What's With All the Numbers?: Quality Indicators within Integrated Behavioral Health Programs

1. Session # 5680745 Friday, October 16th, 2015, H2b, Period 2 What's With All the Numbers?: Quality Indicators within Integrated Behavioral Health Programs Lesley Manson, PsyD Director of Integrated Training Initiatives Arizona State University, Doctor of Behavioral Health David Bauman, PsyD Bridget Bauman, PsyD Behavioral Health Faculty Central Washington Family Medicine Residency  Stacy Ogbeide, PsyD Assistant Professor Dept. of Family & Community Medicine UTHSCSA Melissa Baker,PhD Behavioral Health Consultant HealthPoint Collaborative Family Healthcare Association 17thAnnual Conference October 15-17, 2015 Portland, Oregon U.S.A.

2. Faculty Disclosure We have not had any relevant financial relationships during the past 12 months.

3. Learning ObjectivesAt the conclusion of this session, the participant will be able to: Learning Objective #1 • Identify clinical metrics and benchmarks for PCBH programs. Learning Objective #2 • Describe and discuss data mining options for collecting metrics to demonstrate quality improvement related to PCBH. Learning Objective #3 • Discuss unique barriers in collecting and assessing metrics for developing and sustaining PCBH programs. 

4. Bibliography / Reference Robinson, P. & Reiter, J. (2015). Behavioral Consultation and Primary Care: A Guide to Integrating Services (2nd Edition). Springer International Publishing: Geneva, Switzerland.  Savage, A., Lauby, T., & Burkard, J. F. (2014) Examining selected patient outcomes and staff satisfaction in a primary care clinic at a military treatment facility after implementation of the patient-centered medical home. Military Medicine, 178(2):128 - 134.  Goodie, J. L., Kanzler, K. E., Hunter, C. L., Glotfelter, M. A., & Bodart, J. J. (2013). Ethical and effectiveness considerations with primary care behavioral health research in medical home. Families, Systems, & Health, 31(1), 86-95.  Runyan, C. (2011). Psychology can be indispensable to health care reform and the patient-centered medical home. Psychological Services, 53-68. doi: 10.1037/a0023454  Bendix, J. (2014) RVUs: A valuable tool for aiding practice management. Understanding the basics of the RVU can assist physicians and practice managers in a wide variety of finance and management-related tasks. Med Econ, 91(4): 48-51. 

5. Bibliography / Reference 6. Corso, Hunter, Dahl, Kallenberg, and Manson(2016). Integrating behavioral health in the medical home: A rapid implementation guide. Greenbranch: Phoenix, Maryland. 7. Kilbourne, A. M., Keyser, D., & Pincus, H. A. (2010). Challenges and opportunities in measuring the quality of mental health care. Canadian Journal of Psychiatry, 55(9), 549-557. 8. Vannoy, S. D., Mauer, B., Kern, J., Girn, K., Ingoglia, C., Campbell, J., ... Unutzer, J. (2011). A learning collaborative of CMHCs and CHCs to support integration of behavioral health and general medical care. Psychiatric Services, 62, 753-758. 9. Goldman, Spaeth-Rublee, Pincus (2015). Quality indicators for physical and behavioral health care indicators. Journal of the American Medical Association. 314(8):769-770. doi:10.1001/jama.2015.6447

6. Resources • SAMHSA Center for Integrated Care • http://www.integration.samhsa.gov/ • Agency for Healthcare Research and Quality (AHRQ): “Atlas of Integrated Behavioral Health Care Quality Measures” • http://integrationacademy.ahrq.gov/atlas • Evaluation Processes • AHRQ: https://cahps.ahrq.gov/quality-improvement/improvement-guide/qi-steps/QI-Methods_Models/index.html • Institute of Health Improvement (“How to Improve”) • http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx

7. Learning Assessment • A learning assessment is required for CE credit. • A question and answer period will be conducted at the end of this presentation.

