What’s disturbing Mental Health? Opportunities Lost

November 29, 2011 By scottdm Leave a Comment

In a word, paperwork. Take a look at the book pictured above. That massive tome on the left is the 2011 edition of “Laws and Regulations” governing mental health practice in the state of California. Talk about red tape! Hundreds and hundreds of pages of statutes informing, guiding, restricting, and regulating the “talking cure.” Now, on top of that, layer federal and third party payer policies and paperwork and you end up with…lost opportunities. Many lost opportunities. Indeed, as pointed out in our recent article, The Road to Mastery, as much as 30% of clinicians time is spent completing paperwork required by various funding bodies and regulatory agencies. THIRTY PERCENT. Time and money that could be spent much more productively serving people with mental health needs. Time and money that could be spent on improving treatment facilities and training of behavioral health professionals. In the latest edition of our book, The Heart and Soul of Change, authors Bob Bohanske and Michael Franczak described their struggle to bring sanity to the paperwork required in public mental health service settings in the state of Arizona. “The forms needed to obtain a marriage certificate, buy a new home, lease an automobile, apply for a passport, open a bank account, and die of natural causes were assembled,” they wrote, “…and altogether weighed 1.4 ounces. By contrast, the paperwork required for enrolling a single mother in counseling to talk about difficulties her child was experiencing at school came in at 1.25 pounds” (p. 300). What gives?

The time has come to confront the unpleasant reality and say it outloud: regulation has lost touch with reality. Ostensibly, the goal of paperwork and oversight procedures is to improve accountability. In these evidence-based times, that leads me to say, “show me the data.” Consider the wide-spread practice–mandate, in most instances–of treatment planning. Simply put, it is less science than science fiction. Perhaps this practice improves outcomes in a galaxy far, far away but on planet Earth, supporting evidence is spare to non-existent (see the review in The Heart and Soul of Change, 2nd Edition).

No amount of medication will resolve this craziness. Perhaps a hefty dose of CBT might do some good identifying and correcting the distoreted thinking that has led to this current state of affairs. Whatever happens, the field needs an alternative. What practice not only insures accountability but simultaneously improves the quality and outcome of behavioral health services? Routine outcome measurement and feedback (ROM^Fb). As I’ve blogged about several times, numerous RCT’s document increased effectiveness and efficiency and decreased costs and rates of deterioration. Simply put, as the slide below summarizes, everybody wins. Clinicians. Consumers. Payers.
Everybody wins

Learn about or deepen your knowledge of feedback-informed treatment (FIT) by attending the upcoming “Advanced Intensive” workshop in March 2012; specfically, the 19th-22nd. We will have four magical days together. Space is filling rapidly, so register now. And then, at the end of the last day of the training, fly to Washington, D.C. to finish off the week by attending the Psychotherapy Networker conference. Excellence is front and center at the event and I’ve been asked to do the keynote on the subject on the first day!

Optum Health and the ICCE: Partnering to Achieve Excellence in Behavioral Health

November 26, 2011 By scottdm Leave a Comment

Monday, November 28th, 2011
Chicago, IL & Goldern Valley, MN

The members, associaties, and directors of the International Center for Clinical Excellence are proud to announce a partnership with Optum Health’s Campaign for Excellence. Optum Health works with employers, payers, and providers serving nearly 60,000,000 people. Their “Campaign for Excellence (CFE)” was specifically designed to enhance the quality and outcome of behavioral health services by recognizing top performing clinicians. To date, over 4,000 providers spread across the United States are participating in the CFE, which involves ongoing measurement and benchmarking of client outcome and satisfaction. CFE clinicians are not only provided with feedback regarding the outcome of the individuals they meet and work with but able to compare their overall effectiveness to other providers in the Optum Health network. Performance research makes clear that such comparisons are a necessary first step in the development of expertise. The second? As Miller and Hubble point out in The Road to Mastery, c-o-m-m-u-n-i-t-y. Top performers do not exist in a vacuum. Across a number of domains–chess, mathematics, medicine, or psychotherapy–the “best of the best” benefit from a complex and interlocking network of people, places, resources, and circumstances without which excellence remains out of reach.

