Psychosocial Interventions for Mental and Substance Use Disorders A Framework for Establishing Evidence-Based Standards (2015) / Chapter Skim
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5 Quality Measurement
5 Quality Measurement
Pages 95-130
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disorders. Next, the chapter details a framework for the development of quality measures -- structural, process, and outcome measures -- for psychosocial interventions, including the advantages, disadvantages, opportunities, and challenges associated with each.
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. Quality measures are used at multiple levels of the health care system -- clinicians, practices, clinics, organizations, and health plans -- and for multiple purposes, including clinical care, quality improvement, and accountability.
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Multiple stakeholders also can use the measures for targeting quality improvement efforts and for engaging patients in self-care. The process for developing quality measures includes specific efforts to address each of these criteria.
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While consumer involvement as stakeholders in advising on measure concepts has occurred in some settings, consumer participation on measure development teams has been limited. A large number of quality measures have been developed by accrediting organizations such as the Joint Commission (for hospitals)
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. The small number of nationally endorsed quality measures addressing MH/SU reflects both limitations in the evidence base for what treatments are effective at achieving improvements in patient outcomes and challenges faced in obtaining the detailed information necessary to support quality measurement from
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Pediatric Symptom Checklist (PSC) 0722 Outcome Controlling High Blood Pressure for People with Serious 2602 Outcome Mental Illness Diabetes Care for People with Serious Mental Illness: Blood 2606 Outcome Pressure Control (<140/90 mm Hg)
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Substance Use Screening and Intervention Composite 2597 Process Antipsychotic Use in Children Under 5 Years Old 2337 Process Alcohol Screening and Follow-up for People with Serious 2599 Process Mental Illness Tobacco Use Screening and Follow-up for People with Serious 2600 Process Mental Illness or Alcohol or Other Drug Dependence Body Mass Index Screening and Follow-up for People with 2601 Process Serious Mental Illness Diabetes Care for People with Serious Mental Illness: Hemo- 2603 Process globin A1c (HbA1c) Testing continued
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Of the 13 outcome measures, 4 are focused on depression. The endorsed measures address care in inpatient and outpatient settings, and several address screening and care coordination.
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. State of New Standards for Health "The health home provider is accountable for York Homes engaging and retaining health home enrollees in care; coordinating and arranging for the provision of services; supporting adherence to treatment recommendations; and monitoring and evaluating a patient's needs, including prevention, wellness, medical, specialist, and behavioral health treatment, care transitions, and social and community services where appropriate through the creation of an individual plan of care" (New York State Health Department, 2012)
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. A FRAMEWORK FOR THE DEVELOPMENT OF QUALITY MEASURES FOR PSYCHOSOCIAL INTERVENTIONS To guide the consideration of opportunities to develop quality measures for psychosocial interventions, the committee built on prior work by Brown and colleagues (2014)
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Hence, structural effects on outcomes are mediated through process." -- Donabedian, 1980, p. 84 Appropriately developed and applied structure measures form the basis for establishing a systematic framework for quality measurement and improvement.
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. A framework for leveraging these structural concepts to develop quality measures for psychosocial interventions might include the following: • Population needs assessment -- Determination of the array of services/interventions to be provided based on identification and characterization of the needs of the population served by the orga nization, including clinical (i.e., general/preventive health, mental health, and substance use)
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TABLE 5-3 Opportunities for Measuring the Quality of Psychosocial Interventions Using Structure Measures Examples of Existing or Proposed Measures Potentially Applicable to Measure Concept This Concept Data Sources Capability for delivering Hiring, training, and Documentation submitted by evidence-based supervision of staff provider psychotherapy Capability for measuring Presence of registry with Documentation submitted by outcomes functionality for tracking provider, reports and outcome assessment Infrastructure for quality Involvement of consumers On-site audits, including improvement in quality improvement consumer or staff interviews SOURCE: Adapted from Brown et al., 2014.
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. Process Measures "[Measuring the process of care]
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However, the focus of the field of quality measurement, at least with regard to accountability measures, is shifting to outcomes and eschewing process measures unless they are proximal to outcomes. Process measures, however, remain important for improvement activities.
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. − s EHRs become more widely adopted in the delivery of A MH/SU services, incorporating structured fields on the content of psychosocial interventions could facilitate better documen tation and easier extraction of data for constructing quality measures.
