Quality Standard for Schizophrenia One Year Later Phil Klassen MD FRCPC Vice-President, Medical Affairs Ontario Shores Centre for Mental Health Sciences Assistant Professor, University of Toronto With thanks to Terri Irwin, and HQO

Introduction Overview of the schizophrenia Quality Standard Ontario Shores’ approach to implementation Results of our gap analysis

Quality standards – what are they? Concise sets of 5-15 strong (“must do”), measurable, evidence-based statements guiding care in a topic area Developed in topic areas identified as having high potential for better quality care in Ontario Each quality statement accompanied by quality indicator(s) Every quality standard will be accompanied by a plain language summary for patients and caregivers Strong emphasis on implementation through a variety of vehicles (monitoring/reporting, QBPs, Quality Improvement Plans, etc.) Strong emphasis on partnerships to support development and implementation www.HQOntario.ca

What Quality Standards mean to our key audiences Patients, caregivers and the public can use Quality Standards to understand what excellent care looks like and what they should expect from their health care providers Health care professionals can use Quality Standards to evaluate their practice, identify areas for personal and organizational quality improvement and incorporate them into professional education Provider organizations can use Quality Standards to audit their quality of care, identify gaps, guide organizational improvement strategies and inform clinical program investments LHINs and disease agencies can use Quality Standards to inform regional improvement strategies and monitor the care provided by health service providers Government can use Quality Standards to identify provincial priority areas, inform new data collection and reporting initiatives, and design performance indicators and funding incentives www.HQOntario.ca

Quality Standards: The Elements The Statement The Indicators The Audience Statements Defintions www.HQOntario.ca

Quality Standard foR SCHIZOPHRENIA www.HQOntario.ca

Schizophrenia: Population and Scope Adults aged 18-65 suffering from schizophrenia From the ER/hospital admission to discharge Community treatment for next iteration In Scope Adolescents and the elderly Not specifically about first episode psychosis Not specifically about concurrent disorders Out of Scope

Quality Standard for Schizophrenia: Content www.HQOntario.ca

Steps to Implementation Select the guideline Develop the algorithm Undertake a gap analysis Create the governance structure Select the process adherence and outcome measures Create the project charter Utilize informatics Realign therapeutic services Monitor and support adherence Physician transparency Use of a physician assistant Academic detailing Performance appraisals www.HQOntario.ca

Quality Standards - Lessons we are learning The are numerous statement and many indicators You need to decide where to spend your energy You need to decide how many indicators, and for what purpose Change can be managed by creating three “buckets” Things we are doing already and may not measure Eg comprehensive assessment Things that we are not doing consistently but technology and forcing functions can drive the solution, with some measurement Eg EHR prompts to explain why not an LAI Things that represent a very significant change in our business model, and will require resource re-allocation, technology, change management and staff training or partnerships to accomplish Eg CBT for psychosis www.HQOntario.ca

Gap Analysis & Level of Difficulty Rating Overview Schizophrenia Quality Statements Clinical Gap Data Gap 1 – Screening for Substance Use 2 – Comprehensive, Interprofessional Assessment 3 – Physical Health Assessment *adjustment of the indicators would change this rating 4 – Promoting Physical Activity and Health Eating 5 – Promoting Smoking Cessation 6 – Treatment with Clozapine 7 – Treatment with Long-Acting Injectable Antipsychotic Medication 8 – Cognitive Behavioural Therapy 9 – Family Intervention 9 – Follow-Up Appointment After Discharge 10 – Transition of Care Highlights: 70% of the quality statements assessed as routine clinical practice Discussion around creating a schizophrenia template to capture applicable data elements for reporting on the identified indicators.

Quality Statement Clinical Gap Data Gap 1. Screening for Substance Use No gap (although capacity levels for provision of service may need to be reviewed) Need to be able to identify if the patient had a referral to concurrent disorders treatment (prior to admission) and are awaiting that service 3. Physical Health Assessment No gap Unable to currently identify if a patient had a comprehensive physical assessment, including metabolic work-up, in the past year (prior to admission). Recommendation to provide feedback to HQO on these indicators. 4. Promoting Physical Activity and Health Eating Need to be able to identify when patients received interventions that promoted physical activity and/or healthy eating 6. Treatment with Clozapine Need to be able to identify when a patient was offered clozapine 7. Treatment with Long-Acting Injectable Antipsychotic Medications Potential gap in clinical practice with regards to whether this is always offered. Need to be able to identify when a patient was offered a long-acting injectable antipsychotic medication. 8. Cognitive Behavioural Therapy Clinical gap with provision of individual CBT for psychosis. 9. Family Intervention Clinical gap with provision of family intervention as specified in this quality statement Need to way to identify if consent was provided for family involvement, who is receiving family intervention services during admission or arranged in discharged plan 10. Follow-up Appointment After Discharge Need to look into approach to report on follow-up appointment timing with other service providers. 11. Transitions of Care Need to confirm if any additional details are required to report on patients discharged to homelessness with shelter arrangements or without shelter arrangements.

