National Voluntary Consensus Standards for Patient Outcomes Mental Health Steering Committee Meeting November 16-17,

1. 1 National Voluntary Consensus Standards for Patient OutcomesMental Health Steering Committee Meeting November 16-17, 2009 

2. Meeting goals Orientation to NQF and current activities Orientation to Outcomes project and work plan Discussion of the scope of the Mental Health Outcomes Project Discuss upcoming “Call for Measures” Discussion of the measure evaluation process 2

3. 3 What is NQF ? The National Quality Forum is a private, non profit voluntary consensus standards-setting organization. Membership: 400+ Member organizations – organized into 8 stakeholder Councils NQF Structure: Board of Directors Consensus Standards Approval Committee (CSAC) National Priorities Partnership (NPP) Leadership Network The NQF Board of Directors mirrors the diversity of stakeholders interested in our mission with a deliberate but slight over representation of consumers and purchasers due to our mission – which is summarized on this next slide. ‘(1) IN GENERAL- For purposes of activities conducted under this Act, the Secretary shall identify and have in effect a contract with a consensus-based entity, such as the National Quality Forum, that meets the requirements described in subsection (c). Such contract shall provide that the entity will perform the duties described in subsection (b). The NQF Board of Directors mirrors the diversity of stakeholders interested in our mission with a deliberate but slight over representation of consumers and purchasers due to our mission – which is summarized on this next slide. ‘(1) IN GENERAL- For purposes of activities conducted under this Act, the Secretary shall identify and have in effect a contract with a consensus-based entity, such as the National Quality Forum, that meets the requirements described in subsection (c). Such contract shall provide that the entity will perform the duties described in subsection (b).

4. www.qualityforum.org 4

5. NQF Mission To improve the quality of American healthcare by setting national priorities and goals for performance improvement, endorsing national consensus standards for measuring and publicly reporting on performance, and promoting the attainment of national goals through education and outreach programs.

6. 6 Quality Measurement in Evolution Drive toward higher performance Shift toward composite measures Measure disparities in all we do Harmonize measures across sites and providers Promote shared accountability & measurement across patient-focused episodes of care: Outcome measures Appropriateness measures Cost/resource use measures coupled with quality measures

7. 7 NQF Strategic Goals NQF-endorsed™ standards will become the primary standards used to measure the quality of healthcare in the United States; NQF will be the principal body that endorses national healthcare performance measures, quality indicators and/or quality of care standards; NQF will increase the demand for high quality healthcare; and NQF will be recognized as a major driving force for and facilitator of continuous quality improvement of American healthcare quality.

8. 8 Growth of NQF Endorsed Measures Expanded set of measures with several drivers: Measures needed for pay-for-performance programs Measures that address important gaps: Measures at the individual physician level Disparities-sensitive measures Measures of patient experience in multiple settings Cross-cutting areas (e.g., medication management, healthcare associated infections) Key issues for NQF portfolio: Too many, too few, right measures? Availability of data sources Transition to EHRs

9. Quality and Disparities Measurement Assessment of quality by race, ethnicity, primary language and SES status needs to become a routine part of performance measurement Explore direct methods for collecting race, ethnicity, primary language, and SES data in an efficient, effective, patient-centered manner or consider indirect methods Identify measures that are “disparity-sensitive” that should be routinely stratified: NQF Criteria: prevalence, impact of the condition, impact of the quality process, quality gap 9

10. 10 Episode Framework: Acute MI

11. Need for national priorities & goals Focus: Center on high-leverage areas to achieve high return on investment. Align: Harmonize efforts of “multiple groups” around common goals for improvement. Accelerate: Emphasize the urgent need to drive fundamental change in delivery system. Priorities will allow us to FOCUS and ALIGN our efforts to ACCELERATE change. Priorities will allow us to FOCUS and ALIGN our efforts to ACCELERATE change.

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13. 13 Selecting the National Priorities The Partners focused on areas that would have the most immediate impact, and looked for goals that would help to eliminate harm, improve the delivery of effective care , eradicate healthcare disparities, and remove waste from the system.  The Partners focused on areas that would have the most immediate impact, and looked for goals that would help to eliminate harm, improve the delivery of effective care , eradicate healthcare disparities, and remove waste from the system. 

