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Abstract

Objective:

This review examined the extent to which existing behavioral health quality measures address the priority areas of the National Behavioral Health Quality Framework (NBHQF) as well as the extent to which the measures have received National Quality Forum endorsement and are used in major reporting programs.

Methods:

This review identified behavioral health quality measures in widely used measure inventories, including the National Quality Measures Clearinghouse, National Quality Forum, and the Center for Quality Assessment in Mental Health. Additional measures were identified through outreach to federal agencies. Measures were categorized by type, condition, target population, data source, reporting unit, endorsement status, and use in reporting programs.

Results:

The review identified 510 measures. Nearly one-third of these measures address broad mental health or substance use conditions rather than a specific condition or diagnosis. Seventy-two percent are process measures. The most common data source for measures is administrative claims, and very few measures rely on electronic health records or surveys. Fifty-three (10%) measures have received National Quality Forum (NQF) endorsement, and 28 (5%) unique measures are used in major quality reporting programs. Several subdomains of the NBHQF, such as treatment intensification, financial barriers to care, and continuity of care, lack measures that are NQF endorsed.

Conclusions:

Despite the wide array of behavioral health quality measures, relatively few have received endorsement or are used in reporting programs. Future efforts should seek to fill gaps in measurement and to identify the most salient and strongest measures in each priority area.
Valid and reliable clinical quality measures are integral to implementing and evaluating ongoing health care reforms (1). Reporting of quality measures and benchmarking performance are components of incentive programs for the use of electronic health records and for reforms in delivery systems, such as health homes, advanced primary care, and accountable care organizations (2). Furthermore, quality measures are critical for monitoring changes in the delivery of care in response to Medicaid eligibility expansions and the implementation of health care exchanges, both of which will likely increase access to care for individuals with behavioral health conditions (3). Given that many of today’s delivery system and financing reforms focus on populations at high risk of mental and substance use disorders, there is particular need for quality measures that assess behavioral health care.
To guide the conceptualization of measures for behavioral health care, the Substance Abuse and Mental Health Services Administration (SAMHSA) developed the National Behavioral Health Quality Framework (NBHQF) (4). The framework, modeled from the National Quality Strategy, prioritizes prevention, treatment, and recovery goals at a variety of levels that range from health systems to providers. In addition, it lays the groundwork for developing and applying measures that may be used to monitor and improve the quality of care at the provider, health plan, or population level for individuals with behavioral health conditions. However, it is unclear whether measures are available to address the wide range of needs of individuals with behavioral health conditions as described in the NBHQF. Furthermore, because measures are increasingly used in national and state public reporting programs and as the basis for financial incentives, there is a need for information on the extent to which measures have demonstrated reliability and validity.
Currently, the National Quality Forum (NQF) endorses health care quality measures through its consensus development process by using a multistakeholder panel that independently reviews a given measure to determine its importance, scientific acceptability (reliability and validity), feasibility (data availability and reporting burden), and usability for quality improvement. In addition, NQF promotes alignment of measures and reduction of reporting burden via the creation of a portfolio of fully harmonized quality measures.
As part of a larger project to develop behavioral health quality measures, we conducted a review of existing quality measures applicable to behavioral health. The review sought to determine to what extent existing measures address a range of behavioral health conditions and how these measures align with NBHQF priority areas. In addition, we determined the number of quality measures that are NQF endorsed and used in public reporting programs.

Methods

The review identified measures related to behavioral health care in the three most comprehensive databases of measures: the National Quality Measures Clearinghouse (www.qualitymeasures.ahrq.gov), NQF (www.qualityforum.org), and the online inventory maintained by the Center for Quality Assessment in Mental Health (www.cqaimh.org). The search included measures in these inventories up to March 2015. For each data source, key terms and phrases were used to identify measures (available from the authors on request). Search terms were restricted to behavioral health conditions that included only mental disorders and substance use disorders, substance abuse, or substance dependence. The review did not include measures related to dementia or measures for general medical conditions (some of which could be relevant for individuals with comorbid conditions).
To identify any additional measures not captured by the above sources or any measures under development by federal agencies, we interviewed representatives from SAMHSA, the Agency for Healthcare Research and Quality (AHRQ), the National Institute of Mental Health, and the Office of the Assistant Secretary for Planning and Evaluation (ASPE) of the U.S. Department of Health and Human Services. In addition, we reviewed measures developed by the Veterans Health Administration (5) and the National Association of State Mental Health Program Directors (6).
Measures were categorized by steward, description, numerator, denominator, exclusions, NQF identification number (if any), data source, level of specification (for example, health plan, hospital, or provider), type of measure (structure, process, or outcome), behavioral health condition, and age range of the relevant population. Measures were also assigned to an NBHQF priority area (that is, effective; patient-, family-, or community-centered; coordinated; healthy living; safe; and affordable-accessible) and domains and subdomains created within the framework to provide greater specificity. The additional domains and subdomains were based on a categorization scheme developed for the International Initiative for Mental Health Leadership project, which conducted a review of international initiatives in mental health quality measurement (7).
In addition, the review identified whether measures are used in the following selected federal and state reporting programs: adult Medicaid core set (8) and child Medicaid core set (9) (reporting by state Medicaid and Children’s Health Insurance Programs), Medicaid health home core set (10) (reporting by health home providers), star ratings for Medicare Advantage and prescription drug plans (11) (reporting by plans for incentive payments), Physician Quality Reporting System (12) (reporting by providers for incentive payments), Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs or meaningful use (13) (incentive payments to organizations that use EHRs to improve patient care), and Centers for Medicare and Medicaid Services (CMS) Inpatient Psychiatric Facility Quality Reporting Program (14) (reporting by inpatient psychiatric facilities).

