phil klassen md frcpc vice-president, medical affairs ontario shores centre for mental health...
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Phil Klassen MD FRCPCVice-President, Medical AffairsOntario Shores Centre for Mental Health SciencesAssistant Professor, University of Toronto
Quality Standard for Schizophrenia
Introduction1. Project scope
2. Panel composition and selection
3. Methods for the development of quality statements– Identification of key areas for quality improvement – Prioritization of key areas– Review of evidence for each prioritized key area– Drafting of quality statements– Finalization of quality statements
4. Prioritization of key areas for quality statements– Results of topic prioritization survey– Potential guidelines for inclusion– Prioritization of key areas from survey and potential guidelines
• Concise sets of 5-15 strong (“must do”), measurable, evidence-based statements guiding care in a topic area
• Developed in topic areas identified as having high potential for better quality care in Ontario
• Each quality statement accompanied by quality indicator(s)
• Every quality standard will be accompanied by a plain language summary for patients and caregivers
• Strong emphasis on implementation through a variety of vehicles (monitoring/reporting, QBPs, Quality Improvement Plans, etc.)
• Strong emphasis on partnerships to support development and implementation
Quality standards – what are they?
Population and Topic Scope
• Adults aged 18-65 suffering from schizophrenia• From the ER/hospital admission to discharge
• Community treatment for next iteration
In Scope
• Adolescents and the elderly• Not specifically about first episode psychosis• Not specifically about concurrent disorders
Out of Scope
Panel Composition
High Level Timeline
Schizophrenia Quality Standard and QBP Clinical Handbook
High Level Timeline
May 2015 June 2015 July 2015 Aug. 2015 Sept. 2015 Oct. 2015 Nov. 2015 Dec. 2015 Jan. 2016 Feb. 2016 Mar. 2016 Apr. 2016 May 2016 June 2016 July 2016 Aug. 2016
Implementation Phase
Populating the Clinical Handbook Template
July 15
Submit Panel
Membershipto MOH
(August 14) August 2015
Topic Prioritization
Survey Sent to Panel
December 2015
2016
July 15
Expert Panel Established
August 16
Ready For Final Posting
May 2016
Develop Implementation
Plan
March 2016
Quality Standard document drafted
April 16 - July 16
Approvals & EditingPhase
July 2016 - August 2016
Production & Publication
Phase
July 16
Ministry Notification
April 2016
Expert Panel Meeting 4(if necessary)
February 2016
Draft Quality
Indicators
February 16
Expert Panel Meeting 3
October 2015 - April 2016
Development PhaseMay 15 - October 15
Scoping & Planning
October 15
Expert Panel Meeting 1
(September 30)
December 2015
Draft Quality
Statements
December 15
Expert Panel Meeting 2
(December 03)
Method Overview
Identification of Key Areas
Prioritization of Key Areas
Review of Evidence
Drafting Quality
Statements
Finalization of Quality
Statements
• Current activities are focused on review of evidence and drafting quality statements.
• Expert group meeting to discuss scheduled December 3, 2015.
DRAFT QUALITY STATEMENTS(FOR REVIEW AND DISCUSSION PURPOSES)
Primary Key Areas
Secondary Key Areas
Support for carers & family
members
Patient education
Transition to community / ACT
teams
Assessment
Supporting healthy eating &
exercise
Supporting smoking cessation
Early intervention
Treatment of substance
misuse
Monitoring for adverse events
to treatment
Engagement
CBT
Self-management
Monitoring patient health
Management of acute risk
Supporting adherence to
treatment
Choice of pharmacological
treatment
Alternative therapies
Peer support
Non-response to treatment
Services for people in crisis
Training & education of
HCPs
Access to psychiatrist
Psychosocial interventions
Neurocognitive training
Draft Quality Statements
Adults with schizophrenia who are assessed as inpatients in a hospital setting for a mental health diagnosis undergo a comprehensive, multidisciplinary assessment.
Definition: Assessment should be both comprehensive and multidisciplinary, undertaken by health care professionals with expertise in the treatment of people with schizophrenia. The assessment should address the following domains:
– Current and identified sources of distress, including risk of harm to self or others– Family/developmental (social, cognitive and motor development and skills, including coexisting
neurodevelopmental conditions) and education history, including history of trauma/adversity– Social history (accommodation, culture and ethnicity, leisure activities and recreation, and
responsibilities for children or as a carer), social networks, and history of intimate relationships– Occupational and educational (attendance at college, educational attainment, employment and
activities of daily living) history, and economic status– Medical history and full physical examination to identify physical illness (including organic brain
disorders) and prescribed drug treatments that may result in psychosis, and history of substance misuse
– Assessment of self-identified goals and aspirations as regards outcome of mental health care
Draft Quality Statements
Adults with schizophrenia who are assessed in a hospital setting for a mental health diagnosis are assessed for substance misuse.
