Download Kearney Capturing Psychologists` Work in AHCs FINAL

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]