hsj presentationrev2

Commissioning for Outcomes in Mental HealthJon Allen – Director of Mental Health, UHUK

And Dr David Whitehouse – Chief Medical Officer Strategy and Innovation, OptumHealth

Commissioning for Outcomes in Mental Health

•Data Rich•Information Poor

•Knowledge Destitute •Wisdom Bankrupt

As we improve the collection of data and outcome measurements in the UKhow do we ensure we don’t become:


• Explore our thoughts, observations and experiences on using outcomes in the commissioning process: – Indentifying and prioritising high level

outcomes for commissioning mental health services

– Using the findings of outcomes based research to prioritise and focus commissioning plans and decisions

– Using outcomes in service specifications and contracts

– Using outcomes to monitor and evaluate service delivery

Introduction


Indentifying and Prioritising High Level Outcomes

An outcome can be defined as a consequence or result of a set of events or interventions.

In healthcare we usually refer to clinical outcomes, or the change in the status of an individuals health and wellbeing as a result of the intervention.

These can be binary naturalistic outcomes - dead or alive, better or worse. Or measures which capture degrees of change in specific signs, symptoms or functions.

Commissioners are interested in these outcomes but also in a wider variety of outcomes which capture population level changes in health and well being , and changes in the capacity, capabilities, and clinical and cost effectiveness of the services they purchase.

However planning services on the basis of outcomes is a complex task, which in the UK is in its very early stages



• The Commissioning cycle starts with an analysis of the health needs of the population• Local Authorities and PCTs are required to carry out and publish a Joint Strategic Needs Assessment. •The JSNA informs the Local Area Agreement and the PCTs Strategic Commissioning Plan. •In addition national priorities and commitments need to be included e.g.

•Public Sector Agreement Targets and the National Indicators Associated with them •Mental Health national priority and other indicators. •National strategies

•The above processes and information should help identify and support the development of prioritised outcome statements that should drive commissioning strategies and plans.

PSA target National mental health

indicatorJSNA needs analysis

dataHigh level Outcome statement from LAA

Increase the proportion ofsocially excluded adults insettled accommodationand employment,education or training

MH04 Employment status ofspecialist Mental Health useron Care ProgrammeApproach aged between 18and 65

10000 people onincapacity and severedisablement benefits inPCT area with diagnosis

of mental illness

1. Reduce number of people on incapacity benefits.

2. Increase number of people with Level 2 qualifications

MH05 housing status ofspecialist Mental Health useron Care ProgrammeApproach

5% of homelessacceptances are due tomental illness

1. Reduce number of homelessness acceptances



•Following needs assessment in the commissioning cycle are the steps of reviewingservices, identifying gaps and or over provision and then defining the key healthcare risks and deciding on a strategy to manage them.

•Deciding priorities requires each key area of need to be defined in terms of an outcome to be achieved – which in turn requires the identification of the most Cost effective and impactful way of addressing the specific need.

•The available evidence base should provide the starting point for determining theservices and or interventions to be commissioned to achieve the required outcomes.



• The strategic commissioning plan translates the analysis from the first four steps of the commissioning cycle into health oriented outcomes for the PCT population. This in turn drives the Operational and Organisational Development plans. At each level the outcomes to be achieved become increasingly specific.


Using outcomes from evidence based research to focus commissioning plans and priorities

Desired Mental Health Outcome Evidenced based intervention /service Anticipated outcome

Inrease employment of service users on CPA

Burns T, Catty J, Becker T, et al. The effectiveness of supported employment for people with severe mental illness: a randomised controlled trial. Lancet 2007;370:1146–52.

increase number of people on CPA working for at least one day in the year by at least 16%

Individual placement and support programmes are more effective than standard vocation and rehabilitation services

Reduce days lost to work because of depression

Wang PS, Simon GE, Avorn J, et al.

Telephone screening, outreach, and care

management for

depressed workers and

impact on clinical and work productivity

outcomes: a randomized controlled trial. JAMA

2007;298:1401

11.

Depression symptoms of people with depression in work reduced to an adjusted average of 8.9 on QUIDS – SR scale

Effective weekly hours worked by people with depression to be on average 29.5 hours per week within 12 months of treatment

Once a strategic outcome is identified the tactical approach, the specific level ofachievement and methods of measurement and likely costs need to be defined as part of theoperational plan


Using outcomes in service specifications and contracts

The operating plans high level statements need to be operationalised through the next stages of the commissioning cycle.. Service specifications should outline the outcomes providers should achieve, these might include: • the outcomes to be achieved by the service in terms of improvement in population health and well being•The specific clinical outcome data to be collected by the provider•The expected clinical outcomes to be achieved by the services for individuals.•The type and amount of services to be delivered •The workforce to be deployed in terms of skills and numbers•The quality criteria for the service in terms of patient satisfaction, safety and compliance with clinical guidelines

Outcomes Source Indicator Data Requirement

Demonstrably improve the mental health, functioning and well being of children and adolescents accessing CAMHS services

Local , but derived from requirement of N51

Average improvement per episode of care

CORC outcome data set

Reduce year on year the number of children and adolescents requiring a specialist tier 3 or higher mental health service

Local but derived from requirements of N51

Percentage of tier 2 patients referred to tier 3/4 services

Referral data

Increase patient/family/carer satisfaction with service delivery and outcomes achieved

Local but derived from Vital Signs

Patient satisfaction measure

CORC data set - Patient satisfaction and Patient Reported Outcomes


Using outcomes in service specifications and contracts

•Negotiating contracts with chosen provider’s is the penultimate stage in the commissioning cycle.

