CQAIMH, 20021 Social Work’s Role in Behavioral Health Quality Improvement Scott E. Provost, M.M.,...

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

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

CQAIMH, 2002 3

Objective #1

Learn about the status of quality assessment and improvement in behavioral health

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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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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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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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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Evidence-Based Interventions

Children Multi-systemic therapy Therapeutic foster care Family Involvement

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How is Quality Defined?

Quality represents the kind of care that maximizes benefits and minimizes risks (Donabedian, 1980)

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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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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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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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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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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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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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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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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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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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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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Other commonly used terms

Lever

Metric

Indicator

Driver

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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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Ideal Properties of Performance Measures

Objective Based on scientific evidence Not affect or distort results Reliable Valid Standardized/Precisely Specified

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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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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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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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Uses of Performance Measurement

Program Management Accountability Internal Quality Improvement

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Performance Measures & Balanced Scorecards(Kaplan & Norton, 1996;2001)

Vision and Strategy

Internal Business Processes

Customer

Financial

Learning and Growth

CQAIMH, 2002 28

Balanced Scorecards for Nonprofit Organizations(Kaplan & Norton, 2001)

MissionInternal Business

ProcessesLearning and

Growth

Customer

Financial

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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

CQAIMH, 2002 30

Quality Improvement Action Steps

Plan

Do

Check

Act

CQAIMH, 2002 31

Objective #2

Review social work’s role in shaping quality assessment and improvement in behavioral health

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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Psychiatrists

Psychiatric RNs

Primary Care Providers

Justice SystemFamily/Friends

Vocational Counselors

Case ManagerSocial Workers

Psychologists

Other MH/SA Providers

Teachers


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Primary Care Provider

Social Worker

Community MH Center

Mediating Factors & Clinical Processes

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Clinical Social Work Skills

Screening Assessment Case Management Psychotherapy Psychoeducation Medication Facilitation Family Education and Consultation

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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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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

Objective #3

Identify new areas for social work education, practice, and research that can influence the quality of behavioral health care services

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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Research Interventions Research Effectiveness Research Dissemination Research Multidisciplinary Research Process-Outcome Research Quantitative “Epidemiological” Research

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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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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)

CQAIMH, 20021 Social Work’s Role in Behavioral Health Quality Improvement Scott E. Provost, M.M.,...

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