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Using Outcomes in the Quality Improvement Process:
Using Outcomes in the Quality Improvement Process:
Using Outcomes in the Quality Improvement Process:
Using Outcomes in the Quality Improvement Process:
Using Outcomes in the Quality Improvement Process:
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Using Outcomes in the Quality Improvement Process:

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  • 1. Using Outcomes in the Quality Improvement Process: Setting System Level Standards Erik R. Stewart, Ph.D. Vice President, System Performance [email_address] Renee Kopache, M.S. Recovery Coordinator [email_address]
  • 2. History/Purpose of Outcomes <ul><li>Ohio Mental Health Outcomes Task Force (OTF) – 1996 </li></ul><ul><ul><li>Charge </li></ul></ul><ul><ul><ul><li>Develop a statewide approach to measuring consumer outcomes in Ohio’s publicly-supported mental health system </li></ul></ul></ul><ul><li>Vital Signs (1998) </li></ul><ul><li>Outcomes Implementation Pilot Coordinating Group </li></ul><ul><ul><li>Final recommendations were made in 1999. </li></ul></ul>
  • 3. Adult Outcomes Domains <ul><li>Clinical Status </li></ul><ul><ul><li>looks at symptoms that a person may experience from their illness and how much they interfere with their daily living. </li></ul></ul><ul><li>Quality of Life </li></ul><ul><ul><li>examines how “good” a person’s life is, and if their needs are being met. Also examines how much control a person has over the events in their life (empowerment). </li></ul></ul>
  • 4. Adult Outcomes Domains <ul><li>Functional Status </li></ul><ul><ul><li>This domain identifies how well a person is doing in the community including areas such as work, school and social relationships. </li></ul></ul><ul><li>Safety & Health </li></ul><ul><ul><li>Addresses how a person is doing physically and the amount of freedom they have from psychological harm from self and others. </li></ul></ul>
  • 5. Adult Outcomes: Instruments <ul><li>Adult Consumer Form A </li></ul><ul><ul><li>This form is used by consumers with a severe mental illness. (case management) </li></ul></ul><ul><ul><li>The survey consists of four parts: Quality of Life, Safety and Health, Symptom Distress and Empowerment. </li></ul></ul>
  • 6. Adult Outcomes: Instruments <ul><li>Adult Provider Form A </li></ul><ul><ul><li>consists of two parts: Functional Status and Safety & Health. </li></ul></ul><ul><ul><li>Provider’s observations and clinical judgments about the consumer’s social & role functioning, housing status, activities of daily living, criminal justice involvement, harmful behavior and victimization. </li></ul></ul>
  • 7. Adult Outcomes: Instruments <ul><li>Adult Consumer Form B </li></ul><ul><ul><li>Consists of three parts: Quality of Life (excluding empowerment, Safety & Health and Symptom Distress. </li></ul></ul><ul><ul><li>This shorter version of the Adult A form is used for adult outpatient clients. Providers of non-SMD consumers are not required to complete a provider survey. </li></ul></ul>
  • 8. Youth Outcomes Domains <ul><li>Four primary areas or domains of assessment were selected for Ohio Scales: </li></ul><ul><ul><li>Problem severity </li></ul></ul><ul><ul><li>Functioning </li></ul></ul><ul><ul><li>Hopefulness </li></ul></ul><ul><ul><li>Satisfaction with behavioral health services </li></ul></ul>
  • 9. Youth Outcomes: Instruments <ul><li>Ohio Scales </li></ul><ul><li>Three parallel forms: </li></ul><ul><ul><li>Y-form is completed by the youth (self-report for ages 12 and older). </li></ul></ul><ul><ul><li>P-form is completed by the youth’s parent (or primary caretaker). </li></ul></ul><ul><ul><li>W-form is completed by the youth’s agency worker/case manager . </li></ul></ul>
  • 10. Administration Periods <ul><li>Initial </li></ul><ul><li>6 Month </li></ul><ul><li>12 Month </li></ul><ul><li>Annually thereafter </li></ul><ul><li>(Adult Consumer Form B: Initial and Discharge administrations only) </li></ul>
  • 11. OCO History in Hamilton County <ul><li>Data collection begins – September, 2001 </li></ul><ul><li>Regular and varied production reporting begins at same time </li></ul><ul><li>Production performance abysmal , though consistent with other participating areas of State </li></ul>
  • 12. HCCMHB surveys agencies to discern impediments to production
  • 13. Agencies React
  • 14. HCCMHB representatives visit agencies to discern impediments to production
  • 15.  
  • 16. Impediments (in no particular order): 1) Excuses: <ul><li>POV boxes don’t turn on (batteries) </li></ul><ul><li>Staff refuse to complete or administer </li></ul><ul><li>Multi-million $ agency has only 1 printer </li></ul><ul><li>POV box times out too quickly </li></ul>
  • 17. Impediments (in no particular order): 2) Collection technology: <ul><li>POV data system interface with other agency data system(s) </li></ul>
  • 18. Impediments (in no particular order): 3) Lack of agency/staff “buy-in” <ul><li>We know we do good work </li></ul><ul><li>We don’t care about consumer outcomes </li></ul>
  • 19. Impediments (in no particular order): 4) Lack of products/information to staff following administrations (initially) <ul><li>Staff frustration with initial software </li></ul><ul><li>Introduction of ARROW with use limited to POV </li></ul><ul><li>Immediate red flags printout </li></ul><ul><li>Weekly reports to staff </li></ul><ul><li>Consistent supervisor response to problems </li></ul><ul><li>Use of data in “assessment update printout” </li></ul>
  • 20. Impediments (in no particular order): 5) Diffusion of responsibility (a social phenomenon that occurs in groups of people when responsibility is not explicitly assigned) <ul><li>Request made by QA/Outcomes member to resurrect regular IT/IS staff meetings at HCCMHB. Solicitation made. ONE response. </li></ul><ul><li>Lack of departmental ownership </li></ul>
  • 21. Impediments (in no particular order): 6) Agency-specific challenges <ul><li>Central Point of Access </li></ul><ul><li>New administration at agency intake? </li></ul><ul><li>Paper and pencil administration </li></ul><ul><li>Program support staff enter data </li></ul>
  • 22. QA Approach Introduced <ul><li>Quarterly indicator measuring Initial Adult Provider compliance added to existing indicators </li></ul>
  • 23. ODMH Introduces Missing Data Reports - Summer, 2003 <ul><li>Hamilton County Performance </li></ul><ul><ul><li>23% Adult OR/OE </li></ul></ul><ul><ul><li>34% Youth OR/OE </li></ul></ul>
  • 24. October, 2003 - HCCMHB and Agencies Form PI Sub-committee to Develop Production Logic
  • 25. February, 2004 – Ohio Department of Mental Health Presents State Plan for Upcoming PI Requirements
  • 26. PDCA Cycle Plan Do Check Act
  • 27. April, 2004 – Proposed Logic for OCO Production Measures Shared With Membership
  • 28. Initial Adult Consumer Production Analysis
  • 29. Initial Adult Consumer Production Analysis <ul><li>Claims data compiled for quarter under review </li></ul>CPST 10006 19 7/25/2005 2052520 Med Som 10005 19 7/20/2005 2052520 CPST 10001 28 9/2/2005 1005002 Counseling 10002 42 8/1/2005 1000001 CPST 10001 42 7/10/2005 1000001 Service Type UPID Min Age First Svc. Date UCI
  • 30. Initial Adult Consumer Production Analysis <ul><li>“ Pre-quarter period” is determined by subtracting 120 days from first date of service in period </li></ul>3/27/2005 7/25/2005 2052520 3/22/2005 7/20/2005 2052520 5/5/2005 9/2/2005 1005002 4/3/2005 8/1/2005 1000001 3/12/2005 7/10/2005 1000001 Pre-Quarter Period First Svc. Date UCI
  • 31. Initial Adult Consumer Production Analysis <ul><li>Review of claims during pre-quarter period is conducted. Those exhibiting claims are removed </li></ul>No 3/27/2005 7/25/2005 2052520 No 3/22/2005 7/20/2005 2052520 Yes 5/5/2005 9/2/2005 1005002 No 4/3/2005 8/1/2005 1000001 No 3/12/2005 7/10/2005 1000001 Pre-Quarter Claims Pre-Quarter Period First Svc. Date UCI
  • 32. Initial Adult Consumer Production Analysis <ul><li>Unduplicate list by selecting case with highest order service </li></ul>CPST 10006 19 3/27/2005 7/25/2005 2052520 Med Som 10005 19 3/22/2005 7/20/2005 2052520 Counseling 10002 42 4/3/2005 8/1/2005 1000001 CPST 10001 42 3/12/2005 7/10/2005 1000001 Service Type UPID Min Age Pre-Quarter Period First Svc. Date UCI
  • 33. Initial Adult Consumer Production Analysis <ul><li>Create date range for acceptable OCO administrations </li></ul>9/7/2005 5/26/2005 7/25/2005 2052520 8/23/2005 5/11/2005 7/10/2005 1000001 1st Svc. Plus 44 1st Svc. Minus 60 First Svc. Date UCI
  • 34. Initial Adult Consumer Production Analysis <ul><li>Merge Adult Consumer A and Adult Consumer B OCO administrations </li></ul><ul><li>Match by date when acceptable date exists </li></ul><ul><li>Determine production ratio/percentage </li></ul>
  • 35. Period under review (4 th qtr. FY 2005) Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 June 2005 May 2005 April 2005 Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 March 2005 February 2005 January 2005
  • 36. 1 st service in period May 11, 2005 Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 June 2005 May 2005 April 2005 Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 March 2005 February 2005 January 2005
  • 37. Absence of service determined for 120 day period prior to first service (ensures client is new or in new episode of care) Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 June 2005 May 2005 April 2005 Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 March 2005 February 2005 January 2005
  • 38. Outcome administration expected/sought between March 12 and June 24 Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 June 2005 May 2005 April 2005 Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 March 2005 February 2005 January 2005
  • 39. HCCMHB OCO Production Performance Improvement Measures <ul><li>Initial Measures </li></ul><ul><ul><li>Adult Consumer </li></ul></ul>
  • 40. HCCMHB OCO Production Performance Improvement Measures <ul><li>Initial Measures </li></ul><ul><ul><li>Adult Consumer </li></ul></ul><ul><ul><li>Adult Provider </li></ul></ul><ul><ul><li>Youth Consumer </li></ul></ul><ul><ul><li>Youth Provider </li></ul></ul><ul><ul><li>Youth Parent </li></ul></ul><ul><li>Six-Month Measures </li></ul><ul><ul><li>Adult Consumer </li></ul></ul><ul><ul><li>Adult Provider </li></ul></ul><ul><ul><li>Youth Consumer </li></ul></ul><ul><ul><li>Youth Provider </li></ul></ul><ul><ul><li>Youth Parent </li></ul></ul><ul><li>12-Month Measures </li></ul><ul><ul><li>Adult Consumer </li></ul></ul><ul><ul><li>Adult Provider </li></ul></ul><ul><ul><li>Youth Consumer </li></ul></ul><ul><ul><li>Youth Provider </li></ul></ul><ul><ul><li>Youth Parent </li></ul></ul><ul><li>Long-Term Measures </li></ul><ul><ul><li>Adult Consumer </li></ul></ul><ul><ul><li>Adult Provider </li></ul></ul><ul><ul><li>Youth Consumer </li></ul></ul><ul><ul><li>Youth Provider </li></ul></ul><ul><ul><li>Youth Parent </li></ul></ul>
  • 41. June, 2004 – Contract Language Established Obligating Agencies to 70% Compliance on OCO Administrations
  • 42. July, 2004 – HCCMHB Issues First “Test” Measures
  • 43.  
  • 44. PI Products Provided to Agencies:
  • 45. yes 85.71428571 70 4 24 28 Child Consumer Annual 45 10000 yes 95 70 3 57 60 Child Parent Annual 44 10000 yes 93.5483871 70 4 58 62 Child Provider Annual 43 10000 yes 78.10218978 70 60 214 274 Adult Provider Annual 42 10000 yes 84.30656934 70 43 231 274 Adult Consumer Annual 41 10000 no 0 70 5 0 5 Child Consumer 12 month 35 10000 no 66.66666667 70 4 8 12 Child Parent 12 month 34 10000 no 66.66666667 70 4 8 12 Child Provider 12 month 33 10000 no 42.85714286 70 4 3 7 Adult Provider 12 month 32 10000 no 28.57142857 70 5 2 7 Adult Consumer 12 month 31 10000 no 33.33333333 70 8 4 12 Child Consumer 6 month 25 10000 no 56.52173913 70 10 13 23 Child Parent 6 month 24 10000 yes 78.26086957 70 5 18 23 Child Provider 6 month 23 10000 no 20 70 16 4 20 Adult Provider 6 month 22 10000 no 25 70 15 5 20 Adult Consumer 06 month 21 10000 yes 77.77777778 70 4 14 18 Child Consumer initial 15 10000 yes 86.95652174 70 6 40 46 Child Parent initial 14 10000 yes 84.7826087 70 7 39 46 Child Provider initial 13 10000 no 67.44186047 70 14 29 43 Adult Provider initial 12 10000 yes 82.69230769 70 9 43 52 Adult Consumer initial 11 10000 RatioMet Ratiocalc Ratio expectation Not Submitted Submitted Total Expected Type Type Number UPID
  • 46.  
  • 47. Spreadsheet containing: <ul><li>UCI </li></ul><ul><li>First service in period date </li></ul><ul><li>Last service in period date </li></ul><ul><li>OCO time period parameters </li></ul><ul><li>Submission status </li></ul><ul><li>Date of administration for submission </li></ul><ul><li>Age of client </li></ul><ul><li>Service type by numeric rank </li></ul><ul><li>Instrument type of submission </li></ul><ul><li>Admission date </li></ul>
  • 48. Agencies may formally dispute findings on a case-specific basis
  • 49. Measures allow agencies to look closely at specific cases missing administrations to discern issues
  • 50. Had to educate agencies on intricacies of logic Tracking based upon most recent intake date
  • 51. Had to cut through many “trivial” issues that impacted few clients but served as a distraction from dealing with larger issues (those effecting many expected administrations)
  • 52. Had to deal with misunderstandings or “loose” understandings of the administration criteria (ex. Use of “person unable to complete” disposition for unplanned termination/discharges)
  • 53. Had to move past focusing upon issues related to the logic used in the PI exercise to focus on agency issues needing attention
  • 54. Had to manage areas subject to manipulation (ex. Use of “B” consumer administrations when “A” is warranted)
  • 55. ….And in the End….. (Measures of Progress Over Time)
  • 56. The Heavens Opened!!!!
  • 57.  
  • 58. Measures of Progress Relative to Other Board Areas
  • 59.  
  • 60.  
  • 61.  
  • 62.  
  • 63.  
  • 64.  
  • 65.  
  • 66.  
  • 67.  
  • 68.  
  • 69. <ul><li>Additional “learnings” </li></ul><ul><ul><li>120 day absence without new OCO/tx. Plan update – not clinically sound practice </li></ul></ul><ul><ul><li>Delayed tx. Following assessment </li></ul></ul>
  • 70. Data Use
  • 71. Ohio Scales Data
  • 72. Ohio Scales State Data Report
  • 73. Youth Consumer Findings
  • 74.  
  • 75.  
  • 76. Youth Parent Findings
  • 77.  
  • 78.  
  • 79. Youth Worker Findings
  • 80.  
  • 81.  
  • 82. Does Hamilton County data look like Statewide data?
  • 83. Youth Consumer Findings
  • 84.  
  • 85.  
  • 86. Youth Parent Findings
  • 87.  
  • 88.  
  • 89. Youth Worker Findings
  • 90.  
  • 91.  
  • 92. Does a longitudinal design change the picture?
  • 93. Youth Consumer Findings
  • 94.  
  • 95.  
  • 96. Youth Parent Findings
  • 97.  
  • 98.  
  • 99. Youth Worker Findings
  • 100.  
  • 101.  
  • 102. Does looking at everyone together make sense?
  • 103. Should the data be apportioned in some manner when considering outcomes? By Diagnosis?
  • 104. HCCMHB expenditures for treatment of youth with diagnosis of 314.01 (AD/HD) from September 2001 (inception of OCO/OYS) to ~ July, 2005 = $14,470,290 and provided care to 2,652 individuals under the age of 18.
  • 105.  
  • 106.  
  • 107.  
  • 108.  
  • 109.  
  • 110.  
  • 111. Summary: Findings for all groups (Youth, Parents, & Agency Staff) indicate that statistically significant gains are made during the initial period (6 months) of treatment. Findings did not discern statistically significant differences beyond this point.
  • 112. Examination of CY 2001 data indicates that of all children with dx.=314.01, 45% receive greater than 180 days of treatment. 25% receive greater than 375 days of treatment. 11% receive greater than 2 years of treatment.
  • 113. Considerable disparity exists between agencies in regard to the average period of treatment for children with this diagnosis.
  • 114.  
  • 115. Ohio Consumer Outcomes Data Mart http://mhwwwtest.mh.state.oh.us/Screen1/odmhFirstScreen.jsp
  • 116. Erik R. Stewart, Ph.D. Vice President, System Performance [email_address] Renee Kopache, M.S. Recovery Coordinator [email_address]

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