Commissioning for Outcomes in Mental Health Jon Allen – Director of Mental Health, UHUK  And  Dr David Whitehouse – Chief ...
Commissioning for Outcomes in Mental Health <ul><li>Data Rich </li></ul><ul><li>Information Poor  </li></ul><ul><li>Knowle...
Commissioning for Outcomes in Mental Health <ul><li>Explore our thoughts, observations  and experiences on using outcomes ...
Commissioning for Outcomes in Mental Health Indentifying and Prioritising High Level Outcomes  <ul><ul><li>An outcome can ...
Commissioning for Outcomes in Mental Health Indentifying and Prioritising High Level Outcomes  <ul><li>The Commissioning c...
Commissioning for Outcomes in Mental Health Indentifying and Prioritising High Level Outcomes <ul><li>Following needs asse...
Commissioning for Outcomes in Mental Health Indentifying and Prioritising High Level Outcomes  <ul><li>The strategic  comm...
Commissioning for Outcomes in Mental Health Using outcomes from evidence based research to focus commissioning plans and p...
Commissioning for Outcomes in Mental Health Using outcomes in service specifications and contracts  <ul><li>The operating ...
Commissioning for Outcomes in Mental Health Using outcomes in service specifications and contracts  <ul><li>Negotiating co...
Commissioning for Outcomes in Mental Health Using outcomes to monitor and evaluate service delivery  <ul><li>Monitoring an...
Commissioning for Outcomes in Mental Health Using outcomes to monitor and evaluate service delivery – OptumHealth  <ul><li...
Commissioning for Outcomes in Mental Health Using outcomes to monitor and evaluate service delivery – OptumHealth  <ul><li...
Commissioning for Outcomes in Mental Health Using outcomes to monitor and evaluate service delivery – OptumHealth  Facilit...
Commissioning for Outcomes in Mental Health Using outcomes to monitor and evaluate service delivery – OptumHealth  High re...
Commissioning for Outcomes in Mental Health Using outcomes to monitor and evaluate service delivery – OptumHealth  CT Faci...
Commissioning for Outcomes in Mental Health Using outcomes to monitor and evaluate service delivery – OptumHealth  Care Ad...
Commissioning for Outcomes in Mental Health Using outcomes to monitor and evaluate service delivery – OptumHealth  How ALE...
Commissioning for Outcomes in Mental Health Using outcomes to monitor and evaluate service delivery – OptumHealth  Wellnes...
Commissioning for Outcomes in Mental Health Using outcomes to monitor and evaluate service delivery – OptumHealth  Evidenc...
Commissioning for Outcomes in Mental Health Using outcomes to monitor and evaluate service delivery – OptumHealth  ALERT® ...
Depression CHF Medical Cost Medical Cost Depression Diabetes Depression Arthritis Medical Cost Depression Cancer Medical C...
Commissioning for Outcomes in Mental Health Summary  <ul><li>Commissioning for outcomes is a complex activity which impact...
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Hsj Presentationrev2

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Presentation given at recent HSJ mental heath service quality conference

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  1. 1. Commissioning for Outcomes in Mental Health Jon Allen – Director of Mental Health, UHUK And Dr David Whitehouse – Chief Medical Officer Strategy and Innovation, OptumHealth
  2. 2. Commissioning for Outcomes in Mental Health <ul><li>Data Rich </li></ul><ul><li>Information Poor </li></ul><ul><li>Knowledge Destitute </li></ul><ul><li>Wisdom Bankrupt </li></ul>As we improve the collection of data and outcome measurements in the UK how do we ensure we don’t become:
  3. 3. Commissioning for Outcomes in Mental Health <ul><li>Explore our thoughts, observations and experiences on using outcomes in the commissioning process: </li></ul><ul><ul><li>Indentifying and prioritising high level outcomes for commissioning mental health services </li></ul></ul><ul><ul><li>Using the findings of outcomes based research to prioritise and focus commissioning plans and decisions </li></ul></ul><ul><ul><li>Using outcomes in service specifications and contracts </li></ul></ul><ul><ul><li>Using outcomes to monitor and evaluate service delivery </li></ul></ul>Introduction
