Behavioral Health/General Health Integration: Top 10 Issues Harold - - PowerPoint PPT Presentation

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Behavioral Health/General Health Integration: Top 10 Issues Harold - - PowerPoint PPT Presentation

Aug 30, 2023 222 likes •416 views

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

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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

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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

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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?

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NASHP December 2016

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  • 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

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  • 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

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  • 3. Measure development process

Standardize Practice Elements – Clinical assessment – Interventions – IT infrastructure Develop Guidelines – Mental health – Substance use – General health Measure Performance – Operationalizing concepts to measure specifications (numerator/ denominator) Improve Performance – Learn – Reward Strengthen Evidence Base – Document stakeholder value – Evaluate effective strategies – Translate from bench to bedside to community Consumer Participation Leadership (PCP/MH/SUD) Support Clinical (PCP/MH/SUD) Perspectives Integrative Processes

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  • 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

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  • 5. Balanced Portfolio Across Types
  • f 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?

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NASHP December 2016

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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

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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

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NASHP December 2016

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Continuum-Based Framework

(H. Chung, et al, UHF, 2016)

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Illustration of integration continuum for condensed version of the framework

NASHP December 2016

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  • 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

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  • 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

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  • 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

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  • 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

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  • 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

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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

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Delphi Study

Measurement development for integrated care

Strategic framework

Domain 1: Stratification and disparities in general medical evidence-based treatment

Section A: General medical care for individuals with behavioral health conditions

Domain 2: General medical screening or diagnostic assessment and prevention Domain 3: Outcomes and patient perception of care Domain 4: Continuity and coordination of care Domain 5: Access to general medical care

Section B: Behavioral health care in general medical settings

Domain 6: Metal health screening or assessment Domain 7: Behavioral health evidence-based treatment Domain 8: Behavioral health patient-centered care Domain 9: Continuity and coordination of care Domain 10: Access to behavioral health care

Section C: Concepts applying to both general medical and behavioral health settings

Domain 11: Continuity and coordination of care Domain 12: Social service access Domain 13: Cost and efficiency

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Delphi Study

Measurement development for integrated care

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Category Importance Validity Feasibility Implication Strategy A agreement agreement agreement

Ready for measure development Develop specific measures based on the context

B agreement agreement disagreement

Information not available in existing data and hard to capture Measurement innovation; Build the data system capacity

C agreement disagreement disagreement

No existing evidence to support the link between performance and measure Conduct research to explore the association between performance and measure Evidence proved the lack of association between performance and measure Exclude for further development

D disagreement disagreement agreement

Potential balancing measure facilitating the interpretation of other measures Further research on where and how to incorporate with other measures

NASHP December 2016