- Email: [email protected]
Developing Performance Measures for Alcohol and Other Drug Services in Managed Care Plans
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“This timely report should stimulate productive policy discussions about measuring the performance of managed care organizations in providing alcohol and other drug (AOD) treatment services. The report is notable for its emphasis on accountability for the overall process of care, including prevention and treatment. Defining accountability more broadly than for outcomes of specific treatment episodes seems especially appropriate in the context of managed care organizations, which are responsible for the health of defined populations over time. Substantial research evidence supports the notion that AOD disorders are chronic conditions that should be treated and continually monitored much as other chronic medical conditions.”—Michael Polen, MA, Senior Research Associate, Center for Health Research, Kaiser Permanente, Northwest Region, Portland, Oregon. PERFORMANCE MEASURES AND MEASUREMENT
Developing Performance Measures for Alcohol and Other Drug Services in Managed Care Plans FRANK MCCORRY, PHD DEBORAH W. GARNICK, SCD JOHN BARTLETT, MD, MPH FRANCES COTTER, MA, MPH MADY CHALK, PHD FOR THE WASHINGTON CIRCLE GROUP
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ddiction is a treatable condition with expectations of success as positive as for other chronic diseases, such as diabetes, hypertension, and asthma.1 Yet, until now, performance measures that have been developed, tested, and used across the United States for medical and mental health services have not been applied for
alcohol and other drug (AOD) services. The Washington Circle Group (WCG) has begun to fill that gap.
Frank McCorry, PhD, is Chair of the Washington Circle
Schneider Institute for Health Policy, The Heller School, Brandeis University, Waltham, Massachusetts. John Bartlett, MD, MPH, is Vice President, MedHelp.com, New York. Frances Cotter, MA, MPH, is Public Health Advisor, Center for Continued
Group and Director of the Clinical Services Unit, New York State Office of Alcoholism and Substance Abuse, Albany, New York. Deborah W. Garnick, ScD, is Research Professor, Copyright © 2000 by the Joint Commission on Accreditation of Healthcare Organizations
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The WCG As members of the WCG, we have joined to share our expertise in AOD disorders, managed care, and
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THE JOINT COMMISSION Article-at-a-Glance Background: Monitoring the quality and availability of alcohol and other drug (AOD) services must be a central tenet of any health-related performance measurement system. The Washington Circle Group (WCG), which was convened by the Center for Substance Abuse Treatment Office of Managed Care in March 1998, has developed a core set of performance measures for AOD services for public- and private-sector health plans. It is also collaborating with a broad range of stakeholders to ensure widespread adoption of these performance measures by health plans, private employers, public payers, and accrediting organizations. Core performance measures: Four domains were identified, with specific measures developed for each domain: (1) prevention/education, (2) recognition, (3) treatment (including initiation of alcohol and other plan services, linkage of detoxification and AOD plan
services, treatment engagement, and interventions for family members/significant others), and (4) maintenance of treatment effects. Continuing efforts: Four measures that are based on administrative information from health plans and two measures that require a consumer survey of behavioral health care are undergoing extensive pilot testing. The WCG has reached out to a broad range of stakeholders in performance measurement and managed care to acquaint them with the measures and to promote their investigation and adoption. As results of pilot testing become available, these outreach efforts will continue. Conclusions: Performance measures for AOD services need to become an integral part of a comprehensive set of behavioral and physical health performance measures for managed care plans.
performance management to improve the quality and effectiveness of AOD prevention and treatment services through the use of performance measurement systems. Our group, which was convened by the Center for Substance Abuse Treatment Office of Managed Care (Substance Abuse and Mental Health Services Administration, Department of Health and Human Services, Washington, DC) in March 1998, has set two major goals:
1. Develop and pilot test a core set of performance measures for AOD services for public- and private-sector health plans. 2. Collaborate with a broad range of stakeholders to ensure widespread adoption of AOD performance measures by health plans, private employers, public payers, and accrediting organizations. The development of performance measures for AOD services is a complex task for several reasons. AOD
Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Mady Chalk, PhD, is Director, Office of Managed Care, Center for Substance Abuse Treatment. The remaining members of the Washington Circle Policy Group are as follows: Thomas Babor, PhD, MPH, Professor, Department of Psychiatry, University of Connecticut Health Center, Farmington, CT; Spencer Falcon, MD, Executive Vice President, Private Healthcare Systems, Inc, Waltham, MA; David R. Gastfriend, MD, Director of Addiction Services, Department of Psychiatry, Harvard Medical School, Boston; Suzanne Gelber, PhD, Principal, SGR Health Alliance, Berkeley, CA; Patricia A. Harrison, PhD, Manager, Health Care Research and Evaluation, Minnesota Department of Human Services, Minneapolis, MN; Constance Horgan, ScD, Professor, Schneider Institute for Health Policy, The Heller School, Brandeis University, Waltham; A. Thomas McLellan, PhD, Scientific Director, Treatment Research Institute, Philadelphia; Jeffrey Merrill, PhD, Professor, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson
Medical Center, Piscataway, NJ; Hernando Posada, President, Tech2Work, Inc, Columbus, OH; Rhonda Robinson-Beale, MD, Executive Medical Director, Blue Cross Blue Shield of Michigan, Southfield, MI; and Constance Weisner, Dr PH, MSW, Professor, Department of Psychiatry, University of California, San Francisco. The opinions expressed in this article are the views of the authors and do not necessarily reflect the views of their organizations. The authors thank Elizabeth Merrick, PhD, MSW, and Margaret Lee, PhD, for their excellent work in their review of the research literature and their substantive contributions to the report. Michele King, Susan Minstry Wells, and TASCON, Inc, provided invaluable assistance in editing and formatting this report. Please address correspondence to Deborah W. Garnick, ScD, Schneider Institute for Health Policy, The Heller Graduate School, Mailstop 035, Brandeis University, Waltham, MA 02454-9110; phone 781/736-3840; fax 781/736-3985; e-mail [email protected].
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disorders often manifest as a range of physical and psychological conditions that require special treatment or intervention; however, they often go unrecognized and unaddressed in health care settings. Furthermore, many individuals with AOD disorders may minimize the role of alcohol and drug use in their health problems. The illegal nature and stigma of drug use may further inhibit those with such disorders from revealing their problems to their health care providers. Nevertheless, AOD disorders, once identified, can be successfully treated. The focus of the WCG’s efforts is the development of performance measures to track the activities of managed care organizations to prevent, recognize, and treat AOD disorders. We are working with others in the AOD and mental health fields who are developing and implementing performance measures. Through collaboration and dialogue, the WCG is building on existing performance monitoring systems and data sets to ensure more efficient measurement of AOD services.
enforcement expenditures, AOD-related crime, and lost productivity. But numbers alone do not tell the complete story. People with AOD disorders often have multiple and complex health and social problems. Comorbid mental and physical health disorders are common. Suicide, infectious diseases, domestic violence, and child abuse further complicate the picture. Although AOD disorders are frequently chronic, relapsing conditions, they are readily identifiable and eminently treatable. Research studies have consistently demonstrated the overall effectiveness of AOD treatment in reducing substance use and in improving patient functioning in the family, workplace, and community.5–7 (For a current view of the topic, see Principles of Drug Addiction Treatment: A Research-Based Guide, National Institute on Drug Abuse, 1999.8) AOD treatment has been found to be as effective as treatments for other complex, chronic illnesses.1 Only one-quarter of the adults diagnosed with chemical dependency, however, receive any treatment at all.9
Scope of the Problem AOD disorders exact a terrible toll on individuals and their families, employers, health care providers and payers, the economy, and society at large. Though AOD disorders are readily treatable, most individuals are not getting help.2 According to the 1998 National Household Survey on Drug Abuse, conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA),3 an estimated 14 million Americans older than 12 years of age were current users of illicit drugs. About 4 million people met diagnostic criteria for dependence on illicit drugs, including 1 million youths aged 12 to 17 years. Of 113 million Americans aged 12 years and older who reported alcohol use in 1998, 33 million engaged in binge drinking, and 12 million were classified as heavy drinkers. Nearly 50% of underage drinkers (ages 12–20 years) engaged in binge drinking, and 22% were classified as heavy drinkers. The economic impact of AOD disorders is staggering. In 1995 total costs for AOD abuse were estimated at $277 billion ($167 billion for alcohol abuse and $110 billion for drug abuse).4 Only 12% of these costs were directly related to the cost of treatment. The bulk of the costs was due to additional law
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Mission and Values Statement From its inception, the WCG has developed and refined a set of values statements on the provision of care to persons with AOD disorders. A mission statement, which incorporates the WCG’s approach to performance measurement, also has been adopted. The mission statement builds on the earlier work of other performance measures work groups in the field of AOD disorders, which also recognized that any true measurement of performance must cover all domains in the process of care. The values statements and the mission statement have been used to inform the development and selection process of the core measures in this document. The mission statement reads as follows: There is a clear need to promote quality and accountability in the delivery and management of alcohol and other drug (AOD) abuse services by organized systems of care, both public and private. The WCG believes that this is best accomplished through adopting a process of care model and defining a set of measures for each domain within that model. Moreover, the WCG believes that accountability for AOD services is best achieved when system performance is compared across all domains of the process of care. The WCG is committed to developing evidence-based measures that allow for such comparison.
