April Data Jam: Tracking Progress and Facilitating Improvement with your Data Dashboard

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1 April Data Jam: Tracking Progress and Facilitating Improvement with your Data Dashboard Elizabeth Arend, MPH Quality Improvement Advisor National Council for Behavioral Health

2 CMS Change Package: Primary and Secondary Drivers Patient and Family- Centered Care Design Continuous, Data- Driven Quality Improvement Sustainable Business Operations 1.1 Patient & family engagement 1.2 Team-based relationships 1.3 Population management 1.4 Practice as a community partner 1.5 Coordinated care delivery 1.6 Organized, evidence-based care 1.7 Enhanced access 2.1 Engaged and committed leadership 2.2 QI strategy supporting a culture of quality and safety 2.3 Transparent measurement and monitoring 2.4 Optimal use of HIT 3.1 Strategic use of practice revenue 3.2 Staff vitality and joy in work 3.3 Capability to analyze and document value 3.4 Efficiency of operation

3 Robert Basile, Psy.D Director of Clinical Services Chief Associate to the Executive Director Metropolitan Center for Mental Health Lindsay Ragona Quality Improvement Coordinator Central Nassau Guidance and Counseling Center

4 Using the Care Transitions Network (CTN) Dashboard to Drive Quality Outcomes Metropolitan Center for Mental Health

5 Indicator MCMH Dashboard Current Percentages v. OMH/CTN Target Percentages MCMH Current% Target% 1) All-Cause 30-day readmission rate following MH Inpatient D/C 16% 25% 2) 30-day MH re-admission 12% 25% 3) Follow-Up After Hospitalization for Mental Illness, 7 Days 79% 50% 4) Follow-Up After Hospitalization for Mental Illness, 30 Days 89% 50% 5) Adherence to antipsychotic medications (PDC) for people with SZ 54% 80% 6) Adherence to mood stabilizers for people with bipolar 1 disorder 67% 80% 7) Use of Antipsychotic Drug Clozapine for SZ 0% 25% 8) Use of LAIs for SZ 5% 25% 9 Use of multiple concurrent antipsychotics 4% 25% 10) Diabetes screening for ppl w/ SZ or bipolar disorder who are using antipsychotic 71% 80% meds 11) LDL Screening for ppl w/ SZ or bipolar disorder who are using antipsychotic meds 60% 80% 12) 14-day initiation and engagement of AOD dependence treatment (14 Days) 49% 25% 13) 30-Day initiation and engagement of AOD dependence Tx 15% 25%

6 Understanding Our Dashboard Data To help conceptualize our data, we separated the Dashboard Indicators into Four Categories: 1) Transitions of Care/Hospital Usage (Measures 1-4) 2) Medication Management Services (Measures 5-9) 3) Comorbid Medical Conditions (Measures 10 & 11) 4) Substance Use Services (Measures 12 & 13) Knowledge of our clinic population + Relationship between current percentage and OMH Target percentage = Decision of which quality indicators to target (final outcomes)

7 Implementing Process Measures (Clinical Interventions to Achieve Final Outcomes) We reviewed PSYCKES Quality Indicators against the CTN Dashboard to select three (3) process measures which target Dashboard final outcomes: 1. Linking patients to Primary Care Physicians (PCPs) Process Measure Co-Morbid Medical Conditions #10-11 Targeted Outcome Measure 2. Linking eligible patients to Health Homes Process Measure Transitions of Care #1-4 Targeted Outcome Measure 3. Improving medication adherence for patients with Sz. Process Measure Medication Management Services #5-9 Targeted Outcome Measure

8 Steps involved in Implementation of Process Measures: Staff Education: Administration, QI Department, Supervisors, Clinicians Develop a structured template to guide each process measure (intervention strategy) Inform primary clinician of flagged patients with link to intervention strategy QI tracking of process measures implemented & dashboard data

9 Process Measure Example- PCP Intervention Clinical Intervention strategy The PCP Intervention aims to increase PCP connectivity by educating staff of the importance of integrated care and attending to medical issues Ultimate goal is to improve physical and mental health and reduce hospital admissions and ER visits Patients who have not had a PCP visit within the past year are flagged in PSYCKES Primary clinicians of flagged patients are informed and PCP Intervention and Information Form is directed to patient s chart. This form includes: Psychoeducation about the importance of regular PCP visits Regional PCP referral sources Structured guidance to document the intervention, including patient s response

10 PCP Intervention and Information Form Quality Indicator: No Outpatient Medical Visit > 1 year (PCP Visit Needed) The above patient has been flagged for not having had an appointment with his or her PCP within the past year. If your patient has an established PCP, but has not seen him or her within the past year, please encourage patient to schedule an outpatient medical visit and/or assist them in scheduling this appointment. If your patient is not currently connected to a PCP, please find referral information on the back of this form and assist patient in making appropriate referral. Summary of Discussion: Patient Response (i.e., agreed to schedule appointment, refused to schedule appointment): PCP Referral (If a referral is made, indicate Physician Group below):

11 Why are regular PCP visits important? It is well-known that there is a significant, bi-directional relationship between physical and mental health. Poor physical health increases one s risk for depression, anxiety, substance use and other behavioral health concerns, and often contributes to psychosocial stressors that impact overall functioning and well-being. Conversely, mental health and substance issues are often associated with physical health problems or poor adherence to physical or medication regimen. Regular PCP visits provide opportunities for disease prevention and management, health promotion, and continuity of care. When people do not have an established PCP, they end up in the emergency rooms more often and are admitted to hospitals more frequently. In addition to helping patients effectively manage their physical health, which has been shown to improve behavioral health outcomes, PCP s can collaborate with mental health clinicians to promote patient engagement and self-efficacy. It is important for our patients to establish regular contact with a PCP as part of their overall treatment plan.

12 Confirming the Baseline and Identifying Opportunities for Improvement Central Nassau Guidance and Counseling Center

13 Questions?

14 REMINDER: All eligible Care Transitions Network practices have to select their MIPS measures by April 27, 2017!

15 Upcoming Webinars April 20 th : Clozapine Dosing and Side Effects Management Part 1 April 26 th : Moving Past Annual Satisfaction Surveys: Using Person and Family Engagement Data to Drive VBP Transformation Check out our upcoming and archived webinars at

16 Thank you! The project described was supported by Funding Opportunity Number CMS-1L from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. Disclaimer: The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.