Update on the Hospital-Based Inpatient Psychiatric Services HBIPS Core Measure Set

1. Update on the Hospital-Based Inpatient Psychiatric Services (HBIPS) Core Measure Set Celeste Milton, MPH, BSN, RN Associate Project Director Department of Quality Measurement September 28, 2010

2. 2 ORYX Requirements & Reporting HBIPS-1 HBIPS-2 HBIPS-3 HBIPS-4 HBIPS-5 HBIPS-6 HBIPS-7 Agenda

3. 3 HBIPS Demographics 24 vendors supporting HBIPS 311 hospitals participating in HBIPS 238/311 (76%) free-standing psychiatric hospitals 73/311 (24%) acute-care hospitals with psychiatric units

4. 4 National Quality Forum (NQF) Endorsement HBIPS 4,5,6 & 7 endorsed August 2009 HBIPS 2 & 3 endorsed February 2010 HBIPS 1 not endorsed

5. 5 ORYX Requirements Free-Standing Psychiatric Hospitals Surveyed under CAMH HBIPS measure set will be mandatory beginning with January 1, 2011 discharges and events Acute-Care Hospitals with Psychiatric Units One of four sets of core measures

6. 6 ORYX Reporting HBIPS 2-7 will be publicly reported on QualityCheck.org HBIPS 2-7 will be included in Priority Focus Process (PFP) or Strategic Surveillance System (S3) HBIPS-1 will not be publicly reported or included in PFP and S3 All measures included in ORYX Performance Measure Report used during survey

7. 7 HBIPS Measures HBIPS-1: Admission Screening HBIPS-2: Physical Restraint HBIPS-3: Seclusion HBIPS-4: Multiple Antipsychotic Medications at Discharge HBIPS-5: Multiple Antipsychotic Medications at Discharge with Appropriate Justification HBIPS-6: Post Discharge Continuing Care Plan HBIPS-7: Post Discharge Continuing Care Plan Transmitted

8. 8 HBIPS Measure Set Population Inpatient Psychiatric Patients Psychiatric Inpatient Discharges- HBIPS-1,4 5, 6 & 7 Psychiatric Inpatient Days- HBIPS-2 & 3 Includes all ages stratified by four age groups Children (1-12 years old) Adolescents (13-17 years old) Adults (18-64 years old) Older Adults (> 65 years old) Does not include residential treatment programs, outpatient settings or other programs accredited under the BHC manual. In addition to an overall rate, the measures are further stratified by 4 age groups: 1-12 yrs (children), 13-17 (adolescents). 18-64 (adults) & 65 and older (older adults). Does not include residential treatment programs, outpatient settings or other programs accredited under the BHC manual. In addition to an overall rate, the measures are further stratified by 4 age groups: 1-12 yrs (children), 13-17 (adolescents). 18-64 (adults) & 65 and older (older adults).

9. 9 HBIPS Measures # 1, 4, 5, 6 and 7 Discharge Measures

10. 10 HBIPS Measure # 1 Admission Screening for Violence Risk, Substance Use, Psychological Trauma History and Patient Strengths Completed Patient domain- AssessmentPatient domain- Assessment

11. 11 Rationale High prevalence of co-occurring substance use disorders & history of trauma in acute psychiatric settings Risk assessment an important aspect of patient safety Assessment of patient strengths help guide individualized treatment plans that are culturally appropriate

12. 12 Numerator and Denominator Psychiatric inpatients with admission screening within the first three days of admission for all of the following: risk of violence to self or others; substance use; psychological trauma history; and patient strengths _____________________________________ Psychiatric inpatient discharges All 5 components of the initial assessment must be present in order to be included in the numerator population. Data for this measure is reported from acute-care hospitals with the first admission to the psych unit if there were multiple stays in the psych unit during the hospitalization. All 5 components of the initial assessment must be present in order to be included in the numerator population. Data for this measure is reported from acute-care hospitals with the first admission to the psych unit if there were multiple stays in the psych unit during the hospitalization.

