Measuring Quality of Care Measuring Quality of Care

for Co-Occurring Conditionsfor Co-Occurring Conditions

Richard C. Hermann, MD, MS Tufts University School of MedicineDavid J. Dausey, PhD Rand CorporationAmy M. Kilbourne, PhD, MPH University of PittsburghCatherine Fullerton, MD, MPH Harvard Medical School

RWJF Depression in Primary Care Program

Center for Quality Assessment & Improvement in Mental Healthwww.cqaimh.org

OverviewOverview

Co-occurring conditions & deficits in care– Mental disorders & SUD in primary care– Medical conditions in mental health specialty care– Dual diagnoses in mental health & SU specialty sectors

Role of quality measurement in improving mental healthcare Status & prospects for measures of co-occurring conditions Breakout session

– Measure development exercise – Measure selection exercise

Mental disorders & SUD in Primary CareMental disorders & SUD in Primary Care

Prevalence 5 - 27% of primary care patients have depressive or anxiety

disorders 4 -10% of primary care patients have SUDs

Deficits: Poor recognition Low rates of use of brief screening tools Low rates of appropriate treatment in primary care Limited referral for specialty care Barriers to successful referral Poor communication btw. PCP and MH/SU specialists

Medical Conditions among MHS PatientsMedical Conditions among MHS Patients

Prevalence: Elevated rates of diabetes, HIV, pulmonary, CV & GI

disease among individuals with severe mental illness 2 - 5x higher risk of mortality from natural causes

Deficits: Lack of thorough medical evaluation for patients

receiving MHS care for a psychiatric disorder 35% (3 - 92%) psychiatric patients had a significant,

undetected medical condition 50% (12 - 93%) had a significantly undertreated condition

Dual Diagnosis in MH & SUD Specialty SectorsDual Diagnosis in MH & SUD Specialty Sectors

Prevalence: ~ 50% of patients with SMI have an SUD over lifetime ~ 25% of patients with SMI have an active SUD

Deficits: < 40% with dual diagnosis received any treatment, Only 8% receive integrated treatment Among pts in MH or SU specialty care, comorbid

condition is frequently undocumented & untreated

IOM Crossing the Quality Chasm (2005): IOM Crossing the Quality Chasm (2005): Adaptation to Mental Health/Addictive DisordersAdaptation to Mental Health/Addictive Disorders

IOM Recommendation 5-2

Need to implement policies and incentives to increase collaboration among primary care, mental health, & substance-use treatment providers to achieve evidence-based screening and care

IOM Crossing the Quality Chasm (2005): IOM Crossing the Quality Chasm (2005): Recommendations on Measurement-Based QIRecommendations on Measurement-Based QI

Recommendation 4-2 / 4-3

Clinicians & provider organizations should measure & continuously improve the quality of care they provide.

Stakeholders need to reach consensus on standardized quality measures for comparative use

National Inventory of Mental Health Quality MeasuresNational Inventory of Mental Health Quality Measures

> 300 measures proposed for quality assessment & improvement in MH/SUD care – available at http://www.cqaimh.org/quality.htm

Less than 5% assess care for co-occurring conditions Other instruments available, but not widely used for these

populations– surveys of patient perspectives of care– outcome assessment tools– fidelity scales

Role of Measurement in Quality ImprovementRole of Measurement in Quality Improvement

Internal quality improvement– CQI: aims, measurement, diagnosis, intervention– system redesign

External quality improvement– reporting and feedback– benchmarking– contractual goals – financial incentives– consumer & purchaser choice

Framework for Measuring Quality of CareFramework for Measuring Quality of Care

Structure Process

Technical

Outcome

Interpersonal

Structures of Care for Co-Occurring Conditions

Clinicians– Competencies in detecting/ treating COC– Availability of specialists for referral

Facilities & Services– Availability of services across levels of care– Adoption of structures to support COC care

Clinical Information Systems– Availability of medical records between sectors– Procedures to safeguard confidentiality / consent

Financing– Reimbursement for care of COC

Processes of Care for Co-Occurring Conditions

Detection Assessment Access to specialty care Treatment vs. Referral

– appropriateness of decision– referrals: completion rate– treatment: underuse, overuse, misuse; fidelity

Coordination – adequacy of communication / collaboration

Continuity of care Safety

Outcomes of Care for Co-Occurring Conditions

Change in SymptomsBehaviorsFunctioningQuality of lifeAdverse effectsMortalityPatient Satisfaction

Desirable Characteristics of Quality Measures

Meaningful

quality problemclinically importantevidence-basedvalidcomprehensible

Feasible

precisely specifieddata availableaffordablereliableconfidential case mix

Actionable

under user’s control results interpretable

Mental disorders & SUD in Primary Care: Mental disorders & SUD in Primary Care: Existing Quality MeasuresExisting Quality Measures

