Improving Clinical Practice

2007, Volume 3

M AGAZINE A quarterly publication from the National Council for Community Behavioral Healthcare

The Intersection of Policy and Practice Linda Rosenberg discusses how new landmark community mental health legislation can support practice excellence • page 1 Process Improvement in Addictions Treatment Dave Gustafson, Director of NIATx, highlights how addictions treatment organizations are improving access and retention for better outcomes. • page 11 A Signature Approach to Outcomes Measurement Dr. Carl Clark and his team explain how a “360-degree” outcomes measurement process is promoting consumer successes at the Mental Health Center of Denver. • page 26

Healthy Minds.Strong Communities. www.TheNationalCouncil.org

27925National_CouncilCS2.indd c1 11/21/07 12:28:32 PM NationalCouncil Improving Clinical Practice M AGAZINE Mark Blockus, Director of Practice Improvement, National Council for Community PDF available at www.TheNationalCouncil.org Behavioral Healthcare, Contact: [email protected] In Th is Issue Services and clinical practices of the highest quality are vital to the recovery of people with mental illnesses and addictions. And efforts to improve services and practices are THE INTERSECTION OF POLICY AND PRACTICE – e ss ce c e s e e o o g z o . 1 AN OPPORTUNITY FOR ACTION th a uran that quality ar i at th h art fan r ani ati n Linda Rosenberg Practice improvement is often about shifting from customary care to evidence-based 3 NATIONAL COUNCIL PROVIDES RECOMMENDATIONS FOR BRIDGING GAPS and promising practices that focus on prevention, recovery, and resiliency. It is about BETWEEN INPATIENT AND OUTPATIENT SETTINGS using science to achieve outcomes that enhance the lives of people with mental Charles Ingoglia illnesses and addictions and lead to meaningful social inclusion. It is about patient 5 LOST IN TRANSITION: LESSONS FROM THE VIRGINIA TECH TRAGEDY and family focused treatment that is culturally and linguistically appropriate. Tammy Seltzer e c ce o e e s c e o e ec se ces s o s o e PRIMARY CARE AND BEHAVIORAL HEALTH COORDINATION Whil pra ti impr v m nt i l arly ab ut th dir t rvi and upp rt pr vid d 6 LEARNING COLLABORATIVE by clinicians to consumers, improvement is dependent upon an organization having Barbara Mauer in place operations and processes that support staff – operations and processes that c e e e g e o e s e e o e ge s s e o co e es c ge 8 INTRODUCING MENTAL HEALTH FIRST AID r at l arnin nvir nm nt wh r kn wl d i har d, ut m data driv han , Lea Ann Browning McNee staff accomplishments are showcased, and emerging leaders are nurtured. 9 IMPROVING ACCESS AND RETENTION IN COMMUNITY Improvement often encompasses the integration and coordination of services. For BEHAVIORAL HEALTH ORGANIZATIONS e e e e ee o o c o s oes ’ e s o ge e Charles Ingoglia xampl ,m ntal h alth and fr d mfr maddi ti n d n t xi tapart fr m n ral good health. Effective consumer/clinician relationships are dependent upon workforce 11 PROCESS IMPROVEMENT IN ADDICTIONS TREATMENT recruitment, development, and retention activities. And continuity between levels of David Gustafson care positively affects consumer engagement and adherence to treatment. 12 COMMUNITY BEHAVIORAL HEALTHCARE PROVIDERS’ NOISE LEVELS ec oog c e s g o e s o o o es o c ce o e e . David Lloyd T hn l yin r a in ly ff r imp rtant pp rtuniti f rpra ti impr v m nt Electronic health records can save time, reduce errors, and create system transparency. THE ROLE OF PSYCHIATRIC CORE MEASURES IN C c sc ee g oo s c o g sc es c c ec so s o s c e 14 TRANSITIONING FROM HOSPITAL TO COMMUNITY CARE lini al r nin t l ,fun ti nal ratin al ,and lini al d i i n upp rt an b Frank Ghinassi, Kathleen McCann embedded in electronic health records. Technology allows us to more easily monitor o co es e c e o ce. A ec oog c e es o o es o RISK MANAGEMENT IN COMMUNITY MENTAL HEALTH ut m and b n hmark p rf rman nd t hn l y r at pp rtuniti f r 16 CENTER CLINICAL PRACTICE practitioner to practitioner and consumer to consumer sharing and learning. Ronald Zimmet, Nicholas Bozzo In this issue of National Council Magazine devoted to Improving Clinical Practice, we’ve 17 LEAD, CONVENE, SHARE — HOW ASSOCIATIONS FOSTER tried to capture the many dimensions of improvement efforts — from technology to im- QUALITY ON THE GROUND o g ccess e e o o eg e c e o co s e -e se ces o Ron Brand pr vin a and r t nti n, fr mint rat d ar t n um r l d rvi ,and fr m early identification of mental illnesses and addictions to measuring outcomes. We share BENCHMARKING FOR BEST PRACTICES 19 lessons learned from member organizations as well as from National Council practice Paul Lefkovitz improvement initiatives. 20 MEMBERS SHARE We hope you find National Council Magazine useful. And that you take advantage of the 26 A SIGNATURE APPROACH TO OUTCOMES array of business and clinical practice improvement resources we offer — National MEASUREMENT IMPROVES RECOVERY Co c L e e s; e - ee ec c Ass s ce U e Ne se e ; o Carl Clark, P. Antonio Olmos-Gallo un il iv w binar th bi w klyT hni al i tan pdat w l tt r ur practice improvement projects; our learning communities; and our expert consultations. 30 HOW CONSUMERS STEP UP TO DESIGN A TRULY e’ e e c e o e g o o e e e c o s se ces — e e RECOVERY-BASED MENTAL HEALTH SYSTEM W r d di at dt h lpin y uimpr v m ntal h alth and addi ti n rvi l tm Daniel Fisher know how the National Council can be most helpful. COMMUNITY COLLABORATION HELPS TO TARGET EARLY 32 DETECTION AND INTERVENTION FOR PSYCHOSIS Donna Downing, Elizabeth Spring IMPROVING ENGAGEMENT WITH YOUTH AND FAMILIES National Council Magazine is a publication of the National Council for 34 WHEN TREATING MENTAL HEALTH DIFFICULTIES Community Behavioral Healthcare, 12300 Twinbrook Parkway, Suite 320, Samira Ali, Mary Cavaleri, Mary McKay Rockville, MD 20852. www.TheNationalCouncil.org. CLINICAL SERVICES AND THE ELECTRONIC HEALTH RECORD: Managing Editor: Meena Dayak 36 COST, QUALITY, AND ACCESS Editorial Associate: Nathan Sprenger Jodi Mahoney, Diane Farrell Editorial, subscription, and advertising inquiries to CONNECTED CARE IN A CONNECTED WORLD [email protected] or 301.984.6200, ext. 240. 38 Kevin Scalia We welcome your feedback and submissions for future issues on Cultural Diversity, Children’s Services, and Board Development.

27925National_CouncilCS2.indd c2 11/20/07 6:56:04 PM editorial The Intersection of Policy and Practice – An Opportunity for Action Linda Rosenberg, MSW, President and CEO, National Council for Community Behavioral Healthcare

The Surgeon General, the President’s efforts and our commitment to service of the National Coordinator of Health New Freedom Commission, and the excellence culminated in the introduc- Information Technology and SAMHSA Institute of Medicine reports have tion on October 17, 2007 of landmark to develop and implement a plan for helped Americans understand that legislation, the “Community Mental ensuring that various components there are effective treatments that make Health Services Improvement Act” of the National Health Information recovery from mental illnesses and ad- by Senators Jack Reed (D-RI) and Infrastructure address mental health dictions possible. And the trade press Gordon Smith (R-OR) in the United and substance abuse provider needs is fi lled with articles about the efforts States Senate. supported by $10 million in funding of National Council member organiza- in FY 2009. Provisions of The Community Mental tions to provide the most effective Health Services Improvement Act Commissioning a paperwork re- treatments, introduce innovation, and • (S.2182) include: duction study to be submitted to improve care. In this issue of National Creating a new federal grants program Congress no later than a year after Council Magazine devoted to “Improv- • to support co-locating primary care enactment that evaluates the coming Clinical Practice” you’ll read about services at community mental health bined paperwork burden of safety the improvement initiatives and service facilities funded at $50 million in net behavioral healthcare programs accomplishments of member organiza- FY 2009 and authorized through FY funded at $550,000. tions from around the country. 2013. Directing a nationwide analysis and When I joined the National Council, • Integrating treatment for mental submission of a report to Congress of we committed to being the strongest • health and substance abuse co-occur- the compensation structure of profes- possible advocacy voice on behalf of ring disorders funded at $14 million sional and paraprofessional behavior- member organizations, the nation’s in FY 2009, $20 million in FY 2010 al health personnel as compared with community-based mental health and and authorized through FY 2013. that of other health safety net and addictions service organizations and private sector employers also funded the adults and children served by these Improving the workforce through • at $550,000. organizations. Our focus on advo- grants for the recruitment and reten- cacy – mental health and addictions tion of mental health professionals What You Can Do legislation, policies and regulations funded at $10 million in FY 2009 and Charles Ingoglia, the National Council’s that protect and expand access to authorized through FY 2013. Vice President, Public Policy and our adequately funded, effective treatment, entire team are conducting a compre- Enhancing behavioral health educa- rehabilitation and support services – is • hensive lobbying effort supporting tion and training of para professional complemented by our efforts to enable S.2182 in the U.S. Senate and in the staff through a new grants program member to member learning and to House when a companion bill is intro- funded at $4 million in FY 2009 and offer members practice improvement duced there. We are working very hard authorized through FY 2013. resources and technical assistance. And to explain the importance of the provi- over this past year the National Council • Establishing a new $20 million sions of S.2182 and value of community has provided leadership in several key federal grants program to fi nance treatment and rehabilitation services to areas — integration and coordination infrastructure costs for telecom- every Congressional offi ce we can reach. of behavioral and general healthcare; munications technology supporting But no matter how hard and smart we mental health services to returning tele-psychiatry and patient educa- work in Washington, S.2182 and other veterans; continuity of care between tion at community behavioral health measures good for consumers and com- levels of service; access, retention and facilities located in rural and other munities have little chance of advancing adherence to treatment, and workforce medically underserved areas. without strong support from back home and leadership development. • Requiring the Secretaries of the HHS – including the support of National Most recently, our assertive advocacy and DVA collaborate with the Offi ce Council Magazine readers.

Continued on page 2

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27925National_CouncilCS2.indd 1 11/16/07 4:54:28 PM Editorial, continued from page 1

coalitions, etc.) “Getting well takes time and money and there are • Veterans (VFW, American Legion, no shortcuts. And improving practice demands Vietnam Veterans of America, etc.) • Medical (medical associations, physi- opportunities and resources. The Community cian specialty societies, hospitals, Mental Health Services Improvement Act promises medical centers, etc.) both. You can help make promises realities – • Academia (medical, social science, take action now!” public policy, etc,) • State and local chapters of mental Only you can contact your Senators, companion and support its passage health and addictions advocacy as- Representatives and their staffs to let – or do so here in Washington. Bring key sociations (Mental Health America, them know that you support S.2182. allies with you who will resonate with NAMI, etc.) And only you can help generate critical the Senator or Representative based on This exercise may prove to be one of support from leaders and organizations party, issue interests, background, and the most effective things the behavioral in your state and local communities other considerations healthcare community can do to reach that your Senators, Representatives and Step 2: Inform, Educate and Mobi- out to other key interests to lend their their staffs will recognize as important lize Key State and Local Leaders and support for our issues within the legisla- voices in the political process. Groups tive and political processes. Step 1: Contact Your Senators, Just as the National Council will be Results Representatives and Staff reaching out to a broad range of Results that we can produce together Everyone reading National Council Mag- national organizations for support of through this two-step process include: azine should take a few minutes in the S.2182 and its House companion bill, next day to write to their two U.S. Sena- you can conduct similar outreach to • A strong group of Senate cosponsors tors asking them to cosponsor S.2182 important leaders and organizations in for S.2182 and its House companion and send it off to Washington by fax and your state and on a local basis. Effec- • Awareness of the legislation among e-mail. Template letters are available on tively informing, educating, developing, staff members in both Senate and our website at www.TheNationalCouncil. and mobilizing these allies is a critical House org. Once our House bill is introduced, success factor in bringing the provisions you should do the same with your U.S. of S.2182 to fruition. • Hundreds of state and maybe even Representative. thousands of local organizations and Speciﬁ cally, we urge you to sign up the leaders across the country supporting Besides writing a strong letter, you following kinds of organizations: the bill should follow-up with a phone call to State legislative caucuses the Senator or Representative’s Legisla- • • Enhanced capacity for advocacy for mental health and addictions services tive Director to ask them to make sure • Local government (mayors, counties, the issue gets proper focus by the staff cities, etc.) at the national, state and local levels person responsible for health care, as a result of new and strengthened Law enforcement (police, sheriffs, mental health and related issues. • relationships with key political con- judges, prosecutors, etc.) stituencies and leaders We ask that you forward copies of your Business (State and local Chambers letters – and the responses that you • Getting well takes time and money and of Commerce, economic development receive – to us so that we can use them there are no shortcuts. And improving groups, etc.) here when we visit these ofﬁ ces and practice demands opportunities and resources. The Community Mental Health know what they are saying when they • Church leaders and culturally diverse respond to you. organizations Services Improvement Act promises both opportunities and resources. You Further, we urge you to meet personally • Civic groups (United Way, League of can help make promises realities – take with your Senators and Representative Women Voters, Rotary, etc.) action now! when they are back home to ask them Low income advocacy groups (Salva- to cosponsor S.2182 and its House • tion Army, AMVETS, homelessness

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27925National_CouncilCS2.indd 2 11/16/07 4:54:32 PM NationalNa Council Initiatives Lost in Transition: People with Mental Illness Slipping through Fault Lines Along Continuum of Care National Council Provides Recommendations for Bridging Gaps Between Inpatient and Outpatient Settings Charles Ingoglia, MSW, Vice President, Public Policy, National Council for Community Behavioral Healthcare Millions of Americans experience schizo- charge are not forgotten. Seeking to stem • Encourage collaborations between hos- phrenia or other serious mental illnesses the tide of patients who are “lost in transi- pitals and community-based organiza- and the most vulnerable period in their tion” every day, in December 2006, the tions. recovery is the transition from hospital to National Council assembled a 24-member • Use a quality improvement approach to local, community-based services. Yet nearly independent panel of experts to develop enhance continuity of therapy by bench- 50% of individuals with mental illnesses a consensus approach to coordination marking a performance and outcomes who are discharged from inpatient care and between inpatient and outpatient settings standards at the organizational level. referred to community-based treatment, fail and engage people with mental illness in to make the transition. continued care. The panel included repre- • Ensure all patients have a level of care sentatives from leading accrediting bodies management for the transition from inpa- The National Council and its members are and hospital and community treatment tient to community including reimburs- deeply concerned about the signifi cant hu- organizations, as well as patients, family able care management services by all man, social, and fi nancial consequences members, researchers, state authorities, payers. of this interruption and discontinuation and psychiatric leaders. in mental healthcare. Individuals with • Focus on the “Pull Model” of transition mental illnesses who discontinue care Summary of Experts’ Recommendations from inpatient to outpatient care by upon discharge from inpatient settings to Improve Continuity of Care involving community providers in the can fi nd themselves in crisis, ending up in The National Council expert panel’s recom- transition before patients get discharged. emergency rooms or even jails. mendations to address the gap in care • Align accreditation standards that ad- between inpatient and outpatient settings Hospitals and community-based organiza- dress and improve continuity of therapy. were released in April 2007. These recom- tions need uniform standards, education, mendations, which span the administra- • Educate patients and their families on and better collaboration to ensure that tive, professional, and human elements importance of maintaining a personal patients with schizophrenia who fail to required to ensure complete continuity of health care history. continue treatment following hospital dis- care, include the following Continued on page 4

Many people with mental illness are ‘falling between the cracks’ when shifting from an acute inpatient setting into the community, often stopping the recovery process altogether. Interruptions of treatment interfere with recovery and prevent people from being able to function as contributing members of their community.

Joseph Parks, MD Medical Director, Missouri Department of Mental Health Member of the National Council’s Expert Panel on Continuity of Care

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27925National_CouncilCS2.indd 3 11/16/07 4:54:32 PM NationalN Council Initiatives Lost in Transition: People with Mental Illness Slipping through Fault Lines Along Continuum of Care

Recommendations for Bridging Gaps in Care, continued from page 3

• Promote more thoughtful use of inpatient services to reduce emergency room use and an eventual decrease in the number of l The National Council expert panel hospitalizations. • Share data about mental health services with appropriate on Continuity of Therapy included organizations in usable and timely ways. representatives from the... • Involve patients and their advocates in all levels of system delivery and evaluation. » American Association of Community Psychiatrists Continuity of Care: Systemic Beneﬁ ts Continuity of care supports patient recovery and re-entry into the » Assertive Community Treatment Association community and has a positive, measurable impact on the health- » Commission on Accreditation of Rehabilitation Facilities care delivery system in terms of the following: » Mental Health America • Reduced incidence of use of emergency room services by people with schizophrenia or other serious mental illnesses » National Alliance on Mental Illness • Access to appropriate treatment settings » National Association of Psychiatric Health Systems • Enhanced efﬁ ciencies across the discharge planning process » National Association of Social Workers The National Council will continue to work with member organiza- » National Association of State Mental tions and other stakeholders to disseminate the expert panel’s Health Program Directors recommendations, and to support implementation of the recom- » National Council for Community Behavioral Healthcare mendations through practice improvement initiatives (see article on page 9). » Substance Abuse and Mental Health Services Administration Continuity of therapy is a vital component of quality care for people with serious mental illnesses and must be given more attention Constella Group » by consumers themselves, family members, advocates, providers, And individuals with serious mental illness. administrators, and researchers alike. Th e panel was supported by Janssen, L.P. Charles Ingoglia is Vice President of Public Policy for the National Council for Community Behavioral Healthcare. He directs the federal affairs function and oversees policy and practice improvement outreach to more than 1,300 member organizations across the nation. He also serves as adjunct faculty at the George Washington University Graduate School of Political Management. Prior to joining the National Council, Ingoglia provided policy and program design guidance, including the review of state Medicaid Waiver applications and other HHS regulations, to the Center for Mental Health Services at the Substance Abuse and Mental Health Services Administration under the U.S. Department of Health and Human Services.

