Advanced Clinical Social Work Practice
in Integrated Healthcare
Module 15
Marion Becker, PhD
School of Social Work
University of South Florida
Evaluation of Client Progress and Treatment
Effectiveness
Module 15: Outline
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Using technology to evaluate progress
Electronic Health Record
Health Complexity
INTERMD Methodology
Care Plan Development and Evaluation
Outcome Measurement
Using Technology to Improve Care
• For decades federal reports have prioritized the development of a
national telecommunication system for surveillance of health and
mental health data for monitoring and improving the health and
mental health of Americans. 1
• The G.W. Bush administration created the Office of the National
Coordinator for Health IT. The Obama administration is continuing &
enhancing this. H IT is bi-partisan solution
• As a result America faces an unprecedented opportunity to improve
healthcare through technology use and creation.
Electronic Health Record (EHR)
• The Electronic Health Record (EHR) is a longitudinal electronic
record of patient health information generated by one or more
encounters in any care delivery setting.
• Included in EHR information are patient demographics, progress
notes, problems, medications, vital signs, past medical history,
immunizations, laboratory data and radiology reports.
• The EHR automates and streamlines the clinician's workflow. The
EHR has the ability to generate a complete record of a clinical
patient encounter - as well as supporting other care-related activities
directly or indirectly via interface - including evidence-based
decision support, quality management, and outcomes reporting. 2
Electronic Health Record (EHR)
• To encourage the use of EHRs the government funds Medicare
and Medicaid EHR Incentive Programs that provide incentive
payments to eligible professionals, eligible hospitals and critical
access hospitals (CAHs) if they adopt, implement, upgrade or
demonstrate meaningful use of certified EHR technology to
improve care outcomes. 2
• Within the private sector, many companies are now moving
forward in the development, establishment and implementation of
EHRs as well as medical record banks and health information
exchanges to support continuous quality improvement programs
Using Technology to Evaluate Progress
• In our fragmented healthcare system medical and mental health
providers have historically used different parameters and outcome
measures to evaluate client progress and provider effectiveness.
• Before information from EHRs or other data sources can be used to
evaluate client progress and/or provider effectiveness a common
set of outcome measures and metrics must be agree upon to
document client progress over time in particular outcomes.
• In addition to traditional clinical and functional outcome measures
social workers focus on other outcome parameters emphasizing
quality of life, client goal attainment and client satisfaction with
services as markers of provider effectiveness and client progress.
Using Technology to Evaluate Progress
• Systematically collected clinical outcomes data and information from
electronic health records (EHRs) can now be used to serve clinical,
organizational and research needs. The data can also be used to
gain evidence about best clinical practices for optimal health
outcomes among different populations.
• However, to be used effectively, clinical information must be
collected regularly, stored and made accessible for those who will
use the data. Social workers should involve themselves in
institutional records, policies and the development of electronic
health records (EHR) to assure the inclusion of comprehensive
biopsychosocial information needed to evaluate social work practice
outcomes.
Evaluating Outcomes for IC
• Currently professionals in IC settings are lacking in agreement and
common procedures for identifying patient needs and evaluating
outcomes for the clinically complex clients they serve.
• For accurate evaluation of IC outcomes (including client progress
and provider effectiveness) or comparison of different treatment
approaches over time, agreed upon measures and metrics that are
collected during care are an essential first step.
• However, it is also essential to adjust outcomes based on the case
mix or health complexity of clients served.
Health Complexity and IC
• Health complexity is an important concept in healthcare outcome
measurement in that it helps identify those patients who are at risk for
high service use and poor outcomes. It is a necessary component of
outcome measurement particularly in IC settings where many patients
have complex needs and co-occurring disorders 4
• Health complexity is the interference in standard care by biological,
psychological, social and health system factors, which require a shift
from standard biomedical care to integrated care for patients to
improve. Clinically complex patients with co-occurring disorders are a
top priority for IC.
Health Complexity and IC
• Health complexity is a composite measure of interacting historical,
current state, and vulnerability health risks and health needs. It
measures both care and case complexity by examining biological,
psychological social and health system factors.4
• Health complexity measurement goes beyond the usual measures
of acuity and severity traditionally used in case mix adjustment for
outcome evaluation. Health complexity also focuses on health
system factors which can be a important barrier to optimal
healthcare outcomes.
Health Complexity and IC
• The cost off-set and economic value of IC may be greatest for
complex patients with co-occurring mental and physical health
conditions. For example, research has documented the value of IC
for patients with co-occurring medical (e.g. diabetes and rheumatoid
arthritis) and mental health conditions (e.g. depression and anxiety).
