Screening for Co-occurring Disorders Within a Quality Improvement Framework

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Screening for Co-occurring Disorders Within a
Quality Improvement Framework

• Susan Brandau
• NYS Office of Alcoholism and Substance Abuse
  Services
• SusanBrandau_at_oasas.state.ny.us

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OASAS Vision A Transformed System

• Actively combats stigma
• Values quality
• Continuously improves
• Measures success by measuring individual recovery
• Adopts evidence based practices
• Tailors evidence based practice combinations to
  the needs of individual clients
• Stresses adequate housing, employment and social
  integration

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Shifts in Conceptual Framework and Policy

• No Wrong Door
• No third system of care
• Integration is Local
• No large infusion

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What is Continuous Quality Improvement?

• A quality management model whereby healthcare is
  seen as a series of processes and a system
  leading to an outcome. QI strives to make
  changes in the structural and process components
  of care to achieve better outcomes.

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Quality Improvement and Healthcare

• Added element of the client
• Passive vs. active Individuals are empowered
• Medical Errors
• Outcome of Care
• Basing Practice on Evidence

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Quality Improvement is an Orientation and Attitude

• We understand our work as processes and systems.
• We are committed to continuous improvement of
  processes and systems

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Core Principles of Continuous Quality Improvement

• Customer Focus
• Recovery Oriented
• Employee Empowerment
• Leadership Involvement
• Data Informed Practice
• Using Statistical Tools
• Prevention over Correction
• Continuous Improvement
• Participation and Communication at all levels

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Overview of a CQI Program

• Essential Program Aspects
• Provide a structure through which the core
  organization functions are evaluated and improved
• Core functions will be defined by the Mission,
  Vision, and Values of the organization
• Examples of core functions
• Outcomes client safety, clinical outcomes,
  client satisfaction
• Process client flow, fiscal issues
• Core functions operationalized for data
  collection purposes
• Examples of operationalized functions
• Outcomes med errors, suicide attempts,
  satisfaction survey data
• Process wait list latency, no show rates,
  medication costs
• Evaluation of the functions achieved through
  analysis of collected data
• Improvements accomplished through
  projects/initiatives

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Overview of a CQI Program

• Where do projects and initiatives come from?
• Internal
• Unacceptable variation in key indicators
• Management initiatives
• Client complaints
• Incidents
• External
• Literature, e.g. Evidenced Based Practices
• Benchmarking comparing organizations results to
  other, like organizations
• Regulatory agencies, changes in law/standards

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Overview of a CQI Program

• Internal and external factors will be reviewed by
  QI Committee (and others Board of Directors,
  etc)
• Projects/initiatives will be started based on
  results of prioritization process

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Setting Priorities

• Always more improvement opportunities than can be
  effectively addressed
• Set Priorities based on
• Relevance to mission
• Clinical Importance High volume, high risk,
  problem-prone
• Expected impact on outcome of care
• Available resources and cost

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What is a Project or Initiative?

• A planned activity, often involving a group of
  people, with a specific goal or expected outcome
• Quality improvement is about doing something
  based on our priorities
• Requires a planned and systematic approach

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Shared Core Method of Quality Improvement
Approaches

• Plan
• Do
• Study
• Act

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Quality Improvement Plan

• Select the project
• Understand and clarify the process
• Data
• Flowcharting
• Brainstorming
• Fishbone Diagram
• Develop a Plan of Action

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Quality Improvement Plan

• Plan the action
• Plan the pilot test of the action
• Include in the plan a measure of performance

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What is a Performance Indicator

• A quantitative tool that provides information
  about the performance of a process

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Quality Improvement Do

• Collect data
• Analyze and prioritize
• Determine most likely solutions
• Test whether our action really works before we
  make it a routine part of our daily operations

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Quality Improvement Study

• At the end of the pilot period, determine whether
  the action has had the desired effect.
• Is the modified process stable?
• Did the process improve?