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27925National_CouncilCS2.indd 4 11/16/07 4:54:43 PM Lost in Transition: Lessons from the Virginia Tech Tragedy Tammy Seltzer, JD, Director of State Policy, National Council for Community Behavioral Healthcare

“One can’t help but wonder if the April 2007 tragedy at Virginia Tech could have been avoided if the shooter, Cho Seung-Hui, had received court-ordered treatment. It’s easy to blame ﬂ aws in the mental health care system for Cho’s failure to receive treatment, but the real issue is a failure to communicate – the failure of the criminal justice, public mental health, and university counseling services to communicate with each other and for all of these entities to communicate with Cho and his family.”

Two years prior to America’s most deadly shoot- of treatment and services. Providers must have schools — are working together so that the young ing on the campus of Virginia Tech University adequate resources and staff to attend commit- person is not “lost” between systems. in April 2007, a Virginia judge found that the ment hearings and conduct mobile outreach with Providers can attend commitment hearings, gunman, Cho Seung-Hui, met the legal standard individuals in need of treatment to ensure a solid make contact with the patient and family, share for commitment to a hospital or outpatient hand-off from court to treatment. Once a court is their expertise with the court, and know what setting. Although the judge found Cho to be an involved, the judge must have a mechanism to the court expects from them. Providers can “imminent danger” to himself, he ordered Cho ensure that the individual is receiving treatment work with hospitals to ensure that a workable to receive outpatient services — services that and that any barriers are addressed. treatment plan is in place before the individual Cho tried three times to access at the university’s How can we stem the tide of students and is discharged — and work with the individual counseling center, but never received. other individuals in need of mental healthcare and family to smooth the transition from • Imagine how different things might be today who are lost in transition? Here are a few hospital to community. — for 33 young people and their families — basics to consider. Scarce resources often result in long waiting lists if Cho’s case had played out this way: Focus on Prevention for community-based programs. States must • The court that committed Cho to outpatient Ensure that young adults have ready access to ensure that providers have sufficient resources care received assurance that a specific pro- necessary mental health services and are encour- to address the full range of community needs, vider was able to treat Cho immediately. aged to take advantage of these services before from prevention programs to crisis services to a crisis occurs. long-term care. • The court order named a specific provider and contained a follow up date for the provider Use providers to train staff, students, resident In the end, the Virginia Tech tragedy is not about and Cho to report back to the court. advisors, campus police, and others who come needing a new law or about blaming one system into contact with students. Everyone should or another. It’s about talking to one another. It’s • Provider staff reached out to Cho’s family be familiar with the signs of mental illness and about providing sufficient resources. It’s about to ask for their assistance in developing an suicide risk, know how to access services in the working together to ensure that no one is lost in appropriate treatment plan for Cho, much like community, and how to respond in an emer- transition. the successful plan that was put in place at his gency situation. high school. Tammy Seltzer, JD, is the Director of • The provider, the university’s counseling center Be Prepared for Emergencies State Policy for the National Council. She in this case, promptly moved Cho from intake Ensure that communities have a range of focuses on the coordination of federal to treatment. emergency and crisis services available 24 hours a day, 7 days a week. and state policy, and has special exper- • The court had a community liaison who tise and interest in children and criminal contacted Cho to find out whether he was Providers can make available crisis lines and mo- justice issues. Seltzer has given technical receiving treatment and acted swiftly to name bile crisis units to evaluate and stabilize a young assistance to states and mental health an alternative community provider if the person in crisis, and support to individuals who advocates on a variety of issues involving university counseling center did not meet must be transported to emergency rooms when children’s mental health, such as funding his needs. they are not safe to remain in the community. for home- and community-based services to reduce reliance on institutional care. If we are to stem the tide of those, like Cho, who Make Sure Everyone Works Together are “lost in transition,” then we need better Ensure that the different systems — justice, communication, collaboration, and coordination law enforcement, mental health providers, and

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27925National_CouncilCS2.indd 5 11/20/07 7:07:07 PM National Council Initiatives Primary Care and Behavioral Health Coordination Learning Collaborative Barbara J. Mauer, MSW CMC, MCPP Healthcare Consulting and Senior Consultant, National Council for Community Behavioral Healthcare

Since 2002, the National Council for Community Project started in January 2007 with four sites medications or psychotherapy. The lowest quality of Behavioral Healthcare and its member organiza- — each site is a partnership between a com- care occurred among those with the most serious tions have played a leadership role in improving munity behavioral healthcare organization and symptoms, including those with evidence of suicide clinical care through integrated behavioral health a community health center. The second phase of or substance use. A major learning was that, “Right and primary care initiatives. The National Council’s the project expanded to an additional eight sites now PCPs don’t have the tools necessary to decide current Primary Care-Behavioral Health Collabora- in September 2007. This project will continue as which patients to treat and which to refer on to tive Project is yet another step toward ensuring a systems improvement activity and we will create specialized mental healthcare.” that comprehensive, effective healthcare for mind and disseminate toolkits based on learning and Recent reports that the population with serious and body is available to all those with serious materials from the sites. mental illness has an average life span that is 25 mental illness. The project reflects the increasing The Need for Clinically Sound years less than that of the general population also importance of collaborative care in regional and Collaborative Care point to the need for collaborative care. national dialogues and begins to answer the More than 30 studies in the U.S. and abroad, need for more structured clinical improvement A 2007 National Council survey of community be- conducted since 1990, document that systematic approaches in this arena. havioral organizations revealed that while 91% of collaborative care is more effective than usual respondents place high or medium priority on in- The learning collaborative model that the National primary care for depression. creasing the quality of general medical healthcare Council has adopted for this project is based on An article in the Annals of Internal Medicine for their clients, only one in two providers has the 20 years of pioneering work by the Institute for (September 2007) reported that most primary capacity to provide any treatment for those condi- Healthcare Improvement and the application of care practitioners do a good job of diagnosing and tions, and one in three has the capacity to provide that work in the Health Disparities Collaboratives beginning treatment for depression, but do less the services onsite. The most common barriers to sponsored by the Health Resources and Services. well in following up with treatment over time — less providing general medical services were problems The Primary Care-Behavioral Health Collaborative than half of patients completed a minimal course of in reimbursement (72.1%), workforce limitations (68.4%), physical plant constraints (60.8%), and lack of community referral options (55.8%). Project Goals Diagram Project Goals The goals of the National Council’s Primary Care- Current Referral Chasm Current Referral Chasm Behavioral Health Collaborative Project are to • Only 50% get to MH upon referral • Expedited support for referrals and • Little information ﬂ ows between PCP and MH engagement • Patients get pushed back and forth, rather • Increase ability of primary care clinics to screen • Psychiatry training and support for PCPs than jointly served for bipolar, addictions, and suicide risk as a • Psychiatric evaluation and treatment for referrals part of depression screening. Primary Care Clinic • Track weight, lipids, glycemia for patients on SGAs • Increase capacity of primary care clinics to • Screen all patients for depression • Support/information from PCPs regarding provide proactive follow-up and management • Screen all depressed patients for bipolar, health status , joint planning f or patients suicide, substance use with medical co -morbidities of patients identified with depression. • Refer per protocols for specialty MH , • Evidence based MH services and c ase referral includes medical co -morbidity management • Increase community mental health organiza- information • Transition stable patients back to PCP tions’ provision of psychiatry training and • Provide depression care and care per protocols management for those not referred • Data tracking regarding care processes clinical support for primary care, to enable a • Use PHQ – 9 for proactive follow -up and and patient status more comprehensive stepped care model. management of depression • Access to psychiatry to support PCP and care management and assure stepped • Establish processes for ongoing communica- • Provide primary care services tion regarding collaborative care between • Support/information from PCPs to MH primary care and community mental health regarding health status , joint planning f or Improved Referral Process patients with medical co -morbidities organizations, including: • Data tracking regarding care processes • Agree on who needs spec ialty MH and 100% and patient status of them get there and get engaged • Information ﬂ ows between PCP and MH • Protocols for referral of individuals with bipo- • Patients are collaboratively cared for, with attention lar disorder and suicide risk from primary to medical co -morbidities exacerbated by SGAs care clinics to community mental health organizations, to assure seamless transition from primary care to specialty mental healthcare.

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27925National_CouncilCS2.indd 6 11/16/07 4:54:46 PM The Four Quadrant Clinical Integration Model • Return of stable patients to primary care follow up as appropriate. QuadrantQuadrant II QuadrantQuadrant II High • Establish shared methods for medical BHÈ PHÍ BHÈ PHÈ management of patients treated in community • BH Case Manager ww/responsibility/responsibility foforr • PCP (with standard screening tools and BH mental health settings who are at risk for coordination w/PCPw/PCP practice guidelines)guidelines) • PCP (with standard screening tools and • BH Case Manager w/ responsibility for coordina-coordina- metabolic syndrome. BH practicepractice guidelines)guidelines) tion w/ PCP and Disease MgrMgr • SSpecialtypecialty BBGG • Care/Disease ManagerManager • Increase capacity of both primary care and • ResiResidentialdential BH •Specialty medical/surgical • CrisisCrisis/ER/ER • Specialty BHBH community mental health organizations • BehBehavioralavioral HeHealthalth IP • Residential BHBH • Other community support • Crisis/ER to document and track care processes and • BH and medical/surgicalmedical/surgical IP performance. • OtOtherher community susupportspports Stable SMI would be served in either setting. setting Plan and deliverdelivere services based upon the needs of the individual The work is grounded in the National Council’s consumer choice and the speciﬁ cs ofof the community and collaboration. Four Quadrant Model, which has been adopted QuadrantQuadrant II QuadrantQuadrant IIII widely as the foundation for initiatives in col- BHÍ PPHHÍ BHÍ PHPHÈ

laborative care. • PCP ((withwith standard screening tools and BH • PCP (with(with standard screening tools and BH practicepractice guidelines) practicepractice guidelines)guidelines)

There is always a boundary between primary Risk/Status Health Behavioral • PCP-PCP-basedbased BH* • Care/DiseaseCare/Disease Manager • SpecialtySpecialty medicalmedical/surgical/surgical care and specialty care and there will always be • PCP-based BH (or in speciﬁspeciﬁ c sspecialties)*pecialties)* • ER tradeoffs between the benefits of specialty exper- • Medical/surgicalMedical/surgical IPIP tise and of integration. Stepped care is a clinical • SNF/homeSNF/home based care • Other community supports approach to assure that the need for a changing

level of care is addressed appropriately for each Low person — a person may begin receiving services in Q I and need specialty mental health/sub- Low Physical Health Risk/Status High

stance abuse services (Q II) or specialty medical *PCP-based BH provider might work for the PCP organization, a specialty BH provider, or as an individual practitioner, is compe- services (Q III). Those who need specialty mental tent in both MH and SA assesment and treatment health/substance abuse services and medical services as well as primary care (Q IV) have a critical need for collaborative care. The National grams to generate reports for additional EHR • Non specific due dates. Council’s collaborative care project is intended to programming. result in a stepped care model that the behavioral This list is probably applicable to clinical practice health and primary care agencies agree upon and • Real time access to data, treatment outcome improvement initiatives in every setting—the implement in daily practice. data not readily available. learning collaborative project has tools to help sites overcome barriers to improvement, and the • Design and implementation of screening, Self-identified Barriers to Clinical Improvement toolkits that emerge will assist many other organi- collection, and analysis techniques that are not In order to be successful at clinical practice im- zations in improving care. If you are thinking about burdensome. provement, any organization must have a planned starting a clinical practice improvement initiative approach to change and assuring improvement. • Difficulty sharing medical records between MH of any kind, use this list to assess whether these Prior to the learning session, a self-assessment and PC, one party as an EHR, the other not. barriers exist and to develop strategies to address tool was completed by each of the eight sites them. convened in September 2007. Identified the • Too many meetings, full schedules, attendance following barriers to clinical improvement and the at meetings a problem. The Learning Process use of data: The National Council project, using a learning • Too much autonomy of providers, lack of buy in. collaborative model, convened primary care and • Lack of staff follow through in implementing • Lack of systematic measures for tracking and specialty mental health teams in an initial learning procedural changes, implementation does not program improvement. session. The teams generally were composed of match plan, failing to carry out the Check-Act the medical director of the primary care clinic, the part of the Plan-Do-Check-Act (PDCA) cycle, not • Inconsistent use of screening tools and gather- medical director of the community mental health following up to make sure changes implementing of data. organization, the person who serves as the men- ed were effective and have resulted in better • Inefficient communication. tal health care manager in the primary care setting outcomes. (either a primary care or mental health employee • Not including all provider levels in process, who sees patients and tracks their care), and one • Staff overload/crisis oriented, busy schedules, improvements don’t fit actual workflow. other person selected by the two organizations. not enough time to focus, new electronic health record. • Weakly defined action steps, who is respon- At the learning session, teams received clinical sible for details and deliverables. education materials and training, reviewed project • Finite IT resources to design and write pro- measurement requirements, and planned their

Continued on page 10

NATIONAL COUNCIL MAGAZINE 2007 • VOLUME 3 / 7

27925National_CouncilCS2.indd 7 11/16/07 6:18:03 PM National Council Initiatives Introducing Mental Health First Aid

Lea Ann Browning McNee, Outreach and Development Ofﬁ cer, National Council for Community Behavioral Healthcare

Fear is generally the root of most stigmas. The stigma surrounding mental illnesses in the United States is no different: fear I’m so pleased the National Council has taken the lead in of not understanding the problem, fear of bringing Mental Health First Aid to the United States. This doing or saying the “wrong” thing and fear of not knowing what to do when someone program will help us achieve so many critical objectives: needs help. from educating our communities and fi ghting stigma to Today, we recognize First Aid as the help serving as a valuable public policy tool. administered to an ill or injured person before medical treatment can be ob- — Don Miskowiec, President, tained. Mental Health First Aid is the help North Central Behavioral Health Systems, Inc., LaSalle, IL provided to a person developing a mental health problem or experiencing a mental First Aid to the United States by training our sess the situation, to select and implement health crisis. The fi rst aid is given until ap- member organizations — community-based appropriate interventions, and to help the propriate professional treatment is received providers of mental health and addictions individual in crisis connect with appropriate or until the crisis resolves. It gives primary services— to lead and manage certifi cation professional care. The course covers a range care providers, educators, businesses, and programs in their communities. Slated to of common disorders and potential crises others in the public a tool and a resource to launch in May 2008 in approximately six such as helping someone who is having a help overcome the fear. locales, Mental Health First Aid Programs panic attack, is suicidal, or has experienced The National Council is adapting the well-re- will be active in at least 30 communities by an addictions relapse. searched Mental Health First Aid program for the end of 2009. As provider organizations the American public. Our vision is that by the already connected with other healthcare As the Outreach & Development Of- year 2025, Mental Health First Aid certifi ca- groups, community leaders, advocates and fi cer for the National Council, Lea Ann tion will be as common and as well-known families, National Council members are Browning McNee creates new pro- as CPR and other fi rst aid certifi cations. uniquely positioned to educate their com- grams that connect education to policy munities, promote the certifi cation program The Certifi cation Program and practice priorities Before joining and to provide effective, culturally-relevant Mental Health First Aid is a 12-hour certifi ca- the National Council, she oversaw training across broad audiences. The Na- tion course originally designed to increase the external relations programs of the tional Council will also work with members to the skill of primary care providers in helping National Mental Health Association. offer Mental Health First Aid to key audiences a person cope with a mental health crisis. She currently serves as adjunct faculty — primary care professionals, educators, col- Developed in 2000 by Betty Kitchener and at the George Washington University lege leaders, human resource professionals, Professor Tony Jorm with the aim to improve Graduate School of Political faith leaders, and family members. the mental health literacy of Australians, it is Management. To learn more about now auspiced by ORYGEN Research Centre at Mental Health First Aid certifi cation, which Mental Health First Aid, contact her at the University of Melbourne, Department of must be renewed every three years, provides [email protected] Psychiatry. The program has since been rep- trainees with the skills, resources and licated in six countries,including Scotland, knowledge to provide short-term interven- Great Britain, and Canada. tion for an individual experiencing a mental The National Council will bring Mental Health health problem. Participants will learn to as-

8 / NATIONAL COUNCIL MAGAZINE 2007 • VOLUME 3

27925National_CouncilCS2.indd 8 11/16/07 4:54:48 PM National Council Initiatives Improving Access and Retention in Community Behavioral Health Organizations Charles Ingoglia, MSW, Vice President, Public Policy, National Council for Community Behavioral Healthcare { “While all changes do not lead to improvement, all improvement requires change.” } The National Council launched a practice How Does the Initiative Work? The most fundamental aspect of the Access and improvement initiative focused on improving Through a competitive Request for Proposals Retention Initiative is measurement. Measuring access to and retention in care for persons with process, four community-based behav- the progress toward our aims is fundamentally mental illness in August of 2007. This project ioral healthcare organizations were chosen to important to achieving those aims. Through- is based on an approach used by industry, and participate in this intensive, year-long change out the Initiative, the focus will be on results more recently embraced by healthcare orga- process. The organizations are the Carlsbad with a strong, early emphasis on establishing nizations, that recognizes that consumers are Mental Health Center in Carlsbad, New Mexico; performance measurement systems within served by an organization’s processes — the LifeWorks NW in Portland, Oregon; Northside participating institutions. Results depend series of action steps taken to convert inputs Mental Health Center in Tampa, Florida; and on the performance of numerous planned, into outcomes. It is estimated that 85% of the Sweetser in Saco, Maine. structured tests of change while collecting data problems that organizations have in serving to learn from those tests. The ideas being tested For 12 months, the sites will form a collabora- consumers are caused by the organization’s are in general already proven in the literature, tive to engage in a series of structured activities processes, and that the failure to make im- successfully used elsewhere, and supported by designed to advance their improvement work provements are most likely operational failures. experts in the field. as rapidly as possible. Participating organiza- Why Focus on Access and Retention? tions come together for “Learning Sessions” The National Council has retained MTM Services In December 2006, the National Council — in-person, conference calls, discussion – David Lloyd, Randy Love, Scott Lloyd, and convened an Expert Roundtable comprising groups, exchange of printed reports — where Bill Schmlter — to serve as the faculty for this representatives of the mental health commu- they clarify the science, plan their own tests of project. This team combines the data collection nity— consumers, family members, inpatient change, and learn from each other’s efforts. The and analysis, as well as the clinical and and outpatient provider organizations, state term “Learning Session,” although now fixed in organizational change expertise necessary to mental health authorities, and accrediting our jargon, can be deceptive. The participants lead the participating sites to improve their organizations to develop recommendations not only learn from the experts, but work closely processes, and in turn increase access to and to improve continuity of treatment for persons with them and with each other to refine the retention in care. transitioning from inpatient to outpatient treat- science of improvement. ment systems. This Expert Roundtable devel- While all changes do not lead to improvement, Charles Ingoglia is Vice President of Public oped a series of nine consensus recommen- all improvement requires change. The ability Policy for the National Council for Com- dations to improve continuity and to ensure to develop, test, and implement changes is munity Behavioral Healthcare. He directs that treatment is seamless and continuous for essential for any individual, group, or organiza- the federal affairs function and oversees consumers (see article on page 3). tion that wants to continuously improve. A policy and practice improvement outreach The Access and Retention Initiative represents change concept is a general notion or approach to more than 1,300 member organiza- the National Council’s initial response to these to change that is useful in developing specific tions across the nation. He also serves as recommendations as embodied in concrete ideas for changes that lead to improvement. adjunct faculty at the George Washington University Graduate School of Political action to improve the status quo. This initiative Creatively combining these change concepts Management. Prior to joining the National with knowledge about specific subjects can seeks to make it easier for consumers to access Council, Ingoglia provided policy and pro- care and to improve the ability of staff to help generate ideas for tests of change. After gram design guidance, including the re- engage clients. It is our belief that these generating ideas, Plan-Do-Study-Act cycles test view of state Medicaid Waiver applications improvements will also enhance treatment a change or group of changes on a small scale and other HHS regulations, to the Center retention and medication adherence. It makes to see if they result in improvement. If they do, for Mental Health Services at the Sub- sense to us to apply the concept and tools of the tests are expanded and gradually incor- stance Abuse and Mental Health Services performance improvement to the problems of porate larger and larger samples until there is Administration under the U.S. Department access and retention. confidence that the changes should be of Health and Human Services. adopted more widely.

