1. Advanced Clinical Social Work Practice in Integrated Healthcare Module 15 Marion Becker, PhD School of Social Work University of South Florida

2. Evaluation of Client Progress and Treatment Effectiveness Module 15: Outline Using technology to evaluate progress Electronic Health Record Health Complexity INTERMD Methodology Care Plan Development and Evaluation Outcome Measurement

3. Using Technology to Improve Care For decades federal reports have prioritized the development of a national telecommunication system for surveillance of health and mental health data for monitoring and improving the health and mental health of Americans. 1 The G.W. Bush administration created the Office of the National Coordinator for Health IT. The Obama administration is continuing & enhancing this. H IT is bi-partisan solution As a result America faces an unprecedented opportunity to improve healthcare through technology use and creation.

4. Electronic Health Record (EHR) The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in EHR information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates and streamlines the clinician's workflow. The EHR has the ability to generate a complete record of a clinical patient encounter - as well as supporting other care-related activities directly or indirectly via interface - including evidence-based decision support, quality management, and outcomes reporting. 2

5. Electronic Health Record (EHR) To encourage the use of EHRs the government funds Medicare and Medicaid EHR Incentive Programs that provide incentive payments to eligible professionals, eligible hospitals and critical access hospitals (CAHs) if they adopt, implement, upgrade or demonstrate meaningful use of certified EHR technology to improve care outcomes. 2 Within the private sector, many companies are now moving forward in the development, establishment and implementation of EHRs as well as medical record banks and health information exchanges to support continuous quality improvement programs

6. Using Technology to Evaluate Progress In our fragmented healthcare system medical and mental health providers have historically used different parameters and outcome measures to evaluate client progress and provider effectiveness. Before information from EHRs or other data sources can be used to evaluate client progress and/or provider effectiveness a common set of outcome measures and metrics must be agree upon to document client progress over time in particular outcomes. In addition to traditional clinical and functional outcome measures social workers focus on other outcome parameters emphasizing quality of life, client goal attainment and client satisfaction with services as markers of provider effectiveness and client progress.

7. Using Technology to Evaluate Progress Systematically collected clinical outcomes data and information from electronic health records (EHRs) can now be used to serve clinical, organizational and research needs. The data can also be used to gain evidence about best clinical practices for optimal health outcomes among different populations. However, to be used effectively, clinical information must be collected regularly, stored and made accessible for those who will use the data. Social workers should involve themselves in institutional records, policies and the development of electronic health records (EHR) to assure the inclusion of comprehensive biopsychosocial information needed to evaluate social work practice outcomes.

8. Evaluating Outcomes for IC Currently professionals in IC settings are lacking in agreement and common procedures for identifying patient needs and evaluating outcomes for the clinically complex clients they serve. For accurate evaluation of IC outcomes (including client progress and provider effectiveness) or comparison of different treatment approaches over time, agreed upon measures and metrics that are collected during care are an essential first step. However, it is also essential to adjust outcomes based on the case mix or health complexity of clients served.

9. Health Complexity and IC Health complexity is an important concept in healthcare outcome measurement in that it helps identify those patients who are at risk for high service use and poor outcomes. It is a necessary component of outcome measurement particularly in IC settings where many patients have complex needs and co-occurring disorders 4 Health complexity is the interference in standard care by biological, psychological, social and health system factors, which require a shift from standard biomedical care to integrated care for patients to improve. Clinically complex patients with co-occurring disorders are a top priority for IC.

10. Health complexity is a composite measure of interacting historical, current state, and vulnerability health risks and health needs. It measures both care and case complexity by examining biological, psychological social and health system factors. 4 Health complexity measurement goes beyond the usual measures of acuity and severity traditionally used in case mix adjustment for outcome evaluation. Health complexity also focuses on health system factors which can be a important barrier to optimal healthcare outcomes. Health Complexity and IC

11. The cost off-set and economic value of IC may be greatest for complex patients with co-occurring mental and physical health conditions. For example, research has documented the value of IC for patients with co-occurring medical (e.g. diabetes and rheumatoid arthritis) and mental health conditions (e.g. depression and anxiety). Research with long-term follow-up of these patients indicates that early clinical improvement and cost reductions persist up to 5 years. 5-6