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THE JOINT COMMISSION The values outlined in the values statement follow. Treatment is essential. People with AOD disorders suffer from conditions that are frequently chronic and relapsing in nature, readily identifiable, and eminently treatable. They should receive professional care for these conditions in a timely and respectful fashion, and this professional care should be followed with continuing support through Alcoholics Anonymous (AA), Narcotics Anonymous (NA), or other community support organizations. Recognition is a key first step. AOD disorders often go unrecognized and untreated in health care settings. Identifying people in need of AOD services and providing them with access to appropriate care are “first-order” responsibilities of managed care organizations. Comprehensive treatment is critical to recovery. People with AOD disorders deserve to have the full range of evidence-based treatment options available to them, including pharmacotherapies and residential care. Self-help and peer support such as provided through AA/NA, although an important component of a comprehensive treatment plan, is not a substitute for needed treatment delivered by properly trained clinicians. Support services for family members are crucial. Family members of individuals with AOD disorders are often at increased risk for AOD abuse and other problems. Support services to family members are an important component of treatment for the affected individual. Quality AOD care yields multiple benefits.
Monitoring the quality and availability of AOD services must be a central tenet of any health-related performance measurement system, because the benefits of quality AOD care accrue not only to the individual and family in need but to the broader community as well, in terms of improved public health and safety and reduced social welfare costs.
Framework for Developing Core Measures Measurement for External Accountability The WCG’s goal is to develop performance measures for the purpose of external accountability. Historically, accrediting bodies and regulatory agencies responsible for ensuring external accountability examined descriptive documentation of health care system structure
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and process. More recently, performance measurement has become a preferred means of ensuring external accountability. Measurement for external accountability examines the extent to which a health care system meets a preexisting, agreed-on standard. As the principal audience for this information, purchasers, payers, and health care consumers use performance measures to compare across different health care organizations. The focus of accountability measurement is on the outputs or results of health care delivery and does not address how these outputs are achieved or how internal processes need to be changed to improve output.10 Other approaches to questions of quality and accountability, such as quality improvement, may examine and measure the internal processes of production to improve output. Although the core set of measures presented in this article may prove useful in these activities, their primary purpose is to promote external accountability and compare the performance of health care systems. Accountability for the Process of Care To develop effective performance measures that gauge external accountability in AOD services, the WCG has considered both whom should be held accountable for such measurement and for what they should be held accountable. Specifically, the WCG believes that responsibility for performance measurement rests at the service delivery level and that organized delivery systems (for example, managed care plans) should be held accountable for the entire process of care for people with AOD disorders. Accountability at the Delivery System Level With the major transformations that have occurred in the behavioral health care marketplace, it is clear that responsibility for treatment planning and implementation no longer involves only the clinician and the patient. Health plans, managed behavioral health care organizations, and other forms of organized delivery systems (such as the criminal justice system or social service system) play a significant role in the decisions about what treatment is provided, to whom, and for how long. Moreover, delivery systems have authority over defined populations and all the resources allocated to those populations. With this authority comes responsibility and accountability for performance measurement.
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Accountability for the Entire Process of Care The WCG believes it is insufficient to hold delivery systems accountable only for AOD services delivered within a particular episode of care. The chronic, relapsing nature of AOD disorders argues for a system of accountability beyond the confines of a discrete treatment episode. Indeed, how individuals manage their recovery following a particular episode of care is as important to their long-term success as the delivery of the care itself. This has been shown to be true in the treatment and management of other chronic disorders as well. Consequently, how a system of care organizes its services to support individuals’ posttreatment sobriety is an important indicator of performance. Furthermore, there is convincing evidence that early recognition and timely prevention and intervention can positively affect the course of an individual’s AOD problems. Organized systems of care must be held accountable for their members through the entire process of care—from prevention and early recognition services through treatment and posttreatment activities—if a true measure of performance is to be realized. There are several justifications for broadening the base of accountability in the area of AOD treatment. First, responsible stewardship for public and private dollars requires that the impact of these resources be monitored and maximized. To concentrate on only a small segment of the process of care for people with AOD disorders would ignore the body of knowledge that has been developed over the past 25 years about the importance of each phase of that care in achieving positive outcomes for people with AOD problems. To hold delivery systems clinically accountable for coordination and oversight of the entire care
process does not necessarily imply that they must pay for all the care and services provided. They are responsible, however, for ensuring that all the required components of the process of care occur with reasonable efficiency and effectiveness over time. Underlying Assumptions In developing its approach to performance measurement, the WCG made three assumptions. Use of existing data collection systems. Measures were identified for which data are available in existing administrative data systems or through currently planned consumer surveys (Table 1, below). This design decision parallels the approach taken in other medical and mental health measurement efforts. Currently, managed care plans use their administrative data systems to calculate many ratebased HEDIS (Health Employer Data and Information Set; National Committee for Quality Assurance, Washington, DC) measures (rate of follow-up visits after hospitalization for depression, for example). The developers of the Experience of Care and Health Outcomes (ECHO™) survey, which includes questions for two of the WCG measures, are suggesting that it be field tested using a similar protocol to the one developed for the commonly used Consumer Assessment of Health Plans (CAPHS™). Initial focus on process measures. Assessing reduction in the use of AODs and related problems is the ideal standard by which the performance of a substance abuse program can be measured. Because of existing limitations in the science and availability of appropriate databases for outcome measures, however,
Table 1. Washington Circle Group Core Performance Measures*
Domain
Measure
Data Source
Prevention/Education
Educating patients about AOD disorders
Enrollee survey
Recognition
Identification rates
Administrative data
Treatment
Initiation of AOD plan services Linkage of detoxification and AOD plan services Treatment engagement Interventions for family members/significant others of AOD clients in treatment
Administrative data Administrative data Administrative data
Maintenance
Maintenance of treatment effects
Patient survey
Patient survey
* AOD, alcohol and other drug.
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THE JOINT COMMISSION Table 2. Core Performance Measures*
Prevention/Education: This domain encompasses delivery system activities designed to raise the general awareness of substance abuse as a major debilitating disorder affecting individuals, families, and the greater society. Also included are those activities designed to target high-risk individuals and groups for more focused interventions. Educating patients about AOD disorders. Percentage of adult patients with primary care visits who are advised or given information about AOD disorders. Recognition: This domain addresses the plan’s efforts, in all clinical settings, at case-finding, including screening and assessment. It also includes referral of affected individuals into treatment. Identification rates. Number of cases per 1,000 members who were diagnosed with AOD abuse or dependence or who received AOD-related plan services on an annual basis. Treatment: This domain encompasses the delivery system activities associated with the rehabilitation of individuals who have a substance abuse disorder diagnosis. This includes a broad range of services associated with an episode of care, including medications, testing, counseling, medical services, psychiatric and psychological services, social services, and coordination with other treatment resources. Detoxification and emergency room care may be viewed as the initiation of a treatment episode, but do not by themselves constitute treatment for AOD disorders. In turn, AA/NA and other community support fellowships are clearly important for
the continuation of treatment-initiated sobriety and social function. However, by their own charters, AA and NA are not structured to provide professional services that are so often needed to stabilize psychologically and emotionally unstable patients, nor to address the complications of addiction that can interfere with behavioral change. Initiation of AOD plan services. Percentage of individuals with an index diagnosis of AOD abuse or dependence who receive any additional AOD services within 14 days. Linkage of detoxification and AOD plan services. Percentage of patients with an index detoxification who initiated AOD plan services within 14 days following detoxification. Treatment engagement. Percentage of clients diagnosed with AOD disorders that receive three plan-provided AOD services within 30 days of the initiation of care. Interventions for family members/significant others of AOD clients in treatment. Percentage of survey respondents who report using AOD services and who also report that their family member/significant other received preventive interventions. Maintenance: This domain includes delivery system activities related to sustaining long-term positive outcomes. Included are such areas as self-management and peer support strategies to sustain posttreatment abstinence or reduction in use, improvements in role functioning and well-being, and life-style changes. Maintenance of treatment effects. Percentage of clients who report specific services provided and/or monitored by the plan to promote and sustain positive treatment outcomes postdischarge.
