Delophg a Utilization Review Model for Community Mental Hecilth Centers JEAN TIPPEU, PH.D. Chief of Clinical Information Area A Community Mental Washington, D.C.
and Health
Research Center
BARBARA SMITH Research Assistant Mount Sinai Hospital Hartford, Connecticut During their struggles to develop a utilization review model for a community mental health center, members of an interdisciplinary committee identified several issues they believe are important In establishing such a model. They include comprehensiveness of participation and of areas for review (the review committee should rep’esent all disciplines and programs, and should be concerned with any aspect of center functioning), a prohlem-review approach In which subcommittees carry out documented studies of issues or problems, and specific provision for feedback and Implementation of the results. UUtilization review is a process of appraising and improving the quality, effectiveness, and appropriateness of services provided by a facility to its clients. It should serve as a vehicle for raising standards of health and mental health care and should increase the assurance that the standards are being met. It is based on the concept of peer review and is carried out by a committee made up of staff from the facility. The committee should be regarded as an educational body, and the information it gathers should be instructive to the total staff of the facility. Becently the National Institute of Mental Health has given support to utilization review in community mental health centers and has considered making such review a requirement for center funding. However, current available models, as well as the original Medicare formulation, are not appropriate in many Dr. Tippett mittee and and research
formerly was chairman Ms. Smith was a research at the Area B Community
of the utilization assistant in clinical Mental Health
review cominformation Center.
aspects for community mental health centers. Since there can be flexibility in translating the Medicare guidelines into practice, careful thought should be given to the kind of utilization review model that is best suited for community mental health. The Area B Community Mental Health Center in Washington, D.C., is one of four community mental health centers that participated in Yale University’s Psychiatric Utilization Review and Evaluation Project.’ As part of the project a committee including mental health technicians, nurses, psychiatrists, psychologists, social workers, researchers, and a medical records librarian was established to write a plan for utilization review. The committee struggled for several months to develop a plan that included a chart-review checklist that would be useful for reviewing charts in a community mental health center, and that organized the results of sample review in a way that would lead to the improvement of services. However, when all items thought to be relevant to good client care were included, the checklist was very long and involved. It was clear that no comprehensive list could be developed that would cover the range of issues and problems. The committee concluded that the general chartreview checklist, with its accompanying sample review of charts, had been the outgrowth of fuzzy concepts about the specific goals of utilization review. The committee spent several more months in study sessions to clarify the issues and after a final, rather drastic revision, developed a plan based on a problem-oriented method of review. The plan was adopted for use in 1972, and in early 1974 the Area A Community Mental Health Center also adopted the same basic model. During the struggles to develop the final plan at the Area B center, we identified several issues we believe are important in establishing a utilization review model for community mental health centers. These issues include breadth of participation, comprehensiveness of review areas, problem focus using documented studies, 1
D. C.
and
Community
VOLUME
et al., “Developing
Riedel
Evaluation
in Community Psychiatry, Vol.
26
NUMBER
a System
Mental Health 22, August 1971,
3 MARCH
1975
for
Utilization
Review
Centers,” Hospital pp. 229-232.
&
165
range of information sources, implementation of studies, and feedback of findings and recommendations. The first issue involves the formation of a utilization review committee. In a community mental health center, with its professional and indigenous workers, its expanded areas of service, and its goal of active community participation in policy-making and services, a broad representation of staff, programs, and community members is mandatory. All programs and disciplines should be represented on the committee, and center staff not on the committee should be used on subcommittees or individually as needed. Staff from contract agencies that provide services to center clients, members of the center’s community advisory board, or other community representatives should be involved in the utilization review process as consultants and subcommittee members, rather than as committee members. Committee activities should include a review of any aspect of the center’s functions that could result in recommendations for changes beneficial to the client, institution, or community. Thus anything related to direct client care or to indirect services, including community consultation and education, administrative issues, or staff training and development cah be a valid subject for review. Evaluation of activities related to such concepts as catchment-area responsibility, accessibility, comprehensiveness of services, community maintenance, continuity of care, and primary prevention can therefore be a legitimate and important part of the review process. We recommend a problem-issue review approach patterned after medical-care evaluation studies.2 Documented studies should be done on particular issues or problem areas. The topics for study should be chosen because of their importance to effective services and to the center’s functioning, because they represent a recurrent problem in a particular pattern of client care, or because they constitute the basis for Medicare or other review requirements. Some study topics appropriate to community mental health centers include the development of treatment standards, with a review of each major therapeutic modality and indications for its use; review of cases of brief and extended duration of treatment; quality and appropriateness of treatment plans for clients; staffing patterns of programs as they relate to quality of services; intake procedures; continuity of care; interprogram relationships; the use of medication in tlient care; and evaluation of consultation activities in the schools. Studies of some topics need to be continuing while others can be time-limited. Sources of information for the studies can include clinical and statitical material in the center’s data bank, interviews and responses to questionnaires, data 2
J.
