Social Work’s Role in Behavioral Health Quality Improvement

1. Social Work’s Role in Behavioral Health Quality Improvement Scott E. Provost, M.M., M.S.W. Associate Director for Research Center for Quality Assessment & Improvement in Mental Health www.cqaimh.org May 10, 2002 CQAIMH, 2002

2. Learn about the status of quality assessment and improvement in behavioral health Review social work’s role in shaping quality assessment and improvement in behavioral health Identify new areas for social work education, practice, and research that can influence the quality of behavioral health care services Objectives CQAIMH, 2002

3. Learn about the status of quality assessment and improvement in behavioral health Objective #1 CQAIMH, 2002

4. To facilitate oversight of health plans, hospitals & delivery systems, and clinicians To encourage healthcare purchasing based on quality, not just cost To increase market share, growth, and revenues To meet standards set by professional societies Why Measure Quality? CQAIMH, 2002

5. Quality can be defined as: Conformance to Specifications Value Dependability Responsiveness/timeliness Authority/Consumer Empowerment Empathy Support/Follow-up Service Psychological Impressions How is Quality Defined? CQAIMH, 2002

6. “The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” (Sackett, et al., 1996) Quality and Evidence-Based Practice CQAIMH, 2002

7. Adults Psychopharmacological Interventions Assertive Community Treatment Illness Self-Management Supported Employment Family Support Services Integrated Dual Diagnosis Treatment Evidenced-Based Interventions CQAIMH, 2002

8. Children Multi-systemic therapy Therapeutic foster care Family Involvement Evidence-Based Interventions CQAIMH, 2002

9. Quality represents the kind of care that maximizes benefits and minimizes risks (Donabedian, 1980) How is Quality Defined? CQAIMH, 2002

10. National Reports on Health Care Quality Quality First: Better Health Care for All Americans, (President’s Advisory Commission 1998) To Err is Human (IOM, 2000) Crossing the Quality Chasm(IOM, 2001) Envisioning the National Health Care Quality Report(IOM, 2001) Status of Quality Assessment and Improvement in Behavioral Health CQAIMH, 2002

11. Reports on Behavioral Health Care Quality Managing Managed Care: Quality Improvement in Behavioral Health(IOM, 2001) U.S. Surgeon General’s Report on Mental Health(DHHS, 1999) Report of the Surgeon General’s Conference on Children’s Mental Health: A National Action Agenda(DHHS, 2000) Mental Health: New Understanding, New Hope(WHO, 2001) Status of Quality Assessment and Improvement in Behavioral Health CQAIMH, 2002

12. Quality of Care for Depression Detection One-third to one-half of patients with major depressive disorder are properly recognized by primary care and other practitioners(AHCPR: Depression in Primary Care: Volume 1. Detection & Diagnosis, 1993) Medication Treatment 55.6-62.6% of individuals enrolled in participating health plans who initiate treatment for major depression discontinue medication prior to 12 weeks(NCQA: Quality Compass, 2000) Status of Quality Assessment and Improvement in Behavioral Health CQAIMH, 2002

13. Quality of Care for Schizophrenia Medication Treatment 22.5% were given a dosage above 1,000 CPZ equivalents 15% were prescribed a dosage less than 300 CPZ equivalents Lehman AF, et al., 1998 (N= 719 Individuals with Schizophrenia) 13.0% Dosed above PORT guidelines 23.3% Dosed below PORT guidelines Leslie DL, Rosenheck RA, 2001 (N=34,925 VA Patients) Family Services 40.8% of inpatients were offered or received a familyservice Lehman AF, et al., 1998 (N= 719 Individuals with Schizophrenia) Status of Quality Assessment and Improvement in Behavioral Health CQAIMH, 2002

14. Quality of Care for ADHD About 50% of children with identified ADHD seen in real-world practice settings receive care that conforms to American Academy of Child & Adolescent Psychiatry Guidelines Hoagwood K, et al. (2000) 47.3% of pediatric visits for psychiatric reasons involving stimulant medications included any form of psychosocial intervention Hoagwood K, et al. (2000) 68% of children receiving treatment for ADHD by a primary care provider did not have any contact with a mental health specialist Bussing R, et al. (1998) Status of Quality Assessment and Improvement in Behavioral Health CQAIMH, 2002

15. Quality of Care for Panic Disorder Fewer than 1 in 4 patients receives adequate pharmacotherapy and only 1 in 8 received adequate psychotherapy Roy-Byrne PR, et al. (Archives of General Psychiatry, 2001) Status of Quality Assessment and Improvement in Behavioral Health CQAIMH, 2002

16. Follow-Up After Hospitalization for Mental Illness In a sample of 305,574 Medicare beneficiaries enrolled in Medicare: 52.% received follow-up care When stratified by race, the results were: 54% (Whites) 33.2% (Blacks) Schneider EC, et al. (JAMA, 2002) Status of Quality Assessment and Improvement in Behavioral Health CQAIMH, 2002

17. Structure measures: “represent the relatively stable characteristics of the providers of care, of the tools and resources they have at their disposal, and of the physical and organizational settings in which they work” (Donabedian, 1980) Fidelity measures: are tools to evaluate whether or not treatment programs are implemented according to a specified manual or protocol. Common Categories of Measures CQAIMH, 2002

18. Outcome measures: are indicators of a patient’s health status, i.e., medical and physiologic (biological, pathological, behavioral) functional status and well-being (quality of life, productivity, disability) habits or health risk states (Donabedian, 1980) Process measures: assess the set of activities that go on within and between patients and practitioners (Donabedian, 1980) Common Categories of Measures CQAIMH, 2002

