Understanding the Quality Landscape in Psychiatry...HQA PQRI IHI new NCQA CARF Leapfrog indicators AHQR CAHPS HBIPS monthly CMS QMIS NQF ... Electronic Prescribing (eRx) Year Incentive

Rhode Island Hospital/Hasbro Children’s Hospital,

The Miriam Hospital, Bradley Hospital, Newport Hospital

Understanding the Quality

Landscape in Psychiatry

Richard J Goldberg, MD, MS, FAPA

Psychiatrist-in-Chief,

Rhode Island Hospital and

The Miriam Hospital

Professor, Department of Psychiatry &

Human Behavior,

The Warren Alpert Medical School of

Brown University



Unsettling News…

•Most Americans do not

receive optimal medical care.

•Many receive ineffective or

unnecessary care.

•Significant variation in

delivery processes and

outcomes.

IOM, 2006

Wennberg JE, et al. Dartmouth Inst.

For Health Policy, 2008.

•No evidence that not-for-

profit or academic centers

have better quality

Jha AK, et al. NEJM; 353(3):265-74, 2005



Traditional Quality Metrics

• Research dollars

• Staff pedigree

• “Top” residents

• Clinical volumes

• Objective data of

outcomes?



Examples of Shortcomings

in Psychiatry Quality:

A Minority of Practices:

• Follow accepted guidelines

Bauer M. Harvard Rev Psychiatry 135-153, 2002

• Provide science-based knowledge treatment for substance use McGlynn EA, et al. NEJM; 348(26):2635-45, 2003

• Provide minimally adequate care Kessler RC, et al. JAMA; 289:3095-3105, 2003

• Adopt effective treatments; e.g.,

• CBT for suicide attempters

• Supported employment for schizophrenics

• Collaborative care for geriatric depression Pincus HE, et al. Am J Psychiatry 2007;164:712-719



2006: Institute of Medicine 5 years after “Crossing the Quality Chasm”

• Improving our nation’s general health care system depends upon equally attending to quality problems in health care for M/SU conditions

• Unipolar major depression and drug and alcohol use and dependence are the leading cause of death and disability among American women and the second among men

Michaud CM, et al. JAMA 285(5):535-539; 2001



Compared to Other Medical Specialties:

Psychiatry Has Lagged in Quality Reporting

• Need for more linkages across clinicians,

disciplines, settings, and systems

• Less widespread use of IT

• Differently structured market place with

relative insulation from market pressures



No Shortage of “Advice” from IOM

• 6 Aims for High Quality Care

• 10 Rules to Guide Redesign

• 6 Critical Pathways for achieving the prescribed Aims and Rules

• 5 Practices Essential to undertaking and sustaining quality improvement

• 4 Practices and 4 Mechanisms to bridge the separation between providers

IOM. Improving the Quality of Health

Care for Mental and Substance-Use Conditions, 2006



How the World of Quality

Appears to Clinical Staff

TJC CQAIMH ECHO …and,

HQA PQRI IHI new

NCQA CARF Leapfrog indicators

AHQR CAHPS HBIPS monthly

CMS QMIS NQF

HEDIS NQMC ORYX

NPSG NREPP DNV

QIO AQA NIATX



THE QUALITY PYRAMID

Safety

Accreditation Indicators

Patient Experience

Pay for Performance

Outcomes

High

Value Care



THE QUALITY PYRAMID

High

Value Care

Outcomes

Pay for Performance

Patient Experience


Safety



The Joint Commission:

Patient Safety Advisory Group

• Sentinel Events: an unexpected occurrence

involving death or serious injury, or risk thereof.