Research with long-term follow-up of these patients indicates that
early clinical improvement and cost reductions persist up to 5
years.5-6
INTERMED Methodology
• Health complexity can be measured efficiently with INTERMED
methodology using the IMTERMED-Complexity Assessment Grid (IMCAG).3
• INTERMED is the formal name for a method of health complexity
measurement and outcome assessment that has been developed to
reconnect traditionally ignored (siloed) factors including service
system characteristics that influence patient outcomes. It has
undergone development, standardization and validation in seven
languages over the last 15 years.7
INTERMED Methodology
• With the INTERMED method all the patient health risks and needs
are assessed and translated into scores which lead to provider action
and care planning. Interdisciplinary medical and mental health
communication is facilitated when using INTERMRD by the
organization of health risks and care needs in a Complexity
Assessment Grid (CAG) in which seriousness of risks and needs are
recorded and visualized with colors for easy identification and
discussion by team members.
• The CAG was specifically designed for IC. It provides an overall
picture of the healthcare needs and risks of complex patients and it
can also used to direct care planning and evaluation of clinically
complex patient care outcomes.
INTERMED Methodology
• The IM-CAG is constructed with an understanding that the relationship
between the patient, family and social worker or other care provider is
what drives the achievement of goals and leads to improvement and
good healthcare outcomes. It is therefore patient-centered and can be
enhanced with motivational interviewing techniques.
• INTERMED methodology is endorsed by the Case Management
Society of America and supported with software found at
www.intermedfoundation.org.
Developing and Evaluating Care Plans
• The IM-CAG is also a convenient tool for developing care plans and
monitoring client progress. When the IM-CAG care management
software is used the care planning process can work seamlessly
with the electronic comprehensive assessment grid using an
electronic record instead of relying on paper records and care plans.
• The advantage of the IM-CAG method and IM-CAG scores is that
they produce a holistic picture of patient health status and
healthcare needs and identify areas that may need immediate
attention. The CAG automatically records longitudinal assessments
of client progress. It identifies potential barriers to improvement and
actions need to reverse them, as well as, actions needed to improve
the patient’s health and well-being.
Outcome Measurement
• To develop increased support for IC it is necessary for social
workers and other professionals to document the value that
integrated care brings about in as many areas as possible.
• INTERMED is just one of many available approaches to
comprehensive assessment , care planning and outcome
evaluation. Social workers have many other options for monitoring
and evaluating patient outcomes in their clinical practice. They can
document changes and progress in clinical and functional status of
patients that he or she works with, as well costs of the clinical care
provided.
Outcome Measurement
• Common outcome measures used in primary care settings
include HbA1c, Personal Health Questionnaire 9 (PH-9)
evaluations, weight measurements, Generalized Anxiety
Disorder-7 (GAD-7) evaluations, health care service use,
emergency room visits, hospital admissions and readmissions,
and total cost of care. Other measures include ORS, SRS,
CORS, CSRS, and YCORS/SRS.
• While personal health information needs to be protected with
appropriate assurances, HIPPA allows aggregated assessment of
employed populations on relevant measurement, such as
disability costs, workers compensation, absenteeism and
productivity which can be used to assess the value of IC.
Evidence-based Practices for MH Used and
Researched in Primary Care
• There are a number of evidence-based practices (EBP) for
persons with mental and substance use disorders they have been
researched and evaluated for use in primary care settings
including: BRITE, DIAMOND, IMPACT, PRISM-E, PROSPECT,
RESPECT-D and TEAM. Each of these EBP approaches to
practice has it’s own specific protocol and associated outcome
measures.
• The EBPs listed above are described and reviewed in detail in the
AHRQ Publication No. 09-E003 “Evidence Report/Technology
Assessment Number 173”.
Continuous Quality Improvement (CQI)
• Continuous Quality Improvement (CQI) programs are essential to
improving healthcare outcomes. CQI in integrated healthcare is a
process of creating an environment in which management and care
providers work together to create constantly improving healthcare
quality.
• CQI is a theory-based management system that looks at processes
as well as outcomes and promotes a patient-centered philosophy of
care that is supported with process and outcomes data.
• The following slides contain information about key agencies that
support and are devoted to CQI. Visit their websites for detailed
information about their activities.
CQI-AHRQ
• AHRQ is part of the U.S. Department of Health and Human Services.
It is the lead federal agency charged with supporting research
designed to improve the quality of healthcare, reduce its cost, and
broaden access to essential services. AHRQ-supported research is
leading to a rethinking of what does and does not work at the
healthcare systems level.
• AHRQ is the agency responsible for and maintains the Consumer
Assessment of Health Plans (CAHPS) website. This website has
comprehensive information on medical errors and patient safety.
Under consumer health it also features the "Improving Healthcare
Quality – A Guide for Patients and Families", which provides very
complete information about how to get healthcare quality.