19. Performance measures: “estimate the extent to which the actions of a health care practitioner or provider conform to practice guidelines, medical review criteria, or standards of quality.” (Academy for Health Services Research & Health Policy) Quality Measure: “A quantitative measure that can be used as a guide to monitor and evaluate the quality of important patient care and support service activities.” (JCAHO, 1989) How is a Quality Measure Defined? CQAIMH, 2002

20. Lever Metric Indicator Driver Other commonly used terms CQAIMH, 2002

21. Domains of Quality* * Explorations in Quality Assessment & Monitoring: The Criteria and Standards of Quality (Donabedian A, 1982) CQAIMH, 2002

22. Objective Based on scientific evidence Not affect or distort results Reliable Valid Standardized/Precisely Specified Ideal Properties of Performance Measures CQAIMH, 2002

23. Denominator:The total number of individuals admitted to an inpatient psychiatric hospital over a 30-day period Numerator:The number of individuals from the denominator whose medical record documents a psychosocial screening that address potential high risk areas including at least three of the following five factors--stability of housing, employment, dependent family members, treatment compliance, and adequacy of self-care--recorded in the admission note or progress note for the first three days of hospitalization Timely Psychosocial Risk Factor Screening CQAIMH, 2002

24. Timely Psychosocial Risk Factor Screening The number of individuals from the denominator whose medical record documents a psychosocial screening that address potential high risk areas including at least three of the following five factors--stability of housing, employment, dependent family members, treatment compliance, and adequacy of self-care--recorded in the admission note or progress note for the first three days of hospitalization The total number of individuals admitted to an psychiatric hospital during a 30-day period CQAIMH, 2002

25. Quality Measures in Action • Quality can be improved without planning or effort OR • Quality can be improved systematically using well-tested methods and tools CQAIMH, 2002

26. Program Management Accountability Internal Quality Improvement Uses of Performance Measurement CQAIMH, 2002

27. Performance Measures & Balanced Scorecards(Kaplan & Norton, 1996;2001) Financial Customer Vision and Strategy Internal Business Processes Learning and Growth CQAIMH, 2002

28. Balanced Scorecards for Nonprofit Organizations(Kaplan & Norton, 2001) Customer Learning and Growth Mission Internal Business Processes Financial CQAIMH, 2002

29. Quality Improvement Action Steps Define the Project • Generate List of Potential Projects • Organize Project Team Diagnose the Problem • Analyze Existing Processes • Construct Hypotheses/Theories • Test Hypotheses/Theories • Identify Root Causes Address the Problem • Develop Remedies • Design Interventions • Overcome Barriers and Resistance • Implement QI Interventions Sustain Progress • Evaluate Performance • Monitor Progress • Provide Feedback and Support CQAIMH, 2002

30. Quality Improvement Action Steps Plan Act Do Check CQAIMH, 2002

31. Review social work’s role in shaping quality assessment and improvement in behavioral health Objective #2 CQAIMH, 2002

32. Understanding Social Work’s Role in Quality Improvement Social Workers Teachers Psychologists Other MH/SA Counselors Psychiatrists Psychiatric RNs Vocational Counselors Primary Care Providers Family/ Friends Justice System CQAIMH, 2002

33. Understanding Social Work’s Role in Quality Improvement Teachers CaseManager Social Workers Psychologists Other MH/SA Providers Psychiatrists Psychiatric RNs Primary Care Providers Vocational Counselors Family/Friends Justice System CQAIMH, 2002

34. Understanding Social Work’s Role in Quality Improvement Primary Care Provider Social Worker Community MH Center Mediating Factors & Clinical Processes CQAIMH, 2002

35. Screening Assessment Case Management Psychotherapy Psychoeducation Medication Facilitation Family Education and Consultation Clinical Social Work Skills CQAIMH, 2002

36. Negotiation Skills Program Evaluation Information Technology Organizational Design Organizational Behavior Operations Management Industrial Quality Improvement Multidisciplinary Collaboration Social Work Administration and Quality Improvement CQAIMH, 2002

37. Complexity of Social Work Administration Delivery System Facility A Facility B Facility C Facility D Social Work Staff Social Work Staff Social Work Staff Social Work Staff C C C C C C C C C C C C CQAIMH, 2002

38. Identify new areas for social work education, practice, and research that can influence the quality of behavioral health care services Objective #3 CQAIMH, 2002

39. Clinical Roles Performing Psychosocial Assessment Reading Evidence-Based Reviews Understanding Disease Management Practices Continuing Education Ongoing Supervision Trends in the Social Work Profession CQAIMH, 2002

40. Research Interventions Research Effectiveness Research Dissemination Research Multidisciplinary Research Process-Outcome Research Quantitative “Epidemiological” Research Trends in the Social Work Profession CQAIMH, 2002

41. Education and Curriculum Issues Practice Guideline Development and Education Continuous Quality Improvement and TQM Organizational Behavior and Change Operations Research and Management Epidemiology/Statistics Cross-Disciplinary Training Trends in the Social Work Profession CQAIMH, 2002

42. Acknowledgements Richard C. Hermann, M.D., M.S. Massachusetts NASW Symposium 2002 Program Committee AHRQ (R01-HS10303) Social Work’s Role in Behavioral Health Quality Improvement CQAIMH, 2002