11 Improving the Quality of Mental Health Care: Can Ireland Cross the Quality Chasm? Harold Alan...

11

Improving the Quality of Mental Health Care:

Can Ireland Cross the Quality Chasm?

Harold Alan Pincus, MDProfessor and Vice Chair, Department of Psychiatry

Co - Director, Irving Institute for Clinical and Translational ResearchColumbia University

Director of Quality and Outcomes ResearchNewYork-Presbyterian Hospital

Senior Scientist, RAND Corporation

Improving Mental Health Services Conference Dublin, Ireland- 10.21.2015

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?

2Improving Mental Health Services Conference

Dublin, Ireland- 10.21.2015

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 3

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?



5

To Err Is Human: Building A Safer Health System

First Report

Committee on

Quality of Health Care

in America

To order: www.nap.edu



6

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!



7

Six Aims For Improvement

•Safe

•Effective

•Patient-centered

•Timely

•Efficient

•Equitable



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 Rules1. 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.

8

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 Rules6. 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).

9

Evidence-Based Planned Care Model

Prepared, ProactivePractice Team

Informed, Empowered Patient and Family

Productive InteractionsPatient-Centered Coordinated

Timely and Evidence- Efficient Based and Safe

Improved Outcomes

DeliverySystemDesign

Decision Support

ClinicalInformation

Systems

Self-Management

Support

Health SystemCommunity

Health Care OrganizationResources and Policies



11Published 2006

INSTITUTE OF MEDICINE

Committee on Developing Evidence-Based Standards

for Psychosocial Interventions for Mental Disorders

Published 2015


“Crossing the Quality Chasm”



Follow-up after Hospitalization for Mental Illness within 7 Days (HMOs only) 2003-2012

(NCQA October 2013)



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



Antidepressant Medication Management: Continuation Phase- HMO Means

Trends, 2002-2009



Engagement of Alcohol and Other Drug

Dependence Treatment: HMO Means Trends, 2004-2009



18

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

18Public Psychiatry Presentation

01.28.2015 18

20

Preparing for the Future

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

Consumer Participation

Administrative/Academic

Support

Clinical Perspectives

Integrative Processes



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 21

Develop Trustworthy Evidence-Based Guidelines

– BOGSAT Model

– Economic Model

– Evidence-Based Model

– Filling in the gaps?


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– Accessibility– Therapeutic alliance– Recovery orientation– Cultural competence

24MED Behavioral Health WorkGroup Meeting

08.24.2015

10 Key Organizational Practices1. 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. Decision Support for Measurement-Based/Stepped Care 6. Care Management with Relentless Follow-Up* 7. Clinical Registries for Tracking and Coordination*8. Recovery-Oriented, Shared Decision-making/Self

Management Tools and Services9. Data-Driven Quality Measurement and Improvement* 10. Health Information Technology Support*


08.24.2015

“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)



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

28Improving Mental Health Services Conference Dublin, Ireland- 10.21.2015

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?



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



“6 P” Conceptual FrameworkPatient/User

Carer

Practices/Teams

Purchasers (Local/National)

• 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

Populations and Policies

• Engage community stakeholders; adapt models to local needs

• Develop community capacities• Increase demand for quality care enhance policy advocacy

Providers

Programs/Clinical Organizations



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



Components of Quality Measures

• Numerator• Denominator• Exclusion criteria• Standardization• Risk adjustment• Benchmarks?



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



Choosing Indicators

• Explicit Criteria• Scientific Acceptability

– Reliability– Validity (proximal to outcomes)

• Importance• Useability/Improvability • Feasibility • Other?



Using Indicators to Improve Performance

• Learning– Quality Improvement Techniques/Tools– PDSA/Six Sigma/LEAN/Toyota– US Institute for Healthcare Improvement

• Incentivizing– Fear – Shame– $------$$$– Pride?



