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Psych hospitals adopt core measures
With the July 21 announcement of accreditation reporting requirements on seven “core measures” for Hospital-Based Inpatient Psychiatric Services (HBIPS), the Joint Commission, through a decade-long partnership with key public and private associations and stakeholders, expanded its system of core measures beyond general medicine to behavioral healthcare, specifically to freestanding psychiatric hospitals or acute care hospitals that operate psychiatric care units.
In a July 20 letter to hospitals, the Joint Commission stated that all freestanding psychiatric hospitals surveyed and accredited under its Comprehensive Accreditation Manual for Hospitals will be required to use the new HBIPS core measure set for all discharges and episodes of care, effective January 1, 2011. Acute care hospitals that operate psychiatric care units can choose to use the measures to meet or exceed current overall ORYX core measure set reporting requirements. However, HBIPS-1 (Admission screening for violence risk, substance use, psychological trauma history and patient strengths completed) will not be utilized in Joint Commission processes until National Quality Forum (NQF) endorsement is obtained.
The announcement was welcomed by psychiatric healthcare providers and associations, since the HBIPS core measures represent the first widely recognized core set of safety, quality, and accountability measures for inpatient psychiatric treatment. Among the organizations who contributed to the Joint Commission's core measure development effort were four key partners: the National Association of State Mental Health Program Directors (NASMHPD) and its National Research Institute (NRI), the National Association of Psychiatric Health Systems (NAPHS), and the American Psychiatric Association (APA).
Like other Joint Commission core measure sets, the HBIPS measures were developed, refined, and tested under the guidance of a Technical Advisory Panel (TAP). The 18-member TAP that created the HBIPS core measures was chaired by Frank A. Ghinassi, PhD, of Western Psychiatric Institute and Clinic of UPMC Presbyterian Shadyside, University of Pittsburgh Medical Center (Pittsburgh, Penn.). Recently, Ghinassi, together with Kathleen McCann, director of quality and regulatory affairs for the National Association of Psychiatric Health Systems (Washington, D.C.), and Celeste Milton, MPH, BSN, RN, associate project director in the Center for Performance Measurement at the Joint Commission (Oakbrook Terrace, Ill.), joined Behavioral Healthcare for an exclusive interview.
According to Ghinassi, the seven core measures evolved through five years of work as the panel whittled down dozens of possible measures through repeated cycles of drafting, comment, and revision. After the panel considered some 2,000 comments from the field, the seven core measures were finalized. Then, through “painstaking” efforts by the Joint Commission's research team, the details of the seven HBIPS measures were fully specified and offered for “pilot” testing by interested institutions. Despite what McCann called “significant and detailed process measurement requirements,” 196 institutions piloted the measures-a strong demonstration of provider interest.
Meeting an urgent need
In light of sweeping healthcare reform in the U.S., the HBIPS measures symbolize a now-urgent need to integrate behavioral healthcare into the broader healthcare system. Because HBIPS now offers a nationally accessible core measure set, built on the Joint Commission ORYX measurement/reporting system, they ensure uniformity and, for the first time, allow for national quality measurement and benchmarking of inpatient psychiatric services similar to that for other medical specialties.
The core measures aim to promote high quality and effective treatment by focusing provider attention on:
Essential elements of care and continuing care plans;
Practices that maximize patient and staff safety during treatment; and
Practices that balance the benefits and risks of powerful antipsychotic medications.
Measure 1: Intake assessment
HBIPS Meaure 1 emphasizes a group of assessments that the TAP felt were particularly important—and sometimes neglected—in the patient admission process:
Violence risk to self (suicidality);
Violence risk to others (homicide risk);
Substance use (co-occurring substance use issues);
History of psychological trauma (critical to treatment plan, key to outcome); and
Patient strengths (key to recovery/re-assimilation).
“When things go awry in the mental health and substance abuse fields, it is often an act of violence against self or others that comes to the fore in media and public awareness,” Ghinassi explains, noting that “assessment of violence potential, to self or to others, is very much a patient and staff safety issue, as well as a quality of care issue.” He says that the next two elements-substance use and history of trauma-were selected largely because the TAP “felt that anecdotal evidence and the literature support that there has been a tendency to under-investigate and under-explore these factors in the patient and family history when making a diagnosis.” He adds that within the last decade, the field has recognized that treatment planning must not only be “trauma-informed,” but founded on an understanding of individual strengths-essential elements of a recovery-focused approach.
Ghinassi and Milton note that the five factors are only a subset of an adequate intake assessment. “There are many more areas of inquiry present in a thorough medical and psychosocial assessment,” says Ghinassi. “The panel highlighted these five items because they are of key importance in terms of safety and overall quality of care.”
Measures 2 and 3: Restraint and seclusion
Milton explains that Measures 2 and 3, involving physical restraint and seclusion, are structured in much the same way as other patient and staff safety measures-falls, medication errors, or medical mistakes-as a ratio in hours per thousand inpatient hours. She notes that “chemical restraints,” notably the administration of medications to calm patients, are not considered in either measure.