8. PCBH…. What is it? • Consultant model • Member of primary care team, work side-by-side • Goal is to improve PCP management of behavioral issues and improve satisfaction • Wide variety of interventions and goals • Brief visits, limited follow-up • Immediate feedback to PCP • Any behaviorally-based problem, any age • Immediate access, minimal barriers • Population health principles

9. Program Questions • Integration is the standard • Not a question of should we integrate, rather how do we integrate? • Identify Barriers to QI • Model Fidelity • QI Metrics and QI Healthcare Alignment • Provider Satisfaction • Patient Satisfaction • Clinical Quality Indicators

10. Barriers to QA/QI

11. Barriers to Quality Assurance and Improvement • What barriers have you faced in your practice settings? • Clinical? • Administrative? • Time • Resources (manpower) • Electronic Health Records • Stakeholders • Be Pro-active with identifying Vannoy et al., 2011

12. Barriers to QA/QI • Poorly defined quality measures • Lack of linked electronic health information • Limited descriptions of behavioral health for program metrics • Limited to MH • Lacking • Medical linkage • Clinical relevance • Fiscal outcomes Kilbourne, Keyser, & Pincus, 2010

13. Overcoming Barriers • Promotes organization self-monitoring • Promotes improvement • Accountability • Sustainability

14. Overcoming Barriers • Quality improvement as part of standard clinical training curricula • Refinement of technologies to promote adequate data capture of mental health services • Need for behavioral health researchers to improve the evidence base for behavioral health treatment • Use of incentives to promote provider accountability for improving care Kilbourne, Keyser, & Pincus, 2010

15. Barriers • Barriers will exist • what works best for your practice • Team-based approach to QA/QI management • “Change fatigue” will happen • Start small and celebrate victories along the way! • Use management QI strategies • (PDSAs, pro formas, PI teams, LEAN, ReAim, RIE)

16. Start with Standardizing • Executive leadership review and definition of how you are implementing and fostering the culture of integrated care • Identify expectations from leadership, providers, staff, and patients • Mirror the quality management to the medical practice review and consider reviewing the established metrics first • Every quality indicator MUST be measureable and SMART!

17. Quality Indicator Focus Consider process, structure, workflows, benchmarks, and outcomes • Operational • Model fidelity • Culture specific • Fiscal • Program sustainability • Program growth • Quality • Value based • Experience of care • Population health • Satisfaction • Cost Ultimately: Help clinics meet the Triple Aim & providers manage their patients

18. How do we evaluate PCBH? Operational and Model Fidelity • Productivity/Access • Session frequency • Time spent with patients • Penetration rates • Top diagnoses • Clinical quality indicators • Care team meetings • Huddling • Documentation • Communication • Location • Provider satisfaction • Patient satisfaction • Utilization outcomes • Many others

19. Operational / ModelSession Specific Metrics • Number of visits per episode of care • Why important? • Benchmarks • Clinic dependent • Mean number of visits = 2- 4 visits • Median = 2 visits • Mode = 1 visits • No more than 10-15% of patients receiving more than 6 visits in 12 month period with specific justification of care: PHM or group medical visit focus

20. Increase percentage of patients who are seen for mental, medical, or behavioral health treatment needs by the integrated behavioral health provider. • Percentage of clinic patients having a BH consult • Benchmark • Clinic dependent • 25-30% of clinic • Care team / pod specific • Top diagnosis • Benchmark • Clinic dependent • PHM focus • Quality improvement focus • Provider study • Duplicated vs unduplicated • 40-100% for a robust clinic

21. Clinical Quality Metrics Review PCMH NCQA Requirements for IBH. Review NQF, UDS, HEDIS Metrics PCMH 2, Element D, Factor 3: MUST PASS The Practice Team: Increase frequency of utilization of huddle care team form / IBH as part of daily primary care team huddles NQF 0710: Depression Remission at Twelve Months: PCMH 3, Element B, Factor 9: Improve percentage of depression remission (PHQ-9 score of less than 5) at 12 months for patient’s with PHQ-9 over 9.

22. Experience of Care Process Outcomes Level of pt satisfaction with access Level of pt satisfaction with effectiveness Pt recommendation of office to others Level of provider satisfaction with role enhanced, job, engagement, and quality of care delivered • Percentage of pts that were asked to complete a healthcare satisfaction measure • Percentage of providers asked to complete satisfaction measure

23. Population Health • Review PCMH NCQA Requirements • Review NQF, UDS, HEDIS Metrics Process Outcome Pt quality of life functioning (e.g., score on a quality of life measure) Pthealth functioning (e.g., score on PHQ) Ptphysical health indicators (e.g., body mass index, waist girth, weight, blood pressure, blood glucose levels, lipid levels, pain level, alcohol use, physical activity, tobacco use) • Number of pts seen in PC in a week/month/quarter • Percentage of pts seen in PC that were screened for a given problem (e.g., health status, depression, AOD) • Percentage of pts that screen positive for a problem • Percentage of pts that screen positive that were referred to the PC BH staff for further assessment or intervention

