Developing a Tool for Comprehensive Behavioral

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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  

–––––  

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.