“This is a very important safety issue since our field has experienced sentinel events involving physical restraints that have resulted in permanent disability to a patient, or even in death,” says Milton. Recalling what he terms “Hollywood stereotypes” involving straightjackets and isolation rooms, Ghinassi notes that “for a decade or more, all psychiatric hospitals have moved toward protocols that employ physical restraints as an absolute last resort, and are to be avoided whenever possible thorough a pro-active, collaborative process of anticipation and attention to individual needs for safety, space, and autonomy.”
“Institutions, by and large, now collaborate with individual patients to develop joint behavioral plans,” he says. “They speak in advance with patients about how to interact verbally, how to use places and interventions the patient understands as ‘safe,’ and how to identify symptoms and take steps before a situation, behavior, or symptom gets out of control.” He adds that restraints are rarely used outside of emergency situations, where there is imminent risk of self-harm or harm to others.
Measure 3, hours of seclusion use, highlights a second outdated practice that “we're trying to limit,” says Milton, noting that seclusion is already used far less often than restraints.
“The ideal goal for both of these measures is to bring the reported utilization down to zero,” says Ghinassi. He suggests that by supplementing measured data with additional information such as diagnosis, type of restraint or seclusion employed, prior interventions attempted, or staff involved, hospitals may discover new ways to reduce or eliminate these practices.
Measures 4 and 5: Antipsychotic medication therapy
These measures work as a pair, with Measure 4 “getting us a raw measure of just how many antipsychotics are being used at the time of discharge,” Milton explains, while Measure 5 seeks a more qualitative response, asking whether the rationale for antipsychotic poly-pharmacy matches with any of three currently accepted justifications. According to Milton, justification for poly-pharmacy includes documentation in the patient's medical record of:
A minimum of three failed multiple trials of mono-therapy.
A recommended plan to:
Taper to mono-therapy from previous use of multiple antipsychotic medications at the time of discharge, or
Complete a cross-taper in progress at the time of discharge.
Use of an antipsychotic medication to augment clozapine.
“There's been a lot of evidence that individuals with severe and chronic mental health issues live shorter lives-sometimes 20 to 25 years shorter, due to a higher incidence of co-occurring chronic physical illnesses,” says Ghinassi.
The goal of Measure 5 is to ensure that patients receive evidence-supported dosages and combinations of antipsychotic medications. This is of particular importance as these medications (along with genetic predisposition and lifestyle choices and habits) have been linked to a condition referred to as “metabolic syndrome.” This is a condition that is manifested by weight gain, increases in abdominal fat, high glucose levels, diabetes, high blood pressure, heart disease, and other cardiovascular complications.
“The current evidence base and prescribing practice algorithms suggests that finding the best mono-therapy is preferred, and that it can also help in minimizing the risk of metabolic syndrome. The literature and anecdotal accounts also indicate that for some individuals, mono-therapies are not effective … so a combination of antipsychotic medications may be the next step,” Ghinassi says. “We don't want to uniformly place those uses in a negative light, but we do want to make clear that the panel of physician experts on the Technical Advisory Panel recommended that three adequate (in terms of time and dosage) mono-therapy trials are expected before combinations are tried.”
Due to shorter inpatient psychiatric stays, he says that patients are frequently discharged on multiple medications while the outpatient clinicians continue the process of titrating in order to determine optimal medication compounds and dosing.
Milton adds that while “there might be other reasoning out there, these three justifications are recognized as appropriate for this measure.” She indicates that, because Measures 4 and 5 are paired, they enable further comparison: “If two hospitals are equal on Measure 4, you want to look at Measure 5 to see which hospital justifies its dosing practices more consistently-indicating rational use of evidence-based treatment. A high rate on Measure 5 may also indicate that you are treating patients for whom first-line prescribing algorithms have not provided satisfactory relief and enhanced functioning.”
Measures 6 and 7: Continuity of care
Another paired set, Measures 6 and 7, identify how psychiatric hospitals support continuity of care at the time a patient is discharged from inpatient to the range of available ambulatory care settings. Measure 6, specifically, looks for a post-discharge continuity of care plan with a minimum of four key elements:
Presenting symptoms at time of patient's admission;
Final diagnosis;
Treatment plan/recommendations for the next level of treatment; and
Medication plan at time of discharge, including dosages and indications for use.
Measure 7 requires that the transmittal of discharge continuity of care plans to the next level of care is completed and documented. Milton says that transmittal and documentation can be managed in a number of ways: by a confirming fax hardcopy, by proof of mailing, or by providing next-level-of-care providers’ access to the hospital's electronic medical records (EMR) system. She adds that many hospitals have already designated key documents as elements of their “continuity of care” plans-a step that simplifies process verification during required audits.
For comprehensive information about the HBIPS core measures, visit the Joint Commission Web site at www.jointcommission.org/hbips.
Behavioral Healthcare 2010 September;30(8):24-29