NATIONAL COUNCIL MAGAZINE 2007 • VOLUME 3 / 9

27925National_CouncilCS2.indd 9 11/16/07 4:54:50 PM Primary Care and Behavioral Health Coordination, continued from page 7

initial approach to achieving the project goals. 7. Percent of patients referred to mental health Training topics included: specialty care who attend initial visit* • IMPACT model and tools 8. Average time to initial visit after referral to Participants in the National mental health specialty care* • STABLE toolkit (bipolar) Council’s Primary Care-Behavioral 9. Average number of contacts (phone and in • Suicide risk and substance use assessment Health Learning Collaborative person) between primary care and specialty • Rapid Cycle Improvement mental health to coordinate care Phase I • Performance measures 10. Percent of patients with bipolar disorder with » Behavioral Health Network/ evidence of level of function evaluation at Holyoke Health Center, Inc. (Springﬁ eld, MA) • Tools for planning and reporting the time of the initial assessment and again Over a six-month period, the teams submit peri- within 12 weeks of initiating treatment** » Behavioral Health Resources/ Primary Health Care, Inc (Des Moines, IA) odic reports and participate in three conference 11. Percent of patients with bipolar disorder with calls with the project faculty and all other project evidence of monitoring for weight twice within » Cowlitz County Guidance Association/ participants. The teams reconvene in a final learn- the initial 12 weeks of treatment** Cowlitz Family Health Center (Longview, WA) ing congress to present their accomplishments, » South Central Montana Regional Mental Health data, learning and tools to one another. 12. Percent of patients with bipolar disorder who were assessed initially for their symptom Center/Deering Community Health Center / Measurement of Results complex and then assessed for change in Yellowstone City – County Health Department In the Rapid Cycle Improvement model, measure- their symptom complex within 12 weeks of (Billings, MT) ment is essential to determine whether an initiating treatment** implemented change results in a quantifiable improvement. 13. Percent of patients treated for bipolar disorder Phase II with evidence of screening for hyperglycemia » Austin Travis County Mental Health & Mental The project has 15 core performance measures within 16 weeks after Retardation/Community Care Services Department necessary to evaluate the quality of care being initiating treatment with an atypical (Austin, TX) provided. Each site begins with a baseline assess- antipsychotic agent** ment of the measures in use, and must provide a » Colorado West Regional Mental Health Inc./ final report at the end of the project. 14. Percent of patients treated for bipolar disorder Summit Community Care Clinic (Frisco, CO) with evidence of an assessment 1. Percent of patients screened annually for » Community Counseling Services/ for hyperlipidemia within 16 weeks after Horizon Health Care, Inc (Huron, SD) depression in primary care* initiating treatment with an atypical Heritage Behavioral Health Center/Community 2. Percent of primary care patients with depres- antipsychotic agent** » Health Improvement Center (Decatur, IL) sion with PHQ-9 on initial evaluation, 4-6 15. Percent of primary care patients with diagno- weeks, 12 weeks, 6 months* sis of depression meeting remission criteria at » Highline West Seattle Mental Health Center/High Point Medical and Dental Clinic Puget Sound 3. Percent of patients treated for depression 12 weeks, 6 months* Neighborhood Health Centers (Seattle, WA) who were assessed, prior to treatment, for * From Center for Quality Assessment & » LifeStream Behavioral Center, Inc./Thomas E. the presence of current and/or prior manic or Improvement in Mental Health, 2006 hypomanic behaviors** Langley Medical Center (Leesburg, FL) ** From STABLE (Standards for Bipolar » North Range Behavioral Health/ 4. Percent of patients diagnosed with depres- Excellence), 2006 sion or bipolar disorder with evidence of an Sunrise Community Health, Inc. (Greeley, CO) initial assessment that includes an appraisal On completion of the year-long learning » Porter-Starke Services, Inc./Hilltop Community for risk of suicide** collaborative, the National Council will Health Center, Inc. (Valparaiso, IN) compile and disseminate learnings from the 5. Percent of patients diagnosed with depression pilot sites to improve clinical practice in provid- or bipolar disorder with evidence of an initial as- ing integrated care. sessment that includes an appraisal for current or past alcohol or chemical substance use** 6. Percent of primary care patients with a major Barbara Mauer is a nationally known expert in consulting services to public and private sector depressive or bipolar disorder meeting sever- behavioral health and primary care integration. health and human service organizations on ity/complexity criteria for specialty mental She has more than 15 years of experience in this integration as well as strategic planning, quality health services (as established by state and ﬁ eld and is a managing consultant for MCPP improvement, and project management. Mauer local payors) referred for specialty mental Healthcare Consulting in Seattle, Washington and has authored many papers and books on behav- healthcare* a National Council senior consultant. She offers ioral health and primary care integration.

10 / NATIONAL COUNCIL MAGAZINE 2007 • VOLUME 3

27925National_CouncilCS2.indd 10 11/16/07 4:54:52 PM Experts Speak Process Improvement in Addictions Treatment

Dave Gustafson, Ph.D., Director, National Program Ofﬁ ce of The Network for the Improvement of Addiction Treatment (NIATx) Reprint from the May/June 2006 issue of National Council News.

The addiction treatment fi eld is working hard admissions. NIATx member organizations use a ment providers through innovative partnerships to meet policy and regulatory requirements to process improvement approach to testing effec- between providers and single state agencies. implement evidence-based practices — inter- tive practices in their specifi c settings. This initiative is expected to improve clinical and ventions that have been scientifi cally proven to administrative practices that impede the use of The improvement process that NIATx members promote positive client outcomes. evidence-based practices. implement is an adaptation of Nolan’s Model for In health services research, the gold standard Improvement2 that uses a “rapid-cycle” PDSA Another initiative is Strengthening Treatment for testing and proving evidence-based practices in conjunction with tools designed to improve Access and Retention—State Implementation is the randomized controlled trial (RCT). Yet the organization’s customer focus and involve (STAR-SI) funded by the Center for Substance randomized controlled trials are time-consuming key stakeholders in the improvement process, Abuse Treatment. This program builds on the and expensive, and evaluate effectiveness only including the CEO and a designated Change fi ndings of NIATx members who have substan- at a global level. Process improvement offers a Leader.3 tially increased client access and retention complement to randomized controlled trials, helping service providers test evidence-based practices in their own unique settings. Over the past decade, businesses and healthcare Through rapid-cycle testing, we can obtain new knowledge organizations have used process improvement in five days or five weeks—rather than five years. successfully to improve performance outcomes. Broadly defi ned, process improvement is a method developed and tested within the fi eld Through PDSA or “Change Cycles,” NIATx of continuous quality improvement (CQI) that using process improvement methods. STAR-SI members take a concept and test it in a specifi c uses Plan-Do-Study-Act (PDSA) Cycles to improve program grantees will use process improvement environment. An organization accomplishes organizational processes. Organizations can use methods to improve both state and agency level improvement by taking an idea, trying it out in a PDSA Cycles to set improvement targets, pilot organizational processes that infl uence client very small context, determining why it succeeds test changes, and analyze outcomes using dem- access to and retention in outpatient addiction or fails, and then trying it again in another rapid- onstrated performance measurement tools.1 treatment services. cycle test. The NIATx process improvement meth- tools. odology can be generalized to other organiza- We look forward to expanding our network tions that desire to improve their own real-world through these two initiatives and to contributing PLAN processes quickly. Along the way, NIATx member to research on evidence-based practices that will organizations are proving the effectiveness of key benefi t both service providers and their patients. practices that can be implemented on a broad

scale. Through rapid cycle testing, we can obtain ACT DO As the National Program Offi ce Director, Dave new knowledge in fi ve days or fi ve weeks—rath- Gustafson provides overall leadership to the er than fi ve years. NIATx initiative. Gustafson is also director of STUDY Since NIATx began in 2003, member organiza- Wisconsin’s Center of Excellence in Cancer Com- tions have been building an evidence base for munications Research (funded by the National practices that they know work, and have been Cancer Institute), and a research professor in the PDSA Cycles are an integral part of process improvement, learning how to implement proven treatment College of Engineering at the UW-Madison. He helping providers test evidence-based practices in their own settings. methods in their unique clinical settings. founded the Center for Health Systems Research NIATx is now promoting the rapid adoption of and Analysis, a multidisciplinary research center evidence-based practices among treatment on the UW campus, best known for its research The Network for the Improvement of Addiction providers through two exciting new initiatives. on improving healthcare quality. Treatment (NIATx) is a learning collaborative First, in partnership with the Treatment Research that consists of almost 50 treatment organiza- References Institute (TRI), NIATx serves as the national tions across the country. NIATx works with its program offi ce for Advancing Recovery: State and 1. Juran, J.M., and Frank M. Gryna. Juran’s Quality Control Handbook. 4th ed. member organizations and the fi eld at large to New York: McGraw-Hill, 1988 Provider Partnerships for Quality Addiction Care. 2. “The Model for Improvement,” The Improvement Guide, by Langley, Nolan, improve treatment access and retention through Nolan, Norman, and Provost, San Francisco, Jossey-Bass Publishers, 1996 Funded by the Robert Wood Johnson Founda- 3. “Findings of innovation research applied to quality management principles organizational changes infl uencing four aims: tion, Advancing Recovery is designed to promote for health care.” Health Care Management, 20:2, 16–33. reducing wait times, reducing noshow rates, the use of evidence-based practices by treat- increasing continuation, and increasing and

NATIONAL COUNCIL MAGAZINE 2007 • VOLUME 3 / 11

27925National_CouncilCS2.indd 11 11/16/07 4:54:52 PM Experts Speak Community Behavioral Healthcare Providers’ Noise Levels David Lloyd, President, MTM Services and Senior Consultant, National Council for Community Behavioral Healthcare

A critical question for community behavioral healthcare organizations is “What is the primary day-to-day focus of the direct care and support/admin staff — the processes used in service delivery OR delivering services to consumers/families?”

The answer can be identifi ed by using 4. Percentage the number of service than directing much needed attention the following data points: delivery process agenda items to delivering more timely and quality compared to items on the agenda services. 1. Review the agendas for the focused on actual delivery of management team/clinical team Below is a typical list of ongoing services to consumers. meetings during the past six seemingly never-ending system process months. Using this measurement model fi fteen noise generators within CBHOs: years ago when I became a manager/ 2. Identify the number of agenda • Documentation timeliness and supervisor at a community behavioral items that were focused on internal completeness health organization, we learned that challenges with the service delivery only 6% of the agenda topics were • Documentation quality process (i.e., documentation is focused on actual delivery of services not being completed by staff and • Direct care and support staff roles to consumers while 94% of the agenda turned in within the submission that create high levels of discontent topics focused on internal challenges standard, support staff are with the service delivery process. • Quality improvement model of the not assisting direct care staff need to create the perfect change adequately, etc.) What has become apparent during the solution that everyone must agree 15 years since, during which I provided 3. Identify the number of agenda with versus using a continuous consultation to more than 400 CBHOs, items that were focused on quality improvement action plan is that internal “noise levels” created by the actual delivery of services to change model that supports timely the re-occurring challenges with service consumers (i.e., the number of implementation and on-going delivery processes create barriers consumers waiting for service, evaluation based modifi cations to to timely and effective change. The how many, in which service/ the process as needed noise levels demand that managers, unit/program and an action plan supervisors, and staff stay focused on • Non-standardized clinical/support to solve the access to care and commit a high percentage of energy staff fl ow processes problem, etc.) and creativity to “the process” rather

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27925National_CouncilCS2.indd 12 11/16/07 4:54:54 PM “Noise levels” created by the re-occurring challenges with service delivery processes demand attention to “the process” rather than to the more critical delivery of timely and quality services.

• Non-standardized documentation and National Council Consultant, system noise that can only be models/styles and I are collaborating on a book resolved when the actual practice is for spring 2008 publication by aligned to the envisioned practice. • Access to care fl ow/processes the National Council that focuses In summary, the ability to reduce service • Lack of computer skills and data/ on the concept of “What we do process noise levels is proportionate information to support objective – what we write.” We have found to the efforts by management teams decision-making nationally, that direct care staffs to measure current processes, identify are providing very important and • High level of “emoting” by staff appropriate solutions, make decisions quality interventions to consumers; when presented with any change about which solutions need to be however, the documentation being requirement implemented, and implement process recorded in the charts does not change. • Lots of ideas about changing the support the level of quality and organization, but relatively low/no interventions being provided. implementation of actual change Specifi c curricula are available David Lloyd, author of How to Deliv- If any of the top ten noise generators to address this workshop based er Accountable Care, has facilitated identifi ed above claim re-occurring training need that uses current the development and implementa- attention of your center’s management documentation in each CBHO’s tion of compliance-based management accountability initiatives with team and staff, then the following charts as the focus of instruction. more than 400 community behav- suggested intervention solutions might 3. Create fl ow charts of current service ioral health organizations, regional be helpful: delivery processes to provide a medical centers, and primary care practices throughout the United 1. Implement a 70% super majority more objective awareness of the redundancy/re-work designed into States. He has been a featured decision-making process in all presenter at numerous national, re- the current processes. Scott Lloyd, meetings of the management and gional, state, and local workshops unit/program teams to facilitate MTM Services and National Council and conferences. He is the founder more effective organizational Consultant, has experienced an and president of MTM Services decision-making to address the interesting phenomenon when based in Raleigh, North Carolina and is a senior consultant for the noise generators. A 70% vote developing fl ow charts for CBHOs. When support staff/direct care National Council. For consulting model used by each team has arrangements, contact MarkB@ staff are asked to identify process proven to effectively solve the thenationalcouncil.org. challenge of a few staff members fl ows without managers present, creating ongoing barriers to service the process fl ows are very different delivery system change. and in many cases in confl ict with the workfl ow charts created by 2. Create quality documentation managers for the same processes. improvement training programs It seems that support staff/direct that provide specifi c instruction staff have adapted the process to for direct care staff on how to their identifi ed needs while the write more objective, effective, managers more often refl ect the and quality documentation. Bill “Policy and Procedure” version. Schmelter, Ph.D., MTM Services These process fl ow variances create

NATIONAL COUNCIL MAGAZINE 2007 • VOLUME 3 / 13

27925National_CouncilCS2.indd 13 11/16/07 4:55:08 PM Experts Speak The Role of Psychiatric Core Measures in Transitioning from Hospital to Community Care

Frank A. Ghinassi, Ph.D., Chair, Technical Advisory Panel, Hospital-Based Inpatient Psychiatric Services Performance Measurement Initiative; Kathleen McCann, R.N., Ph.D., Director of Clinical and Regulatory Affairs, National Association of Psychiatric Health Systems

Inpatient, hospital-based psychiatric core – private and public from 40 states – are now that receive patients transitioning from these measures are now being pilot tested in an participating in the HBIPS pilot test. settings. Core measures on timely communi- exciting and groundbreaking performance cation for continuity at discharge and on use How Community Providers measurement effort in behavioral health. And, of multiple within-class medications will help Will Benefit from HBIPS while these measures are designed for use to ensure transition to community outpatient While the initial core measures are focused on within the hospital setting, they will also pro- providers with the data required to continue inpatient hospital care, the entire process has vide valuable quality of care information and effective treatment. been designed with the expectation that many treatment planning leadership to enhance care continuity with community mental health of the concepts may ultimately be useful to all Continuity Measure (HBIPS 5) settings. Of particular interest will be those levels of care. “Provision of discharge assessment and aftercare recommendations, in a timely manner, to measures that deal with the transition from For the first time, data will be comparable responsible community health providers upon hospital to community care – one of the most across the public and private sectors critical and challenging steps in a patient’s discharge” is a measure that was chosen journey toward recovery. Up to this point, there has been a great deal of by the stakeholder panel for a number of data collection — an important first step — but reasons. Communication between levels of About the Core Measures Initiative with little or no ability to compare data across care is critical for both client safety and conti- At the start of 2007, pilot testing began through systems. While there was interest in many nuity of care. Many clients may not be able to the “Hospital-Based Inpatient Psychiatric of the same measures, common definitions fully report to their next healthcare provider Services Performance Measurement Initiative.” and standardized data collection methodolo- their course of hospitalization or discharge This project was brought to The Joint Commis- gies that were widely supported by diverse treatment recommendations. The aftercare sion by the National Association of Psychiatric stakeholders were lacking — thereby limiting instructions given to the patient at discharge Health Systems, the National Association the ability of data to provide risk adjusted may not be available to the next level of care of State Mental Health Program Directors, benchmarks and improve practice. The core provider at the client’s initial intake or follow- and the NASMHPD Research Institute, Inc., measures initiative will provide consistency up appointment. in operational definitions — vetted and ap- with the support of the American Psychiatric In developing this measure, the Technical proved by diverse constituencies. All clients, Association (see www.naphs.org/quality Advisory Panel felt that it was incumbent families, and providers will benefit from this for background). Together our organizations on hospital providers to ensure that this step toward a common language. are working – with input from all affected data is available to the next level of care. stakeholders, including consumers, families, The core measures initiative puts behavioral The TAP decided to standardize elements of providers, researchers, and others – to identify health on equal footing with general health what information clients should bring. This and implement a test set of core performance measure specifies that – prior to the aftercare This project will give psychiatric inpatient measures that meet the rigorous standards appointment – inpatients leave the hospital providers behavioral health data that is on a used to develop core measures for heart fail- with a brief referral summary that includes all par with the core data (e.g. on heart failure) ure and other general healthcare conditions. of these elements: A diverse and active Technical Advisory Panel that general hospital and community health is now overseeing the project. colleagues have available. Making the case • 5 axial discharge diagnosis. that core measures can be compared across The widespread commitment of all stake- • Current list of all medications with accurate all types of inpatient treatment settings and holders to participating in the development dosing information. that they are using standardized operational process, the willingness of providers to invest definitions will be easier as a result of this • Next level of care treatment recommenda- the human and financial resources needed to project. tions. test these measures, and the enthusiasm of the involved pilot facilities to join in the leader- In particular, two of these core measures will Documentation as to the reason for the current ship of this core measure development has help hospitals improve the dialogue about hospitalization is sent to the next level of care, been extraordinary. More than 190 hospitals patient care with the community services which can be the prescribing clinician, the

