6 Optimization Strategies for Quality Improvement s1

Section 6.4 Optimize Optimization Strategies for Quality Improvement

This tool suggests ways electronic health records (EHR), health information exchange (HIE), and other forms of HIT can support of quality improvement. It offers recommendations for HIT functionality and people, policy, and process elements that may need to be strengthened to achieve your goals.

Time needed: 12 – 16 hours Suggested other tools: Section 2.4 Visioning, Goal Setting, and Strategic Planning for EHR and HIE

1. Introduction Improving the quality of health and health care is a high priority for the Centers of Medicare & Medicaid Services (CMS), other payers who reimburse for behavioral health services, state licensure and voluntary accreditation organizations, and behavioral health clients. A number of facilities have described strategies and processes for quality improvement in behavioral health. However, some quality improvement goals have been difficult to accomplish due to lack of adequate data, inability to provide real-time guidance and direction to staff at the point of service, or difficulty getting reliable reports on outcomes. Health information technology (HIT) that blends quality measures, clinical guidelines, and decision support tools is still a relatively new for most behavioral health EHRs.

2. How to Use 3. Review and analyze behavioral health clinical practice guidelines and clinical quality measures (CQMs), such as those from National Quality Forum. (See also: Optimization Strategies for Incorporating Clinical Practice Guidelines and CQMs into EHR and HIE.) Understand and appreciate issues in performance measurement in behavioral health.1 Review your current goals for improvement and the strategies currently being used to achieve these goals. Identify specific strategies for improvement. The Quality Improvement Organization (QIO) in your state is an excellent point of reference. Many provide tools, training materials, and consultative support for improvement. 4. Identify additional target areas for improvement and target them appropriately. It is more important to identify a few goals that make a big impact, than many goals. Targets can be prioritized based on their impact on the facility’s reimbursement, reputation, and other factors that contribute to the behavioral health of the people in the community served. Attempting to manage too many goals may detract from success with both HIT and quality improvement initiatives.

1 Horgan, CM and DW Garnick. (2005) The Quality of Care for Adults with Mental and Addictive Disorders: Issues in Performance Measurement, Center for Behavioral Health, Schneider Institute for Health Policy, Heller School for Social Policy and Management, Brandeis University. http://sihp.brandeis.edu/ibh/pdfs/IOMJan05submitted.pdf

Section 6 Optimize—Optimization Strategies for Quality Improvement - 1 5. Apply a quality improvement process, such as Plan-Do-Study-Act (PDSA) so that improvements can be planned for, actuated, evaluated, and achieved. 6. Use the tool below to record your goal and baseline performance in each of your target areas. Determine the HIT functionality that is needed to support your quality improvement goals. These goals may have been identified as part of your overall goal setting for EHR and HIE (see Section 2.4 Visioning, Goal Setting, and Strategic Planning), or you may need to get more specific now with respect to specific clinical quality areas. Following acquisition of HIT, record new performance data and determine whether your desired improvement has been achieved. It is often necessary to monitor at specific milestones. 7. Recognize the need to celebrate your success or determine the root cause of less than desired results. Poor results often can be traced to issues involving people (e.g., retraining or counseling is required), policy (e.g., leadership, expectation setting), or process (e.g., workflow, standard vocabulary). In the example provided (shown in italics in the table below), a behavioral health facility’s goal was to reduce the suicide rate among its clients using behavioral health assessment tools in its EHR and improving the speed and rate at which clients were connected with lifesaving services. (See SAMHSA News, Winter 2012, for a description of the Substance Abuse and Mental Health Services Administration’s Prevention of Substance Abuse and Mental Illness Strategic Initiative, one focus of which is preventing suicide, available at: http://www.samhsa.gov/samhsanewsletter/Volume_20_Number_1/Winter2012-volume-20-number-1.pdf).  The facility’s baseline data revealed that, on an annual basis, an average of 90 of its 3,000 clients have serious thoughts of suicide, 30 had made suicide plans, and 10 had attempted suicide.

 The facility planned to use a variety of strategies that could be aided by EHR and HIE, including completion of applicable assessment instruments on a timely basis, connecting clients to the National Suicide Prevention Lifeline via Facebook, and setting clients up with a suicide prevention smart phone “app”. They also used their state-based health information exchange organization (HIO)—with the clients’ permission—to notify applicable clients’ providers of the need to monitor for suicide. The facility also administered the BASIS-24©2 survey to all clients both on intake and after receiving care.

