NQF Voluntary Consensus NQF Voluntary Consensus Standards for Treatment of Standards for Treatment of Substance Use DisordersSubstance Use Disorders

Rick Rawson, Ph.D.Rick Rawson, Ph.D.September 2009September 2009

3939thth and 40 and 40thth Semi-Annual SARC Semi-Annual SARC MeetingsMeetings

What Are Standards?What Are Standards?

Clinical and Administrative StandardsClinical and Administrative Standards are the criteria that describe the are the criteria that describe the expected levels of clinical and system expected levels of clinical and system behavior and courses of action that are behavior and courses of action that are expected to be taken in a system by a expected to be taken in a system by a clinician based on research and clinician based on research and experience.experience.

Clinical GuidelinesClinical Guidelines

Clinical guidelines are recommendations for the Clinical guidelines are recommendations for the appropriate treatment and care of people with appropriate treatment and care of people with specific diseases and conditions, including:specific diseases and conditions, including:

Identification of key decisions and their effects Identification of key decisions and their effects Review of the relevant, valid evidence on the benefits, Review of the relevant, valid evidence on the benefits,

risks, and costs of alternative decisions risks, and costs of alternative decisions Presentation of the evidence required to inform key Presentation of the evidence required to inform key

decisions in a simple, accessible format that is flexible decisions in a simple, accessible format that is flexible to meet stakeholder preferences to meet stakeholder preferences

What is the NQF?What is the NQF?

The National Quality Forum (NQF) is a The National Quality Forum (NQF) is a voluntary nonprofit membership voluntary nonprofit membership organization created to develop and organization created to develop and implement a national strategy for health implement a national strategy for health care quality measurement and reporting. care quality measurement and reporting.

NQF is a public-private partnership that NQF is a public-private partnership that develops consensus measures and develops consensus measures and standards for a variety of clinical standards for a variety of clinical conditions.conditions.

What is the NQF?What is the NQF?

Broad stakeholder representation and the Broad stakeholder representation and the formal consensus development process formal consensus development process implemented by the NQF has given “NQF-implemented by the NQF has given “NQF-endorsed” measures and standards endorsed” measures and standards special legal standing with the government special legal standing with the government and with employers.and with employers.

NQF WorkshopNQF Workshop

A workshop with broad representation and A workshop with broad representation and membership was conducted in December, 2004 membership was conducted in December, 2004 and identified an initial set of effective treatments and identified an initial set of effective treatments covering alcohol, nicotine, and drugs as well as covering alcohol, nicotine, and drugs as well as all populations, provider organizations, and all populations, provider organizations, and clinicians.clinicians.

A commissioned paper was used as the basis A commissioned paper was used as the basis for establishing evidence-based practices and for establishing evidence-based practices and program attributes in treatment of SUD.program attributes in treatment of SUD.

Workshop GoalsWorkshop Goals

Establish a candidate set of effective Establish a candidate set of effective organizational and clinical treatment practicesorganizational and clinical treatment practices

Recommend practices of highest priority for Recommend practices of highest priority for widespread implementationwidespread implementation

Identify the attributes of treatment programs that Identify the attributes of treatment programs that are ready to implement evidence-based are ready to implement evidence-based practicespractices

Identify barriers and ways to address barriers to Identify barriers and ways to address barriers to accelerate adoption of practicesaccelerate adoption of practices

NQF Consensus Development ProjectNQF Consensus Development Project

A Technical Advisory Panel and a Steering A Technical Advisory Panel and a Steering Committee were formed with members from the Committee were formed with members from the field, healthcare, and quality improvement for the field, healthcare, and quality improvement for the formal consensus process. Public input was also formal consensus process. Public input was also sought.sought.

A formal NQF Consensus Development project A formal NQF Consensus Development project in 2006 assembled a detailed, fully specified in 2006 assembled a detailed, fully specified setset of evidence-based practices, evaluated them, of evidence-based practices, evaluated them, and achieved consensus about those practicesand achieved consensus about those practices ..