14 / NATIONAL COUNCIL MAGAZINE 2007 • VOLUME 3

27925National_CouncilCS2.indd 14 11/16/07 4:55:10 PM The “Hospital-Based Inpatient Psychiatric Services Performance Measurement Initiative” is ushering in a revolution that will place behavioral healthcare on an equal footing with general healthcare by providing core measures that allow for data comparison across multiple treatment settings.

prescribing outpatient entity, or the treating cli- equate trials of monotherapy may benefit from 3. Seclusion use nician or entity (in the absence of medications) the addition of a second agent (Learner, et. 4. Patient discharge on multiple antipsychotic prior to the aftercare appointment. al., 2000). In an era of short hospital stays, a medications patient may be started on a new antipsychotic The measure will look to see that every medication but discharged before the prior 5. Provision of discharge assessment and hospital record is reviewed by the hospital for agent can be tapered off (Ananth, Gunatilake, aftercare recommendations to respon- completion. As hospitals use this standard- 2004). Thus, clinically appropriate rationales sible community health providers upon ized measure, community mental heath for multiple antipsychotics include: 1) the discharge organizations and other community providers patient has failed multiple adequate trials of should feel the impact of improved communi- monotherapy; or 2) the inpatient physician Throughout 2007, psychiatric hospitals cation more and more. intends that one or more antipsychotics be have been testing these measures. For details on the project, visit Multiple Medication Use (HBIPS 4) tapered off following discharge. www.jointcommission.org (look under “Patients discharged on multiple antipsychot- The goal of measuring this information is to Performance Measurement Initiatives). ic medications” is a measure that is intended ensure that hospitals send providers in the next to make this information an explicit part of the level of care a very clear picture of the intended discharge summary for all hospital inpatients. plan for continuing use of antipsychotic medica- Frank A. Ghinassi is Vice President, This measure evaluates the proportion of tions. This information is intended to be an inpatients discharged on two or more anti- Quality and Performance Improvement at explicit part of the discharge summary. Western Psychiatric Institute and Clinic of psychotic medications without one of several UPMC Presbyterian Shadyside. He is an acceptable clinical rationales outlined in the The HBIPS core measures initiative is moving Assistant Professor in the Department of discharge summary. behavioral health on to an equal footing with general healthcare in terms of data collection Psychiatry at the University of Pittsburgh According to the Joint Commission, research and reporting. The primary goal of this project School of Medicine and serves as the studies have found that 5% to 18% of is to have a positive impact on the quality of principal investigator on a research grant outpatients and 50% of inpatients treated patient care through standardized measure- aimed at studying the effectiveness of mental healthcare for Medicaid recipients with an antipsychotic medication concurrently ment, benchmarking, and greater transpar- in Allegheny County. He is a frequent pre- receive two or more antipsychotics (Stahl, ency of practice decision-making – both within senter at national professional meetings Grady, 2004). Studies have also found that, the hospital and as individuals are discharged and conferences. compared to treatment with a single antipsy- and move to receiving community services. chotic agent, use of multiple antipsychotics Kathleen McCann is the director of clinical for schizophrenia or other major psychiatric The Psychiatric Core Measures and regulatory affairs for the National disorders is generally associated with more The five candidate measures in the psychiatric Association of Psychiatric Health Systems. core measure set address quality-related severe side effects and generally not associ- She provides clinical consultation to more dimensions of inpatient, hospital-based ated with better clinical outcomes (Ananth, than 600 member psychiatric health psychiatric care: Gunatilake, 2004). system facilities in the areas of clinical pro- 1. Assessment of potential risks, previous gramming, performance improvement, There are exceptions to practice guidelines trauma, existence of substance abuse, and and regulatory compliance. She serves as recommending monotherapy, which are client strengths the NAPHS liaison to the Hospital Based reflected in this core measure. For example, Inpatient Psychiatric Systems core mea- some patients who have failed multiple, ad- 2. Restraint use surement development project.

NATIONAL COUNCIL MAGAZINE 2007 • VOLUME 3 / 15

27925National_CouncilCS2.indd 15 11/16/07 4:55:11 PM Experts Speak Risk Management in Community Mental Health Center Clinical Practice

Ronald Zimmet, General Counsel and Nicholas Bozzo, President — Mental Health Risk Retention Group

It is easy to believe that most lawsuits quality care possible. The best use of a been obtained with reasonable diligence or against healthcare providers are the result of center’s risk management dollar is to con- that the provider was not thorough enough too many lawyers bringing frivolous claims centrate on those areas of clinical practice because factors that should have been and jurors run amok. However, because most likely to result in serious injuries and considered were not. Additionally, we often lawsuits sometimes accurately identify lawsuits. see allegations that an assessment was not done when it was important to do one. failures in quality care, we can learn from the The most frequent lawsuits against com- patterns that are evident after analysis of a munity mental health centers are for Community mental health center manage- large body of cases. Over time, the allega- ment should design procedures to ensure (1) Sexual misconduct with patients tions in categories of cases repeat from one that adequate information is available for case to the next. In fact, despite unique (2) Suicide malpractice staff doing assessments. It is especially circumstances in each case, it is striking how important that the assessor have access to (3) Patient’s violent acts with another similar the allegations are about deﬁ ciencies and be trained to consider the center’s own patient at a center facility or with in clinical mental health care. relevant records. third parties Because the costs in bringing a lawsuit can Sometimes access to relevant information is (4) Medication errors. be quite high, many cases actually resulting difﬁ cult because it is buried in a thick chart in litigation involve serious injuries. Lawyers Except for the sexual misconduct claims, and time constraints present a barrier to are more likely to bring claims when there these cases almost always involve an allega- reading the whole chart. Separate, easily ac- are serious injuries because the greater tion of some type of failure in adequately cessible sections on a computer network for the injury, the higher the potential for large assessing or monitoring the patient’s condi- those areas most important to quality care settlements or jury awards. tion. The mental health expert witnesses and presenting the highest risk of lawsuits often assert that an assessment was based could alleviate this concern. These computer In fact, the best clinical risk management on incomplete information that could have sections could document suicidal and violent is simply the process of providing the best behavior, the treatment provided over time, and whether the treatment was effective. Furthermore, they could document the baseline and historical data, such as lab test reports and physical exam information that are required for decisions about medication The best clinical prescriptions. Descriptions about side effects and whether the medication was effective risk management could also be included. Other mental healthcare provider records is simply the process usually contain information important to an of providing assessment but are not always easily and quickly available. Consider entering into the best quality agreements with other local providers such as hospitals, physicians groups, and as- care possible. sociations as well as other clinics to expedite the availability of their relevant records. Sometimes other providers make their records available but not all relevant records are obtained. For instance, if an emergency room doctor refers a patient for crisis

Continued on page 18

16 / NATIONAL COUNCIL MAGAZINE 2007 • VOLUME 3

27925National_CouncilCS2.indd 16 11/16/07 4:55:13 PM Associations are ideally equipped to foster Experts Speak quality through education, benchmarking, Lead, Convene, Share — How member services, and advocacy. Associations Foster Quality on the Ground

Ron Brand, Director, Minnesota Association of Community Mental Health Programs

Associations have long played a unique and • Sponsoring training, development, and sustainable. For consumers and family, it critical role in how American communities consultation services. supported earlier intervention before disability have addressed problems, promoted civic and deterioration and all the related social • Facilitating knowledge transfer and replica- engagement, and served the public inter- consequences. tion of innovations and best practices. est. Associations are “common ground” The state association with state leaders, for cooperation and collaboration among • Convening vendors and providers on joint consumer advocates, and private healthplan vendors/providers who otherwise compete projects that link products and services in executives involved the MMHAG are also mov- with each other. the “supply chain.” ing ahead with a project to establish common Quality improvement through education, • Advocating removing regulatory barriers methods to assess quality and performance benchmarking, member services, and that interfere with quality. indicators for multiple payers and funders. The advocacy is a core activity for associations. • Advocating for reimbursement methods Minnesota Association role in these efforts, as Associations can be a key partner in state and that support and reward quality and best a founding member of the MMHAG steering national efforts to foster best practices and practices. committee and various workgroups, arises a culture of competence and quality. Many from its mission and a strategic goal set by its associations strive to be a non-governmental The Minnesota Association of Community board to improve coverage of intensive non- vehicle to address quality through a variety of Mental Health Programs, Inc. (MACMHP) mis- residential services for continuous, coordi- strategies. Understanding the opportunities sion is “Improving quality through education, nated care built on high quality standards. and challenges for deploying these quality member services and public policy advocacy.” improvement strategies will help association The following examples show how we’ve New Connections for Telehealth leaders and their members develop durable creatively used association strategies to foster This is another Minnesota Association-spon- partnerships with payers, policy makers, and quality improvement. Similar activities are sored project to use high quality televideo consumers. sponsored by other associations nationwide. conferencing for client clinical services, professional education, and administrative Association Strategies to Improve Quality A Model Benefit Set and Performance meetings. The project involves a combination • Benchmarking or measuring key indicators Measurement. of activities that tap into association expertise: of performance and outcomes such as pro- Minnesota’s mental health system trans- ductivity, financial ratios, staffing patterns, formation focused on public and private • Fundraising to secure financing and local no-show rates, or client satisfaction and sector services and the interaction between match for equipment grants and staff. functioning. them through the Minnesota Mental Health • Negotiating group purchasing arrange- Action Group. A key initiative was to develop • Setting industry norms through a common ments to leverage best prices and services. an evidenced-based “model benefit set” vision, values, and code of ethics. that goes beyond traditional outpatient and • Training staff in the use of telehealth equip- • Sharing effective processes that support inpatient benefits to include intensive, inter- ment. quality and “make it easier to do the mediate-level services typically available only • Advocating with public and private payers right thing.” to public sector consumers. With both public regarding reimbursement methods. and private payers committed to the model • Standard-setting through credentialing, benefit set, services and programs would • Exploring business opportunities and new expert opinion, guidelines, and protocols. need to be adjusted to meet the multiple ways to use the telehealth capabilities. • Fostering communication among payers quality expectations of employed commercial Some lessons in quality from the Minnesota and providers regarding quality, cost, and clients, poor, disabled consumers and the Association’s experiences are access. interests of the employer-purchasers, the local sheriff, or the hospital emergency room. • Quality requires that multiple activities • Raising awareness of how to differentiate For the Association’s provider members, this work together to yield the best outcomes, quality through “sell-right” strategies. approach broadened the payer mix to support even when component services are sup- services that require sufficient volume to be plied by multiple providers/vendors.

Continued on page 18

NATIONAL COUNCIL MAGAZINE 2007 • VOLUME 3 / 17

27925National_CouncilCS2.indd 17 11/16/07 4:55:25 PM Lead, Convene, Share, continued from page 16

stabilization or inpatient care because of suicidal behavior, the hospi- with a fi rearm after checking into a hotel alone without telling any- tal should provide its records relevant to the decisions as a reference body has a high risk of success and a low chance of rescue. for further care and medication. QA committees should audit charts When doing the initial assessment it is also important to plan the to monitor whether all relevant records are obtained in time. need for reassessments. Appropriate assessments should be done All possible sources of relevant information should be contacted. As when a patient fi rst presents for care, when discharged, when there appropriate to the specifi c case, patients should be asked to give is a signifi cant change in clinical status, and on the occurrence of any permission for the assessor to confer with such sources as family, suicidal or violent behavior. friends, police, and primary care physicians who may be prescribing psychiatric medication. Center management should also design systems to ensure that as- The Mental Health Risk Retention Group offers professional and general liability and directors and offi cers insurance as well as sessments are suffi ciently thorough. For example, charts we have re- a wide variety of risk management materials for the community viewed in suicide malpractice cases more often than not contain only mental health industry. minimal documentation of the consideration of suicide risk. Often the documentation is limited to comments about whether the patient Ronald Zimmet is general counsel to the Mental Health Risk denies suicidal ideation and includes a plan that does not consider Retention Group. He is the featured speaker in the company’s why the patient should be believed. Consideration of the lethality of risk management video and audio presentations. He writes past suicide attempts is only infrequently documented. a column on risk management for Behavioral Healthcare magazine. He is a trial lawyer and provides risk management Consider adopting protocols for assessments such as those de- consulting for mental health centers. scribed in The Harvard Medical School Guide to Suicide Assessment Nicholas Bozzo is the president of the Mental Health Risk and Intervention (Jossey Bass, 1999). The lethality of past suicide Retention Group and the managing director of Negley attempts could be analyzed in relation to the risk for success of the Associates. He has many years of experience in insurance attempt and the probability of rescue. For instance, a suicide attempt industry management.

Risk Management, continued from page 17

• Quality improvement is not a top-down process — it involves pay- encing, benchmarking surveys, and data reports. Increasing diversifica- ing attention to how things work on the ground and how services tion and specialization by providers requires increased association staff interact as well as focus on workﬂ ow efﬁ ciencies and the customer capacity, yet there are resource constraints. And, fragmented funding experience. silos fracture and frustrate efforts to improve quality. • Often public mental health programs, piloted with grant funding, are Despite the challenges, associations’ focus on quality is critical to unable to be sustained and replicated because they have not been efforts to shorten the time lag from science to practice in a range of positioned to live in the world of reimbursement-based financing; initiatives from primary care and behavioral health integration to dual and often real world payers have not been able to relate to the diagnosis treatment. Through leadership, convening, and sharing of innovative services developed with grant funds. Services need to be practical ideas, associations can bring a practical emphasis on how designed and developed from the start to meet the quality standards best practices can operate on the ground. and interests of multiple payers and consumers. • Compliance and quality improvement are interrelated; however, compliance is a minimum goal, not an excellence goal. Compliance Ron Brand is Executive Director of the Minnesota Association of Community Mental Health Programs, Inc., a position that he is a key foundation on which to build interest and consensus for has held since 1990. In this capacity he is involved with public broader quality initiatives. policy advocacy, education, and member services. Previously, • A focus on quality improvement adds credibility to the association’s he worked in a community counseling center, in substance traditional advocacy efforts—that associations can both advocate abuse treatment, as a school psychologist, and for a private and implement is a powerful combination. foundation focused on organizational development and community care. Brand has a Masters degree in psychology Associations undoubtedly face many challenges in fostering quality. The from the University of Minnesota. information and communications technology needed for collaboration and dissemination of quality practices is expensive — collaboration software, listserves, online learning, web meetings, televideo confer-

18 / NATIONAL COUNCIL MAGAZINE 2007 • VOLUME 3

27925National_CouncilCS2.indd 18 11/16/07 4:55:27 PM Performance Measurement Benchmarking for Best Practices Paul M. Lefkovitz, Ph.D., President, Behavioral Pathway Systems In the absence of context, no- The measurement of organizational performance top performers and others may be has become ubiquitous in behavioral health regarded as potential best practices. show rates, access, productiv- settings. Its acceptance as a management tool Behavioral Pathway Systems, an organi- has been facilitated by commitment to mission, zation that specializes in benchmarking, ity, cost per unit of service, and marketplace dynamics, and regulatory man- developed the process benchmarking dates. Yet behavioral health leaders often report methodology. BPS has conducted other performance metrics are that such data has limited impact on organiza- numerous process benchmarking tional performance. In spite of commonly held workshops around the country to identify simply numbers — they do not beliefs that performance data should stimulate potential best practices. Electronic audi- ongoing improvement, in many behavioral serve to inform. Benchmark- ence polling technology is used to lend health settings, performance data does not anonymity and efficiency to the exercises. inform organizational vision and does not drive ing provides the vital context An interesting feature of process bench- key management decisions. marking is that the findings are quite that transforms numbers into Why is this? Consider this — how helpful would sensitive to regional differences. Poten- a thermometer be as a measure of your health tial best practices in one geographic area actionable information. if you did not know that 98.6° was “normal?” may not exhibit similar promise in other In the absence of context, your measured localities. temperature would not provide information Another noteworthy characteristic of process These fi ndings represent a small sample of — it would just be a number. The same applies benchmarking is that the findings are frequently what was learned in BPS process benchmark- to behavioral health performance data. In the unexpected. That is because recognized and ing workshops. They are presented as illustra- absence of context, no-show rates, access, popular tactics are already widely adopted by tions of the technique and should be regarded productivity, cost per unit of service, and other most organizations. The methods that actually with appropriate caution. These fi ndings have performance metrics are simply numbers—they prove to separate top performers from others are not been replicated suffi ciently to allow for do not serve to inform. often subtle and little-known, representing the generalization across all geographic regions Benchmarking provides the vital context that “leading edge” of best practice. and types of settings. transforms numbers into actionable information. For example, in conducting process benchmark- In summary, benchmarking represents a Benchmark metrics, most often provided in the ing exercises in the area of access to services powerful management tool that brings static form of percentile rankings, reveal exactly how (length of time to be seen for initial session), performance data to life and facilitates ongoing your organization is performing in comparison to it was found that organizations that generally organizational improvement. Interest in bench- others. This leads to the identification of relative eschew the use of voicemail were five times marking is on the rise and its broader use within strengths and opportunities for improvement. more likely to reside in the “top performer” the behavioral health field should prove to be Concrete evidence pointing to organizational group. Also, top performers were much more highly beneficial. performance that is lagging in particular areas likely to limit the control clinicians have over their readily calls most leaders to action. schedules. In addition, top performers were con- In addition to illuminating opportunities for siderably more likely to have a Utilization Review Paul M. Lefkovitz, Ph.D., a licensed clinical improvement, benchmarking offers insights process in place to manage the “back end” of the psychologist, is president of Behavioral as to how to improve. A technique known as access process (excessive no-shows, therapist Pathway Systems. He has been an active process benchmarking1 uses benchmark data cancellations, etc.). contributor to professional literature as a vehicle to identify potential best practices. and presents regularly at regional and In the area of staff retention, top performers were Process benchmarking is based on a very national conferences. He serves as chair found to be over twice as likely to establish pro- simple premise — top performing organiza- of the Joint Commission Behavioral Health cedures to ensure that individuals have a clear tions employ different methods than others Care Professional and Technical Advisory understanding of the job characteristics and and it is those unique methods that account Committee. Dr. Lefkovitz is active on the hurdles before being hired. Top performers were for their high level of performance. Process boards of behavioral health advocacy also more likely to actively encourage supervi- benchmarking is an investigative technique associations at the local, regional, and sors to give positive feedback to staff regularly. In that systematically compares the methods national levels. addition, organizations with high staff retention used by top performers with those used were more likely to have an employee newsletter 1. Lefkovitz, Paul M. (2005). Process Benchmarking: Moving Beyond ‘the by others. Tactics that distinguish between Numbers’. Behavioral Healthcare Tomorrow, 14 (5): 18-23. that comes out at least quarterly.