* AOD, alcohol and other drug; AA, Alcoholics Anonymous; NA, Narcotics Anonymous.
such assessment of treatment outcomes is not financially or technically feasible for most systems at the present time. Therefore, as an intermediate approach, the WCG targeted a set of process measures that research has shown to be related to treatment outcomes. As the field of performance measurement evolves, outcome measures will be added to the core set as well. Links to the accreditation process. Data for some measures (for example, screening) cannot be obtained through current administrative data systems or through patient self-report. Although identification rates, which imply a screening or an identification
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process, can be measured, it is not feasible at present to measure directly important clinical areas such as screening or multidisciplinary treatment planning. Therefore, the WCG recommends that the accreditation process incorporate some of these clinical and organizational areas as standards.
Core Performance Measures We propose seven measures as the WCG initial core set for comparing systems’ performance in the delivery of AOD services to adults (see Table 2, above). These measures fit into four domains representing the continuum of AOD services—prevention/education,
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recognition, treatment, and maintenance. These domains are comparable to those used in the management of other chronic illnesses.
Rationale and Evidence Base for Core Measures For each core measure, a rationale of its importance and a summary of the supporting literature are presented. Of course, all the activities we include should be tailored to the particular patient’s needs. Moreover, this core set describes the activities that all plans should be striving for in identifying and treating their members with AOD problems.
further help. These activities can also take place in a broad range of settings, including emergency rooms, mental health treatment facilities, medical practices (for example, obstetrics/gynecology, adolescent medicine, general medicine), and welfare agencies.13 By calculating the rate of AOD claims per 1,000 members and comparing it to current population estimates, this measure will show how successful plans are over time in identifying members who need AOD services. One source of comparison is the regional estimates (and in future years, state-level estimates) included in the National Household Survey on Drug Abuse.3 Treatment
Prevention/Education
Percentage of adult patients with primary care visits who are advised or given information about AOD disorders. The provision of general medical care is an excellent opportunity to address issues of AOD abuse. As with other chronic conditions,11,12 patient education is an important aspect of prevention. Plans should ensure that primary care providers address issues of the use of AODs, as part of an interview or health risk appraisal, through the distribution of print materials, or as part of other contacts with enrollees; provide information and/or guidance regarding moderate use of alcohol and the risks involved in using other drugs; and recommend follow-up actions when indicated. This measure will permit evaluation of AOD educational efforts in primary care settings. Educating patients about AOD disorders.
Recognition Identification rates. Number of cases per 1,000 members who were diagnosed with AOD abuse or dependence or who received AOD-related plan services on an annual basis. AOD disorders and their associated health problems lead to social and family disruption, as well as to increased medical utilization and costs. Therefore, it is important that managed care plans identify cases among their enrollees and refer them to treatment. If health plans conducted screening and casefinding activities, including the use of validated brief questionnaires, they could identify members with AOD disorders and encourage these individuals to get
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Initiation of AOD plan services. Percentage of individuals with an index diagnosis of AOD abuse or dependence who receive any additional AOD services within 14 days. Studies indicate that only a small fraction of the population with AOD disorders enters treatment.14 Identification of individuals with AOD disorders is an important first step in the process of care, but one that does not routinely lead to initiation of treatment. Plans must also ensure that individuals with an AOD diagnosis initiate treatment. This measure will permit the comparison of plans’ effectiveness in initiating care after the need has been identified by a formal diagnosis of abuse or dependence. There are many reasons individuals who are diagnosed with AOD disorder do not initiate treatment. The primary care provider may avoid confronting a patient due to the stigma associated with AOD disorders, or when a referral is made to AOD treatment, the provider may not always follow through to see if the patient began treatment.15 In other cases, individuals who were appropriately referred may choose not to enter treatment. Some individuals may still believe that they can control their substance use or deny that there is a problem.16–18 Studies indicate that a lack of “immediately available” treatment services may also pose a barrier to treatment initiation. In one study, a majority of individuals on a waiting list (52%) reported that their interest in entering treatment had decreased since they had been placed on the list.19 Linkage of detoxification and AOD plan services. Percentage of patients with an index detoxification
who initiated AOD plan services within 14 days following
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THE JOINT COMMISSION detoxification. Detoxification is a medical intervention that manages an individual safely through the process of acute withdrawal. The goals of detoxification are fairly limited. A detoxification program is not designed to resolve the long-standing psychological, social, and behavioral problems associated with AOD abuse. Detoxification is most effective when it is viewed as a first step to active treatment and is followed by assessment and referral to ongoing AOD treatment.8 Without linkage to treatment after detoxification, research has found no significant improvements that are discernable from untreated withdrawal.1,20,21 This measure will permit evaluation of how often plans successfully link clients to treatment following detoxification. Detoxification offers an opportunity to recruit clients into treatment; however, the overall completed referral rates are unacceptably low. Discharge data from the 1980 Client Oriented Data Acquisition Process* (CODAP) report indicated that only 14% of clients detoxifying from opiates were transferred or referred into treatment. There is also significant variation across the country in successfully linking detoxification clients to treatment. Of the 62 reporting areas, 12 had a transfer/referral rate of less than 5%, and only 14 areas had rates greater than 25%.21 More recent data from the period 1991 to 1997 from 14 employer groups whose behavioral health care benefits are managed by United Behavioral Health showed that 79% of patients received formal substance abuse treatment following inpatient detoxification, the majority within one week.22 Treatment engagement. Percentage of clients diagnosed with AOD disorders that receive three planprovided AOD services within 30 days of the initiation of care. Engagement in treatment is critical for treatment effectiveness. Treatment engagement is defined as an intermediate step between initially accessing care (in a first visit) and completing a full course of treatment. (As noted earlier, detoxification alone does not constitute treatment.) Studies of treatment retention indicate that patients who remain in treatment for a longer duration of time have better outcomes.5,23,24 However, studies indicate that many clients with AOD disorders leave treatment prematurely. The 1990 Drug Services Research Survey,25 a * CODAP is a data collection system in the state of Texas.
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study of U.S. drug treatment facilities, reported that 52% of clients who entered treatment did not complete the planned course of treatment. Given the positive association between retention and treatment success, a plan’s ability to engage clients in treatment is an important intermediate measure that is closely related to outcomes. A review of length of stay studies found that the length of time in treatment is related to posttreatment reduction in drug use, reduced criminal activity, and improved employment status.26 Studies of alcoholdependent clients have shown that longer stays in treatment and treatment completion are associated with greater reduction in alcohol use, even after controlling for severity at admission.24 Thus, treatment engagement is positively associated with positive treatment outcomes. Furthermore, intensity of engagement, as measured by how frequently the client attends sessions and how many types of services are provided during treatment, is important to engagement and to treatment outcomes.24,27–29 Engagement in treatment also is important to the reduction of risk for drug-related illnesses.4,30,31 It may be asked why simple referral to AA or NA support instead of treatment has been considered not responsive to the treatment engagement criterion. While AA/NA and other community support organizations are essential for the continuation and maintenance of gains following treatment interventions, there are two major reasons AA/NA by themselves cannot be considered treatment. First, these organizations do not consider themselves treatments, but rather “support fellowships.” Second, since there are (purposely) no records of activity or even attendance at AA/NA meetings, there is (purposely) no way to monitor patient activity in these organizations. Thus for both conceptual and procedural reasons, referral to AA/NA sessions not accompanied by formal treatment services is not considered responsive to the treatment engagement criterion. However, referral to AA/NA is considered responsive to the maintenance criterion (see below). Interventions for family members/significant others of AOD clients in treatment. Percentage of
survey respondents who report using AOD services and who also report that their family member/significant other received preventive interventions. The involve-
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ment of family members in the treatment process may be crucial to long-term success because of its effects on the patient and the family in dealing with AOD-related problems. Family members are subject to a host of negative consequences from a member’s AOD abuse, such as lost wages, domestic violence, depression, and inappropriate role modeling for children. For example, research has documented that children of individuals with AOD disorders are more at risk than their peers for AOD use. 32–34 Consequently, interventions for family members are an important addition to the support, education, and counseling provided to the client. This measure is focused on plans’ efforts to include family members of individuals undergoing treatment for AOD disorders. Maintenance Maintenance of treatment effects. Percentage of clients who report specific services provided and/or monitored by the plan to promote and sustain positive treatment outcomes postdischarge. As with other chronic disorders, AOD abuse requires continued engagement of the patient in psychosocial and/or pharmacological services to maintain the patient’s gains after the completion of treatment.1,35 Thus, plans’ activities to maintain their members’ recovery after treatment is an important domain to measure. For many patients, successful recovery postdischarge involves the utilization of self-management strategies and self-help groups such as AA or NA. Self-management strategies include a range of services provided by the treatment program during and immediately following discharge, including referral to AA/NA, relapse prevention training, and follow-up calls/monitoring. Indeed, use of self-help groups and such follow-up techniques as phone calls or reminder letters have been shown to be effective.36–38 Relapse prevention focuses on helping the client to identify high-risk or “trigger” situations that contribute to relapse and has been shown to be effective for people with AOD disorders.39 Relapse prevention strategies can help the client develop behaviors to avoid or better manage highrisk situations.40 Other services that assist in maintaining treatment effects include training in the use of family support mechanisms, coping skills, and employment counseling.
