Transcript Measuring Quality of Care for Co-Occurring Conditions Richard C. Hermann, MD, MS David J.

Measuring Quality of Care
for Co-Occurring Conditions
Richard C. Hermann, MD, MS
David J. Dausey, PhD
Amy M. Kilbourne, PhD, MPH
Catherine Fullerton, MD, MPH
Tufts University School of Medicine
Rand Corporation
University of Pittsburgh
Harvard Medical School
RWJF Depression in Primary Care Program
Center for Quality Assessment & Improvement in Mental Health
www.cqaimh.org
Overview
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Co-occurring conditions & deficits in care
– Mental disorders & SUD in primary care
– Medical conditions in mental health specialty care
– Dual diagnoses in mental health & SU specialty sectors
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Role of quality measurement in improving mental healthcare
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Status & prospects for measures of co-occurring conditions
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Breakout session
– Measure development exercise
– Measure selection exercise
Mental disorders & SUD in Primary Care
Prevalence
 5 - 27% of primary care patients have depressive or
anxiety disorders
 4 -10% of primary care patients have SUDs
Deficits:
 Poor recognition
 Low rates of use of brief screening tools
 Low rates of appropriate treatment in primary care
 Limited referral for specialty care
 Barriers to successful referral
 Poor communication btw. PCP and MH/SU specialists
Medical Conditions among MHS Patients
Prevalence:
 Elevated rates of diabetes, HIV, pulmonary, CV & GI
disease among individuals with severe mental illness
 2 - 5x higher risk of mortality from natural causes
Deficits:
 Lack of thorough medical evaluation for patients
receiving MHS care for a psychiatric disorder
 35% (3 - 92%) psychiatric patients had a significant,
undetected medical condition
 50% (12 - 93%) had a significantly undertreated condition
Dual Diagnosis in MH & SUD Specialty Sectors
Prevalence:
 ~ 50% of patients with SMI have an SUD over lifetime
 ~ 25% of patients with SMI have an active SUD
Deficits:
 < 40% with dual diagnosis received any treatment,
 Only 8% receive integrated treatment
 Among pts in MH or SU specialty care, comorbid
condition is frequently undocumented & untreated
IOM Crossing the Quality Chasm (2005):
Adaptation to Mental Health/Addictive Disorders
IOM Recommendation 5-2
Need to implement policies and incentives to
increase collaboration among primary care,
mental health, & substance-use treatment
providers to achieve evidence-based screening
and care
IOM Crossing the Quality Chasm (2005):
Recommendations on Measurement-Based QI
Recommendation 4-2 / 4-3
 Clinicians
& provider organizations should measure &
continuously improve the quality of care they provide.
 Stakeholders
need to reach consensus on
standardized quality measures for comparative use
National Inventory of Mental Health Quality Measures
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> 300 measures proposed for quality assessment &
improvement in MH/SUD care
– available at http://www.cqaimh.org/quality.htm
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Less than 5% assess care for co-occurring conditions
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Other instruments available, but not widely used for these
populations
– surveys of patient perspectives of care
– outcome assessment tools
– fidelity scales
Role of Measurement in Quality Improvement

Internal quality improvement
– CQI: aims, measurement, diagnosis, intervention
– system redesign
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External quality improvement
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–
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reporting and feedback
benchmarking
contractual goals
financial incentives
consumer & purchaser choice
Framework for Measuring Quality of Care
Structure
Process
 Technical
 Interpersonal
Outcome
Structures of Care for Co-Occurring Conditions
Clinicians
– Competencies in detecting/ treating COC
– Availability of specialists for referral
 Facilities & Services
– Availability of services across levels of care
– Adoption of structures to support COC care
 Clinical Information Systems
– Availability of medical records between sectors
– Procedures to safeguard confidentiality / consent
 Financing
– Reimbursement for care of COC
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Processes of Care for Co-Occurring Conditions
Detection
Assessment
Access to specialty care
Treatment vs. Referral
– appropriateness of decision
– referrals: completion rate
– treatment: underuse, overuse, misuse; fidelity
 Coordination
– adequacy of communication / collaboration
 Continuity of care
 Safety
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Outcomes of Care for Co-Occurring Conditions
Change in
 Symptoms
 Behaviors
 Functioning
 Quality of life
 Adverse effects
 Mortality
 Patient Satisfaction
Desirable Characteristics of Quality Measures
Meaningful
quality problem
clinically important
evidence-based
valid
comprehensible
Feasible
Actionable
precisely specified under user’s control
data available
results interpretable
affordable
reliable
confidential
case mix
Mental disorders & SUD in Primary Care:
Existing Quality Measures
HEDIS measures adopted for health plans
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% pts started on antidepressant for depression who
remain on medication at 12 weeks & 6 months