12. INTERMED Methodology Health complexity can be measured efficiently with INTERMED methodology using the IMTERMED-Complexity Assessment Grid (IM- CAG). 3 INTERMED is the formal name for a method of health complexity measurement and outcome assessment that has been developed to reconnect traditionally ignored (siloed) factors including service system characteristics that influence patient outcomes. It has undergone development, standardization and validation in seven languages over the last 15 years. 7

13. With the INTERMED method all the patient health risks and needs are assessed and translated into scores which lead to provider action and care planning. Interdisciplinary medical and mental health communication is facilitated when using INTERMRD by the organization of health risks and care needs in a Complexity Assessment Grid (CAG) in which seriousness of risks and needs are recorded and visualized with colors for easy identification and discussion by team members. The CAG was specifically designed for IC. It provides an overall picture of the healthcare needs and risks of complex patients and it can also used to direct care planning and evaluation of clinically complex patient care outcomes. INTERMED Methodology

14. The IM-CAG is constructed with an understanding that the relationship between the patient, family and social worker or other care provider is what drives the achievement of goals and leads to improvement and good healthcare outcomes. It is therefore patient-centered and can be enhanced with motivational interviewing techniques. INTERMED methodology is endorsed by the Case Management Society of America and supported with software found at www.intermedfoundation.org.

15. Developing and Evaluating Care Plans The IM-CAG is also a convenient tool for developing care plans and monitoring client progress. When the IM-CAG care management software is used the care planning process can work seamlessly with the electronic comprehensive assessment grid using an electronic record instead of relying on paper records and care plans. The advantage of the IM-CAG method and IM-CAG scores is that they produce a holistic picture of patient health status and healthcare needs and identify areas that may need immediate attention. The CAG automatically records longitudinal assessments of client progress. It identifies potential barriers to improvement and actions need to reverse them, as well as, actions needed to improve the patient’s health and well-being.

16. Outcome Measurement To develop increased support for IC it is necessary for social workers and other professionals to document the value that integrated care brings about in as many areas as possible. INTERMED is just one of many available approaches to comprehensive assessment, care planning and outcome evaluation. Social workers have many other options for monitoring and evaluating patient outcomes in their clinical practice. They can document changes and progress in clinical and functional status of patients that he or she works with, as well costs of the clinical care provided.

17. Outcome Measurement Common outcome measures used in primary care settings include HbA1c, Personal Health Questionnaire 9 (PH-9) evaluations, weight measurements, Generalized Anxiety Disorder-7 (GAD-7) evaluations, health care service use, emergency room visits, hospital admissions and readmissions, and total cost of care. Other measures include ORS, SRS, CORS, CSRS, and YCORS/SRS. While personal health information needs to be protected with appropriate assurances, HIPPA allows aggregated assessment of employed populations on relevant measurement, such as disability costs, workers compensation, absenteeism and productivity which can be used to assess the value of IC.

18. Evidence-based Practices for MH Used and Researched in Primary Care There are a number of evidence-based practices (EBP) for persons with mental and substance use disorders they have been researched and evaluated for use in primary care settings including: BRITE, DIAMOND, IMPACT, PRISM-E, PROSPECT, RESPECT-D and TEAM. Each of these EBP approaches to practice has it’s own specific protocol and associated outcome measures. The EBPs listed above are described and reviewed in detail in the AHRQ Publication No. 09-E003 “Evidence Report/Technology Assessment Number 173”.

19. Continuous Quality Improvement (CQI) Continuous Quality Improvement (CQI) programs are essential to improving healthcare outcomes. CQI in integrated healthcare is a process of creating an environment in which management and care providers work together to create constantly improving healthcare quality. CQI is a theory-based management system that looks at processes as well as outcomes and promotes a patient-centered philosophy of care that is supported with process and outcomes data. The following slides contain information about key agencies that support and are devoted to CQI. Visit their websites for detailed information about their activities.

20. CQI-AHRQ AHRQ is part of the U.S. Department of Health and Human Services. It is the lead federal agency charged with supporting research designed to improve the quality of healthcare, reduce its cost, and broaden access to essential services. AHRQ-supported research is leading to a rethinking of what does and does not work at the healthcare systems level. AHRQ is the agency responsible for and maintains the Consumer Assessment of Health Plans (CAHPS) website. This website has comprehensive information on medical errors and patient safety. Under consumer health it also features the "Improving Healthcare Quality – A Guide for Patients and Families", which provides very complete information about how to get healthcare quality.