NATIONAL COUNCIL MAGAZINE 2007 • VOLUME 3 / 19

27925National_CouncilCS2.indd 19 11/16/07 4:55:29 PM Members Share Tracer Methodology Offers Burke Center a Qualitative Assessment Option Susan Rushing, MA, CEO and Donna Moore, MA, Director of Quality Management — Burke Center, Lufkin, TX Contact: [email protected]

As part of its Shared Visions-New Pathways® management plans. The tool also served as how the individual’s needs are assessed, how accreditation process, the Joint Commission on a prompt to follow up on issues that staff had problems to be treated are identifi ed, and the Accreditation of Healthcare Organizations intro- struggled with in the past, such as assessing means by which these needs are addressed. duced an onsite process, the tracer methodol- for nutritional risk and identifying the need Questions such as “Why did you choose to work ogy. Tracer methodology involves the tracking for integration of care in mental health and on this?” are asked. Thoroughness, timeliness, of care recipients’ experiences throughout the substance abuse. Although the tool was useful and appropriateness of the documentation are entire organization, and is used to assess or- as a prompt and in recording information, this reviewed. Follow up over time of critical issues ganizational systems and processes that drive process does not lend itself to measurement, in an individual’s treatment is explored. care.¹ Since 2005, Burke Center, a community a tradition in quality improvement. The merit Most important, staff are given the opportunity mental health and mental retardation center of the process lies not in measurement but in to identify not only what they did but why they did it, thus reinforcing the larger purpose of the processes. While reviewing the care (still all in hard copy at our organization), use of the cor- rect, most recent forms and procedures is also assessed. Staff are given the opportunity to ask questions, offer suggestions on improvements, and identify ineffi cient processes. Following completion of the tracers, all fi ndings are compiled onto a spreadsheet, under headings of program, issue, action needed, and status of action. Over the ensuing months, action plans based on tracer fi ndings are identifi ed and implemented, and the following years’ tracers identify if the actions taken were effective. The process is used to analyze how in Deep East Texas has used this process as a the interactive process and opportunity to “drill Burke Center as a whole approaches care and quality improvement tool. down” into issues that drive compliance, such provides services. as training needs or lack of communication With services being provided in more than 40 between providers. The process has helped the Burke Center sites spread out over 12 counties encompass- ing 10,000 square miles, Burke Center has en- Each year, tracer appointments are set up with • Identify training needs of staff. countered challenges in assuring that programs staff in every direct care program and every • Assess effectiveness of past trainings. implement processes consistently and that site where Burke Center provides services. This changes are communicated effectively. This was process spans three months. The director of • Assess effectiveness of communication in fact identifi ed as a need for improvement in quality management, assisted at times by other throughout the organization. our most recent Joint Commission accreditation managers, conducts the tracers. Cases chosen • Providing a venue for staff to ask questions survey. Recognizing the limitations to traditional for review included complex cases, those and make suggestions. auditing and monitoring in identifying short- receiving services in more than one program, falls, Burke Center used tracer methodology as dual diagnoses, new admissions, individuals • Identify ineffi cient or laborious processes. a means to assess consistency and quality in with rights’ restriction or behavior plans, and • Afford staff the opportunity to become famil- programs and areas in need of organizational those receiving high volume of services. For the iar with the Joint Commission accreditation improvements. last two years, approximately 70 tracers have process been scheduled. A tool was developed to help assess important Tracer methodology affords a qualitative, inter- aspects of service delivery and included as- In meeting with staff, the process is explained, active assessment of services, as opposed to sessment, treatment planning, service delivery, with an emphasis that the organization, not traditional audit and measurement activities. medical needs, and other areas requiring the individual staff, is being assessed. In special attention, such as the use of behavior conducting the tracer, a discussion is held on

¹ Tracer Methodology: Tips and Strategies for Continuous Systems Improvement, Joint Commission Resources, 2004

20 / NATIONAL COUNCIL MAGAZINE 2007 • VOLUME 3

27925National_CouncilCS2.indd 20 11/16/07 4:55:29 PM National Council member organizations share their successes and challenges in implementing quality improvement measures as well as best and promising practices and/or evidenced-based treatment for { people with mental illnesses and addiction disorders. }

Client-Directed, Outcome-Informed Approach Produces Results for Community Health and Counseling Services Mary Haynes, Clinical Director, Community Health and Counseling Services, Bangor, ME Contact: [email protected] Joanne is a 47 year-old woman diagnosed with bipolar disorder. When Community Health and Counseling Services began case management with her, she had been in mental health services most of her adult life, and was frequently suicidal. She was in despair, and felt helpless to change it. Charlotte, her case manager, had recently been trained in our Client-Directed, Outcome-Informed clinical approach, which provides a strengths-focused recovery pathway. She asked Joanne to complete a brief measurement tool rating how well she had been doing in the previous week on four scales. Joanne rated herself a 0.8 out of a possible 40, indicating serious distress. Charlotte wanted to validate Joanne’s distress, but she also knew from her training that it would likely be more effective to focus on Joanne’s heroism in the face of such adversity. Accordingly, she pointed out that Joanne was clearly having a tough time, but she couldn’t help but notice that in the interpersonal area of the measure, she was doing just a little bit better. Charlotte asked how that could be, given that everything else was so distressing for her. Joanne told her that she had been suicidal again the night before, and had discussed it with her husband. He encouraged her by Thus we are in a position to make immediate adjustments in our telling her that she was a strong woman, that he loved her, and found approach to maximize the likelihood of a successful outcome. The her delightful. She disagreed with him, but wanted to be the woman clinical conversations engendered by the use of the measures provide a her husband saw her as. roadmap to rapid recovery. The use of measurement tools, in combination with our clinical judgment and the continuing input of the client Charlotte and Joanne discussed what it means to be a strong person, and of others concerned about the client’s well-being, provide a vehicle which led to Joanne’s decision to start an exercise program. She for determining the effi cacy of continuing services. Thus, we are able couldn’t see herself as an emotionally strong woman, but she decided to closely tailor services to the specifi c needs of the client, and to make to at least become physically strong. They went to a women’s gym, services accountable both to clients and payer sources. This approach where Charlotte accompanied and supported Joanne, with permission is called “practice-based evidence” and was developed by Drs. Barry from the owner, until Joanne felt comfortable to go there by herself. One Duncan and Scott Miller at the Institute for the Study of Psychotherapy year later, she had built muscle, lost weight, and was no longer sui- (www.talkingcure.com). cidal. She was ready to end her case management services. Charlotte remarked that she would not have thought to have that initial conversa- Since implementing CDOI four years ago, CHCS has reduced length of tion with Joanne or known how to capitalize fully on her strengths, prior stay by an average of 60% across programs, the percentage of long to her training in CDOI. term clients in our community support program by 49%, and our client no show and cancellation rates by 30%. Implementation of this ap- Joanne and Charlotte’s experience together is not unusual at CHCS proach enabled us to confi dently assure our clients that recovery is not these days. CDOI de-emphasizes model and technique, as well as so- just a possibility, but a probability, and it ensures that we are account- called “evidence-based practices,” in favor of attending to the factors able in our use of public funding for mental health services. that research has shown to be most important — bringing out the heroism in clients, and the quality of the helping relationship. CDOI was initially developed for use with an outpatient psychotherapy population. CHCS is the fi rst agency in the world to apply this ap- Working with clients through their preferred method (called the proach systematically to community support services and group home client’s theory of change) and measuring client self-report of progress programs. We are now developing an initiative in which a network at regular intervals with real-time feedback to both clients and clini- of consumers, including those incarcerated, and both inpatient and cians, allows us to partner with clients to note early, small signs of outpatient providers, join together to bring a collaborative, focused, progress or deterioration. recovery approach to an entire community.

NATIONAL COUNCIL MAGAZINE 2007 • VOLUME 3 / 21

27925National_CouncilCS2.indd 21 11/16/07 4:55:32 PM Members Share Family Services of Western Pennsylvania Improves Services with the Toyota Model Donald H. Goughler, President & Chief Executive Offi cer; Annette C. Trunzo, Ph.D., L.C.S.W., Director of Research and Quality Improvement; Stephen Christian-Michaels, Chief Operating Offi cer — Family Services of Western Pennsylvania, Pittsburgh, PA Contact: [email protected] The Toyota Production System is a well-known 1. All work is highly specifi ed as to content, their proposed solutions and use data approach to enhancing quality in industrial sequence, timing, and outcome. from this scientifi c approach to clarify if the organizations. Family Services of Western Each time a team is formed around a prob- chosen solution improves the process and Pennsylvania in Pittsburgh, PA has adopted lem to be solved; its initial activity focuses if the goal is achieved. TPS as a strategy to improve delivery of behav- on identifying the existing need, value, goal At Family Services, Quality Council is a com- ioral health and other social services. and/or expectation related to the issue mittee representing staff from all service sites, of focus. The team determines what the Family Services of Western Pennsylvania is a foster parents, and individuals receiving current condition is and what factors have $21 million agency with 425 employees and services. The Council provides oversight and led to it by collecting available metrics to operates 35 social service programs in clinical, coordinates activities for continuous quality understand the situation. residential and community settings in a multi- improvement. Part of the Council’s function county area. Consequently, this dispersed and 2. Every customer connection must be direct was the implementation of a full evaluation diverse agency requires quality enhancement and there must be an unambiguous yes plan of the TPS process. Components of the strategies that are not static and that can be or no way to send requests and receive evaluation involve tracking the results of the adapted to a multi-faceted workplace. responses. TPS training, recording the number of staff The team identifi es all people, locations, across the agency that is involved in a VIP Family Services received funding for the inten- and steps that occur during the process team, and monitoring the outcomes to assure sive training required for its TPS implementa- that is being examined. They draw these that the procedures are effective. tion from the Jewish Healthcare Foundation, steps on a chart, showing connections which has adapted the Toyota model as To promote problem-solving using this among them while soliciting confi rmation Perfecting Patient Care© and uses it in health- method, the agency is publicizing specifi c from individuals who participate in the care settings to train nurses, physicians, and team activities and results across the agency process that the documentation of these quality managers in improving quality. Family through feature articles in the agency’s weekly connections is accurate. Services attended a system wide orientation e-newsletter as well as formal team presenta- conducted by the foundation, followed by 3. The pathways for every product and service tions at quarterly staff meetings. targeted training of 25 key individuals from all must be simple and direct. Family Services has eleven early success sectors of the agency. After subsequent train- This rule serves as a guiding discipline in stories with several VIP teams that have con- ing of agency staff by a newly hired quality im- redesigning a work process and involves ducted projects during the past ten months. provement manager, the quality department exploration of how to simplify the targeted These projects have included, streamlining created an organizing model called Values in process to add value to the customer and to training procedures, improving the process Practice teams to operate inter-agency quality decrease waste. This activity redefi nes long for credentialing, using technology to collect improvement projects. These teams adopt a held beliefs and challenges staff to look at daily work hours in the vocational workshop, practice change challenge and seek a better old processes in new ways and discover and reducing wait time for psychiatric service way to conduct the targeted practice by using alternatives for themselves. appointments. the four rules of the Toyota model. 4. Any improvement must be made in accor- In a recent team, the central intake system of the dance with the scientifi c method under the outpatient department was revamped to allow guidance of a teacher at the lowest possible for customers who are requesting appointments level in the organization to talk “live” with an intake worker, reducing by The organization fl attens the customary days the length of time it takes for an individual authority structure to enable individuals to be scheduled for an appointment. who are closest to an activity to propose change. Since the team includes those Successes such as these have a positive and who are involved in and familiar with the sometimes immediate impact on the quality process, they are able to specify the actions of service delivery and customer satisfaction. that need to be taken and may address the The implementation of TPS has engaged staff problem without seeking approval from and stakeholders throughout Family Services traditionally higher authorities. The caveat in working together to identify goals for quality to this process is that the team must test improvement and enhancement.

22 / NATIONAL COUNCIL MAGAZINE 2007 • VOLUME 3

27925National_CouncilCS2.indd 22 11/16/07 4:55:33 PM QI Scoring Tool Changes the Mindset and Performance at Fellowship Health Resources Kristen Guilfoyle, Director of Quality Improvement & Corporate Compliance, Fellowship Health Resources, Inc., Lincoln, RI Contact: [email protected] Fellowship Health Resources, which serves approximately 3,000 clients ance rate to each program to better track performance over time. During in seven states, has a Quality Improvement and Corporate Compliance the pilot process, the benchmark compliance rate was set for 85%. The Department, through which it imposes its expectations of unwavering tool is separated into sections which all hold varying amounts of weight to excellence. Responsible for implementing the organization’s quality the overall score. Sections related to the client record piece of the scoring improvement plan in over 50 sites, the department consists of a director, tool include psychiatric, medical, assessment, treatment planning, and manager, northeast region specialist and southeast region specialist. progress notes. A score is calculated for each section, which also must The team continually reviews and improves upon the organization’s meet the 85% compliance rate. Should a program achieve a score below systematic framework. It is through the program evaluation process benchmark, a follow-up review from the QI Team would take place within that the team has the ability to formally, and in more detail, review each the next three months to assess progress with the established Corrective program’s performance. This has evolved over the years into a more Action Plan. streamlined, data-driven process by which programs are held account- Initial reaction from program staff during the pilot phase of the scoring able for individual performance ratings. tool was that of apprehension, which negatively affected the introduction In previous years, the program evaluation process consisted of a visit to of the new program review process. Though the review process itself did each FHR program site on a semi-annual basis by a member of the QI not change, program directors were unhappy with the idea of a “grade” Team. Utilizing a checklist itemizing FHR policy and best practice stan- attached to each review. The QI Team worked closely with programs, dards developed by the QI Team, a review of client records, medications, educating staff on how the tool operates and why it is important to collect funds, and the environment of care was conducted. At the end of the visit, such performance data. During the fi rst reviews following implementa- fi ndings were reviewed with the program director. A narrative report was tion of the new scoring tool, the average compliance score was 90%, then developed outlining trends noted during the review. This process exceeding the required 85% compliance benchmark. Following each had been in place for some time and was received well by program staff. review, program staff was consistently pleased with the newly developed However, among the many downfalls of the narrative report was that tool. There evolved a more competitive spirit among peers to achieve the without actual data outlining performance, the QI Team was unable to highest score. Those programs that meet or exceed the benchmark score precisely assess performance. receive a certifi cate for posting within the program, along with recognition in the agency newsletter and website. The Program Review Scoring Tool was developed in September 2005 and uses internal and external benchmarks, as well as regulatory and best In 2007, the FHR Program Review Scoring Tool has yielded an average practice standards, to evaluate performance. Specifi cally for the PACT score of 96%. The benchmark compliance rate has increased to 90%, program model, a Fidelity Scale was added to the Scoring Tool integrating and the individual scores will soon become a part of the staff performance regulatory standards through the Dartmouth Assertive Community Treat- evaluation process for program directors. ment Scale. The premise of this Excel-based tool was to attach a compli-

Jefferson Center Uses Senior Reach to Proactively Reach Older Adults with Mental Health Needs Vicki K. Rodgers, Deputy Chief Operating Ofﬁ cer, Jefferson Center for Mental Health, Jefferson, CO Contact: [email protected] The aging of the U.S. population in the United States is expected to have a adults when effective and less costly services are delivered in a proactive man- major impact on general health service and costs and increase the need for ner rather than waiting for more serious symptoms to develop. mental health services. Early intervention for older adults will minimize the Jefferson Center for Mental Health and The Mental Health Center serving need for more costly and intensive services. However, many older adults with Boulder and Broomfield Counties partnered with Seniors’ Resource Center mental health needs do not self refer and are reluctant to access traditional to develop the Senior Reach program. The program is in five counties with mental health services so they do not come to the attention of the mental approximately 116,000 older adults. health and aging service delivery systems that could help them at an early stage of distress. It is more compassionate to manage care for these older Senior Reach was designed using research-based Gatekeeper models from Continued on page 24

NATIONAL COUNCIL MAGAZINE 2007 • VOLUME 3 / 23

27925National_CouncilCS2.indd 23 11/16/07 4:55:35 PM Members Share Maumee Looks Within to Reduce No-Show/Late Cancel Rates William Bierie, President & CEO, Maumee Valley Guidance Center, Deﬁ ance, OH Contact: [email protected] Managing the therapeutic encounter as an event Then while visiting the Institute for Healthcare However, in practice, access actually increased in time is mission critical for all behavioral health- Improvement website, I came across what has and clients and therapists have greater flexibility care providers and high no-show/late cancel become a perspective changing quote. “Every with “working clients in” when crises arise. Wait rates frustrate both the community service and system is perfectly designed to produce the times also decreased, enabling clients to receive business goals of the organization. The inability results it gets.” WOW! Reworded in the context a scheduled appointment earlier on from date to fill a scheduled appointment due to a no-show of our no-show/late cancel challenge, we had a of intake. Our earlier research indicated that a or late cancel means lost access to care for the system which was perfectly designed to produce critical indicator of no show behavior from intake community and, depending upon how your a 37-38% no show/late cancel rate. to first appointment was the time span between service is financed, a lost revenue opportunity. these two events. No show behavior doubled Imagine that! It might be more about us, the when the time between intake and first therapy Maumee Valley Guidance Center is a regional organization, than them, the consumers. We session went beyond ten working days. behavioral healthcare provider serving the began examining our internal processes and residents of Defiance, Fulton, Henry, and Wil- focused on our patient scheduling assumptions Medication management clients, seen in half liams counties of northwest Ohio. It features a and practices. IHI website links led us to examine hour appointment blocks, are now scheduled progressive behavioral healthcare environment innovative patient scheduling strategies such as two on the hour. Research into patient wait time involved in research on adults with severe mental “open access” and “same day” scheduling used tolerance suggested that a 20-minute wait was disabilities as well as in implementing advanced in primary care clinic environments and guided within a tolerance range for most clients. The first electronic medical records systems. Maumee our solution to reduce no show rates. client in reception was seen first and customer was experiencing a 37-38% no-show/late cancel support representatives notified physicians if With some modifications to these two scheduling rate for psychiatry and outpatient counseling and their second client was a no show. The physician strategies, we reduced our 37-38% no show/late a 50% no show/late cancel rate for nursing out- then has the option to extend the first client’s 30 cancel rate down to 15% within five weeks. patient visits. We spent numerous meetings over minute session or utilize the time for paperwork a significant period of time trying to understand Previously, staff were giving multiple future support to service. Considering the complexity and impact this phenomenon. appointments to clients resulting in booked-up of many of our clients, both physician and client schedules and reduced availability of clinicians. value the additional time if available. Billable Invariably our discussions centered on consumer And clients, feeling better one week, simply failed productivity increased by 13%. behaviors. Serving a large regional population of to show presumably confident that they had adults with severe mental disability, our explana- With a new perspective on scheduling, we’ve future appointments already scheduled. Unless tions focused on non-compliant behaviors and increased access, created greater flexibility in clinically indicated by specific conditions and other issues — all revolving around the character- meeting our clients’ evolving treatment needs, approved by the Clinical Practice Committee as a istics of the populations we serve. Consequently, increased productivity, and correspondingly group standard of care, only one future appoint- we spent hours on strategies to change consumer captured more revenue as well as reduced our ment is now scheduled for clients. behaviors. Groups focusing on non-compliant frustration with client behaviors seldom within behaviors, patient education, and other strategies Providing only one future appointment created our immediate control. made little to no impact on the problem. some concern for clinicians and some clients.

