Introduc=on. Results: Provider & Pa=ent Perspec=ves. Results: Key Considera=ons by Theme. Na=onwide efforts to integrate behavioral and physical health ...
Keeping Score: Developing a Tool for Comprehensive Behavioral Health Evalua4on at Confluence Health
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Maureen Lara, MHA1, Kilee LippincoG, MHA1, Corissa Luedtke, MHA1, and Suzanne J. Wood, PHD, MS, FACHE1 1University of Washington, SeaGle, WA
Abstract Na/onwide efforts to integrate behavioral and physical health services are being implemented to beCer coordinate care and improve pa/ent outcomes following the passage of the Affordable Care Act (2010). Confluence Health, to address the need to provide value over volume of care, set a goal to develop a well-‐rounded assessment tool for the behavioral health service line that would allow them to monitor and track the efficacy of services they provide as well as pa/ents’ long-‐term health. Leveraging consulta/ve literature supplemented by focus groups, internal surveys, and key informant interviews, our findings suggest the crea/on of a dashboard containing four broad categories is required: 1) evidence-‐based clinical guidelines; 2) pa/ent sa/sfac/on; 3) lifestyle outcomes; and 4) produc/vity. By developing metrics within each of these four dimensions, Confluence Health will be able to evaluate delivery of behavioral health services both holis/cally and longitudinally.
Results: Key Considera/ons by Theme Clinical Guidelines
Lifestyle Measures
Introduc/on Crea/ng an effec/ve way to measure a mul/-‐axial approach to care is crucial to improve health outcomes in an increasingly collabora/ve environment (Advancing Integra/ve Mental Health Solu/ons, 2016; Velamoor & State, 2016). Evalua/ng pa/ent outcomes using a holis/c approach is a rela/vely new concept. Research on the development of associated metrics, to include combining them a formalized evalua/on tool, has not yielded a single best prac/ce. The scarcity of effec/ve tools is a par/cularly salient problem in rural areas. This study explores benchmark data collec/on approaches for the purpose of incorpora/ng best prac/ces into a comprehensive behavioral health evalua/on tool relevant to a rural health system. The focus of our study is to address the following ques/ons: 1. Which evidence-‐based approaches should be incorporated into the tool? 2. What is the most effec=ve way to measure holis=c and long-‐term outcomes? 3. What is the best approach to gauge pa=ent sa=sfac=on in a behavioral health seCng? 4. At what levels should behavioral health providers’ produc=vity be set?
Methods This project resulted from a ten-‐week exploratory assessment in which a team of graduate students and faculty partnered with a Confluence Health clinical execu/ve to create an evalua/on tool for behavioral health services. IRB approvals were obtained from the Human Subjects Division at the University of Washington wherein data collec/on was found to pose minimal risk. Data sources included: • suppor4ng literature • pa4ent focus group • pa4ent surveys (n=16) • clinical staff surveys (n=23) • key informant interviews with execu4ve leaders
Pa4ent Sa4sfac4on
Conclusions: Evidence-‐Based Dashboard
• Care Integra/on • Evidence-‐based suppor/ng policies • Standardized prac/ces • Pa/ent educa/on: misrepresenta/ons about illness, course of treatment, risk of relapse, recogni/on of symptoms, and when to seek treatment • Provider communica/on – between departments and with pa/ents • Leveraging electronic health records to enhance communica/on between pa/ents and providers
Clinical Guidelines and Process Metric
• Tools: Short Form Health Survey 12 (SF 12), Short Form Health Survey 36 (SF 36), and Rapid Assessment Scale (RAS) • Emphasize: a) hope and self-‐determina/on; b) targeted support for self empowerment; c) enhanced job and/or school performance; d) housing stability and purposeful reduc/ons in homelessness • Resources to modify behavior; strategies to cope with difficult situa/ons and become mentally healthy overall; understanding care plan • Personalized, phased health and mental well-‐being leading to a reduc/on in necessary support