24. Cost Process Outcomes Annual percent increase in per capita costs Emergency room visits Emergency room visits for mental health presentation alone Frequency of hospital admissions Annual revenue generation • Percentage of pts that were referred to the PC BH staff that kept the appointment (pts with untreated problems have higher overall cost) • Percentage reduction in ED usage / specific utilization • Percentage of patients that were referred for a BH appointment outside of the primary care clinic • Type and duration of PC BH treatment • Percentage of types of billing codes used and reimbursed

25. Questions to Form Decision-Making • What is your goal for the program? • What are the predictors of model fidelity? • How can I measure success? • How can I demonstrate • Patient impact? • Fiscal impact? • Provider impact? • How do I get reliable data?

26. Data Mining Options Collecting metrics to demonstrate quality improvement in PCBH

27. Where/How do I find the Data? • Claims data • ROI for insurance companies • Joint ventures with insurance companies • Registries • Survey Data • Electronic Health Records • HIE (Health Information Exchanges) • HEDIS, UDS, NQF, Physician Quality Reporting • Self-reporting • Other ways?

28. Electronic Health Systems and Technology • EHR Systems/ HIT • Population identification • Identification of care gaps • Stratification • Patient engagement • Care management • Outcomes measurement

29. Barriers to Data • Forms of Data: How to choose? • Claims • Chunking • Small amounts • Analytical vs Clinical • Volume of Data • How to understand it? • How is it relevant?

30. Data Points • Clinical Indicators • Mortality • Health status • Biometrics • Disease prevalence • Disability status • Health Maintenance • Health assessments (screening tools) • ED visits • Re-admission • PHM • Standardization • HEDIS • UDS / NQF / CMS  • Annual QI Goals • RVUs/Productivity • Fiscal ROI • NCQA PCMH • Organizational • Employee wellness • Job satisfaction • employment sustainment • Satisfaction • Model • Length of session • CPT coding • Diagnosis coding • Visit type • Productivity • Huddles • Communication • Documentation

31. Quality Assurance/ Evaluation • Plan-Do-Study-Act (PDSA) • RE-AIM Framework (Reach, Effectiveness, Adoption, Implementation, Maintenance): As you design, plan, or evaluate an intervention, there are questions that you should ask yourself: • Reach your intended target population • Efficacy: Intervention effectiveness; negative consequences? • Adoption by target staff, settings, or institutions • Implementation consistency, costs and adaptations made during delivery • Maintenance of intervention effects in individuals and settings over time • Process and Program Evaluations (e.g., Precede-Proceed): 1) Planning 2) Evaluation

32. Since time is ticking… • We will focus on only a few metrics, mainly related to productivity/access to care standard examples • Benchmark provided but unique to each clinic/organization We will have time for questions!

33. Productivity / Access to Care • Patient per hour/clinic • Benchmarks • 1.5 patients per hour OR • 50% of PCP’s expectations per clinic • PCPs expected to see 10 patients per clinic, BHCs expected to see 5 patients per clinic • Initial vs. Follow-ups • Danger to both sides of the coin • Benchmarks • 1:1 or 50% of visits being initials • Warm-handoffs/Same-day visits • Benchmark • 50% of all visits

34. Managing: Productivity/Access Per Clinic The solid straight bars indicate your control limits for standard expectation, lowest limit, and possible productivity bonus

35. Initials/RA vs. F/u

36. Warm-handoff/Same day percentage

37. Productivity and Access to Care Efforts • Improved patient and family care and satisfaction;early identification; pt centered; enhanced adherence and collaboration; shared decision making • Consultation; self management support, reduced health disparities; improved care team access • Improved cost containment; targeted use of resources; revenue generation; decreased other specialty visits, brief screenings for early identification; increased provider coding

38. QUESTIONS Lesley Manson, Psy.D. Email: lesley.manson@asu.edu David Bauman, PsyD Email:davidbauman4@gmail.com Bridget Bauman, PsyD Email: bridgetbeachy@gmail.com Stacy Ogbeide, PsyD, MS Email: stacy.ogbeide@gmail.com Melissa Baker, PhD Email: mbaker@healthpointchc.org

39. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!