Jefferson Center, continued from page 23

Iowa and Washington. The program began in October 2005 and in fewer than emotional or behavioral problems, suicide risk, poor health, social isolation, two years, has become a significant part of the older adult community in these abuse or neglect, substance abuse problems, and reluctance or inability to counties. In the Senior Reach program, at least one-half of the older adults seek help on their own behalf or the absence of someone to seek help for them. referred could benefit from mental health services for depression and anxiety. From December 2005 through June 2007, more than 4,000 people have been trained by Senior Reach staff to be the “eyes and ears” of the community. In the education component of Senior Reach, staff and volunteers train community members and referral sources like Adult Protective Services, primary The outreach/treatment component of Senior Reach is supported by better care physicians, home health agencies, banks, grocery stores, and bus drivers infrastructure and collaboration between agencies including a single entry to be community partners. The community partners are trained to identify and point toll free number for older adults, and community partners are used refer older adults living independently who are experiencing any of the follow- to refer someone to the program and access mental health services using ing signs or symptoms of distress — a serious and persistent mental illness, a brief, focused treatment model. Seniors have appreciated the pragmatic

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27925National_CouncilCS2.indd 24 11/16/07 4:55:37 PM Rushford Provides Integrated Services for Dual Diagnosis Clients Amy Hickey, Manager – Development and Kathleen Whelan-Ulm, Vice President — Rushford Center Inc., Rushford, CT Contact: [email protected] In 2007, Rushford Center Inc., one of the “We look at clients individually to assess largest behavioral healthcare providers their needs,” said DeStefano. “The ﬁ rst in Connecticut, received a grant to begin step is conducting a comprehensive evalu- implementing the New Hampshire-Dart- ation that helps us determine the client’s mouth Integrated Dual Disorder Treatment primary diagnosis. Once that is completed, model. IDDT is an evidence-based practice the client is placed in a treatment program IDDT promotes that improves the quality of life for people that best meets his or her needs.” with co-occurring mental and substance In anticipation of the implementation of ongoing recovery from use disorders through integrated treat- new evidenced-based models like IDDT, ment and services. Rushford integrated its case management mental and substance The IDDT model promotes consumer and and clinical services in January 2007, which family involvement in service delivery, took about 12 months of careful planning. stable housing as a necessary condi- use disorders “We screened 250 of our clients on the in- tion for recovery, and employment as an tegrated teams for both mental health and expectation for many, according to Lou through four stages of substance abuse using the Modiﬁ ed Mini DeStefano, clinical director of adult mental and CAGE-AID,” said DeStefano. “We also health services for Rushford. DeStefano implemented these screening techniques interaction with works hand in hand with Bill Savinelli, with our admissions staff in order to more Rushford’s clinical director of adult addic- quickly identify clients that are dually diag- tion services, to ensure best practices are consumers and nosed. Our vision is to have a continuum being employed in delivering treatment to of care for co-occurring disorder clients the dual population. caregivers: engagement, from outpatient to intensive outpatient In the IDDT model, clients receive services and partial hospitalization programs.” at the same time from a multi-disciplin- persuasion, active IDDT promotes ongoing recovery from men- ary team that includes a clinician, case tal and substance use disorders through manager, prescriber, and a vocational treatment and relapse four stages of interaction with consumers specialist. IDDT utilizes treatment that and caregivers: engagement, persuasion, combines psychopharmacological, psycho- active treatment and relapse prevention. prevention. logical, educational and social interven- “Today, our case managers and clinicians tions. Some of the new methods Rushford are equally involved in decisions that is applying include the Stages of Change impact a client’s treatment plan, which model in conjunction with motivational has resulted in improved quality of care,” interviewing. said DeStefano.

approach of brief, focused therapy, and the privacy of assessment in To date, 86% of referrals from the community have accepted services and their homes. 4,000 people in the community have been trained on the needs of older adults. Senior Reach is a SAMHSA grant project and has rigorous data requirements for Senior Reach has resulted in better overall services to older adults in the com- producing outcomes described in the section for pertinent data. We have had munity, good research-based outcomes, less fragmentation in service delivery, significant (<.05) outcomes using this Senior Reach treatment model in: more people in the community who understand the special needs of seniors, a spirit of volunteerism to be the “eyes and ears” in the community to assist older Reduction in indicators of depression • adults, and better intra-agency collaboration. Improvement in hopefulness – optimism about the future • More information can be obtained from www.seniorreach.org and a DVD • Reduction in social isolation about the program to share with your community is available by e-mail to [email protected].

NATIONAL COUNCIL MAGAZINE 2007 • VOLUME 3 / 25

27925National_CouncilCS2.indd 25 11/16/07 4:55:38 PM Performance Measurement A Signature Approach to Outcomes Measurement Improves Recovery

Carl Clark, MD, Chief Executive Ofﬁ cer and P. Antonio Olmos-Gallo, PhD, Director of Evaluation & Research — Mental Health Center of Denver “As clinicians, we have historically used anecdotal data to inform clinical practice to promote recovery outcomes for consumers. With Recovery Markers, we now have longitudinal, empirical data to support our clinical judgment and decisions.”

Measuring our success in recovery requires tive services, aligns with MHCD’s operational instituting system change and promoting those of us in mental health service delivery to definition of recovery: “Recovery is a non-linear consumer recovery successes for MHCD. be more accountable to our communities and process of growth by which people move from to demonstrate the difference we make in the lower to higher levels of fulfillment in the areas Using Data to Inform System Change lives of the people we serve. of sense of safety, hope, symptom manage- The intent of MHCD’s measurement process ment, satisfaction with social networks, and is to improve clinical practices, rather than to The Mental Health Center of Denver received active/growth orientation.” (1) evaluate performance. Measurement is based the Community Provider of Excellence Award on a formative and summative process that from the National Council for Community In keeping with its progressive recovery-fo- creates a constant loop of client recovery infor- Behavioral Healthcare in 2005 for implement- cused philosophy, MHCD has developed a mation while providing empirical feedback to ing integrated, evidence-based approaches to “360-degree” process of recovery mea- recovery. surement, using environmental, clinical, and client-specific individual indicators. The “Denver Approach,” which encompasses The outcomes measurement process training, education, social, and arts programs, is proving to be a critical component in Sample Outcomes from the as well as employment and other rehabilita- MHCD Recovery Markers Inventory (RMI) (Based on 44 new intakes)

Compared to their situation at intake:

• 36.6% of the consumers had an improvement in their employment situation 1 year later

• Almost half of the consumers (47.6%) had an improvement in their active/growth orientation 1 year later

• 37% of the consumers had an improvement in their symptoms 1 year later

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27925National_CouncilCS2.indd 26 11/16/07 4:55:40 PM Recovery Markers Client History Report

assist in system transformation. The process one of four levels of service corresponding to health recovery using a Consumer Recovery promotes recovery at multiple levels within the where their need is the greatest. For instance, Measure (CRM). The CRM is a 15-item survey mental health system (consumers, clinicians, a consumer may have high needs in symptom which includes questions regarding active/ managers, and directors) and from multiple management but have low need in housing. growth orientation, hope, symptom interfer- view points (consumers and clinicians). MHCD administers the assessment at three ence, sense of safety, and social networks. and six months after admission, and every six Likert-type responses are measured on a 0 Tools for Holistic Measurement of Recovery months thereafter to match the consumer’s (strongly disagree) to 3 (strongly agree) scale. and Provider Effectiveness needs and keep him/her moving forward in Clinicians receive regular reports of con- To gather a holistic view of mental health recovery. sumer perceptions of progress in the various recovery, MHCD developed state-of-the-art domains to help them to be more responsive tools to assess recovery from the perspec- Every two months, case managers complete to consumer needs. (4) tive of both the clinician and the consumer. a Recovery Markers Inventory (RMI), which Psychometrics of these four recovery tools rates each consumer’s progress based on The Promoting Recovery in Mental Health were established using Item Response Theory his or her own goals in six survey areas: em- Organizations (PRO) tool is utilized once a (IRT) techniques and have proven to be highly ployment, education/learning, active/growth year to provide consumer evaluation of how reliable. (2) orientation, symptom interference, engage- the overall MHCD environment supports his ment, and housing. This tool is effective in or her recovery. Consumers interview peers to Initially, new consumers are administered identifying consumers who are having more assess MHCD staff, including case manag- a Recovery Needs Level (RNL) assessment, difﬁ culty than others and in determining in ers, therapists, psychiatrists, front desk staff, which rates them on a variety of clinical crite- which areas they need more help. (3) rehabilitation staff, and residential staff. ria. The RNL assesses a consumer’s current In addition to serving as a general needs status and progress in achieving his or her Approximately every six months, consumers assessment, the PRO survey was designed recovery goals. It then assigns the consumer to rate their own perceptions of their mental to help gain an understanding of what staff Continued on page 28

NATIONAL COUNCIL MAGAZINE 2007 • VOLUME 3 / 27

27925National_CouncilCS2.indd 27 11/16/07 4:55:43 PM A Signature Approach, continued from page 27

characteristics best support consumer recovery.(5) Recovery data reporting Data regarding consumers’ recovery outcomes is made user-friendly and accessible through online reports developed by MHCD for use in clinical decision-making by clinicians, managers, and directors. MHCD’s progressive, recovery-oriented outcomes measures are pivotal in providing the opportunity to look at clinical performance over time. In addition, the reports have allowed MHCD to make system changes that advance recovery for consumers. The Reaching Recovery Initiative at MHCD is currently working with other mental health centers to pilot the use of this data reporting system to increase understanding of data interpretation and to determine the type of training required for successful recovery outcomes for consumers. For more information about research on mental health recovery at MHCD, go to www.outcomesmhcd.com. For more information about the Reaching Recovery Initiative at MHCD, contact Roy Starks at 303.504.1721 or at [email protected].

The Mental Health Center of Denver is a private, not-for- proﬁ t, community mental health care organization Follow the leader providing comprehensive, recovery-focused services to more than 6,500 residents in the Denver metro area each year. The CEO, Dr. Carl Clark, was formerly the Medical Negley Associates, founded in 1960, is the leading Director of MHCD. In 1993, Dr. Clark was chosen as NAMI’s Exemplary Psychiatrist of the Year and in 2000, he was underwriting management firm serving the insurance elected Professional Man of the Year by the Colorado Busi- ness Council. Dr. Clark is also Assistant Clinical Professor needs of BEHAVIORAL HEALTHCARE and at the Department of Psychiatry at the University of Colo- SOCIAL SERVICE rado School of Medicine and the Second Vice-Chair of the agencies. We are proud of our role National Council for Community Behavioral Healthcare’s Board. P. Antonio Olmos-Gallo, PhD is the Director of in the development of innovative insurance policies Evaluation and Research at MHCD. He is also an adjunct designed to meet emerging coverage needs. We are professor at the Department of Psychology, University of Denver, where he teaches graduate level statistics and committed to providing outstanding service to our research design. 1 MHCD Recovery Committee (2004)

insured clients, and to the nationwide network of 2 Hambleton, R.K., Swaminathan, H., Rogers, H.J. (1991). Fundamentals of Item Response Theory, Newbury Park, CA: Sage.

3 A partial credit Rasch model was applied, suggesting good model fit (N = 2,108), including: Individual Response Theory (IRT): insurance professionals who market our products. person reliability = .75, item reliability = 1.00; Classical Test Theory (CTT): reliability = .78

4 A Rasch Rating Scale model was applied, suggesting good model fit (N = 525), including: IRT: person reliability = .83, item reliability = .96; CTT: reliability = .86

5 The PRO survey is in its pilot phase, where a trained consumer survey team is currently collecting data. Expected completion March 2008

388 Pompton Avenue • P.O. Box 206 • Cedar Grove, NJ 07009 Voice: 973-239-9107 • Fax: 973-239-6241 [email protected] • www.jjnegley.com

28 / NATIONAL COUNCIL MAGAZINE 2007 • VOLUME 3

27925National_CouncilCS2.indd 28 11/16/07 5:10:50 PM Today’s environment demands accountability: SPQM… NOT Executive Dashboard Providing from clinical outcomes to demonstrated, proven Key Indicator Measurement cost-effectiveness. JUST ANOTHER SOFTWARE David Lloyd and the SPQM Consultants will work closely with PROGRAM... your management team to help identify strategic quality service process outcomes/variances, compliance levels and AN ESSENTIAL performance measurement. MANAGEMENT Take the SPQM test drive and T ake a free SPQM test drive: Schedule a complimentary CONSULTATION unleash your company’s potential Internet-based consultation and SPQM report set today. 919-387-9892 or [email protected] TOOL!

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NATIONAL COUNCIL MAGAZINE 2007 • VOLUME 3 / 29

27925National_CouncilCS2.indd 29 11/21/07 1:17:02 PM Consumers and Families How Consumers STEP UP to Design a Truly Recovery-based Mental Health System

Daniel Fisher, MD, PhD, Executive Director, National Empowerment Center

Recently there have been spirited discussions The President’s New Freedom Commission that manner, the medical model is reinforced among consumers about what we want to mapped out the bold new vision of “a future and recovery becomes just another term for propose as a basic change in the mental when everyone with a mental illness would remission. health system. Several of us have proposed recover.” The Commission went on to state Secondly, for peer specialists to be reim- that legislation be passed to ensure that every that this vision could best be carried out by bursed, supervision needs to be carried out state and every community have reliable fund- transforming the system to a consumer-driven by “qualified mental health professionals,” ing for consumer-run support and advocacy system based on recovery. I want to see us groups similar to the independent living cen- carry out the vision but it is yet to be truly which means by traditionally trained clini- ters for people with other disabilities. I liked supported. Only piecemeal solutions have cians who have little understanding of peer the idea, but then I started to worry that those been attempted. To transform the system support or recovery. Instead of validating the centers would be marginalized or co-opted to a recovery-based one, C/S/Xs (consum- importance of lived experience, this type of as long as the mental health system remains ers/survivors/ex-patients) will need to almost supervision turns peers into junior clinicians. narrowly medical. I have concluded, and have completely redesign it. The first indication of this pitfall was revealed preliminary support from other leaders, that to me at a progressive mental health enter in as consumers, we need to redesign the whole An example of the failure of piecemeal solu- California several years ago. The administrator system and society from the bottom up, based tions lies in the use of peer support special- proudly introduced me to 13 newly hired peer on our lived experiences with mental health is- ists. Most people concur that peer support specialists. I was shocked to learn however sues. I believe that only by having a vision of a is a vital component of the spirit of recovery. that each was primarily checking people’s truly recovery-transformed system and society, Accordingly, Georgia led the charge among medication and had no opportunity to share will we ever see lasting and genuine change. states to make peer support a reimbursable their personal experiences. We agents of service. In order for the system to accept peer In 2007, 27 statewide consumer organiza- change should not underestimate the skill support as a service, it made severe changes with which the system is able to preserve tions and three National Technical Assistance to the concept of peer support and recovery. Centers united to form a broad-based national the status quo by absorbing the language consumer group called the National Coali- Recovery was broken down into a set of institu- of peer support and recovery into its existing tion of Mental Health Consumer/Survivor tionalized steps. The first step is that a person structure. That is why we are proposing a Organizations (www.ncmhcso.org). With this has to accept that he or she is mentally ill. genuine transformation of the system, which newfound unity and strength, the Coalition The condition is then defined as a permanent is designed and carried out by persons with needs a national agenda. deficit resulting in a chemical imbalance. In the lived experience who identify as C/S/Xs.

A consumer-driven system means one which is guided by people with a lived experience. We know better than anyone else what helps and what hurts in our recovery. Every significant administrative body in mental health needs to have significant participation by Consumers/ Survivors/Ex-Patients.