  4. 4. Commissioning for Outcomes in Mental Health Indentifying and Prioritising High Level Outcomes <ul><ul><li>An outcome can be defined as a consequence or result of a set of events or interventions. </li></ul></ul><ul><ul><li>In healthcare we usually refer to clinical outcomes, or the change in the status of an individuals health and wellbeing as a result of the intervention. </li></ul></ul><ul><ul><li>These can be binary naturalistic outcomes - dead or alive, better or worse. Or measures which capture degrees of change in specific signs, symptoms or functions. </li></ul></ul><ul><ul><li>Commissioners are interested in these outcomes but also in a wider variety of outcomes which capture population level changes in health and well being , and changes in the capacity, capabilities, and clinical and cost effectiveness of the services they purchase. </li></ul></ul><ul><ul><li>However planning services on the basis of outcomes is a complex task, which in the UK is in its very early stages </li></ul></ul>
  5. 5. Commissioning for Outcomes in Mental Health Indentifying and Prioritising High Level Outcomes <ul><li>The Commissioning cycle starts with an analysis of the health needs of the population </li></ul><ul><ul><li>Local Authorities and PCTs are required to carry out and publish a Joint Strategic Needs Assessment. </li></ul></ul><ul><ul><li>The JSNA informs the Local Area Agreement and the PCTs Strategic Commissioning Plan. </li></ul></ul><ul><ul><li>In addition national priorities and commitments need to be included e.g. </li></ul></ul><ul><ul><ul><li>Public Sector Agreement Targets and the National Indicators Associated with them </li></ul></ul></ul><ul><ul><ul><li>Mental Health national priority and other indicators. </li></ul></ul></ul><ul><ul><ul><li>National strategies </li></ul></ul></ul><ul><li>The above processes and information should help identify and support the development of prioritised outcome statements that should drive commissioning strategies and plans. </li></ul><ul><li>Reduce number of homelessness acceptances </li></ul>5% of homeless acceptances are due to mental illness MH05 housing status of specialist Mental Health user on Care Programme Approach   <ul><li>Reduce number of people on incapacity benefits. </li></ul><ul><li>Increase number of people with Level 2 qualifications </li></ul>10000 people on incapacity and severe disablement benefits in PCT area with diagnosis of mental illness MH04 Employment status of specialist Mental Health user on Care Programme Approach aged between 18 and 65 Increase the proportion of socially excluded adults in settled accommodation and employment, education or training High level Outcome statement from LAA JSNA needs analysis data National mental health indicator PSA target
  6. 6. Commissioning for Outcomes in Mental Health Indentifying and Prioritising High Level Outcomes <ul><li>Following needs assessment in the commissioning cycle are the steps of reviewing </li></ul><ul><li>services, identifying gaps and or over provision and then defining the key health </li></ul><ul><li>care risks and deciding on a strategy to manage them. </li></ul><ul><li>Deciding priorities requires each key area of need to be defined in terms of an </li></ul><ul><li>outcome to be achieved – which in turn requires the identification of the most </li></ul><ul><li>Cost effective and impactful way of addressing the specific need. </li></ul><ul><li>The available evidence base should provide the starting point for determining the </li></ul><ul><li>services and or interventions to be commissioned to achieve the required outcomes. </li></ul>
  7. 7. Commissioning for Outcomes in Mental Health Indentifying and Prioritising High Level Outcomes <ul><li>The strategic commissioning plan translates the analysis from the first four steps of the commissioning cycle into health oriented outcomes for the PCT population. This in turn drives the Operational and Organisational Development plans. At each level the outcomes to be achieved become increasingly specific. </li></ul>
  8. 8. Commissioning for Outcomes in Mental Health Using outcomes from evidence based research to focus commissioning plans and priorities Once a strategic outcome is identified the tactical approach, the specific level of achievement and methods of measurement and likely costs need to be defined as part of the operational plan Depression symptoms of people with depression in work reduced to an adjusted average of 8.9 on QUIDS – SR scale Effective weekly hours worked by people with depression to be on average 29.5 hours per week within 12 months of treatment Wang PS, Simon GE, Avorn J, et al. Telephone screening, outreach, and care management for depressed workers and impact on clinical and work productivity outcomes: a randomized controlled trial. JAMA 2007;298:1401 11. Reduce days lost to work because of depression   Individual placement and support programmes are more effective than standard vocation and rehabilitation services   increase number of people on CPA working for at least one day in the year by at least 16% Burns T, Catty J, Becker T, et al. The effectiveness of supported employment for people with severe mental illness: a randomised controlled trial. Lancet 2007;370:1146–52. Inrease employment of service users on CPA Anticipated outcome Evidenced based intervention /service Desired Mental Health Outcome