CQI-IHI
• The Institute for Healthcare Improvement (IHI) is a non-profit
organization working to accelerate improvement in healthcare systems
in the United States, Canada, and Europe by fostering collaboration
among healthcare organizations.
• It is also recognized as an organization that hosts both seminars and a
collaborative approach to reducing error in healthcare, and therefore,
contributes to improving patient safety. One important service is their
Breakthrough Series Collaborative on reducing adverse drug events
and medical errors. Their Website has a very good resource section
with relevant documents on CQI and patient safety.
CQI-JCAHO
• The mission of the Joint Commission on Accreditation of Healthcare
Organizations is to continuously improve the safety and quality of care
provided to the public through the provision of healthcare accreditation
and related services that support performance improvement in
healthcare organizations.
• The Joint Commission is a nationally recognized accreditation agency
for hospitals, managed care entities and other types of healthcare
facilities. Accreditation by the JCAHO is often used as a general mark
of quality to enhance consumer confidence, meet certain certification
requirements.
CQI-JCAHO
• JCAHO uses outcome and other performance measures to compile
reports made available to the public.
• Their website is divided into four main sections to provide customized
information to different interest groups.
1. general public
2. healthcare organizations and professionals
3. purchasers, employers, and unions
4. the international community
CQI-NAHQ
• The National Association for Healthcare Quality (NAHQ) is a leading
organization for healthcare quality professionals. The association is
dedicated to the continuous improvement of quality in healthcare and
to supporting the development of professionals in healthcare quality.
• NAHQA publishes the Journal for Healthcare Quality (JHQ), which is a
professional forum that endeavors to advance healthcare quality. It
also provides other publications and products related to CQI, with a
focus on building continuous quality improvement in healthcare teams.
CQI-NCQA
• The National Committee for Quality Assurance (NCQA) is a non-profit
organization devoted to assessing and reporting on the quality of
managed care plans.
• NCQA's mission is "to improve the quality of health care delivered to
people everywhere and to provide information that enables purchasers
and consumers of managed healthcare to distinguish among plans
based on quality, thereby allowing them to make more informed
decisions."
CQI-NCQA
• The NCQA website identifies and explains the processes of
accreditation and performance measurement, including the HEDIS
report card. HEDIS, the Health Plan Employer Data and Information
Set, is the most widely used set of performance measures for
analyzing the quality of managed care plans.
• NCQA is also in charge of the Managed Behavioral Health
Accreditation Program for managed behavioral healthcare
organizations (MBHOs). It will require the MBHO to implement a
quality improvement (QI) process centered on structure, process and
outcome, and to use this process to demonstrate improvements in the
care and service its members receive. Their website is informative
and lends itself to easy navigation.
CQI-NCQA
• Included on the NAHQ website are reports on quality, descriptions of
quality measures, a list of NCQA accredited managed care
organizations, and separate sections with information dedicated to
consumer, employer, provider, and government issues.
References
1. U.S. Department of Health and Human Services. (2000). Healthy
people 2010, With understanding and improving health and
objectives for improving health (2 vols.) (2nd ed.). Washington,
DC: U.S. Government Printing Office.
2. CMS
Http://www.cms.gov/EHRIncentivePrograms/25_Certification.asp#
3. Jha AK, DesRoches CD, Campbell EG, et al. Use of electronic
health records in U.S. hospitals. New England Journal Med
2009;360:1628–38.
4. deJonge, P.M , Bauer, I., Huyse, F.J., & Latour, C.H. (2003).
Medical inpatients at risk of extended hospital stay and poor
discharge health status: Detection with COMPRI and INTERMED.
Psychosomatic Medicine 65(4)m 534-541
References
5. Urutzer. J., Knox, W., Callahan, C., Williams, J. et al. (2008).
Collaborative care management of late-life depression in the
primary care setting: A randomized controlled trial. The Journal of
the American Medical Association, 288(22) 2836-2845
6. Stiefel, F.C. Zdrojewski, C., Bel Hadj, F., Boffa, D., Dorogi, Y. et al.
(2008). Effects pf multifaceted psychiatric intervention targeted for
complex medically ill: A randomized controlled trial. Psychotherapy
Psychosomatics, 77 (4) 247-256.
7. Stiefel, F.C., de Jonge, P.,M, Huyne, F. J.,Guex, P. et al (1999).
“INTERMED” a method to assess health service needs. Results on
its validity and clinical use. General Hospital Psychiatry, 21(1), 4956.
8. De Jonge, P.M., Huyse, F.J., . & Stiefel, F.C. (2006). Case and
care complexity in the medically ill. Medical Clinics of North
America. 90(4), 679-692.