CollaborativeOutcomes™ Improve Mental Health Care

Patient Reported Outcomes & Performance Measures (PROM)

Patient Reported Outcomes Measures (PROMs) are patient self-reports about their own health outcomes. They include symptoms and symptom burden, health-related quality of life (including functional status), experience with care and health behaviors. PROMs also include progress, alliance and/or satisfaction measures. PROM data can be aggregated for providers and an accountable healthcare entity. For example, PROM data might be used to describe the percentage of patients whose depression score, as measured by the PHQ-9, have improved over a 6-month period.

The healthcare industry promotes the use of Patient Reported Outcome Measures (PROMs) which engage patients in giving information to their health care providers about patients’ responses to care given for their health conditions, medical and mental health symptoms, pain, substance use, level of functioning, etc. PROMs allow health care providers valuable feedback concerning patients’ well-being, health behaviors, experience of care, and their physical, emotional, and functional status.

PROMs use standardized questionnaires and scales completed by patients to obtain quantitative and qualitative measures regarding one or more domains of care.

For more on PROMs see:
The Role of Patient Reported Outcome Measures in Mental Health?
https://www.mentorresearch.org/the-role-of-patient-reported-outcome-measuress-in-mental-health

CollaborativeOutcomes ™

CollaborativeOutcomes™ supports accountable care. This model offers both (1) Feedback Informed Treatment (FIT) and (2) Patient Reported Outcomes Measurement (PROMS) systems to obtain feedback and information about individual patient’s response to treatment— measurable Clinical Outcome Improvements. This feedback and information can evolve to Population Focused Improvements. The CollaborativeOutcomes™ model has been in development by IMHPA (formerly AMHA) & Mentor Research Institute (MRI) since 2012. CollaborativeOutcomes™ currently offers the only fully integrated feasible model which can engage mental health professionals, promote consumer confidence, and improve ethical care in a scalable, measurable, and accountable manner.

For visual information display see:
CollaborativeOutcomes™ brief handout which is also appended below.
CollaborativeOutcomes Handout PDF

CollaborativeOutcomes™ offers a solution that resolves the infrastructure and system redesign processes promoted by CMS and the Healthcare Payment Learning and Action Network. CollaborativeOutcomes supports clinical outcome improvements using an electronic questionnaire builder and delivery system allowing a wide range of devices to gather, aggregate, process, analyze and report baselines, progress, satisfaction, and outcome measures to patients, therapists, physicians and Healthplans. CollaborativeOutcomes also supports screening, progress data collection and coordinated care activities.

What follows is an overview of the CollaborativeOutcomes™ model.

PROMs in CollaborativeOutcomes™:

  • Comprehensive medical and mental health screening, data collection and review

  • Performance measures (i.e. symptom and functional change)

  • Patient & case specific measures

  • Patient satisfaction and therapist-patient alliance

For more on progress & outcomes measures see:
Patient Reported Outcomes & Performance Measures (PROM-PM).
https://www.mentorresearch.org/patient-reported-outcomes-progress-measures

Collaborative Data Gathering, Aggregation, Analysis and Reporting

The CollaborativeOutcomes™ model offers a growing list of questionnaires (19 available 5/10/21) which can be administered electronically using SMS text, email, a patient portal or manual entry for paper and pencil collection. The questionnaires available include a variety of screening, progress, outcome, satisfaction, and therapist-patient alliance measures. The library of questionnaires is being expanded to address various populations, problems, and clinical approaches. Questionnaires can be created which, based on patient responses, can skip to specific questions. Text boxes can be inserted. Based on the patient’s response to a question a follow up question along with a text box can be opened for a patient to enter a personal response.

Secure links to Questionnaires can delivered by SMS text, email, or using a key code that links the question to a psychotherapist’s personal secure online electronic dashboard. Questionnaires work on smart phones, tablets and desktop computers. Questionnaire and measures available as of May 10, 2021 include:

  1. ACE Adverse Childhood Experience

  2. ACE-PC Adverse Childhood Experience - Parent/Caregiver

  3. PSC-35 Pediatric Symptom Checklist - Comprehensive v1.8

  4. Comprehensive Mental Health Screening v1.3

  5. Mental Health Progress and Alliance v1.3

  6. GAD7 Generalized Anxiety DisordersOCD-25 OCD Thoughts and Behavior v1.2

  7. PHQ-9 Physical Health Questionnaire (Depression)

  8. PHQ-2 and GAD-2 Brief Screening for Depression and Anxiety v1.0

  9. Attention Deficit & Hyperactivity Disorder Questionnaire (ADHD) v1.9

  10. AUDIT-10 Alcohol Screening Questionnaire (AUDIT) v1.1

  11. Traumatic Life Events v1.2

  12. PCL-5 (20) Post-Traumatic Stress Disorder Check List DSM-5 v1.0

  13. COVID-19 Comprehensive Infection Risk Screening v1.33

  14. COVID-19 Routine Screening v1.0

  15. Viral Post Infection and Long COVID Symptoms v1.5

  16. Social, Psychological, and Pandemic Determinants of Health v1.4

  17. Suicide Risk Screening - Past 2 Weeks v1.02

  18. Suicide Risk Screening - Past Month v1.01

  19. Suicide Risk, Progress and Alliance - Past 2 Weeks v.1.21

The CollaborativeOutcomes™ approach is a feedback informed and patient reported informed treatment and measurement system based on evidence and best practices. CollaborativeOutcomes™ software is integrated with an ONC certified EMR created in collaboration between Mentor Research Institute (MRI), the Independent Mental Health Practices Alliance (IMHPA) and Private Practice Cloud (PPC).