14. 14 National Priorities & Goals Ensure patients receive well-coordinated care across all providers, settings, and levels of care Medication reconciliation Preventable hospital readmissions Preventable ED visits Improve the health of the population Preventive services Healthy lifestyle behaviors Population health index Improve the safety and reliability of America’s health care system Hospital-level mortality rates Serious adverse events Healthcare associated infections

15. 15 National Priorities& Goals Engage patients and families in managing health and making decisions about care Informed decision-making Patient experience of care Patient self-management Guarantee appropriate and compassionate care for patients with life-limiting illnesses Relief of physical symptoms; meet psychosocial and spiritual needs Communication regarding treatment options and prognosis Access to palliative care & hospice services Eliminate waste while ensuring the delivery of appropriate care

16. Potential Areas of Overuse Inappropriate medication use Unnecessary laboratory testing Unwarranted diagnostic procedures Unnecessary maternity care interventions Unnecessary consultations Potentially harmful preventive services (USPSTF “D” list) Preventable hospitalization and ED visits Inappropriate non-palliative care at end-of-life 16

17. www. .nationalprioritiespartnership.org 17

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19. 19  Health IT Landscape Accelerate ongoing efforts defining how health information technology can evolve to effectively support performance measurement. The American Recovery and Reinvestment Act (ARRA) Adoption of qualified electronic health records Includes patient demographic and clinical health information, such as medical history and problem lists Has the capacity to provide clinical decision support; to support physician order entry; to capture and query information relevant to health care quality; to exchange electronic health information with, and integrate such information from other sources

20. Comprehensive Data Needed to Generate Performance Information Moved this slide up – it sets up next slideMoved this slide up – it sets up next slide

21. 21 NQF Health IT Expert Panel Quality Data Set (QDS): Data types and data elements needed for quality measurement and clinical decision support Data Workflow: Sources and flow of data within and across healthcare Plans to develop a measure authoring tool to ensure consistency and harmonization

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23. Outcomes Project Funded by HHS 3 Outcomes Steering Committees ( main, child health and mental health) Focus on cross-cutting and condition- specific outcomes Expand NQF’s current portfolio of mental health outcome measures 23

24. Outcomes Project Conditions Phase 1 Cross-cutting Respiratory: asthma, COPD Cardiovascular: CAD, AMI, HF, a-fibrillation, stroke/TIA Metabolic: diabetes, chronic kidney disease Phase 2 Bone and joint: Rheumatoid and osteoarthritis, osteoporosis, hip fracture Cancer: breast, colo-rectal, prostate, lung, endometrial GI/biliary: cholecystitis, GERD, ulcer disease Infectious disease: UTI, pneumonia Eye care: glaucoma, cataract Phase 3 Mental health: Depression and serious mental illness; Alzheimer’s and related disorders Child Health 24

25. Mental Health Outcomes Project Goals To identify, evaluate and endorse additional measures suitable for public reporting and quality improvement that specifically address outcomes of mental health. This project includes cross-cutting (not condition-specific) outcome measures as well as condition specific outcome measures (e.g., depression, Alzheimer’s & related disorders). To identify gaps in existing outcome measures and recommend potential outcome measures to fill those gaps. 25

26. NQF-endorsed Outcome Measures 16 endorsed mental health measures 3 endorsed mental health outcome measures 26

27. NQF Endorsed Measures for Mental Health Disease specific Bipolar Depression Assessment Adherence 27

28. Challenges to Mental Health Measurement Traditional emphasis on measures for adults, especially older adults in the acute healthcare setting Multi dimensional mental health paradigm (e.g., disease, disease processes, substance abuse co-morbidities or varying points of service utilization) Inconsistent application of cross-cutting measures for the mental health population (e.g., medication reconciliation, asthma) Source of information 28

29. NQF Plans to Increase Value of Measures Re-tooled measures appropriate for the mental health population Convene mental health stakeholders to identify endorsed measures that could be “re-tooled” and specified for the mental health population Outcome measures for the mental health population Launching new consensus development project on Mental Health Outcomes Measures applicable to NPP National Priorities and Goals for the mental health population Endorse measures related to national priorities and goals applicable to the mental health population 29

30. 30 Developing Consensus Formal consensus development process (CDP) Attention to overall strategy for measuring and reporting healthcare quality, including establishing national goals Multi-stakeholder membership including consumers, purchasers, plans, professionals, providers, quality and researchers, community and public health and supplier and industry organizations Public and private sector representation on governing board Focus is on the entire continuum of healthcare Formal endorsement as “voluntary consensus standards” NQF has several unique features that are worth summarizing. First, as I mentioned we apply a very specific process – that we call the Consensus Development Process or CDP – to gain consensus about which measures/practices should be national voluntary consensus standards under the National Technology Transfer and Advancement Act which I’ll review next. As previously mentioned, we are an open membership organization, with diverse representation from the full spectrum of healthcare stakeholders including private and public organizations As you will learn, we are ecumenical about our interests in healthcare quality – our work crosses settings, conditions, populations, and providers NQF has several unique features that are worth summarizing. First, as I mentioned we apply a very specific process – that we call the Consensus Development Process or CDP – to gain consensus about which measures/practices should be national voluntary consensus standards under the National Technology Transfer and Advancement Act which I’ll review next. As previously mentioned, we are an open membership organization, with diverse representation from the full spectrum of healthcare stakeholders including private and public organizations As you will learn, we are ecumenical about our interests in healthcare quality – our work crosses settings, conditions, populations, and providers

