1. 1 TMAP

2. 2 NorthSTAR IMPLEMENTATION PLANNING TEAM 12-13-2002

3. 3 PLANNING MEETING GOALS Define specific goals for successful implementation Define specific goals for successful implementation Define activities to achieve goals Define activities to achieve goals Troubleshoot barriers to carrying out activities Troubleshoot barriers to carrying out activities Assign activities to achieve goals to team members Assign activities to achieve goals to team members Identify timeline for completing activities Identify timeline for completing activities

4. 4 CONSULTANTS TO PROCESS Dr. Steve Shon, TDMHMR Medical Director Dr. Steve Shon, TDMHMR Medical Director Dr. Ken Altshuler, TDMHMR Board of Directors & UTSMC Professor Dr. Ken Altshuler, TDMHMR Board of Directors & UTSMC Professor Carole Matyas, ValueOptions V-P Carole Matyas, ValueOptions V-P Dr. Lynelle Yingling, DANSA Board Chair Dr. Lynelle Yingling, DANSA Board Chair

5. 5 Review of Basics Dr. Shon

6. 6 Everyone “Just Doing Their Best”

7. 7 TMAP: Aligning the Arrows

8. 8 Algorithm Algorithm “A step by step procedure for solving a problem or accomplishing some end.” Webster’s Dictionary

9. 9 GOALS OF MEDICATION GUIDELINES/ALGORITHMS l Systematic Approach to Medication Management l Quantifiable and Reliable Outcome Measures l Documentation of Medications and Outcomes l Enhance Medication Adherence by Patients

10. 10 Clinical Reasons for Algorithms Facilitate clinical decision-making Facilitate clinical decision-making Improve quality of care Improve quality of care Make treatment plans consistent across sites and physicians Make treatment plans consistent across sites and physicians Tailor treatment to individuals Tailor treatment to individuals Provide adequate clinical documentation Provide adequate clinical documentation Define where new medications fit for optimal outcomes Define where new medications fit for optimal outcomes

11. 11 Administrative Reasons for Algorithms Accountability for scarce resources Accountability for scarce resources Uniform expectations for providers Uniform expectations for providers Improve cost efficiency Improve cost efficiency Predictable costs Predictable costs Define where new medications are cost- effective Define where new medications are cost- effective Define costs related to specific treatments or outcomes Define costs related to specific treatments or outcomes

12. 12 Medication Algorithms Three disorder groups Three disorder groups Major depressive disorders Major depressive disorders Schizophrenia Schizophrenia Bipolar disorders Bipolar disorders Strategies (identifying the what) Strategies (identifying the what) Tactics (identifying the how) Tactics (identifying the how) Specific guidelines Specific guidelines Planned revisions Planned revisions

13. 13 DOCUMENTATION

14. 14

15. 15

16. 16 PATIENT AND FAMILY EDUCATION

17. 17 Educational Materials Patient objectives Patient objectives Teaching patients disease management Teaching patients disease management Involving patients in treatment choices Involving patients in treatment choices Optimizing treatment benefits Optimizing treatment benefits Provider objectives Provider objectives Optimizing treatment benefits Optimizing treatment benefits Teaching optimal medication use Teaching optimal medication use Clarifying and documenting clinical decision-making Clarifying and documenting clinical decision-making Patient objectives Patient objectives Teaching patients disease management Teaching patients disease management Involving patients in treatment choices Involving patients in treatment choices Optimizing treatment benefits Optimizing treatment benefits Provider objectives Provider objectives Optimizing treatment benefits Optimizing treatment benefits Teaching optimal medication use Teaching optimal medication use Clarifying and documenting clinical decision-making Clarifying and documenting clinical decision-making

18. 18 The Texas Medication Algorithm Project (TMAP): Outcomes for Persons with Schizophrenia (SCZ)

19. 19 SCZ Adjusted Mean Symptoms (BPRS 18 ): All Subjects Quarter BPRS 18

20. 20 SCZ: Sum of Cognition z Scores: All Subjects

21. 21 Cognitive Impairment Positive Symptoms Negative Symptoms Adaptive Function Cognitive Impairment Predicts Functional Outcomes Velligan et al. Schizophr Res 1997;25:21-31.

22. 22 HOSPITALIZATIONS FOR SCZ ALGO ALGO Patients165 % Admits 3.0% # Admitted 5 Days/Pt.1.48 # of Admits 6 TAU TAU Patients300 % Admits 8.7% # Admitted 26 Days/Pt.3.84 # of Admits 36

23. 23 The Texas Medication Algorithm Project (TMAP): Outcomes for Persons with Bipolar Disorder (BPD)

24. 24 BPD Adjusted Mean Manic/Hypomanic Symptoms (CARS- M): All Subjects Quarter

25. 25 The Texas Medication Algorithm Project (TMAP): Outcomes for Persons with Major Depressive Disorder (MDD)

26. 26 MDD Adjusted Mean Symptoms (IDS-C 30 ): All Subjects

27. 27 http://www.mhmr.state.tx.us/ centraloffice/medicaldirector Official TMAP/TIMA/CMAP Internet Sites

28. 28 Goals for NS TMAP Implementation Develop a clear implementation plan Develop a clear implementation plan Begin changes with incorporating medical records used with TMAP by summer Begin changes with incorporating medical records used with TMAP by summer Begin with computerized version Begin with computerized version

29. 29 Activities to Achieve Goals Initial workgroup [VO, Dr. Shon, Dr. Altshuler, DANSA ED + PAC] review TDMHMR implementation guides for appropriateness/adaptation Initial workgroup [VO, Dr. Shon, Dr. Altshuler, DANSA ED + PAC] review TDMHMR implementation guides for appropriateness/adaptation VO meet with Dr. Altshuler to plan electronic requirements VO meet with Dr. Altshuler to plan electronic requirements VO pilot with 1 or 2 providers to refine the process before full implementation VO pilot with 1 or 2 providers to refine the process before full implementation

30. 30 Barriers & How To Overcome Startup cost Startup cost Ongoing cost of meds Ongoing cost of meds Mental mindset Mental mindset Training large number of private providers [1 day of training initially] Training large number of private providers [1 day of training initially] Develop a uniform plan with a large number of providers Develop a uniform plan with a large number of providers Possible software grant Possible software grant Long-term reduced meds Long-term reduced meds Careful planning Careful planning Possibly minimize time required by using teleconferencing Possibly minimize time required by using teleconferencing Pilot first & streamline Pilot first & streamline

31. 31 Assignment of Specific Tasks Share implementation guides with initial workgroup for review & possible modification Share implementation guides with initial workgroup for review & possible modification Meet to plan electronic requirements Meet to plan electronic requirements David David [to Carole, DANSA PAC, Dr. Altshuler] [to Carole, DANSA PAC, Dr. Altshuler] David, Carol, Dr. Altshuler David, Carol, Dr. Altshuler

32. 32 Timeline Spring 2003 Spring 2003 Summer 2003 Summer 2003 Fall 2003 Fall 2003 Plan for implementation defined Plan for implementation defined Pilot project fully implemented and evaluated Pilot project fully implemented and evaluated Plan for complete NS implementation defined Plan for complete NS implementation defined

33. 33 Next Step to Success

34. 34 Demonstration of Software Resource Dr. Altshuler