Psychosocial Interventions for Mental and Substance Use Disorders A Framework for Establishing Evidence-Based Standards (2015) / Chapter Skim
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6 Quality Improvement
6 Quality Improvement
Pages 131-158
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From page 131... ...
. Evidence-based psychosocial interventions and meaningful measurement tools are key drivers of quality improvement in the delivery of services for persons with mental health and substance use disorders; however, they will not lead to improvements in quality unless they are used appropriately and applied in a system or organization that is equipped to implement change.
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From page 132... ...
• Clinical settings/provider organizations -- This term is used broadly to include clinics, practices, large health systems, medical homes, community settings, schools, jails, and other sites where psycho social interventions are rendered. In clinical settings, quality and quality improvement are affected by some of the same factors as those that affect clinicians, but also by the practice culture, the ad equacy of team-based care, clinic workflow, leadership for change and quality improvement, and clinic-level implementation efforts.
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From page 133... ...
Community of Practice • Dashboards available to clinicians Clinical Settings/ • Care management/ • Use of registries Provider population management/care • Allowance for team huddles, Organizations delivery team-building exercises • Quality improvement • Provision of on-site care infrastructure managers • Measure reporting and • Shared medical records across feedback disciplines and sites of service • Electronic data systems • Telehealth resources • Learning collaboratives • Plan, Do, Study, Act teams • Continuing professional established and supported education Health Plans/ • Benefit design • Pay for performance Purchasers • Provider network • Public reporting • Provider payment methods • Prior authorization • Care management/ requirements coordination • Coinsurance • Utilization management • Value-based insurance design Regulators • Accreditation • Training in evidence-based • Licensure practices • Implementation of evidence based practices
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From page 134... ...
. Roles for consumers include involvement in evaluation, training, management, and service provision, as well as active participation in their own care, such as through shared decision making, self-management programs, and patient-centered medical homes.
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From page 135... ...
Consumers take on a wide variety of service delivery roles as peer support workers, a general term applying to people with a lived experience of mental illness who are empathetic and provide direct emotional support for a consumer. Operating in these roles, peers can play an important part in quality management and transformation (Drake et al., 2010)
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From page 136... ...
Many, if not most, efforts to improve the quality of psychosocial interventions have focused on providers, reflecting their key role in helping clients achieve recovery and quality of life. Provider-focused efforts to improve quality of care include dissemination of treatment information, such as through manuals and guidelines; various forms of training, coaching, expert consultation, peer support, and supervision; fidelity checks; and provider profiling and feedback on performance.
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From page 137... ...
Importantly, as noted above with regard to consumers, providers actively working in clinical settings should be engaged in the quality improvement culture and the design and application of these levers. Provider Education and Training The delivery of quality mental health care requires a workforce adequately trained in the knowledge and skills needed for delivering evidencebased psychosocial interventions.
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From page 138... ...
. Because there are no agreed-upon standards for postgraduate training methods and assessment of skill acquisition beyond a brief knowledge-based quiz, continuing education activities and postgraduate training and certification programs vary widely in content and method.
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From page 139... ...
. Since embarking on providing training and support in the delivery of evidence-based psychosocial interventions, the VHA has seen positive effects in suicidal ideation, posttraumatic stress disorder, and depression in veterans seeking care (Watts et al., 2014)
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From page 140... ...
. CLINICAL SETTINGS AND PROVIDER ORGANIZATIONS Behavioral health settings vary widely in organizational readiness and capacity for quality improvement (Aarons et al., 2012; Emmons et al.,
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From page 141... ...
Quality improvement collaboratives, including the Institute for Healthcare Improvement's Breakthrough Series Collaborative Model (Ebert et al., 2012; IHI, 2003) , have proven helpful to organizations in implementing interventions for physical health conditions (Pearson et al., 2005)
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PURCHASERS AND PLANS Purchasers (including private employers and the government, in the case of insurance programs such as Medicare and Medicaid) and health plans have a number of levers available for encouraging quality improvement for psychosocial interventions.
