing In Research to Measure and Improve Quality
• Actually Improving Quality and Outcomes
NIMH Meeting
07.14.2014
71
Challenges
• Countries are in differing stages of
developing/ implementing recovery
frameworks and measures
• Multiple frameworks and measures exist
• Remaining challenges include:
– Achieving consensus on overarching framework
(or ontology)
– Assessing utility/validity of existing measures
(and fit for purpose)
– Moving from measurement to use at clinical,
organizational and policy levels
Improving Mental Health Services Conference
Dublin, Ireland- 10.21.2015
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A Framework to Improve Quality
INSTITUTE OF MEDICINE
Patient-Centered Medical Home
Standard
Content/Summary
Enhance
Access/Continuity
• Patients have access to culturally and linguistically appropriate routine/urgent care and clinical advice during and
after office hours
• The practice provides electronic access
• Patients may select a clinician
• The focus is on team-based care with trained staff
Identify/Manage
Patient
Populations
• The practice collects demographic and clinical data for population management
• The practice assesses and documents patient risk factors
• The practice identifies patients for proactive and point-of-care reminders
Plan/Manage Care
• The practice identifies patients with specific conditions, including high-risk or complex care needs and conditions
related to health behaviors, mental health or substance abuse problems
• Care management emphasizes:
– Pre-visit planning
– Assessing patient progress toward treatment goals
– Addressing patient barriers to treatment goals
• The practice reconciles patient medications at visits and post-hospitalization
• The practice uses e-prescribing
Provide Self-Care
Support/
Community
Resources
• The practice assesses patient/family self-management abilities
• The practice works with patient/family to develop a self-care plan and provide tools and resources, including
community resources
• Practice clinicians counsel patients on healthy behaviors
• The practice assesses and provides or arranges for mental health/substance abuse treatment
Track/Coordinate
Care
• The practice tracks, follows-up on and coordinates tests, referrals and care at other facilities (e.g., hospitals)
• The practice follows up with discharged patients
Measure/Improve
Performance
• The practice uses performance and patient experience data to continuously improve
• The practice tracks utilization measures such as rates of hospitalizations and ER visits
• The practice identifies vulnerable
patientOF
populations
INSTITUTE
MEDICINE
• The practice demonstrates improved performance
Improving Mental
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Little Action, Until………….
Recent Events:
•
•
•
•
•
•
•
Affordable Care Act institutes new policies
Parity of benefits for MH and SUD
Public reporting programs
Value-based purchasing programs
CMMI demonstration programs
NQF endorsement process
Measurement Applications Partnership
review
Improving Mental Health Services Conference
Dublin, Ireland- 10.21.2015
75
Research Needs
•
•
•
•
Not unique to BH, but more acute/complex
“What” works?
How do we measure the “what”?
Does doing the “what” (as measured)
improve outcomes?
• How to feasibly and fairly measure
outcomes?
• Funding?
• Stewardship?
Improving Mental Health Services Conference
Dublin, Ireland- 10.21.2015
76
Health Information Technology
Gaps
•
•
•
•
•
Slow uptake
Lack of funding (small non-profits/solo)
HITECH exclusion
Multiple vendors/Lack of interoperability
Clinical assessment and treatment
practices not standardized and classified
for use in administrative datasets
• No field of behavioral health informatics
Improving Mental Health Services Conference
Dublin, Ireland- 10.21.2015
77
Fewer Psychiatrists Seen Taking Health
Insurance
WASHINGTON — Psychiatrists are
significantly less likely than doctors in other
specialties to accept insurance, researchers
say in a new study, complicating the push to
increase access to mental health care.
http://www.nytimes.com/2013/12/12/us/politics/psychiatrists-less-likely-toaccept-insurance-study-finds.html?_r=0
Improving Mental Health Services Conference
Dublin, Ireland- 10.21.2015
78
Actually Improving Quality
• Outcomes measurement not widely applied despite reliable
and valid instruments (“measurement-based care”)
• Quality Improvement methods not yet permeating day-to-day
operations
– No IHI for BH
• Work force not trained in quality measurement and
improvement
• Fragmentation of field limits ability to form collaborative
Learning Healthcare Organizations
• No real agreement on borders, accountability and systems
across mental health, substance use, general health and
social services
Improving Mental Health Services Conference
Dublin, Ireland- 10.21.2015
79
The greatest value of a picture is when it
forces us to notice what never expected to
see.
- John Tukey, American Mathematician
Improving Mental Health Services Conference
Dublin, Ireland- 10.21.2015
80
Stages of Facing Reality
• “The data are wrong”
• “The data are right, but it’s not a problem”
• “The data are right; it is a problem; but it is
not my problem.”
• “I accept the burden of improvement”
Improving Mental Health Services Conference
Dublin, Ireland- 10.21.2015
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The Utility of Data
1. Data will help you understand current performance
• This is usually referred to as developing a baseline
2. Data will help you come up with ideas to improve the
process
• Where or when might there be opportunities for improvement?
3. Data will help you test changes to see if they lead to
improvement
4. Data will help you ensure those improvements are
being maintained
Improving Mental Health Services Conference
Dublin, Ireland- 10.21.2015
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Strategies for Influencing
Quality of Care
•
•
•
•
•
•
•
•
•
•
•
Guidelines/”Black Boxes”
Provider Training/Education/CME
Academic detailing (no business model)
Preferred lists/Prior auth/Second opinion
Certification/Accreditation/Licensure
Provider Reminder System/Decision Support
Patient Education/Reminders
Quality Measurement/”Sentinel Effect”
Quality Improvement/PDSA/Six Sigma/IHI
Public Reporting/Profiling/Feedback
Financial Incentives/P4P/VBP
NIMH Meeting
07.14.2014
83
What Does All This Mean to the
Typical Clinician/BH Organization?
• Practice evidence-based care and learn/apply
measurement-based care and quality improvement
strategies
– You will be accountable and compensated based on quality
• Screen for co-morbid conditions, apply relentless
follow-up and routinely assess treatment response
– Systematic, longitudinal, action-oriented measurement to
achieve targeted outcomes/”Measurement-Based Care”
• Elicit patient preferences and involve consumers at
every level of decision making
– Measures of patient engagement, perceptions, shared
decision-making and outcomes will be part of the package
Public Psychiatry Presentation
01.28.2015
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What Does All This Mean for
Typical Clinician/BH Organization?
(continued)
• Learn how to effectively use technology
– Beyond EMR to clinical decision aids, predictive modeling,
registries, population health management, and more
• Build infrastructure (or affiliate with organizations to
access infrastructure)
– Increasing pressures on isolated solo practices and on
clinics to meet PCMH-like structural requirements
• Link behavioral health, general health, substance use
care and social services
– Behavioral health must get comfortable in the mainstream of
medicine (and vice versa) – Shared Accountability
Public Psychiatry Presentation
01.28.2015
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In God we trust.
All others must bring data.
- W. Edwards Deming
Improving Mental Health Services Conference
Dublin, Ireland- 10.21.2015
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