Definition: The use of alcohol, tobacco, prescription and non-prescription medication and illicit drugs should be discussed with the individual, and carer if appropriate. The possible interference of substance misuse with the therapeutic effects of both pharmacological and non-pharmacological treatments should be discussed.
Draft Quality Statements
Adults with schizophrenia are offered peer support during their hospitalization by a trained peer support worker who has recovered from psychosis or schizophrenia and remains stable.
Definition: Peer support programs may include information and advice about:• Psychosis and schizophrenia• Effective use of medication• Identifying and managing symptoms• Accessing mental health and other support service• Coping with stress and other problems• What to do in crisis• Building a social support network• Preventing relapse and setting personal recovery goals
Draft Quality Statements
Caregivers of adults with schizophrenia who are assessed in a hospital setting for a mental health diagnosis are offered access to relevant and appropriate carer-focused training and education.
Definition: Carer-focused training and education is designed to improve caregivers’ experience and reduce burden and may include:• Psychoeducation• Support groups• Self-help interventions
Draft Quality Statements
Adults with schizophrenia who are assessed in a hospital setting for a mental health diagnosis undergo physical health assessments focusing on problems common in people with schizophrenia.
Definition: Physical health interventions should measure:• Weight/body mass index/waist circumference• Pulse and blood pressure• Fasting blood glucose• Lipid panel (total cholesterol, low-and high-density lipoprotein, cholesterol, triglycerides)• Extrapyramidal symptoms and signs• Overall physical health
Draft Quality Statements
Adults with schizophrenia who are assessed in a hospital setting for a mental health diagnosis are offered combined physical health and healthy eating interventions.
Definition: Behavioural interventions that combine support for healthy eating and physical exercise should be considered for initiation in the acute care setting. Such interventions may follow a psychoeducation/information-based approach and provide information and support for how to increase levels of physical activity and healthy eating.
Draft Quality Statements
Adults with schizophrenia who are assessed in a hospital setting for a mental health diagnosis are offered help to reduce or stop smoking through behavioural or pharmacological interventions.
Definition: A range of interventions to help reduce or stop smoking should be considered for initiation in the acute care setting. These may include:• Behavioural support• Pharmacotherapy
– Nicotine replacement therapy products (e.g. transdermal patches, gum, inhalation cartridges, sublingual tablets, or spray)
– Varenicline– Bupropion
Draft Quality Statements
Adults with schizophrenia who have failed to respond to treatment with at least two antipsychotic medications including a second-generation antipsychotic medication are offered clozapine.
Draft Quality Statements
Adults with schizophrenia who are assessed in a hospital setting for a mental health diagnosis are offered individual cognitive behavioural therapy for psychosis in addition to oral antipsychotic medication.
Definition: Cognitive behavioural therapy (CBT) for psychosis should be delivered on a one-to-one basis over at least 16 planned sessions and should be delivered according to a treatment manual. CBT psychosis can be initiated during all phases of psychosis (including the initial phase, the acute phase, or the recovery phase) and should be delivered by professionals with an appropriate level of competence who, wherever possible, receive regular supervision by the relevant specialists.
Draft Quality Statements
Adults with schizophrenia who are assessed in a hospital setting for a mental health diagnosis are offered family intervention in addition to oral antipsychotic medication. Family members of adults with schizophrenia are also offered family intervention.
Definition: The term ‘family’ can describe members of the individual’s family or caregivers who live with or are in close contact with an adult with schizophrenia.
Family intervention should:• Include the person with psychosis or schizophrenia if practical• Be carried out for between 3 months and 1 year• Include at least 10 planned sessions (these may or may not be part of the acute setting and planning for
subsequent sessions should be part of the discharge planning)• Take account of the whole family’s preference for either single-family intervention or multi-family group
intervention• Take account of the relationship between the main carer and the person with psychosis or schizophrenia• Have specific supportive, educational or treatment function and include negotiated problem solving or crisis
management work
Draft Quality Statements
Transition to the Community:
Adults with schizophrenia are assessed prior to discharge to determine further levels of care and linkage with primary care or community care support.
Adults with schizophrenia discharged from a hospital setting are scheduled a follow-up appointment with a psychiatrist within X days of discharge.
Additional Areas for Draft Quality Statements
1. Recovery
2. Trauma-informed care
3. Early intervention
4. Polypharmacy and LAI
5. Other non-pharmacological interventions– Art therapy– Social skills training– Psychoeducation– Supportive therapy– Mindfulness – Motivational interviewing– Cognitive remediation
Key Next Steps
• Further refinement of draft quality statements and review of evidence
• Expert group meeting – December 3, 2015
QUESTIONS?