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27925National_CouncilCS2.indd 30 11/16/07 4:55:49 PM What Would a Consumer-driven, Trans- at the deepest levels. Underlying all these enter into discussions about the future we formed, Recovery-based System Look Like? new descriptions is an understanding that if want. We need to share and pool the best people are surrounded by people who believe information, experience and ideas we have First and foremost, a consumer-driven system in them and connect on the most human of for a new recovery-based system. means one which is guided by people with levels, then these periods of change are op- a lived experience. We know better than We need to take that knowledge and prin- portunities for growth. • anyone else what helps and what hurts in our ciples to the public and draw them into the recovery. For too long we have tried to educate Viewing these periods as opportunities need for a bottom up change. We need to decision makers. The time is coming when we instead of symptoms of an illness means that overcome the discrimination and discredit- will need to be those decision makers. This there is meaning in unusual thoughts and ing we are subjected to by tbe media. means that every significant administrative behavior. It means that these unusual aspects We need to collectively develop a compre- body in mental health needs to have signifi- of the person need to be understood and • hensive new set of proposals to genuinely cant participation by C/S/Xs. incorporated, not removed and eliminated. transform this system. This would be a type Young people today are particularly turned off A useful acronym for the changes that need to of national C/S/X white paper. by the concept of stamping out mental illness be made is STEP UP: as shown in the Icarus Project’s materials. • We should use that white paper an advo- Consumer-Driven Services, Training, Evalua- cacy tool and educate decision makers, A few of the innovative projects, which C/S/Xs tion & Policy: United for Power media, and public at every organizational have already piloted, are: level. S: Services and supports need to be con- • Five peer-run crisis respites — the Rose • We could pick the top 2-3 recommended sumer-driven House in New York is the most developed steps and push for success in those first. with a drop-in center, crisis respite for up to T: Training needs to be consumer-driven 5 people (at 1/5th the cost of a hospital), • Carry out all these steps with as broad- outreach to people’s homes at times of based participation as possible to ensure E: Evaluation and research needs to be crisis, and a warmline. “nothing about us without us” but also consumer-driven recognize the advantage of working Self-determination accounts in Florida, • through a national consumer group such headed by consumer Patrick Hendry, which Policy and planning needs to be con- as the National Coalition of Mental Health P: give decision-making power to the C/S/Xs. sumer-driven Consumer/Survivors. • The Consumer Quality Initiative, a peer-run These changes need to be accompanied by evaluation team in Massachussetts (www. a shift in the understanding of the problems Daniel Fisher is a psychiatrist who has recov- cqi-mass.org). known as mental illness and the best way to ered from schizophrenia. He is a role model help people recover. • Peers working as peer specialists (they for others who are struggling to recover, and are setting up their own national group, was a member of the White House Com- Those of us with a lived experience have National Association of Peer Specialists or mission on Mental Health. He is presently been constructing a new paradigm over NAPS) and a variety of other jobs such as the last 35 years. We need to be the people Executive Director of the National Empower- peer bridgers. who deﬁ ne these problems based on our ment Center and a practicing psychiatrist experience, not on some outdated textbook. • Drop-in-centers and recovery centers in at Riverside Outpatient Clinic, Wakeﬁ eld, We need to instill hope at the very outset of a almost every state and county. MA. Dr. Fisher conducts workshops, gives person’s recovery journey. keynote addresses, teaches classes, and • Consumers working as personal care as- organizes conferences for consumers/survi- The consumer movement started as a civil sistants for their peers in Oregon. vors, families, and mental health providers rights movement to right the wrongs that • National Coalition of Mental Health to promote recovery of people with labeled are perpetrated against people labeled with Consumer/Survivor Organizations with mental illness by incorporating the mental illness. In the last 15 years, this has (www.ncmhcso.org) with 27 statewide principles of empowerment. He has been also become the recovery movement. Instead networks as members. featured on many radio and television of describing the problems as mental illness, programs, including CNN Special Report. we who experience these problems prefer Next Steps He is the recipient Mental Health America’s terms such mental health issues or life chang- • C/S/Xs and advocates need to seriously Clifford Beers Award and the Bazelon Center ing experiences. Dr. John Weir Perry described discuss what we would like to see in a these as periods of reorganization of the self redesigned system and society. We need to for Mental Health Law’s advocacy award.

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27925National_CouncilCS2.indd 31 11/16/07 4:55:50 PM Youth Community Collaboration Helps to Target Early Detection and Intervention for Psychosis

Donna Downing, MS, OTR/L, Director of Training, Early Detection and Intervention for the Prevention of Psychosis Program; Elizabeth Spring, RN, BSN, MS, Deputy Director, Michigan Prevents Prodromal Progression

There is a unique treatment research pro- inability to maintain friendships, and diffi - them and the PIER staff would develop and gram in Portland, Maine called the Portland culty attaining life goals, such as completing lead to early referrals of “at risk” youth. The Identifi cation and Early Referral Program, school and working. It has been estimated community education presentations and out- PIER. PIER’s mission is to identify young that the cost to society can be higher than reach activities were designed to give specifi c people between the ages of 12 and 25 who $10 million over the course of an individual’s information about early signs of psychosis, to might be at risk for psychosis in the Greater lifetime, especially if they have schizophre- network with community members outside Portland area, and then offer appropriate nia. When we consider that psychosis can the mental health system, and to demystify treatment. In August 2006, the Robert Wood derail a young person’s life permanently, it and destigmatize mental illness. These train- Johnson Foundation recognized PIER, under is hopeful to think that offsetting an illness ings offered important information about the the direction of Dr. William McFarlane, for its process early in its development is possible. biology of the brain, which raised awareness pioneering work in the fi eld of early interven- PIER’s outreach effort to educate community about brain disorders versus personality tion for psychosis by awarding a signifi cant members was based on initiatives developed disorders. They also offered resource and grant to replicate the program in other loca- in Australia, Norway, and Denmark — where referral suggestions for stakeholders. The tions in the U.S. the focus was to interrupt the progression result of PIER’s outreach was that school Following an application process, four sites of schizophrenia and other severe psychotic professionals, teachers, health profession- were chosen in April 2007 to replicate the PIER disorders. PIER’s goal was to improve out- als, parents, and mental health practitioners Program in Sacramento, California; Salem, comes and prevent the onset of the psychotic became familiar with PIER’s message, knowl- Oregon; Washtenaw County, Michigan; and phase of those illnesses. The Australian and edgeable about the importance of making Glen Oaks, New York. PIER and the four other Norwegian initiatives identifi ed stakeholders early referrals as a deterrent to disability, and sites are now part of a replication study known outside of the mental health system who learned how to make referrals. as the Early Detection and Intervention for the could participate in early detection and show PIER has been designed to respond Prevention of Psychosis Program or EDIPPP. commitment to the effort. Stakeholders were quickly to referrals and to partner with young recognized as people who were in a unique persons and their families from the start — through the intake assessment process and then through various client-centered Psychotic illnesses are disabling and expensive. It has psychosocial interventions, such as family been estimated that the cost to society can be higher than psychoeducation, counseling, supported education, and supported employment. $10 million over the course of an individual’s lifetime, When appropriate, clients have also had { especially if they have schizophrenia. } occupational therapy assessments to better understand cognitive and functional diffi culties —results and recommendations are then position to identify young people demon- shared with the family and treatment team. Starting in December of 2000, the multi- strating the early mental changes predictive disciplinary PIER team began educating Most participants have been on low-dose of a developing psychosis. Stakeholders community stakeholders about the early medications, but overall, their symptoms were also “the general public.” The PIER signs of psychosis. Psychotic illnesses, such have subsided as they and their families have team made the assumption that certain as schizophrenia, are known to be disabling learned to keep stress low and identify early groups of professional and lay people spent and expensive in multiple ways. There is a signals of symptom recurrence. Research has more time with teens and young adults, and tremendous cost to individuals with these ill- been an important component of the program would therefore notice early symptoms and nesses, as well as to their families and com- because much still needs to be learned about respond more quickly. munities, e.g., lost productivity, increased the early phases of illness, what works in family stress, increased physical illnesses, It was reasoned that if specifi c community terms of interventions, and what individuals diminished self-esteem, increased depen- professionals were offered information and and their families need. The result is that the dency, repeated need for hospitalizations, support, collaborative relationships between majority of young people who have participated in the program have stayed in school,

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27925National_CouncilCS2.indd 32 11/16/07 4:55:52 PM graduated, held jobs, maintained relationships, participated in extra-curricular PIER’s community outreach has helped school professionals, activities, and set goals for the future. teachers, health professionals, parents, and mental health The M3P (Michigan Prevents Prodromal practitioners became knowledgeable about the importance of Progression) Program is one of the EDIPPP replication sites and is located in the { making early referrals as a deterrent to disability. } diverse community of Washtenaw County, Michigan. M3P prepared for outreach M3P is a replication site, and therefore uses activities by completing a community mapping the same content for its outreach materials tool, which allowed it to prioritize efforts. and messages to audiences that PIER and the other program sites use. An important Community outreach started in the spring of part of the research is to better understand 2007 and to date, has reached seven public what messages work with what audiences in high schools, six middle schools, several different communities, especially in culturally primary care physicians and nurse managed diverse communities. The EDIPPP “youth clinics, the local community college, as well brand” bookmarks are visually appealing as two major universities and two major and carry simple messages about getting health systems. In most instances, outreach help early and recognizing the early warning to a school involves a minimum of two to signs that “something’s not quite right.” To three visits, fi rst with the counselors or social date, these bookmarks have been instru- workers, followed by the administrators and mental in helping community members of teachers, and frequently, a request to meet all ages gather basic information about the with various student groups. Outreach efforts importance of dealing with symptoms early, have extended beyond the schools to include along with going to the website to gather student advocacy centers, churches, multi- further information. cultural groups, the local National Alliance for Mental Illness chapter, police, campus If most citizens can understand that there are security staff, resident assistants, the local very early signals that point to brain changes, health department, veteran services, and then perhaps more individuals will get help county administrators. early and avoid a major mental illness. Part of M3P’s strategy is to create extensive and inclusive outreach opportunities. Outreach Donna Downing, M.S., OTR/L is Direc- targets include any professional or community tor of Training for the EDIPPP Study, group that encounters those aged 12 to 25. overseeing the clinical functions of each When reaching out to a wide variety of com- replication site. She served as the fi rst munity members, it is important to tailor the team leader of the PIER Program, from information presented, including the develop- 2000-2006. She has worked in various ment of “leave behind” materials. For example, psychiatric in-patient and community »EARLY SIGNS OF PSYCHOSIS what one would present to a group of teachers settings throughout her career and has or counselors would be different from what taught at the university level. Her area of In combination… is presented to hospital staff, students or the expertise is Family Psychoeducation. police. The most effective leave behind material e Being fearful for no good reason Elizabeth Spring, R.N., B.S.N, M.S., Deputy has been the “youth brand” bookmark, which e Jumbled thoughts and confusion includes the early warning signs of early psycho- Director of M3P, has training and expertise sis and program information. When crafting a in health promotion, prevention, engag- e Feeling “something’s not quite right” ing at risk populations and program message, M3P considers the age of the target e development and implementation. She Declining interest in people, population, as well as the circumstances activities, and self-care under which the community group encounters is also a part-time faculty member at them. The community response to date has Washtenaw Community College, teaching e Hearing sounds/voices that are not there been remarkable. A local school principal has mental health nursing and has an adjunct e Trouble speaking clearly requested weekly M3P onsite offi ce hours for appointment at the University of Michigan School of Nursing. support and screening of students. This is a l Don’t ignore the early symptoms! model that truly focuses on health promotion www.preventmentalillness.org and secondary prevention services.

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27925National_CouncilCS2.indd 33 11/16/07 4:55:54 PM Youth Improving Engagement with Youth and Families when Treating Mental Health Difﬁ culties Samira B. Ali, MSW, Advocate Supervisor, Court Appointed Special Advocate; Mary A. Cavaleri, PhD, LCSW, Post Doctoral Fellow, Mount Sinai School of Medicine; Mary M. McKay, PhD, LCSW, Professor of Psychiatry and Community Medicine, Mount Sinai School of Medicine

Evidence-based phone and in person engagement strategies which aim to reduce potential barriers to care have resulted in about 448 more children attending treatment and decreased the number of treatment dropouts.

Background ers such as stigma, mistrusting providers, and age increase of 14% in the rate of attendance Service underuse is a major problem confront- being blamed for their child’s diffi culties19,20, at child mental health intake appointments ing the child and adolescent mental health sys- and to instead utilize alternate sources of care across 12 agencies serving predominantly tem, as indicated by a set of studies in which instead of formal mental health services21. low-income children and families of color (the 11% to 36% of youth in need of treatment equivalent of 448 more children attending 1,2 Engagement Strategies were not engaged in services while 35% to 32 In spite of this, multiple service delivery efforts treatment) , as well as decreasing the number 75% of the children who were initially engaged which address these barriers to care appear to of treatment dropouts29. in treatment dropped out prematurely3,4. Ser- be effective at improving service use, especially vice underutilization appears to be particularly Yet although these engagement strategies among youth of color. For example, intensive 5,6 pronounced among children of color , espe- phone engagement and letter reminders for have shown much promise, delivering these 7 cially if they are impoverished , despite the fact appointments in the initial stages of treatment techniques in real world settings has been that their risk of being affl icted with mental have been shown to be effective for engaging diffi cult because there is relatively little guid- health diffi culties is greater than that of Cauca- families and decreasing rates of premature ance given to providers as to how to admin- 8,9 sian youth of higher socioeconomic status . termination22-24. Particularly, phone engage- ister these interventions32. Moreover, there Consequently, only a small fraction of children ment is most benefi cial when the conversation is a severe lack of systematic dissemination and adolescents with mental health diffi culties goes beyond intake procedures and discusses methods within the fi eld in general33,34, and receive adequate care, and ethnic minority potential diffi culties and past experiences child mental health in particular35. Thus, in youth from low-income families are particularly 25 in similar settings . Moreover, research addition to implementing successful evidence- unlikely to receive needed services6. indicates that community representatives based strategies, transporting such methods Impediments to Service Utilization serving as advocates for the family have been throughout the child mental health system Research investigating the disparity between involved in an attempt to decrease the stigma 26,27 presents multiple challenges. service need and utilization has revealed an of seeking help . In closing, it is clear that youth and families association between service underuse and In addition, Dr. Mary McKay and colleagues multiple child, parent, and family-level factors have developed a series of evidence-based are encumbered by a vast array of logistical, ranging from the child’s gender, parental engagement strategies delivered by telephone perceptual, and provider impediments, which pathology, and low socioeconomic status 9-14, and in person which identify and discuss nega- in addition to child, parental, and family- to perceptual factors such as parental mistrust, tive perceptions and prior experiences with level factors, results in the underutilization of concerns about stigma, and fears of losing mental health providers and care; explore and mental health services for youth. Therefore, it custody of their children or being blamed aim to reduce potential barriers such as time is imperative that effective interventions which for the child’s illness15,16 to larger logistical constraints, transportation and childcare is- improve service use be disseminated through- and provider barriers including transporta- sues; clarify the roles of the agency and mental out the child mental health system in order to tion, childcare diffi culties, waiting lists, and health providers; and establish a founda- improve the health and well-being of children 17,18 insuffi cient/lack of insurance . Low-income tion for a collaborative relationship between with mental health diffi culties. children and families of color are thought to be provider and family25, 28-31. The use of these particularly apt to experience perceptual barri- techniques has been associated with an aver-

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27925National_CouncilCS2.indd 34 11/16/07 4:55:56 PM 10. Ringel, J.S. & Sturm, R. (2001). National estimates of mental health Koren, P. & Friesen, B. (1998). Improving access to children’s mental health utilization and expenditures for children in 1998. Journal of Behavioral Health services: The Family Associate approach (pp. 581-609). In M. Epstein & K. Services & Research, 28, 319– 333. Kutash (Eds.). Outcomes for children and youth with emotional and behav- Samira Ali, MSW is a Supervisor for Court ioral disorders and their families: Programs and evaluation best practices. 11. Attar, B.K., Guerra, N.G., Tolan, P.H. (1994) Neighborhood disadvantage, Pro-Ed., Inc: Austin, TX. Appointed Special Advocate in New York City. stressful life events, and adjustment in urban elementary-school children. Journal of Clinical Child Psychology, 23, 391– 400. 27. McCormick, A., McKay, M.M., Gillming, G., & Paikoff, R. (2000). Involving She is also a research assistant with Dr. Mary families in an urban HIV preventive intervention: How community collaboration 12. Zwaanswijk, M., Van der Ende, J., Verhaak, P.F., Bensing, J.M., Verhulst, addresses barriers to participation. AIDS Education and Prevention, 12, 1-9. Mckay’s research lab. Her research interests F.C. (2003) Factors associated with adolescent mental health service need and include HIV interventions for adolescents and utilization. Journal of the American Academy of Child & Adolescent Psychiatry, 28. McKay, M.M., McCadam, I., & Gonzales, J. (1996). Addressing the barriers 42, 692–700. to mental health services for inner-city children and their caretakers. Com- high-risk populations, barriers to mental munity Mental Health Journal, 32, 353-361. 13. Griffi n, J.A., Cicchetti, D., Leaf, P.J. (1993). Characteristics of youths identi- health care, and increasing services to children fi ed from a psychiatric case register as fi rst-time users of services. Hospital & 29. McKay, M.M., Nudelman, R., McCadam, K., & Gonzales, J. (1996). Community Psychiatry, 44, 62 –65. Evaluating a social work engagement approach to involving inner-city children in foster care. and their families in mental health care. Research on Social Work Practice, 14. Wu, P., Hoven, C.W., Bird, H., Moore, R.E., Cohen, P., Alegria, M. (1999). 6, 462-472. Mary A. Cavaleri is currently a Post Doctoral Depressive and disruptive disorders and mental health service utilization in children and adolescents. Journal of the American Academy of Child & 30. McKay, M.M., Stoewe, J., McCadam, K. & Gonzales, J. (1998). Increasing Fellow at Mount Sinai School of Medicine. She Adolescent Psychiatry, 38, 1081– 1090. access to child mental health services for urban children and their care givers. Health and Social Work, 23, 9-15. holds a PhD in Clinical Social Work from New 15. Starr, S., Campbell, L.R., & Herrick, C.A. (2002). Factors affecting use of the mental health system by rural children. Issues in Mental Health Nursing, 31. McKay, M.M.& Bannon, W.M. (2004). Engaging families in child mental York University, where she has studied barriers 23, 291-304. health services. Child and Adolescent Psychiatric Clinics of North America, to health and mental health services among 13, 905-921. 16. Kopiec, K., Finkelhor, D., & Wolak, J. (2004). Which juvenile crime victims vulnerable populations including inner-city get mental health treatment? Child Abuse & Neglect, 28, 45-59. 32. Cavaleri, M.A., Gopalan, G., McKay, M.M., Appel, A., Bannon, W.M., Bigley, M.F., Fazio, M., Harrison, M., Nayowith, G., Salerno, A., Sher, T., & Thaler, S. youth, families of color, and adults affl icted 17. Bannon, W.M. & McKay, M.M. (2005) Are barriers to service and parental (2006). Impact of a learning collaborative to improve child mental health preference for service related to urban child mental health service use? service use among low-income urban youth and families. Best Practices in with HIV. Families in Society, 86(1), 30-34. Mental Health, 2(2), 67-79. Dr. McKay is a Professor of Psychiatry and 18. Harrison, M.E., McKay, M.M., & Bannon, W.M. (2004). Inner-city child 33. Hoagwood, K., Burns, B.J., Kiser, L., Ringeisen, H., & Schoenwald, S.K. mental health service use: The real question is why youth and families do not (2001). Evidence-Based Practice in Child and Adolescent Mental Health Community Medicine. She directs a large use services. Community Mental Health Journal, 40(2), 119-131. Services. Psychiatric Services, 52, 1179-1189.