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Continuing Efforts Pilot Testing of the Initial Core Set Pilot testing is being conducted on two parallel tracks. First, the four measures that are based on administrative information from health plans are being calculated using a common set of questions and programming instructions across a range of settings, including a Medicaid plan that carves out behavioral health services to a managed care vendor, a large group-model health maintenance organization, and a major specialty behavioral health care vendor. In each setting, the goals of the initial testing are to explore the measurement feasibility, to test the sensitivity of the measures to alternate specifications, and to compare results across plans and with statistics published in the literature. In addition, WCG members are planning ways to incorporate further validity testing into their ongoing or new research projects. Second, the two measures that require a consumer survey of behavioral health care are being tested as part of the overall testing of the ECHO survey. Earlier versions of the survey were field tested with 7,000 consumers of behavioral health care in five public assistance and five commercial health insurance plans.41,42 The team of investigators at Harvard Medical School and the Center for Survey Research, University of Massachusetts at Boston, are conducting cognitive testing and pilot tests of the current version with 750 members of public and private health insurers managed by behavioral health care organizations. They plan to continue their development efforts using a revised version of the survey with approximately 20,000 commercially and publicly insured members of 20 health insurance plans and managed behavioral health care organizations across the United States, with results of the field tests expected to be available by the end of December 2000. Adoption of Additional Measures In developing its core set of measures, the WCG sought to identify candidate measures that had a strong evidence base and that covered the domains of the process of care for addictive disorders. Moreover, the group decided to include only those measures that could be captured from existing administrative data systems or from a consumer survey method. From the WCG’s perspective, it is essential that national accrediting bodies and plans begin to monitor the delivery of
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THE JOINT COMMISSION AOD services and compare the performance of managed care plans sooner rather than later. Given these criteria, several measures across all domains were deferred for development at a future time. Specifically, a recognition measure of co-occurring mental health and addictive disorders and a treatment measure on the use of laboratory tests (such as urinalysis) and medication in treatment were deferred. Other measures of interest included a treatment measure on the reduction of AOD use among pregnant women, and a maintenance measure on sustained reductions in AOD use postdischarge. As a clearer picture of the performance of managed care plans emerges from the use of the initial core set, the WCG hopes to add these and additional measures to its menu of measures. Moreover, as research into the nature and treatment of addictive disorders yields new insights, other measures will be considered for development by the WCG. Dissemination The WCG has reached out to a broad range of stakeholders in performance measurement and managed care to acquaint them with the measures and to promote their investigation and adoption. Members of the group have made presentations at the American College of Mental Health Administration (March 1999), the American Public Health Association’s annual meeting (November 1999), and the Maryland Task Force to Develop Performance Quality Measures for Managed Behavioral Health Care Organizations (October 1999). In addition, the WCG has initiated discussions with the national accrediting organizations,
beginning with a presentation to the NCQA’s Behavioral Health Measurement Advisory Panel. The measures are cited in an inventory of quality measures in behavioral health care that will soon be available on the Web (www.challiance.org/cqaimh).43 Moreover, the WCG measures relate clearly to Section I, “PatientFocused Functions,” of the Joint Commission on Accreditation of Healthcare Organizations accreditation manual for behavioral health care.44 The measures focus on assessment, treatment, education, and the continuum of care. If implemented in full, they also serve as the basis for continuously analyzing and improving organization performance of clinical and other processes (“Section II, Organization-Focused Functions”); and for benchmarking the organization’s performance against that of other organizations. Finally, the WCG has earned endorsement from the American Society on Addiction Medicine. As results of pilot testing become available, these outreach efforts will continue.
Conclusion The WCG remains committed to pursuing all promising avenues for developing AOD performance measures. In doing so, we will continue to be guided by our vision of advancing quality and accountability in AOD services through the development and application of evidence-based performance measures across all domains of the process of care. We will have reached our goal when the performance measures for AODs are an integral part of a comprehensive set of behavioral and physical health performance measures for managed care plans. J
References 1. O’Brien CP, McLellan AT: Myths about the treatment of addiction. Lancet 347:237–240, 1996. 2. Schneider Institute for Health Policy, Brandeis University: Substance Abuse: The Nation’s Number One Health Problem. Updated chartbook prepared for the Robert Wood Johnson Foundation, Princeton, NJ. Forthcoming. 3. Substance Abuse and Mental Health Services Administration: National Household Survey on Drug Abuse Main Findings 1998. Rockville, MD, Mar 2000. 4. Harwood HJ, Fountain G, Livermore G: The Economic Costs of
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Alcohol and Drug Abuse in the United States. NIH Publication No. 98–4327. Bethesda, MD: NIH, 1998. 5. Hubbard RL, et al: Overview of 1-year follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS). J Addict Beh 11: 261–278, 1997. 6. Gerstein DR, et al: Evaluating Recovery Services: The California Drug and Alcohol Treatment Assessment (CALDATA). Report submitted by the National Opinion Research Center and Lewin-VHI, Inc, to the State of California Department of Alcohol and Drug
Programs, 1994. 7. McLellan AT, et al: Similarity of outcome predictors across opiate, cocaine and alcohol treatments: Role of treatment services. J Consult Clin Psychol 62:1141–1158, 1994. 8. National Institute on Drug Abuse (NIDA): Principles of Drug Addiction Treatment: A ResearchBased Guide. NIH Publication No. 99–4180. Bethesda, MD: NIH, 1999. Also available on NIDA Web site. 9. Regier DA, Narrow WE, Rae DS: The de facto U.S. mental and addictive disorders service system: Epidemiological catchment area
prospective 1-year prevalence rates of disorders and services. Arch Gen Psychiatry 50:85–94, 1993. 10. Solberg LI, Mosser G, McDonald S: The three faces of performance measurement: Improvement, accountability, and research. Jt Comm J Qual Improv 23:135– 147, 1997. 11. Perine JL, Schare ML: Effect of counselor and client education in nicotine addiction on smoking in substance abusers. Addict Behav 24: 443–447, 1999. 12. Botvin GT, et al: Smoking initiation and escalation in early adolescent girls: One-year follow-up
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JOURNAL of a school based prevention intervention for minority youth. Journal of the American Medical Womens Association 54(3):139–143, 1999. 13. Weisner C, Schmidt L: Alcohol and drug problems among diverse health and social service populations. Am J Public Health 83: 824–829, 1993. 14. Committee on Treatment of Alcohol Problems, Institute of Medicine: Broadening the Base of Treatment for Alcohol Problems. Washington, DC: National Academy Press, 1990. 15. D’Aunno T: Linkage of substance-abuse treatment and primary health care. In Egertson JA, Fox DM, Leshner AI, (eds): Treating Drug Abusers Effectively. Malden, MA: Blackwell Publishers, 1997. 16. U.S. Dept Health and Human Services: CSAT TIPS #19: Detoxification from alcohol and other drugs. DHHS Publication No. (SMA) 95–3046. Washington, DC, 1995. 17. Rapp RC, et al: Strengthsbased case management: A role in addressing denial in substance abuse treatment. J Case Manag 3(4):139– 144, 1994. 18. Morse RM, Flavin DK: The definition of alcoholism. JAMA 268:1012–1014, 1992. 19. Brown BS, et al: The functioning of individuals on a drug treatment waiting list. Am J Drug Alcohol Abuse 15:261–274, 1989. 20. Mattick RP, Hall W: Are detoxification programs effective? Lancet 347:97–100, 1996. 21. Gerstein DR, Harwood HJ,
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Committee for the Substance Abuse Coverage Study, Institute of Medicine: Treating Drug Problems vol 1: A Study of the Evolution, Effectiveness, and Financing of Public and Private Drug Treatment Systems. Washington, DC: National Academy Press, 1990. 22. Stein B, Orlando M, Sturm R: The effect of copayments on drug and alcohol treatment following inpatient detoxification under managed care. Psychiatric Serv 51: 195–198, 2000. 23. Edmunds M, et al (eds): Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: Institute of Medicine, National Academy Press, 1997. 24. McLellan AT, et al: Evaluating effectiveness of addiction treatments: Reasonable expectations, appropriate comparisons. In Egertson JA, Fox DM, Leshner AI (eds): Treating Drug Abusers Effectively. Malden, MA: Blackwell Publishers, 1997. 25. Batten HL, et al: Drug Services Research Survey, Final Report: Phase II. Submitted by the Bigel Institute for Health Policy, Brandeis University to the National Institute on Drug Abuse, Waltham, MA, 1992. 26. McLellan AT: Patient characteristics associated with outcome. In Cooper JR, et al (eds): Research on the Treatment of Narcotic Addiction: State of the Art. DHHS Publication No. ADM 83–1281, Washington, DC: U.S. Government Printing Office, 1983.