Consensus Development GoalsConsensus Development Goals

Improve the quality of care for patients with substance Improve the quality of care for patients with substance use disorders, incl. outcomes for patients, families, and use disorders, incl. outcomes for patients, families, and communitiescommunities

Provide guidance for providers on how to achieve Provide guidance for providers on how to achieve desired treatment outcomesdesired treatment outcomes

Provide useful information to purchasers for coverage Provide useful information to purchasers for coverage and reimbursement, and consumers for decision-making and reimbursement, and consumers for decision-making about treatmentabout treatment

Serve as the basis for development of quality measures Serve as the basis for development of quality measures that can be used for public accountabilitythat can be used for public accountability

FrameworkFramework

The NQF standards are focused on improving The NQF standards are focused on improving quality of care using the aims for high-quality quality of care using the aims for high-quality treatment identified by the IOM treatment identified by the IOM Crossing the Crossing the Quality Chasm (2001)Quality Chasm (2001) report: report:

• SafeSafe• TimelyTimely• EffectiveEffective• EfficientEfficient• Patient-centeredPatient-centered

Basic PrinciplesBasic Principles

Treatment of SUD involves a Treatment of SUD involves a continuum of continuum of carecare and a long-term perspective that is and a long-term perspective that is based on a based on a chronic care modelchronic care model for for individuals who are more severely ill.individuals who are more severely ill.

Treatment of severe SUD requires Treatment of severe SUD requires comprehensive services with multiple comprehensive services with multiple interventions.interventions.

A Chronic Care ModelA Chronic Care Model

Detox

Substance Abusing Patient

Continuing CareRecovering Patient

RehabDurationDetermined byPerformanceCriteria

DurationDetermined byPerformanceCriteria

A Continuum of CareA Continuum of Care

HospitalDetox

ResidentialRehab

IOPCare

OutpatientCont Care

AA -TeleMonitoring

TeleMonitoring

Basic PrinciplesBasic Principles

Treatment should be coordinated with Treatment should be coordinated with general and mental health care settings general and mental health care settings (as appropriate).(as appropriate).

Treatment should incorporate the NIDA Treatment should incorporate the NIDA Principles of Addiction Treatment and the Principles of Addiction Treatment and the approach identified in the NIAAA approach identified in the NIAAA Clinician’s Guide.Clinician’s Guide.

Service Settings Where AOD Care Service Settings Where AOD Care Services Should be DeliveredServices Should be Delivered

Mental Health Treatment Mental Health Treatment Services: Hospitals, clinics, Services: Hospitals, clinics, practionner offices. practionner offices. Psychiatrists, psychologists, Psychiatrists, psychologists, social workers, marriage and social workers, marriage and family therapistsfamily therapists

Substance Abuse Service Substance Abuse Service System: Therapeutic System: Therapeutic communities, Hospital based communities, Hospital based care, Methadone programs, care, Methadone programs, Outpatient clinics: Modest Outpatient clinics: Modest number of MDs and Ph.D.s number of MDs and Ph.D.s Many paraprofessional workers Many paraprofessional workers

Social Service System: Social Service System: Agencies to provide support Agencies to provide support for food, housing, child welfare for food, housing, child welfare and other services. Social and other services. Social

workers and paraprofessionalsworkers and paraprofessionals

Primary Care and Public Primary Care and Public Health System: Hospitals, Health System: Hospitals, Clinics, MD offices: Family Clinics, MD offices: Family practice; internal medicine, practice; internal medicine, other medical specialists, other medical specialists, Nursing and medical support Nursing and medical support staffstaff

Principles of Addiction TreatmentPrinciples of Addiction Treatment

Priority AreasPriority Areas

Apply broadly to multiple populations and age Apply broadly to multiple populations and age groupsgroups

