Consumer Driven Outcomes Management: A New Paradigm for Quality Improvement in Behavioral Health

Transcription

1 2009 MOBILE DIRECT OBSERVATION TREATMENT (MDOT) OF TUBERCULOSIS PATIENTS PILOT FEASIBILITY STUDY IN NAIROBI, KENYA March 2, 2009 Consumer Driven Outcomes Management: A New Paradigm for Quality Improvement in Behavioral Health April 15, 2009 Innovative Solutions for Social Impact 1 Danya International, Inc.

2 Consumer Driven Outcomes Management: A New Paradigm for Quality Improvement in Behavioral Health Table of Contents Executive Summary... 1 The Call for Consumer Empowerment... 2 The Drive for Accountability... 3 April 15, 2009 The Solution: Consumer-Drive Outcomes Management... 4 A Call to Action... 5 About the Authors... 6 Authors: Jonathan Hunt Glassman, B.A., Barry M. Duncan, Psy.D., Scott D. Miller, Ph.D., and Jeffrey Hoffman, Ph.D. Innovative Solutions for Social Impact i Danya International, Inc.

3 Executive Summary The call for consumer empowerment and the drive for accountability have both been key planks in the decade-long campaign to transform the behavioral health care system. Both have achieved positive results. The field s leading authorities have recognized the dramatic improvements in outcomes that ensue when clients are engaged in shared decisionmaking that incorporates their cultural and personal preferences, and a shift toward accountable service delivery has begun with the development of uniform national standards for performance-based outcomes. Too often, however, policymakers and regulators Consumer-driven outcomes management has been repeatedly demonstrated to dramatically improve the quality and efficiency of services. have pursued consumer empowerment and outcomes accountability initiatives along parallel paths rather than in tandem. Most tellingly, this lack of coordination has frequently resulted in accountability mechanisms that fail to fully incorporate the voices of consumers. To achieve the full extent of quality improvement promised by greater empowerment and accountability, the behavioral health care system must embrace a new paradigm of consumer-driven outcomes management. The paradigm is defined by the use of valid and reliable measures to solicit continuous, real-time, and direct consumer feedback that enables the adjustment of services on an individualized basis to achieve improved outcomes. Consumer-driven outcomes management has been shown to be highly feasible for clinicians, easily implemented using technology, and consumer-friendly. Most importantly, it has been repeatedly demonstrated to dramatically improve the quality and efficiency of services. Published, peerreviewed research has demonstrated the following results: Length of stay in psychotherapy was reduced by 50 percent across a broad range of behavioral health services (Duncan, Miller, Wampold, & Hubble, in press). Policymakers and regulators should explore legislative and regulatory actions that promote evidence-based consumer-driven outcomes management. Cancellation rates declined by 40 percent and no-shows by 25 percent (Miller, Duncan, Sorrell, & Brown, 2005). Outcomes improved while average number of sessions decreased 40 percent (Miller, Duncan, Sorrell, & Brown, 2005). Success rates for consumers at risk for negative outcomes increased in one study by 65 percent and by as much as 100 percent in others (Miller, Duncan, Brown, Sorrell, & Chalk, 2007). Percentage of clients who completed substance abuse treatment increased from 50 percent to 82 percent in one study and from 22 percent to 70 percent in another (Duncan, Miller, & Wampold, in press). In order to achieve dramatic improvements in the quality and efficiency of the behavioral health care system, policymakers and regulators should explore legislative and regulatory actions that promote evidence-based consumer-driven outcomes management. Innovative Solutions for Social Impact 1 Danya International, Inc.

