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Capturing Psychologists’ Work : Measuring and Documenting Clinical and Administrative Outcomes Lisa K. Kearney, Ph.D., ABPP Senior Consultant for Technical Assistance Office of Mental Health Operations VA Central Office Learning Objectives Identify potential administrative outcome measures to assess integrated care programs from a health care management perspective Identify common measures utilized for screening and brief assessment of common symptoms treated within integrated care settings Screening and Brief Assessments: Monitoring Clinical Outcomes over Time Why is Screening Critical in Primary Care? Primary Care: de facto gatekeepers to mental health care Early interventions improve overall outcomes and result in cost savings. Majority of mental health conditions are undetected and/or untreated Mental health conditions are highly prevalent in PC Identifies individuals with undiagnosed concerns who may overuse services and decrease inappropriate referrals for unneeded treatments (Beacham, Herbst, Streitwieser, Scheu, & Sieber, 2012; Kessler, 2009; Auxier, Farley, & Seifert, 2011; Derogatis & Lynn, 2000) First-Stage Screening Brief standardized measures administered on a routine basis Designed for asymptomatic, apparently “normal” patients Does not provide a diagnosis but identifies those in need of further assessment Results in further discussion, second-stage screening, or referral for a formal evaluation Helps to formulate referral questions Establishing Screening Practices WHO will ask the screening questions and how will they be trained? WHAT are the concerns of the clinic which you wish to establish screening for? WHEN will the screening occur? WHERE will the screening occur and where will paper measures (if applicable) be stored? HOW will screens be scored, results be communicated to providers, and results entered into the record? HOW much time will screening require? (Robinson & Reiter, 2007) Establishing Measurement-Based Outcomes Evaluation • Identify WHAT outcomes are important to you and your stakeholders • Identify the best measures which have been validated for your setting • Establish SOPs for your entire practice so that all measures are uniformly administered on standardized timetables • Create methods to improve ease of administration and data extraction • Create timelines for regular feedback on outcomes to all stakeholders Template Notes in Electronic Records Patient Tracking: Panel Management Clinical Outcome Data by Panel Example slide from Behavioral Health Lab, VISN 4 MIRECC Depression Screening for Adults § Major depressive disorder is present in 5%– 13% of patients seen by PC physicians (Pignone et al., 2002). § Many patients with depression are initially detected in PC settings, with 13 %–20% of PC patients screening positive for depressive symptoms (Foster et al., 1999). § Routine screening improves detection of depression by 10%–47% (Pignone et al., 2002). Depression Screening and Brief Assessment for Adults Patient Health Questionnaire-2 (PHQ-2; Lowe, Kroenke, & Grafe, 2005) 9-item Patient Health Questionnaire (PHQ-9; Kroenke, Spitzer, & Williams, 2001) Center for Epidemiologic Studies-Depression Scale (CES-D; Williams, Pignone, Ramirez, & Perez Stellato, 2002) Geriatric Depression Scale (GDS; Watson & Pignone, 2003) Beck Depression Inventory-2 (Arnau et al., 2001) Additional Screenings/Assessments Suicidal Screening 5-item Paykel Questionnaire PHQ-9 item #9, BDI-II item #9 Secondary Affective States Questionnaire Beck Hopelessness Scale Beck Scale for SI Modified Scale for SI Scale for Suicidal Ideation Bipolar Disorder Mood Disorder Questionnaire Mini-International Neuropsychiatric Interview Anxiety Disorders Generalized Anxiety Disorder-2 Secondary Generalized Anxiety Disorder-7 Beck Anxiety Inventory Beck Anxiety Inventory – Primary Care Penn State Worry Questionnaire Additional Screening/Assessment PTSD Substance Use Disorders • 4-item Primary Care – PTSD • 17-item PTSD Checklist (PCL) • Alcohol: AUDIT, AUDIT-C, CAGE • Drug Use: DAST-10, MINI • Tobacco: functional, Fagerström Test Cognitive Disorders/ ADHD • Cognitive: BLESSED, Mini-COG, SLUMS, Informant screenings • ADHD: ASRS 6 or 18, WURS Pain • Brief Pain Inventory or Short • McGill Pain Questionnaire-Short Form • Pain Outcome Questionnaire-Short Form Sleep • Epworth Sleepiness Scale • Insomnia Severity Index • Pittsburgh Sleep Quality Index Intimate Partner Violence • 4 item HITS Scale • 3 item Partner Violence Screen Monitoring Administrative Outcomes over Time Productivity Clinic Utilization Access/Wait Time Problems Productivity Measurement Can Address for Leadership Identify and prevent potential burnout Review emerging programs to anticipate need for resources or prepare for resource reallocation Provide standardization of expectations Identify inaccurate coding processes