Outcome Based Management Clinically Informed Outcomes (CIOM ) Ann Doucette, Ph.D. Toby Martin, Ph.D. Jennifer Schwartz,, M.Ph.

Transcription

1 Outcome Based Management Clinically Informed Outcomes (CIOM ) Ann Doucette, Ph.D. Toby Martin, Ph.D. Jennifer Schwartz,, M.Ph.

2 Goals: Changing the System Beyond the Individual Practitioner/Provider Changing the environment that affects organizational and professional behavior Changing the systems and organizations that deliver treatment/services Changing and/or enhancing services, treatment, and care Establishing best practices Identifying practice-based evidence interventions Improved consumer outcomes

3 Clinically Informed Outcomes Keeping Pace With National Efforts Institute of Medicine Crossing the Quality Chasm Patient centered care New Freedom Commission on Mental Health Report Consumer driven care SAMHSA consumer driven treatment planning NOMS GRPA

4 What We Need... Data That Supports Quality Management From Compliance driven data collection Rule and regulation driven administration Best-guess decision-making Preference given to distinct professional roles System reacts to need Information is withheld To Outcome-based monitoring Goal driven management Data-based decision-making Cooperation across professionals is a priority Need is anticipated Information is disseminated, transparent Ann Doucette, PhD, 1999

5 Function Physical Health A Fragmented System Social Connection Symptoms Hopefulness Alliance

6 Actionable Data Health Alliance Social Connection Outcomes Hope Symptoms Administrative / Case-level Dashboards

7 Outcome-based Management

8 Outcome-based Management Framework Input Program Innovation Output Outcomes Resources Funding Staff Expertise Supplies Supportive regulations Volunteers Facilities / supplies Acceptance Intervention Service change Staff change Regulation change Access change Benefit change Training Product development Products Counseling sessions provided Service units delivered Psycho-socialeducational materials developed / disseminated #consumers served Medication dispensed #staff trained #participants in job training Outcomes Decreased symptoms Increased function % safe / affordable housing % steadily employed % trained staff using intervention with fidelity Reduced costs Reduction in use of hospital services Reduction in relapse

9 Measuring Outcome Clinically Informed Outcomes (CIOM )

10 Targeting Objectives and Outcomes If you don t know where you re going, you might end up someplace else. Casey Stengel

11 Envisioning Continuous Quality Improvement

12 Objectives Provide consumers a voice in assessing their own therapeutic progress and improvement Enhance treatment/service outcomes though consumer reported progress, and training and educational supports for Treatment Teams Establish a practice based evidence approach that identifies effective treatments and interventions provided by Treatment Teams Provide alerts to counselors, therapists, case managers when consumers report unexpected deterioration or unidentified problems

13 Collecting Information Concurrent with Treatment Actionable Data Consumer completes brief questionnaire at selected standardized intervals (e.g., each treatment session, once a week, every other week, etc.) to monitor: Perceived improvement Functional status Symptomatology Reduction of risk Quality of the therapeutic alliance Expectations of treatment Openness to change (stages of change) Optimism, hopefulness Recovery Social support Data collected during treatment and follow-up Item Bank (Public Domain)

14 Clinically Informed Outcomes Management Profiles are established based on consumer questionnaire data The Treatment Team is alerted about Consumer status Improvement Stability Deterioration Likelihood of prematurely leaving treatment

15 Providing Feedback Consumer is experiencing a high level of distress. Consider a more thorough assessment, the presence of cooccurring disorders (e.g., substance use, physical health care issues Consumer reports feeling very depressed and sad, 2 worry about most everything, and difficulty concentrating Consumer reports inability to cope when things go wrong, unable to accomplish things, anger outbursts, and decline school performance. Consider anger management, tutorial services. Distress Symptom Function Alliance Recovery Social Consumer reports liking therapist feels understood, and that they are both on the same page, however child expresses some concern about whether information will be shared with parents and teachers. Consumer reports having few friends to hang out with or to talk with when troubled. Reinforce links with peer support groups, explore hobbies and interests Consumer reports little to moderate optimism about things getting better for him/her. Consider linkages with peer supports

16 Feedback Report Graphic Summary Recommendations Report on specific domains

17 Illustrating Change Across Time Distress Symptoms Function Alliance Social Connect Alcohol/Drug Mild Moderate Severe /15/07 8/30/07 9/12/07 9/20/07 10/16/07 Overall level of distress remained consistent with some decrease in functional status, but a decrease in symptoms. Concerns about alcohol and drugs use remained minimal over time concern regarding occasional experimentation continues The quality of the therapeutic relationship remains very favorable, except for the second session where the child reported concerns about sharing information with caregivers and teachers. This was obviously addressed and alliance returned to very favorable levels. Social connection continues to be problematic, a result from feeling stigmatized.