Static Feedback Informed Measurement Systems.

There are 3 measurement systems which have dominated mental health measurement processes for several years, dissatisfaction with which led to the decision to create and develop the CollaborativeOutcomes™ model.

Those include:

  1. ACORN: https://www.acorncollaboration.org/

  2. PCOMs: https://betteroutcomesnow.com/

  3. MyOutcomes: https://www.myoutcomes.com/

The Opportunity Cost of Static Measurement Systems.

The opportunity cost for using any of the 3 third-party measurement systems listed above is significant.

Some Healthplans require use of these or other static measures. Requiring psychotherapists to use a specific intervention and measurement system is anticompetitive, potentially a violation of antitrust law. Psychotherapists who are required to expend time, resources and subscribe to measurement systems should do so for their own purposes and for the benefit of their patients.

An opportunity cost is a loss of potential gain from other alternatives when only one alternative is chosen. The loss or gain can be a benefit, a profit, or value of something that must be given up in-order to acquire, achieve or use something else. Opportunity costs are fundamental costs in economics and must be considered in computing the cost benefit analysis of a project. Opportunity costs are calculated in decision making by computing outlays of cash and time and the resulting profit or loss. Some Healthplans require use of these or other static measures. Requiring psychotherapists to use a specific intervention and measurement system is anticompetitive, potentially a violation of antitrust law. Psychotherapists who are required to expend time, resources and subscribe to measurement systems should do so for their own purposes and for the benefit of their patients.

Estimated cost to provide psychotherapy services for some CCOs.’

Based on labor and technology requirements, therapists’ cost to provide services to a CCO using ACORN is calculated at $205 cost per provider per month. The cost calculation for the CollaborativeOutcomes model is calculated at $75 cost per provider per month. CollaborativeOutcomes is similar functionally to the 3 systems listed above and is a viable alternative that keeps clients’ data at “arm’s length” from Healthplans.

ACORN, PCOMs and MyOutcomes are Limited Measures.

ACORN, PCOMs and MyOutcomes each offer a fixed number of questions answered in specific order, regardless of prior responses that have been given. CollaborativeOutcomes allows therapists to create and select questionnaires designed for broad range of issues and/or for specific patient problems, goals, and useful clinical feedback. Unlike ACORN and PCOMs, the CollaborativeOutcomes design strategy allows some questions to be delivered in the context of prior questions, thus allowing wide-range surveys of potential problems and diagnoses. This approach is called “branching” where the question displayed depends on the previous question or response. Furthermore, CollaborativeOutcomes™ questionnaires can also elicit written responses from patients based on their responses to certain questions by opening a text box along with a question to elicit written information.

HIPAA & Patient Privacy Issues.

Because CollaborativeOutcomes™ data is under the control of each psychotherapist, not a Healthplan, CollaborativeOutcomes provides much greater patient privacy than a system which passes individual client data to a payer. In the event of a data breach by a Healthplan providers may still be held responsible for assuring incident and breach investigation, mitigation, and notification to their patients. The CollaborativeOutcomes data collection system offers HIPAA assurance and a BAA.

From therapists’ perspective, payer required use of PCOMS or ACORN, is not a healthcare-operations support activity. The requirement to use static systems is intended to release protected health information for payers’ cost management purposes. Insurance payers, as an industry, have the highest number of HIPAA security breaches.

CollaborativeOutcomes™ incorporates a comprehensive quality improvement program including an integrated EMR.

CollaborativeOutcomes™ generates basic statistics including a reliable change index, rate of change, and can provide visual displays identifying value by contrasting standardized cost vs effect size. Normalizing costs allows CollaborativeOutcomes™ providers to see which providers and Healthplans provide the greatest value regardless of reimbursement rates. For example, data analyses could determine that Healthplan A, which has a lower reimbursement rate, can show greater value for each dollar spent than a Healthplan that provides higher reimbursements. CollaborativeOutcomes’ capacity and ability to gather data across Healthplans allows participants to see where psychotherapists provide the greatest value and potentially how they can provide greater value. CollaborativeOutcomes can support coordination of care in an efficient and inexpensive manner. CollaborativeOutcomes can efficiently support provider-led outcome and quality research in a cost-effective manner.

Legal, Ethical and Financial Considerations when dealing with CCOs

Measurement systems are themselves interventions and become an integral part of the treatment process. Their intended purpose is to inform patients and providers and to improve services, outcomes, and patient satisfaction. CollaborativeOutcomes is a model which (1) integrates measurement into services in a clinically useful and efficient manner (2) has greater value to providers and patients and (3) can efficiently support coordination of care.