 As the facility implemented its HIT resources, it monitored utilization and outcomes at three-month intervals. Results included:

 During the first six months, an average of 10 additional clients per year were identified to be at risk for suicide via the EHR assessment tools and the BASIS-24© survey.

 To reduce the data entry burden for completing assessments quickly, the facility began to communicate with its HIO to arrange for hospitals and providers to send client health summaries using the Consolidated – Clinical Document

2 See Goldstein, LA, et al. (2011) Outcome Assessment via Handheld Computer in Community Mental Health: Consumer Satisfaction and Reliability, J Behav Health Serv Res, 38(3): 414-423. 2 Architecture (C-CDA) standard that could pre-populate some parts of the assessment. They had no baseline data, but hoped to further improve identification of clients at risk. After the first three months, staff members found they could receive health summaries for 40 percent of their clients.

 Despite not having summary data for 60 percent of their clients, the staff was able to complete the applicable portion of the assessments for 97 percent of all clients. This further step increased identification of an average of another five at-risk clients per year.

 For 85 percent of at-risk clients identified, the facility conducted planned interventions and found a 35 percent reduction in suicide planning and a 50 percent reduction in suicides during the first year.

 In monitoring results using HIT, it is important to observe that technology is not the only factor in achieving quality improvement results:

 Where technology is believed to help, it must be fully deployed. The example behavioral health facility has done well considering that they hoped to reduce the data entry burden for their users in completing assessments to identify clients at risk by having referring providers supply health summaries in C-CDA format. Not all providers were able to do this initially, and some clients refused to grant permission for the facility to obtain the summaries.

 All who are intended users must use the system to ensure that every client has a chance of benefiting from use of the HIT. One therapist was identified as having great difficulty using the system.

 Where progress is not as expected, the root cause must be determined. In the example, the facility evaluated protocol, decided there were issues with one data point, and took specific corrective measures. This may or may not prove fruitful.

 Other potential issues can impede progress. These may be related to the application’s design, or to people, policy, or process.

 It is often necessary to stage adoption of HIT, especially where there may not be supporting resources. Some communities may not have an HIO, or an HIO that is set up to support the desired exchange of information. However, the facility could start using the Direct protocol for email with other providers.

 Another important factor in using HIT is to ensure that the underlying clinical strategies are sound and that professional users are still applying professional judgment to client care.

Section 6 Optimize—Optimization Strategies for Quality Improvement - 3  In the example, there probably is not a perfect protocol for identifying every client at risk. If a therapist believes the client is at risk even if the assessment does not, the facility must establish a policy to address the situation. Will the facility err on the side of increasing monitoring when it may not be necessary, or err on the side of not increasing monitoring?

 Many “human factors” play into the success of using HIT. If an automated PHR was feasible, the therapist must still assess whether the client is reporting information accurately.

 HIT cannot overcome a therapist who ignores an alert or an administrator who waits too long to bring in additional resources when guidelines call for them. HIT is not a substitute for a culture of quality care.

8. HIT and Related Resources for Quality Improvement

Goal Clinical HIT Resources B Milestone Results Corrective Improvement a Action as Strategies s Needed el 6 mo 12 mo 18 mo. in e D at a Improve 9 35% fewer identification of 0 clients with clients at risk for cli suicidal suicide e plans nt Reduce suicide s 50% fewer rate w/ clients s attempting ui suicide ci d al th o u g

4 Goal Clinical HIT Resources B Milestone Results Corrective Improvement a Action as Strategies s Needed el 6 mo 12 mo 18 mo. in hte s 3 0 cli e nt s wi th s ui ci d al pl a n s 1 0 cli e nt s at te m pt in g s ui ci d e More quickly Easy-to-use template to complete 97% completion of One therapist

Section 6 Optimize—Optimization Strategies for Quality Improvement - 5 Goal Clinical HIT Resources B Milestone Results Corrective Improvement a Action as Strategies s Needed el 6 mo 12 mo 18 mo. in complete risk assessment e applicable parts of resistance assessment to assessment identify clients at Alerts to missing data for risk for suicide assessment 10 additional clients identified

Clients at risk alert Added at 6 mos.

C-CDA to pre-populate 40% assessment received

Connect to Community resources 85% of lifeline resources clients Facebook 85% of clients Care Notification to providers Client permission coordination Promote client BASIS-24 app 85% of Access to smart Self- Suicide prevention app clients phone management