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Quality Improvement Act

• If the action works
• Make it part of routine operations
• Continue to gather data to make sure you are
  holding the gains

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Quality Improvement Act

• If the action does not work
• Return to the Plan stage
• Use the test to plan a better action

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PDCA is a Cycle

• It is not about one single dramatic action, but
  about trying things to see if they work.
• Remember, life is a series of experiments.

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Evidence Based Practice

• A special QI method Systematically copying a
  process or system that works better
• Care of psychiatric disorders is an increasingly
  research based activity
• The Challenge Transfer of knowledge
• A formal rather than informal activity
• Approach fidelity.
• Objective assessment.

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Lessons and Challenges

• Collect only the data that is tied to the
  improvement you want to make.
• Keep it simple and Non-Burdensome. (Most clinics
  collect data by hand)
• Make sure the findings are communicated and that
  leadership knows about the QI project. It is part
  of the overall agency management framework.
• Dont take shortcuts. Dont skip the PDCA.
• Call your colleagues.
• Compare results across sites in an agency.

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Quality Improvement PlanTemplate

• Optional
• Sections to be completed
• Mission, Vision and Scope of services
• Leadership and QI committee
• Goals and objectives
• Selection and description of indicator
• Assessment strategies
• Approach or model to be used

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Mission/Vision Scope of ServicesSection 1 of
the plan

• Describe program philosophy
• Provide basic descriptive information including
• Description of individuals served
• Catchment area
• Type of services
• Size of the organization

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Leadership and QI CommitteeSection 2 of the plan

• The Quality Improvement Committee
• Membership issues
• Responsibilities
• Meeting frequency
• Critical role of leadership support
• Sharing of findings with stakeholders

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Goals and Objectives Section 3 of the Plan

• Long term core goals of any quality improvement
  program
• Objectives
• Related to selected goals
• Specific to the clinic
• Measurable
• Expected completion within 12 months
• A basis for the annual evaluation

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Things to Consider in Selecting a Performance
Indicator Section 4 of the Plan

• Mission of the Clinic
• Clinical importance High Volume, High Risk,
  Problem Prone
• Outcome
• Available resources and cost

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Description of Performance IndicatorSection 4 of
the Plan

• A quantitative tool that provides information
  about the performance of a clinics processes,
  services, functions or outcomes
• Data collection
• Assessment frequency

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EXAMPLE Screening for Co-Occurring Disorders

• Relevance to Mission and Clinical Importance
  Less than 20 of providers could identify a tool
  they used to screen all clients for co-occurring
  disorders
• High prevalence of co-occurring disorders in the
  population served
• Undiagnosed, untreated COD means as a client
  moves into recovery, they will have a higher rate
  of relapse-why is my client not getting better?
• Clinic 30-day retention of co-occurring disorders
  clients low

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INDICATORS

• The number of dually diagnosed clients screened
  initially and at 3, 6 and 12 month intervals
• The number of clients with COD that progress
  through treatment

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Implementation of Screening Desired Result?

• By implementing a validated screening tool such
  as the Modified Mini Screen (MMS), a provider
  will be able to identify clients in need of a
  complete mental health assessment, refer clients
  for a MH assessment, and incorporate specific
  goals into the development of a clients
  treatment plan thereby becoming more responsive
  to their needs and retain the client in treatment

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Guiding Knowledge Adoption Principles

• Training and printed material as dissemination
  strategies are necessary but not sufficient for
  practitioner behavior change
• Comprehensive and effective dissemination
  requires an ongoing interpersonal component
• Credibility of the source of information is
  critical
• Interpersonal contact promotes relationship
  building and trust

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Guiding principles (contd)

• User-friendly materials must be utilized
• Practitioners must be integral partners in the
  design and implementation process
• Provider implementation plans make the locus of
  responsibility the provider organization
• Idea champions within providers are essential for
  internal marketing and staff buy-in

