Measurement Based Care: Behavioral Health Joint …

Measurement Based Care: Behavioral Health Joint Commission Accredited Organizations Share Their Experiences

Scott Williams, PsyD

Maeve O’Neill, MEd, LCDC, LPC-S, CHC

Shawna Granato, LISW-S

Antoinette Giedzinska, PhD

January 30, 2020

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© 2019 The Joint Commission. All Rights Reserved.

CTS.03.01.09(Effective January 1, 2018)

– Standard CTS.03.01.09 – The organization assesses the outcomes of care,

treatment, or services provided to the individual served

– EP 1 – The organization uses a standardized tool or instrument to monitors the individual’s

progress in achieving his or her care, treatment, or service goals

– EP 2 – The organization gathers and analyzes the data generated through standardized

monitoring, and the results are used to inform the goals and objectives of the

individual’s plan for care, treatment, or services as needed

– EP 3 – The organization evaluates the outcomes of care, treatment, or services provided to

the population(s) it serves by aggregating and analyzing the data gathered through the

standardized monitoring effort

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Complying with Standard CTS.03.01.09

Ultimately… to comply with the standard you need to:

−Select an instrument that is appropriate for measurement-

based care

−Administer it consistently throughout the care process

−Actually look at the data and do something in response to it

https://attendee.gotowebinar.com/register/7417914957620236547

Webinar Replay available at:

https://attendee.gotowebinar.com/register/7417914957620236547

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What is Measurement-Based Care?

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XX

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1 1 3 4

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− Implementation will vary

based upon:

− Type of population, service and

setting

− Frequency of repeated

administration

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What Kind of Instruments Meet the Requirement?

– The instrument should:

– Have well-established reliability and validity for use as a repeated

measure

– Be sensitive to change

– Be appropriate for use as a repeated measure

– Be capable of discriminating between populations that may or may

not benefit from services (if appropriate)

–e.g., clinical/non-clinical, healthy/non-healthy functioning,

typical/non-typical, etc.

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Measures NOT Complying with Standard CTS.03.01.09

– A measure that assesses the use of evidence-based care or clinical

practice guidelines

– A perception of care questionnaire or patient satisfaction survey

– A measure of medication/treatment compliance

– An assessment of outcome after the completion of service, even if it

compares a baseline score to a subsequent point of measurement

(e.g., intake/termination, admission/discharge)

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Scoring Standard CTS.03.01.09

– 111 compliance issues

were identified for

standard CTS.03.01.09

on 8% (98 of 1293) of

full survey events from

January 1, 2017 –

December 31, 2017.

– 36th most frequently

scored BHC standard

2017

BHC Program, Full Survey Events, January 1, 2017 – December 31, 2017

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Scoring Standard CTS.03.01.09

– 1,339 compliance

issues were identified

for standard

CTS.03.01.09 on 50%

(1,231 of 2,448) of full

survey events from

January 1, 2018 –

December 31, 2019.

2018 - 2019

BHC Program, Full Survey Events, January 1, 2018 – December 31, 2019

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The Good News…

−The other 50% of surveyed organizations

appear to be meeting the requirements of the

standard

− In late-2018 we interviewed a sample of these

organizations to get a better understanding of

what they were doing to comply

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Instruments Being Used:

− PHQ- 9 (Patient Health Assessment Questionnaire)

− The Clinical Opiate Withdrawal Scale (COWS)

− BAM (Brief Addiction Monitor)

− GAD-7 (Generalized Anxiety Disorder)

− CIWA (Clinical Institute Withdrawal Assessment for Alcohol)

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Instruments Being Used:

− Quality of Life Inventory (QOLI)

− OASAS forms PAS-26n, PAS-44, PAS-45

− Modified FAF

− Achenbach

− VISTA

− Severity of Dependence Scale (SDS)

− RSES-4

− SWLS

− Beck’s tool

− PTSD Checklist for DSM-5 (PCL-5)

− Outcome Rating Scale (ORS)

− Columbia Suicide Assessment

− Insight 20

− Physical Appearance Comparison Scale

− Child/Adolescent Behavioral Assessment

(CABA-Y and CABA-I)

− SF-36

− DAST-10

− AUDIT

− Alcohol Abstinence Self-Efficacy Scale

− Drug Avoidance Self Efficacy Scale

− AWARE

− Adult Global Health Scale

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Surveyor Examples of Data Use

– Using the tool and it's results to create discussions with

clients

– The system tracks the results and graphs them per client

as well as outcomes for the program.