Results

The review identified 510 measures that address all of the NBHQF priority areas (Table 1). The largest number of available measures are for effective treatment (N=147) and healthy living (N=129). Some topics have many measures, which often address the same concept or variations on a theme. For example, we identified 25 measures that address follow-up after hospital discharge. They focus on various populations or subpopulations (for example, follow-up after hospitalization for mental illness versus follow-up after hospitalization for schizophrenia) or assess the same type of event but specify different time frames (for example, readmission to facilities within 14 versus 30 days).
TABLE 1. Behavioral health quality measures (N=510), by NBHQF priority area, domain, and subdomain and by NQF endorsementa
NBHQF priority area, domain, and subdomainNEndorsed by NQF
N%
Total5105310
Effective treatment1471913
 Pharmacotherapy   
  Use of medications (not specific)240
  Medication adherence (duration)22314
  Medication dosage110
  Polypharmacy8113
  Treatment intensification30
 Psychosocial   
  Tobacco cessation advice or counseling14643
  Psychosocial interventions and psychotherapy160
 Combined   
  Pharmacotherapy and psychosocial interventions1417
 Substance use   
  Symptom reduction14429
  Alcohol brief intervention5360
 Outcomes   
  Outcome assessment1318
  Getting care when needed30
Person or family centered   
 Person or family centered 3213
  Patient involvement (shared decision making and treatment options)120
  Family or caregiver involvement100
  Experiences of care7114
  Financial barriers to care30
Coordination7868
 Efficiency   
  Follow-up after discharge2528
  Overuse30
 Continuity and coordination of care   
  Readmission160
  Care plan or discharge plan12217
  Case management80
  Medication monitoring (visits or monitoring levels)6117
  Functioning30
  Continuity of provider or clinician30
  Follow-up after emergency department visit2150
Healthy living1292419
 Functioning   
  Screening and assessment981313
  Housing20
  Criminal justice encounters10
 General medical health   
  General medical health monitoring (includes side effects of medications)281139
Safe6023
 Safety   
  Seclusion1915
  Restraint1716
  Injuries110
  Assaults50
  Medication errors30
  Elopement20
  Falls20
  Adverse events10
Affordable-accessible6412
 Utilization and access   
  Treatment retention310
  Availability of treatment70
  Initiation of treatment6117
  Primary care access30
  Utilization170
a
NBHQF, National Behavioral Health Quality Framework; NQF, National Quality Forum
Only 10% of the 510 behavioral health measures (N=53) are endorsed by NQF. The largest numbers of endorsed measures are in the “screening and assessment” subdomain of the healthy living NBHQF priority area. Of the 98 measures identified, 13 are endorsed by NQF, which includes several measures that consider screening for general medical conditions (for example, diabetes screening for people with schizophrenia or body mass screening for those with serious mental illness). Although some areas have a number of measures, few are endorsed. For example, although we found 60 measures addressing safety, only two are NQF endorsed. Similarly, in the affordable-accessible priority area, we found 64 total measures and one NQF-endorsed measure.
Most measures found were process based (72%), and nearly one-third (32%) of the measures broadly defined mental health or substance use populations in the denominator rather than a single condition or diagnostic group (Table 2). In addition, most measures are specified for providers or ambulatory care (49%) and use administrative claims data (89%). Among the measures focused on a single disorder, the largest number (22%) focus on depression.
TABLE 2. Characteristics of 510 behavioral health quality measures
CharacteristicMeasures (N=510)Endorsed by NQFa (N=53)
N%N%
Type of measure    
 Process368724483
 Outcome10921917
 Structure3360
Conditionb    
 Depression111221324
 Schizophrenia6212611
 Tobacco use6312815
 Alcohol use5912815
 Drug use541147
 Bipolar disorder33647
 PTSD2240
 ADHD1021 
 >1 mental health or substance use condition161321222
 Other710
Age groupb    
 <1868121731
 18–64218434278
 ≥65211413667
 Not specified2404724
Data sourceb    
 Administrative claims or pharmacy data452894889
 Medical records348683157
 Patient survey601247
 Provider survey1530
 Electronic health records8259
Level of specificationb    
 Provider or ambulatory care252491324
 Hospital144281324
 Health plan108212648
 Other or not specified87170
a
NQF, National Quality Forum
b
