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Slide 1: MOBILE DIRECT OBSERV OBSERVATION TREATMENT (MDOT) OF TUBERCULOSIS PATIENTS PILOT FEASIBILITY STUDY IN NAIROBI, S KENYA 2010 March 2, 2009 Consumer Driven Consumer-Driven Outcomes Management: A New Paradigm for Quality and Efficiency Improvement in Behavioral Health February 1, 2010 Innovative Solutions for Social Impact 1 Danya International, Inc.
Slide 2: A New Paradigm for Quality and Efficiency Improvement in Behavioral Health Consumer-Driven Outcomes Management: Consumer-Driven Outcomes Management: A New Paradigm for Quality and Efficiency Improvement in Behavioral Health Table of Contents Executive Summary ................................ 1 The Call for Consumer Empowerment ........................................ 2 The Drive for Accountability .................. 3 February 1, 2010 The Solution: Consumer-Drive Outcomes Management .......................... 4 A Call to Action ...................................... 5 About the Authors ................................... 6 Authors: Jonathan Hunt-Glassman, B.A., Barry L. Duncan, Psy.D., Scott D. Miller, Ph.D., and Jeffrey A. Hoffman, Ph.D. Innovative Solutions for Social Impact i Danya International, Inc.
Slide 3: A New Paradigm for Quality and Efficiency Improvement in Behavioral Health Consumer-Driven Outcomes Management: Executive Summary The call for consumer empowerment and the drive for accountability have both been key planks in the decade-long campaign to transform the behavioral health care system. Both have achieved positive results. The field’s leading authorities have recognized the dramatic improvements in outcomes that ensue when clients are engaged in shared decisionmaking that incorporates their cultural and personal preferences, and a shift toward accountable service delivery has begun with the development of uniform national standards for performance-based outcomes. Too often, however, policymakers and regulators have pursued consumer empowerment and outcomes accountability Consumer-driven outcomes initiatives along parallel paths rather than in tandem. Most tellingly, management has been repeatedly this lack of coordination has frequently resulted in accountability demonstrated to dramatically mechanisms that fail to fully incorporate the voices of consumers. improve the quality and efficiency Achieving the full extent of quality and efficiency improvement promised by greater empowerment and accountability will require the behavioral health care system to embrace a new paradigm of consumer-driven outcomes management. The paradigm is defined by the use of valid and reliable measures to solicit continuous, real-time, and direct consumer feedback that enables the adjustment of services on an individualized basis. Consumer-driven outcomes management has been shown to be consumer-friendly, highly feasible for clinicians, and easily implemented using technology. Most importantly, it has been repeatedly shown to dramatically improve the quality and efficiency of services. Policymakers and regulators Published, peer-reviewed research has shown the following results:  Total program costs were reduced by 10 percent to 35 percent while outcomes and satisfaction improved. (Bohanske & Franczak, 2010). Length of stay in psychotherapy was reduced by 40 percent to 50 percent across a broad range of behavioral health services (Bohanske & Franczak, 2010; Duncan, Miller, Wampold, & Hubble, 2010; Miller, Duncan, Sorrell, & Brown, 2005). Cancellation rates declined by 40 percent and no-shows by 25 percent (Bohankse & Franczak, 2010; Duncan, Miller, Wampold, & Hubble, 2010). Success rates increased in one study by 65 percent and by as much as 100 percent in others (Anker, Duncan, & Sparks, 2009; Miller, Duncan, Brown, Sorrell, & Chalk, 2006). Independently confirmed by Reese, Norsworthy, and Rowlands, 2009. Percentage of clients who completed substance abuse treatment increased from 50 percent to 82 percent in one study and from 22 percent to 70 percent in another (Bohanske & Franczak, 2010; Duncan, Miller, Wampold, & Hubble, 2010). should explore legislative and regulatory actions that promote evidence-based consumer-driven outcomes management. of services.     To achieve significant improvements in the quality and efficiency of the behavioral health care system, policymakers and regulators should explore legislative and regulatory actions that promote evidencebased consumer-driven outcomes management. Innovative Solutions for Social Impact 1 Danya International, Inc.
