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Behavioral Health Outcomes


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Behavioral Health Outcomes

  1. 1. Outcomes Pilot Proposal Integrating Behavioral Health Outcomes Into Routine Practice Kaiser Permanente Behavioral Health Department
  2. 2. Why integrate outcome data into clinical practice? <ul><li>OT - (on-track) patients continue to do well whether or not therapists received feedback. </li></ul><ul><li>NOT-NFb (not-on-track no feedback) patients deteriorated slightly. </li></ul><ul><li>NOT-Fb (not-on-track feedback) patients improved over the no feed back group. </li></ul><ul><li>NOT-Fb+CST (not-on-track feedback + Clinical Support Tools) patients improved over the feedback only group. </li></ul><ul><li>T/PatFb (therapist/patient feedback) patients improved over all groups. </li></ul>
  3. 3. Potential benefits to providers <ul><li>Improves outcomes for patients who are most in need of treatment. </li></ul><ul><li>Shortens treatment because barriers to progress are identified and resolved. </li></ul><ul><li>Provides objective support for discussing termination of treatment. </li></ul><ul><li>Requires minimal training and effort and is trans-theoretical. </li></ul><ul><li>High scoring patients are most at risk for poor outcome, therefore the least distressed patients may not need to be continually monitored. </li></ul>
  4. 4. Purpose of the pilot <ul><li>To investigate the feasibility of integrating an outcome measure into the routine office visits of a small group of behavioral health providers. Feasibility will be studied for patients and behavioral health providers. </li></ul>
  5. 5. How will feasibility be defined? <ul><li>Feasibility is defined in broad terms as the perceived value to patients and behavioral health providers of being given feedback on how well the patient is responding to treatment. The mechanics of administering, collecting, and recording the outcome data is not the focus of the current study. </li></ul>
  6. 6. How will feasibility be measured? <ul><li>The number of OQ-45.2’s that are administered and entered into Health Connect over the course of the study period will be measured. </li></ul><ul><li>The number of cases where OQ-45.2 data are recorded into Health Connect for every patient visit during the course of the study will be measured. </li></ul>
  7. 7. How will feasibility be measured? <ul><li>Patients’ perception of the value of receiving feedback will be measured using a survey. </li></ul><ul><li>Providers’ perception of the value of receiving feedback will be measured using a survey. </li></ul><ul><li>Providers will participate in creating the surveys. </li></ul>
  8. 8. Who will participate in this study? <ul><li>Participation will be offered to all behavioral health providers at all 3 offices. </li></ul><ul><li>Both psychotherapists and psychiatrists will be invited to participate. </li></ul><ul><li>A total of approximately 10 providers will be recruited for the study. </li></ul>
  9. 9. How will outcome data be collected and recorded? <ul><li>The paper version of the OQ-45.2 will be used as the outcome measure. </li></ul><ul><li>Support staff will administer the OQ-45.2 when the member checks in. </li></ul><ul><li>Patients will self-score the OQ-45.2 </li></ul><ul><li>Providers will enter the OQ-45.2 total score into a Health Connect questionnaire. </li></ul>
  10. 10. How will feedback be given to patients by providers? <ul><li>Providers will graph the OQ-45.2 scores for multiple visits and show the patient the graph. </li></ul><ul><li>The provider will interpret the patient’s progress as either “on track” or “not on track”, and as making “reliable progress” or “recovered”. </li></ul><ul><li>An appropriate pre-written feedback message will be pasted into the AVS and printed for the patient. </li></ul>
  11. 11. Sample feedback for poor progress <ul><li>Dear Member: </li></ul><ul><li>Research shows that therapists and clients who receive feedback on their progress in therapy have better outcomes. The following feedback is based on your responses to the questionnaire that you completed prior to our visit. </li></ul><ul><li>Your responses suggest that you are not making the expected progress in therapy, and may even have considered discontinuing visits due to lack of progress. </li></ul><ul><li>I suggest that we discuss the reasons you may not be making better progress. I encourage you to share with me any concerns or dissatisfaction you may have with me, our visits, or our treatment plan. I can explain and modify my approach to better suit your needs. Together we can find a way to get on track to a positive outcome. </li></ul>
  12. 12. Sample feedback for recovered patient <ul><li>Dear Member: </li></ul><ul><li>Research shows that therapists and clients who receive feedback on their progress in therapy have better outcomes. The following feedback is based on your responses to the questionnaire that you completed prior to our visit. Your responses show that your level of emotional distress and dysfunction is similar to the average person in the community. These results suggest that you have relatively good mental health and may not be in need of further treatment. We have discussed your current progress toward your treatment goals, and we have agreed to not schedule an additional visit at this time. I recommend you take the following action to continue making additional progress on your own (add suggestions). If you experience additional problems or believe you need an additional visit, please contact me right away. </li></ul>