More than one may be selected. For example, some measures use both administrative claims and medical records. Some measures may be specified for several levels of reporting.
Selected quality reporting programs use a total of 28 (5%) unique measures. As summarized in Table 3, some reporting programs include relatively few behavioral health measures. The Medicare and Medicaid EHR Incentive Program for Eligible Professionals (also known as “meaningful use” and currently in stage 2) includes 11 measures. We found no behavioral health measures in the Medicare and Medicaid EHR Incentive Program for Eligible Hospitals and Critical Access Hospitals. The child Medicaid core set includes four behavioral health measures. As a result of efforts to align reporting requirements, a number of measures are used in more than one program, with antidepressant medication management (NQF 0105) and follow-up after hospitalization for mental illness (NQF 0576) used in four and five programs, respectively.
TABLE 3. Behavioral health quality measures used in selected federal or state reporting programs
NameaStewardbNQF numbercAdult Medicaid coreChild Medicaid coreMedicaid health homeStar ratings for Medicare Advantage and prescription drug plansPhysician Quality Reporting SystemEHR Incentive Program for Eligible Professionals (meaningful use)dInpatient Psychiatric Facility Quality Reporting Program
Depression, bipolar disorder, and schizophrenia         
 Preventive care and screening: screening for clinical depression and follow-up planCMS0418X X XX 
 Antidepressant medication managementNCQA0105X  XXX 
 Major depressive disorder: diagnostic evaluationPCPI0103    X  
 Major depressive disorder: suicide risk assessmentPCPI0104    XX 
 Child and adolescent major depressive disorder: suicide risk assessmentPCPI1365 X  XX 
 Maternal depression screeningNCQA1401    XX 
 Depression utilization of PHQ-9 toolMNCM0712    XX 
 Depression remission at 12 monthsMNCM0710    XX 
 Adult major depressive disorder: coordination of care of patients with specific comorbid conditionsPCPI     X  
 Bipolar disorder and major depression: appraisal for alcohol or chemical substance useCQAIMH0110    XX 
 Adherence to antipsychotics for individuals with schizophreniaCMS1879X      
Other mental health         
 Improving or maintaining mental healthCMS    X   
 Behavioral health risk assessment (for pregnant women)PCPI  X     
 ADHD: follow-up care for children prescribed ADHD medicationNCQA0108 X  XX 
 Follow-up after hospitalization for mental illnessNCQA0576XXXX  X
 HBIPS-4: patients discharged on multiple antipsychotic medicationsTJC0552      X
 HBIPS-5: patients discharged on multiple antipsychotic medications with appropriate justificationTJC0560      X
Substance use         
 Substance use disorders: screening for depression among patients with substance abuse or dependenceNCQA, PCPI     X  
 Substance use disorders: counseling regarding psychosocial and pharmacologic treatment options for alcohol dependenceAPA, NCQA, PCPI     X  
 Preventive care and screening: unhealthy alcohol use: screening and brief counselingPCPI2152    X  
 SUB-1: alcohol use screeningTJC1661      X
 Preventive care and screening: tobacco screening and cessation interventionPCPI0028    XX 
 Medical assistance with smoking and tobacco use cessationNCQA0027X      
 Initiation and engagement of alcohol and other drug treatmentNCQA0004X XXXX 
Cross-cutting         
 HBIPS-2: hours of physical restraint useTJC0640      X
 HBIPS-6: postdischarge continuing care plan createdTJC0557      X
 HBIPS-7: postdischarge continuing care plan transmitted to next level of care provider on dischargeTJC0558      X
 HBIPS-3 hours of seclusion useTJC0641      X
Total N of behavioral health quality measures in program (%)  6 (23%)5 (20%)3 (38%)4 (5%)16 (6%)11 (17%)8 (100%)
Total N of measures in program  2624877283648
a
HBIPS, Hospital-Based Inpatient Psychiatric Services; PHQ-9, 9-item Patient Health Questionnaire; SUB-1, Substance Use
b
APA, American Psychiatric Association; CMS, Centers for Medicare and Medicaid Services; CQAIMH, Center for Quality Assessment and Improvement in Mental Health; MNCM, Minnesota Community Measurement; NCQA, National Committee for Quality Assurance; PCPI, Physician Consortium for Performance Improvement; TJC, The Joint Commission
c
NQF, National Quality Forum
d
EHR, electronic health record
Eleven of the 28 total behavioral health measures used in public reporting programs focus on depression care. Depression remission at 12 months (NQF 0710) is the only NQF-endorsed behavioral health outcome measure used in any of the national reporting programs. The other 27 measures focus on screening-assessment, medication management, coordination, restraint, and seclusion.

