In today's managed care environment sponsors and payers are demanding that their providers demonstrate the efficacy of their treatment protocols. They are asking for demonstrable proof that the patients' level of functioning and quality of life is improving. This may be measured by the staff, patient and significant others, including their employers.
These outcome studies are used by the payers and plan sponsors to identify efficacy, practice patterns and cost effectiveness which are reviewed when selecting and referring a provider and clinician, negotiating contracts applying for accreditation.
Payers are interested in measures of cost, length of stay and recidivism, while sponsors (employers) are interested in client satisfaction and level of functioning, particularly with respect to on-the job performance. Unfortunately in mental health and substance abuse treatment areas there are no clearly defined standards for quality based on outcome measures. The accreditation bodies like JCAHO and CARF have developed guidelines on how to internally develop indicators of quality. JCAHO has now developed its ORYX initiative mandating some specific indicators and the federal government's HEDIS requirements do cover behavior health reporting.
Nevertheless, a myriad of different systems for monitoring and analyzing outcome data has evolved over the years. This provides the therapist with several options. One alternative is to develop your own outcome measurement instrument internally. The advantage to this approach is that it can be custom tailored to meet your exact specifications. The disadvantage is that it takes considerable effort to develop a set of reliable outcome factors that are orthogonal with respect to one another. It may also take several years to build a large database to conduct the necessary research required to properly evaluate your clinicians, programs and services.
Another option is to purchase a third party commercial product. This approach offers several benefits, not the least of which is the fact that the design and testing of the instrument has been completed.
Typically, there is a large pool of data collected using the survey that can be used as a reference point. With some of the more sophisticated psychometric tests the vendor will provide scoring, analysis and interpretation services. The disadvantage to this method is the cost. If the researcher is lucky, a well-documented and researched instrument may be found in the public domain, which will eliminate most of the cost.
Finally, there are outcome evaluation consulting firms that will conduct your research.
They will do a professional, independent and objective job and most have their own database for comparisons. Regardless of the method employed for monitoring, measuring and analyzing outcomes, the measures should be standardized among all staff members and providers participating in the project.
Information systems can play a major role in the collection, processing and reporting of outcome data. If stand-alone packages are used, they may be run on a PC or network. The results of a questionnaire or test can then be recorded in a separate database or added to the patient file on the central MIS. Some of the behavioral healthcare information systems have integrated assessment modules that allow the user to build their own outcome monitoring tools on-line.
Outcome indices must be based on standardized measurable parameters that are consistently applied by all staff. A management information system can assist in this process by forcing the therapist to used a standardized assessment tool and to answer preprogrammed questions regarding the patient's history, presenting problems, behavior, mental status, affect, etc. Code is also used to standardize responses. The coded response has the added benefit of allowing the user to select and sort records based on the content of the field. Finally, setting up text or memo fields that allow the therapist to record free form text can further individualize the outcome evaluation record.
Outcome studies will also vary by population and program type. The following bullets represent a sample list of outcomes for a children and youth service:
- Recidivism/Readmission
- Cost per episode (how effective is the service protocol?)
- Cost per presenting problem
- Contract compliance
- Billing Accuracy: Exceptions, Denials, Timelines
- Preventable adverse outcomes
- Omission of treatment or administrative procedures
- Inappropriate utilization of resources, funds, programs, staff
- Access, availability, referral, triage
- Continuity of Care problems: transfers, referrals, outside consultations, etc.
- Client, Family, Purchaser dissatisfaction
- Amount of Intervention Activity
- Referral Source dissatisfaction
- Client Records Errors/Omissions (Chart Audit)
- Number of reports of child maltreatment of clients living in their own homes
- Number of sustained reports
- Number of critical incidents
- Number and frequency of runaways
- Number of accidental injuries
- Number of suicides
- Number and rate of placement with kin
- Number of clients remaining in own school
- Number of clients with significant improvement in functioning using a standard assessment scale (the GAF would be one example)
- Number of parents with improved parenting skills
- Rate of improvement in mental health status
- Number of clients with improved school attendance
- Number of clients attaining service goals
- Percent of programs meeting performance standards defined by contract or agreement
- Percent of accredited providers
- Percent of fully licensed staff
- Average caseloads meet or below national benchmarks
- Average percentage of direct client contact versus administrative chores
- Percent of staff with advanced degrees, licenses, etc.
- Staff turnover
- Number and percentage of staff trained in cultural competency
- Number and percent of clients remaining with their family
- Number of percent of clients receiving family preservation to prevent placement
- Average LOS in out of home care
- Number and percent of clients in out of home care over 15 months
- Recidivism; number and percent of clients re-entering out of home placement
- Number of youth 18+ in independent living, employed, incarcerated after completing care
- Overall reduction in level of care
- Average reduction in length of stay in out of home care
- Number and percent of clients placed in each level of care
- Average number of placement moves per year
- Number of emergency placement changes
- Percentage of clients who feel they received the help they need
- Percentage of clients who feel they received the help they need
- Percentage of families who feel they received the help they need
- Percentage of clients and families who felt the care they received was respectful and culturally competent.
About The Authors:
Bruce Johnson, M.S., is President of Johnson Consulting Services, Inc., an information management consulting firm that specializes in working with healthcare, social service and managed care organizations. He can be reached at (800) 988-0934, www.jcsconsultants.com or by e-mail at jcs@eos.net. Mr. Schafer is a clinical records and operations management consultant. He specializes in working with managed care, behvavioral healthcare and child welfare organizations. He can be reached at (800) 661-2435, www.schaferconsulting.com or by e-mail at steve@schaferconsulting.com.
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