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From page 143... ...
The RAND Health Insurance Experiment, an RCT of the impact of cost sharing on health care utilization and spending conducted in the 1970s and 1980s, found that use of health care services declined sharply as cost-sharing requirements increased (Manning et al., 1988) ; other nationally representative surveys have yielded similar findings (Horgan, 1985, 1986)
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From page 144... ...
However, a carefully constructed utilization management strategy could serve to improve the quality of psychosocial interventions if it resulted in more appropriate use of these interventions among those most likely to benefit from them. On the other hand, as with benefit design, the differential application of utilization management across treatment modalities could affect treatment decision making (i.e., individuals might be less likely to use services subject to stricter utilization management)
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From page 145... ...
FFS payment creates incentives for the delivery of more services, as each service brings additional reimbursement, but does not encourage the coordination of care or a focus on quality improvement. Since their introduction more than 20 years ago, managed behavioral health care carve-outs -- a dominant method of financing mental health/substance use care whereby specialty benefits for this care are separated from the rest of health care benefits and managed by a specialty managed care vendor -- also have shaped the financing and delivery of behavioral health services.
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From page 146... ...
Both public and private purchasers and plans also have embraced P4P approaches to encouraging quality improvement. Under P4P, clinicians or provider organizations receive bonuses if they meet or exceed certain quality thresholds that are specified in provider contracts.
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From page 147... ...
A review by the Cochrane Collaborative found evidence of improvement in clinical standards (Jamtvedt et al., 2006) , although a later study found mixed evidence that provider profiling served as a catalyst for quality improvement activities (Fung et al., 2008)
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From page 148... ...
. On the other hand, the review found evidence of a positive effect of public reporting systems on the behavior of clinicians and provider organizations, including improvements in quality measures over time among profiled providers, increased focus on quality improvement activities, evidence that some surgeons with the worst outcomes left surgical practice, and hospitals offering new services in response to public reporting (AHRQ, 2012)
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From page 149... ...
As with professional schools, state professional organizations may need to determine whether a continuing education activity meets quality standards for adult learning and establish clear guidance on what competencies may need to be renewed. MULTILEVEL QUALITY IMPROVEMENT AND IMPLEMENTATION A growing body of research demonstrates the effectiveness of quality improvement efforts focused on each of the stakeholders discussed in this chapter.
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From page 150... ...
CONCLUSION AND RECOMMENDATIONS This chapter and the report as a whole have described the need to consider quality not as a binary, static characteristic but as existing within a complex context and as part of a cycle of actions leading to the implementation of quality improvement by the multiple stakeholders involved in the delivery of care for mental health and substance use disorders. These stakeholders -- from consumers who receive psychosocial interventions; to the providers who render the interventions; to their clinics and the organizations in which the clinics are embedded; to payers, regulators, and policy makers -- each have levers, incentives, and other means by which they can move the system toward higher quality.
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From page 151... ...
Quality improvement systems also should include measures of clinician core competencies in the delivery of evidence-based psychosocial interventions. Public reporting systems, provider profiling, pay-for-performance, and other accountability ap proaches that include outcome measures should account for differences in patient case mix (e.g., using risk adjustment methods)
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From page 152... ...
2012. Closing the quality gap se ries: Public reporting as a quality improvement strategy.
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2007. Empirically supported psychother apy in social work training programs: Does the definition of evidence matter?
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2008. Systematic review: The evidence that publishing patient care performance data improves quality of care.
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1999. Episodes of mental health and substance abuse treatment under a managed behavioral health care carve-out.
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2012. Seizing opportunities under the Affordable Care Act for transforming the mental and behavioral health system.
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2005. Assessing the implementation of the chronic care model in quality improvement collaboratives.
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From page 158... ...
https://www.ucl.ac.uk/pals/research/cehp/research groups/core/competence-frameworks (accessed June 16, 2015)
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