Commissioning for outcomes

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Commissioning for outcomes

• Dominic FordAssociate Director of Healthcare
  Standards

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Workshop

• Outcomes measurement
• Barriers and drivers
• Learning from the US Harkness Fellowship
• Incentives and levers
• Success factors
• Discussions

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Outcomes measurement counting the hoops

• Without (outcomes measurement) it would be like
  trying to tell who won a basketball game with no
  hoops in place to keep score. The winner then
  becomes the team with the loudest fans or the
  best story about how well they played.

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Barriers

• Psychiatrists in the UK do not use outcomes
  measures (Gilbody 2002)
• Simplisticpseudo-scientific gloss
• Robust infrastructure admin/IT resources
• Time
• Utility in clinical practice
• Detracts from therapeutic relationship
• HoNOS time, psychometric properties, added
  value, lack of support for

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Drivers

• Payment by results HoNOS
• SHA operating framework
• Minimum Data Set
• Competing for scarce resources
• Demonstrating quality to commissioners
• Refocusing CPA guidance
• Standard mental health contract
• Demands of regulators

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Pacificare Managed Behavioral Health Care
Organisation (1)

• Outcomes management in routine practice through
  periodic user ratings, feedback and provider
  assessments 7,000 participating clinicians
• Outcomes measured using (Youth) Life Status
  Questionnaire 30 items
• Completed at first, third, fifth and ongoing
  appointments easy completion

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Pacificare Managed Behavioral Health Care
Organisation (2)

• Forms faxed to Pacificare assessed using
  case-mix adjusted database rapid analysis
• Part of treatment process - tracks actual versus
  predicted change
• Feedback to clinicians produces better outcomes
  (Lambert 2001, Brown 2001)

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Pacificare Managed Behavioral Health Care
Organisation (2)

• Combines self-reports with algorithms using range
  of variables
• Reports identify at-risk cases, premature
  termination of treatment care management
  interventions, review treatment plan
• Systematic difference in patient and provider
  reports around suicide risk, substance use and
  improvement (Brown 2003)

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Pacificare Managed Behavioral Health Care
Organisation (3)

• Reduces risk and targets resources to need
  through feedback and care manager intervention
• Incentivizes providers through automatic
  authorization of treatment
• Leadership, market differentiation

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Ohio Consumer Outcomes Program (1)

• Measuring outcomes using periodic consumer,
  provider and family reports for adults, children
  and families in a devolved public system
• Multi-stakeholder task force set up in 1996
  consensus-building
• Program value-based and framed around recovery
  from users perspective symptom distress,
  quality of life, safety and health, role
  performance

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Ohio Consumer Outcomes Program (2)

• Self-reports at intake and every 6 months or
  intake and termination
• Used by consumers in recovery, for care
  management and service planning
• Mandated by state rule (linked to lower
  regulatory burden) with technical assistance,
  training and subsidy
• Producing individual red flag, strengths and
  aggregate reports including hopefulness, quality
  of life

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Massachusetts Behavioral Health Partnership (1)

• Requires network providers to use approved (18!)
  instrument
• 3.2 subsidy to cover costs of outcomes
  measurement additional subsidy for preferred
  tool Treatment Outcomes Package
• Focus on quality improvement rather than
  performance management

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Massachusetts Behavioral Health Partnership (2)

• Training and technical assistance
• BHL provides real-time (15 minutes) case-mix
  adjusted feedback summary scores in 12 domains
• First appointment and routinely

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Conclusions (1)

• Outcomes measurement far from generalised but
  increasing
• Developed through combination of sticks and
  carrots mandate, subsidy, technical assistance,
  training, feedback, continued referrals
• Developed for different reasons values, market
  share, accountability, demonstrate effectiveness,
  accreditation, cost containment

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Conclusions (2)

• Measurable improvement in outcomes essential in
  competing for resources
• Bi-dimensional approach reflecting outcomes from
  different perspectives. Whose outcomes?
• User ratings essential in recovery-oriented
  system
• Strategies to go beyond the coalition of the
  willing

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Success Factors

• Managerial and clinical champions, political will
• Integral to care
• Useful, timely data and clarity around use
• Incentives and levers to achieve buy-in
• Consensus on values and aims
• Strategic use of resources
• Training and communications
• Valid and reliable instruments
• Minimal burden
• Economical technology

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