• Review of 3548 events in 2005:

– Suicide 13.1%

– Medication errors 10.1%

– Falls 5.3%

– Restraint death/injury 3.9%

– Elopement 1.9%

• APA SAFE MD: 2009 scholarly guidance



The Joint Commission:

National Patient Safety Goals (2002)

• Evidence-based, practical

– Patient identification

– Caregiver communication

– Medication safety and reconciliation

– Infection reduction

– Patient involvement in care

– Risk identification



THE QUALITY PYRAMID

Safety


Patient Experience

Pay for Performance

Outcomes

High

Value Care



Psychiatry Quality

Inpatient Measures: TJC • Nat’l Assoc. of Psychiatric Health Systems

Nat’l Assoc. of State Mental Health Program Directors Developed measures for 2008 (submitted to NQF)

• Hospital-Based Inpatient Psychiatric Services (HBIPS): 7 Core Measures – Admission screening for violence, SI, trauma, strengths

– Hours of restraint use

– Hours of seclusion use

– Discharges on multiple antipsychotics

– Justification for multiple antipsychotics

– Discharge plan

– Discharge plan communicated



Outpatient Quality Measures

• National Committee for Quality Assurance (NCQA)

– Accredits MCOs, BHCOs, and Health Plans

– Healthcare Effectiveness Data and Information Set (HEDIS)

– HEDIS measures endorsed by NQF and Ambulatory Quality Alliance (AQA) 2004: AAFP, ACP, AHIP, AHRQ.

• 71 measures

• Some pertain to psychiatry

– F/U of children on ADHD medication

– Depression medication use

– Use of SA and MH services

– Elderly:

» Use of high-risk medication

» Potentially harmful drug-disease interactions



Measure

Defined

Sample

Defined

Data

Source

Provid

er

1st

Qtr

FY

10

2ns

Qtr

FY 10

3rd

Qtr

FY 10

4th

Qtr

FY

10

Sentinel Events

Suicide

Severe medication

errors

Falls with injury

Elopement

Assault

High Risk Marker

Suicide assessment

Patient Experience

Overall Press

Ganey

TJC 7 Core Measures

Admission

screening

Physical Restraints

Seclusion

>2 antipsychotics

on discharge

Antipsychotics

justified

Discharge plan

created

Discharge plan

communicated

HEDIS Outpatient Measures

Other Measures

Access to care



THE QUALITY PYRAMID

Safety


Pay for Performance

Outcomes

High

Value Care

Patient Experience



Level 3: Quality of the

Patient Experience

“



Patient Centered Care

• Picker Foundation and Commonwealth Fund (1987): 8 dimensions of measurable patient-centered care:

– Access

– Respect for patient values, preferences

– Coordination of care

– Information, communication, education

– Physical comfort

– Emotional support, alleviation of fear/anxiety

– Involvement of friends and family

– Transition and community

Cleary PD, et al. JAMA 1997;278:1608-12



Consumer Assessment of Healthcare

Providers and Systems (CAHPS)

• Agency for Healthcare Research and Quality

(AHRQ): (lead Federal agency in developing and

distributing standardized, evidence-based

surveys)

– launched CAHPS in mid-1990s based on work by the

Picker Foundation and Commonwealth Fund

– NCQA and CMS require CAHPS

– No application for psychiatry

www.cahps.ahrq.gov



Quality of The Patient Experience

• ECHO (The Experience of Care and Health

Outcomes Survey):

– A registered CAHPS instrument

(public domain, validated, and usable for

comparisons)

– Designed for MH/SU outpatient areas.

http://www.cahps.ahrq/gov/CAHPSkit/files

http://www.hcp.med.harvard.edu/echo/home

http://www.cahps.ahrq/gov/CAHPSkit/files

http://www.hcp.med.harvard.edu/echo/home



Press Ganey

• National patient satisfaction survey vendor

• Health industry’s most widely used approach to

collecting data on patient perspectives

– Data can be compared with prior years and

with comparable hospitals

• Inpatient domains include:

– Admission, unit, meals, nursing, psychiatry,

treatment team, program, discharge



This is Incorrect…

“Total Quality Management is 70 percent

attitude and 30% quality control.”

From Labovitz G, Chang YS, Rosansky V. Making Quality Work: A Leadership Guide for the

Results-Driven Manager, 1993. Wiley.