Slide 4: A New Paradigm for Quality and Efficiency Improvement in Behavioral Health Consumer-Driven Outcomes Management: The Call for Consumer Empowerment Behavioral health care authorities broadly agree that a defining characteristic of the field’s transformation must be the universal adoption of consumer and family-directed care. This commitment reflects the broader health care industry’s direction. After its seminal 2000 report To Err Is Human revealed that health care in the United States was not only often of poor quality but also unsafe, the Institute of Medicine’s (IOM) Committee on the Quality of Health Care in America issued a second and final report, Crossing the Quality Chasm: A New Health System for the 21st Century (Kohn, Corrigan, & Donaldson, 2000; Committee on Quality of Health Care in America, 2001). This report:  The annual summit of the American College of Mental Health Administration directly affirmed the relevance of the IOM’s report and endorsed translating its findings to the behavioral health care field (Daniels & Mintz, 2002). Issued in 2003, the final report of the President’s New Freedom Commission on Mental Health answered the call to apply the IOM’s findings and recommendations to behavioral health care, including the need for consumer empowerment. Envisioning a system in which care is consumer- and family-centered and focused on recovery, the report asserted: Consumer needs and preferences should drive the type and mix of services provided, and should take into account the developmental, gender, linguistic, or cultural aspects of providing and receiving services. Providers should develop these customized plans in full partnership with consumers, while understanding changes in individual needs across the lifespan and the obligation to review treatment plans regularly (President’s New Freedom Commission on Mental Health, 2003). Although the need to adjust services in accordance with client preferences has sometimes been set in false opposition to the imperative to implement evidence-based practice (EBP), the American Psychological Association’s (APA) 2005 Policy Statement defines EBP as “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.” APA further explains that “services are most effective when responsive to the patient’s specific problems, strengths, personality, sociocultural context, and preferences” and concludes with the 2 Danya International, Inc. Identified six aims to guide quality improvement efforts: safe care, effective care, patient-centered care, timely care, efficient care, and equitable care Defined patient-centered care as “respectful of and responsive to individual patient preferences, needs, and values and ensures that patient values guide all clinical decisions” Recommended that systems be redesigned to give patients the “opportunity to exercise the degree of control they choose over health care decisions that affect them” Suggested that “the health system should be able to accommodate differences in patient preferences,” including those shaped by ethnic and cultural beliefs and practices    Innovative Solutions for Social Impact
Slide 5: Consumer-Driven Outcomes Management: A New Paradigm for Quality Improvement in Behavioral Health unequivocal statement that “ongoing monitoring of patient progress and adjustment of treatment as needed are essential to EBP” (APA, 2005). Consumer empowerment’s transformational effect upon quality improvement was distilled by Kaiser Permanente’s Senior Vice President of Quality and Systems Support in a 2007 article in Health Affairs. She wrote: Clinicians do not change outcomes alone but can do so in partnership with patients. Throughout most of the history of health care, we have focused on the clinician side of the equation. We have invested far less effort working with patients to understand how to leverage their participation in their own care. This represents an enormous untapped opportunity (Liang, 2007). Given that meta-analytic research about mental health outcomes indicates that consumer factors account for 87 percent of change achieved in behavioral health services, harnessing consumers’ capacity to contribute to change represents not only a socially just endeavor, but also the paramount quality improvement imperative (Duncan, 2010; Wampold, 2001). Administration (SAMSHA) defined 10 National Outcome Measures (NOMS) for use across all SAMHSA-funded programs. In introducing the NOMs, Charles G. Curie, former SAMHSA Administrator, said: Increasingly, policymakers and budget planners at all levels—Federal, State, local, and private—are basing funding decisions on outcome data. Eventually, this Web-based tool—SAMHSA’s National Outcome Measures (NOMs)—will provide the public and policymakers with the information to improve the management and performance of our programs and make the most of the limited dollars available to help people attain and sustain recovery (SAMHSA, 2005) Most reported NOMs data is collected in keeping with the standards of the Uniform Reporting System (URS), a federal reporting system used by state mental health agencies to compile and report annual data as part of the SAMSHA/CMHS Federal Community Mental Health Block Grant program. Developed by SAMHSA and used by state agencies since 1997, URS provides “uniform reporting of State-level data to describe the public mental health system and the outcomes of its programs,” using 21 standard data output tables (National Mental Health Information Center, 2004). Although they provide a useful quantitative framework for measuring the effectiveness of service delivery and are a necessary performance-based yardstick, the NOMs and URS have two major blind spots.  The Drive for Accountability The leading institutions for behavioral health policy have also recognized that quality improvement requires the widespread adoption of accurate measures of effectiveness. Federal government agencies have facilitated a consensus-driven process to identify and disseminate a small group of common measures to ensure accountability. In 2004, the Substance Abuse and Mental Health Services They do not emphasize consumer-driven care. Soliciting client’s direct evaluation of satisfaction with services is required Danya International, Inc. Innovative Solutions for Social Impact 3