4 The Call for Consumer Empowerment Behavioral health care authorities broadly agree that a defining characteristic of the field s transformation must be the universal adoption of consumer and family-directed care. This commitment reflects the broader health care industry s direction. After its seminal 2000 report To Err Is Human revealed that health care in the United States was not only often of poor quality but also unsafe, the Institute of Medicine s (IOM) Committee on the Quality of Health Care in America issued a second and final report, Crossing the Quality Chasm: A New Health System for the 21st Century (Kohn, Corrigan, & Donaldson, 2000; Committee on Quality of Health Care in America, 2001). This report: Identified six aims to guide quality improvement efforts: safe care, effective care, patient-centered care, timely care, efficient care, and equitable care Defined patient-centered care as respectful of and responsive to individual patient preferences, needs, and values and ensures that patient values guide all clinical decisions Recommended that systems be redesigned to give patients the opportunity to exercise the degree of control they choose over health care decisions that affect them Suggested that the health system should be able to accommodate differences in patient preferences, including those shaped by ethnic and cultural beliefs and practices The annual summit of the American College of Mental Health Administration directly affirmed the relevance of the IOM s report and endorsed translating its findings to the behavioral health care field (Daniels & Mintz, 2002). Issued in 2003, the final report of the President s New Freedom Commission on Mental Health answered the call to apply the IOM s findings and recommendations to behavioral health care, including the need for consumer empowerment. Envisioning a system in which care is consumer- and family-centered and focused on recovery, the report asserted: Consumer needs and preferences should drive the type and mix of services provided, and should take into account the developmental, gender, linguistic, or cultural aspects of providing and receiving services. Providers should develop these customized plans in full partnership with consumers, while understanding changes in individual needs across the lifespan and the obligation to review treatment plans regularly (President s New Freedom Commission on Mental Health, 2003). Although the need to adjust services in accordance with client preferences has sometimes been set in false opposition to the imperative to implement evidence-based practice (EBP), the American Psychological Association s (APA) 2005 Policy Statement defines EBP as the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences. APA further explains that services are most effective when responsive to the patient s specific problems, strengths, personality, sociocultural context, and preferences and concludes with the Innovative Solutions for Social Impact 2 Danya International, Inc.

5 unequivocal statement that ongoing monitoring of patient progress and adjustment of treatment as needed are essential to EBP (APA, 2005). Consumer empowerment s transformational effect upon quality improvement was distilled by Kaiser Permanente s Senior Vice President of Quality and Systems Support in a 2007 article in Health Affairs. She wrote: Clinicians do not change outcomes alone but can do so in partnership with patients. Throughout most of the history of health care, we have focused on the clinician side of the equation. We have invested far less effort working with patients to understand how to leverage their participation in their own care. This represents an enormous untapped opportunity (Liang, 2007). Given that meta-analytic research about mental health outcomes indicates that consumer factors account for 87 percent of change achieved in behavioral health services, harnessing consumers capacity to contribute to change represents not only a socially just endeavor, but also the paramount quality improvement imperative (Wampold, 2001). The Drive for Accountability The leading institutions for behavioral health policy have also recognized that quality improvement requires the widespread adoption of accurate measures of effectiveness. Federal government agencies have facilitated a consensus-driven process to identify and disseminate a small group of common measures to ensure accountability. In 2004, the Substance Abuse and Mental Health Services Administration (SAMSHA) defined 10 National Outcome Measures (NOMS) for use across all SAMHSA-funded programs. In introducing the NOMs, Charles G. Curie, former SAMHSA Administrator, said: Increasingly, policymakers and budget planners at all levels Federal, State, local, and private are basing funding decisions on outcome data. Eventually, this Web-based tool SAMHSA s National Outcome Measures (NOMs) will provide the public and policymakers with the information to improve the management and performance of our programs and make the most of the limited dollars available to help people attain and sustain recovery (SAMHSA, 2005) Most reported NOMs data is collected in keeping with the standards of the Uniform Reporting System (URS), a federal reporting system used by state mental health agencies to compile and report annual data as part of the SAMSHA/CMHS Federal Community Mental Health Block Grant program. Developed by SAMHSA and used by state agencies since 1997, URS provides uniform reporting of State-level data to describe the public mental health system and the outcomes of its programs, using 21 standard data output tables (National Mental Health Information Center, 2004). Although they provide a useful quantitative framework for measuring the effectiveness of service delivery and are a necessary performance-based yardstick, the NOMs and URS have two major blind spots. They do not emphasize consumer-driven care. Soliciting client s direct evaluation of satisfaction with services is required Innovative Solutions for Social Impact 3 Danya International, Inc.