HEDIS measures adopted for health plans % pts started on antidepressant for depression who remain on

medication at 12 weeks & 6 months % children receiving medication for ADHD w/ follow-up visit w/in

30 days, 2 additional visits w/in 9 months Service utilization for SUD

– treated prevalence: any utilization in 12-months– initiation: 2nd service w/in 14 days– engagement: 2 additional services w/in 30 days

Mental disorders & SUD in Primary Care: Mental disorders & SUD in Primary Care: Measures Under DevelopmentMeasures Under Development

Structures supporting evidence-based practice– % of primary care practices using registries, rating

scales, case management for depression Processes recommended for primary care practice

– % patients screened for SUD– % of pts. diagnosed with alcohol abuse or dependence

receiving a brief intervention– % pts. w/ depression receiving case mgmt support

Outcome Measures– average change in PHQ score at defined interval

Mental disorders & SUD in Primary Care: Mental disorders & SUD in Primary Care: Need for Measures of Boundary-Spanning CareNeed for Measures of Boundary-Spanning Care

Potential measure topics Completion rates for referrals Communication btw PCPs and MHS Outcomes of referred or collaborative careObstacles to overcome Carve-outs result in segregation of data btw. sectors Tension btw. sharing clinical information & confidentiality Unclear accountability for outcome Lack of defined standards for boundary spanning care

Measures of Conformance to Standards & GuidelinesMeasures of Conformance to Standards & Guidelines

Research Consensus Evidence Development

Practice guidelines / standards of care

Conformance

Structures Processes Outcomes Delivery of Care

Breakout Group 1: Measure DevelopmentBreakout Group 1: Measure Development Information exchange between PCP & MHS Information exchange between PCP & MHS

Proposed Measure: % primary care patients referred to MHS for psychiatric care whose PCP received “adequate” feedback

Need for standards: what? by when? how?

What data sources are available?

Different forms of measure useful to different stakeholders?

Quality Measurement for Quality Measurement for Medical Conditions in MHS CareMedical Conditions in MHS Care

Detection % patients with general medical history % patients with documented smoking status % patients screened for DM, fasting lipidsTreatment % of patients receiving appropriate preventive care

– pap smear, vaccines, colonoscopy % of patients with DM with HgA1c testing % of patients with COPD with spirometry testing

Background: Integrated Care for MH/SUDBackground: Integrated Care for MH/SUD

~50% of individuals with a mental disorder have at least one co-occurring substance use disorder (MH/SUD)

When compared to individuals with a single MH disorder individuals with MH/SUD have higher:– Rates of treatment utilization– Use of emergency and hospital services– Rates of violent behavior– Risk of HIV infection

Research for two decades has demonstrated that individuals with MH/SUD that receive integrated or linked care have better outcomes than those who receive “silo care”

Deficits in Quality of Care for MH/SUDDeficits in Quality of Care for MH/SUD

Limited current service linkages between MH and SA providers

Failure to identify MH/SUD patients in MH specialty settings

Program fidelity challengesLack of performance measures despite growing

evidence base and standards

Structural Measure: Service LinkagesStructural Measure: Service Linkages

% of programs that have:– Integrated services (MH and SA services in the

same treatment program)– Co-location (MH and SA services in the same

location)– Formal relationships (referral agreements or

contractual relationships among providers)– Informal or ad hoc (absence of formal relationships)

Research indicates that programs with integrated services have the best outcomes

Process Measure: Model FidelityProcess Measure: Model Fidelity

Average fidelity score across participating programs:– New Hampshire/Dartmouth Integrated Dual Disorder

Treatment (IDDT) model 26 Item fidelity scale Each item represents an org. or tx component of model

Scores from individual programs can be compared to the mean score or a recognized benchmark

Research indicates that Critical program components must be replicated to achieve good outcomes

Outcome Measure: AbstinenceOutcome Measure: Abstinence

% of patients with any SA diagnosis discharged from a MH specialty setting who report abstinence from drugs or alcohol over 6 months.

MH specialty settings can be compared against the mean across all MH specialty settings or a recognized benchmark.

Breakout Session 2: Measure SelectionBreakout Session 2: Measure Selection Integrated Care for Patients with MH/SUD Integrated Care for Patients with MH/SUD

Comparing and contrasting different measures for MH/SUD

Focus on measures for state mental health agencies

Rate and discuss 3 different measures on feasibility and meaningfulness

Consider appropriate data sources for measures

Group 1: Measure DevelopmentInformation exchange between PCP & MHS

Group 2: Measure Selection Integrated treatment for patients with dual diagnoses

Report back: 9:40 am

Breakout SessionBreakout Session