Screening for Co-occurring Disorders Within a Quality Improvement Framework

1. Screening for Co-occurring Disorders Within a Quality Improvement Framework Susan Brandau NYS Office of Alcoholism and Substance Abuse Services SusanBrandau@oasas.state.ny.us

2. OASAS Vision: A Transformed System • Actively combats stigma • Values quality • Continuously improves • Measures success by measuring individual recovery • Adopts evidence based practices • Tailors evidence based practice combinations to the needs of individual clients • Stresses adequate housing, employment and social integration

3. Shifts in Conceptual Framework and Policy • No “Wrong Door” • No third system of care • Integration is Local • No large $ infusion

4. What is Continuous Quality Improvement? A quality management model whereby healthcare is seen as a series of processes and a system leading to an outcome. QI strives to make changes in the structural and process components of care to achieve better outcomes.

5. Quality Improvement and Healthcare • Added element of the client • Passive vs. active: Individuals are empowered • Medical Errors • Outcome of Care • Basing Practice on Evidence

6. Quality Improvement is an Orientation and Attitude • We understand our work as processes and systems. • We are committed to continuous improvement of processes and systems

7. Core Principles of Continuous Quality Improvement • Customer Focus • Recovery Oriented • Employee Empowerment • Leadership Involvement • Data Informed Practice • Using Statistical Tools • Prevention over Correction • Continuous Improvement • Participation and Communication at all levels

8. Overview of a CQI Program • Essential Program Aspects • Provide a structure through which the core organization functions are evaluated and improved • Core functions will be defined by the Mission, Vision, and Values of the organization • Examples of core functions • Outcomes: client safety, clinical outcomes, client satisfaction • Process: client flow, fiscal issues • Core functions operationalized for data collection purposes • Examples of operationalized functions • Outcomes: med errors, suicide attempts, satisfaction survey data • Process: wait list latency, no show rates, medication costs • Evaluation of the functions achieved through analysis of collected data • Improvements accomplished through projects/initiatives

9. Overview of a CQI Program Where do projects and initiatives come from? • Internal • Unacceptable variation in key indicators • Management initiatives • Client complaints • Incidents • External • Literature, e.g. Evidenced Based Practices • Benchmarking – comparing organizations results to other, like organizations • Regulatory agencies, changes in law/standards

10. Overview of a CQI Program • Internal and external factors will be reviewed by QI Committee (and others – Board of Directors, etc) • Projects/initiatives will be started based on results of prioritization process

11. Setting Priorities • Always more improvement opportunities than can be effectively addressed • Set Priorities based on: • Relevance to mission • Clinical Importance: High volume, high risk, problem-prone • Expected impact on outcome of care • Available resources and cost

12. What is a Project or Initiative? • A planned activity, often involving a group of people, with a specific goal or expected outcome • Quality improvement is about doingsomething based on our priorities • Requires a planned and systematic approach

13. Shared Core Method of Quality Improvement Approaches • Plan • Do • Study • Act

14. Quality Improvement: Plan • Select the project • Understand and clarify the process • Data • Flowcharting • Brainstorming • Fishbone Diagram • Develop a Plan of Action

15. Quality Improvement: Plan Plan the action • Plan the pilot test of the action • Include in the plan a measure of performance

16. What is a Performance Indicator A quantitative tool that provides information about the performance of a process

17. Quality Improvement: Do • Collect data • Analyze and prioritize • Determine most likely solutions • Test whether our action really works before we make it a routine part of our daily operations

18. Quality Improvement: Study • At the end of the pilot period, determine whether the action has had the desired effect. • Is the modified process stable? • Did the process improve?

19. Quality Improvement: Act If the action works: • Make it part of routine operations • Continue to gather data to make sure you are holding the gains

20. Quality Improvement: Act If the action does not work: • Return to the Plan stage • Use the test to plan a better action

21. PDCA is a Cycle It is not about one single dramatic action, but about trying things to see if they work. Remember, life is a series of experiments.

22. Evidence Based Practice • A special QI method: Systematically copying a process or system that works better • Care of psychiatric disorders is an increasingly research based activity • The Challenge: Transfer of knowledge • A formal rather than informal activity • Approach fidelity. • Objective assessment.

23. Lessons and Challenges • Collect only the data that is tied to the improvement you want to make. • Keep it simple and Non-Burdensome. (Most clinics collect data by hand) • Make sure the findings are communicated and that leadership knows about the QI project. It is part of the overall agency management framework. • Don’t take shortcuts. Don’t skip the PDCA. • Call your colleagues. • Compare results across sites in an agency.

24. Quality Improvement PlanTemplate • Optional • Sections to be completed • Mission, Vision and Scope of services • Leadership and QI committee • Goals and objectives • Selection and description of indicator • Assessment strategies • Approach or model to be used

25. Mission/Vision: Scope of ServicesSection 1 of the plan • Describe program philosophy • Provide basic descriptive information including: • Description of individuals served • Catchment area • Type of services • Size of the organization

26. Leadership and QI CommitteeSection 2 of the plan • The Quality Improvement Committee • Membership issues • Responsibilities • Meeting frequency • Critical role of leadership support • Sharing of findings with stakeholders

27. Goals and Objectives Section 3 of the Plan • Long term core goals of any quality improvement program • Objectives • Related to selected goals • Specific to the clinic • Measurable • Expected completion within 12 months • A basis for the annual evaluation