Discussion

Even though many behavioral health quality measures exist, many measures address similar content areas, and relatively few measures have received national endorsement or are used in major quality reporting programs. Although several NBHQF priority areas have few measures, having more measures in a particular domain is not necessarily better. Some domains have many measures, but it is unclear which of these measures have the strongest potential to improve the quality of care. This underscores the importance of obtaining stronger consensus on well-validated measures that are most useful for improving quality in particular areas where quality issues persist. Nonetheless, opportunities for measure development exist for combined pharmacotherapy and psychosocial treatments, family or caregiver involvement in care, medication errors, and injuries, because no NQF-endorsed measures were found in these topic areas.
This review identified several other limitations associated with existing measures. First, most measures rely solely or in part on administrative or claims data. Even though measures based on claims data are less burdensome to implement than measures that require data collection from medical records, they may not provide the clinical detail sufficient to guide quality improvement. In addition, measures that rely solely on claims data may not lend themselves to comparisons across provider organizations, health plans, or states because of the use of different billing codes for similar behavioral health services (15). Second, few NQF-endorsed measures rely on data collected from EHRs. Even though such measures could provide rich clinical detail, the lack of adoption of EHRs among behavioral health providers limits their use (16). To realize the potential of EHR measures in behavioral health will require the continued development of data systems and infrastructure to support reporting on such measures and using them for quality improvement. Furthermore, data sharing between primary care and behavioral health providers and managed care organizations will be needed for robust measurement and streamlined data collection and to accurately measure the delivery of care.
Most measures focus on processes of care rather than on structures or outcomes, probably because structure and outcome measures are particularly difficult to specify and may lack evidence. At the same time, even though process measures may help improve clinical processes, it is often difficult to link processes to outcomes. Therefore, future measurement development and implementation efforts may wish to focus directly on outcomes, although challenges such as appropriate risk adjustment may impede such efforts. Structural measures may also have value to help guide the field in the implementation of evidence-based practices, but future work is needed to understand what structural aspects of care are associated with the implementation and outcomes of evidence-based care (17).
Several ongoing measure development projects are likely to produce new measures relevant to the NBHQF. Under the Child Health Insurance Program Reauthorization Act, AHRQ and CMS have designated seven Centers of Excellence in Pediatric Quality Measurement. Two of the centers are developing behavioral health measures, including measures related to adolescent depression and attention-deficit hyperactivity disorder. In addition, several behavioral health topics are proposed for future assignment to the centers. Other federal projects include behavioral health measure development through a partnership between the ASPE and SAMHSA. This effort has developed measures for states and health plans that focus on screening, follow-up, and monitoring of chronic general medical conditions among people with serious mental illness and alcohol and other drug dependence. Screening measures specifically for the CMS Inpatient Psychiatric Facility Quality Reporting Program are also being developed by CMS and ASPE. There is at least one federal grant from the National Institute on Alcohol Abuse and Alcoholism that focuses on quality measurement. ASPE, in collaboration with the National Institute of Mental Health, is developing quality measures for posttraumatic stress disorder.
This review has a few important limitations. The scope of the review was largely limited to three databases. Even though the databases are national in scope and widely used, they may not include measures applied in local efforts or research (for example, Medicaid or state behavioral health agencies). In addition, the field is dynamic and rapidly changing, such that the data represent a point-in-time perspective. To our knowledge, this review is the most current aggregation of behavioral health measures in the literature.

Conclusions

Given that health care reforms will likely influence the organization and financing of behavioral health care, strong quality measures will be a pivotal component of efforts to monitor the delivery of care and identify opportunities for quality improvement. Despite the existence of a wide array of behavioral health measures, few have received national endorsement or been adopted by reporting programs. Future measure development and implementation efforts should focus on identifying the strongest measures within each domain of the NBHQF and filling gaps where existing measures are insufficient.