Current
Benchmark
Target
PHQ-‐9 completed (Collabora/ve Care) Decreased ED U/liza/on for Mental Health Management
-‐
100%
100%
-‐
0
0
Pa/ent Educa/on of Mental Illness
-‐
100%
100%
Use of SSRI's prescribed when appropriate over MAOIs
-‐
100%
90%
Suicide Risk Assessment Completed
-‐
100%
80%
Pa/ent portal ac/va/on
-‐
90%
70%
Current
Benchmark
Target
ACORN comple/on rates
-‐
95%
75%
Self-‐management resources
-‐
85%
75%
Consistent employment/educa/on
-‐
100%
100%
Access to stable housing
-‐
100%
100%
Improved mental health wellbeing (self-‐reported)
-‐
100%
100%
Improved overall physical health (self-‐reported)
-‐
100%
100%
Current
Benchmark
Target
Collec/on of surveys (response rate)
-‐
35%
25%
Involved in decision making
-‐
85%
75%
Overall sa/sfac/on with care delivery
-‐
75%
70%
Sa/sfied with care provider
-‐
75%
70%
Current
Benchmark
Target
Unknown
1300
1300
1.5 months
1 week
3 weeks
3 months
2 weeks
1 month
45%
20%
30%
Lifestyle Metric
• Purpose – improve experience or outcomes, enhance the care delivery structure, focus on episodic care or more generalized service delivery • Validity and Content – comple/on rate, pa/ent involvement in decision making, overall sa/sfac/on, and provider sa/sfac/on • Process – electronic health record, in-‐person paper, mailed, telephone
Pa4ent Sa4sfac4on
Produc4vity
Metric
• MGMA, 2009: RVUs calculated based upon: • physician work, which includes /me, technical skill and level of educa/on; • prac/ce expense (direct and indirect expenses of providing the service); and • malprac/ce expense • Petzel, 2013: VA Health System -‐ Work Rela/ve Value Units (wRVU) • Mean and median level wRVUs by provider type
Produc4vity Metric Therapist wRVUs
Results: Provider & Pa/ent Perspec/ves Confluence Health providers iden/fied appointment availability as the greatest barrier to care for behavioral health pa/ents.
Pa/ent wait for ini/al appointment (access to care)
Behavioral health pa=ents most frequently iden/fied improved mental health and well-‐being and development of self-‐management skills as successful treatment outcomes.
Provider Responses – Barriers to Behavioral Health Care
Pa/ent wait for follow-‐up appointment (access to care) Combined no-‐show/cancella/on rate (access/quality)
Recommenda/ons
Pa4ent Responses – Successful Treatment Outcomes
Financial
Support & peace of mind Cumbersome intake process
Improved mental health and well-‐ being
Not enough providers
Clear ac/on plan aker each appointment
Con/nuity of care
S/gma around mental illness
Help modifying behavior Access to BH records
Self-‐management tools/Coping skills Appointment availability
0
2
4
6
8
Number of Physicians
10
12
14
16
18
20
0
1
2
Number of Pa/ents
3
4
5
6
This dashboard is divided into four overarching categories consistent with the framework used throughout the study: (1) clinical guidelines, (2) lifestyle, (3) pa/ent sa/sfac/on, and (4) produc/vity. Our research team recommends four to six metrics for each category as a star/ng point for the behavioral health team to begin collec/ng data and tracking outcomes. The “Current” column is meant to document the current state of the clinic for each metric. Most of this column has been lek blank because data are not currently being collected or were not available to the research team. As leaders begin collec/ng data, current states for each metric can be completed. The “Benchmark” column is meant to serve as a gold standard based upon current industry prac/ces and recommenda/ons found in the literature. Values in this column can serve as long-‐term goals for the clinic. Lastly, the values in the “Target” column are meant to serve as more immediate and aCainable goals for the clinic. Since most of these metrics are not currently being measured, “Target” goals would be more feasible for Confluence Health to achieve in the near future. Targets should be re-‐evaluated six months aker implementa/on, and annually thereaker.