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% children receiving medication for ADHD w/ follow-up
visit w/in 30 days, 2 additional visits w/in 9 months
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Service utilization for SUD
– treated prevalence: any utilization in 12-months
– initiation:
2nd service w/in 14 days
– engagement:
2 additional services w/in 30 days
Mental disorders & SUD in Primary Care:
Measures Under Development
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Structures supporting evidence-based practice
– % of primary care practices using registries, rating
scales, case management for depression
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Processes recommended for primary care practice
– % patients screened for SUD
– % of pts. diagnosed with alcohol abuse or dependence
receiving a brief intervention
– % pts. w/ depression receiving case mgmt support
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Outcome Measures
– average change in PHQ score at defined interval
Mental disorders & SUD in Primary Care:
Need for Measures of Boundary-Spanning Care
Potential measure topics
 Completion rates for referrals
 Communication btw PCPs and MHS
 Outcomes of referred or collaborative care
Obstacles to overcome
 Carve-outs result in segregation of data btw. sectors
 Tension btw. sharing clinical information & confidentiality
 Unclear accountability for outcome
 Lack of defined standards for boundary spanning care
Measures of Conformance to Standards & Guidelines
Research
Evidence
Consensus
Development
Practice guidelines / standards of care
Conformance
Structures
Processes
Delivery of Care
Outcomes
Breakout Group 1: Measure Development
Information exchange between PCP & MHS
Proposed Measure:
% primary care patients referred to MHS for psychiatric care
whose PCP received “adequate” feedback
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Need for standards: what? by when? how?
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What data sources are available?
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Different forms of measure useful to different stakeholders?
Quality Measurement for
Medical Conditions in MHS Care
Detection
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% patients with general medical history
% patients with documented smoking status
% patients screened for DM, fasting lipids
Treatment
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% of patients receiving appropriate preventive care
– pap smear, vaccines, colonoscopy
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% of patients with DM with HgA1c testing
% of patients with COPD with spirometry testing
Background: Integrated Care for MH/SUD
~50% of individuals with a mental disorder have at least
one co-occurring substance use disorder (MH/SUD)
 When compared to individuals with a single MH
disorder individuals with MH/SUD have higher:
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Rates of treatment utilization
Use of emergency and hospital services
Rates of violent behavior
Risk of HIV infection
Research for two decades has demonstrated that
individuals with MH/SUD that receive integrated or
linked care have better outcomes than those who
receive “silo care”
Deficits in Quality of Care for MH/SUD
Limited current service linkages between MH
and SA providers
 Failure to identify MH/SUD patients in MH
specialty settings
 Program fidelity challenges
 Lack of performance measures despite growing
evidence base and standards
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Structural Measure: Service Linkages
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% of programs that have:
– Integrated services (MH and SA services in the
same treatment program)
– Co-location (MH and SA services in the same
location)
– Formal relationships (referral agreements or
contractual relationships among providers)
– Informal or ad hoc (absence of formal relationships)
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Research indicates that programs with
integrated services have the best outcomes
Process Measure: Model Fidelity
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Average fidelity score across participating programs:
– New Hampshire/Dartmouth Integrated Dual Disorder
Treatment (IDDT) model
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26 Item fidelity scale
Each item represents an org. or tx component of model
Scores from individual programs can be compared to
the mean score or a recognized benchmark
 Research indicates that Critical program components
must be replicated to achieve good outcomes
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Outcome Measure: Abstinence
% of patients with any SA diagnosis discharged
from a MH specialty setting who report
abstinence from drugs or alcohol over 6 months.
 MH specialty settings can be compared against
the mean across all MH specialty settings or a
recognized benchmark.
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Breakout Session 2: Measure Selection
Integrated Care for Patients with MH/SUD
Comparing and contrasting different measures
for MH/SUD
 Focus on measures for state mental health
agencies
 Rate and discuss 3 different measures on
feasibility and meaningfulness
 Consider appropriate data sources for measures
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Breakout Session
Group 1: Measure Development
 Information exchange between PCP & MHS
Group 2: Measure Selection
 Integrated treatment for patients with dual diagnoses
Report back: 9:40 am