THE QUALITY PYRAMID

Safety


Patient Experience

Pay for Performance

Outcomes

High

Value Care



Electronic Prescribing (eRx)

Year Incentive Penalty

2009 2%

2010 2%

2011 1%

2012 1% -1%

2013 0.5% -1.5%

2014 0 -2%

Incentive payment is the % of all Medicare Part B (FFS)

allowed charges during the reporting period.

http://www.cms.gov/PQRI/03_EPrescribingProgram

http://www.cms.gov/PQRI/03_EPrescribingProgram



Physician Quality

Reporting Initiative (PQRI)

•2006 Tax Relief and Healthcare

Act

•Some of the 186 measures pertain

to behavioral health

•Documenting 3 in 80% of

applicable visits qualifies for 1.5%

bonus on allowable Medicare

charges.

• Document DSM-IV criteria

for new episode MDD

• Document suicide risk at

each visit

• Maintaining anti-depressants

for 12 weeks

• Assessing pain

• Asking about tobacco use

• Counseling for smoking

cessation www.cms.hhs.gov/PQRI

http://www.cms.hhs.gov/PQRI



Pay For Performance

• Of the hundreds of PFP

programs,

few are in Behavioral Health

– Mostly in primary care,

mostly depression

Bremer RW et al. Psychiatry Serv 2008; 59:1419-29

• On the threshold of an explosion

of PFP

• Potential for non-incentivized

activities to be neglected



Some Problems with PFP

• Incentives must be

meaningful

• Socioeconomic

penalty factor

• Professionalism

• Issue of how much

MDs control (e.g.,

pt. self-care)



THE QUALITY PYRAMID

Patient Experience

Outcomes

Pay for Performance


Safety

High

Value Care



Emerging Quality Outcomes

in Surgical Care

• If you were going to have a knee replacement, you would want to know: How many procedures your surgeon had done

Time under anesthesia

Complication/infection rates

Post op days in hospital

Rehab days to recovery

6 month/1 year outcomes

Time to return to PGA tour



Some Things You

Might Want to Know

• If you’re a 60 year old woman with 2 episodes

of major depression, now entering a third:

How often have you treated people like me?

Do you use evidence based methods?

For your practice:

• Rates of recovery/remission?

• Times to recovery/remission?

• Success in maintenance of recovery/remission?

• Success in getting patients back to work/family

• Quality of life



We should provide evidence-based care…



From Process to Outcome…

• The routine use of clinical outcomes measures is vital to determining what works and what does not work and to improve quality and reduce costs.

Berwick DM, et al. Med Care 2003;130-138

• Programs should move away from measures that focus on individual processes (e.g., whether 2 antipsychotics are prescribed) toward broader measures of quality, e.g., clinical outcomes The Commonwealth Fund Commission on a High Performance Health System, 2008



Inherent Limitations of Process

(care segment) Indicators – Do not necessarily cover the

most important issues, but those with easily available consensus data

– Limited number:

• limits conclusions of overall quality

• does not appear to diffuse to overall quality

• focuses provider attention on limited scope

– There can be wide quality variation even if compliance with a few measures is uniform

– Can inhibit innovation

– May overwhelm providers

– Show problems but do not

suggest solutions

– Will inevitably lead to

micromanagement

Improving Mental Healthcare: A Guide to

Measurement-Based Quality Improvement. Richard

Hermann. APA Press, Washington, DC, 2005.



Measuring Outcome:

Not the Standard of Care

in the Treatment of Depression

Survey of 314 Psychiatrists:

– 6.5% use scales almost all the time

– 11.4% use scales frequently

– 21.3% sometimes use scales

– 60.8% rarely or never use scales Zimmerman M, et al. J Clin Psychiatry 2008; 69: 1916-1919.

