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Measuring Quality of Care for Co-Occurring Conditions


Medical conditions in mental health specialty care ... Medical Conditions among MHS Patients. Prevalence: ... had a significant, undetected medical condition ... – PowerPoint PPT presentation

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Title: Measuring Quality of Care for Co-Occurring Conditions

Measuring Quality of Care for Co-Occurring
  • Richard C. Hermann, MD, MS Tufts University
    School of Medicine
  • David J. Dausey, PhD Rand Corporation
  • Amy M. Kilbourne, PhD, MPH University of
  • Catherine Fullerton, MD, MPH Harvard Medical
  • RWJF Depression in Primary Care Program
  • Center for Quality Assessment Improvement in
    Mental Health

  • Co-occurring conditions deficits in care
  • Mental disorders SUD in primary care
  • Medical conditions in mental health specialty
  • Dual diagnoses in mental health SU specialty
  • Role of quality measurement in improving mental
  • Status prospects for measures of co-occurring
  • Breakout session
  • Measure development exercise
  • Measure selection exercise

Mental 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
  • Limited referral for specialty care
  • Barriers to successful referral
  • Poor communication btw. PCP and MH/SU specialists

Medical Conditions among MHS Patients
  • Prevalence
  • Elevated rates of diabetes, HIV, pulmonary, CV
    GI disease among individuals with severe mental
  • 2 - 5x higher risk of mortality from natural
  • 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

Dual Diagnosis in MH SUD Specialty Sectors
  • Prevalence
  • 50 of patients with SMI have an SUD over
  • 25 of patients with SMI have an active SUD
  • Deficits
  • lt 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)
Adaptation 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)
Recommendations 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
  • gt 300 measures proposed for quality assessment
    improvement in MH/SUD care
  • available at http//
  • Less than 5 assess care for co-occurring
  • 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 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 Care
Structure Process Technical Outcome
Structure Interpersonal Outcome
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
  • Symptoms
  • Behaviors
  • Functioning
  • Quality of life
  • Adverse effects
  • Mortality
  • Patient Satisfaction

Desirable Characteristics of Quality Measures
Meaningful quality problem clinically important evidence-based valid comprehensible Feasible precisely specified data available affordable reliable confidential case mix Actionable under users control results interpretable
Mental disorders SUD in Primary Care Existing
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 Measures
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 Need for
Measures of Boundary-Spanning Care
  • Potential measure topics
  • Completion rates for referrals
  • Communication btw PCPs and MHS
  • Outcomes of referred or collaborative care
  • Obstacles to overcome
  • Carve-outs result in segregation of data btw.
  • Tension btw. sharing clinical information
  • Unclear accountability for outcome
  • Lack of defined standards for boundary spanning

Measures 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 Development
Information exchange between PCP MHS
  • Proposed Measure
  • primary care patients referred to MHS for
    psychiatric care whose PCP received adequate
  • Need for standards what? by when? how?
  • What data sources are available?
  • Different forms of measure useful to different

Quality Measurement for Medical Conditions in
MHS Care
  • Detection
  • patients with general medical history
  • patients with documented smoking status
  • patients screened for DM, fasting lipids
  • Treatment
  • of patients receiving appropriate preventive
  • pap smear, vaccines, colonoscopy
  • of patients with DM with HgA1c testing
  • of patients with COPD with spirometry testing

Background Integrated Care for MH/SUD
  • 50 of individuals with a mental disorder have
    at least one co-occurring substance use disorder
  • 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/SUD
  • Limited current service linkages between MH and
    SA providers
  • Failure to identify MH/SUD patients in MH
    specialty settings
  • Program fidelity challenges
  • Lack of performance measures despite growing
    evidence base and standards

Structural 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
  • Formal relationships (referral agreements or
    contractual relationships among providers)
  • Informal or ad hoc (absence of formal
  • Research indicates that programs with integrated
    services have the best outcomes

Process Measure Model Fidelity
  • Average fidelity score across participating
  • New Hampshire/Dartmouth Integrated Dual Disorder
    Treatment (IDDT) model
  • 26 Item fidelity scale
  • Each item represents an org. or tx component of
  • 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

Outcome 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 Selection Integrated
Care for Patients with MH/SUD
  • Comparing and contrasting different measures for
  • Focus on measures for state mental health
  • Rate and discuss 3 different measures on
    feasibility and meaningfulness
  • Consider appropriate data sources for measures


Breakout Session
  • Group 1 Measure Development
  • Information exchange between PCP MHS
  • Group 2 Measure Selection
  • Integrated treatment for patients with dual
  • Report back 940 am