PERFORMANCE MEASURES FOR SUBSTANCE USE DISORDERS: CURRENT KNOWLEDGE AND KEY QUESTIONS
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1 PERFORMANCE MEASURES FOR SUBSTANCE USE DISORDERS: CURRENT KNOWLEDGE AND KEY QUESTIONS Deborah Garnick Constance Horgan Andrea Acevedo, The Heller School for Social Policy and Management, Brandeis University Addiction Health Services Research October 5, 2011 Travel partially supported by SAMHSA.
2 TODAY S PRESENTATION Context for performance measurement Expert Panel goals Three areas for development and research 2
3 CONTEXT Impetus for performance measurement Focus on accountability of clinicians and treatment programs Payment reforms, including incentive based approaches 2008 Mental Health Parity and Addiction Equity Act 2010 Patient Protection and Affordable Care Health Information Technology for Economic and Clinical Health Act (HITECH Act) Current understanding of substance use disorders and treatment 3
4 CONTEXT (continued) Institute of Medicine call for performance measures (IOM 2006, Horgan and Garnick 2005) More organizations developing, endorsing and implementing measures Washington Circle Convened in 1998 by SAMHSA to develop and pilot test performance measures for substance abuse services and promote adoption Core measures identification, initiation and engagement for commercial managed care plans (Garnick et al 2002), public sector adaptation (Garnick et al 2009) Current development of measures for Medication Assisted Treatment (MAT) (Thomas et al 2010), screening 4
5 Goals EXPERT PANEL (2010) Review current status of performance measures focused on substance use disorders Identify gaps in measures and opportunities for research, in light of our current understanding of addictive disease and recovery Develop a research agenda Support National Institute on Drug Abuse The Substance Abuse and Mental Health Services Administration s (SAMHSA) Center for Substance Abuse Treatment 5
6 THREE AREAS FOR DEVELOPMENT AND RESEARCH 1. Development of new performance measures 2. Methodological and other considerations in using performance measures 3. Implementation research -- using performance measures for accountability and quality improvement 6
7 1. DEVELOPMENT OF NEW PERFORMANCE MEASURES Structural measures Process Measures Outcome Measures Composite Measures 7
8 NEW PERFORMANCE MEASURES STRUCTURAL MEASURES Definition and use Features of a healthcare organization or system focused on capacity to provide health care Used in contracts between health plans and managed behavioral healthcare organizations, and in accreditation New measures Inclusion of drugs used in medication assisted therapy (MAT) on formulary Rates of clinicians use of evidence-based practices Rates of care coordination 8
9 NEW PERFORMANCE MEASURES PROCESS MEASURES Definition and examples Adherence to recommendations for clinical practice based on evidence or consensus Current measures include: initiation and engagement, screening/brief counseling for unhealthy alcohol use (AMA 2011), counseling on psychosocial/pharmacologic treatment options (AMA 2011), medication assisted treatment (Thomas, et al 2011) New measures Maintenance of treatment effects Tailored for specific groups of clients Additional measures for medication assisted treatment 9
10 NEW PERFORMANCE MEASURES OUTCOME MEASURES Definition and examples Health states, clinical outcomes or functioning - reflect the cumulative impact of multiple processes of care For substance use disorders -- abstinence, stable and supportive housing, employment, educational involvement, criminal justice involvement New measures Addiction as a chronic condition Focus on well-being, severity of alcohol or substance use, days of use, functionality in work and home life, health status 10
11 NEW PERFORMANCE MEASURES COMPOSITE MEASURES Definition Combine multiple measures to give a broader picture Some research on composites for co-ocurring substance use disorders and mental health Little research on composites for co-occurring substance use disorders and chronic medical conditions. New measures Aggregation of current substance abuse process measures (e.g., engagement, client was offered MAT) Composite process measures that include care for medical conditions Composite outcome measures that include multiple outcomes (e.g., abstinence, housing, employment) 11
12 2. METHODOLOGICAL AND OTHER CONSIDERATIONS IN USING PERFORMANCE MEASURES Associations between process or structural performance measures and outcomes Design issues and their impact on measure development and use New sources of information, particularly electronic health records (EHRs) Integration of performance measures -- settings outside specialty treatment and with performance measures for medical conditions 12
13 METHODOLOGICAL AND OTHER CONSIDERATIONS ASSOCIATIONS Current knowledge Treatment retention associated with better outcomes Limited literature on specific process/structural measures and outcomes Outpatient clients who engaged less likely to be arrested/incarcerated (Campbell 2009, Garnick et al 2007) Adolescents with continuity of care after residential treatment more likely to be abstinent at 3-months (Garner et al 2010) VA patients who engaged had greater reductions in addiction severity, although clinically modest (Harris et al 2010) New research What structural measures are associated with better outcomes? What process measures are associated with better outcomes? Does association vary by client group (e.g., race/ethnicity) or treatment setting? How much variation in outcomes explained by a structural or process measure? 13
14 METHODOLOGICAL AND OTHER CONSIDERATIONS DESIGN ISSUES What are appropriate approaches to case mix adjustment? What contributes to variation in performance measures? How is research influenced by the timing of data collection during the course of treatment and follow-up? How does the definition of a treatment episode influence the development of performance measures? 14
15 METHODOLOGICAL AND OTHER CONSIDERATIONS EHRs AND INTEGRATION Electronic Health Records What new opportunities for the development and assessment of measures arise from EHRs? What is the validity of data collected through EHRs? Integration In integrated settings, do settings with higher performance scores for substance use disorders also have higher scores for medical treatment? How might performance measures capture key transitions across treatment settings or sectors? 15
16 3. IMPLEMENTATION RESEARCH Focus on examining how performance measures are used for accountability and quality improvement Current implementation Capacity requirements Reporting results Policy and cost impacts Incentives 16
17 IMPLEMENTATION RESEARCH - CURRENT IMPLEMENTATION What results of performance measurement are available and how are they used? What are various stakeholders roles in selecting performance measures and educating clinicians and treatment programs about them? What efforts are in place to implement performance measures in terms of staffing, data capacity, and evaluation of the implementation? 17
18 IMPLEMENTATION RESEARCH- CAPACITY AND REPORTING Capacity How does the method for selecting measures influence their use? What is the impact of organizational culture/leadership, clinician education, incentives, or participation in national programs? Reporting How do consumers and their families preferences for information match current measures? What is the impact of providing feedback to treatment programs? 18
19 IMPLEMENTATION RESEARCH- POLICY/COST IMPACT What is the impact of health reform legislation on the implementation of measures? Does the cost of implementing measures outweigh the potential improvements in quality and savings? What is the return on investment of implementing performance measures? 19
20 IMPLEMENTATION RESEARCH- INCENTIVES (Horgan 2011) What is the right type and number of measures to make a connection between behavior and reward? Who should receive the incentive? What is the desirable balance between attainment and improvement of performance measure benchmarks? How frequent should payouts be to reinforce preferred behavior? What is the effect of non-financial interventions? 20
21 SUMMARY Key role of performance measures in quality improvement and transformations stemming from health reform Keen interest in performance measurement for substance use disorders Currently, several widely used measures Opportunities in three areas new measure development, methodological and other issues, and implementation Research dissemination and infrastructure required 21
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