Stephen Crystal, Ph.D. Center for Health Services Research on Pharmacotherapy, Chronic Disease

1. Accelerating Utilization of CEFindings in Medicaid Mental Health:The Medicaid Mental Health Network for Evidence Based Care Stephen Crystal, Ph.D. Center for Health Services Research on Pharmacotherapy, Chronic Disease Management, and Outcomes/ Center for Education and Research on Mental Health Therapeutics Rutgers University Presented at AHRQ Annual Meeting Bethesda September 27, 2010

2. The Challenge • State Medicaid programs play a central role in the provision of mental health services in the U.S., especially for lower-income youth and for adults with severe mental illness. The quality of this care strongly impacts the lives of millions of vulnerable beneficiaries. Resources spent on this care are substantial. • Medicaid will assume an even larger role in this area in the wake of coverage expansions under the Affordable Care Act. • However, mental health treatment for MA benes varies widely; utilization of evidence-based treatment practices is uneven; care and outcomes are often sub-optimal. Safe, effective, and evidence-consistent use of psychotropic medications is a particular challenge (cf. AHRQ evidence report on off-label use of antipsychotics.) • In prior collaborative work, states have identified improvement of mental health treatment processes and increasing utilization of existing CE evidence in this area as an important priority. Several states have implemented innovative quality improvement initiatives, but programs are often “siloed” across states and translation of promising practices is needed.

3. Background: The ACP Project • The NET builds on the experience of a prior collaboration between 16 states participating in AHRQ’s Medicaid Medical Directors Learning Network (MMDLN) and the AHRQ-funded Rutgers Center for Education and Research on Mental Health Therapeutics (mental health CERTs). • At a 2007 MMDLN meeting in Seattle, mental health CERTs investigators and state mental health directors discussed challenges of Medicaid mental health care with MMDLN. MMDs prioritized the issue of APs in youth as top priority for a collaborative project, which became the Antipsychotics in Children Project (ACP). Results were presented at a forum on stakeholder/researcher collaboration at the 2009 AHRQ Annual Meeting.

4. Background: The ACP Project • Issues addressed in ACP project included widespread off-label use of antipsychotics despite limited evidence base for safety and effectiveness; adequacy of initial assessment and monitoring; use by very young children; drug treatment without concomitant mental health services; polypharmacy. • Project activities included benchmarking of AP prescribing practices across states, with states conducting own analyses, and documentation/sharing of promising practices. • A Report and Resource Guide was developed and is publicly available on Rutgers website. A number of states have already implemented new and promising practices as a result of participation, as documented in the report.

5. Lessons Learned from ACP Project • ACP demonstrated potential of researcher/state collaboration in multistate QI initiatives in Medicaid mental health as well as the scope of the challenge and the need for a more extensive follow-on project to support more robust implementation of evidence based practices, further engagement of providers and other stakeholders, necessary data/metrics infrastructure, and initiatives to address treatment challenges in adults. • Project experience, as well as other evidence on translation and implementation of delivery system interventions for evidence adoption in this area, indicates: • vital role of stakeholder engagement and systematic collaboration; • need for development and implementation of appropriate quality metrics for use both at statewide and provider levels; • a systematic process for setting goals and measuring progress; • and active provider feedback with systematic educational followup, as incorporated in the NET approach

6. Genesis of NET • Building on experience of the ACP, a group of 7 states worked together with Rutgers and other partners to develop a plan for a systematic, collaborative, multistate initiative to accelerate the implementation of comparative effectiveness findings in Medicaid funded mental health care, addressing treatment challenges for adults as well as children and utilizing common quality metrics to support problem identification, monitoring, and provider feedback interventions.

7. NET Mission • Accelerate adoption in Medicaid mental health of two types of CE findings: • Findings on effectiveness and safety of specific clinical practices, in particular patient populations; • Findings on effectiveness of organizational practices, strategies and policies related to management of these treatments and of risks associated with treatments across subpopulations.