28. Things to Consider in Selecting a Performance IndicatorSection 4 of the Plan • Mission of the Clinic • Clinical importance: High Volume, High Risk, Problem Prone • Outcome • Available resources and cost

29. Description of Performance IndicatorSection 4 of the Plan • A quantitative tool that provides information about the performance of a clinic’s processes, services, functions or outcomes • Data collection • Assessment frequency

30. EXAMPLE: Screening for Co-Occurring Disorders • Relevance to Mission and Clinical Importance: Less than 20% of providers could identify a tool they used to screen all clients for co-occurring disorders • High prevalence of co-occurring disorders in the population served • Undiagnosed, untreated COD means as a client moves into recovery, they will have a higher rate of relapse-why is my client not getting better? • Clinic 30-day retention of co-occurring disorders clients low

31. INDICATORS • The number of dually diagnosed clients screened initially and at 3, 6 and 12 month intervals • The number of clients with COD that progress through treatment

32. Implementation of Screening: Desired Result? • By implementing a validated screening tool such as the Modified Mini Screen (MMS), a provider will be able to identify clients in need of a complete mental health assessment, refer clients for a MH assessment, and incorporate specific goals into the development of a client’s treatment plan thereby becoming more responsive to their needs and retain the client in treatment

33. Guiding Knowledge Adoption Principles • Training and printed material as dissemination strategies are necessary but not sufficient for practitioner behavior change • Comprehensive and effective dissemination requires an ongoing interpersonal component • Credibility of the source of information is critical • Interpersonal contact promotes relationship building and trust

34. Guiding principles (cont’d) • User-friendly materials must be utilized • Practitioners must be integral partners in the design and implementation process • Provider implementation plans make the locus of responsibility the provider organization • Idea champions within providers are essential for internal marketing and staff buy-in

35. PLAN,PLAN,PLAN • Provider selects “idea champion” to coordinate all screening activities • Agency completes a written implementation plan • Idea champion selects and recruits key staff (clinical director, clinical supervisors, utilization review coordinator, psychiatric social worker, psychiatrist) to receive training and replicate the training with their supervisees • Provider collects baseline prevalence data and examines its client population

36. Implementation Plan • Identifies what clients are to be screened • When screening should occur • How clinicians will present the tool and the results to the client • How the program will monitor the use of the screen • What “cut-point” will trigger a referral for a complete MH assessment • Timetables for inclusion of screening on the client’s treatment plan

38. Key Training Concepts • What is Screening? A formal process of testing to determine whether a client requires further attention in regard to a particular disorder • Does the chemical dependence client show signs of a possible MH problem that requires a complete MH assessment by a licensed practitioner?

39. Screening vs. Assessment • Screening: process for evaluating the possible presence of a problem • Assessment: process for defining the nature of that problem and developing specific treatment recommendations that address the problem

40. Key Training Concepts • Role play how to conduct a screen using the MMS • Identify the strengths/limitations of the MMS: 22-item scale to screen for mood, anxiety and psychotic disorders-does not screen for personality disorders • Understanding the client population: Identify treatment characteristics of clients with COD

41. Basic Competencies Inherent within a “No Wrong Door” Principle • Perform a basic screening to determine whether COD might exist • Form a preliminary impression of the nature of the disorder (anxiety, mood, psychosis, personality disorders) • Conduct a preliminary screening for whether the client poses an immediate danger to self/others

42. Basic Competencies (cont’d) • Be able to engage the client to enhance and facilitate future interaction • De-escalate an agitated, anxious, angry client • Coordinate care with a MH counselor/program

43. DO • Key selected staff receive training on the MMS • All staff become familiar with the agency’s implementation plan • Provider begins to screen all clients for COD within the first 30 days of treatment • Provider collects data (# of positive screens, # of positively screened clients that in fact have a MH diagnosis)

44. DO • Idea Champion ensures all clients receive screening • Clinical Supervisors monitor client treatment record for presence of a timely completed screen • Utilization Review Coordinator monitors charts to ensure integration of screen results within the client treatment plan • Track and evaluate progress of COD clients as a group

45. STUDY • Review data and discuss findings in monthly QI meetings • Revise agency implementation plan, if needed- is the preliminary “cut-point” effective for identifying clients with COD? • Are the current service provider agreements sufficient ? • Do all clients identified as needing a complete MH assessment receive one in a timely manner (access is less than 2 weeks)? • Have clinicians bought into the process? • Are procedures adequate for monitoring of clients that did not initially meet the agency’s cut-point?

46. ACT • Revised processes are implemented • Data collection continues to ensure that positive results are maintained over time; adherence to screening protocol monitored over time • Staff learned from each other-successful strategies are reinforced at staff meetings • Additional projects are formulated that respond to staff identified needs (motivational interviewing to strengthen engagement skills, more in depth training on co-occurring disorders, development or expansion of integrated treatment groups, use of other EBPs)

47. Lessons Learned • No “one size fits all model-agencies must develop their own QI process and screening protocol • Organizational readiness, commitment to screening and leadership critical • Written implementation plans developed with clinician feedback provide a template • Programmatic idea champions coordinate the processes • Participation of a critical mass of agency interdisciplinary staff • Local models of adoption key to success • Utilization of peer mentors helps to promote integration

48. Buckminster Fuller: • “If you want to change the way people think, give them a tool the use of which will lead them to think differently”