Prepare the Infrastructure in Your Setting

Collect and Use Data for Quality Improvement

Data are the foundation for building a practice’s workflows, quality reporting, and improvement initiatives. A practice can use patient-level data to identify patients who may benefit from integrated behavioral health care, monitor their progress and make mid-course treatment adjustments when needed, track health outcomes, and lower the cost of care. Using data aggregated at the practice level, a practice can initiate quality improvement activities to refine processes and improve health outcomes. Data collection in itself is of little use unless it feeds into a robust quality improvement plan.

North Star

The practice uses data (1) at the patient level to identify, treat, and manage patients; and (2) at the practice level for quality improvement.

What is the North Star?

The North Star

The North Star reflects ideal practices of an integrated behavioral health and ambulatory care setting. The North Star can act as a goal or guide toward your desired state of integration.

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How Do You Do It?

Consider hiring or assigning a current staff member to lead the effort to collect and use data. The person you hire or assign to this role should understand how to use data for quality improvement and be familiar with the data already available at your practice.

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Your practice likely collects data on the medical care received by patients, participates in a registry, and /or meets Physician Quality Reporting System (PQRS) requirements. If the data you already collect are sufficient for quality improvement, additional data collection efforts will not be necessary.

During the early stages of integrating behavioral health in your ambulatory care practice, your data needs are likely to be related to the operational and financial aspects of integration. Data can help answer questions such as:

  • Can patients be seen by an integrated behavioral health provider within a reasonable timeframe?
  • Are the behavioral health provider(s) busy enough to cover expenses?
  • Which providers are referring patients to the behavioral health provider(s)?
  • Which patients are being referred to the behavioral health provider(s)?
  • Are patients in the integrated care target population being seen by a behavioral health provider?

Data from billing and scheduling systems may be adequate to answer many of these questions. If additional data elements must be captured, think about whether they can be collected as part of existing work processes and whether they need to be collected continuously or periodically.

Consider the following questions to help inform your data collection plan:

What data do you currently collect?

Take inventory of what data you collect. You might be collecting more data than you realize, especially if you have an electronic health record (EHR) system, use patient registries, or participate in mandatory reporting.

What data do you want to collect?

After reviewing the data your practice has readily available, look for any gaps or data needs. Consider these questions:

  • Do the available data help you identify, track, and manage patients in need of integrated care?
  • Do the available data allow you to aggregate information at the practice level for monitoring and improving the quality of integrated care?
  • Do the available data help you assess quality of care for patients in your practice?

What data collection tools exist?

The next step is to map your data needs to available tools or other data sources. Data collection tools are available for functions such as these:

  • Identifying patients who may benefit from integrated care.
  • Monitoring treatment progress.
  • Assessing quality of care.

When assessing the outcomes of integrated care, it is important to think broadly and adopt a “balanced scorecard” of measures to help you understand the impact of integration. A balanced scorecard might include:

  • Clinical outcome measures.
  • General functional measures.
  • Measures of financial impact (e.g., total cost of care).
  • Patient experience of care.
  • Provider and staff experience of care.

How Others Are Doing It

  • MaineHealth spread behavioral health integration to several dozen primary care practices over a multi-year period. Program staff recognized that performance data were needed to monitor the operations during the period of expansion. They had to negotiate with organizational leaders in each region to obtain data on productivity, access, and other aspects of operations. MaineHealth worked with a billing organization to identify and adapt an existing performance dashboard for their integrated care practices. This allowed MaineHealth to gain insight into important aspects of behavioral health providers’ performance. Read about MaineHealth’s Behavioral Integration Program at https://www.mainehealth.org/mh_body.cfm?id=3020&fr=true.

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If your practice does not collect data on a regular basis, consider small rapid-cycle initiatives or pilot efforts before launching into full-scale data collection. By starting small, you can implement a number of consecutive data collection, reporting, and quality improvement cycles, each building on the previous one. This process will allow your practice to fine-tune the data collection and quality improvement plan.

Consider these questions when planning for the pilot or rapid-cycle initiative:

What is the purpose of the pilot or rapid-cycle initiative? Each pilot/rapid cycle might focus on only one of the following aspects:

  • Identifying patients in need of integrated care.
  • Monitoring patient progress and making needed adjustments to the treatment plan.
  • Monitoring patients who have improved.
  • Tracking patients who do not adhere to their followup appointment schedules.
  • Improving patient experience.
  • Improving health outcomes.