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



“Measurement should be used for learning not judgment”

Don Berwick


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



40

National Program Evaluation of VA Mental Health Services

A collaboration among RAND, Altarum

Institute, University of Pittsburgh and

Columbia University



41

We Evaluated Quality by Examining the Structure, Process, and Outcomes of Care

Structure of Care

Process of Care

Outcomes of Care

Does it make a difference?

E.g.,• Patient satisfaction• Quality of life• Functional status• Cost

What services do veterans receive?

E.g.,• Extent evidence-based

practices are implemented

• Frequency and timing of services

• Appropriate monitoring for side effects

E.g.,• Type/level of staffing • How many patients

can be served

• Hours of operation• Provider workloads• Cost per workload

unit• Availability of

evidence-based practices

What services are available to veterans?

Structure of Care

Process of Care

Outcomes of Care

Does it make a difference?

E.g.,• Patient satisfaction• Quality of life• Functional status• Cost

What services do veterans receive?

E.g.,• Extent evidence-based

practices are implemented

• Frequency and timing of services

• Appropriate monitoring for side effects

E.g.,• Type/level of staffing • How many patients

can be served

• Hours of operation• Provider workloads• Cost per workload

unit• Availability of


What services are available to veterans?

– Type/level of staffing– How many patients

can be served– Hours of operation– Provider workloads– Cost per workload

unit– Availability of


- Extent evidence-based practices are implemented

- Frequency and timing of services

- Appropriate monitoring for side effects

- Patient satisfaction

- Quality of life

- Functional status

- Cost41


42

IOM Quality of Care Paradigm Drove the Development of the Performance Indicators

EquityPatient-

CenterednessSafetyTimelinessEfficiency

IOM Quality of Care Paradigm

Evidence Guidelines PerformanceIndicators

Data Sources:• Facility Surveys• Administrative Data• Medical Record Review• Client Surveys

Effectiveness



43

Performance Varied by VISNSuicide: 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)



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



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



Evidence-Based Planned Care Model

Prepared, ProactivePractice Team

Informed, Empowered Patient and Family

Productive InteractionsPatient-Centered Coordinated

Timely and Evidence- Efficient Based and Safe

Improved Outcomes

DeliverySystemDesign

Decision Support

ClinicalInformation

Systems

Self-Management

Support

Health SystemCommunity

Health Care OrganizationResources and Policies



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, Exposure-

Based, ACT, Supported Employment• Recovery-Oriented, Shared Decision-making Tools

and Services


08.24.2015

Shared AccountabilityBreaking 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



53

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?



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



56

“Crossing the Quality Chasm”


57NIMH Meeting

07.14.2014 57

Back-Up Slides

• And leftovers


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



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



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



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



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 )



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



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

hospitals65


England Benchmarking Project

66

© NHS Benchmarking Network 2014

2013/14 Mean average = 198 per 100,000 bed days• 2012/13 Mean seclusions = 282• London peergroup shown

Benchmarking service quality – illustrative exampleUse of seclusion per 100,000 bed days - Improving


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.)



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)



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


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?



Measuring the Quality of Mental Health Care

• Providing Resources And Stewardship• Implementing Standardized, Longitudinal, Action-Oriented

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


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




A Framework to Improve Quality


Patient-Centered Medical HomeStandard 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 patient populations• The practice demonstrates improved performance

74Improving Mental Health Services

Conference Dublin,

Ireland- 10.21.2015

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



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?



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



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-to-accept-insurance-study-finds.html?_r=0



http://www.nytimes.com/2013/12/12/us/politics/psychiatrists-less-likely-to-accept-insurance-study-finds.html?_r=0

http://www.nytimes.com/2013/12/12/us/politics/psychiatrists-less-likely-to-accept-insurance-study-finds.html?_r=0

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



The greatest value of a picture is when it forces us to notice what never expected to see.

- John Tukey, American Mathematician



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”



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



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


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 84

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 85

In God we trust.

All others must bring data.

- W. Edwards Deming



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