31. 31 Consensus Development Process This slide is a visual schematic of the CDP. This slide is a visual schematic of the CDP.

32. 32 Roles of the Steering Committee Act as a proxy for the NQF multi-stakeholder membership for a specific project Work with NQF staff to achieve the goals of the project Evaluate candidate measures against the formal measure evaluation criteria Make recommendations to the NQF membership for endorsement Respond to comments submitted during the review period Co-chair(s) represent the Steering Committee when the CSAC meets Respond to any directions from the CSAC Make earlier, after presentation of project goalsMake earlier, after presentation of project goals

33. Roles of the Steering Committee Bring clinical expertise to a large project that addresses many different clinical conditions Advise the Steering Committee: Consider the information submitted by the measure steward Draft measure evaluation of the sub-criteria Respond to Committee questions Provide comments to the Committee on a measure’s strengths and/or weaknesses 33

34. 34 Role of NQF Staff NQF project staff works with SC to achieve the goals of the project and ensure adherence to the consensus development process: Organize and staff SC meetings and conference calls Guide the SC through the steps of the CDP and advises on NQF policy and procedures Draft measure evaluations and reports for SC review Ensure communication among all project participants (including SC and measure developers) Facilitate necessary communication and collaboration between different NQF projects

35. 35 Roles of NQF Staff Respond to NQF member or public queries about the project Maintain documentation of project activities Post project information to NQF website Work with measure developers to provide necessary information and communication for the SC to fairly and adequately evaluate measures for endorsement NQF project staff works with communications department to publish final report

36. 36 NQF Endorsement Criteria New NQF measure evaluation criteria were approved by Board of Directors in August 2008 Clarify, strengthen and recommend changes to endorsement criteria in order to achieve: a stronger link to national priorities and higher-level performance measures; greater measure harmonization; greater emphasis on outcome measures; and for process measures, a tighter outcomes-process link

37. 37 NQF Endorsement Criteria

38. 38 Conditions for Consideration The measure is in the public domain or an intellectual property agreement is signed. 2. The measure owner verifies there is an identified responsible entity and process to maintain and update the measure. 3. The intended use of the measure includes both public reporting and quality improvement. The requested measure submission information is complete. Generally, measures should be fully developed and tested so that all information needed to evaluate the measure is available. Measures that have not been tested are only potentially eligible for a time-limited endorsement Measure owners must verify that testing will be completed within 24 months of endorsement. Less text? Maybe lose bullets – explain or provide handout?Less text? Maybe lose bullets – explain or provide handout?

39. Project Timeline Selection of SC Members: October 2009 Mental Health Steering Committee Meeting #1: November 2009 Phase 3 Call for Measures: Mid-January 2010 Mental Health Steering Committee Meeting #2: April 2010 39

40. SCOPE What are Outcome Measures? Donabedian: Outcome refers to changes (desirable or undesirable) in individuals and populations that are attributed to healthcare. 40

41. Framework for Mental Health Outcomes Potential domains: Disease type (psychosomatic) Health status (healthy, chronic illness, special needs) Settings of care (hospital, outpatient, the community & living environment) 41

42. Data Source for Outcomes Information about outcomes from: Patient or care giver reported outcome Clinician observed outcome Physiologic outcome (vital signs, lab results) 42

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46. Population Health Perspective for Mental Health Outcome Measures Bonnie Zell, MD, MPH Senior Director, Population Health November 16, 2009 National Quality Forum Mental Health Outcomes

47. Defining Population Health World Health Organization (WHO): Health is a state of complete physical, mental and social well- being and not merely the absence of disease or infirmity Institute of Medicine (IOM): State of well-being and capacity to function in the face of changing circumstances Positive concept emphasizing social and personal resources as well as physical capabilities Shared responsibility of healthcare providers, governmental public health and a variety of actors in the community

