Improving Outcomes and Costs With System-Level, Physician-Led Interdisciplinary Case Review
Abstract
Improving outcomes and reducing costs for individuals with frequent acute episodes of care is a high priority for community behavioral health systems and managed care organizations. This column illustrates the application of interdisciplinary, interagency teamwork—with clinical leadership by the system psychiatric medical director—to a county-level quality improvement team process, a change that resulted in significant improvements in outcomes and costs over a 7-year period.
HIGHLIGHTS
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Psychiatrist-led multidisciplinary collaboration is associated with improved outcomes for at-risk populations.
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Multidisciplinary collaboration inspires innovative intervention for at-risk populations.
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Multidisciplinary collaboration may enhance the performance and improve the morale of frontline clinicians.
Individuals with complex needs are more likely to have higher costs and poorer outcomes, including the more frequent use of acute care. Physician-led interdisciplinary teams have gained considerable experience in better meeting the needs of such patients on the clinical program level. Multidisciplinary teams, comprised of staff who vary in educational and professional experience, bring together diverse perspectives, expertise, and skills (1). Physician leadership provides the clinical authority to coordinate the activities of the team to create an integrated and successful treatment plan. Common examples include physician-led teamwork in psychiatric inpatient care and the emerging expansion of physician-led collaborative care teams for individuals with combined general medical and behavioral health needs in primary care (2). Although the recommended role of a medical director in providing interdisciplinary system leadership and continuous quality improvement support for large behavioral health systems was described over 20 years ago (3), we could find no published literature describing examples of physician-led interdisciplinary case conferencing and interagency teamwork that led to better results on the system or population level. This article illustrates one example of such an effort. (A list of suggested reading materials related to this topic is available as an online supplement to this column.)
Background
Oakland Community Health Network (OCHN) functions as the managing entity and Medicaid-managed care intermediary for behavioral health services in Oakland County, Michigan. Services are contracted to providers at more than 300 sites, for approximately 25,800 citizens. The organization serves individuals of all ages with mental illness, intellectual and developmental disabilities, and substance use disorders.
OCHN’s mission is to ensure that all people receiving specialty mental health services through OCHN have access to services and supports that improve their health and quality of life. As part of this effort, OCHN operates a robust quality-improvement program, part of which is dedicated to identifying individuals who are not faring well in current services and finding ways of improving their outcomes. OCHN flags high-risk individuals through its state-mandated quality assurance performance improvement plan (QAPIP), using the following criteria: have engaged in high-risk, self-destructive, or antisocial behaviors; have had six or more visits to crisis screening units in the past 6 months; have had 12 or more visits to emergency rooms in the past 6 months; have had three or more admissions to a psychiatric unit or crisis residential unit in the past 3 months; have relapsed following treatment in a residential substance-abuse unit within 6 months of discharge; have failed to respond to outpatient substance use treatment for the past 6 months; have had three or more criminal charges within 3 months; and have had two or more failed specialized residential placements in the past 12 months.
OCHN also has a sentinel event review committee (SERC), which reviews all adverse events, including death, involving people served.
In 2010, based on recurrent poor outcomes flagged by SERC, the CEO of OCHN tasked the system medical director (L.J.R.) with developing a mechanism to achieve improvement. In consultation with a quality improvement specialist from the Johns Hopkins School of Business (Paul Gurney, M.B.A.), the medical director established the outcomes improvement committee (OIC).
Structure and Process of the OIC
The stated goal of the OIC is to stabilize the high-risk population by reducing hospital recidivism, incarceration, substance use, and homelessness and increasing the use of effective outpatient services and support to promote recovery.
The OIC's regular members currently include seven who represent OCHN (the medical director, quality analyst, two clinical analysts, hospital liaison, recipient rights specialist, and administrative support specialist) and seven who represent each of the most significant community mental health provider agencies in Oakland County. In addition, individuals working with clients whose care is under review participate as needed for their client. All participants sign confidentiality agreements to participate as quality-improvement committee members in order to facilitate information sharing. Clients whose care is under review also sign permission for their cases to be discussed.
The OIC holds twice-monthly meetings, led by the OCHN medical director, where both new and follow-up cases are presented. Review requests may come to the OIC by referral from OCHN, providers, or outside sources. OCHN may identify individuals for review through multiple mechanisms, such as evidence from quality analysts that a person meets the QAPIP criteria; multiple complaints presented to customer service; or excessive utilization reported by utilization review or nurse case managers. Providers (including the county’s contracted crisis provider) may also identify clients whom they expect to benefit from team review because of frequent crises or serious instability. Finally, the Medicaid health plan serving the county can identify “high-utilizer” clients with co-occurring general medical and behavioral health needs.
