Behavioral Health/General Health Integration: Top 10 Issues Harold Alan Pincus, MD Professor and Vice Chair, Department of Psychiatry Co-Director, Irving Institute for Clinical and Translational Research Columbia University Director of Quality and Outcomes Research NewYork-Presbyterian Hospital Senior Scientist, RAND Corporation
Behavioral Health/General Health Integration: Top 10 Issues 1. Importance of the interface 2. Assessing both sides of the interface 3. Understanding the process of measure development 4. Navigating the “Quality Measurement Industrial Complex” 5. Balanced portfolio across types of measures 6. “Measurement-Based Care” as a core concept 7. “Shared Accountability” as a core concept 8. Serious Mental Illness as a “Disparities Category” 9. Barriers to measurement 10. Creating a measurement agenda • Commonwealth Fund Project NASHP December 2016 2
A Reality Check • How do YOU choose a doctor for yourself, your children, your parents? • How do YOU choose a mental health provider for your children or suggest one for a friend or a family member? • How do YOU determine whether your children are receiving high quality medical care? • High quality mental health care? • What DATA do you examine to answer these questions? What data do you WISH you had? NASHP December 2016 3
1. Importance of the interface and need for measures • 35 year old male with schizophrenia, diabetes, and tobacco dependence – Can expect up to 25 year shortened life span, increased medical costs • 25 year old HIV+ female IV drug user with PTSD – Frequent ED visits, non adherence to meds, increased medical costs • 60 year old female with diabetes, CHF and depression – Frequent (re-) hospitalizations, poor self management and adherence, early candidate for LTC • Costs, “Hotspotting”, poor quality, VBP,etc NASHP December 2016 4
2. Assessing both sides of the interface • Patients primarily in contact with the general medical sector with co-morbid BH conditions (e.g., depression, substance abuse) – Not identified or treated as acute problems with little follow-up • Patients with severe and persistent BH conditions (e.g., schizophrenia, bipolar disorder) and treated in BH specialty settings – Poor self-care, medications worsen general medical conditions – Limited provider capacity and incentives for • Accessing treatment of co-morbid medical conditions • Preventive and wellness care • Medical and BH providers operate in silos NASHP December 2016 5
3. Measure development process Consumer Participation Standardize Practice Elements – Clinical assessment – Interventions – IT infrastructure Develop Guidelines – Mental health – Substance use – General health Leadership Clinical Measure Performance (PCP/MH/SUD) (PCP/MH/SUD) – Operationalizing concepts to Support Perspectives measure specifications (numerator/ denominator) Improve Performance – Learn – Reward Strengthen Evidence Base – Document stakeholder value – Evaluate effective strategies – Translate from bench to bedside to community Integrative Processes NASHP December 2016 6 6
4. The “Quality Measurement Industrial Complex” • Evidence Developers – Researchers, NIH, PCORI, AHRQ • Guideline Developers – Professional Associations • Measure Developers/Stewards – NCQA, TJC, CMS, Contractors, Researchers, Professional Associations • Measure Endorsers – NQF, MAP • Measure Users – CMS, Plans, Provider Organizations, Media, Public NASHP December 2016 7
5. Balanced Portfolio Across Types of Measures • Structure – Are adequate personnel, training, facilities, QI infrastructure, IT resources, policies, etc. available for providing care? – Structures that support use and reporting of outcomes – TJC, Patient-Centered Medical Homes, C-CBHC/PAMA Sec. 223 • Process – Are evidence-based processes of care delivered? – Underuse, Overuse, Appropriateness, Fidelity • Outcome – Does care improve clinical outcomes? • Patient Experience – What do users and other stakeholders think about the system ’ s structure, the care they have received, and their outcomes? • Resource Use – What/How much resources are expended for providing care? – Are resources being used in an efficient way? NASHP December 2016 8
