Performance Improvement Projects (PIP) Clinic May 13, PDF Free Download

Behavioral Health Concepts, Inc. Performance Improvement Projects (PIP) Clinic May 13, 2016 Amy McCurry Schwartz, Esq., MHSA California EQRO Consultant

OMB Approval No. 0938-0786 EQR PROTOCOL 3: VALIDATING PERFORMANCE IMPROVEMENT PROJECTS (PIPs) A Mandatory Protocol for External Quality Reviews (EQR)

CMS Protocol: Validating Performance Improvement Projects 10 Protocol Steps: 1) Select the study topic(s) 2) Define the study question(s) 3) Use a Representative and Generalizable study population 4) Select the study variable(s) 5) Use sound sampling techniques

CMS Protocol: Validating Performance Improvement Projects 10 Protocol Steps Continued: 6) Reliably collect data 7) Analyze data and interpret study results 8) Implement intervention/improvement strategies 9) Plan for real improvement 10) Achieve sustained improvement

Step 1: Select the Study Topic (s) The MHP stated: We are always encouraged by EQRO to use data in designing and executing a PIP. The MHP asked: How do we design a PIP to look at How to use Data?

Step 1: Select the Study Topic (s) ANSWER: Use the data you already have. Possible Sources of data: Data from the Performance Measures section of your EQRO report.

For Example: The MHP s CY13 to CY14 overall penetration rate declined at a greater rate than the decline that was observed in both the small-rural and the statewide averages. However, the MHP s penetration rate remains above the statewide average. and While the MHP s average overall approved claims per beneficiary served rose from CY13 to CY14 and exceeded the small-rural county average, it remains less than the statewide average. On the surface, this data is not bad for this MHP. However, the MHP may want to investigate what contributed to the decline? Is there something unique to this MHP that should be looked at further?

For Example: The primary diagnosis of Depressive Disorders accounted for the largest number of beneficiaries served by the MHP. However, this percentage exceeded that of the statewide average. and The MHP also had a higher percentage of anxiety and adjustment disorders when compared to the statewide average and lower rates of Psychotic and Other disorders. Again, this may not be bad, per se, but this is a place to begin looking for answers and determining if an issue exists.

Other Possible Sources of Data Categories of case closing: One MHP analyzed data on categories of case closing reasons, which indicated that 42% of individuals assessed to have medical necessity for services are discharged as non-compliant with treatment. Successful treatment discharges were found to exist in 30% of the baseline case closing data. The MHP cited quarterly discharge data from 7/1/14 through 12/31/15, in which non-compliant discharges ranged from 36-46%. Non-compliance was the single most frequent selected status at discharge. This MHP determined that it should study this issue and seek to improve the occurrence of positive discharge status, which relates to the performance indicator of reducing the percent of discharges categorized as non-compliant.

Other Possible Sources of Data Conduct a client survey Assess satisfaction Assess participation in treatment Assess whether they have a PCP Assess other County services they utilize

Other Possible Sources of Data Use your EHR What reports can you run from your EHR system? Appointments scheduled and missed Diagnosis of those who missed appointments Timeliness of appointments By Diagnosis By Gender By Age

OMB Approval No. 0938-0786 EQR PROTOCOL 3: VALIDATING PERFORMANCE IMPROVEMENT PROJECTS (PIPs) A Mandatory Protocol for External Quality Reviews (EQR)

Step 2: Define the Study Question(s) MHP Question: How do we design a study question that is consumer/client focused?

Step 2: Define the Study Question(s) Example of an MHP ACTUAL STUDY QUESTION: Can health status be improved for clients being served by County Behavioral Health Services, who have health issues when there is better integration with primary care? IMPROVED SQ with possible data: Will ensuring that all clients diagnosed with Depression see their PCP once a year improve their blood pressure by X points? This MHP needs to collect more information in order to better identify the service patterns and health needs of consumers. Based on the data, they will determine who will be the target population for this PIP (e.g., high cost beneficiaries, FSPs, or meds only clients, etc.) and what physical health element to target. After determining the criteria, the PIP team will define the intervention.