48. How Population Health Happens Health happens: one person at a time one day at a time one decision at a time Within the context of where and how people live: where they work, learn, play, shop influenced by their level of education, income, employment determined by their access to healthy food, safe environments, available transportation, healthcare services Health does not happen primarily within healthcare sector: it happens within the context of each person’s life – their cultural, social, and economic frameworks modified by their values and priorities Individuals aggregate to populations

49. Defining Populations Determined by defining boundaries of individuals: Racial, ethnic, disease specific, life-stage, level of poverty Health system’s population of patients Health insurer’s population of patients across health systems Clinician’s entire practice of patients Segment of a clinician’s practice Patients with depression or adolescents or elderly…. Geographic region - county, city, neighborhood or block Healthcare resource utilization high utilizers 49

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56. Defining Population Health in Relationship to Healthcare Bring population level assessments into healthcare: query healthcare data to understand populations (patients with depression, for example) utilize publically available data to understand community context (GIS mapping of healthcare and public data) 56

57. Defining Population Health in Relationship to Healthcare Bring population level strategies into healthcare: targeted outreach for screening and follow-up after visits by population segments suggest available community –level mental health and health promotion resources targeted to specific populations disseminate newsletters to segments with population-specific health-related information partner with community stakeholders (schools, businesses, faith-based)

58. Defining Population Health in Relationship to Healthcare IN ADDITION TO ASSESSING: “Did Alissa complete her depression assessment and leave her appointment with her symptom-management plan, counseling appointments and Zoloft prescription? ALSO ASK: How many individuals that we care for in our practice have completed a mental health assessment in the past 12 months? What % of our patients with depression have completed a mental health assessment in the past 12 months and have a symptom-management plan, counseling or community-support plan and indicated medications ordered (composite measure)?

61. 61 With an aging population and rising costs of health care we need to look at a different model for treating, managing and supporting elderly who have a high rate of multiple co-morbidities outside of the healthcare delivery system within the community. With an aging population and rising costs of health care we need to look at a different model for treating, managing and supporting elderly who have a high rate of multiple co-morbidities outside of the healthcare delivery system within the community.

62. 62 Recent evidence reveals a significant increase in morbidity and mortality in the population with a serious mental illness (SMI).2 “In fact, people with a serious mental illness are now dying 25 years earlier than the general population”.3 Although, 87 percent of the years of lost life due to premature death can be attributed to medical illnesses, one’s mental health status has a significant impact on therapeutic response or engagement in treatment of medical conditions.4 Much of the increased morbidity and mortality in this population is predominately due to treatable medical conditions caused by modifiable risk factors (e.g., obesity, substance abuse, smoking, medication side effects or inadequate access to healthcare or health-promoting factors).5Recent evidence reveals a significant increase in morbidity and mortality in the population with a serious mental illness (SMI).2 “In fact, people with a serious mental illness are now dying 25 years earlier than the general population”.3 Although, 87 percent of the years of lost life due to premature death can be attributed to medical illnesses, one’s mental health status has a significant impact on therapeutic response or engagement in treatment of medical conditions.4 Much of the increased morbidity and mortality in this population is predominately due to treatable medical conditions caused by modifiable risk factors (e.g., obesity, substance abuse, smoking, medication side effects or inadequate access to healthcare or health-promoting factors).5

63. Population Health Perspective in Measure Development  Should other sectors in the community that significantly influence health status, in addition to healthcare, have accountability for health in their communities? How might we connect performance measures in healthcare with activities in other sectors? (school nurses?)

64. Population Health Perspective in Measure Development CAN WE EXPAND OUR FRAME FROM: “Why does this patient have this disease or condition at this time?” TO INCLUDE: “What population circumstances are the underlying causes of the disease or condition incidence in this population?”

66. References Association for Community Health Improvement The National Steering Committee on Hospitals and the Public’s Health http://www.communityhlth.org/ Http://www.aone.org/hret/programs/content/reportnsc.pdf US Preventive Services Task Force (USPSTF) http://www.ahrq.gov/CLINIC/uspstfix.htm The Guide to Community Preventive Services (The Community Guide) http://www.thecommunityguide.org/index.html The Community Tool Box http://ctb.ku.edu/en/About.htm  Mobilizing for Action through Planning and Partnerships (MAPP) http://www.naccho.org/topics/infrastructure/MAPP/index.cfm Institute of Medicine Community Health Improvement Process (CHIP) http://books.nap.edu/openbook.php?record_id=5298&page=77

67. Bonnie Zell, MD, MPHSenior Director, Population HealthNational Quality Forumbzell@qualityforum.org202-590-7936