8. NET Consortium • Multi-partner collaboration focused on increasing utilization of evidence-based clinical and service delivery system practices in provision of mental health treatment for Medicaid beneficiaries. • Partners include states of California, Washington, Texas, Missouri, Oklahoma, Maine, and Arizona, in addition to Rutgers, New York State Psychiatric Institute/Columbia University, AcademyHealth and Mayo Clinic. • Participating states account for about 33% of FFS Medicaid enrollment nationally, with approximately 20 million enrollees including 10.4 million children and youth. • Analyses of MAX data from 5 of these states for 2005 indicate that more than 550,000 beneficiaries received antipsychotic medication prescribed by more than 74,000 prescribers at a cost of $1.4 billion (most costly med class for MA).

9. NET Consortium • Collaborating states will develop a multi-stakeholder quality collaborative, a state quality improvement plan, and a continuous quality improvement process. • With TA from partners, each state will implement a set of QI initiatives, building on experience of programs that have been successful in collaborating states.

10. Within-State and Cross-State Collaboration • Within states, quality collaboratives will bring together leaders from multiple state agencies (Medicaid, state mental health, children’s services) along with other clinical providers, consumer and family organizations, and other key stakeholders to assess data on current practices, and to develop and implement state QI plans. • The larger cross-state consortium will support sharing of knowledge and translation of successful practices across states, as well as common approaches to development and use of metrics and implementation of QI systems. Further subsequent translation to additional states beyond the consortium will be facilitated through dissemination activities in collaboration with MMDLN, AcademyHealth, NASMHPD, NASMD and other partners.

11. Targeted Clinical Practices The NET will focus primarily on increasing implementation of evidence-based practices in the following areas: • Psychotropic polypharmacy, including concurrent use of multiple antipsychotic medications; • Safe dosing; • Managing metabolic risks of antipsychotics; • Improving treatment adherence for adults with SMI; • Use of appropriate mental health services and psychosocial interventions as complement or alternative to antipsychotic medication; • Antipsychotic use in children under age 6 and in foster care ; • Assessing and addressing geographical, provider, racial/ethnic, and other variations in treatment practices that lack apparent clinical or epidemiological rationale and may add costs and risks without concomitant benefit; • Consistency of treatments and diagnoses (e.g., antipsychotic use in children diagnosed only with ADHD; cf. Crystal et al, Health Affairs 2009).

12. Approach and Core Strategies • For each clinical issue, NET will develop and deploy a core set of measures of treatment practices, and utilize measures to provide each state with a profile of treatment patterns. • Profiles will identify within-state and between-state variation in practices; examine consistency of treatment practices with evidence and guidelines; identify variation across provider types and providers. Periodic profiles will track treatment patterns over time, space and subpopulations as QI initiatives proceed. • Quality measures will be refined into metrics to support provider feedback interventions. States will receive TA in implementing metrics on ongoing production basis as a foundation for QI. • States will designate state project directors, co-project directors and data liaisons; form state quality collaborative engaging clinical leaders and other stakeholders; develop and implement state plan for QI.

13. Approach and Core Strategies • QI program will be implemented in each state incorporating systematic provider feedback with followup, using project-developed metrics, in concert with related QI and provider education initiatives from a menu of project-supported programs, in accordance with state plan and supported by project TA. • Menu of NET-supported initiatives will include clinic-based quality improvement building on New York’s PSYCKES model, a prescriber outreach model building on Missouri’s Mental Health Medicaid Pharmacy Partnership program and other existing state initiatives; and an expert consultation program modeled after Washington State’s Second Opinion program.

14. Approach and Core Strategies • QI initiatives will be supported with web-based and other educational modules for clinicians, webinars, technical assistance, and other program support activities, translating existing evidence on effectiveness and safety of clinical practices into formats tailored to clinician types and settings. • Ongoing feedback will be provided to states on impact of initiatives on treatment patterns. • Results will be disseminated nationally to additional states and stakeholders to increase utilization of evidence-based practices more broadly, building on experience of the NET.

15. For Further Information ACP Report/Resource Guide and other materials at: http://chsr.rutgers.edu/MMDLNAPKIDS.html (or google Rutgers MMDLN Resource Guide) Clinician’s Toolkit for Management of Atypical Aggression in Youth http://www.chainonline.org/content.cfm?menu_id=232 Email: scrystal@rci.rutgers.edu