1. Measuring Quality of Care for Co-Occurring Conditions Richard C. Hermann, MD, MSTufts University School of Medicine David J. Dausey, PhDRand Corporation Amy M. Kilbourne, PhD, MPH University of Pittsburgh Catherine Fullerton, MD, MPHHarvard Medical School RWJF Depression in Primary Care Program Center for Quality Assessment & Improvement in Mental Health www.cqaimh.org

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

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

4. Medical Conditions among MHS Patients Prevalence: Elevated rates of diabetes, HIV, pulmonary, CV & GI disease among individuals with severe mental illness 2 - 5x higher risk of mortality from natural causes 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 condition

5. Dual Diagnosis in MH & SUD Specialty Sectors Prevalence: ~ 50% of patients with SMI have an SUD over lifetime ~ 25% of patients with SMI have an active SUD Deficits: < 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

6. 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

7. 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

8. National Inventory of Mental Health Quality Measures > 300 measures proposed for quality assessment & improvement in MH/SUD care – available at http://www.cqaimh.org/quality.htm Less than 5% assess care for co-occurring conditions Other instruments available, but not widely used for these populations – surveys of patient perspectives of care – outcome assessment tools – fidelity scales

9. 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

10. Framework for Measuring Quality of Care Structure Process Technical Outcome Interpersonal

11. 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

12. 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

13. Outcomes of Care for Co-Occurring Conditions Change in Symptoms Behaviors Functioning Quality of life Adverse effects Mortality Patient Satisfaction

14. 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 user’s control results interpretable

15. 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

16. 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

17. 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. sectors Tension btw. sharing clinical information & confidentiality Unclear accountability for outcome Lack of defined standards for boundary spanning care

18. Measures of Conformance to Standards & Guidelines Research Consensus Evidence Development Practice guidelines / standards of care Conformance Structures Processes Outcomes Delivery of Care

19. 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” feedback Need for standards: what? by when? how? What data sources are available? Different forms of measure useful to different stakeholders?

20. 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 care – pap smear, vaccines, colonoscopy % of patients with DM with HgA1c testing % of patients with COPD with spirometry testing

21. Background: Integrated Care for MH/SUD ~50% of individuals with a mental disorder have at least one co-occurring substance use disorder (MH/SUD) 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”

22. 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

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

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

25. 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.

26. Breakout Session 2: Measure Selection Integrated Care for Patients with MH/SUD Comparing and contrasting different measures for MH/SUD Focus on measures for state mental health agencies Rate and discuss 3 different measures on feasibility and meaningfulness Consider appropriate data sources for measures

27. Group 1: Measure Development Information exchange between PCP & MHS Group 2: Measure Selection Integrated treatment for patients with dual diagnoses Report back: 9:40 am Breakout Session