35



Six Potential Obstacles

in Measuring Outcome

1. Patient acceptance

2. Clinician acceptance

3. Clinical utility

4. Cost

5. Clinical heterogeneity

6. Data aggregation

= Data aggravation

36



Using Scales to Assess Outcome

Impractical to use the Ham-D in clinical practice

Use of a self-report scale

• Consider patient time

• Clinically Useful Depression Outcome Scale

(CUDOS) *

*CUDOS scale development and the following slides on Outcomes were developed by

Mark Zimmerman, MD, and are used here with permission

37



15 Desirable Features of a

Self-report Depression Outcome Scale

• Brief

• Acceptable to patients

• Covers all DSM-IV diagnostic criteria for major

depressive disorder

• Reliable (internal consistency and test-retest reliability)

• Convergent validity

• Discriminant validity

• Indicator of symptom severity

• Indicator of remission status

38



15 Desirable Features of a Self-report

Depression Outcome Scale

• Case-finding capability as a screening instrument

• Assesses psychosocial function

• Assesses quality of life

• Assesses suicidal thoughts

• Sensitive to change

• Easy to score

• Inexpensive

• Published in scientific literature

39



Major Advantages of the CUDOS

• Covers the DSM-IV symptom criteria

• Assesses psychosocial function and quality of life

• < 2 minutes to complete (mean=103 seconds)

• <10 seconds to score

• Reliable, valid, sensitive to change

• Can be used to determine remission

• Free

Zimmerman, M., Posternak, M.A., & Chelminski, I. Using a self-report depression scale to

identify remission in depressed Outpatients. Am J Psychiatry 2004;161:1911-1913.

40



Patient Acceptability of

Measurement-based Care

50 depressed outpatients in ongoing treatment

who completed CUDOS:

Measure of perceived burden and acceptability:

– 98% none-minimally burdensome

to complete

– 94% willing to complete at every visit

Zimmerman et al., Annals of Clinical Psychiatry, 2008

41



The Problem with Paper

Six Potential Obstacles in Measuring Outcome

1. Patient acceptance

2. Clinician acceptance

3. Clinical utility

4. Cost

5. Clinical heterogeneity

6. Data aggregation

– Data aggravation













How Might Outcome Data Be Used?

Evaluate efforts to improve outcome (quality)

Compare:

Institutions

Practices

Clinicians

The issue of case-mix severity will have to be

addressed.

48



How Can Outcomes Data Improve Outcome,

Treatment Efficiency, or Costs?

Examples of outcomes that could be assessed:

– Response

– Remission

– Treatment drop-out

– Disability days

– Work absenteeism/presenteeism

49



Questions That Could Be Asked

If We Tracked Outcomes

• Do changes in formulary or co-pays affect response and remission rates?

• Do changes in insurance benefit impact outcome?

• Should visit frequency be decreased/increased for patients receiving

medication management?

• Does outcome tracking improve early identification of poor treatment

outcomes, thereby reducing emergency and hospital services?

• Does measurement based care result in improved outcome?

• Does measurement based care improve compliance and outcome?

50



How Do You Get Clinicians to Adopt a

Measurement-based Care Approach?

• Demand

• Educate and engage

• Incentives

– Improve referral stream

– Eliminate oversight

– Augment reimbursement

– Subsidize EMR management

51



THE QUALITY PYRAMID

Safety


Patient Experience

Pay for Performance

Outcomes

High

Value Care



Evolving Towards High Value Care

• The goal is value: defined as better health per dollar spent

• Care is organized around medical conditions and care cycles

• Risk-adjusted outcomes and costs measured for each condition

• Rewards tied to results, not compliance

Outcome measurement is the only convincing way to make the case for more generous reimbursement for non-procedure based services

Porter ME and Teisberg EO. JAMA 2007;297:1103-1111



Challenges to the AMC

• One of NIMH 4 major objectives:

“Improve understanding of factors that affect access, quality and costs, and

means by which new evidence is disseminated and implemented.”

• Creates potential new and powerful alliance between academic talent and

quality initiatives

• Most academic programs lack mechanisms to encourage faculty engaged in

QI activities

Insel TR. Arch Gen Psychiatry 2009;66:128-133

Shojania KG, et al. JAMA 2009;301:766-768



What if We Don’t?

Our inability to transform care based on outcomes will lead to

blunt approaches to cost cutting and limitations of services.



Documents

Understanding the Quality Landscape in Psychiatry...HQA PQRI IHI new NCQA CARF Leapfrog indicators AHQR CAHPS HBIPS monthly CMS QMIS NQF ... Electronic Prescribing (eRx) Year Incentive