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PLAN,PLAN,PLAN

• Provider selects idea champion to coordinate
  all screening activities
• Agency completes a written implementation plan
• Idea champion selects and recruits key staff
  (clinical director, clinical supervisors,
  utilization review coordinator, psychiatric
  social worker, psychiatrist) to receive training
  and replicate the training with their supervisees
• Provider collects baseline prevalence data and
  examines its client population

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Implementation Plan

• Identifies what clients are to be screened
• When screening should occur
• How clinicians will present the tool and the
  results to the client
• How the program will monitor the use of the
  screen
• What cut-point will trigger a referral for a
  complete MH assessment
• Timetables for inclusion of screening on the
  clients treatment plan

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Key Training Concepts

• What is Screening? A formal process of testing to
  determine whether a client requires further
  attention in regard to a particular disorder
• Does the chemical dependence client show signs of
  a possible MH problem that requires a complete MH
  assessment by a licensed practitioner?

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Screening vs. Assessment

• Screening process for evaluating the possible
  presence of a problem
• Assessment process for defining the nature of
  that problem and developing specific treatment
  recommendations that address the problem

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Key Training Concepts

• Role play how to conduct a screen using the MMS
• Identify the strengths/limitations of the MMS
  22-item scale to screen for mood, anxiety and
  psychotic disorders-does not screen for
  personality disorders
• Understanding the client population Identify
  treatment characteristics of clients with COD

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Basic Competencies Inherent within a No Wrong
Door Principle

• Perform a basic screening to determine whether
  COD might exist
• Form a preliminary impression of the nature of
  the disorder (anxiety, mood, psychosis,
  personality disorders)
• Conduct a preliminary screening for whether the
  client poses an immediate danger to self/others

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Basic Competencies (contd)

• Be able to engage the client to enhance and
  facilitate future interaction
• De-escalate an agitated, anxious, angry client
• Coordinate care with a MH counselor/program

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DO

• Key selected staff receive training on the MMS
• All staff become familiar with the agencys
  implementation plan
• Provider begins to screen all clients for COD
  within the first 30 days of treatment
• Provider collects data ( of positive screens,
  of positively screened clients that in fact have
  a MH diagnosis)

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DO

• Idea Champion ensures all clients receive
  screening
• Clinical Supervisors monitor client treatment
  record for presence of a timely completed screen
• Utilization Review Coordinator monitors charts to
  ensure integration of screen results within the
  client treatment plan
• Track and evaluate progress of COD clients as a
  group

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STUDY

• Review data and discuss findings in monthly QI
  meetings
• Revise agency implementation plan, if needed- is
  the preliminary cut-point effective for
  identifying clients with COD?
• Are the current service provider agreements
  sufficient ?
• Do all clients identified as needing a complete
  MH assessment receive one in a timely manner
  (access is less than 2 weeks)?
• Have clinicians bought into the process?
• Are procedures adequate for monitoring of clients
  that did not initially meet the agencys
  cut-point?

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ACT

• Revised processes are implemented
• Data collection continues to ensure that positive
  results are maintained over time adherence to
  screening protocol monitored over time
• Staff learned from each other-successful
  strategies are reinforced at staff meetings
• Additional projects are formulated that respond
  to staff identified needs (motivational
  interviewing to strengthen engagement skills,
  more in depth training on co-occurring disorders,
  development or expansion of integrated treatment
  groups, use of other EBPs)

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Lessons Learned

• No one size fits all model-agencies must develop
  their own QI process and screening protocol
• Organizational readiness, commitment to screening
  and leadership critical
• Written implementation plans developed with
  clinician feedback provide a template
• Programmatic idea champions coordinate the
  processes
• Participation of a critical mass of agency
  interdisciplinary staff
• Local models of adoption key to success
• Utilization of peer mentors helps to promote
  integration

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Buckminster Fuller

• If you want to change the way people think, give
  them a tool the use of which will lead them to
  think differently