  9. 9. Commissioning for Outcomes in Mental Health Using outcomes in service specifications and contracts <ul><li>The operating plans high level statements need to be operationalised through the next stages of the commissioning cycle.. Service specifications should outline the outcomes providers should achieve, these might include: </li></ul><ul><li>the outcomes to be achieved by the service in terms of improvement in population health and well being </li></ul><ul><li>The specific clinical outcome data to be collected by the provider </li></ul><ul><li>The expected clinical outcomes to be achieved by the services for individuals. </li></ul><ul><li>The type and amount of services to be delivered </li></ul><ul><li>The workforce to be deployed in terms of skills and numbers </li></ul><ul><li>The quality criteria for the service in terms of patient satisfaction, safety and compliance with clinical guidelines </li></ul>CORC data set - Patient satisfaction and Patient Reported Outcomes Patient satisfaction measure Local but derived from Vital Signs Increase patient/family/carer satisfaction with service delivery and outcomes achieved Referral data Percentage of tier 2 patients referred to tier 3/4 services Local but derived from requirements of N51 Reduce year on year the number of children and adolescents requiring a specialist tier 3 or higher mental health service CORC outcome data set Average improvement per episode of care Local , but derived from requirement of N51 Demonstrably improve the mental health, functioning and well being of children and adolescents accessing CAMHS services Data Requirement Indicator Source Outcomes
  10. 10. Commissioning for Outcomes in Mental Health Using outcomes in service specifications and contracts <ul><li>Negotiating contracts with chosen provider’s is the penultimate stage in the commissioning cycle. </li></ul><ul><li>The standard mental health contract provides a clear set of guidance and schedules for defining the </li></ul><ul><li>expected activity and quality , outcomes and data and reporting requirements for successful delivery of the contract. </li></ul><ul><li>The contract contains key national requirements for mental health services including the requirement to comply with the minimum mental health data set and national standards and guidelines relevant to the services. </li></ul><ul><li>The national contract incentivises quality through implementing Commissioning for Quality and Innovation Scheme, (CQUIN). </li></ul><ul><li>CQUIN can be used to promote the collection of specific outcome measures as baselines, or the reporting/achievement of outcomes the commissioner and provider are interested in. </li></ul>
  11. 11. Commissioning for Outcomes in Mental Health Using outcomes to monitor and evaluate service delivery <ul><li>Monitoring and evaluating services is the final step in the commissioning cycle. </li></ul><ul><li>Requires measurement of clinical and health outcomes and economic evaluation of those outcomes. </li></ul><ul><li>The Office for Health Economic report into outcome measurements recognise that this has only recently been a serious consideration in UK health policy. </li></ul><ul><li>In mental health the challenge in the UK has been engaging clinicians and service users in the routine collection of outcome data, and effectively linking outcome data to service and cost data to demonstrate benefit. </li></ul><ul><li>In the US the submission of provider claims data to health management organisations, and the incentivisation of providers to also submit outcome data has meant that there are significant, longitudinal, time series data sets of both activity and outcomes. This data is used by HMOs for; </li></ul><ul><ul><li>Quality assurance of providers </li></ul></ul><ul><ul><li>Supporting patient choice </li></ul></ul><ul><ul><li>Proactive management effectiveness and efficiency of high cost care </li></ul></ul><ul><ul><li>Predictive modelling of utilisation and preventative service provision </li></ul></ul><ul><li>The introduction of PBR in mental health and other elements of commissioning reform may introduce the opportunity to learn from US systems and processes. </li></ul>
