Tracking trajectory of change to improve outcomes Jeb Brown, PhD Center for Clinical Informatics

1. Tracking trajectory of change to improve outcomes Jeb Brown, PhD Center for Clinical Informatics

2. Outcomes initiative • PacifiCare Behavioral Health, Inc. • 4,000,000 covered lives in seven western states • Outcomes program initiated in 1999, still being expanded • Over 60 clinics and 3000 mental health providers participating

3. ALERT clinical information system • Outcome measures • Life Status Questionnaire (adults) • Youth Life Status Questionnaire (children) • Over 6000 protocols per month into system • Database contains over 50,000 cases; over 20,000 with multiple measurement points

4. Benchmarking outcomes • Definition: The practice of comparing treatment outcomes from one sample to another much larger normative sample • Requirement: Case mix adjustment methodology to predict expected outcome based on normative sample • Purpose: Provide a valid method of evaluating outcomes across sites/providers

5. Benchmarking method • Regression techniques used to model relationship between intake score and effect size • Linear relationship, even at extremes of distribution • Change Index: residualized change score (difference between predicted and actual effect size)

6. Regression lines by diagnosis PacifiCare Behavioral Health project

7. Comparing results

8. Clinics versus solo providers • Clinics are multidisciplinary • Effect size 177% greater in clinics • Length of treatment and cost of care 25% lower in clinics • Results not attributable to differences in provider type or use of medications

9. Targeting at risk cases • Change in early sessions highly predictive of outcome • This can be used to target at risk cases • Most likely outcome is patient terminates prematurely • In 2001 began to provide immediate feedback to provider to try and prevent premature termination

10. Tracking trajectory of change Case at risk

11. ALERT high risk case report(provided immediately to treating professional) Patient Name: DOB: 8/8/47 Most recent session #: 3 Session date: 11/17/01 Provider Data Date of most recent clinician assessment: 12/16/01 Diagnoses: 296.89 Life time hospitalizations: 2 Most recent hospitalization: Provider assessment of CD problem: No Provider assessment of risk of harm to self: Mild Test results Questionnaire: LSQ Intake score: 86 Target score: 68 Most recent score: 95 Severity Range: Severe Change score: -9 Change Index: -27 Critical items I have thoughts of ending my life: Always I feel hopeless about the future: Always I use alcohol or a drug to get going in the morning: Always People criticize my drinking (or drug use): Never I have trouble at work/school or other daily activities because of drinking or drug use: Never ALERTTM Notes The patient’s rate of improvement is significantly worse than expected, indicating a high risk for premature termination. The patient reports a high freguency of suicidal ideation while provider assessed no or mild risk. The patient reports possible substance abuse problem while provider assessment indicates no substance abuse problem. Treatment history indicates risk for hospitalization.

12. Increased length of treatment for at risk cases

13. Improved outcome for at risk cases • Impact of intervention most evident for solo providers • Clinics have better overall outcomes but…. • Outcome for solo providers’ at risk cases .26 effect greater than clinics’ at risk cases during 2001 (p<.05)

14. About the presenter Jeb Brown is a licensed psychologist with a Ph.D. from Duke University. His twenty plus year career he has taken him from full time clinician to clinician/administrator/researcher and finally to full time researcher and clinical informatics consultant. Jeb has over a decade’s experience in all aspects of managed behavioral healthcare. He served as the Executive Director for United Behavioral Systems of Utah (an United Health Care subsidiary) from 1987 to 1993. In 1993 he accepted a position as the Corporate Clinical Director for Human Affairs International (then a subsidiary of Aetna Health Plans). Jeb was the primary driver behind HAI’s outcomes management initiative, and in 1996 his title was changed to Director of Clinical Informatics. He left HAI (then part of Magellan Health Services family of companies) in 1998 to found the Center for Clinical Informatics. Prior to joining United Behavioral Systems in 1987, Jeb served for five years as the Executive Director for the Center for Family Development, a non profit agency specializing in the treatment and prevention of family violence and sexual abuse. He is a frequent presenter at national conferences. Recent publications include a chapter entitled “What really makes a difference in psychotherapy outcomes? Why does managed care want to know?” appearing in The Heart and Soul of Change, Hubble, M.A., Duncan, B.L. & Miller, S.D., Eds.; American Psychological Association Press, 1999.

15. http://www.clinical-informatics.com jebbrown@clinical-informatics.com 1821 Meadowmoor Rd. Salt Lake City, UT 84117 Voice 801-541-9720 Fax 801-278-2329