Quality Statements Implementation Plan Summary Comprehensive Assessment Comprehensive assessments considered routine practice, with the exception of the requirement for a physical examination Referral process updates: Inclusion of requirement to complete PHQ-9 (a validated assessment tool for assessing severity) to confirm suspected severity Updates to priority setting standardization to include suspected severity Meditech changes: Ability for psychiatrists and clinicians to complete the PHQ-9 at assessment, and thereafter, to track progress. Prompts to include recommendation to complete a physical health assessment as part of consult (if not already completed) Suicide Risk Assessment and Intervention Assessed as routine clinical practice already. Leverage PHQ-9 results to trigger the addition of a suicide risk assessment to worklist as applicable Shared Decision-Making Development of decision aid for use with patients Provide decision aid resource and record use of decision aid with patients Treatment After Initial Diagnosis New depression treatment note, including checks to record initiation of medication and/or psychotherapy as applicable. Adjunct Therapies and Self-Management Assessed as routine clinical practice already (although not recorded as discrete data) Queries added to record that this information was shared with the patient. Monitoring for Treatment Adherence and Response New depression progress note, with queries to capture treatment adherence & response, as well as remission Optimizing, Switching, or Adding Therapies New depression progress note, with specific queries record offering of a different or additional antidepressant, psychotherapy, or a combination, if they have not responded to their antidepressant medication after 8 weeks. Continuation of Antidepressant Medication Assessed as routine practice already (although not recorded as discrete data). Queries added to record that this requirement is being completed. Electroconvulsive Therapy Assessed as routine practice already (although not capturing when it was offered as discrete data) Query added to capture when ECT is offered Assessment and Treatment for Recurrent Episodes Same implementation plan as outlined in quality statement #1. Education and Support Queries added to record that this was offered Transitions in Care Assessed as routine clinical practice for inpatients being discharged Replace current outpatient physician discharge summary note with a shorter outpatient physician D/C report with diagnosis template and add query to clinician depression note to identify as a final note, ability to add receiving provider contact information and notice to HIM to send report.

Physician Workflow in the EHR

Estimating psychotherapy needs We went to our clinicians, and DS How many patients carry schizophrenia as a principal diagnosis? How many patients are screened in/accept/complete therapy? Used the following equation 100% x .5 (screened in) x .5 (accepted) x.5 (completed) We calculated hours per treatment x patient numbers x available resources Looked at training/supervision gap Ascertained manuals Material into HER Short-stay: inpatient continued as outpatient or deferred Long-stay: inpatient

15%-30% time conversion

Clinical Decision Support: Physician Admission Assessment PRESENTER: Nander Stevens www.HQOntario.ca

Clinical Practice Guidelines: Dashboard www.HQOntario.ca

CBT for Psychosis Referrals (Comparison with Pre-Implementation Baseline) Desired direction CPG Implementation Note – April 2013 – October 2013 data is not showing any referrals so it has not been included in this graph. www.HQOntario.ca

Progression over time www.HQOntario.ca Measure 2013-14 Median (pre-implementation) 2013-14 Mean (pre-implementation) 2014-15 Median 2014-15 Mean 2015-16 Median 2015-16 Mean March Snapshot (March 31, 2016) Polypharmacy (excluding clozapine) 46.5% 46.25% 40.2% 41.52% 41.7% 40.1% 30.2% Metabolic Monitoring 76.8% 77.1% 79.5% 79.28% 80.9% 82% 89.6% CBT-Psychosis Referral 5% 5.6% *calculated with data from Nov-13-Mar- 14. No referrals shown in the reports from Apr-13 – Oct-14 7.85% 9.2% 16.9% 25% 52.2% Voc. Services Referral 37.5% 37.67% 41.39% 43.6% 45.3% 57.2% www.HQOntario.ca

July 2016 www.HQOntario.ca

Indicators chosen Process (annual audit for the remainder) Tracking Percent screened for CBTp Percent referred for CBTp Percent received family intervention Percent care plan within 7 days Percent appointment within 7 days Outcome Improvement in positive symptoms between admission and discharge

CPGs - Lessons Learned Recommendations need to be evidence-based Implementation needs to be led by physicians/clinicians Choices need to be transparent and justifiable Structured templates/order sets/automated decision-support help promote adherence: reflex orders (can be built on paper if EMR is not available) Many factors outside of physician behaviour affect adherence (interprofessional team, patient choices) Need to pay attention to data-quality and have a mechanism for sharing data with the clinicians Medical Directors incentivized to deliver rates Data push On-unit champions www.HQOntario.ca

Conclusions These quality standards will go “live” in 2017-2018 It is not clear yet if, or how, they will be linked to funding They are iterative; expect updates The next mental health and addiction standard is for community treatment of schizophrenia.