  12. 12. Commissioning for Outcomes in Mental Health Using outcomes to monitor and evaluate service delivery – OptumHealth <ul><li>Continual enhancement to both the provider and member experience is critical to our success. Our key monitoring evaluation initiatives focus on both of these </li></ul>CQI FQM Rewards & Incentive Programs Provider Report Card Provider Report Card Provider Report Card <ul><li>Case mix-adjusted utilization and outcomes </li></ul><ul><li>Complaints </li></ul>Provider Web Portal Online access to clinician CQI profile, supporting educational material and patient ALERT information Care Advocate Treatment Reviews Receive calls to review treatment from care advocates in algorithm-identified cases Automated Provider Letters Targeted interventions with clinicians to address clinical risk factors and unexplained practice variation Provider ALERT <ul><li>Wellness Assessments </li></ul><ul><li>Claims </li></ul>Relational Transactional Predictive Modeling & Analytics Clinical Learning & Training Outcomes & Program Evaluation Appeals & Grievances
  13. 13. Commissioning for Outcomes in Mental Health Using outcomes to monitor and evaluate service delivery – OptumHealth <ul><li>Project I started July 2005 and completed December 2005. </li></ul><ul><li>Objective: Develop a standardized tool and process to provide objective performance feedback to facility network </li></ul><ul><li>Outcome: Facility Scorecard created </li></ul><ul><li>Project II started January 2006 and completed August 2006 </li></ul><ul><li>Objective: Tier the Facility Network and increase the number of facilities on a Self-Managed protocol </li></ul><ul><li>Outcome: Parameters of Tiers defined, FQM program descriptions developed and rolled out to the Care Advocacy sites in August 2006 </li></ul><ul><li>Facility Scorecard Metrics </li></ul><ul><ul><li>Average Length of Stay </li></ul></ul><ul><ul><li>Case-Mix Adjustment </li></ul></ul><ul><ul><li>30-Day Readmission Rate </li></ul></ul><ul><ul><li>Appointments Made Prior to Discharge </li></ul></ul><ul><ul><li>Percentage of 7-Day Follow-up Appointments Kept </li></ul></ul><ul><ul><li>Outcome/Experience of Care </li></ul></ul>Facility Quality Management
  14. 14. Commissioning for Outcomes in Mental Health Using outcomes to monitor and evaluate service delivery – OptumHealth Facility Quality Management
  15. 15. Commissioning for Outcomes in Mental Health Using outcomes to monitor and evaluate service delivery – OptumHealth High readmission rate & Inefficient Ok with regard to readmission rate BUT Not v. efficient
  16. 16. Commissioning for Outcomes in Mental Health Using outcomes to monitor and evaluate service delivery – OptumHealth CT Facility Quality 2008 CT facilities compared for: Readmits % of appts scheduled in 7 days % of f/u appts kept in 7 days
  17. 17. Commissioning for Outcomes in Mental Health Using outcomes to monitor and evaluate service delivery – OptumHealth Care Advocate Interventions Encounter Data Automated Clinician ALERT Messages 4-month Follow-up Wellness Assessment Questionnaire Measuring Sustainable Outcomes Required High-Risk Wellness Assessment Questionnaire between visits 8 & 10 And/Or PROPRIETARY ALGORITHMS Modified Member Questionnaire (Wellness Assessment) + Increase Frequency to Measure Treatment in Progress 1 & 3–5 New Generation ALERT® Model
  18. 18. Commissioning for Outcomes in Mental Health Using outcomes to monitor and evaluate service delivery – OptumHealth How ALERT® Benefits The Population <ul><ul><li>Focuses clinical resources on the best opportunities to impact treatment outcomes, affordability and the member experience </li></ul></ul><ul><ul><li>Appropriately manages over- and under-utilization of outpatient services </li></ul></ul><ul><ul><ul><ul><li>People who want “help” vs. need “treatment” </li></ul></ul></ul></ul><ul><ul><ul><li>Variation in practice patterns and clinician effectiveness </li></ul></ul></ul><ul><ul><li>Strengthens focus on treatment outcomes and evidence-based treatment </li></ul></ul><ul><ul><li>Better facilitates member-centric treatment planning through the use of enhanced data collection tools and analytics </li></ul></ul><ul><ul><li>Accelerates collection of treatment outcome data for care advocacy, network management and quality improvement </li></ul></ul><ul><ul><li>Improves sustainable outcomes over the long term </li></ul></ul>