13. HBIPS-1a: Admission Screening for Violence Risk, Substance Use, Psychological Trauma History and Patient Strengths Completed

14. HBIPS-1b: Admission Screening for Violence Risk, Substance Use, Psychological Trauma History and Patient Strengths Completed

15. HBIPS-1c: Admission Screening for Violence Risk, Substance Use, Psychological Trauma History and Patient Strengths Completed

16. HBIPS-1d: Admission Screening for Violence Risk, Substance Use, Psychological Trauma History and Patient Strengths Completed

17. HBIPS-1e: Admission Screening for Violence Risk, Substance Use, Psychological Trauma History and Patient Strengths Completed

18. HBIPS Measure # 4 Patients Discharged on Multiple Antipsychotic Medications 18 Patient domain- Patient Safety This measure has been split into 2 measuresPatient domain- Patient Safety This measure has been split into 2 measures

19. 19 Rationale Use of multiple antipsychotics associated with severe side effects 50% of current inpatients on 2 or more antipsychotics Practice guidelines in place Previous failed trials of monotherapy Tapering down to one antipsychotic after discharge Augmentation of Clozapine

20. 20 Numerator and Denominator Psychiatric inpatients discharged on two or more routinely scheduled antipsychotic medications _______________________________ Psychiatric inpatient discharges Patients are only included in the numerator if the they are discharged on two or more antipsychotics. This measure expresses a raw rate only. Patients on more than 1 antipsychotic are more prone to develop undesirable side effects such as metabolic syndrome; therefore, this measure reflects that the lower the rate the better just like the restraint and seclusion measures that I will be discussing later. Patients are only included in the numerator if the they are discharged on two or more antipsychotics. This measure expresses a raw rate only. Patients on more than 1 antipsychotic are more prone to develop undesirable side effects such as metabolic syndrome; therefore, this measure reflects that the lower the rate the better just like the restraint and seclusion measures that I will be discussing later.

21. HBIPS 4a- Patients Discharged on Multiple Antipsychotic Medications 

22. HBIPS 4b- Patients Discharged on Multiple Antipsychotic Medications 

23. HBIPS 4c- Patients Discharged on Multiple Antipsychotic Medications 

24. HBIPS 4d- Patients Discharged on Multiple Antipsychotic Medications 

25. HBIPS 4e- Patients Discharged on Multiple Antipsychotic Medications 

26. 26 HBIPS Measure # 5 Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification Patient domain- Patient Safety This is the counter part measure to HBIPS-4 that looks at documentation of appropriate justification.Patient domain- Patient Safety This is the counter part measure to HBIPS-4 that looks at documentation of appropriate justification.

27. 27 Numerator and Denominator Psychiatric inpatients discharged on two or more routinely scheduled antipsychotic medications with appropriate justification _________________________________ Psychiatric inpatients discharged on two or more routinely scheduled antipsychotic medications (Derived from HBIPS-4) Patients are only included in the numerator if the appropriate justification for two or more antipsychotics documented. Patients from the numerator population from HBIPS-4 make-up the denominator population for this measure. This measure reflects that the higher the rate the better just like HBIPS 1, 6 & 7. When comparing 2 hospitals with high rates of patients discharged on multiple antipsychotics, it will be important to view the results of this measure to better determine whether the practice is supported by the evidence in the field. Patients are only included in the numerator if the appropriate justification for two or more antipsychotics documented. Patients from the numerator population from HBIPS-4 make-up the denominator population for this measure. This measure reflects that the higher the rate the better just like HBIPS 1, 6 & 7. When comparing 2 hospitals with high rates of patients discharged on multiple antipsychotics, it will be important to view the results of this measure to better determine whether the practice is supported by the evidence in the field.