The OIC adheres to a psychiatrist-led team structure in which challenging clinical situations are reviewed and addressed in a safe and consistent context. The key intervention is a grand rounds model (4), administered by an interdisciplinary, interagency team and led by the medical director. When clinically appropriate, the people served, their family members, or both are invited to participate. Following case presentation, the medical director leads a supportive, collaborative discussion of differential diagnosis and recovery-oriented treatment planning, then helps finalize recommendations. Presenters are not criticized but helped to feel safe to contribute to team deliberations. Substance use and health issues (e.g., smoking and diabetes) are commonly integrated into the discussion.
Unlike typical grand rounds, cases are followed in the OIC after initial presentation, ideally until sufficient progress is made, as measured by a reduction in hospitalizations, emergency visits, criminal justice involvement, and other indicators. The medical director plays a crucial role by exercising clinical leadership and authority and by recommending or approving clinical interventions and payments that would not otherwise occur.
Cost Outcomes
The OIC has reviewed 108 cases since its establishment in 2010. On average, 20 cases are followed at one time. As an illustration, in 2017, the OIC met 19 times, conducting 65 case reviews for 32 people (21 adults, 11 children). As of early 2018, 13 cases (eight adults, five children) have been closed: four patients improved to the point of being restabilized within the community, two were admitted to long-term residential facilities, seven moved or were unavailable for follow-up care, and 19 were still being followed.
Formal cost-benefit analyses were conducted for OCHN leadership in fiscal years 2010, 2012, and 2014. Data used for reporting purposes were inpatient hospital days based on fiscal year date ranges, using a per-day hospital rate of $620. The OIC followed all individuals in the data set for 12 months or more and compared the number of hospital days during the six months before and after the patients’ initial OIC review. Persons mainly using substance use disorder services were not included in 2010.
In 2010, OCHN served 19,463 people. The 12 clients tracked totaled 730 pre-OIC community inpatient days and 237 post-OIC inpatient days, for a savings of 493 days ($305,660). In 2012 OCHN served 21,858 people. The 13 clients totaled 620 pre-OIC inpatient days and 224 post-OIC inpatient days, for a savings of 386 days ($239,320). In 2014, OCHN served 24,934 people. The 12 clients tracked totaled 703 pre-OIC inpatient days and 252 post-OIC inpatient days, for a savings of 452 days ($279,620).
In total, 2,043 community hospital days were decreased to 713, representing a savings of 1,330 days, or $824,600 in a three-year period.
Although these data were not reported annually, the experience in these three years appears typical of other years of the program and has led to continued support by OCHN leadership for the OIC.
Case Examples
Case 1.
A single female in her twenties with anorexia nervosa, C presented to the OIC with extreme weight loss (5′2”, 80 lbs.) and repeated admissions to psychiatric and medical units for weight loss, fatigue, nausea, electrolyte imbalance, and dehydration. At a pivotal OIC meeting, C had been a medical inpatient for 4 days. The internist in charge informed the family that C was medically stable and would be discharged in the next 24 hours.
In addition to OIC committee members, at the meeting were C's treatment team (psychiatrist and therapist from the community mental health clinic) and parents. The Medicaid health plan medical director was present by invitation of the OCHN medical director. C's medical history from the treatment team described repeated episodes of weight loss since adolescence, plus refusal to acknowledge any mental disorder, insisting she had a physical illness. She refused psychotropic medications. The Medicaid health plan medical director acknowledged that multiple medical hospitalizations over the past 2 years had simply “bandaged” the problem without any real progress.
The OIC agreed that immediately discharging C from the medical unit, without any change in treatment plan, was a recipe for failure. However, the hospital had been unsuccessful in arranging a psychiatric consultation since their psychiatrists were not paneled in C’s health plan. In return for an agreement to keep C in the medical unit, OCHN’s medical director arranged for a stat consult with a psychiatrist with expertise in eating disorders.
The consultant saw C the following day and was able to establish a therapeutic relationship. C accepted his suggestion to begin taking a selective serotonin reuptake inhibitor (SSRI) and to see him for outpatient treatment. The OIC followed C for 6 months, during which she gained 20 pounds, while enrolling at a local university and earning excellent grades.
Having both medical directors physically present at the pivotal OIC meeting was instrumental in this result, given that administrative decisions could be made immediately.
Case 2.