•The standard mental health contract provides a clear set of guidance and schedules for defining the expected activity and quality , outcomes and data and reporting requirements for successful delivery of the contract.

•The contract contains key national requirements for mental health services including the requirement to comply with the minimum mental health data set and national standards and guidelines relevant to the services.

•The national contract incentivises quality through implementing Commissioning for Quality and Innovation Scheme, (CQUIN).

•CQUIN can be used to promote the collection of specific outcome measures as baselines, or the reporting/achievement of outcomes the commissioner and provider are interested in.


Using outcomes to monitor and evaluate service delivery

• Monitoring and evaluating services is the final step in the commissioning cycle. •Requires measurement of clinical and health outcomes and economic evaluation of those outcomes. •The Office for Health Economic report into outcome measurements recognise that this has only recently been a serious consideration in UK health policy.•In mental health the challenge in the UK has been engaging clinicians and service users in the routine collection of outcome data, and effectively linking outcome data to service and cost data to demonstrate benefit. •In the US the submission of provider claims data to health management organisations, and the incentivisation of providers to also submit outcome data has meant that there are significant, longitudinal, time series data sets of both activity and outcomes. This data is used by HMOs for;

•Quality assurance of providers•Supporting patient choice •Proactive management effectiveness and efficiency of high cost care •Predictive modelling of utilisation and preventative service provision

•The introduction of PBR in mental health and other elements of commissioning reform may introduce the opportunity to learn from US systems and processes.


Using outcomes to monitor and evaluate service delivery – OptumHealth

•Continual enhancement to both the provider and member experience is critical to our success. Our key monitoring evaluation initiatives focus on both of these

CQICQI

FQMFQM

Rewards & Incentive Programs

Provider Report Card






• Case mix-adjusted utilization and outcomes

• Complaints

Provider Web

Portal

Provider Web

Portal

Online access to clinician CQI

profile, supporting educational material and

patient ALERT information

Care Advocate Treatment Reviews

Receive calls to review

treatment from care

advocates in algorithm-identified

cases

Automated Provider Letters

Targeted interventions with clinicians to address clinical risk factors and unexplained practice variation

Provider

ALERT

• Wellness Assessments

• Claims

Predictive Modeling & Analytics

Predictive Modeling & Analytics

Clinical Learning & Training

Outcomes & Program

Evaluation

Appeals & Grievances



Project I started July 2005 and completed December 2005.Objective: Develop a standardized tool and process to provide objective performance feedback to facility networkOutcome: Facility Scorecard created

Project II started January 2006 and completed August 2006Objective: Tier the Facility Network and increase the number of facilities on a Self-Managed protocolOutcome: Parameters of Tiers defined, FQM program descriptions developed and rolled out to the Care Advocacy sites in August 2006 Facility Scorecard Metrics

Average Length of StayCase-Mix Adjustment30-Day Readmission RateAppointments Made Prior to DischargePercentage of 7-Day Follow-up Appointments KeptOutcome/Experience of Care

Facility Quality Management



Facility Quality Management



High readmission rate&Inefficient

Ok with regard to readmission rate BUT Not v. efficient



CT Facility Quality 2008

CT facilities compared for:Readmits% of appts scheduled in 7 days% of f/u appts kept in 7 days



Care Advocate Interventions

Encounter Data

Automated Clinician ALERT Messages

4-month Follow-up Wellness Assessment Questionnaire

Measuring Sustainable Outcomes

Required High-Risk Wellness Assessment Questionnaire between

visits 8 & 10

Brief Wellness Assessment – Youth

Completing this brief questionnaire will help us provide services that meet your child’s needs. Answer each question as best you can and then review your responses with your child’s clinician. Please completely fill in the circle for your responses like this ?

Complete all information -- please print

Patient Information Clinician Information MRef Ο

Child’s Name: Clinician Name:

Subscriber ID: Clinician ID:

Today’s Date: Date of Birth: Clinician Phone: ( ) State:

Authorization #: Visit #: Ο 1st or 2nd visit Ο 3rd to 5th visit Ο Other

Relationship to the child: Ο Mother Ο Father Ο Stepparent Ο Other Relative Ο Child/Self Ο Other

For questions 1-21, please think about your experience in the past week.