28. 28 Appropriate Justifications Three previous failed trials of monotherapy by history Recommended plan to taper to monotherapy Augmentation of Clozapine The TAP conducted a review of research studies on the impact of multiple antipsychotics versus monotherapy published from 1965 through 2007 and determined that these are 3 appropriate justifications for more than 1 antipsychotic . This measure reflects that the higher the rate the better just like HBIPS 1, 6 & 7. When comparing 2 hospitals with high rates of patients discharged on multiple antipsychotics, it will be important to view the results of this measure to better determine whether the practice is supported by the evidence in the field. For the purposes of this measure failed trials are defined as at least 3 by history. The TAP conducted a review of research studies on the impact of multiple antipsychotics versus monotherapy published from 1965 through 2007 and determined that these are 3 appropriate justifications for more than 1 antipsychotic . This measure reflects that the higher the rate the better just like HBIPS 1, 6 & 7. When comparing 2 hospitals with high rates of patients discharged on multiple antipsychotics, it will be important to view the results of this measure to better determine whether the practice is supported by the evidence in the field. For the purposes of this measure failed trials are defined as at least 3 by history.

29. HBIPS 5a- Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification 

30. HBIPS 5b- Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification

31. HBIPS 5c- Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification

32. HBIPS 5d- Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification

33. HBIPS 5e- Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification

34. 34 HBIPS Measure # 6 Post Discharge Continuing Care Plan Created Patient Domain- Continuity/ transition of care This measure has also been split into 2 measures. The requirement to send the plan has been moved to the next measure, HBIPS-7. A continuing care plan may consist of one document or many documents which would be considered a continuing care “packet”. The hospitals needs to be able to identify which documents make up the continuing care plan.Patient Domain- Continuity/ transition of care This measure has also been split into 2 measures. The requirement to send the plan has been moved to the next measure, HBIPS-7. A continuing care plan may consist of one document or many documents which would be considered a continuing care “packet”. The hospitals needs to be able to identify which documents make up the continuing care plan.

35. 35 Rationale Patients may not be able to report details of hospitalization and follow-up required Aftercare recommendations given to the patient not always available Information necessary to provide optimum care

36. 36 Numerator and Denominator Psychiatric inpatients for whom the post discharge continuing care plan is created and contains all of the following: the reason for hospitalization, principal discharge diagnosis, discharge medications and next level of care recommendations _____________________________________ Psychiatric inpatient discharges All 4 components must be present in the continuing care plan in order to be included in the numerator population. In an acute-care hospital, if there are multiple admissions to psych unit, abstract once at time of discharge from the hospital. All 4 components must be present in the continuing care plan in order to be included in the numerator population. In an acute-care hospital, if there are multiple admissions to psych unit, abstract once at time of discharge from the hospital.

37. HBIPS 6a- Post Discharge Continuing Care Plan Created

38. HBIPS 6b- Post Discharge Continuing Care Plan Created

39. HBIPS 6c- Post Discharge Continuing Care Plan Created

40. HBIPS 6d- Post Discharge Continuing Care Plan Created

41. HBIPS 6e- Post Discharge Continuing Care Plan Created

42. 42 HBIPS Measure # 7 Continuing Care Plan Transmitted to the Next Level of Care Provider upon Discharge Patient Domain- Continuity/ transition of care This is the counter part measure to HBIPS-6.Patient Domain- Continuity/ transition of care This is the counter part measure to HBIPS-6.

43. 43 Numerator and Denominator Psychiatric inpatients for whom the post discharge continuing care plan was transmitted to the next level of care _______________________________ Psychiatric inpatient discharges All 4 components must be present in the continuing care plan and each must be sent in order to be included in the numerator population. The requirement to look for evidence that an aftercare appointment has been made, has been removed from this measure, instead the hospital should be sending the continuing care plan to the next level of care provider or entity optimally by the next business day but no later than 5 days after discharge. Once again, in an acute-care hospital, if there are multiple admissions to psych unit, abstract once at time of discharge from the hospital. All 4 components must be present in the continuing care plan and each must be sent in order to be included in the numerator population. The requirement to look for evidence that an aftercare appointment has been made, has been removed from this measure, instead the hospital should be sending the continuing care plan to the next level of care provider or entity optimally by the next business day but no later than 5 days after discharge. Once again, in an acute-care hospital, if there are multiple admissions to psych unit, abstract once at time of discharge from the hospital.