27. Fiorentine R, Anglin MD: More is better: Counseling participation and the effectiveness of outpatient drug treatment. J Subst Abuse Treat 13:341–348, 1996. 28. Simpson DD, et al: Client engagement and change during drug abuse treatment. J Subst Abuse Treat 7:117–134, 1995. 29. McLellan AT, et al: The effect of psychosocial services in substance abuse treatment. JAMA 269:1953–1996, 1993. 30. Aszalos R, et al: Engaging hospital heroin-dependent patients into substance abuse treatment. J Subst Abuse Treat 17:149–158, 1999. 31. Caplehorn JR, et al: Retention in methadone maintenance and heroin addicts’ risk of death. Addiction 89:203–207, 1994. 32. Huang LX, Cerbone FG, Gfroerer JC: Children at Risk Because of Parental Substance Abuse (working paper). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies, 1998. 33. Catalano RF, et al: An experimental intervention with families of substance abusers: One-year follow-up of the Focus on Families project. Addiction 94:241–254, 1999. 34. Richards TM: Working with disturbed children of alcoholic mothers. Curr Alcohol 7:521–527, 1979. 35. Volpicelli JR, et al: Naltrexone in the treatment of alcohol dependence. Arch Gen Psychiatry 49:876–880, 1992. 36. Gilbert FS: The effect of type of aftercare follow-up on treatment
among alcoholics. J Studies Alcohol 49:149–159, 1988. 37. Lash SJ, Blosser SL: Increasing adherence to substance abuse group therapy. J Subst Abuse Treat 1:55–60, 1999. 38. Morgenstern J, et al: Affiliation with Alcoholics Anonymous following treatment: A study of its therapeutic effects and mechanisms of action. J Consult Clin Psychol 65: 768–777, 1997. 39. Irvin JE, et al: Efficacy of relapse prevention: A meta-analytic review. J Consult Clin Psychol 67: 563–570, 1999. 40. U.S. General Accounting Office: Cocaine Treatment: Early Results from Various Approaches. GAO/HEHS-96-80. Washington, DC: U.S. Government Printing Office, 1996. 41. Eisen SV, et al: Development of a consumer survey for behavioral health services. Psychiatr Serv 50: 793–798, 1999. 42. CABHS-MHSIP Research Team (Eisen SV, et al): Consumer Assessment of Behavioral Health Services (CABHS): Mental Health Statistics Improvement Project (MHSIP) Consumer Survey Evaluation Project: Field Study Report. Boston, Jan 1, 1999. 43. Hermann RC, et al: Quality measures for mental health care: Results from a national inventory. Med Care Res Rev, in press. 44. Joint Commission on Accreditation of Healthcare Organizations: 1999–2000 Comprehensive Accreditation Manual for Behavioral Health Care. Oakbrook Terrace, Ill, 1999.
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“This timely report should stimulate productive policy discussions about measuring the performance of managed care organizations in providing alcohol and other drug (AOD) treatment services. The report is notable for its emphasis on accountability for the overall process of care, including prevention and treatment. Defining accountability more broadly than for outcomes of specific treatment episodes seems especially appropriate in the context of managed care organizations, which are responsible for the health of defined populations over time. Substantial research evidence supports the notion that AOD disorders are chronic conditions that should be treated and continually monitored much as other chronic medical conditions.”—Michael Polen, MA, Senior Research Associate, Center for Health Research, Kaiser Permanente, Northwest Region, Portland, Oregon. PERFORMANCE MEASURES AND MEASUREMENT
Developing Performance Measures for Alcohol and Other Drug Services in Managed Care Plans FRANK MCCORRY, PHD DEBORAH W. GARNICK, SCD JOHN BARTLETT, MD, MPH FRANCES COTTER, MA, MPH MADY CHALK, PHD FOR THE WASHINGTON CIRCLE GROUP
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ddiction is a treatable condition with expectations of success as positive as for other chronic diseases, such as diabetes, hypertension, and asthma.1 Yet, until now, performance measures that have been developed, tested, and used across the United States for medical and mental health services have not been applied for
alcohol and other drug (AOD) services. The Washington Circle Group (WCG) has begun to fill that gap.
Frank McCorry, PhD, is Chair of the Washington Circle
Schneider Institute for Health Policy, The Heller School, Brandeis University, Waltham, Massachusetts. John Bartlett, MD, MPH, is Vice President, MedHelp.com, New York. Frances Cotter, MA, MPH, is Public Health Advisor, Center for Continued
Group and Director of the Clinical Services Unit, New York State Office of Alcoholism and Substance Abuse, Albany, New York. Deborah W. Garnick, ScD, is Research Professor, Copyright © 2000 by the Joint Commission on Accreditation of Healthcare Organizations
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The WCG As members of the WCG, we have joined to share our expertise in AOD disorders, managed care, and
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THE JOINT COMMISSION Article-at-a-Glance Background: Monitoring the quality and availability of alcohol and other drug (AOD) services must be a central tenet of any health-related performance measurement system. The Washington Circle Group (WCG), which was convened by the Center for Substance Abuse Treatment Office of Managed Care in March 1998, has developed a core set of performance measures for AOD services for public- and private-sector health plans. It is also collaborating with a broad range of stakeholders to ensure widespread adoption of these performance measures by health plans, private employers, public payers, and accrediting organizations. Core performance measures: Four domains were identified, with specific measures developed for each domain: (1) prevention/education, (2) recognition, (3) treatment (including initiation of alcohol and other plan services, linkage of detoxification and AOD plan
services, treatment engagement, and interventions for family members/significant others), and (4) maintenance of treatment effects. Continuing efforts: Four measures that are based on administrative information from health plans and two measures that require a consumer survey of behavioral health care are undergoing extensive pilot testing. The WCG has reached out to a broad range of stakeholders in performance measurement and managed care to acquaint them with the measures and to promote their investigation and adoption. As results of pilot testing become available, these outreach efforts will continue. Conclusions: Performance measures for AOD services need to become an integral part of a comprehensive set of behavioral and physical health performance measures for managed care plans.
performance management to improve the quality and effectiveness of AOD prevention and treatment services through the use of performance measurement systems. Our group, which was convened by the Center for Substance Abuse Treatment Office of Managed Care (Substance Abuse and Mental Health Services Administration, Department of Health and Human Services, Washington, DC) in March 1998, has set two major goals:
1. Develop and pilot test a core set of performance measures for AOD services for public- and private-sector health plans. 2. Collaborate with a broad range of stakeholders to ensure widespread adoption of AOD performance measures by health plans, private employers, public payers, and accrediting organizations. The development of performance measures for AOD services is a complex task for several reasons. AOD
Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Mady Chalk, PhD, is Director, Office of Managed Care, Center for Substance Abuse Treatment. The remaining members of the Washington Circle Policy Group are as follows: Thomas Babor, PhD, MPH, Professor, Department of Psychiatry, University of Connecticut Health Center, Farmington, CT; Spencer Falcon, MD, Executive Vice President, Private Healthcare Systems, Inc, Waltham, MA; David R. Gastfriend, MD, Director of Addiction Services, Department of Psychiatry, Harvard Medical School, Boston; Suzanne Gelber, PhD, Principal, SGR Health Alliance, Berkeley, CA; Patricia A. Harrison, PhD, Manager, Health Care Research and Evaluation, Minnesota Department of Human Services, Minneapolis, MN; Constance Horgan, ScD, Professor, Schneider Institute for Health Policy, The Heller School, Brandeis University, Waltham; A. Thomas McLellan, PhD, Scientific Director, Treatment Research Institute, Philadelphia; Jeffrey Merrill, PhD, Professor, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson
Medical Center, Piscataway, NJ; Hernando Posada, President, Tech2Work, Inc, Columbus, OH; Rhonda Robinson-Beale, MD, Executive Medical Director, Blue Cross Blue Shield of Michigan, Southfield, MI; and Constance Weisner, Dr PH, MSW, Professor, Department of Psychiatry, University of California, San Francisco. The opinions expressed in this article are the views of the authors and do not necessarily reflect the views of their organizations. The authors thank Elizabeth Merrick, PhD, MSW, and Margaret Lee, PhD, for their excellent work in their review of the research literature and their substantive contributions to the report. Michele King, Susan Minstry Wells, and TASCON, Inc, provided invaluable assistance in editing and formatting this report. Please address correspondence to Deborah W. Garnick, ScD, Schneider Institute for Health Policy, The Heller Graduate School, Mailstop 035, Brandeis University, Waltham, MA 02454-9110; phone 781/736-3840; fax 781/736-3985; e-mail [email protected].