Fill in the circle that best describes your child: Never Sometimes Often 1. Destroyed property 2. Was unhappy or sad 3. Behavior caused school problems 4. Had temper outbursts 5. Worrying prevented him/her from doing things 6. Felt worthless or inferior 7. Had trouble sleeping 8. Changed moods quickly 9. Used alcohol 10. Was restless, trouble staying seated 11. Engaged in repetitious behavior 12. Used drugs 13. Worried about most everything 14. Needed constant attention

Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο

How much have your child’s problems caused:

Not A at All A Little Somewhat Lot

15. Interruption of personal time? 16. Disruption of family routines? 17. Any family member to suffer mental or physical problems? 18. Less attention paid to any family member? 19. Disruption or upset of relationships within the family? 20. Disruption or upset of your family’s social activities?

Ο Ο Ο Ο

Ο Ο Ο Ο

Ο Ο Ο Ο

Ο Ο Ο Ο

Ο Ο Ο Ο

Ο Ο Ο Ο 21. How many days was your child’s usual routine interrupted by their problems? Days

Please answer the following questions only if this is your first time completing this questionnaire.

22. In general, would you say your child’s health is: Ο Excellent Ο Very Good Ο Good Ο Fair Ο Poor

23. In the past 6 months, how many times did your child visit a medical doctor? Ο None Ο 1 Ο 2-3 Ο 4-5 Ο 6+

24. In the past month, how many days were you unable to work because of your child’s problems?

(answer only if employed) Days

25. In the past month, how many days were you able to work but had to cut back on how much you got done because of your child’s problems? (answer only if employed) Days

C103 – v.073106

And/Or

PROPRIETARY ALGORITHMS

Modified Member Questionnaire (Wellness Assessment)+ Increase Frequency to Measure Treatment in Progress 1 & 3–5

New Generation ALERT® Model



How ALERT® Benefits The Population

•Focuses clinical resources on the best opportunities to impact treatment outcomes, affordability and the member experience•Appropriately manages over- and under-utilization of outpatient services

•People who want “help” vs. need “treatment”•Variation in practice patterns and clinician effectiveness

•Strengthens focus on treatment outcomes and evidence-based treatment •Better facilitates member-centric treatment planning through the use of enhanced data collection tools and analytics •Accelerates collection of treatment outcome data for care advocacy, network management and quality improvement•Improves sustainable outcomes over the long term



Wellness Assessment ─ Patient Questionnaires

• “Adult” Wellness Assessment 24 items Depression and anxiety symptoms Functional impairment Well-being Workplace absenteeism and presenteeism Substance abuse risk and use Health and medical comorbidity

• “Youth” Wellness Assessment 25 items Global impairment in child (interpersonal, emotional,

academic, behavioral) Caregiver strain Parental workplace absenteeism and presenteeism Health



Evidenced-Based Algorithms

ALERT’s evidenced-based algorithms identify at-risk cases by calculating:

Risk factors: global distress score, chemical dependency, workplace risk, medical co-morbidity, admission risk, and complex conditions

Questionnaire score changes or levels: normal level, high score, high score and no change, or worsened

Clinician discordance for substance abuse risk: discrepancies between member self-reported WA responses and encounter data

Utilization pattern: frequency of visits, number of visits linked to diagnosis, or Wellness Assessment



ALERT® 2007 Results

•Health Status (Adult respondents after a 4-month period)•67.4% showed significant improvement•6.3% reported slight improvement

•Workplace Absence and Presenteeism (After 4 months)•29.4% reduction in work days missed•53.7% reduction in days impacted by presenteeism

•Medical Co-Morbidity (Adult respondents who reported at least one medical health concern at baseline)

•74% reported good to excellent health at four months, compared to 71% doing so at baseline•Those using three or fewer medical visits in a four-month period increase from 54% at baseline to 58% at four months

Projected M edical C ost:C H F and D epression

> 25000 < 22000 < 17000 < 12000 < 7000

Projected M edical C ost:D iabetes and D epression

> 15000 < 11000 < 6000

Projected M edica l C ost:Arthritis and D epression

> 15000 < 12000 < 7000

Projected M edical C ost:C ancer and D epression

> 15000 < 12000 < 7000

22

DepressionCHF

MedicalCost

MedicalCost

DepressionDiabetes

DepressionArthritis

MedicalCost

DepressionCancer

MedicalCost


Using outcomes to monitor and evaluate service delivery – OptumHealth Predictive Model Demonstrates the Effect of Depressionon medical costs


Summary

•Commissioning for outcomes is a complex activity which impacts on all stages of the commissioning cycle •National priorities and strategic needs assessments indentify the high level outcomes to be achieved•The Local Area Agreement and Strategic Commissioning Plan prioritize the health and social outcomes to be achieved over five years.•The Local operating plan defines the services to be put in place and outcomes and indicators to be achieved over the forthcoming year•Service specification define detailed outcomes, indicators and measures for a service to be commissioned•New standard contracts provide the legal means and methods to enforce and incentivise not only the delivery of services, but the achievement of outcomes and the provision of data. •Effective performance monitoring and evaluation needs the routine collection and patient level linking of outcome, activity and price data•The UK may be able to learn from systems and processes developed in the US as we move forward with commissioning reform in mental health in the UK

Thank You

hsj presentationrev2

Documents

health oriented outcomes

clinical outcomes

required outcomes

high level outcomes

findings of outcomes

basis of outcomes

mental health indentifying

work productivity outcomes