21. CQI-IHI The Institute for Healthcare Improvement (IHI) is a non-profit organization working to accelerate improvement in healthcare systems in the United States, Canada, and Europe by fostering collaboration among healthcare organizations. It is also recognized as an organization that hosts both seminars and a collaborative approach to reducing error in healthcare, and therefore, contributes to improving patient safety. One important service is their Breakthrough Series Collaborative on reducing adverse drug events and medical errors. Their Website has a very good resource section with relevant documents on CQI and patient safety.

22. CQI-JCAHO The mission of the Joint Commission on Accreditation of Healthcare Organizations is to continuously improve the safety and quality of care provided to the public through the provision of healthcare accreditation and related services that support performance improvement in healthcare organizations. The Joint Commission is a nationally recognized accreditation agency for hospitals, managed care entities and other types of healthcare facilities. Accreditation by the JCAHO is often used as a general mark of quality to enhance consumer confidence, meet certain certification requirements.

23. JCAHO uses outcome and other performance measures to compile reports made available to the public. Their website is divided into four main sections to provide customized information to different interest groups. 1.general public 2.healthcare organizations and professionals 3.purchasers, employers, and unions 4.the international community CQI-JCAHO

24. CQI-NAHQ The National Association for Healthcare Quality (NAHQ) is a leading organization for healthcare quality professionals. The association is dedicated to the continuous improvement of quality in healthcare and to supporting the development of professionals in healthcare quality. NAHQA publishes the Journal for Healthcare Quality (JHQ), which is a professional forum that endeavors to advance healthcare quality. It also provides other publications and products related to CQI, with a focus on building continuous quality improvement in healthcare teams.

25. CQI-NCQA The National Committee for Quality Assurance (NCQA) is a non-profit organization devoted to assessing and reporting on the quality of managed care plans. NCQA's mission is "to improve the quality of health care delivered to people everywhere and to provide information that enables purchasers and consumers of managed healthcare to distinguish among plans based on quality, thereby allowing them to make more informed decisions."

26. The NCQA website identifies and explains the processes of accreditation and performance measurement, including the HEDIS report card. HEDIS, the Health Plan Employer Data and Information Set, is the most widely used set of performance measures for analyzing the quality of managed care plans. NCQA is also in charge of the Managed Behavioral Health Accreditation Program for managed behavioral healthcare organizations (MBHOs). It will require the MBHO to implement a quality improvement (QI) process centered on structure, process and outcome, and to use this process to demonstrate improvements in the care and service its members receive. Their website is informative and lends itself to easy navigation. CQI-NCQA

27. Included on the NAHQ website are reports on quality, descriptions of quality measures, a list of NCQA accredited managed care organizations, and separate sections with information dedicated to consumer, employer, provider, and government issues. CQI-NCQA

28. References 1.U.S. Department of Health and Human Services. (2000). Healthy people 2010, With understanding and improving health and objectives for improving health (2 vols.) (2nd ed.). Washington, DC: U.S. Government Printing Office. 2.CMS Http://www.cms.gov/EHRIncentivePrograms/25_Certification.asp# Http://www.cms.gov/EHRIncentivePrograms/25_Certification.asp# 3.Jha AK, DesRoches CD, Campbell EG, et al. Use of electronic health records in U.S. hospitals. New England Journal Med 2009;360:1628–38. 4.deJonge, P.M, Bauer, I., Huyse, F.J., & Latour, C.H. (2003). Medical inpatients at risk of extended hospital stay and poor discharge health status: Detection with COMPRI and INTERMED. Psychosomatic Medicine 65(4)m 534-541

29. References 5.Urutzer. J., Knox, W., Callahan, C., Williams, J. et al. (2008). Collaborative care management of late-life depression in the primary care setting: A randomized controlled trial. The Journal of the American Medical Association, 288(22) 2836-2845 6.Stiefel, F.C. Zdrojewski, C., Bel Hadj, F., Boffa, D., Dorogi, Y. et al. (2008). Effects pf multifaceted psychiatric intervention targeted for complex medically ill: A randomized controlled trial. Psychotherapy Psychosomatics, 77 (4) 247-256. 7.Stiefel, F.C., de Jonge, P.,M, Huyne, F. J.,Guex, P. et al (1999). “INTERMED” a method to assess health service needs. Results on its validity and clinical use. General Hospital Psychiatry, 21(1), 49- 56. 8.De Jonge, P.M., Huyse, F.J.,. & Stiefel, F.C. (2006). Case and care complexity in the medically ill. Medical Clinics of North America. 90(4), 679-692.