APPENDIX
Methods: Identification of Key Areas
• Topic Prioritization Survey– Aimed to engage panel members to identify key areas for quality
improvement– Modelled on NICE’s method of stakeholder engagement during their
Quality Standard development process
Methods: Prioritization of Key Areas
• Clinical epidemiologist (CE) summarizes key areas identified in topic survey, along with areas identified through scoping exercise
• Panel will prioritize up to 10 key areas for quality statement development
• Considerations for prioritization:
1. Potential to improve health outcomes or health resources
2. Variation in current practice
3. Maintenance of important current standards of care
Methods: Review of Evidence
• CE will identify recommendations or statements from relevant guidelines (such as NICE or NICE-accredited guidelines, guidelines used in current practice, or those otherwise identified through scoping exercise) that may support potential quality statement development
Summary of relevant
recommendations and guidance
statements
• If limited or no evidence exists for key area, the CE will conduct an evidence review using the most appropriate review method
Evidence review
• If there is no evidence, the panel may wish to:• Use expert consensus• Note prioritized key area for future
consideration
Establishment of consensus
For each prioritized area:
Methods: Review of Evidence
• Identification and Inclusion of Clinical Guidelines– Identify relevant guidelines covering the population(s) and setting(s) of
interest– Use the AGREE II instrument to select 4–5 highest quality clinical
guidelines, including at least 1 contextually relevant (Canadian) guideline
Appraisal of Guidelines for Research & Evaluation II
1) Scope and Purpose
2) Stakeholder Involvement
3) Rigour of Development
4) Clarity of Presentation
5) Applicability
6) Editorial Independence
Methods: Review of Evidence
• Acceptable Evidence Threshold– The recommendations or statements identified from relevant guidelines
will be examined by the CE to determine whether they meet an acceptable evidence threshold
– Suggested thresholds:• Moderate to high quality of evidence for diagnostic or therapeutic
interventions• Expert consensus is sufficient when quality of evidence is low for
certain principles, processes, or system-level interventions
Methods: Drafting of Quality Statements
• Up to 15 quality statements will be drafted, based on either recommendations from relevant guidelines or an evidence review
• Quality statements are not verbatim restatements of the relevant recommendations from source guideline(s)
• One quality statement may map to recommendations from one or more guidelines, and/or may be derived by rewording one or more recommendations into a single statement
Methods: Finalization of Quality Statements
• The panel will agree up to 15 quality statements for publication within the quality standard and clinical handbook
Key Areas Identified by Topic Prioritization Survey
Topic Areas
Early intervention: Early intervention may improve clinical outcomes, such as admission rates, symptoms and relapse
Services for people in crisis: Crisis resolution and home-treatment teams to support people in crisis
Support for carers and family members: Family-based interventions; family psychoeducation; family education
Non-pharmacological interventions: Cognitive behavioural therapy; alternative therapies; neurocognitive training; psychosocial interventions
Promoting physical health: Education and interventions to encourage healthy eating and exercise; assessment and treatment of substance misuse; supporting smoking cessation; improving medical care and monitoring of physical health and metabolic parameters
Pharmacological interventions: Choice of antipsychotic treatment (drug and route; access, use and monitoring of clozapine); supporting adherence with treatment; partial or non-response to antipsychotic treatment; monitoring of adverse events
Transition to the community: Supportive and knowledgeable staff to ease transition; strategies and methods to facilitate care transition
Peer support: Support from people with lived experience can help individuals with schizophrenia
Training and education of healthcare providers: Specialized training for all providers who care for people with schizophrenia
Access to psychiatrist: Access to psychiatric care is often limited
Other Key Topic Areas
Topic Areas
Assessment: Psychiatric assessment; comprehensive multidisciplinary assessment; physical health assessment to identify co-existing or comorbid conditions
Management of risk: Management of individuals at immediate risk to themselves or others during an acute episode
Patient education: Improved patient understanding of the assessment process, their diagnosis, and treatment options
Engagement: Experience of staff in working with people from diverse ethnic and cultural backgrounds
Self-management: Self-management to promote recovery and empower individuals
Out of scope
Emergency department or inpatient setting (including transition to community)
• People in the criminal or youth justice systems• Pre-natal and post-natal support• Support of people with learning difficulties• Prevention of psychosis in those at higher risk• People with PTSD symptoms• Transition from youth to adult care
In scope?
Services for people in crisis
Transition to the community / ACT teams
Early intervention services
Promoting physical health
Encouraging healthy eating and exercise
Monitoring of patient health status
Supporting smoking cessation
Treatment of substance misuse
Support for carers and family members
Access to psychiatrist
Engagement(e.g., First Nations,
immigrants/ refugees)
Training and education of HCPs
Self-management Peer support
• Improving community attitudes (reducing stigma)• Access to primary care• Supportive housing/assisted living• Supporting employment• Community integration
Management of acute risk
Patient education
*BLUE indicates identified by topic prioritization survey
Non-pharmacological interventions
Cognitive behavioural therapy
Alternative therapies
Psychosocial interventions
Neurocognitive training
Assessment
Psychiatric assessment
Comprehensive multidisciplinary
assessment
Physical health assessment (for co-existing conditions)
Pharmacological interventions
Choice of antipsychotic medication
Supporting adherence to antipsychotic
medication
Monitoring for adverse events
Partial- or non-response to anti-
psychotic medication