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disorders often manifest as a range of physical and psychological conditions that require special treatment or intervention; however, they often go unrecognized and unaddressed in health care settings. Furthermore, many individuals with AOD disorders may minimize the role of alcohol and drug use in their health problems. The illegal nature and stigma of drug use may further inhibit those with such disorders from revealing their problems to their health care providers. Nevertheless, AOD disorders, once identified, can be successfully treated. The focus of the WCG’s efforts is the development of performance measures to track the activities of managed care organizations to prevent, recognize, and treat AOD disorders. We are working with others in the AOD and mental health fields who are developing and implementing performance measures. Through collaboration and dialogue, the WCG is building on existing performance monitoring systems and data sets to ensure more efficient measurement of AOD services.
enforcement expenditures, AOD-related crime, and lost productivity. But numbers alone do not tell the complete story. People with AOD disorders often have multiple and complex health and social problems. Comorbid mental and physical health disorders are common. Suicide, infectious diseases, domestic violence, and child abuse further complicate the picture. Although AOD disorders are frequently chronic, relapsing conditions, they are readily identifiable and eminently treatable. Research studies have consistently demonstrated the overall effectiveness of AOD treatment in reducing substance use and in improving patient functioning in the family, workplace, and community.5–7 (For a current view of the topic, see Principles of Drug Addiction Treatment: A Research-Based Guide, National Institute on Drug Abuse, 1999.8) AOD treatment has been found to be as effective as treatments for other complex, chronic illnesses.1 Only one-quarter of the adults diagnosed with chemical dependency, however, receive any treatment at all.9
Scope of the Problem AOD disorders exact a terrible toll on individuals and their families, employers, health care providers and payers, the economy, and society at large. Though AOD disorders are readily treatable, most individuals are not getting help.2 According to the 1998 National Household Survey on Drug Abuse, conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA),3 an estimated 14 million Americans older than 12 years of age were current users of illicit drugs. About 4 million people met diagnostic criteria for dependence on illicit drugs, including 1 million youths aged 12 to 17 years. Of 113 million Americans aged 12 years and older who reported alcohol use in 1998, 33 million engaged in binge drinking, and 12 million were classified as heavy drinkers. Nearly 50% of underage drinkers (ages 12–20 years) engaged in binge drinking, and 22% were classified as heavy drinkers. The economic impact of AOD disorders is staggering. In 1995 total costs for AOD abuse were estimated at $277 billion ($167 billion for alcohol abuse and $110 billion for drug abuse).4 Only 12% of these costs were directly related to the cost of treatment. The bulk of the costs was due to additional law
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Mission and Values Statement From its inception, the WCG has developed and refined a set of values statements on the provision of care to persons with AOD disorders. A mission statement, which incorporates the WCG’s approach to performance measurement, also has been adopted. The mission statement builds on the earlier work of other performance measures work groups in the field of AOD disorders, which also recognized that any true measurement of performance must cover all domains in the process of care. The values statements and the mission statement have been used to inform the development and selection process of the core measures in this document. The mission statement reads as follows: There is a clear need to promote quality and accountability in the delivery and management of alcohol and other drug (AOD) abuse services by organized systems of care, both public and private. The WCG believes that this is best accomplished through adopting a process of care model and defining a set of measures for each domain within that model. Moreover, the WCG believes that accountability for AOD services is best achieved when system performance is compared across all domains of the process of care. The WCG is committed to developing evidence-based measures that allow for such comparison.
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THE JOINT COMMISSION The values outlined in the values statement follow. Treatment is essential. People with AOD disorders suffer from conditions that are frequently chronic and relapsing in nature, readily identifiable, and eminently treatable. They should receive professional care for these conditions in a timely and respectful fashion, and this professional care should be followed with continuing support through Alcoholics Anonymous (AA), Narcotics Anonymous (NA), or other community support organizations. Recognition is a key first step. AOD disorders often go unrecognized and untreated in health care settings. Identifying people in need of AOD services and providing them with access to appropriate care are “first-order” responsibilities of managed care organizations. Comprehensive treatment is critical to recovery. People with AOD disorders deserve to have the full range of evidence-based treatment options available to them, including pharmacotherapies and residential care. Self-help and peer support such as provided through AA/NA, although an important component of a comprehensive treatment plan, is not a substitute for needed treatment delivered by properly trained clinicians. Support services for family members are crucial. Family members of individuals with AOD disorders are often at increased risk for AOD abuse and other problems. Support services to family members are an important component of treatment for the affected individual. Quality AOD care yields multiple benefits.
Monitoring the quality and availability of AOD services must be a central tenet of any health-related performance measurement system, because the benefits of quality AOD care accrue not only to the individual and family in need but to the broader community as well, in terms of improved public health and safety and reduced social welfare costs.
Framework for Developing Core Measures Measurement for External Accountability The WCG’s goal is to develop performance measures for the purpose of external accountability. Historically, accrediting bodies and regulatory agencies responsible for ensuring external accountability examined descriptive documentation of health care system structure
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and process. More recently, performance measurement has become a preferred means of ensuring external accountability. Measurement for external accountability examines the extent to which a health care system meets a preexisting, agreed-on standard. As the principal audience for this information, purchasers, payers, and health care consumers use performance measures to compare across different health care organizations. The focus of accountability measurement is on the outputs or results of health care delivery and does not address how these outputs are achieved or how internal processes need to be changed to improve output.10 Other approaches to questions of quality and accountability, such as quality improvement, may examine and measure the internal processes of production to improve output. Although the core set of measures presented in this article may prove useful in these activities, their primary purpose is to promote external accountability and compare the performance of health care systems. Accountability for the Process of Care To develop effective performance measures that gauge external accountability in AOD services, the WCG has considered both whom should be held accountable for such measurement and for what they should be held accountable. Specifically, the WCG believes that responsibility for performance measurement rests at the service delivery level and that organized delivery systems (for example, managed care plans) should be held accountable for the entire process of care for people with AOD disorders. Accountability at the Delivery System Level With the major transformations that have occurred in the behavioral health care marketplace, it is clear that responsibility for treatment planning and implementation no longer involves only the clinician and the patient. Health plans, managed behavioral health care organizations, and other forms of organized delivery systems (such as the criminal justice system or social service system) play a significant role in the decisions about what treatment is provided, to whom, and for how long. Moreover, delivery systems have authority over defined populations and all the resources allocated to those populations. With this authority comes responsibility and accountability for performance measurement.
