Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

• Measurement and outcomes need consensus definitions
• State Medicaid programs need robust HEDIS and NCQA measures for all severe and persistent mental health conditions.
• Consensus definitions would help answer questions such as “Does the use of validated and evidence-based outcomes measures improve care (outcomes) for people with SPMI’s?” “Does the use of validated and evidence-based outcomes measures improve clinician outcomes?”—meaning, does the provider get better at what he or she does through the use of outcomes measures? “Do systems of care get better when they use validated, evidence-based outcomes measures?”—meaning, do whole systems get better at what they are intended to do through the use of outcomes measures?
• Overall, can systematic outcomes measurement be used to improve outcomes for patients, individual providers, and systems?

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

• Compare the effectiveness of common treatments for people with SMI with regard to patient-centered and patient-relevant outcomes (e.g., disability, functional capacity, quality of life, employment, and housing).
• Compare the effectiveness of alternative redesign strategies- such as using multidisciplinary treatment, electronic health records, decision support capabilities, and personal health records- for increasing health professionals’ compliance with evidence-based guidelines, increasing patients’ adherence to guideline-based regimens, and improving continuity of care and communication.
• Compare technological interventions with standard care.
• Compare the effectiveness of systems that build routine outcomes measurement into the care path with those that do not take this approach.
• Within systems that are moving toward routine outcomes measurement, compare the effectiveness of providers (or programs) that use this approach with those that do not.
• Within systems that build routine outcomes measurement into the care path compare outcomes of providers (or programs) that actively use these measures to inform care vs. those who do not. For instance by tracking log ons by clinicians to systems that report outcomes on their clients.

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

• Patients with Serious Mental Illness (SMI) (or specific mental illnesses)
• Age range
• Other clients who engage with a mental health or substance abuse treatment system

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

• Shared decision making with patients in order to capture more information and to lead to more valid measures of coded medical data
• Identifying standard, accepted mental health outcomes --- much like blood pressure is accepted for general health --- such as the PHQ9 as part of records for mental health assessment
• Clearly identified priority outcomes for consumers
• Need for nationally recognized measures that are evidence based for MH conditions
• Identify best approaches for implementing measurement-based care
• Use outcomes data generated to improve outcomes for patients, providers, and systems. Not enough to capture the information. It must be used to drive improvement.

Describe any health-related risks, side effects, or harms that you are concerned about.

• None to minor risks, such as annoyance for patients who do not like to fill out forms. It can take time away from “treatment,” but the point is that outcomes measurement needs to be seen as part of treatment given the potential to guide and improve care.

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Depression and other mental health disorders

AHRQ Priority Populations

• Low income groups
• Minority groups
• Women
• Elderly
• Individuals with special health care needs, including individuals with disabilities or who need chronic care or end-of-life health care

Federal Health Care Program

• Medicaid
• Medicare

Importance

Describe why this topic is important.

There is a need to develop appropriate measurements for mental health research that are based in a chronic care model and are appropriate metrics for mental health, rather than the inadequate metrics that exist today that are based on an acute-care model. These must include defining more appropriate outcomes criteria, larger sample sizes, and longer-term studies that include follow-up over time. Standardized assessments/tools for mental health are currently lacking. The way that documentation requirements (which are driven by a multiplicity of payers & regulatory agents) drives assessment, treatment & the nature of the relationship between the clinician and the individual receiving care has not been well studied, either in terms of benefits, in influencing quality of benefits, or in terms of the “unintended consequences” of specific requirements that decreased quality. Attention to documentation & specific research to develop effective & efficient approaches is particularly important to enhancing interoperability to developing electronic health records that adequately meet the needs of professionals and patients. We need to encourage more standard and consistent documentation (in patient records) vs. reality vs. consumer/providers’ perspective. Our managed care program contracts with CCNC for robust reporting on quality measures around prevention, chronic disease and risk stratification that are both chart and claims derived. Providers support and work to adopt national measures. Care alerts are created that allow for a population health approach that seeks to support at risk patients. Chronic care model holds providers accountable for the care of an individual over time. Combined this process improves care and increases the providers’ accountability to the Medicaid program for the quality of services provided. Routine use of validated, evidence-based outcomes measures can improve outcomes for patients, providers, and systems. Outcomes information can be used

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

• NC Medicaid is committed to improving the quality of care provided to our SMI population.
• Building outcomes measurement into our care is a strategic priority for Mental Health and Chemical Dependency Services for Kaiser Permanente in Northern California. We are currently piloting different approaches for bringing outcomes information into the care path to improve outcomes for members, providers, and systems.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

While this field is promising, we need to know more about the size of the impact that bringing routine outcomes measurement into the care path can have. We need to have better standardization of what outcomes to look at to facilitate comparisons across organizations. We need to know more about the best way to engage clinicians in the practice change required for them to adopt outcomes measurement as an essential part of care. Accountability for quality services may make some clinicians uncomfortable. This may increase as financial incentives are tied to quality of work vs quantity of work. Policy makers as a general rule welcome clear evidence based guidelines that can be used to support clinically sound policy.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

One nominator indicated that they would anticipate increased measurement, reporting, and training to increase the adoption of evidenced based care. Clinical policy and contract outcomes could potentially be shaped by well defined expectations.

Describe the timeframe in which an answer to your question is needed.

As soon as possible. This topic was prioritized during a series of stakeholder meetings focused on SMI, held July-August 2010.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

• There are well documented health disparities for the SMI population.
• Routine use of outcomes-informed care has the potential to delineate hidden disparities in how different groups respond to care systems. It can also point the way to practices that are particularly successful for underserved or vulnerable groups.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

One nominator indicated that they would anticipate increased measurement, reporting, and training to increase the adoption of evidenced based care. Clinical policy and contract outcomes could potentially be shaped by well defined expectations.

Are you making a suggestion as an individual or on behalf of an organization?

Individual

Please tell us how you heard about the Effective Health Care Program

1- RTI-UNC IEF topic nomination process; 2- Referred by Sharon Levine, MD, Associate Executive Director, The Permanente Medical Group; 3- Through AHRQ and CTSA activities