Continuum-Based Framework for PC/BH Structural Integration (H. Chung, et al, UHF, 2016) • Case finding, screening, and referral to care – Predictive modeling – Screening, initial assessment, and follow-up – Referral facilitation and tracking • Multi-disciplinary team used to provide care – Care team membership – Systematic team-based caseload review and consultation – Availability for interpersonal contact between PCP and BH specialist/psychiatrist • Ongoing care management – Coordination, communication, and longitudinal assessment • Systematic quality improvement – Use of quality metrics for program improvement NASHP December 2016 9
Continuum-Based Framework for PC/BH Structural Integration (H. Chung, et al, UHF, 2016) • Decision support for measurement-based, stepped care – Evidence-based guidelines/treatment protocols – Use of pharmacotherapy – Access to evidence-based psychotherapy treatment with BH specialists • Self-management support that is culturally adapted – Tools utilized to promote patient activation and recovery • Information tracking and exchange among providers – Clinical registries for tracking and coordination – Sharing of treatment information • Linkage with community/social services – Linkages to housing, entitlement, and other social support services NASHP December 2016 10
Continuum-Based Framework (H. Chung, et al, UHF, 2016) Illustration of integration continuum for condensed version of the framework NASHP December 2016 11
6. Measurement-Based Care • Systematically apply appropriate clinical measures – e.g. HA1c, PHQ-9, Vanderbilt Assessment Scales – Create a measurement tool kit • Assure consistent, longitudinal assessment – “Ruthless” Follow-Up/Care Management • Use action-oriented menu of evidence-based options – Treatment intensification/“Stepped Care” • Establish practice-based infrastructure – Build IT/Registry Capacity • Enhance Connectivity among Systems – MH/PC/SUD/Social Services/Education • Incentivize Structures that Produce Outcomes NASHP December 2016 12
7. Shared Accountability Breaking Down Silos • Relatively simple concept • Applies to all participants caring for a patient • For example, PCP is jointly responsible for assuring quality for both GH and BH care • BHS is jointly responsible for assuring quality for both BH and GH care • The same applies to Med/Surg Health Plan and BH Carveout • Instantiated in training, practice, health plan contracts, performance incentives…… ……..And, ultimately, culture NASHP December 2016 13
8. Serious Mental Illness as a “Disparities Category” • High level of general medical co-morbidity • Lack of access to primary/preventive care • Poor quality of care • Reduced life span • Potential easily implemented measurement strategy • Report existing endorsed measures for this population segment, for example: – Receipt of preventive health interventions, screening, immunizations – Process and outcomes measures for common general medical comorbidities such as smoking, diabetes, hypertension, cardiovascular • Include in national disparity reports NASHP December 2016 14
9. Barriers to Measurement • Adequacy/Specificity of evidence base! • Agreement/development/HIT integration of clinical measures for “Measurement-Based Care” • Codifying psychosocial interventions in administrative data (psychotherapy/“90806” v. CBT v. CBT with fidelity) • Adequacy of data sources--Documentation or Reality • Determining benchmarks/Risk adjustment • Linking S-P-O (e.g. ACCORD) • Who is stewarding/funding measure development? • Far behind in implementation of HIT/(exclusion from HITECH) • Heterogeneity of providers/training/certification • Who is accountable for performance? Shared accountability NASHP December 2016 15
10. Creating a Measurement Agenda: Commonwealth Fund Project • Reviews of potential – Process – Structure – Access – Outcome/Patient Perceptions – Costs/Efficiency • Expert/Delphi Panel Process • Priorities/Next Steps • Engaging the QMIC NASHP December 2016 16
Delphi Study Measurement development for integrated care Modified RAND/Delphi process • Existing measures overview from literature review • Measure concepts creation • Delphi survey questionnaire development • Identify/Invite experts across a range of stakeholder groups (BH/GH providers, plans, state/Medicaid and federal policymakers, consumers, TJC, NCQA, researchers • First-round Delphi survey rating on importance, validity and feasibility for each measure concept (1-9 Scale) • Delphi panel meeting and second-round Delphi survey • Data analysis and findings dissemination NASHP December 2016 17
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