Slide 6: Consumer-Driven Outcomes Management: A New Paradigm for Quality Improvement in Behavioral Health to assess only one of the NOMs’ 10 domains (perception of care) and to complete only 2 of the URS’ 21 output tables (adult consumer measures and child/family consumer measures). Accountability mechanisms are not client-centered when they exclude clients from participating in 90 percent of their measurements.  The Solution: Consumer-Driven Outcomes Management The full quality improvement benefits promised by the consumer empowerment and accountability movements will only be realized when consumer-driven outcomes management—an approach that synthesizes empowerment and accountability—is widely adopted. Outcomes management empowers consumers to be the agents of accountability Using valid and reliable measures to solicit realtime, direct consumer feedback, consumerdriven outcomes management empowers consumers to be the agents of accountability. Consumer-driven outcomes management amplifies consumers’ voices, enabling ongoing monitoring of individual service delivery and encouraging the tailoring of treatment as needed. Consumer-driven outcomes management systems share several common characteristics:  They provide objective, quantifiable data on the effectiveness of providers and systems of care. They use measures that are valid and reliable, but also brief enough to be feasibly administered during the service session. They favor the consumer’s voice and provide a formalized mechanism for using the client’s ideas and preferences to guide the choice of technique and model. The current outcomes reporting process is divorced from the delivery of clinical services. Typically administered once per year and via mail, formal assessments of consumer satisfaction stand little chance of having an impact on the course of services for the individual consumers who complete them. Even if providers sought to incorporate these satisfaction measures as part of an ongoing feedback loop, feasibility and relevancy would be significant concerns, as the standard URS measure of client satisfaction is a 24-item instrument that asks for retrospective assessment. While invaluable for compiling system-wide data, such measurement fails to incorporate direct consumer input into service delivery in a way that informs and improves treatment on a case-by-case basis. As such, the field’s currently favored mechanisms of accountability risk being overly attentive to the requirements of reporting and insufficiently responsive to the needs of consumers. Without measures of outcomes that are available in real-time and practical for continuous administration, behavioral health services providers cannot hope to implement the “ongoing monitoring of patient progress and adjustment of treatment” deemed by the APA to be an essential component of EBP.   Innovative Solutions for Social Impact 4 Danya International, Inc.
Slide 7: Consumer-Driven Outcomes Management: A New Paradigm for Quality Improvement in Behavioral Health  They solicit each client’s direct feedback regarding factors proven to predict success regardless of treatment model or technique: the client’s self-assessment of progress early in the service process and/or the client’s perception of the alliance with the provider They compare each client’s responses to normative data to identify at-risk cases in real-time and provide empiricallybased feedback messages that enable providers to adjust the course of services when needed.   from 50 percent to 82 percent in one study and from 22 percent to 70 percent in another (Bohanske & Franczak, 2010; Duncan, Miller, Wampold, & Hubble, 2010). Separation/divorce rates reduced by nearly 50 percent; 4 times the rate of clinically significant change (Anker, Duncan, & Sparks, 2009). The use of consumer-driven outcomes management systems has been proven to dramatically improve both the quality and efficiency of services. Published, peer-reviewed research has demonstrated the following results:  Total program costs were reduced by 10 percent to 35 percent while outcomes and satisfaction improved. (Bohanske & Franczak, 2010). Length of stay in psychotherapy was reduced by 40 percent to 50 percent across a broad range of behavioral health services (Bohanske & Franczak, 2010; Duncan, Miller, Wampold, & Hubble, 2010). Cancellation rates declined by 40 percent and no-shows by 25 percent (Bohankse & Franczak, 2010; Duncan, Miller, Wampold, & Hubble, 2010). Success rates increased in one study by 65 percent and by as much as 100 percent in others (Anker, Duncan, & Sparks, 2009; Miller, Duncan, Brown, Sorrell, & Chalk, 2006; Reese, Norsworthy, & Rowlands, 2009). Percentage of clients who completed substance abuse treatment increased 5 Recent technological advances have increased the feasibility of implementing consumer-driven outcomes management systems in large agencies, provider networks, and managed care organizations. For example, MyOutcomes is a scalable and secure Web-based application. MyOutcomes supplements Web versions of the valid and reliable Outcome Ratings Scale and Session Ratings Scale with instant calculations and graphs of results, empirically-based feedback messages, sophisticated data aggregation, record management, and HIPAAcompliant security and privacy measures.  A Call to Action Given its demonstrated potential to effect precisely the transformation of the behavioral health care system called for by leading experts, federal policymakers and regulators should explore legislative and regulatory avenues to promote the widespread adoption of consumerdriven outcomes management systems. In all federally-funded programs, consumer-driven outcomes management should be considered as a supplement to existing outcomes measurement programs and as an independent quality improvement mechanism. Consumer-driven outcomes management is a promising and successful approach to a stronger role for consumers as agents of accountability in health care.    Innovative Solutions for Social Impact Danya International, Inc.
