1 / 36

Chart Review Project

2. Questions to be Answered by this Project. Why are some individuals so costly to treat?Can these high costs be prevented?Can quality of care for costly persons be improved?. 3. Secondary Questions. Are high costs related to the medication issues this committee has been discussing, such as m

annick
Download Presentation

Chart Review Project

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

    1. 1 Chart Review Project Sharon Farmer With help from Marc Avery, Rick Ries, and Marla Hoffmann

    2. 2 Questions to be Answered by this Project Why are some individuals so costly to treat? Can these high costs be prevented? Can quality of care for costly persons be improved?

    3. 3 Secondary Questions Are high costs related to the medication issues this committee has been discussing, such as medication adherence, multiple prescribers, and excessive use of atypical antipsychotics? Are we drawing the correct conclusions from state pharmacy data?

    4. 4 Persons Studied HRSA identified the 200 most costly persons in 2006 who: Had a diagnosis of schizophrenia Were King County residents for at least one month in 2006 Were the most costly, totaling community psychiatric inpatient claims, psychiatric medication claims, and emergency room claims for all diagnoses.

    5. 5 Chart Review Subset Forty of the 200 were randomly selected for intensive chart reviews

    6. 6 Initial Data Problems Noted The 200 included many children. Many missing pharmacy claims.

    7. 7 Final Study Samples 161 persons for analysis using King RSN electronic data and 29 ( out of the 161) persons in the “chart review subset”

    8. 8 Cost Breakdown from State Data

    9. 9 Additional RSN Costs

    10. 10

    11. 11 Who are these 161 people? Average age 42 (range 18-74) 60% men

    12. 12 RSN Diagnoses Schizoaffective disorder 40% of people Substance abuse 40% Schizophrenia 31% Personality disorder 18% Bipolar disorders 16% Depression 15% Anxiety disorders 8% Dementia/delirium/cognitive/MR 7% Other 10%

    13. 13 These people received a lot of RSN-funded services during the part of 2006 when they were in the community Outpatient/residential services (133 people) Average contacts 92 Average hours 59 Psychiatric medical services (108 people) Average contacts 10 Average hours 6.3

    14. 14 There was a high rate of incarcerations 24% of these 161 people had at least one incarceration in 2006 Maximum incarcerations 5 Maximum days 210

    15. 15 What was learned from the records of the chart review subset?

    16. 16 These people have a lot of physical health problems The expected problems Serious trauma Abortions Nutritional problems Tardive dyskinesia

    17. 17 Prescribing practices were often exemplary Multiple prescribers was usually justifiable, when this occurred. The average person received only 2.25 different antipsychotics during 2006. Since these people were doing poorly, a change in antipsychotic medication may well have been to address emerging symptoms.

    18. 18 (exemplary, cont.) Medication adherence was promoted in 7 persons by the use of liquid medications, Zydis, and Consta. “Treatment resistance” was addressed with clozapine trials in 4 persons.

    19. 19 High Dose and Simultaneous Atypicals In 20% of courses of treatment, at least one prescription was over the FDA maximum. Only one prescription was more than double the FDA maximum. Simultaneous use of two antipsychotics was very common.

    20. 20 Reasons for being High Cost Active refusal of recommended psychiatric medications---52% refused medications most of the time and an additional 7% refused primarily just prior to a hospitalization Abuse of substances and active refusal of CD treatment----31% Poor response to antipsychotic medications---17% High acuity when first eligible for RSN services---17% Assault in a nursing home---14% High price of medications---7% ER abuse---3% Other---7%

    21. 21 Why the conclusion is active refusal: most of the people in the chart review subset where in highly structured and highly supervised settings for large percentages of 2006. (Graph below shows where the average person was for the percentage of days noted in 2006.)

    22. 22 Also, the average person in the subset was on a civil commitment (involuntary hospitalization +/- a “less restrictive” outpatient court order) for 36% of the year.

    23. 23 The Lives Behind the Data

    24. 24

    25. 25

    26. 26 Where are they now? 15 persons are in outpatient/residential or specialized services in King County 7 persons are known to be dead 3-4 persons are currently at WSH 3 we think are no longer in the area 1 is in an intensive residential program for persons with high medical needs

    27. 27 Areas for Quality Improvement

    28. 28 To address psychiatric treatment refusal Make mental health treatment more desirable for this population Recovery Enhanced relationships with treatment providers Encourage more use of long-acting injectable antipsychotics

    29. 29 To address CD treatment refusal Need improvements in the involuntary treatment law for substance abuse Broader eligibility requirements More coercion (currently, most orders must be “agreed” orders) More residential programs that can treat seriously mentally ill people Improve skills of health professionals in identifying and motivating persons in need of treatment. Primary care providers are in a good position to catch these problems early.

    30. 30 To address poor response to medications Need medications developed that will work for these people

    31. 31 To address the needs of people who are highly acute at the time of entry into state/RSN-funded services Improved crisis services Improve the public’s awareness of crisis services

    32. 32 To address the long hospitalizations subsequent to assaults in nursing homes Prevent the assaults Improve training of NH staff (and reduce staff turnover) Screen for assault risk and address in treatment plan (e.g. with closer monitoring) Change regulations for the use of restraints and antipsychotic medications, so these can be used appropriately when needed In general, try to avoid discharging violent psychiatric inpatients to nursing homes Develop more placement options for this population. Need further development of the concept of “secure residential facilities” and funds to create them

    33. 33 To address ER abuse We need ongoing state data regarding ER use of persons receiving services in King RSN

    34. 34 Summary There are opportunities to decrease the costs and improve the quality of care for high cost persons in King County. King RSN is already working on many of these. The state can help us in the areas of involuntary CD treatment laws and resources, identification of ER abusers, and improvements for persons in need of nursing homes.

    35. 35 Important Points for DUR Members Claims data can be the tip of the iceberg HRSA needs to improve the quality of its diagnosis data. Gaps in antipsychotic prescriptions and multiple prescribers involved in the treatment of an individual may be prone to misinterpretation, at least for high cost persons.

    36. 36 Questions? Sharon Farmer MD King County Regional Support Network sharon.farmer@kingcounty.gov 206-263-8945

More Related