Consumer Driven Outcomes Management

MOBILE DIRECT OBSERV OBSERVATION TREATMENT (MDOT) OF TUBERCULOSIS PATIENTS PILOT FEASIBILITY STUDY IN NAIROBI, S KENYA March 2, 2009 2010 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.

Consumer-Driven Outcomes Management: A New Paradigm for Quality and Efficiency Improvement in Behavioral Health Consumer-Driven Outcomes Management: A New Paradigm for Quality and Table of Contents Efficiency Improvement in Behavioral Health 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.

Consumer-Driven Outcomes Management: A New Paradigm for Quality and Efficiency Improvement in Behavioral Health 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 improve the quality and efficiency mechanisms that fail to fully incorporate the voices of consumers. of services. 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. Published, peer-reviewed research has shown the following results: Policymakers and regulators should explore legislative and regulatory actions that promote  Total program costs were reduced by 10 percent to 35 evidence-based consumer-driven percent while outcomes and satisfaction improved. outcomes management. (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). 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 evidence- based consumer-driven outcomes management. Innovative Solutions for Social Impact 1 Danya International, Inc.

Consumer-Driven Outcomes Management: A New Paradigm for Quality and Efficiency Improvement in Behavioral Health The Call for Consumer The annual summit of the American College of Mental Health Administration directly affirmed Empowerment the relevance of the IOM’s report and endorsed translating its findings to the behavioral health Behavioral health care authorities broadly agree care field (Daniels & Mintz, 2002). that a defining characteristic of the field’s transformation must be the universal adoption of Issued in 2003, the final report of the consumer and family-directed care. President’s New Freedom Commission on Mental Health answered the call to apply the This commitment reflects the broader health IOM’s findings and recommendations to care industry’s direction. After its seminal 2000 behavioral health care, including the need for report To Err Is Human revealed that health care consumer empowerment. Envisioning a system in the United States was not only often of poor in which care is consumer- and family-centered quality but also unsafe, the Institute of and focused on recovery, the report asserted: Medicine’s (IOM) Committee on the Quality of Health Care in America issued a second and Consumer needs and preferences final report, Crossing the Quality Chasm: A should drive the type and mix of New Health System for the 21st Century (Kohn, services provided, and should take into Corrigan, & Donaldson, 2000; Committee on account the developmental, gender, Quality of Health Care in America, 2001). This linguistic, or cultural aspects of report: providing and receiving services. Providers should develop these  Identified six aims to guide quality customized plans in full partnership improvement efforts: safe care, effective with consumers, while understanding care, patient-centered care, timely care, changes in individual needs across the efficient care, and equitable care lifespan and the obligation to review  Defined patient-centered care as treatment plans regularly (President’s “respectful of and responsive to New Freedom Commission on Mental individual patient preferences, needs, Health, 2003). and values and ensures that patient values guide all clinical decisions” Although the need to adjust services in  Recommended that systems be accordance with client preferences has redesigned to give patients the sometimes been set in false opposition to the “opportunity to exercise the degree of imperative to implement evidence-based control they choose over health care practice (EBP), the American Psychological decisions that affect them” Association’s (APA) 2005 Policy Statement defines EBP as “the integration of the best  Suggested that “the health system should available research with clinical expertise in the be able to accommodate differences in context of patient characteristics, culture, and patient preferences,” including those preferences.” APA further explains that shaped by ethnic and cultural beliefs and “services are most effective when responsive to practices the patient’s specific problems, strengths, personality, sociocultural context, and preferences” and concludes with the Innovative Solutions for Social Impact 2 Danya International, Inc.

Consumer-Driven Outcomes Management: A New Paradigm for Quality Improvement in Behavioral Health unequivocal statement that “ongoing monitoring Administration (SAMSHA) defined 10 National of patient progress and adjustment of treatment Outcome Measures (NOMS) for use across all as needed are essential to EBP” (APA, 2005). SAMHSA-funded programs. In introducing the NOMs, Charles G. Curie, former SAMHSA Consumer empowerment’s transformational Administrator, said: effect upon quality improvement was distilled by Kaiser Permanente’s Senior Vice President Increasingly, policymakers and budget of Quality and Systems Support in a 2007 article planners at all levels—Federal, State, in Health Affairs. She wrote: local, and private—are basing funding decisions on outcome data. Eventually, Clinicians do not change outcomes this Web-based tool—SAMHSA’s alone but can do so in partnership with National Outcome Measures patients. Throughout most of the (NOMs)—will provide the public and history of health care, we have focused policymakers with the information to on the clinician side of the equation. improve the management and We have invested far less effort performance of our programs and working with patients to understand make the most of the limited dollars how to leverage their participation in available to help people attain and their own care. This represents an sustain recovery (SAMHSA, 2005) enormous untapped opportunity (Liang, 2007). Most reported NOMs data is collected in keeping with the standards of the Uniform Given that meta-analytic research about mental Reporting System (URS), a federal reporting health outcomes indicates that consumer factors system used by state mental health agencies to account for 87 percent of change achieved in compile and report annual data as part of the behavioral health services, harnessing SAMSHA/CMHS Federal Community Mental consumers’ capacity to contribute to change Health Block Grant program. Developed by represents not only a socially just endeavor, but SAMHSA and used by state agencies since also the paramount quality improvement 1997, URS provides “uniform reporting of imperative (Duncan, 2010; Wampold, 2001). State-level data to describe the public mental health system and the outcomes of its The Drive for Accountability programs,” using 21 standard data output tables (National Mental Health Information Center, The leading institutions for behavioral health 2004). policy have also recognized that quality improvement requires the widespread adoption Although they provide a useful quantitative of accurate measures of effectiveness. framework for measuring the effectiveness of service delivery and are a necessary Federal government agencies have facilitated a performance-based yardstick, the NOMs and consensus-driven process to identify and URS have two major blind spots. disseminate a small group of common measures to ensure accountability. In 2004, the Substance  They do not emphasize consumer-driven Abuse and Mental Health Services care. Soliciting client’s direct evaluation of satisfaction with services is required Innovative Solutions for Social Impact 3 Danya International, Inc.