Footnotes

The authors conducted this work under contract to the Office of the Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human Services (HHS) (HHSP23320100019WI, HHSP23337001T).
Funding was provided by the Substance Abuse and Mental Health Services Administration.
The views and opinions expressed are those of the authors and do not necessarily reflect the views, opinions, or policies of ASPE, the Substance Abuse and Mental Health Services Administration, or HHS.

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Information & Authors

Information

Published In

Go to Psychiatric Services
Go to Psychiatric Services

Cover: The Violoncellist, by Lilla Cabot Perry, 1906. Private collection.

Psychiatric Services
Pages: 865 - 871
PubMed: 26073415

History

Received: 26 December 2014
Revision received: 1 May 2015
Accepted: 13 May 2015
Published online: 15 June 2015
Published in print: August 01, 2015

Authors

Details

Milesh M. Patel, M.S.
Mr. Patel, Ms. Lewis, Dr. Liu, and Dr. Scholle are with the National Committee for Quality Assurance, Washington, D.C. Dr. Brown and Ms. Croake are with Mathematica Policy Research, Washington, D.C. Dr. Patton is with the Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Ms. Potter is with the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, Washington, D.C. Send correspondence to Dr. Scholle (e-mail: [email protected]).
Jonathan D. Brown, Ph.D., M.H.S.
Mr. Patel, Ms. Lewis, Dr. Liu, and Dr. Scholle are with the National Committee for Quality Assurance, Washington, D.C. Dr. Brown and Ms. Croake are with Mathematica Policy Research, Washington, D.C. Dr. Patton is with the Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Ms. Potter is with the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, Washington, D.C. Send correspondence to Dr. Scholle (e-mail: [email protected]).
Sarah Croake, M.P.P.
Mr. Patel, Ms. Lewis, Dr. Liu, and Dr. Scholle are with the National Committee for Quality Assurance, Washington, D.C. Dr. Brown and Ms. Croake are with Mathematica Policy Research, Washington, D.C. Dr. Patton is with the Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Ms. Potter is with the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, Washington, D.C. Send correspondence to Dr. Scholle (e-mail: [email protected]).
Rita Lewis, M.P.H.
Mr. Patel, Ms. Lewis, Dr. Liu, and Dr. Scholle are with the National Committee for Quality Assurance, Washington, D.C. Dr. Brown and Ms. Croake are with Mathematica Policy Research, Washington, D.C. Dr. Patton is with the Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Ms. Potter is with the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, Washington, D.C. Send correspondence to Dr. Scholle (e-mail: [email protected]).
Junqing Liu, Ph.D., M.S.W.
Mr. Patel, Ms. Lewis, Dr. Liu, and Dr. Scholle are with the National Committee for Quality Assurance, Washington, D.C. Dr. Brown and Ms. Croake are with Mathematica Policy Research, Washington, D.C. Dr. Patton is with the Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Ms. Potter is with the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, Washington, D.C. Send correspondence to Dr. Scholle (e-mail: [email protected]).
Lisa Patton, Ph.D.
Mr. Patel, Ms. Lewis, Dr. Liu, and Dr. Scholle are with the National Committee for Quality Assurance, Washington, D.C. Dr. Brown and Ms. Croake are with Mathematica Policy Research, Washington, D.C. Dr. Patton is with the Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Ms. Potter is with the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, Washington, D.C. Send correspondence to Dr. Scholle (e-mail: [email protected]).
D. E. B. Potter, M.S.
Mr. Patel, Ms. Lewis, Dr. Liu, and Dr. Scholle are with the National Committee for Quality Assurance, Washington, D.C. Dr. Brown and Ms. Croake are with Mathematica Policy Research, Washington, D.C. Dr. Patton is with the Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Ms. Potter is with the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, Washington, D.C. Send correspondence to Dr. Scholle (e-mail: [email protected]).
Sarah Hudson Scholle, M.P.H., Dr.P.H.
Mr. Patel, Ms. Lewis, Dr. Liu, and Dr. Scholle are with the National Committee for Quality Assurance, Washington, D.C. Dr. Brown and Ms. Croake are with Mathematica Policy Research, Washington, D.C. Dr. Patton is with the Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Ms. Potter is with the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, Washington, D.C. Send correspondence to Dr. Scholle (e-mail: [email protected]).

Funding Information

Office of the Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human Services (HHS): HHSP23320100019WI/ HHSP23337001T
The authors report no financial relationships with commercial interests.

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