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. Challenges A number of challenges need to be considered in the design of process measures, many related to the nature of the data source itself.
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. Consumers may have difficulty recalling therapy sessions, the elements of psychotherapy may change during the course of treatment, and there are burdens and costs associated with data collection (Brown et al., 2014)
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But this advantage is also a handicap, since it is not possible to say precisely what went wrong unless the antecedent process is scrutinized." -- Donabedian, 1988, p. 1746 Of all quality measures, outcome measures have the greatest potential value for patients, families, clinicians, and payers because they indicate whether patients have improved or reached their highest level of function and whether full symptom or disease remission has been achieved.
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Patient-reported outcomes shift the focus from the content of the intervention to its results; quality measures that evaluate outcomes overcome the limitations of structure and process measures. Outcome measures also offer a means of making care more patient-centered by permitting consumers to report directly on their symptoms and functioning.
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Screeners. See http://phqscreeners.com/pdfs/02_ PHQ-9/English.pdf (accessed June 22, 2015)
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instruments for hospitals, health plans, and providers, as well as the Experience of Care and Health Outcomes (ECHO) survey, which is used to assess care in behavioral health settings (AHRQ, 2015a,b)
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Table 5-5 summarizes opportunities for measuring the quality of psychosocial interventions using patient-reported outcome measures. Quality measures based on patientreported outcome measures typically define a specific population at risk, a time period for observation, and an expected change or improvement in outcome score.
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lack of a cohesive and comprehensive plan requiring the use of standardized MH/SU outcome measures as part of routine care; and (4) the difficulty of extracting data and the lack of electronic health information.
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The large number of tools available for assessing diverse outcomes makes comparisons across organizations and populations highly challenging. In the CMS EHR incentive program, specification of quality measures that use patient-reported outcomes requires specific code sets (CMS, 2015b)
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Consumers need to be encouraged to track their own recovery; clinicians to monitor patient responses and alter treatment strategies based on those responses; and organizations to use this information for quality improvement, network management, and accountability. Difficulty of extracting data and lack of electronic health information Even if a basic set of outcome measures were universally endorsed, the information obtained would remain fragmented absent agencies and payers committed to developing the infrastructure needed to collect the data for the measures.
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. While there is enthusiasm for incorporating quality measures based on patient-reported outcome measures, there is no consensus on which outcomes should take priority and what tools are practical and feasible for use in guiding ongoing clinical care, as well as monitoring the performance of the health care system, with respect to treatment for MH/SU disorders.
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In the short term, structure measures that set expectations for the infrastructure needed to support outcome measurement and the delivery of evidence-based psychosocial interventions need to be a priority to establish the capacity for the expanded routine clinical use of outcome measures. A second priority is the development of process measures that can be used to assess access to care (in light of concerns about expanded populations
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The measurement strategy needs to take into account how performance measures can be used to support patient care in real time, as well as the quality improvement efforts of care teams, organizations, plans, and states, and to encompass efforts to assess the impact of policies concerning the application of quality measures at the local, state, and federal levels. HHS is best positioned to lead efforts to gain consensus on the priority of developing and applying patient-reported outcome measures for use in quality assessment and of validating patientreported outcome measures for gap areas such as recovery.
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should designate a locus of responsibility and leadership for the devel opment of quality measures related to mental health and substance use disorders, with particular emphasis on filling the gaps in measures that address psychosocial interventions. HHS should support and promote the development of a balanced portfolio of measures for assessing the structure, process, and outcomes of care, giving priority to measuring access and outcomes and establishing structures that support the moni toring and improvement of access and outcomes.
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2014. Developing measures for pediat ric quality: Methods and experiences of the CHIPRA pediatric quality measures program grantee.
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2015d. Annual update of 2014 eligible hospitals and eligible professionals Electronic Clinical Quality Measures (eCQMs)
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Presentation to Committee on Developing Evidence-Based Standards for Psychosocial Interventions for Mental Disorders. Workshop on Approaches to Quality Measurement, May 19, Washington, DC.
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2014. Tutorials on quality measures: Desirable attributes of a quality measure.
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https://depts.washington. edu/pbhjp/projects-programs/page/mental-health-statistics-improvement-program-adult consumer-survey-acs (accessed June 15, 2015)
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