Consumer-Driven Outcomes Management: A New Paradigm for Quality Improvement in Behavioral Health to assess only one of the NOMs’ 10 The Solution: Consumer-Driven domains (perception of care) and to complete only 2 of the URS’ 21 output Outcomes Management tables (adult consumer measures and The full quality improvement benefits promised child/family consumer measures). by the consumer empowerment and Accountability mechanisms are not accountability movements will only be realized client-centered when they exclude when consumer-driven outcomes clients from participating in 90 percent management—an approach that synthesizes of their measurements. empowerment and accountability—is widely  The current outcomes reporting process adopted. is divorced from the delivery of clinical services. Typically administered once Outcomes management empowers per year and via mail, formal consumers to be the agents of assessments of consumer satisfaction accountability stand little chance of having an impact on the course of services for the individual consumers who complete Using valid and reliable measures to solicit real- them. Even if providers sought to time, direct consumer feedback, consumer- incorporate these satisfaction measures driven outcomes management empowers as part of an ongoing feedback loop, consumers to be the agents of accountability. feasibility and relevancy would be Consumer-driven outcomes management significant concerns, as the standard amplifies consumers’ voices, enabling ongoing URS measure of client satisfaction is a monitoring of individual service delivery and 24-item instrument that asks for encouraging the tailoring of treatment as retrospective assessment. needed. While invaluable for compiling system-wide Consumer-driven outcomes management data, such measurement fails to incorporate systems share several common characteristics: direct consumer input into service delivery in a way that informs and improves treatment on a  They provide objective, quantifiable data case-by-case basis. As such, the field’s currently on the effectiveness of providers and favored mechanisms of accountability risk being systems of care. overly attentive to the requirements of reporting and insufficiently responsive to the needs of  They use measures that are valid and consumers. reliable, but also brief enough to be Without measures of outcomes that are feasibly administered during the service available in real-time and practical for session. continuous administration, behavioral health  They favor the consumer’s voice and services providers cannot hope to implement provide a formalized mechanism for the “ongoing monitoring of patient progress using the client’s ideas and preferences and adjustment of treatment” deemed by the to guide the choice of technique and APA to be an essential component of EBP. model. Innovative Solutions for Social Impact 4 Danya International, Inc.

Consumer-Driven Outcomes Management: A New Paradigm for Quality Improvement in Behavioral Health  They solicit each client’s direct feedback from 50 percent to 82 percent in one regarding factors proven to predict study and from 22 percent to 70 percent success regardless of treatment model or in another (Bohanske & Franczak, 2010; technique: the client’s self-assessment of Duncan, Miller, Wampold, & Hubble, progress early in the service process 2010). and/or the client’s perception of the  Separation/divorce rates reduced by alliance with the provider nearly 50 percent; 4 times the rate of clinically significant change (Anker,  They compare each client’s responses to Duncan, & Sparks, 2009). normative data to identify at-risk cases in real-time and provide empirically- Recent technological advances have increased based feedback messages that enable the feasibility of implementing consumer-driven providers to adjust the course of services outcomes management systems in large when needed. agencies, provider networks, and managed care organizations. For example, MyOutcomes is a The use of consumer-driven outcomes scalable and secure Web-based application. management systems has been proven to MyOutcomes supplements Web versions of the dramatically improve both the quality and valid and reliable Outcome Ratings Scale and efficiency of services. Published, peer-reviewed Session Ratings Scale with instant calculations research has demonstrated the following results: and graphs of results, empirically-based feedback messages, sophisticated data  Total program costs were reduced by 10 aggregation, record management, and HIPAA- percent to 35 percent while outcomes compliant security and privacy measures. and satisfaction improved. (Bohanske & Franczak, 2010).  Length of stay in psychotherapy was A Call to Action reduced by 40 percent to 50 percent Given its demonstrated potential to effect across a broad range of behavioral health precisely the transformation of the behavioral services (Bohanske & Franczak, 2010; health care system called for by leading experts, Duncan, Miller, Wampold, & Hubble, federal policymakers and regulators should 2010). explore legislative and regulatory avenues to  Cancellation rates declined by 40 promote the widespread adoption of consumer- percent and no-shows by 25 percent driven outcomes management systems. In all (Bohankse & Franczak, 2010; Duncan, federally-funded programs, consumer-driven Miller, Wampold, & Hubble, 2010). outcomes management should be considered as  Success rates increased in one study by a supplement to existing outcomes measurement 65 percent and by as much as 100 programs and as an independent quality percent in others (Anker, Duncan, & improvement mechanism. Consumer-driven Sparks, 2009; Miller, Duncan, Brown, outcomes management is a promising and Sorrell, & Chalk, 2006; Reese, successful approach to a stronger role for Norsworthy, & Rowlands, 2009). consumers as agents of accountability in health care.  Percentage of clients who completed substance abuse treatment increased Innovative Solutions for Social Impact 5 Danya International, Inc.

Consumer-Driven Outcomes Management: A New Paradigm for Quality and Efficiency Improvement in Behavioral Health 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.

Consumer-Driven Outcomes Management: A New Paradigm for Quality and Efficiency Improvement in Behavioral Health 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.

Consumer Driven Outcomes Management

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