44. HBIPS 7a-Continuing Care Plan Transmitted to the Next Level of Care Providers upon Discharge

45. HBIPS 7b-Continuing Care Plan Transmitted to the Next Level of Care Providers upon Discharge

46. HBIPS 7c-Continuing Care Plan Transmitted to the Next Level of Care Providers upon Discharge

47. HBIPS 7d-Continuing Care Plan Transmitted to the Next Level of Care Providers upon Discharge

48. HBIPS 7e-Continuing Care Plan Transmitted to the Next Level of Care Providers upon Discharge

49. 49 HBIPS Measures # 2 and 3 Event Measures Patient domain- Patient SafetyPatient domain- Patient Safety

50. 50 HBIPS Measure # 2 Hours of Physical Restraint Use Patient domain- Patient Safety This measure will now be looking at physical restraint use only. Patient domain- Patient Safety This measure will now be looking at physical restraint use only.

51. 51 Rationale Need to respect the patient’s independence, autonomy and safety Avoid the use of dangerous or restrictive interventions at all times Restraint use should be closely monitored and analyzed to reduce further use

52. 52 Numerator and Denominator The total number of hours that all psychiatric inpatients were maintained in physical restraint ________________________________ Number of psychiatric inpatient days This is the first ratio measure from TJC. The numerator population is patient level data that is reported as the total number of minutes per day for the entire reporting month that the patient spent in restraints. The denominator population is the actual cumulative patient census for the reporting month. Both values are converted to hours, divided and then multiplied by 1,000. The final value is expressed as a rate per 1,000 hours. This measure reflects that the lower the rate the better.This is the first ratio measure from TJC. The numerator population is patient level data that is reported as the total number of minutes per day for the entire reporting month that the patient spent in restraints. The denominator population is the actual cumulative patient census for the reporting month. Both values are converted to hours, divided and then multiplied by 1,000. The final value is expressed as a rate per 1,000 hours. This measure reflects that the lower the rate the better.

53. HBIPS 2a- Hours of Physical Restraint UsePer 1,000 Hours

54. HBIPS 2b- Hours of Physical Restraint Use Per 1,000 Hours

55. HBIPS 2c- Hours of Physical Restraint Use Per 1,000 Hours

56. HBIPS 2d- Hours of Physical Restraint Use Per 1,000 Hours

57. HBIPS 2e- Hours of Physical Restraint UsePer 1,000 Hours

58. 58 HBIPS Measure # 3 Hours of Seclusion Use Patient domain- Patient SafetyPatient domain- Patient Safety

59. 59 Numerator and Denominator The total number of hours that all psychiatric inpatients were held in seclusion _________________________________ Number of psychiatric inpatient days The numerator population is patient level data that is reported as the total number of minutes per day for the entire reporting month that the patient spent in seclusion. The denominator population is the actual cumulative patient census for the reporting month. Values are also converted to hours, divided and multiplied by 1000 to express a rate per 1000 hours. This measure reflects that the lower the rate the better. The numerator population is patient level data that is reported as the total number of minutes per day for the entire reporting month that the patient spent in seclusion. The denominator population is the actual cumulative patient census for the reporting month. Values are also converted to hours, divided and multiplied by 1000 to express a rate per 1000 hours. This measure reflects that the lower the rate the better.

60. HBIPS 3a- Hours of Seclusion UsePer 1,000 Hours

61. HBIPS 3b- Hours of Seclusion Use Per 1,000 Hours

62. HBIPS 3c- Hours of Seclusion Use Per 1,000 Hours

63. HBIPS 3d- Hours of Seclusion Use Per 1,000 Hours

64. HBIPS 3e- Hours of Seclusion Use Per 1,000 Hours

65. 65 To view the HBIPS Measure Specifications Manual and to submit questions….. http://manual.jointcommission.org

66. 66 Questions