6 to assess only one of the NOMs 10 domains (perception of care) and to complete only 2 of the URS 21 output tables (adult consumer measures and child/family consumer measures). Accountability mechanisms are not client-centered when they exclude clients from participating in 90 percent of their measurements. The current outcomes reporting process is divorced from the delivery of clinical services. Typically administered once per year and via mail, formal assessments of consumer satisfaction stand little chance of having an impact on the course of services for the individual consumers who complete them. Even if providers sought to incorporate these satisfaction measures as part of an ongoing feedback loop, feasibility and relevancy would be significant concerns, as the standard URS measure of client satisfaction is a 24-item instrument that asks for retrospective assessment. The Solution: Consumer-Driven Outcomes Management The full quality improvement benefits promised by the consumer empowerment and accountability movements will only be realized when consumer-driven outcomes management an approach that synthesizes empowerment and accountability is widely adopted. Outcomes management empowers consumers to be the agents of accountability Using valid and reliable measures to solicit realtime, direct consumer feedback, consumerdriven outcomes management empowers consumers to be the agents of accountability. Consumer-driven outcomes management amplifies consumers voices, enabling ongoing monitoring of individual service delivery and encouraging the tailoring of treatment as needed. While invaluable for compiling system-wide data, such measurement fails to incorporate direct consumer input into service delivery in a way that informs and improves treatment on a case-by-case basis. As such, the field s currently favored mechanisms of accountability risk being overly attentive to the requirements of reporting and insufficiently responsive to the needs of consumers. Without measures of outcomes that are available in real-time and practical for continuous administration, behavioral health services providers cannot hope to implement the ongoing monitoring of patient progress and adjustment of treatment deemed by the APA to be an essential component of EBP. Consumer-driven outcomes management systems share several common characteristics: They provide objective, quantifiable data on the effectiveness of providers and systems of care. They use measures that are valid and reliable, but also brief enough to be feasibly administered during the service session. They favor the consumer s voice and provide a formalized mechanism for using the client s ideas and preferences to guide the choice of technique and model. Innovative Solutions for Social Impact 4 Danya International, Inc.

7 They solicit each client s direct feedback regarding factors proven to predict success regardless of treatment model or technique: the client s self-assessment of progress or positive change early in the service process and/or the client s perception of the alliance with the provider They compare each client s responses to normative data to identify at-risk cases in real-time and provide empiricallybased feedback messages that enable providers to adjust the course of services when needed. The use of consumer-driven outcomes management systems has been proven to dramatically improve both the quality and efficiency of services. Published, peer-reviewed research has demonstrated the following results: Length of stay in psychotherapy was reduced by 59 percent (Duncan, Miller, & Wampold, in press). Cancellation rates declined by 40 percent and no-shows by 25 percent Miller, Duncan, Sorrell, & Brown, 2005). Outcomes improved while average number of sessions decreased 40 percent (Miller, Duncan, Sorrell, & Brown, 2005). Success rates patients at risk for negative outcomes increased in one study by 65 percent and by as much as 100 percent in others (Miller, Duncan, Brown, Sorrell, & Chalk, 2007). Percentage of clients who completed substance abuse treatment increased from 50 percent to 82 percent in one study and from 22 percent to 70 percent in another (Duncan, Miller, Wampold, & Hubble, in press). Separation/divorce rates reduced by 50 percent (Anker, Duncan, & Sparks, in press). Recent technological advances have increased the feasibility of implementing consumer-driven outcomes management systems throughout large public and private agencies, provider networks, and managed care organizations. For example, MyOutcomes is a Web-based application that that provides a scalable, secure client-driven outcomes management system. MyOutcomes supplements Web versions of the valid and reliable Outcome Ratings Scale and Session Ratings Scale with instant calculations and graphs of results, empirically-based feedback messages, sophisticated data aggregation, record management, and HIPAA-compliant security and privacy measures. A Call to Action Given its demonstrated potential to effect precisely the transformation of the behavioral health care system called for by its leading experts, federal policymakers and regulators should explore legislative and regulatory avenues to promote the widespread adoption of consumer-driven outcomes management systems. In all federally-funded programs, consumer-driven outcomes management should be considered as a supplement to existing outcomes measurement programs and as a distinct, independent quality improvement measure. Consumer-driven outcomes management is a promising and successful approach to a stronger role for consumers as agents of accountability in health care. Innovative Solutions for Social Impact 5 Danya International, Inc.