What metric or indicator will illustrate that this pilot “worked”?

  • Identify metrics that you are interested in, and decide what level of improvement would be considered a success before moving forward with full-scale data collection.
  • It may help to use a driver diagram or logic model for specific targeted problems. A mapped out theory of change can help you determine if your pilot efforts are really leading to improved quality, improved health outcomes, and increased cost-effectiveness.

What will be the size of the pilot or rapid-cycle data collection plan?

  • How many participants will be included in your pilot? How long will it last?

What will the sample of patients for the pilot look like?

  • How will you sample patients for the pilot?

If you conduct a pilot or rapid-cycle initiative, pay attention to what works and what doesn’t as you transition into full-scale data collection. Make any refinements to the process as needed.

Useful Resource(s) for Creating a Data Collection and Quality Improvement Plan

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The data you collect can provide invaluable information for quality improvement. For example, you can use data to identify areas for improvement or assess the outcomes of your integrated care initiatives. Remember to continually revisit the Playbook as an upward spiral, gradually approaching the North Star of a seamlessly integrated behavioral health and ambulatory care setting.

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Other data considerations include data storage and security. Consider the following questions:

  • Are data stored in an existing database, or does your practice need to choose a database platform?
  • If you are selecting a database platform, will an off-the-shelf platform suit your needs, or do you need a platform that is custom-designed for your setting?

It is important to gain knowledge of HIPAA requirements and ensure that data are stored and used according to the requirements.

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What Not to Do

  • Don’t jump into data collection without first determining what is important to measure and how to best collect the data.
  • Don’t collect data in a random or inconsistent manner. Plan to collect data on an ongoing basis.
  • Don’t adopt a data collection strategy without considering how the data will be used for quality improvement.
  • Don’t add data collection plans that are separate from your practice’s workflows.

Contribute

The Playbook includes many examples of how sites have implemented specific aspects of integration. If you would like to contribute, please send us your example of how your organization collects or uses data.

Send Us Your Example

Resources

Tools: Clinical Outcome Measures

A collection of tools to assess clinical outcomes, such as anxiety, depression, and diabetes.

Source: AHRQ Academy
Tools: Core Measures to Assess the Quality of Integrated Behavioral Health Care

These measures can be used to assess the quality of your integrated care program.

Source: AHRQ Academy
Using Driver Diagrams to Improve Population Health

This resource provides information about using driver diagrams and includes links to driver diagram tools.

Source: The Public Health Foundation
MaineHealth Behavioral Health Integration

Homepage for MaineHealth’s Behavioral Health Integration Program

Source: MaineHealth
About RE-AIM: Reach, Effectiveness, Adoption, Implementation, Maintenance

This Web site provides guidance on using the RE-AIM framework.

Source: Virginia Tech
The CAHPS Improvement Guide

This Web-based resource offers strategies to improve patient experience of care.

Source: AHRQ
How to Improve

Read about the Model of Improvement and how it can help with improvement initiatives.

Source: Institute for Healthcare Improvement
Improvement Stories

The Institute for Healthcare Improvement offers a collection of improvement stories to help organizations learn from one another.

Source: Institute for Healthcare Improvement
Engaging Patients in Improving Ambulatory Care: A Compendium of Tools from Maine, Oregon, and Humboldt County, California

A toolkit to help organizations engage patients and families in quality improvement activities.

Source: Robert Wood Johnson Foundation
Science of Improvement: Establishing Measures

The Institute for Healthcare Improvement provides an overview of three types of measures: outcome, process, and balancing measures.

Source: Institute for Healthcare Improvement
Duke Health Profile (The DUKE)

A self-report tool to measure various domains of patients’ health.

Source: Duke University Medical Center
Screening Tools

A collection of screening tools for depression, anxiety, bipolar disorder, and other mental health and substance use disorders.

Source: SAMHSA-HRSA Center for Integrated Health Solutions
Fine Print: Rules for Exchanging Behavioral Health Information in California

A report that describes the legal boundaries related to information sharing in California.

Source: California Healthcare Foundation

Community

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The Academy Community is an online community that brings together individuals and practices that are interested and committed to delivering comprehensive, integrated health care.