Have a substantial evidence baseHave a substantial evidence base Support immediate improvement and are Support immediate improvement and are

appropriate for widespread adoptionappropriate for widespread adoption Have potential as the basis for measurementHave potential as the basis for measurement Have the greatest effect on people’s lives if the Have the greatest effect on people’s lives if the

practice is implementedpractice is implemented

Criteria for Evaluation of Criteria for Evaluation of PracticesPractices

Evidence of EffectivenessEvidence of Effectiveness: will improve : will improve outcomes based on research studies, broad outcomes based on research studies, broad expert opinion or professional consensus, and expert opinion or professional consensus, and data from other settingsdata from other settings

GeneralizabilityGeneralizability: able to be used in multiple : able to be used in multiple clinical settings with multiple types of patientsclinical settings with multiple types of patients

BenefitBenefit: will improve patient outcomes or the : will improve patient outcomes or the likelihood of improved outcomes if more widely likelihood of improved outcomes if more widely utilizedutilized

DomainsDomains

Identification of SUD:Identification of SUD: screening/case finding, screening/case finding, diagnosis and assessmentdiagnosis and assessment

Initiation and Engagement in TreatmentInitiation and Engagement in Treatment: brief : brief interventions, engagement in treatment, and interventions, engagement in treatment, and withdrawal managementwithdrawal management

Therapeutic InterventionsTherapeutic Interventions: psychosocial : psychosocial interventions and pharmacotherapyinterventions and pharmacotherapy

Continuing Care ManagementContinuing Care Management

IdentificationIdentification

Screening and Case FindingScreening and Case FindingNew patients and at least annually, patients in general and mental New patients and at least annually, patients in general and mental health settings should be screened for at risk usehealth settings should be screened for at risk use

Healthcare providers should use a systematic method to identify Healthcare providers should use a systematic method to identify patients who use substancespatients who use substances

Diagnosis and AssessmentDiagnosis and AssessmentPatients who have a positive screen for substance use disorders Patients who have a positive screen for substance use disorders should receive a further biopsychsocial assessment to guide should receive a further biopsychsocial assessment to guide patient-centered treatment planning, incl. for coexisting conditionspatient-centered treatment planning, incl. for coexisting conditions

Initiation and EngagementInitiation and Engagement

Brief InterventionBrief InterventionAll patients identified will unhealthy use substances should All patients identified will unhealthy use substances should receive a brief intervention by a trained healthcare clinicianreceive a brief intervention by a trained healthcare clinician

Promoting Engagement in TreatmentPromoting Engagement in TreatmentHealthcare providers should systematically promote Healthcare providers should systematically promote patient initiation of and engagement in treatment, incl. use patient initiation of and engagement in treatment, incl. use of supportive services to promote engagement.of supportive services to promote engagement.

Withdrawal ManagementWithdrawal ManagementSupportive pharmacotherapy should be available and Supportive pharmacotherapy should be available and provided for withdrawal based on an systematic provided for withdrawal based on an systematic assessment of symptoms and risks; withdrawal assessment of symptoms and risks; withdrawal management is not treatmentmanagement is not treatment

Therapeutic InterventionsTherapeutic Interventions

Psychosocial InterventionsPsychosocial InterventionsEmpirically validated psychosocial treatment interventions should be Empirically validated psychosocial treatment interventions should be used for all patient with substance use disorders.used for all patient with substance use disorders.

PharmacotherapyPharmacotherapyMedications should be recommended and available to all adult Medications should be recommended and available to all adult patients with opioid dependence or alcohol dependence and directly patients with opioid dependence or alcohol dependence and directly linked with comprehensive clinical serviceslinked with comprehensive clinical services

Medications should be recommended and available to all adult Medications should be recommended and available to all adult patients with nicotine dependence and directly linked with brief patients with nicotine dependence and directly linked with brief counseling.counseling.

Continuing CareContinuing Care

Management of Substance Use DisordersManagement of Substance Use Disorders

Patients with substance use disorders should be offered Patients with substance use disorders should be offered long term, coordinated management of their care, incl. long term, coordinated management of their care, incl. care for coexisting conditionscare for coexisting conditions

Care management should be adapted based on ongoing Care management should be adapted based on ongoing

monitoring of patient progressmonitoring of patient progress..