  19. 19. Commissioning for Outcomes in Mental Health Using outcomes to monitor and evaluate service delivery – OptumHealth Wellness Assessment ─ Patient Questionnaires <ul><li>“ Adult” Wellness Assessment </li></ul><ul><ul><li>24 items </li></ul></ul><ul><ul><li>Depression and anxiety symptoms </li></ul></ul><ul><ul><li>Functional impairment </li></ul></ul><ul><ul><li>Well-being </li></ul></ul><ul><ul><li>Workplace absenteeism and presenteeism </li></ul></ul><ul><ul><li>Substance abuse risk and use </li></ul></ul><ul><ul><li>Health and medical comorbidity </li></ul></ul><ul><li>“ Youth” Wellness Assessment </li></ul><ul><ul><li>25 items </li></ul></ul><ul><ul><li>Global impairment in child (interpersonal, emotional, academic, behavioral) </li></ul></ul><ul><ul><li>Caregiver strain </li></ul></ul><ul><ul><li>Parental workplace absenteeism and presenteeism </li></ul></ul><ul><ul><li>Health </li></ul></ul>
  20. 20. Commissioning for Outcomes in Mental Health Using outcomes to monitor and evaluate service delivery – OptumHealth Evidenced-Based Algorithms <ul><li>ALERT’s evidenced-based algorithms identify at-risk cases by calculating: </li></ul><ul><ul><li>Risk factors : global distress score, chemical dependency, workplace risk, medical co-morbidity, admission risk, and complex conditions </li></ul></ul><ul><ul><li>Questionnaire score changes or levels : normal level, high score, high score and no change, or worsened </li></ul></ul><ul><ul><li>Clinician discordance for substance abuse risk : discrepancies between member self-reported WA responses and encounter data </li></ul></ul><ul><ul><li>Utilization pattern : frequency of visits, number of visits linked to diagnosis, or Wellness Assessment </li></ul></ul>
  21. 21. Commissioning for Outcomes in Mental Health Using outcomes to monitor and evaluate service delivery – OptumHealth ALERT® 2007 Results <ul><li>Health Status (Adult respondents after a 4-month period) </li></ul><ul><ul><li>67.4% showed significant improvement </li></ul></ul><ul><ul><li>6.3% reported slight improvement </li></ul></ul><ul><li>Workplace Absence and Presenteeism (After 4 months) </li></ul><ul><ul><li>29.4% reduction in work days missed </li></ul></ul><ul><ul><li>53.7% reduction in days impacted by presenteeism </li></ul></ul><ul><li>Medical Co-Morbidity (Adult respondents who reported at least one medical health concern at baseline) </li></ul><ul><ul><li>74% reported good to excellent health at four months, compared to 71% doing so at baseline </li></ul></ul><ul><ul><li>Those using three or fewer medical visits in a four-month period increase from 54% at baseline to 58% at four months </li></ul></ul>
  22. 22. Depression CHF Medical Cost Medical Cost Depression Diabetes Depression Arthritis Medical Cost Depression Cancer Medical Cost Commissioning for Outcomes in Mental Health Using outcomes to monitor and evaluate service delivery – OptumHealth Predictive Model Demonstrates the Effect of Depression on medical costs
  23. 23. Commissioning for Outcomes in Mental Health Summary <ul><li>Commissioning for outcomes is a complex activity which impacts on all stages of the commissioning cycle </li></ul><ul><li>National priorities and strategic needs assessments indentify the high level outcomes to be achieved </li></ul><ul><li>The Local Area Agreement and Strategic Commissioning Plan prioritize the health and social outcomes to be achieved over five years. </li></ul><ul><li>The Local operating plan defines the services to be put in place and outcomes and indicators to be achieved over the forthcoming year </li></ul><ul><li>Service specification define detailed outcomes, indicators and measures for a service to be commissioned </li></ul><ul><li>New standard contracts provide the legal means and methods to enforce and incentivise not only the delivery of services, but the achievement of outcomes and the provision of data. </li></ul><ul><li>Effective performance monitoring and evaluation needs the routine collection and patient level linking of outcome, activity and price data </li></ul><ul><li>The UK may be able to learn from systems and processes developed in the US as we move forward with commissioning reform in mental health in the UK </li></ul><ul><li>Thank You </li></ul>
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