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Accountability for the Entire Process of Care The WCG believes it is insufficient to hold delivery systems accountable only for AOD services delivered within a particular episode of care. The chronic, relapsing nature of AOD disorders argues for a system of accountability beyond the confines of a discrete treatment episode. Indeed, how individuals manage their recovery following a particular episode of care is as important to their long-term success as the delivery of the care itself. This has been shown to be true in the treatment and management of other chronic disorders as well. Consequently, how a system of care organizes its services to support individuals’ posttreatment sobriety is an important indicator of performance. Furthermore, there is convincing evidence that early recognition and timely prevention and intervention can positively affect the course of an individual’s AOD problems. Organized systems of care must be held accountable for their members through the entire process of care—from prevention and early recognition services through treatment and posttreatment activities—if a true measure of performance is to be realized. There are several justifications for broadening the base of accountability in the area of AOD treatment. First, responsible stewardship for public and private dollars requires that the impact of these resources be monitored and maximized. To concentrate on only a small segment of the process of care for people with AOD disorders would ignore the body of knowledge that has been developed over the past 25 years about the importance of each phase of that care in achieving positive outcomes for people with AOD problems. To hold delivery systems clinically accountable for coordination and oversight of the entire care
process does not necessarily imply that they must pay for all the care and services provided. They are responsible, however, for ensuring that all the required components of the process of care occur with reasonable efficiency and effectiveness over time. Underlying Assumptions In developing its approach to performance measurement, the WCG made three assumptions. Use of existing data collection systems. Measures were identified for which data are available in existing administrative data systems or through currently planned consumer surveys (Table 1, below). This design decision parallels the approach taken in other medical and mental health measurement efforts. Currently, managed care plans use their administrative data systems to calculate many ratebased HEDIS (Health Employer Data and Information Set; National Committee for Quality Assurance, Washington, DC) measures (rate of follow-up visits after hospitalization for depression, for example). The developers of the Experience of Care and Health Outcomes (ECHO™) survey, which includes questions for two of the WCG measures, are suggesting that it be field tested using a similar protocol to the one developed for the commonly used Consumer Assessment of Health Plans (CAPHS™). Initial focus on process measures. Assessing reduction in the use of AODs and related problems is the ideal standard by which the performance of a substance abuse program can be measured. Because of existing limitations in the science and availability of appropriate databases for outcome measures, however,
Table 1. Washington Circle Group Core Performance Measures*
Domain
Measure
Data Source
Prevention/Education
Educating patients about AOD disorders
Enrollee survey
Recognition
Identification rates
Administrative data
Treatment
Initiation of AOD plan services Linkage of detoxification and AOD plan services Treatment engagement Interventions for family members/significant others of AOD clients in treatment
Administrative data Administrative data Administrative data
Maintenance
Maintenance of treatment effects
Patient survey
Patient survey
* AOD, alcohol and other drug.
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THE JOINT COMMISSION Table 2. Core Performance Measures*
Prevention/Education: This domain encompasses delivery system activities designed to raise the general awareness of substance abuse as a major debilitating disorder affecting individuals, families, and the greater society. Also included are those activities designed to target high-risk individuals and groups for more focused interventions. Educating patients about AOD disorders. Percentage of adult patients with primary care visits who are advised or given information about AOD disorders. Recognition: This domain addresses the plan’s efforts, in all clinical settings, at case-finding, including screening and assessment. It also includes referral of affected individuals into treatment. Identification rates. Number of cases per 1,000 members who were diagnosed with AOD abuse or dependence or who received AOD-related plan services on an annual basis. Treatment: This domain encompasses the delivery system activities associated with the rehabilitation of individuals who have a substance abuse disorder diagnosis. This includes a broad range of services associated with an episode of care, including medications, testing, counseling, medical services, psychiatric and psychological services, social services, and coordination with other treatment resources. Detoxification and emergency room care may be viewed as the initiation of a treatment episode, but do not by themselves constitute treatment for AOD disorders. In turn, AA/NA and other community support fellowships are clearly important for
the continuation of treatment-initiated sobriety and social function. However, by their own charters, AA and NA are not structured to provide professional services that are so often needed to stabilize psychologically and emotionally unstable patients, nor to address the complications of addiction that can interfere with behavioral change. Initiation of AOD plan services. Percentage of individuals with an index diagnosis of AOD abuse or dependence who receive any additional AOD services within 14 days. Linkage of detoxification and AOD plan services. Percentage of patients with an index detoxification who initiated AOD plan services within 14 days following detoxification. Treatment engagement. Percentage of clients diagnosed with AOD disorders that receive three plan-provided AOD services within 30 days of the initiation of care. Interventions for family members/significant others of AOD clients in treatment. Percentage of survey respondents who report using AOD services and who also report that their family member/significant other received preventive interventions. Maintenance: This domain includes delivery system activities related to sustaining long-term positive outcomes. Included are such areas as self-management and peer support strategies to sustain posttreatment abstinence or reduction in use, improvements in role functioning and well-being, and life-style changes. Maintenance of treatment effects. Percentage of clients who report specific services provided and/or monitored by the plan to promote and sustain positive treatment outcomes postdischarge.
* AOD, alcohol and other drug; AA, Alcoholics Anonymous; NA, Narcotics Anonymous.
such assessment of treatment outcomes is not financially or technically feasible for most systems at the present time. Therefore, as an intermediate approach, the WCG targeted a set of process measures that research has shown to be related to treatment outcomes. As the field of performance measurement evolves, outcome measures will be added to the core set as well. Links to the accreditation process. Data for some measures (for example, screening) cannot be obtained through current administrative data systems or through patient self-report. Although identification rates, which imply a screening or an identification
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process, can be measured, it is not feasible at present to measure directly important clinical areas such as screening or multidisciplinary treatment planning. Therefore, the WCG recommends that the accreditation process incorporate some of these clinical and organizational areas as standards.
Core Performance Measures We propose seven measures as the WCG initial core set for comparing systems’ performance in the delivery of AOD services to adults (see Table 2, above). These measures fit into four domains representing the continuum of AOD services—prevention/education,
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recognition, treatment, and maintenance. These domains are comparable to those used in the management of other chronic illnesses.
Rationale and Evidence Base for Core Measures For each core measure, a rationale of its importance and a summary of the supporting literature are presented. Of course, all the activities we include should be tailored to the particular patient’s needs. Moreover, this core set describes the activities that all plans should be striving for in identifying and treating their members with AOD problems.
further help. These activities can also take place in a broad range of settings, including emergency rooms, mental health treatment facilities, medical practices (for example, obstetrics/gynecology, adolescent medicine, general medicine), and welfare agencies.13 By calculating the rate of AOD claims per 1,000 members and comparing it to current population estimates, this measure will show how successful plans are over time in identifying members who need AOD services. One source of comparison is the regional estimates (and in future years, state-level estimates) included in the National Household Survey on Drug Abuse.3 Treatment
Prevention/Education
Percentage of adult patients with primary care visits who are advised or given information about AOD disorders. The provision of general medical care is an excellent opportunity to address issues of AOD abuse. As with other chronic conditions,11,12 patient education is an important aspect of prevention. Plans should ensure that primary care providers address issues of the use of AODs, as part of an interview or health risk appraisal, through the distribution of print materials, or as part of other contacts with enrollees; provide information and/or guidance regarding moderate use of alcohol and the risks involved in using other drugs; and recommend follow-up actions when indicated. This measure will permit evaluation of AOD educational efforts in primary care settings. Educating patients about AOD disorders.
Recognition Identification rates. Number of cases per 1,000 members who were diagnosed with AOD abuse or dependence or who received AOD-related plan services on an annual basis. AOD disorders and their associated health problems lead to social and family disruption, as well as to increased medical utilization and costs. Therefore, it is important that managed care plans identify cases among their enrollees and refer them to treatment. If health plans conducted screening and casefinding activities, including the use of validated brief questionnaires, they could identify members with AOD disorders and encourage these individuals to get
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Initiation of AOD plan services. Percentage of individuals with an index diagnosis of AOD abuse or dependence who receive any additional AOD services within 14 days. Studies indicate that only a small fraction of the population with AOD disorders enters treatment.14 Identification of individuals with AOD disorders is an important first step in the process of care, but one that does not routinely lead to initiation of treatment. Plans must also ensure that individuals with an AOD diagnosis initiate treatment. This measure will permit the comparison of plans’ effectiveness in initiating care after the need has been identified by a formal diagnosis of abuse or dependence. There are many reasons individuals who are diagnosed with AOD disorder do not initiate treatment. The primary care provider may avoid confronting a patient due to the stigma associated with AOD disorders, or when a referral is made to AOD treatment, the provider may not always follow through to see if the patient began treatment.15 In other cases, individuals who were appropriately referred may choose not to enter treatment. Some individuals may still believe that they can control their substance use or deny that there is a problem.16–18 Studies indicate that a lack of “immediately available” treatment services may also pose a barrier to treatment initiation. In one study, a majority of individuals on a waiting list (52%) reported that their interest in entering treatment had decreased since they had been placed on the list.19 Linkage of detoxification and AOD plan services. Percentage of patients with an index detoxification
who initiated AOD plan services within 14 days following
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THE JOINT COMMISSION detoxification. Detoxification is a medical intervention that manages an individual safely through the process of acute withdrawal. The goals of detoxification are fairly limited. A detoxification program is not designed to resolve the long-standing psychological, social, and behavioral problems associated with AOD abuse. Detoxification is most effective when it is viewed as a first step to active treatment and is followed by assessment and referral to ongoing AOD treatment.8 Without linkage to treatment after detoxification, research has found no significant improvements that are discernable from untreated withdrawal.1,20,21 This measure will permit evaluation of how often plans successfully link clients to treatment following detoxification. Detoxification offers an opportunity to recruit clients into treatment; however, the overall completed referral rates are unacceptably low. Discharge data from the 1980 Client Oriented Data Acquisition Process* (CODAP) report indicated that only 14% of clients detoxifying from opiates were transferred or referred into treatment. There is also significant variation across the country in successfully linking detoxification clients to treatment. Of the 62 reporting areas, 12 had a transfer/referral rate of less than 5%, and only 14 areas had rates greater than 25%.21 More recent data from the period 1991 to 1997 from 14 employer groups whose behavioral health care benefits are managed by United Behavioral Health showed that 79% of patients received formal substance abuse treatment following inpatient detoxification, the majority within one week.22 Treatment engagement. Percentage of clients diagnosed with AOD disorders that receive three planprovided AOD services within 30 days of the initiation of care. Engagement in treatment is critical for treatment effectiveness. Treatment engagement is defined as an intermediate step between initially accessing care (in a first visit) and completing a full course of treatment. (As noted earlier, detoxification alone does not constitute treatment.) Studies of treatment retention indicate that patients who remain in treatment for a longer duration of time have better outcomes.5,23,24 However, studies indicate that many clients with AOD disorders leave treatment prematurely. The 1990 Drug Services Research Survey,25 a * CODAP is a data collection system in the state of Texas.