J, a 7-year-old, presented to the OIC after multiple recent episodes during which he choked his brother, pulled out clumps of his mother’s hair, and ran away from home.
The family environment was supportive, with both parents involved in treatment at the community mental health clinic. There was no clear precipitant and no known history of trauma.
J had several psychiatric hospitalizations in the 6 months prior to presentation at the OIC and was diagnosed as having attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). Despite individual and home-based family therapy, J’s aggressive behaviors had continued. Family and friends had encouraged J's parents to place J outside the home. Numerous hospitalizations along with high-risk behavior (running away) and physical violence toward family members led to J’s referral to the OIC.
As a part of the evaluation process, J’s parents were invited to the OIC. The OIC learned that J’s explanation for his aggressive and elopement behaviors was hearing a scary man’s voice telling him to run away and hurt others: “Bad J made me do it.” The OIC also learned that the father’s brother had been given a diagnosis of severe schizophrenia. The OIC concluded that the current diagnoses of ADHD and ODD did not adequately explain the severity of J’s symptoms. A complete physical examination and neuropsychological testing were recommended. The findings from neuropsychological testing confirmed a diagnosis of psychosis not otherwise specified (NOS) with no evidence of pervasive developmental disorder. Surprisingly, blood tests revealed elevated blood sugar, leading to a diagnosis of type I diabetes.
The OIC recommended continuing antipsychotic medication plus active treatment for diabetes, while continuing in-home supports. Knowing the parents were feeling overwhelmed by the severity of their son’s symptoms, the OIC encouraged the treatment team to support the parents with the hope that J’s aggressive behaviors would improve and a belief that recovery was possible.
After the OIC intervention, with the continuation of antipsychotics and the addition of insulin to the treatment regimen, there was a significant decrease in aggressive behaviors. Psychiatric hospitalization was no longer required. J took pride in his new ability to control his behaviors by using the skills he had developed in treatment and by monitoring his diet and HbA1c. This progress, along with continued support from parents and practitioners, allowed J to start to overcome his self-image as a “bad person.”
Conclusions
The OIC experience may demonstrate the value of a regularly scheduled interagency, interdisciplinary quality-improvement conference, led by a system medical director, in reducing costs (as measured by decreased hospital days) through improving clinical outcomes for a subset of clients. Participation by staff from multiple contracted agencies enhances interagency partnership, as well as collaboration between providers and OCHN. In addition, case consultations represent an opportunity to share ideas and reinforce the application of organizational values (recovery-oriented, person-centered planning and trauma-informed care) and evidence-based practices (e.g., careful diagnostic assessment; appropriate psychotropic medication management; engagement and education of families and other support systems; integrated interventions for co-occurring mental health, substance use disorder, cognitive, and general medical conditions; and interventions matched to stage of change, such as motivational interviewing).
It is noteworthy that overall cost-benefits appear to accrue to OCHN even though not all clients presented to the OIC have demonstrably positive results. Some clients do not engage with the recommendations or remain in ongoing treatment. Further, providers do not always consistently follow the OIC recommendations. Nonetheless, the OIC approach may be worthy of replication. It is a venue demonstrating the potential value of the leadership provided by a behavioral health system medical director and could therefore be considered for inclusion as part of a comprehensive quality-improvement strategy in any behavioral health system.
Footnote
The authors have confirmed that details of the cases presented have been disguised to protect patient privacy.
Supplementary Material
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References
1.
Kutash K, Acri M, Pollock M, et al: Quality indicators for multidisciplinary team functioning in community-based children's mental health services. Adm Policy Ment Health 2014; 41:55. doi https://doi.org/10.1007/s10488-013-0508-2
2.
Lake J, Turner MS: Urgent need for improved mental health care and a more collaborative model of care. Perm J 2017; 21:17–024. https://www.ncbi.nlm.nih.gov/pubmed/28898197
3.
AACP guidelines for psychiatric leadership in organized delivery systems for treatment of psychiatric and substance use disorders. Community Psychiatrist 1995; 9:6–7
4.
Carter JJ, Christopherson B, Sminkey PV, et al: Assessing the whole person: case managers take a holistic approach to physical and mental health. Prof Case Manag 2015; 41:140–146
Information & Authors
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Cover: XXXX
History
Received: 9 April 2018
Revision received: 29 June 2018
Revision received: 10 September 2018
Revision received: 3 December 2018
Accepted: 20 December 2018
Published online: 13 February 2019
Published in print: May 01, 2019
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The authors report no financial relationships with commercial interests.
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