– Tracking change using data, adjusting the treatment plan

as appropriate.

– Used a part of the high alert system.

– Data projected electronically and magnified for

consideration during treatment team meetings..

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What process did your organization utilize to selecta standardized instrument for measurement based care?

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What process did you use to implementmeasurement based care?

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How are you using your MBC data in care, treatment and services and to improve the overall services for the population you serve?

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Our story...


Served as Chief Ethics & Compliance Officer at Addiction Campuses 2017-2019

Holly Steward, MEd, LPC

Clinical Director, The Treehouse

Mareikie Muszynski, MSW, LICSW

Clinical Director, Swift River


Clinical Director, The Bluffs

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Our experience implementing MBC...

TJC-”Using data as feedback toward achieving outcomes”

*Leadership/Culture enhanced and supportive of outcomes

*Teamwork empowered and challenges addressed

*Staff engaged and services improved care

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Leadership - Teamwork - Staff

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Leadership and Culture● Part of a robust and integrated Compliance program/plan

● Researched several standardized tools

● Reviewed numerous options and consulted with experts

● Discussed with all locations and teams

● Decision to utilize current tool-DASS weekly

● Education and Training of all providers

● Worked with IT/EMR for data

● Weekly calls to monitor

● Monthly data to audit

● Culture of Quality and Performance Improvement

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Payors saw the value and authorized more care!

UR used in appeals with insurance companies.

Insurance Companies asked about MBC and were

impressed with weekly scales and how integrated into

care.

Getting in-network with insurance panels was easier

based on MBC data.

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Teamwork and Challenges

● Building trust in purpose of the tool with staff/patients

● Integrating with existing workflow

● Onboarding new staff to process

● Evaluating staff performance in administering the tool

● Adjusting as needed-EMR

● Management investment in auditing and staff coaching

● Staff remembering to do it

● Staff turnover were challenges

● EMR functionality in data collection

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Patients noted value in surveys!

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Staff and Service Outcomes:

● Patients saw value in looking at scores during treatment

● Better documentation

● Improved treatment planning and discharge planning

● More individualized care based on DASS scores

● Added services such as yoga, meditation path, ropes

● Adjusted schedules and curricula to meet patient needs

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Staff saw value and impact!

Integrated DASS scores with tracking patient risk

assessments to manage safety needs.

Shared understanding and language about patient

status in regards to their coping with depressions,

anxiety and stress.

Daily emails and communicaiton aided proper

intervention and early detection of patient risk.

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Antoinette Giedzinska, PhD

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3 Levels Of Care• Acute Inpatient

• Residential• Mood• ADD/CO• Trauma Recovery• Chronic Pain

Recovery

• Outpatient• PHP• IOPJaime W. Vinck, MC, LPC, NCC

Group Chief Executive Officer

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Assessment Selection: #1 Define

− Operationalization of Sierra Tucson Mission Statement &

Treatment Philosophy … to provide a safe place for emotional, physical, and spiritual healing with a collaborative community of professionals who provide insight,

understanding, and empowerment enhanced by a lifetime of alumni support.

Social

Component

Bio–Psycho–Social

Integrative Mental Health

Physical

Component

Psychological

Component

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Assessment Selection: #2 Identify

Comprehensive Psychological Profile (CPP)

Measurable Constructs Validated Measures (Public Domain)

·Overall Quality of Life & Functioning ·WHOQOL-BREF (WHO Brief Quality of Life, '97)

·Mood ·CESD (Centers for Epidemiological Studies, Depression Scale, '04)

·Anxiety ·MAQ* (Multidimensional Anxiety Questionnaire, '99)

·Substance Use / Craving ·ASSIST (Alcohol, Smoking, & Substance Involvement, '03)

·Trauma (PTSD) ·PCL-5 (Post-Traumatic Stress Disorder Checklist, '04)

·Stress coping ·CSE (Coping Self-Efficacy Scale, '06)

·Resiliency ·BRS (Brief Resiliency Scale, '08)

·Sleep ·PROMIS - Sleep (8b, '12)

·Relational attachment ·RAAS (Revised Adult Attachment Scale, '90)

·Existential issues ·4-item Analog Scale (homegrown, '16)

·Pain Interference ·PROMIS – Pain Interference (6a, '15)

·National Outcomes Measures ·NOMs (8-items from SAMHSA, '17)

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Methodology: Pre-Treatment Profile Assessment (PTE)

At Admission

All Admitted Patients

Admission Paperwork Outcomes Consent

ResidentialFirst 1-3 days

PTE - Admins Pre-Tx Evaluation

Proctor AdministrationData Entry & MergeStaff Tasks:

24-hourTurn-around

Staff Tasks:

PTE - Prep

PDFs uploaded to EMRHand-outs to Med Provider

ResidentialFirst 3-5 days

Medical Provider

PTE - Feedback Review PTE ProfileTx Plan Decision MakingUpdate EMR

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Residential1-3 Pre-Mid-Point

MTE - Admins Mid-Tx Evaluation

Proctor AdministrationData Entry & MergeStaff Tasks:

24-hourTurn-around

Staff Tasks:

MTE - Prep

PDFs uploaded to EMRHand-outs to Primary Therapist

ResidentialMid-Treatment

Primary Therapist

PTE - Feedback Review Progress ProfileTx Plan Adjustment(s)Update EMR

Methodology: Mid-Treatment Profile Assessment (MTE)

Measurement-Based Care is literally woven into the patient treatment experience; with expectations set early-on that patients will discuss findings & progress with their treatment team.

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Implementation: Pre-Treatment Profile Results

-

10

20

30

40

50

60

70

80

Physical Emotional Social Environment

Sum

mar

y Sc

ore

s:

X <

20

= V

ery

Po

or;

X <

40

= P

oo

r;

40

< X

< 6

0, =

Fai

rX

> 6

0 =

Go

od

;

X >

80

= V

ery

Go

od

Domains of Life Quality

Quality of Life FunctioningHigher Scores are Better

General

You

Your MAQ T-score is: 84 99 (your percentile)

Which indicates that you may be experiencing a severe degree of Generalized Anxiety at this time.

Panicky Symptoms: T-Scores Percentile

Likely to be present or may be a problem for you. 80 98%

Social Anxiety:


Worrying:


Negative chatter:


MAQ Summary

Anxiety

Data graphs are given to Patients & are discussed with Medical Providers, engendering:

• Treatment Decision Making• Therapeutic Alliance

• Insight / Understanding• Substantiation of Clinical Diagnosis

• Validation

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Implementation: Mid-Treatment Profile Results

-

10

20

30

40

50

60

70

80

90

Physical Emotional Social Environment

77 7572 72

69

31

19

50

81

56

6963

Sum

mar

y Sc

ores

: X

< 20

= V

ery

Poor

;

X <

40

= Po

or;

40 <

X <

60,

= F

air

X >

60 =

Goo

d;

X

> 80

= V

ery

Goo

d

Domains of Life Quality

Quality of Life FunctioningHigher Scores are Better

General Admission 12/27/2019 Mid-Tx 01/07/2020

Comparative data graphs are given to Patients & discussed with Primary Therapists, engendering:

• Treatment Plan Changes• Therapeutic Alliance

• Clinical Discussion of Progress/Inertia• Treatment Compliance

• Hope• Validation

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Implementation: Mid-Treatment Profile Results

30

40

50

60

70

80

90

100

110

Physiological-Panic Social Anxiety Worry-Fears Negative Affect

66 65 65 64

80 80 7976

6864

82

64

Anxiety T-Score Comparison

Clinical Cut Off Your PRE T-score Your Mid-Tx T-score

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Measure to Improve: Aggregating & Analysis

− Minimum Sample size: N= 500

− Multivariate analyses (hierarchical multiple regression, path analyses, etc).

− Identifying predictor & contributing variables associated with recovery success and relapse.

− What’s working? What’s not?

− Repeated measures analyses

− Are “changes” due to chance?

− Clinical v Statistical significance

− Program Fidelity

− Correlations to investigate interactions & associations of programmatic effectiveness.

− Understanding AMA behaviors

− Patient Satisfaction (e.g., Net-Promoter Score)

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Questions

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To register for a webinar or watch a replay, visit:https://www.jointcommission.org/webinarsBHC

https://www.jointcommission.org/webinarsBHC

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Behavioral Health Care Accreditation

Business Development Team

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Julia Finken, BSN, MBA, CPHQ, CSSBB

Executive Director

[email protected]

630-792-5790

Darrell Anderson

Manager- BHC

[email protected]

630-792-5866

Yvonne Rockwood, MBA,MHA,CPHQ

Associate Director – BHC

[email protected]

630-792-5792

Eastern Region Western Region

Tiffany Holloway

Manager - BHC

[email protected]

630-792-5810

Colette Bukowski, LPCC-S

Associate Director -BHC

630-792-5812

[email protected]

Measurement Based Care: Behavioral Health Joint …

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