research lab focused on inner-city mental 19. Breland-Noble, A.M., Bell, C., & Nicolas, G. (2006). Family ﬁ rst: The 34. Schoenwald, S.K., & Hoagwood, K. (2001). Effectiveness, transportability, development of an evidence-based family intervention for increasing participa- and dissemination of interventions: What matters when? Psychiatric Services health services research and family and tion in psychiatric clinical care and research in depressed African American 52, 1190-1197. community-based prevention and intervention adolescents. Family Process, 45(2), 153-169. 35. McKay, M.M.: Collaborating with consumers, providers, systems and research. Her research lab currently consists 20. Schraufnagel, T.J., Wagner, A.W., Miranda, J., & Roy-Byrne, P.P. (2006). Treat- communities to enhance child mental health services research in Collaborative ing minority patients with depression and anxiety: What does the evidence tell Research to Improve Child Mental Health Services. Edited by Hoagwood K, of approximately 65 staff members, almost us? General Hospital Psychiatry, 28, 27-36. in press.

exclusively staff of color with substantial exper- 21. McMiller, W.P. & Weisz, J.R. (1996). Help-seeking preceding mental health tise in conducting community-based research. clinic intake among African-American, Latino, and Caucasian youths. Journal of the American Academy of Dr. McKay is also the recipient of two career Child & Adolescent Psychia- try, 35(8), 1086-1094. scientist awards from the National Institute of 22. Kourany, R.F., Garber, Mental Health. Dr. McKay is also the Assistant J., & Tornusciolo, G. (1990) Improving ﬁ rst appoint- Director of Social Work in Psychiatry at the ment attendance rates in Mount Sinai School of Medicine. child psychiatry outpatient clinics. Journal of the American Academy of Child References and Adolescent Psychiatry, 29, 657-660. 1. Harrison, M.E., McKay, M.M., & Bannon, W.M. (2004). Inner-city child mental health service use: The real question is why youth and families do not 23. MacLean, L.M., use services. Community Mental Health Journal, 40(2), 119-131. Greenough, T., Jorgenson, V., & Couldwell, M. (1989). 2. Wu, P., Hoven, C.W., Cohen, P., Liu, X., Moore, R.E., Tiet, Q., Okezie, N., Wicks, Getting through the front J., & Bird, H.R. (2001). Factors associated with use of mental health services for door: Improving initial depression by children and adolescents. Psychiatric Services, 52(2), 189-195. appointment attendance at a mental-health clinic. 3. Kazdin, A.E. & Mazurick, J.L. (1994). Dropping out of child psychotherapy: Canadian Journal of Com- Distinguishing early and late dropouts over the course of treatment. Journal of munity Mental Health, 8, Consulting and Clinical Psychology, 62, 1069-1074. 123-133.

4. Luk, E.S.L., Staiger, P.K., Mathai, J., Wong, L., Birleson, P., & Adler, R. 24. Szapocznick, J., Perez- (2001). Children with persistent conduct problems who dropout of treatment. Vidal, A., Brickman, A.L., European Child & Adolescent Psychiatry, 20, 28-36. Foote, F.H., et al. (1988). Engaging adolescent 5. Garland, A.F., Lau, A.S., Yeh, M., McCabe, K.M., Hough, R.L., & Landsverk, drug abusers and their J.A. (2005). Racial and ethnic differences in utilization of mental health families in treatment: a services among high-risk youths. The American Journal of Psychiatry, 162(7), strategic structural systems 1336-1343. approach. Journal of Consulting and Clinical 6. Lindsey, M.A., Korr, W.S., Broitman, M., Bone, L., Green, A., & Leaf, P.J (2006) Psychology, 56, 552-557. Help-seeking behaviors and depression among African American adolescent boys. Social Work, 51(1), 49-58. 25. McKay, M.M., Hib- bert, R., Hoagwood, K., 7. Department of Health and Human Services. Mental Health: A Report of the Rodriguez, J., Murray, L., Surgeon General, 1999: Washington, DC: U.S. Government Printing Ofﬁ ce. Legerski, J., Fernandez, D. (2004). Integrating evi- 8. Kataoka, S.H., Zhang, L., & Wells, K.B. (2002). Unmet need for mental dence-based engagement health care among U.S. children: Variation by ethnicity and insurance status. interventions into “real The American Journal of Psychiatry, 159(9), 1548-1555. world” child mental health settings. Brief Treatment 9. Padgett, D.K., Patrick, C., Burns, B.J., Schlesinger, H.J., Cohen, J. (1993). The and Crisis Intervention, 4, effect of insurance beneﬁ t changes on use of child and adolescent outpatient 177-186. mental health services. Medical Care, 31, 96-110. 26. Elliott, D., Koroloff, N,

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27925National_CouncilCS2.indd 35 11/16/07 4:55:58 PM Technology Clinical Services and the Electronic Health Record: Cost, Quality, and Access

Jodi Mahoney, Chief Operating Ofﬁ cer & Diane Farrell, Director of Clinical Operations — North Central Behavioral Health Systems, Inc.

The EHR has enhanced our quality of care by generating the ability to have an immediate response to any clinical issue.

It is our responsibility as community achieve operational goals identifi ed Clinical staff have identifi ed that behavioral healthcare providers to in our strategic plan. And we were treatment is more collaborative when assure that resources allocated to able to infl uence and control all three the EHR is updated immediately and our system are maximized to deliver variables by utilizing an EHR. staff can review consumer progress the highest volume and quality of provided by all treatment providers services feasible. At North Central Cost involved in the consumer’s care. Behavioral Health Systems, process Our return on investment analysis Where once care providers operated improvement is an ongoing effort that focused on a review of four functional in silos, each department working has demonstrated positive achieve- areas that could be measured quan- toward its own specifi c goal, we now ment of fi scal, operational, and clini- titatively and have a direct impact on operate within a system that has cal service quality objectives. cost: productivity, human resources, broken down the barriers and works fi nance, and compliance. In North toward the common goal of consumer In conjunction with implementation Central’s EHR implementation and recovery. of an electronic health record, North use, analysis of standard perfor- Central measured the three inter- Utilizing the EHR provides the op- mance benchmarks revealed that related variables of cost, quality, and portunity for the consumer to drive the cost variable was controlled and access. Many providers have achieved care. Sessions can be used to review two of the three variables, but few unit costs were signifi cantly reduced a consumer’s progress towards goals, show mastery of all three — some within an environment of increased complete progress notes with the providers may achieve the ability to client satisfaction. consumer, and establish new goals. deliver high quality services but at a Quality During the session the consumer can high unit cost. Then the provider has The current healthcare environment evaluate progress within the treat- long waiting lists, which limits access has an expectation of immediate re- ment process and ensure that their to those quality services. sponses to one’s needs. The EHR has viewpoint is included in the progress note. At North Central, our leadership team enhanced the quality of care at North challenged this conventional wisdom, by generating the ability to have an Improving the quality of clinical understanding that controlling only 2 immediate response to any clinical supervision further enhances quality of the 3 variables was not suffi cient to issue. of care. The EHR supports an environ-

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27925National_CouncilCS2.indd 36 11/16/07 4:56:00 PM ment that allows for concurrent documentation, provides for the use of reports to assist staff in developing a successful work pattern and caseload management, and ensures that the supervisor has the ability to provide timely case direction. Furthermore, caseload management via reports allows management staff to identify diagnostic patterns of new admissions to assure the appropriate service mix is being offered to meet consumer needs. The opportunities within the EHR for controlling the quality variable are derived from the system’s ability to generate reports, end duplicative work, and track sessions, all of which contribute to the care provider’s ability to focus on treatment, thus improving the quality of care. Access In October 2006, North Central eliminated its waiting list. Leadership concurred that the lack of service access was detrimental to our community and compromised our mission. North Central implemented changes in our operations, which allowed us to work down the waiting list and schedule new clients at the same time. In May 2007, North Central formed a process improvement workgroup that focused on redesigning the access process. North Central Behavioral Health Systems, Inc. is The Access to Services Workgroup identifi ed 3 outcomes for a community behavioral health services provider offering a broad range of mental health and substance the access redesign: abuse services to a seven county area. Jodi Mahoney 1. Initial call to clinical appointment should occur within 7 maintains responsibility for managing and directing business days. all functions related to the clinical services, marketing, human resources, support services, and information 2. Reduce upfront dollar investment in access process. services/technology. She has 10 years experience in the behavioral health field and has held positions as Front 3. Reduce the no show rate for initial appointments from Office Supervisor, Manager Support Services, Director 28% to 17% of Health Promotion and Educational Services, Assistant To date, the fi rst time appointments have doubled in Vice-President/Operations as well as her current availability. Total caseload has increased by 10%. Access position of Vice-President/Chief Operating Officer. to services occurs within 5 business days of the initial call Diane Farrell is the Director of Clinical Operations for and the no show rate for initial appointments has dropped North Central. Her responsibilities include supervision from 28% to 18%. and directing a full continuum of services for outpatient mental health and substance abuse treatment in As our team reviewed the organization’s Key Performance the seven counties. She has more than 20 years Indicators, we realized that the outcomes achieved support experience in the community setting. She has overseen the conclusion that the three variables of cost, quality, and the development and implementation of adult and access have been impacted by North Central’s use of an children’s community based services, and worked EHR. Through management of these interrelated variables, towards implementing a service continuum that meets North Central has achieved an ROI that supports the orga- the consumer’s need in a fee for service system. nization’s clinical quality/service improvement objectives, fi scal objectives, and mission enhancement objectives.

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27925National_CouncilCS2.indd 37 11/16/07 4:56:01 PM Technology Connected Care in a Connected World

Kevin Scalia, Executive Vice President, Corporate Development, Netsmart Technologies

Over the last several years, behavioral foundation to a larger goal – to provide a provider organization. For example, healthcare providers have instituted connected care. many agencies realize immediate a variety of programs and initiatives revenue gains by capturing and billing In its simplest terms, connected care is designed to improve access to and qual- for services that had previously gone sharing clinical information within your or- ity of care for clients. These have taken unrecorded. ganization, with other care providers, and many forms, including “no wrong door,” with clients themselves — all in an effort With the appropriate system, you can “integrated client care” and others. to provide the highest quality care. enhance service utilization and profi t- The reality is that care is becoming ability by program and make fact-based Besides improving the continuity of care more complex, and many behavioral decisions on how to optimize resources. and promoting quality care, connected health providers believe they will never Specifi cally on the clinical side, clinical care reduces medication errors, im- have the funding they feel is required directors can review case information proves effi ciency and, most importantly, to deliver the level of care they think and have more productive case reviews enables consumers to be more involved is truly needed. Trained to maximize with clinicians. in their care process. human potential, clinicians fi nd From an external perspective, care is themselves pushing paper instead of Connected Care Impacts Internal no longer provided just in the offi ce serving clients in need. Therefore, a and External Processes or even just by a single agency. In the breakthrough is required in the way The initial step toward a connected care past, it was easy to locate and talk with care is delivered. Connected care is environment is to link and automate one of your agency’s clinicians -- you that breakthrough. For the past several internal clinical processes with schedul- simply walked down the hall to fi nd years, much of the discussion has been ing, billing/fi nance and other internal them at their desk or meeting with a around electronic health records. While processes and systems. Automating key client. Now, in many cases, clinicians EHRs are critical to ensuring clinical clinical functions and sharing the data spend the majority of their time out of processes are automated, they may with other departments can provide the offi ce meeting with consumers at not be enough. The EHR is only the exponential process improvements to locations and times most convenient

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27925National_CouncilCS2.indd 38 11/16/07 4:56:04 PM Sharing clinical data throughout the care process – both internally as well as externally between independent agencies and with the client will help to promote { quality care, reduce medication errors, and improve efﬁ ciency. }

to them. Clinicians and case managers In a connected care environment, care providers will benefi t greatly from can work disconnected in the fi eld and the incorporation of e-prescribing for this type of interaction. then synchronize their case record upon outpatients and order entry and elec- Making Connected Care a Reality returning to the offi ce, thus eliminating tronic medication administration record How can you prepare for connected the need for error-prone and time-wast- (eMAR) systems for inpatient facilities care? Take an introspective look at your ing re-keying of data. can help reduce polypharmacy, prevent current processes for collecting and medication errors, and effectively track In this more fl uid environment, it is vital managing information, both within your a consumer’s medication history as they to share clinical data throughout the organization and with other care provid- move through different areas of care. In care process – both internally as well as ers who interact with your consumers. fact, many agencies see rapid reduction externally between independent agen- As you do, think about ways clinical in polypharmacy by being able to review cies and with the client. information can be shared more ef- all medication orders in the agency on fi ciently. And think about it not just from For example, if a consumer needs to one screen. your perspective, but from the perspec- be referred to an inpatient facility, Client Involvement in Connected Care tive of the clients you serve each day. how long does it take to create the Clients and their families are becom- referral? Are you able to send medica- Also, be sure your technology platform ing much more proactively involved tion information and other important is fl exible and adaptable enough to sup- and engaged in their care. One newly clinical data to that facility quickly and port this growing trend, and consider developing aspect of connected care is effi ciently? And, when the client is connected care as you do your long-term a secure client web “portal.” Accessible discharged and referred back to an out- strategic planning. via a browser from home or a public patient program, do they arrive before Internet access point, clients could use Let the transformation begin! the discharge summary? the portal to schedule appointments, A true connected care environment also review and comment on their treatment Kevin Scalia has executive includes a health information infrastruc- plans, view current medications and management responsibility ture that treats the clients’ physical track usage, and communicate with for marketing, business as well as mental health by support- their care providers. Through features development, strategic planning, ing connections with other agencies like online journals, clients can record and mergers and acquisitions for involved in the care process, including their feelings prior to a scheduled ses- Netsmart Technologies, which public health and primary care facili- sion, and if required, list psychiatric provides clinical, fi nancial, and ties. This is achievable, but requires advanced directives. management software solutions resources and buy-in from all parts of for more than 1,300 health and Imagine if your clinicians could double the equation. human services organizations. or triple the amount of interaction they Scalia is a founding member of Connected Care and Medication have with their consumers on a monthly the Long Island Software and Management basis without increasing your costs! A Technology Network and a member 60% of preventable medication errors Web portal can serve as the basic tool to of the College of Engineering occur at the prescribing and transcribing enable this additional contact. Advisory Board, State University of stages. The average prescriber’s offi ce New York at Stony Brook. He also Understandably, a client care portal spends 1.25 hours per day handling serves on the board of directors cannot be used by all clients due to the calls about changing prescriptions, up of the Software And Technology lack of Internet accessibility for some to 40% of physicians’ prescriptions Vendors’ Association. clients and other factors; however, many have to be rewritten due to errors, and consumers, and perhaps most impor- 150 million calls are made from phar- tantly, their families are able to access macists to prescribers annually to clarify the Internet from home, libraries, or prescription information. other public access points. Clients and

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27925National_CouncilCS2.indd 39 11/16/07 4:56:06 PM Let’s impact 55,000 M A G A Z I N E lives Reach your buyers through Join Now behavioral By joining the ACTION Campaign, you will be aligning yourself with an unprecedented national healthcare’s partnership in our field. most prestigious To join, and find out about the upcoming National Council ACTION Campaign webinar, publication please visit www.actioncampaign.org

Benefits of Taking ACTION Don’t miss the incomparable opportunity to reach 10,000 behavioral healthcare leaders who serve 1 2 3 6 million adults, children, and families with mental illness and addictions. Connect directly with organizational Providing rapid Improving Creating a seamless access to services client engagement transition between decision makers who buy stafﬁng, training, IT, facilities, levels of care food, furniture, medications, ofﬁce supplies, transport, Joining ACTION is entirely free to providers – all of the technical assistance, tutorials, and tools are available at no cost. Moreover, and more. organizations that have implemented these actions have reported: t 1PTJUJWFJNQBDUTPODMJFOUBDDFTTBOEFOHBHFNFOU Advertise in National Council Magazine at the t *NQSPWFETUBòSFUFOUJPOBOENPSBMFBTBSFTVMUPGinvolving them industry’s most competitive rates. Learn more at in the change process www.TheNationalCouncil.org (click on Resources and t &OIBODFEöOBODJBMQFSGPSNBODFBOEGVOEJOHPQQPSUVOJUJFT Services and then on Advertising and Sponsorships).

To place your ad in the January 2008 issue CAMPAIGN (deadline for submissions is Dec. 18), contact ADOPTING CHANGES TO IMPROVE OUTCOMES NOW Nathan Sprenger at 301.984.6200, ext. 240 or [email protected]. Our growing list of partners includes: American Association for the Treatment of Opioid Dependence ■ Addiction Technology Transfer Centers ■ Don’t have an ad ready to go? Faces and Voices of Recovery ■ Join Together ■ We can help you design one at no extra cost. Legal Action Center ■ National Association of Addiction Treatment Providers ■ National Association of State Alcohol and Drug Abuse Directors ■ National Council for Community Behavioral Healthcare ■ Network for the Improvement of Addiction Treatment ■ Robert Wood Johnson Foundation ■ State Associations of Addiction Services ■ Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment ■ Treatment Research Institute www.actioncampaign.org

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27925National_CouncilCS2.indd 40 11/20/07 7:10:49 PM Join a Memorable Celebration The 2008 Awards of Excellence will be presented at the Awards Dinner on May 2, 2008 at the Kennedy Library in Boston, Massachusetts. Honorary Behavioral Healthcare’s Most Prestigious Awards Chairman Christopher Kennedy Lawford, nephew of President John F. Kennedy, The National Council invites member submissions for our 2008 Awards of Excellence will host the event. Share your organization’s innovation and success in the ﬁelds of service, program. Reserve your Awards Dinner tickets advocacy, and community collaboration or recognize outstanding individual leaders for consumer advocacy and lifetime achievement. when you register for the 38th National Council Conference at www.TheNationalCouncil.org/Boston. Award Categories IN INNOVATION Questions? EXCELLENCE COLLABORATION [email protected] IN COMMUNITY or call 301.984.6200, ext. 223. EXCELLENCE ADVOCACY AND FAMILY IN CONSUMER EXCELLENCE ADVOCACY GRASSROOTS IN LEADERSHIP EXCELLENCE VOLUNTEER — STAFF AND ACHIEVEMENT LIFETIME 2008. Deadline for entries is January 4, Learn more at www.TheNationalCouncil.org/Awards

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27925National_CouncilCS2.indd 41 11/16/07 4:56:20 PM www.ntst.com/ConnectedCare

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