Understanding and Improving
the Quality of Psychotropic Management and
Mental Health Services for Foster Youth:
Metric-Driven State QI Strategies
Stephen Crystal
Director, Center for Education and Research
On Mental Health Therapeutics/PI, MEDNET and
Mental Health CERTs
Rutgers U.
scrystal@rci.rutgers.edu
Presented at ACYF Summit Conference
Because Minds Matter: Collaborating to Strengthen Management of
Psychotropic Medications for Children and Youth in Foster Care
August 27-28, 2012 – Washington, D.C.
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Data Driven State QI Strategies:
Development and Use of Metrics at
Multiple Levels
• Use of Metrics at State Level
– Decision support for data-informed policymaking/planning.
– Assessing treatment rates, patterns, trends, guideline
consistency, comparison to cross-state and other
benchmarks, variation across geographic areas and provider
type.
– Support communication/collaboration with state stakeholders
on identification of needs and improvement strategies.
– Turning data into information: maps, graphics, trend analysis
to support CQI and a “learning care system” for children.
– What outcomes are we achieving? Toward integration of
treatment and outcome data as framework for tracking
progress.
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Use of Metrics at Provider Level
• Identifying outlier providers and prioritizing provider-level
interventions.
• Feedback to clinical providers on treatment patterns;
comparison of patterns to treatment recommendations,
benchmarking vs. other providers, etc.
• Elements of effective provider messaging: well organized
messaging formats; persistence and followup (preferably with
peer clinicians); communication to address pushback.
Change often not immediate, but feedback can have
significant impact over time. Missouri is an example of welldeveloped provider messaging procedures.
• Some states have used incentives for prescribers with best
practices—e.g., TN Best Practice Provider (BPN) network.
Referrals, exemption from PA requirements, CME access, etc.
can serve as incentives.
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Use of Metrics at Patient Level
• “Review flags” for second opinions and other
interventions. (Washington State is significant
example of well-developed, mature second opinion
programs, as will be discussed in Dr. Hilt’s
presentation).
• Prior authorizations.
• Identifying nonadherence.
• Supporting communication among participants in
decisionmaking and care for child, including multiple
prescribers and other clinicians; casework and
agency staff; judges; foster care providers; parents.
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Data Sources for Metrics
• Medicaid pharmacy claims: starting point, but
medication use alone is not an island; use best
understood in context of other clinical and service
information.
• Medicaid data on mental health services,
diagnoses, co-occurring conditions, monitoring.
Challenge: Comparability/integration of FFS, MC.
• Data on carved-out or non-Medicaid-funded
services. Important to consider limitations on
Medicaid data (generated for billing purposes)
including potential bias in diagnosis data; best
complemented with other sources of patient data.
• Integration with CWIS has great potential for
improving care mgt and outcomes assessment.
5
Collaboration Between and Within
States: Key Tool for Effective QI
• MMDLN/CERTs Antipsychotics in Children Project.
• Collaborative development of guidelines
– Texas’ development of foster care parameters.
– T-MAY.
– CERTs toolkit for management of aggression.
• CHCS collaboration.
• MEDNET multistate collaboration.
• State Quality Collaboratives.
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Measuring and Acting on Dimensions of Quality
•
•
•
Antipsychotic use rates.
Too Young: Retrospective and prospective reviews for
antipsychotic treatment of very young children. Trend to PAs for
youngest children: What age to draw the line?
Too Many
– Antipsychotic Polypharmacy
– Cross-Class Polypharmacy.
– Importance of Concurrent Use Measures (Texas an early
exemplar).
•
•
•
Too Much—Dosage Parameters and Reviews.
Managing Metabolic Risk
– Monitoring metabolic parameters, prior to and during treatment.
– Appropriate use of agents with lower metabolic burden.
Mental health evaluation; psychosocial treatment prior
to/concurrent with pharmacological treatment.
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Measuring and Acting on Dimensions of Quality
• Adherence
– MPR
– Gaps
• Diagnosis Consistent with Treatment.
– Widespread Use of APs in Children Diagnosed with ADHD,
Without More Severe Diagnoses.
– Bipolar Diagnosing: Challenges of Consistency and
Appropriateness.
• Mental Health Services Consistent with Treatment.
– Appropriate Evaluation.
– Psychosocial Interventions Prior to/Concurrent with
Pharmacological Treatment.
– Measuring Use of Evidence-Based Interventions: Data and
Coding Challenges.
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Monitoring of Mental Health Evaluation,
Psychosocial Treatment, and Followup
• Need for monitoring includes multiple aspects of treatment,
including access/use of comprehensive psychiatric evaluation
and psychosocial treatment, including supply of and access to
evidence-based psychosocial interventions.
• Particularly for antipsychotic-treated youth, elements of
appropriate management of concern may include:
– Adequate initial psychiatric evaluation;
– Utilization of appropriate psychosocial services prior to or
concurrent with pharmacological treatment;
– Appropriate followup contacts for treatment management and
monitoring, and management of metabolic risks.
• MEDNET mental health services metric in development.
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Collaborative Development of Monitoring and QI Plans
•
•
Collaborative planning, engaging multiple state agencies as
well as other key stakeholders, can be an effective tool in
achieving buy-in, engagement, and coordination across
systems. A state QI collaborative can serve as a vehicle both
for planning and for implementation of the state plan.
Baseline data on current utilization patterns/quality metrics
(optimally utilizing graphic presentations, mapping, etc.) can
be a constructive means of engaging stakeholders in
planning.
• IM-12-03 provides links to numerous resource materials.
• For appropriate psychotropic use in management of
aggression, the CERTs T-MAY (Treatment of Maladaptive
Aggression in Youth) guidelines provide an additional
resource (currently incorporated in T-MAY clinician toolkit
and in in-press papers in Pediatrics).
• Development and refinement of consensus guidelines for
foster youth; Texas parameters and beyond.
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ACP Report/Resource Guide and other materials at:
http://chsr.rutgers.edu/MMDLNAPKIDS.html
(or google Rutgers MMDLN Resource Guide)
Clinician’s Toolkit for Management
of Atypical Aggression in Youth
http://www.chainonline.org/content.cfm?menu_id=232
Email: scrystal@rci.rutgers.edu
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“Ask your doctor if taking a pill to solve all your
problems is right for you.”
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