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Understanding and Improvingthe Quality of Psychotropic Management and

Mental Health Services for Foster Youth: Metric-Driven State QI Strategies

Stephen CrystalDirector, 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 ConferenceBecause Minds Matter: Collaborating to Strengthen Management of

Psychotropic Medications for Children and Youth in Foster CareAugust 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 well-developed 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.

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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.”