Types of Continuing CareTypes of Continuing Care Self/mutual help programsSelf/mutual help programs MedicationsMedications Traditional counseling visitsTraditional counseling visits Home visitsHome visits Recovery “check-ups”Recovery “check-ups”

Specialty care-basedSpecialty care-based Primary care-basedPrimary care-based

Telephone-based protocolsTelephone-based protocols Monitoring Monitoring Monitoring and counselingMonitoring and counseling

Other stuffOther stuff

Recovery Management CheckupsRecovery Management Checkups

Protocol developed by Dennis, Scott et al.Protocol developed by Dennis, Scott et al. Interview patients Interview patients every quarter for 2 yearsevery quarter for 2 years If patient reports any of the following……If patient reports any of the following……

• Use of alcohol or drugs on Use of alcohol or drugs on >> 2 weeks 2 weeks• Being drunk or high all day on any daysBeing drunk or high all day on any days• Alcohol/drug use led to not meeting Alcohol/drug use led to not meeting

responsibilitiesresponsibilities• Alcohol/drug use caused other problemsAlcohol/drug use caused other problems• Withdrawal symptomsWithdrawal symptoms

……Patient transferred to linkage managerPatient transferred to linkage manager

Recovery Management CheckupsRecovery Management Checkups

Linkage Manager provides the following:Linkage Manager provides the following: Personalized feedbackPersonalized feedback Explore possibility of returning to treatmentExplore possibility of returning to treatment Address barriers to returning to treatmentAddress barriers to returning to treatment Schedule an intake assessmentSchedule an intake assessment Reminder cards, transportation, and escort to Reminder cards, transportation, and escort to

intake appointmentintake appointment

Telephone as a continuing care toolTelephone as a continuing care tool

Potential to promote better long-term Potential to promote better long-term engagement and participation because:engagement and participation because: Convenient for clientConvenient for client Reduces stigma of weekly trips to the treatment Reduces stigma of weekly trips to the treatment

programprogram Individualized attentionIndividualized attention Can be automated (Helzer, Searles et al.)Can be automated (Helzer, Searles et al.) Lower costs of ongoing care (?)Lower costs of ongoing care (?)

Practice SpecificationsPractice Specifications

For implementation specification should include:For implementation specification should include:

Description of the care to be providedDescription of the care to be provided Target outcomes/desired resultsTarget outcomes/desired results What the practice entailsWhat the practice entails For whom it is indicatedFor whom it is indicated Who should perform itWho should perform it Settings in which it should be implementSettings in which it should be implement

N.B. This should not be taken to imply that there is a direct causal relationship N.B. This should not be taken to imply that there is a direct causal relationship between implementation of a practice and a desired outcome.between implementation of a practice and a desired outcome.

Other RecommendationsOther Recommendations

Further ResearchFurther Research to improve the NQF- to improve the NQF-Endorsed PracticesEndorsed Practices

Development of Performance MeasuresDevelopment of Performance Measures based on each of the practice standards, based on each of the practice standards, target outcomes, and specifications and target outcomes, and specifications and the necessary systems for reporting on the necessary systems for reporting on performance measuresperformance measures

Measuring the Performance of Measuring the Performance of California’s AOD Treatment ProgramsCalifornia’s AOD Treatment Programs

Some specific issues for discussionSome specific issues for discussion Which CalOMS data elements, alone and in Which CalOMS data elements, alone and in

combination, provide meaningful performance and combination, provide meaningful performance and outcomes measures?outcomes measures?

Are there data elements that need to be added to Are there data elements that need to be added to CalOMS data set to optimally measure performance CalOMS data set to optimally measure performance and outcomes?and outcomes?

Is it possible to operationally define “treatment Is it possible to operationally define “treatment success” and how can this issue be communicated to success” and how can this issue be communicated to the public and policy makers?the public and policy makers?