  13. 13. Interpreting OQ-45.2 Data <ul><li>Approximately 25% of cases may be ‘off track” and at risk for poor outcome. </li></ul><ul><li>OQ-45.2 scores in the range of those treated at community mental health centers may need as many as 8 visits before showing improvement. </li></ul><ul><li>OQ-45.2 scores in the range of those treated in managed behavioral health care clinics may need 4 to 6 visits before showing improvement. </li></ul><ul><li>OQ-45.2 scores in the EAP range should show improvement in the second or third visit. </li></ul><ul><li>OQ-45.2 scores that are 14 or more points higher or lower show reliable improvement or deterioration. </li></ul><ul><li>OQ-45.2 scores below 63 are considered recovered. </li></ul>
  14. 14. Clinical Support Tools Decision Tree
  15. 15. Assess the Therapeutic Alliance <ul><li>Administer a measure of therapeutic alliance such as Haq-2 or SRS. </li></ul><ul><li>Ask for and give feedback on the therapeutic alliance </li></ul><ul><li>Spend additional time exploring and understanding your patient’s experience </li></ul><ul><li>Pay careful attention to the treatment goals that were mutually agreed to and the tasks necessary to achieve the goals </li></ul><ul><li>Accept responsibility ofr your part in alliance ruptures </li></ul><ul><li>Reframe the meaning of tasks or goals or modify them in order to increase cooperation and satisfaction </li></ul><ul><li>Work with resistance by retreating when necessary and explaining that the client’s resistance is understandable </li></ul><ul><li>Provide a simple rationale for your actions, behaviors, and interventions and how they are designed to achieve the patient’s goals </li></ul><ul><li>Pay attention to subtle cues that they may be a problem with the alliance </li></ul><ul><li>Allow the client to express negative feelings about the therapy or therapist. </li></ul><ul><li>Explore client’s fears about expressing negative feelings about the therapy or therapist. </li></ul><ul><li>Discuss patient’s expectations of therapy and the therapist: matching style </li></ul><ul><li>Give the client positive feedback and encouragement </li></ul><ul><li>Discuss shared in therapy experiences </li></ul>
  16. 16. Assess Readiness To Change <ul><li>Ask open ended questions about the client’s problem behaviors. Persuade them to talk about the behavior. Attention alone may help client become aware of their problems </li></ul><ul><li>Discuss positive and negative effects of the behavior, costs and benefits </li></ul><ul><li>Give straightforward advice and professional information about the negative consequences of their behavior only if the client seems ready to hear </li></ul><ul><li>Show confidence that the client has the inner strength to overcome their problems </li></ul><ul><li>Avoid offering solutions for problems at this stage. Focus on helping the client explore and resolve ambivalence for themselves </li></ul><ul><li>Clarify that you and the client have a shared understanding of the problem. The client may not give an apparent problem the same weight as the therapist. The client may have larger concerns that have not yet been revealed. </li></ul>
  17. 17. Assess Social Support <ul><li>Refer client to group therapy as an adjunct to individual therapy </li></ul><ul><li>Encourage client to join a community self-help support group </li></ul><ul><li>Role play social situations to facilitate acquisition of interpersonal skills </li></ul><ul><li>Include significant others in office visits </li></ul><ul><li>Encourage participation in clubs, service projects, special interest groups </li></ul><ul><li>Involve paraprofessional helpers </li></ul><ul><li>Discuss client’s social support network </li></ul><ul><li>Encourage activities that promote social contact </li></ul><ul><li>Intervene in client concerns about trusting others </li></ul><ul><li>Encourage client to befriend others who may need a friend </li></ul><ul><li>Intervene with social anxiety using CBT or desensitization </li></ul>
  18. 18. Communicating Results <ul><li>The results of the feasibility pilot will be discussed with the participating providers in order to gather additional feedback about their experiences using outcomes in routine care. The results and provider feedback on the study will be summarized and shared with all providers. </li></ul>
  19. 19. Next Steps <ul><li>If the results of the feasibility study are positive, a follow up study will be planned to assess the quality and cost benefits of integrating outcomes into routine care. </li></ul><ul><li>An automated process for administering, collecting, and recording outcome data will also be pursued in order to assess the feasibility of a larger scale implementation in the future. </li></ul>