8 About the Authors Jonathan Hunt-Glassman is a Project Director at Danya International, Inc., and the product manager of MyOutcomes, a Web-based client-driven outcomes management system. Barry M. Duncan, Psy.D., and Scott D. Miller, Ph.D., are the co-directors of the Institute for the Study of Therapeutic Change and the developers of the Partners for Change Outcome Management System, a client-driven outcomes management system that is available in paper-based, Excel-based, and Web-based formats. Drs. Duncan and Miller each have extensive experience in training and clinical practice as well as numerous publications. Jeffrey Hoffman, Ph.D., is the Chief Executive Officer of Danya International, Inc, a health communications and technology consulting company based in Silver Spring, MD and is also a clinical psychologist. The authors acknowledge Sandra Lichty, Ph.D., for her assistance with research and drafting. Innovative Solutions for Social Impact 6 Danya International, Inc.

9 References American Psychological Association (APA). (2005). American Psychological Association statement: Policy statement on evidence-based practice in psychology. Washington, D.C.: Author. Retrieved April 15, 2009, from Anker, M., Duncan, B. M., & Sparks, J. (in press). Using client feedback to improve couple therapy outcomes: A randomized clinical trial in a naturalistic setting. Journal of Consulting and Clinical Psychology. Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, D.C.: National Academy Press. Daniels, A. S., & Mintz, H. A. (2002). Crossing the quality chasm: Translating the Institute of Medicine Report for Behavioral Health. Albuquerque, NM: American College of Mental Health Administration. Retrieved April 15, 2009, from Duncan, B. L., Miller, S. D., Wampold, B. E., & Hubble, M. A. (in press). The heart and soul of change: Delivering what works (2nd Ed.). Washington, DC: American Psychological Association. Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system. Washington, D.C.: National Academy Press. Liang, L. (2007). The gap between evidence and practice. Health Affairs (Project Hope), 26(2), w119 w121. Miller, S. D., Duncan, B. M., Brown, J., Sorrell, R., & Chalk, M. B. (2007). Using formal client feedback to improve retention and outcome: Making ongoing, real-time assessment feasible. Journal of Brief Therapy, 5(1), Miller, S. D., Duncan, B. M., Sorrell, R., & Brown, G. S. (2005). The partners for change outcome management system. Journal of Clinical Psychology, 61(2), National Mental Health Information Center. (2004). Uniform Reporting System (URS) data output tables. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved April 15, 2009, from President s New Freedom Commission on Mental Health. (2003). Achieving the promise: Transforming mental health care in America. Rockville, MD: Author. Retrieved April 15, 2009, from Substance Abuse and Mental Health Services Administration (SAMHSA). (2005). Measuring outcomes to improve services. SAMHSA News, 13(4). Retrieved April 15, 2009, from Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Lawrence Erlbaum Associates. Innovative Solutions for Social Impact 7 Danya International, Inc.