Possible Performance MeasuresPossible Performance Measures Treatment Initiation (within 14 days)Treatment Initiation (within 14 days) Treatment Engagement (within 30 days)Treatment Engagement (within 30 days) Treatment Retention (90 days).Treatment Retention (90 days). Continuity of Care Measures (% of clients who Continuity of Care Measures (% of clients who

successfully transfer to next level of care.successfully transfer to next level of care. Treatment “Completion”Treatment “Completion” NIATx MeasuresNIATx Measures Measures for different modalities may be Measures for different modalities may be

different (eg. NTPs vs short term residential)different (eg. NTPs vs short term residential)

Power of Performance MeasurementPower of Performance Measurement

There is a link between effective performance There is a link between effective performance measurement and successful service results.measurement and successful service results.

Performance measurement is a necessary first Performance measurement is a necessary first step to using data to evaluate and improve step to using data to evaluate and improve program performance.program performance.

There is no “one fits all” approach to using There is no “one fits all” approach to using performance measures for different services.performance measures for different services.

Methods to promote effective Methods to promote effective performance improvementperformance improvement

Proceed in a step wise manner:Proceed in a step wise manner: Monitor performance; give programs feedbackMonitor performance; give programs feedback Manage; set benchmarks; acknowledge good Manage; set benchmarks; acknowledge good

performance and technical assistance for performance and technical assistance for othersothers

Improve performance: provide technical Improve performance: provide technical assistance.assistance.

Contract for performance; reimburse Contract for performance; reimburse programs based on performance programs based on performance

Methods to promote effective Methods to promote effective performance improvementperformance improvement

Encourage staff to understand and use program Encourage staff to understand and use program data.data.

Promote evidence-based practices as part of TA Promote evidence-based practices as part of TA and training activityand training activity

Employ process improvement techniques (eg. Employ process improvement techniques (eg. NIATx)NIATx)

Flexibility: allow room for innovationFlexibility: allow room for innovation Don’t forget to recognize and reward good Don’t forget to recognize and reward good

performanceperformance

Strategies for improving AOD Strategies for improving AOD program performanceprogram performance

Reduce staff turnoverReduce staff turnover Increase staff knowledge of other forms of Increase staff knowledge of other forms of

care to promote a “system of care” rather care to promote a “system of care” rather than isolated programsthan isolated programs

Increase staff knowledge and use of Increase staff knowledge and use of evidence-based practicesevidence-based practices

Employ process improvement (NIATx)Employ process improvement (NIATx)

Methods to promote effective Methods to promote effective performance improvementperformance improvement

Encourage staff to understand and use program Encourage staff to understand and use program data.data.

Promote evidence-based practices as part of TA Promote evidence-based practices as part of TA and training activityand training activity

Employ process improvement techniques (eg. Employ process improvement techniques (eg. NIATx)NIATx)

Flexibility: allow room for innovationFlexibility: allow room for innovation Don’t forget to recognize and reward good Don’t forget to recognize and reward good

performanceperformance

Strategies for improving AOD Strategies for improving AOD program performanceprogram performance

Reduce staff turnoverReduce staff turnover Increase staff knowledge of other forms of Increase staff knowledge of other forms of

care to promote a “system of care” rather care to promote a “system of care” rather than isolated programsthan isolated programs

Increase staff knowledge and use of Increase staff knowledge and use of evidence-based practicesevidence-based practices

Employ process improvement (NIATx)Employ process improvement (NIATx)

Other RecommendationsOther Recommendations

ImplementationImplementation of the full set of EB- of the full set of EB- practices with adequate training and practices with adequate training and provider support for adoption, including provider support for adoption, including clinical supervisionclinical supervision

Policy Development,Policy Development, including alignment including alignment of payment/reimbursement and coverage, of payment/reimbursement and coverage, legal and regulatory policies and legal and regulatory policies and management in primary caremanagement in primary care

For More InformationFor More Information

The National Quality ForumThe National Quality Forum

www.qualityforum.orgwww.qualityforum.org

rrawson@mednet.ucla.edurrawson@mednet.ucla.edu