cqaimh, 20021 social work’s role in behavioral health quality improvement scott e. provost, m.m.,...
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CQAIMH, 2002 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 Healthwww.cqaimh.org
May 10, 2002
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CQAIMH, 2002 2
Objectives
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
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CQAIMH, 2002 3
Objective #1
Learn about the status of quality assessment and improvement in behavioral health
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CQAIMH, 2002 4
Why Measure Quality? 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
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CQAIMH, 2002 5
How is Quality Defined?Quality can be defined as:Conformance to Specifications ValueDependabilityResponsiveness/timelinessAuthority/Consumer Empowerment EmpathySupport/Follow-up ServicePsychological Impressions
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CQAIMH, 2002 6
Quality and Evidence-Based Practice
“The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” (Sackett, et al., 1996)
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CQAIMH, 2002 7
Evidenced-Based Interventions
Adults Psychopharmacological Interventions Assertive Community Treatment Illness Self-Management Supported Employment Family Support Services Integrated Dual Diagnosis Treatment
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CQAIMH, 2002 8
Evidence-Based Interventions
Children Multi-systemic therapy Therapeutic foster care Family Involvement
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CQAIMH, 2002 9
How is Quality Defined?
Quality represents the kind of care that maximizes benefits and minimizes risks (Donabedian, 1980)
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CQAIMH, 2002 10
Status of Quality Assessment and Improvement in Behavioral Health
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)
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CQAIMH, 2002 11
Status of Quality Assessment and Improvement in Behavioral Health
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)
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CQAIMH, 2002 12
Status of Quality Assessment and Improvement in Behavioral Health
Quality of Care for DepressionDetectionOne-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)
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CQAIMH, 2002 13
Status of Quality Assessment and Improvement in Behavioral Health
Quality of Care for SchizophreniaMedication Treatment22.5% were given a dosage above 1,000 CPZ equivalents15% were prescribed a dosage less than 300 CPZ equivalentsLehman AF, et al., 1998 (N= 719 Individuals with Schizophrenia)
13.0% Dosed above PORT guidelines23.3% Dosed below PORT guidelines
Leslie DL, Rosenheck RA, 2001 (N=34,925 VA Patients) Family Services40.8% of inpatients were offered or received a family serviceLehman AF, et al., 1998 (N= 719 Individuals with Schizophrenia)
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CQAIMH, 2002 14
Status of Quality Assessment and Improvement in Behavioral Health
Quality of Care for ADHDAbout 50% of children with identified ADHD seen in real-world practice settings receive care that conforms to American Academy of Child & Adolescent Psychiatry GuidelinesHoagwood K, et al. (2000)
47.3% of pediatric visits for psychiatric reasons involving stimulant medications included any form of psychosocial interventionHoagwood 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 specialistBussing R, et al. (1998)
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CQAIMH, 2002 15
Status of Quality Assessment and Improvement in Behavioral Health
Quality of Care for Panic Disorder
Fewer than 1 in 4 patients receives adequate pharmacotherapy and only 1 in 8 received adequate psychotherapyRoy-Byrne PR, et al. (Archives of General Psychiatry, 2001)
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CQAIMH, 2002 16
Status of Quality Assessment and Improvement in Behavioral Health
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)
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CQAIMH, 2002 17
Common Categories of Measures
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.
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CQAIMH, 2002 18
Common Categories of Measures
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)
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CQAIMH, 2002 19
How is a Quality Measure Defined?
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)
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CQAIMH, 2002 20
Other commonly used terms
Lever
Metric
Indicator
Driver
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CQAIMH, 2002 21
Domains of Quality*
Structure Institutions Providers Patients
Community Financing
Process Prevention
Access Assessment Treatment
Coordination Continuity
Safety
Outcomes Symptoms
Functioning Quality of Life
Satisfaction Cost-Effectiveness
* Explorations in Quality Assessment & Monitoring: The Criteria and Standards of
Quality (Donabedian A, 1982)
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CQAIMH, 2002 22
Ideal Properties of Performance Measures
Objective Based on scientific evidence Not affect or distort results Reliable Valid Standardized/Precisely Specified
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CQAIMH, 2002 23
Timely Psychosocial Risk Factor Screening
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
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CQAIMH, 2002 24
Timely Psychosocial Risk Factor Screening
The total number of individuals admitted to an psychiatric hospital during a 30-day period
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
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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
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CQAIMH, 2002 26
Uses of Performance Measurement
Program Management Accountability Internal Quality Improvement
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CQAIMH, 2002 27
Performance Measures & Balanced Scorecards(Kaplan & Norton, 1996;2001)
Vision and Strategy
Internal Business Processes
Customer
Financial
Learning and Growth
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CQAIMH, 2002 28
Balanced Scorecards for Nonprofit Organizations(Kaplan & Norton, 2001)
MissionInternal Business
ProcessesLearning and
Growth
Customer
Financial
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CQAIMH, 2002 29
Quality Improvement Action Steps
Define the Project
Diagnose the Problem
Address the Problem
Sustain Progress
•Generate List of Potential Projects•Organize Project Team
•Analyze Existing Processes•Construct Hypotheses/Theories•Test Hypotheses/Theories•Identify Root Causes
•Develop Remedies•Design Interventions•Overcome Barriers and Resistance•Implement QI Interventions
•Evaluate Performance•Monitor Progress•Provide Feedback and Support
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CQAIMH, 2002 30
Quality Improvement Action Steps
Plan
Do
Check
Act
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CQAIMH, 2002 31
Objective #2
Review social work’s role in shaping quality assessment and improvement in behavioral health
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CQAIMH, 2002 32
Understanding Social Work’s Role in Quality Improvement
PsychologistsOther
MH/SA Counselors
VocationalCounselors
Social Workers Teachers
PsychiatristsPsychiatric
RNs
Primary Care
Providers
Justice System
Family/Friends
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CQAIMH, 2002 33
Psychiatrists
Psychiatric RNs
Primary Care Providers
Justice SystemFamily/Friends
Vocational Counselors
Case ManagerSocial Workers
Psychologists
Other MH/SA Providers
Teachers
Understanding Social Work’s Role in Quality Improvement
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CQAIMH, 2002 34
Understanding Social Work’s Role in Quality Improvement
Primary Care Provider
Social Worker
Community MH Center
Mediating Factors & Clinical Processes
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CQAIMH, 2002 35
Clinical Social Work Skills
Screening Assessment Case Management Psychotherapy Psychoeducation Medication Facilitation Family Education and Consultation
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CQAIMH, 2002 36
Social Work Administration and Quality Improvement
Negotiation Skills Program Evaluation Information Technology Organizational Design Organizational Behavior Operations Management Industrial Quality Improvement Multidisciplinary Collaboration
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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
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CQAIMH, 2002 38
Objective #3
Identify new areas for social work education, practice, and research that can influence the quality of behavioral health care services
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CQAIMH, 2002 39
Trends in the Social Work Profession
Clinical Roles Performing Psychosocial Assessment Reading Evidence-Based Reviews Understanding Disease Management Practices Continuing Education Ongoing Supervision
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CQAIMH, 2002 40
Trends in the Social Work Profession
Research Interventions Research Effectiveness Research Dissemination Research Multidisciplinary Research Process-Outcome Research Quantitative “Epidemiological” Research
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CQAIMH, 2002 41
Trends in the Social Work Profession
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
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CQAIMH, 2002 42
Social Work’s Role in Behavioral Health Quality Improvement
Acknowledgements Richard C. Hermann, M.D., M.S. Massachusetts NASW Symposium 2002 Program
Committee AHRQ (R01-HS10303)