Slide 8: A New Paradigm for Quality and Efficiency Improvement in Behavioral Health Consumer-Driven Outcomes Management: About the Authors Jonathan Hunt-Glassman is a Project Director at Danya International, Inc., and the product manager of MyOutcomes, a Web-based client-driven outcomes management system. Barry L. Duncan, PsyD, (director of the Heart and Soul of Change Project; www.heartandsoulofchange.com) and Scott D. Miller, PhD (director of the International Center for Clinical Excellence; www.centerforclinicalexcellence.com) are the developers of the Partners for Change Outcome Management System, a client-driven outcomes management system that is available in paper-based, Excel-based, and Web-based formats. Drs. Duncan and Miller each have extensive experience in training and clinical practice as well as numerous publications. Jeffrey A. Hoffman, PhD, is the Chief Executive Officer of Danya International, Inc, a health communications and technology consulting company based in Silver Spring, MD and is also a clinical psychologist. The authors acknowledge Sandra Lichty, PhD, for her assistance with research and drafting. Innovative Solutions for Social Impact 6 Danya International, Inc.
Slide 9: A New Paradigm for Quality and Efficiency Improvement in Behavioral Health Consumer-Driven Outcomes Management: References American Psychological Association (APA). (2005). American Psychological Association statement: Policy statement on evidence-based practice in psychology. Washington, D.C.: Author. Retrieved April 15, 2009, from http://www2.apa.org/practice/ebpstatement.pdf Anker, M., Duncan, B.L., & Sparks, J. (2009). Using client feedback to improve couple therapy outcomes: A randomized clinical trial in a naturalistic setting. Journal of Consulting and Clinical Psychology, 77(4), 693-704. Bohankse, R., & Franczak, M. (2010). Transforming public behavioral healthcare. In B.L. Duncan, S.D. Miller, B.E. Wampold, & M.A. Hubble (Eds.), The heart and soul of change: Delivering what works (2nd ed., pp. 299–322). Washington, DC: American Psychological Association. Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, D.C.: National Academy Press. Daniels, A. S., & Mintz, H. A. (2002). Crossing the quality chasm: Translating the Institute of Medicine Report for Behavioral Health. Albuquerque, NM: American College of Mental Health Administration. Retrieved April 15, 2009, from http://www.acmha.org/summit/summit_2002.cfm Duncan, B.L. (2010). On becoming a better therapist. Washington, DC: American Psychological Association. Duncan, B. L., Miller, S. D., Wampold, B. E., & Hubble, M. A. (2010). The heart and soul of change: Delivering what works (2nd ed.). Washington, DC: American Psychological Association. Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system. Washington, D.C.: National Academy Press. Liang, L. (2007). The gap between evidence and practice. Health Affairs (Project Hope), 26(2), w119– w121. Miller, S. D., Duncan, B. M., Brown, J., Sorrell, R., & Chalk, M. B. (2006). Using formal client feedback to improve retention and outcome: Making ongoing, real-time assessment feasible. Journal of Brief Therapy, 5(1), 5–22. National Mental Health Information Center. (2004). Uniform Reporting System (URS) data output tables. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved April 15, 2009, from http://mentalhealth.samhsa.gov/cmhs/MentalHealthStatistics/about_urs2002.asp President’s New Freedom Commission on Mental Health. (2003). Achieving the promise: Transforming mental health care in America. Rockville, MD: Author. Retrieved April 15, 2009, from http://www.mentalhealthcommission.gov/reports/reports.htm Reese, R., Norsworthy, L., & Rowlands, S. (2009). Does a continuous feedback model improve psychotherapy outcomes? Psychotherapy: Theory, Research, Practice, Training, 46, 418-431. Substance Abuse and Mental Health Services Administration (SAMHSA). (2005). Measuring outcomes to improve services. SAMHSA News, 13(4). Retrieved April 15, 2009, from http://www.samhsa.gov/SAMHSA_News/VolumeXIII_4/article9.htm Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Lawrence Erlbaum Associates. Innovative Solutions for Social Impact 7 Danya International, Inc.