impacting revenue Help address access issues In other words….this can help you as a leader! Productivity Measurement • Use of a Relative Value Unit (RVU)-based model for measuring productivity consistent with benchmark data from the Medical Group Management Association (MGMA). • Based on wRVUs as developed by Centers for Medicare and Medicaid Services (CMS). (http://www.cms.gov/PhysicianFeeSched/ PFSRV/list.asp) (Coleman et al., 2003; VHA, 2013) Example CPT and wRVU HCPCS Description wRVUs 90791 Psych diagnostic evaluation 2.8 90792 90832 Psych diag eval w/med srvcs 2.96 1.25 Psytx pt&/family 30 minutes 90833 Psytx pt&/fam w/e&m 30 min 0.98 90834 Psytx pt&/family 45 minutes 1.89 90836 90853 Psytx pt&/fam w/e&m 45 min Group psychotherapy 1.6 .59 96101 Psych testing-psychologist/MD 1.86 96118 Neuropsych testing- psychologist/MD 1.86 96150 Assess health/behavior, initial per 15 min. .5 VA Productivity Targets* *+/- 10% of Median Observed Mean/Median wRVU by Discipline for Outpatient Care - FY 2011* Measure Psychiatrist Psychologist Social Work NP CNS OPC Productivity Mean (wRVU/ FTE(c)) 2671 2017 1299 2070 2224 2374 OPC Productivity Median (wRVU/ FTE(c)) 2574 1926 1194 1811 2227 1977 PA Tracking Productivity % % Clinical STAFF SITE TEAM FTE Time 1 1.0 100% 2 1.0 85% 3 1.0 75% 4 1.0 90% TOTAL/AVE 4.0 88% KEY >110% (Over Target) 90-110% (At Target) <90% (Below Target) wRVU Target 482.0 547.0 371.0 269.0 1,669 Oct- Jan- Apr- Jul%wRVU %wRVU %wRVU %wRVU 89% 109% 121% 110% 98% 108% 99% 112% 115% 103% 90% 100% 106% 111% 106% 118% 102% 108% 104% 110% Year Target 107% 104% 102% 110% 106% Comments psychologist full tim psychiatrist 15% sup RN - 25% program m SW - 10% training 8:00 AM 9:00 AM 10:00 AM 11:00 AM L U N C H Monday Clinic Clinic access Clinic Tuesday Clinic Clinic Clinic Clinic access Clinic Wednesday Dept & other meetings 1:00 PM admin 3:00 2:00 PM PM Clinic Clinic Dep Group access PTSD Grp Admin Thursday admin Clinic Clinic Clinic Clinic Clinic access Friday Clinic Clinic access Clinic admin Clinic Clinic Establishing Productivity Targets Review Your Provider’s Scheduling Grid – Individual and Group Psychotherapy (100% Clinical FTE) – 20*2.0 (90834) = 40 wRVUs per week; 1,920 Adjusted Target • 10% MO rate = 1,728 wRVUs – Group: .59*8 members*48 = 452 wRVUs Adjusted for the two groups • 5 members each group = 283 wRVUs – Open access clinics (5 weekly); 80% utilization = 192 hours; 90834*192 = 384 wRVUs – Target: 2,500 wRVU Calculating Clinical Utilization • Measuring and tracking no-‐‑show rates (mental health average rates are much higher than the larger population of clinics) • Calculating missed opportunity rates (clinic cancellation, patient cancellation, and no-‐‑show) • Demand-‐‑supply data (e.g., percentage of available slots utilized) • Low clinical utilization is a loss of income for your facility • NOTE: Same day access decreases no-‐‑show rates and increases likelihood of engagement Integrated Care Administrative Measures • Penetration rate (percentage of PC patients seen by integrated care providers) – By clinic – By PCP • Same day access rates (% of first appointments with integrated care seen same day) • Percentage of integrated care provider panel which is not referred to specialty MH • Percentage of patients touched by integrated care who engage in SMH once referred Integrated Care Administrative Measures Treatment Engagement (Zanjani et al., 2008) 80% 70% 70% 60% 50% 40% 32% 30% 20% 10% 0% Percentage Attending First Appointment in Specialty Mental Health Referral Management TAU Integrated Care Administrative Measures • Wait time/access measures – When a warm hand off occurs how long until the patient is able to be evaluated? – If patient is not seen same day, what is the mean waiting time in days until they can be seen. • Number of patients served • Average encounters/patient Take Home Exercise You are a new primary care psychologist for a clinic of 10,000 patients. The clinic has never had integrated care services. After your exceptional presentation on the importance of screening, your clinic colleagues have asked you to help design and implement a process for screening for depression. Divide into groups of 4 and address the following within 15 minutes: § Who will ask the screening questions and how will they be trained? § When will the screening occur? § Where will the screening occur and where will paper measures (if applicable) be stored? § How will screens be scored, results be communicated to providers, and results entered into the record? § How much time will screening require? § How will positive results be addressed in follow-up? NOTE: Make sure to design a patient flow process for each step. Questions? • Thank you! • Contact Information: Lisa K. Kearney, Ph.D., ABPP Senior Consultant for Technical Assistance Office of Mental Health Operations, VA Central Office (210) 694-6222 [email protected]