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study of U.S. drug treatment facilities, reported that 52% of clients who entered treatment did not complete the planned course of treatment. Given the positive association between retention and treatment success, a plan’s ability to engage clients in treatment is an important intermediate measure that is closely related to outcomes. A review of length of stay studies found that the length of time in treatment is related to posttreatment reduction in drug use, reduced criminal activity, and improved employment status.26 Studies of alcoholdependent clients have shown that longer stays in treatment and treatment completion are associated with greater reduction in alcohol use, even after controlling for severity at admission.24 Thus, treatment engagement is positively associated with positive treatment outcomes. Furthermore, intensity of engagement, as measured by how frequently the client attends sessions and how many types of services are provided during treatment, is important to engagement and to treatment outcomes.24,27–29 Engagement in treatment also is important to the reduction of risk for drug-related illnesses.4,30,31 It may be asked why simple referral to AA or NA support instead of treatment has been considered not responsive to the treatment engagement criterion. While AA/NA and other community support organizations are essential for the continuation and maintenance of gains following treatment interventions, there are two major reasons AA/NA by themselves cannot be considered treatment. First, these organizations do not consider themselves treatments, but rather “support fellowships.” Second, since there are (purposely) no records of activity or even attendance at AA/NA meetings, there is (purposely) no way to monitor patient activity in these organizations. Thus for both conceptual and procedural reasons, referral to AA/NA sessions not accompanied by formal treatment services is not considered responsive to the treatment engagement criterion. However, referral to AA/NA is considered responsive to the maintenance criterion (see below). Interventions for family members/significant others of AOD clients in treatment. Percentage of
survey respondents who report using AOD services and who also report that their family member/significant other received preventive interventions. The involve-
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ment of family members in the treatment process may be crucial to long-term success because of its effects on the patient and the family in dealing with AOD-related problems. Family members are subject to a host of negative consequences from a member’s AOD abuse, such as lost wages, domestic violence, depression, and inappropriate role modeling for children. For example, research has documented that children of individuals with AOD disorders are more at risk than their peers for AOD use. 32–34 Consequently, interventions for family members are an important addition to the support, education, and counseling provided to the client. This measure is focused on plans’ efforts to include family members of individuals undergoing treatment for AOD disorders. Maintenance Maintenance of treatment effects. Percentage of clients who report specific services provided and/or monitored by the plan to promote and sustain positive treatment outcomes postdischarge. As with other chronic disorders, AOD abuse requires continued engagement of the patient in psychosocial and/or pharmacological services to maintain the patient’s gains after the completion of treatment.1,35 Thus, plans’ activities to maintain their members’ recovery after treatment is an important domain to measure. For many patients, successful recovery postdischarge involves the utilization of self-management strategies and self-help groups such as AA or NA. Self-management strategies include a range of services provided by the treatment program during and immediately following discharge, including referral to AA/NA, relapse prevention training, and follow-up calls/monitoring. Indeed, use of self-help groups and such follow-up techniques as phone calls or reminder letters have been shown to be effective.36–38 Relapse prevention focuses on helping the client to identify high-risk or “trigger” situations that contribute to relapse and has been shown to be effective for people with AOD disorders.39 Relapse prevention strategies can help the client develop behaviors to avoid or better manage highrisk situations.40 Other services that assist in maintaining treatment effects include training in the use of family support mechanisms, coping skills, and employment counseling.
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Continuing Efforts Pilot Testing of the Initial Core Set Pilot testing is being conducted on two parallel tracks. First, the four measures that are based on administrative information from health plans are being calculated using a common set of questions and programming instructions across a range of settings, including a Medicaid plan that carves out behavioral health services to a managed care vendor, a large group-model health maintenance organization, and a major specialty behavioral health care vendor. In each setting, the goals of the initial testing are to explore the measurement feasibility, to test the sensitivity of the measures to alternate specifications, and to compare results across plans and with statistics published in the literature. In addition, WCG members are planning ways to incorporate further validity testing into their ongoing or new research projects. Second, the two measures that require a consumer survey of behavioral health care are being tested as part of the overall testing of the ECHO survey. Earlier versions of the survey were field tested with 7,000 consumers of behavioral health care in five public assistance and five commercial health insurance plans.41,42 The team of investigators at Harvard Medical School and the Center for Survey Research, University of Massachusetts at Boston, are conducting cognitive testing and pilot tests of the current version with 750 members of public and private health insurers managed by behavioral health care organizations. They plan to continue their development efforts using a revised version of the survey with approximately 20,000 commercially and publicly insured members of 20 health insurance plans and managed behavioral health care organizations across the United States, with results of the field tests expected to be available by the end of December 2000. Adoption of Additional Measures In developing its core set of measures, the WCG sought to identify candidate measures that had a strong evidence base and that covered the domains of the process of care for addictive disorders. Moreover, the group decided to include only those measures that could be captured from existing administrative data systems or from a consumer survey method. From the WCG’s perspective, it is essential that national accrediting bodies and plans begin to monitor the delivery of
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THE JOINT COMMISSION AOD services and compare the performance of managed care plans sooner rather than later. Given these criteria, several measures across all domains were deferred for development at a future time. Specifically, a recognition measure of co-occurring mental health and addictive disorders and a treatment measure on the use of laboratory tests (such as urinalysis) and medication in treatment were deferred. Other measures of interest included a treatment measure on the reduction of AOD use among pregnant women, and a maintenance measure on sustained reductions in AOD use postdischarge. As a clearer picture of the performance of managed care plans emerges from the use of the initial core set, the WCG hopes to add these and additional measures to its menu of measures. Moreover, as research into the nature and treatment of addictive disorders yields new insights, other measures will be considered for development by the WCG. Dissemination The WCG has reached out to a broad range of stakeholders in performance measurement and managed care to acquaint them with the measures and to promote their investigation and adoption. Members of the group have made presentations at the American College of Mental Health Administration (March 1999), the American Public Health Association’s annual meeting (November 1999), and the Maryland Task Force to Develop Performance Quality Measures for Managed Behavioral Health Care Organizations (October 1999). In addition, the WCG has initiated discussions with the national accrediting organizations,
beginning with a presentation to the NCQA’s Behavioral Health Measurement Advisory Panel. The measures are cited in an inventory of quality measures in behavioral health care that will soon be available on the Web (www.challiance.org/cqaimh).43 Moreover, the WCG measures relate clearly to Section I, “PatientFocused Functions,” of the Joint Commission on Accreditation of Healthcare Organizations accreditation manual for behavioral health care.44 The measures focus on assessment, treatment, education, and the continuum of care. If implemented in full, they also serve as the basis for continuously analyzing and improving organization performance of clinical and other processes (“Section II, Organization-Focused Functions”); and for benchmarking the organization’s performance against that of other organizations. Finally, the WCG has earned endorsement from the American Society on Addiction Medicine. As results of pilot testing become available, these outreach efforts will continue.
Conclusion The WCG remains committed to pursuing all promising avenues for developing AOD performance measures. In doing so, we will continue to be guided by our vision of advancing quality and accountability in AOD services through the development and application of evidence-based performance measures across all domains of the process of care. We will have reached our goal when the performance measures for AODs are an integral part of a comprehensive set of behavioral and physical health performance measures for managed care plans. J
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