Licensed professionals are legally responsible for the services they provide. As such they must have authority to select the specific processes that gather protected Health Information (PHI) from patients as well as the methods by which they determine the effectiveness of their services. A requirement to determine the effectiveness of services, using static measurement interventions, has financial value to a healthcare payer. A contractual relationship that requires a specific treatment process, which is advantageous to a CCO, provides a hidden benefit to the CCO, paid for by Federal Medicaid and State funds. CCO contracts should not disallow providers’ use of better data collection systems and processes that are preferable to patients and psychotherapists.

PHI provided to Healthplans has value; it can be monetized and sold without providers’ consent. This benefits payers not patients or their psychotherapists. Providers are ethically and legally obligated to hold benefit to patients as highest priority.

CCOs are secondary payers for health care services pass-throughs for State and Federal funding (i.e. Medicaid and OHP). CCOs which require their network of healthcare providers to use specific static feedback informed treatment (FIT) models are operating in ways that primarily benefit the CCO.

Psychotherapists who use measurement methods with equivalent or greater consumer benefit at less expense may not be allowed to contract with a CCO. A specific requirement to use PCOMs or ACORN or other static measures may be in violation of Antitrust Laws (e.g. restraint of trade). An equitable solution would be to require CCOs to support creative and procompetitive providers and contracts that significantly benefit patients.

For more information see “Guide to Antitrust Laws”

https://www.ftc.gov/tips-advice/competition-guidance/guide-antitrust-laws

References

CollaborativeOutcomes™ is a trademark of the Independent Mental Health Practices Alliance (IMHPA) Which began as the American Mental Health Alliance (AMHA)

Talking Points: CollaborativeOutcomes™

Giving Healthplans Patients’ Assessment Data Can be Dangerous

Problems with required use of ACORN, PCOMs or MyOutcomes in Oregon

  1. Coordinated Care Organizations (CCOs) often require providers to use an approved measurement system to receive referrals and reimbursement.

  2. CCO’s have not been consistently transparent in the health care community regarding expectations until after clinician contracts have been signed.

  3. Static 3rd party software systems offer proprietary questionnaires that influence psychotherapy processes, progress and outcomes by introducing changes in how psychotherapy is conducted. These are in fact psychotherapy interventions and require modification of psychotherapy processes and priorities.

  4. Such measures can be used by Healthplans to “steer”, oversee, limit and audit psychotherapy services provided by psychotherapists. They have been used for these purposes. It does not matter if the Healthplan asserts that patient’s identity is not provided to the payer. The static systems have the data and names can be provided to the payer. Furthermore, providing this data allows patients’ data to be compared to a national data base.

  5. ACORN is widely used to market and promote Healthplans. Their data base is proprietary and not available to users who wish to examine and challenge how the PHI collected is used by Healthplans.

  6. Providers using ACORN, particularly those who have group contracts, are required to use an online version on a subscription basis which must be paid for by Healthplans, provider groups and individual psychotherapists. Healthplans are charged $40 per month per psychotherapist. Psychotherapists are charged $30 per month. The cost of creating custom reports is not known but they can be created at a rate of approximately $150 per hour.

  7. The data gathered by Healthplans who fund and direct the use of questionnaire can be used to compare one provider’s data (i.e., PHI) to PHI obtained from other providers. Calculations are routinely performed to determine if a psychotherapist’s treatment is “on-track” or “off-track.” ACORN sponsored research has develop statistical a method to calculate and identify that as many as 50% of psychotherapists are significantly less effective than peers based on the ACORN criteria.

  8. Data gathered by Healthplans using ACORN have considerable financial value to a Healthplan. Once a psychotherapist relinquishes PHI data to a Healthplan it becomes the property of the Healthplan to use or sell to its benefit. Giving this provider-owned data to a Healthplan has no clinical purpose or value to patients.

  9. A secure, less expensive, and more useful system has been developed for Oregon psychotherapists by psychotherapists with the specific purpose of keeping clinical PHI separate from Healthplan databases, providing more reliable diagnoses, creating symptom and problem lists for treatment planning, documenting the medical necessity of care, reducing patient drop-out, and justifying services that patients require if reimbursement is challenged or denied.

  10. Mental health professionals should be encouraged to combine their disidentified data to create trainings and conversations among providers that are of benefit to patients, and support providers’ legal, ethical, clinical, and legitimate contract responsibilities.

  11. Psychotherapists should not participate in Healthplan funded and directed data collection programs. Relinquishing patient symptoms, behaviors and functional status obtained electronically will almost certainly allow payers to establish local norms and to validate their utilization review procedures.

  12. Psychotherapists who participate in Healthplan funded and directed measurement and data collection systems are empowering Healthplans to dictate psychotherapy interventions, procedures, processes, modalities, level of care, duration of treatment and more.

  13. Rather than giving their assessment data to Healthplans, psychotherapists should have opportunities to retain, gather, combine, and analyze disidentified patient data for the purpose of supporting data informed conversations among providers to improve outcomes and the quality of psychotherapy services.

CollaborativeOutcomes™ is a trademark of the Independent Mental Health Practices Alliance (IMHPA) Previously the American Mental Health Alliance (AMHA)