18 Change Over Time Distress Symptoms Function Alliance Social Connect Alcohol/Drug Participant: 2569 Alliance ruptures, but then stabilizes. Social connection worsens as symptoms improve. Consumer reports living in shelter /07 8/11/07 9/06/07 9/27/07 10/11/07

19 Change Across Time Distress Symptoms Function Alliance Social Connect Alcohol/Drug Participant: adexy Symptoms and function remain relatively stable Alliance remains favorable AOD problems fluctuate across time 7/07 8/1/07 8/15/07 8/30/07 9/06/07 9/13/07 9/27/07 10/04/07 10/11/07 10/17/07

20 Feedback Example: Graphic Individual client s progress is based on longitudinal growth curve. Stars are the scores from the client s completed survey, and the dotted line is the score we expected from the client based on a profile established on clients with similar histories, etc. Circles indicate unexpected and potential problem. Sessions

21 Clinically Informed Outcome Management The Treatment Team is prompted to Reconsider diagnosis Assess the quality of the therapeutic relationship Use motivational techniques to increase consumer engagement in treatment Motivational strategies coupled with stages of change Consumer expectations of treatment, active engagement in treatment planning, identification of treatment goals and objectives Examine social resources, e.g., social support The Treatment Team is provided training and education supports to effectively use and respond to feedback

22 Improving Outcomes Decision Flow Clinical Practice: Assessment, Treatment Planning, Concurrent Assessment, Treatment Outcomes 9 Reassess for diagnostic change TX effectiveness NO 8 Diagnosis valid? TX Plan valid? NO 0 Assess service and treatment history. 1 Assess presenting problem 2 Establish treatment plan and TX goals 3 Provide treatment 4 Assess clinical improvement 5 Provide feedback 6 Meaningful Improvement? YES 7 Terminate Treatment 3a Practice guidelines (ADHD, depression, etc. 3b Empirically-supported Treatments (ADHD, depression, etc.

23 Benefits of Clinically Informed Outcomes for Consumers Consumer directed care: treatment is responsive to what the consumer is experiencing Supported by the Institute of Medicine (IOM) Crossing the Quality Chasm, SAMHSA, New Freedom Commission Report, etc. Consumers have an active voice in identifying Improvement Issues that continue to be problematic Clinically Informed Outcomes is a mechanism to involved consumers actively in treatment planning Consumers can see their progress over time Consumers can prioritize outcomes that are meaningful to them and identify strategies to achieve those outcomes

24 Benefits of Clinically Informed Outcomes for Treatment Teams Treatment Teams will be introduced to new interventions Treatment Teams will receive support in the interventions that are suggested with the clinical feedback Supervision Coaching and mentoring Interactive learning community Treatment Teams will have a common approach to clinical outcomes Ability to share information across the Treatment Team and with other teams Ability to make mid-course changes in treatment planning based on evidence/data Ability to target resources to engage consumers in treatment Ability to gather data that supports the effectiveness of the treatment provided practice-based evidence

25 Using Information Continuous Quality Improvement Service System Information Consumer / family Clinician / provider Management Administration System Learning Network Interpretation Outcomes Individual Process System Action System modification Clinical practice modification Guidelines Training Workforce: resources & gaps Focused informative research Ann Doucette, PhD, 1999

26 CIOM Next Steps / Issues Automation Data sharing across agencies Tracking consumer participants across treatment settings Feedback models for consumers Connection to wellness models Incentives for agency participation Clinical support in using feedback data Brown-bag lunches Grand rounds Listserv Dissemination Research

27 Challenges: Quality and Performance Monitoring The most common mistake organizations make is measuring too many variables. The next most common mistake is measuring too few. Mark Graham Brown Keeping Score (1996)... But perhaps an even bigger mistake is to keeping doing the same thing, hoping for better results.

28 Contact Information Ann Doucette, PhD Toby Martin, PhD The George Washington University Medical Center Midge Smith Center for Evaluation Effectiveness Trachtenberg School for Public Policy Public Administration 1922 F St., NW (Old Main), Suite 407-B Washington, DC Tele: efax: