Advancing Standards of Care Pilot Program
2010 Participation Application
We would like to invite you to participate in a new National Council Advancing Standards
of Care Pilot Program. Through participation in this year-long initiative, your organization will
be provided with the tools necessary to:
• Assess whether their treatment regimen is maximizing patient outcomes
• Implement a standardized assessment that focuses on functioning and health
• Identify areas in which structural and treatment barriers continue to block efforts
to improve standards of care.
The National Council’s Advancing Standards of Care Pilot Program is a year-long learning
collaborative involving ten community behavioral health organizations to be chosen through a
competitive application process. Involvement in this project includes both on-site and virtual
(web and phone-based) technical assistance from national experts, data management through
a web portal, and participation in a day-long Learning Congress.
The project is sponsored by Sepracor, Inc. and all project costs, including conference calls,
travel, and consultation time, are free to participants. Additionally, the National Council will
provide participating sites with $3,000 to cover incidental expenses.
Participation is limited. To be considered, please submit this application via email to
RebeccaF@thenationalcouncil.org by close of business (5:00 pm, eastern time) on September
Questions? Contact Rebecca Farley at 202.684.7457, ext. 235, or
The Advancing Standards of Care Pilot Program for People with Schizophrenia is designed
to provide clinicians and program administrators at ten Pilot Program sites with the
opportunity and means to:
• Assess whether their treatment regimen is maximizing patient outcomes
• Implement a standardized assessment that focuses on functioning and health status
• Identify areas in which structural and treatment barriers continue to block efforts to
improve standards of care.
To support the attainment of these goals, The National Council has selected MTM Services to
provide project management, technical assistance and training for the initiative. The MTM
Team of consultants will work with each of the ten selected pilot programs to accomplish the
identified goals through using a proven learning collaborative support process that will include
both onsite and offsite Internet based consultation/training.
Selection Process and Qualifying Criteria:
Ten Community Behavioral Healthcare Organizations (CBHOs) will be selected by the National
Council for participation in this process. The National Council will select sites through review of
the application and support information submitted by each applicant as well as through
individual telephonic and/or in-person site interviews of prospective candidate organizations.
Specific criteria will be used in the selection process including but not limited to:
• CBHO will vary in sizes, geographic location and have a large number of persons
with schizophrenia. Selecting pilot sites of various sizes and locations will
demonstrate that these approaches and outcomes are achievable for any clinic.
CBHO locations will be geographically diverse and represent diverse consumer
• CBHO will have demonstrated a commitment to improving care and have Chief
Executive Officers and Medical Directors willing to commit the time, energy and
enthusiasm to participate in this pilot program.
• CBHO must be able to fully participate in completing the goals of the initiative. This
requirement is especially important if the CBHO knows about a current or impending
fiscal, political, or other crisis that could substantially distract from the organization’s
ability to stay on task. CBHOs must work with the MTM Faculty to review and
assess organizational commitment in such situations as they arise.
• CBHOs must have the capacity to participate in Internet based meetings including an
adequate high speed Internet connection, conference phone equipment and an LCD
Benefits to Participating Organizations:
• Participating organizations will receive the benefit of intense consultation by expert
national consultants to assist in the achievement of project goals and objectives. All
consultant fees and expenses (excluding service encounter data measurement
capacity costs) will be covered.
• Participating organizations will have access to specialized tools and strategies that
they can use beyond the duration of the project.
• Participating organizations will receive consultation support to enhance
comprehensive clinical interventions for person with Schizophrenia and will be able
to compare on a continuing quality improvement basis the outcomes achieved with
the other nine pilot sites.
• Each of the ten CBHO participants in the initiative will receive a $3,000 stipend.
• Participating organizations will have the opportunity for professional recognition as
the initiative receives national, state and local attention and generates presentations
Organizational Commitments Required:
The Executive Team of each CBHO applying for participation must agree to the following levels
of commitment in order to be considered for project involvement:
1. Agree to identify and implement a local Advancing Standards of Care Improvement
Team including core membership by the Executive Director and members of Executive
Leadership (i.e. Executive Director, Medical Director, Clinical Director, QI Director, etc.)
that will commit adequate time, energy and enthusiasm to participate in this CQI
2. Agree to participate in an Internet based pilot program orientation session at the
beginning of the project
3. Agree to conduct a Pilot Site specific baseline Self- Assessment to determine its
current use of the panel’s recommended schizophrenia intervention strategies
4. Agree to conduct assessments on a subset of patients using an assessment tool
determined by an Expert Advisory Panel and project leads to help evaluate functional
outcomes (e.g., living independently, join workforce), QoL (e.g., relationships with
family/friends) and health risks (e.g., weight gain).
5. Commit to selecting and including a cohort of 50 patients with schizophrenia in the
pilot program using the selection criteria identified in Appendix A.
6. Commit to implement the Expert Advisory Panel’s recommended intervention
strategies, tailoring those interventions to account for clinic and community assets
available to each site as well as needs of patients with schizophrenia participating in
7. Agree to work with the National Council and MTM Team, using a Continuous Quality
Improvement model and a “Rapid Cycle Change” project plan framework to identify and
define challenges, generate solutions, implement these solutions and evaluate the
8. Agree to engage in and use the comprehensive technical assistance and training that
will be provided by the MTM consultants to provide support for change management,
solution designs, implementation and evaluation of outcomes achieved efforts. As
part of this continuous quality improvement process, each pilot program will conduct
periodic patient assessments along the three dimensions of function, QoL and health
risk using the assessment tool determined by the panel.
Technical assistance will include:
a. Review and Consultation: Each pilot program will receive consultation services
to support the implementation of identified assessment tools and recommended
intervention strategies. This will include on-site training for clinical staff and
supervisors in the proper administration, scoring and interpretation of the
assessment tools and in the selected interventions.
b. Data Management: Each pilot program will be required to enter assessment tool
scores via a SPQM Web-Based Data Submission and Reporting Portal.
• This includes the development, deployment and hosting a secure data
submission portal for all 10 pilot programs for the duration of the initiative.
Each pilot program will be provided secure SSL enabled access to the
technologies to provide dynamic data validation, error trapping, and
correction at the point of data entry. Such technologies will provide
substantial data quality controls to ensure the authenticity and validity of
• All information entered by each pilot program will be stored and analyzed
by the all pilot programs, the MTM consultation team and the Expert
Advisory Panel to inform the change process.
c. Internet Meetings and Conference Calls: All ten pilot programs will be invited
to attend learning collaborative based Internet based meetings and
teleconferences with MTM consultants to:
• Identify current level of functioning, quality of life and health risks for
identified patients and empower clinicians and teams to identify
opportunities for improvement, such as treatment changes, the
implementation of additional psychosocial interventions, or other changes
needed by the patient.
• Share progress, explore challenges encountered and brainstorm solutions
and next steps.
9. Agree to participate in a one-day Learning Conference at the end of the project period to
share strategies used and outcomes achieved. Travel expenses will be paid for up to
three staff from each pilot site.
10. Consent to and support publishing the findings of the initiative.
By signing and submitting the application below, the organization is indicating that it has read
and agrees to the project commitments outlined above.
Please complete the information requested on the following pages of the Participation
Application and return it by 5:00pm eastern time on Friday, September 3, 2010 to:
Advancing Standards of Care ParticipationTotal FTEs
Organizational Summary Application
What was the size of your
organization in the most
recent fiscal year?
What is Address: Private Non
Mailing your organizational Public Non State Other (describe):
City, State and Zip:
Profit Profit County
State: Zip Code:
Which most closely
describes your geographic Number: Suburban
Phone Fax Number: Email:
How many clinical events/encounters did your agency provide in the previous Number
fiscal year? Advancing Standards Initiative Team Information
Executive the previous Email:
How many unduplicated clients did your organization serve inDirector
What percent of clients Percent Medical Director
served were children/ Children/youth Adults Older Adults
3. Clinical Director 65+
youth, adults, or older 0-17 18-64
4. QI Director Email:
What percent of your clients served in the previous fiscal year received
medication services? Commitment: The above individuals commit that they will individually and collectively
Verification of CBHO
support the Organizational Commitments as outlined in fiscal year1were people
What percentage of your clients served in the previous numbers – 10 above. Percentage
Signed By: Title: Date:
Of the total number of people with Schizophrenia served the previous fiscal year:
1. What percent are seen at least monthly
2. What percent are receiving more than Medication Management Only
Does your organization currently use for persons with Schizophrenia an
assessment tool/measure to help evaluate functional outcomes, QoL and Yes No
health risks? (i.e., DLA-20, LOCUS, BPRS, etc.)
If YES above, please list the 1.
name/type of each 2.
assessment tool being used
for people with 3.
Evidence Based Practices: Has your center implemented and continue
to use any Evidence Based Practices (EBPs) for persons with Schizophrenia?
EBP Summary How Long Practiced?
If YES above, please list the 1. 1.
name/type of each EBP 2. 2.
being used for people with
Schizophrenia: 3. 3.
Health Indicators: Please confirm below all of the health indicators your center measures/monitors for
persons with Schizophrenia:
1. Personal History of Diabetes, Hypertension, Cardiovascular Disease Yes No
2. Family History of Diabetes, Hypertension, Cardiovascular Disease Yes No
3. Weight/Height/Body Mass Index (BMI) Yes No
4. Blood Pressure Yes No
5. Blood Glucose or HbA1C Yes No
6. Lipid Profile Yes No
7. Tobacco Use/History Yes No
8. Substance Use/History Yes No
9. Medication History/Current Medication List, with Dosages Yes No
10. Social Supports Yes No
If YES to any of the ten indicators above, please confirm how your center uses the health information collected
to support services for persons with Schizophrenia:
What is the approximate wait time (in days) from a routine level initial call for
help and the initial Intake/ Assessment for adult clients?
What is the approximate wait time (in days) from Intake/ Assessment to first
Therapy Appointment for adult clients?
What is the approximate wait time (in days) from Intake/ Assessment to first
Psychiatry Appointment for adult clients?
Does your center use a centralized scheduling system? Yes No
Does your center use concurrent documentation? Yes No
Does your center have a separate scheduling manager for the Medical Team? Yes No
Do your psychiatrists and/or advanced nurse practitioners routinely have
“drop- in” Medication Clinics?
Rate (from 1 to 10) the ease with which your organization implements change Easy = 1……….Difficult = 10
in clinical practices and operations.
Rate (from 1 to 10) how quickly your organization implements changes in Rapid = 1 ………….Failure = 10
clinical practices and operations?
What type of medical record documentation system does your organization Paper
Please tell us why your organization would like to participate in this improvement project and/or
provide any other supportive comments:
Thank you for your time, we will be in touch with you after a review
of all of the applications submitted.
Selection Criteria for Inclusion in Schizophrenia Project Pilot Cohort
Each individual entering the pilot cohort must meet the following five criteria:
1. Open Case
2. Age 18 and older
3. Diagnosis Criteria:
4. Psychiatric Hospital/ ER utilization
In the most recent 12 months:
One or more admissions of any duration to inpatient psychiatric treatment, and/or two or
more psychiatric emergency room visits.
5. Functional Criteria
Must meet at least two of the following functional criteria:
1. Has a serious impairment in social, occupational or school functioning.
2. Is unemployed or working only part-time due to mental illness and not for reasons of
physical disability or some other role responsibility (e.g., student or primary
caregiver for dependent family member); is employed in a sheltered setting or
supportive work situation, or has markedly limited work skills.
3. Requires help to seek public financial assistance for out-of-hospital maintenance
(e.g., Medicaid, SSI, SSDI, other indicators).
4. Does not seek appropriate supportive community services, e.g. recreational,
educational or vocational support services, without assistance.
5. Lacks supportive social systems in the community (e.g., no intimate or confiding
relationship with anyone in their personal life, no close friends or group affiliations, is
highly transient or has inability to co-exist within family setting).
6. Requires assistance in basic life and survival skills (must be reminded to take
medication, must have transportation to mental health clinic and other supportive
services, needs assistance in self-care, household management, food preparation
or money management, etc., is homeless or at risk of becoming homeless).
7. Exhibits inappropriate or dangerous social behavior which results in demand for
intervention by the mental health and/or judicial/legal system.