Step 2: Define the Study Question(s) Make the Question: Obvious Simple Answerable

Step 2: Define the Study Question(s) State the Question in a way that: Supports the MHP s ability to determine whether the intervention has a measurable impact for a clearly defined population

Step 2: Define the Study Question(s) #1 What s the problem? Try to define the problem as systems issues, clinical or process oriented, that relate to individual consumers' treatment, outcomes, or satisfaction. IF the problem is No-Show rates: The MHP may see this problem as: Fiscal Efficiency Inconvenience

Step 2: Define the Study Question(s): Don t write a question that asks: Will providing pre-appointment reminder calls for all Psychiatrist appointments reduce the MHP s cost of Psychiatric Services? OR Will providing training to all front line staff get them to enter appointments in a more timely manner into the EHR?

Step 2: Define the Study Question(s): INSTEAD: Think or ASK? What is keeping beneficiaries from their appointments? What are the barriers to making the appointment? Transportation Time off work during the clinic hours Childcare Frame the PIP around these barriers. Provide interventions that mitigate these barriers.

Step 2: Define the Study Question(s): The improved study question: Will providing consumer focused interventions reduce Psychiatry appointment no shows by XX%? Indicators: Number of no-shows per quarter. Number of no-shows during after hours clinic. Number of no-shows when pre-appointment call is made.

Step 2: Define the Study Question(s): Interventions: Offer transportation. Offer afterhours clinic. Offer childcare. Call or text all scheduled appointments 24 hours in advance.

Step 2: Define the Study Question(s): Simplify the question: ACTUAL STUDY QUESTION: Will MHP post-discharge coordination and care services increase with the restructuring of post-discharge services, specifically a referral to XYZ for all eligible adult beneficiaries and/or use of the Urgent Medication Clinic, which supports a contact with the MHP within 7 days of discharge and a follow-up psychiatry appointment within 30 days of discharge, and will the readmission rate decrease? IMPROVE THAT QUESTION: Will restructuring of post-discharge coordination and care services result in a reduction of readmission rates by XX%?

Step 2: Define the Study Question(s): In this improved question we use: a.) contact with the MHP within 7 days of discharge; b.) a completed psychiatry appt. within 30 days of discharge as indicators that readmission rates will decrease. The MHP still measures contact within 7 days of discharge (and designs interventions around this) and completed psychiatry appt. w/in 30 days of discharge (and designs interventions around this). The ultimate goal/outcome is the reduction in readmission. That s what the study/pip is trying to achieve.

Step 2: Define the Study Question(s): ACTUAL STUDY QUESTION: Can we institute Multi-Disciplinary Team Meetings in Child and Adult Services?

Step 2: Define the Study Question(s): IMPROVED STUDY QUESTION: Will instituting Multi-Disciplinary Team Meetings in Child and Adult Services improve: a. b. c. The MHP should go back to its analysis of adverse outcomes and focus on those with greatest negative impact, focus on highest frequency, and focus on those most likely to be effected by the MHP s resources. Then focus MHP efforts on that issue and group.

OMB Approval No. 0938-0786 EQR PROTOCOL 3: VALIDATING PERFORMANCE IMPROVEMENT PROJECTS (PIPs) A Mandatory Protocol for External Quality Reviews (EQR)

Step 8: Implement Intervention and Improvement Strategies Interventions should: Relate to causes/barriers identified through data analysis Be culturally and linguistically appropriate Be implementable system-wide Not be one time efforts

Step 8: Implement Intervention and Improvement Strategies An improvement strategy is an intervention designed to change behavior at an institutional, practitioner, or consumer level. Real, sustained improvement results from a continuous cycle of measuring performance and implementing system-wide improvements. Plan, Do, Check, Act (PDSA)

Step 8: Implement Intervention and Improvement Strategies Think or ASK? What is keeping beneficiaries from their appointments? What are the barriers to making the appointment? Transportation Time off work during the clinic hours Childcare Frame the PIP around these barriers. Provide interventions that mitigate these barriers.

Step 8: Implement Intervention and Improvement Strategies Study Question: Will restructuring of post-discharge coordination and care services result in a reduction of readmission rates by XX%? What are the interventions: Referral to XYZ Use of Urgent Medication Clinic

Step 8: Implement Intervention and Improvement Strategies How to measure the effectiveness of interventions? Referrals to XYZ or Use of Medication Clinic The MHP counts the number of referrals.

Step 8: Implement Intervention and Improvement Strategies What else can the MHP do? * The MHP makes the appointment for XYZ while the consumer is with them (prior to discharge) *The MHP calls/texts the consumer the day before the appointment to remind them

Step 8: Implement Intervention and Improvement Strategies What else can the MHP do? * The MHP measures the number of referrals that resulted in kept appointments *The MHP tracks attendance at Medication Clinic