And now, we are pleased to welcome these CFE providers to the ICCE community. In December 2009, the International Center for Clinical Excellence was launched and since then, it has grown into the largest, global, web-based network of clinicians, researchers, administrators, and policymakers dedicated to excellence in behavioral health. Clinicians can choose to participate in any of the 100-plus forums, create their own discussion groups, immerse themselves in a library of documents and how-to-videos, and most importantly meet with and consult with peers. Indeed, with the addition of clinicians from Optum Health, total ICCE membership will exceed 5000!

ICCE members will most certainly benefit from the knowledge and experience of the CFE clinicians. And if experience of members to date is any indication, CFE providers will find the community helpful in nurturning their continued professional growth. Indeed, what has been so striking about ICCE is that it transcends its online limitations–which often reinforce anonymity and invisibility–to provide members with the same complex norms of personal connection, openness, and honesty, mutual trust and support, challenge and accountability, that any “land-based” community of excellence offers.

Optum Health is providing CFE clinicians with a unique URL for joining the ICCE. Don’t despair if you are not a provider for Optum Health or participant in the CFE. You too can join the ICCE by going to: http://centerforclinicalexcellence.com/register. Look forward to meeting you online!

Cutting Edge Feedback

November 22, 2011 By scottdm Leave a Comment

Earth | Time Lapse View from Space, Fly Over | NASA, ISS

Using feedback to guide and improve the quality and outcome of behavioral health services is growing in popularity. The number of systems available for measuring, aggregating, and interpreting the feedback provided by consumers is increasing. The question, of course, is, “which is best?” And the answer is, “it depends on the algorithms being used.”

Over a decade ago, my colleagues and I developed a set of mathematic equations that enabled us to plot the “expected treatment response” or ETR of a client based on their first session Outcome Rating Scale (ORS) score. Although the math was complicated, the idea was not: therapists and clients could compare outcomes from session to session to the benchmark provided by the ETR. If too much or too little progress were being made, client and therapist could discuss what changes might be made to the services being offered in order to insure more effective or durable progress. It was a bold idea and definately “cutting edge” at the time–after all, 10 years ago, few people were even measuring outcomes let alone trying to provide benchmarks for guiding clinical practice. The formulas developed at that time for plotting change in treatmentare still being used by many around the world with great effect. At the same time, it was merely a first attempt.

I am proud and excited to be able to announce the development and launch of a new set of algorithms–the largest and most sophisticated to date–based on a sample of 427,744 administrations of the ORS, in 95,478 unique episodes of care, provided by 2,354 different clinicians. Unlike the prior formulas–which plotted the average progress of all consumers successful and not–the new equations provide benchmarks for comparing individual consumer progress to both successful and unsuccessful treatment episodes. Consider an analogy to the field of medicine. No one would be interested in a test for the effectiveness of a particular cancer treatment that compared an individual’s progress to to the average of all patients whether they lived or died. People want to know, “will I live?” And in order to answer that question, the ETR of both successful and ultimately unsuccessful treatments must be determined and the individual clients progress compared to both benchmarks. Adjustments can be made to the services offered when the client’s session by session outcomes fit the ETR of treatments that ended unsuccessfully.

An example of the type of feedback provided by the new algorithms is found below. The graph displays three zones of potential progress (or ETR’s) for a client scoring 15 on the ORS at intake. Scores falling in the “green” area from session to session are similar to treatments that ended successfully. As might be expected, those in the “red” zone, ended unsuccessfully. Finally, scores in the “yellow” zone had mixed results. In each instance, both the client and therapist are provided with instant feedback: green = on track, red = off track, yellow = concern.

The new algorithms will be a major focus of the upcoming “Advanced Intensive in Feedback-Informed Treatment (FIT)” scheduled for March 19th-22nd, 2012. All those subscribing to the event also receive the newly released series of FIT treatment manuals. Space is limited, as always, to 35 people and we are filling fast so please don’t wait. So many exciting developments!

Now, if you haven’t already done so, click on the video at the start of this post. I was floored by these satellite images. In some way, I hope that the new algorithms, FIT training manuals, and the ICCE community can inspire a similar sense of perspective!