C. A. Goldberg,
Evaluation
the American 383-387.
166
Studies:
Medical
Needleman, A Utilization
Association,
HOSPITAL
and
S. L. Weinstein,
Review
Vol.
Requirement,”
220,
& COMMUNITY
April
“Medical Journal 17, 1972,
PSYCHIATRY
Care
of pp.
from community sources, and problem-centered chart review. When chart review is used, groups of cases, rather than individual cases, should be examined in order to gather data about patterns of care and recurring problems. STUDIES
BY SUBCOMMITTEES
The studies should be carried out by subcommittees, each of which should include at least one member of the review committee as well as representatives from various programs and disciplines. The subcommittee chairman can be either a committee member or a staff member who is qualified for the position. Broad staff participation in subcommittees allows those with interest and skill in a given area to contribute and relieves committee members of carrying the full burden of implementation of studies. After the review committee assigns a subcommittee to study a topic, the subcommittee members must present a study plan for approval. It should include such information as a statement of the study dimensions, the proposed period of investigation, and the method of data collection. The subcommittee’s report to the full committee at the completion of its study should include, among other things, the actual period of investigation, study procedures and data used, recommendations and actions to be taken, programs and staff involved in recommendations and actions, and dates for discussing findings and recommendations with the appropriate individuals. After approval by the review committee, the subcommittee should be responsible for providing feedback to the appropriate persons and following up on action taken on the recommendation. It then should complete a summary form about actions taken and dates of action and return the completed form to the committee for final review. The entire committee should then be responsible for any additional implementation or action relating to the recommendations. Specific mechanisms, such as those already mentioned, need to be developed for implementing recommendations. Responsibility for the implementatiori needs to be clearly defined and should include participation by staff and community representatives as well as committee members. Feedback of findings to appropriate programs, staff, administrators, and community boards or agencies and implementation of recommendations are crucial aspects of utilization review. Committees have too often fallen into the trap of having spent a lot of time in the review process and then having inadequate mechanisms for acting on recommendations. We feel the utilization review model presented here allows maximum productivity for the time invested. We hope these guidelines can be adapted in other community mental health centers and can be modified for use at other mental health or psychiatric facilities.R
and Health
Research Center
BARBARA SMITH Research Assistant Mount Sinai Hospital Hartford, Connecticut During their struggles to develop a utilization review model for a community mental health center, members of an interdisciplinary committee identified several issues they believe are important In establishing such a model. They include comprehensiveness of participation and of areas for review (the review committee should rep’esent all disciplines and programs, and should be concerned with any aspect of center functioning), a prohlem-review approach In which subcommittees carry out documented studies of issues or problems, and specific provision for feedback and Implementation of the results. UUtilization review is a process of appraising and improving the quality, effectiveness, and appropriateness of services provided by a facility to its clients. It should serve as a vehicle for raising standards of health and mental health care and should increase the assurance that the standards are being met. It is based on the concept of peer review and is carried out by a committee made up of staff from the facility. The committee should be regarded as an educational body, and the information it gathers should be instructive to the total staff of the facility. Becently the National Institute of Mental Health has given support to utilization review in community mental health centers and has considered making such review a requirement for center funding. However, current available models, as well as the original Medicare formulation, are not appropriate in many Dr. Tippett mittee and and research
formerly was chairman Ms. Smith was a research at the Area B Community
of the utilization assistant in clinical Mental Health
review cominformation Center.
aspects for community mental health centers. Since there can be flexibility in translating the Medicare guidelines into practice, careful thought should be given to the kind of utilization review model that is best suited for community mental health. The Area B Community Mental Health Center in Washington, D.C., is one of four community mental health centers that participated in Yale University’s Psychiatric Utilization Review and Evaluation Project.’ As part of the project a committee including mental health technicians, nurses, psychiatrists, psychologists, social workers, researchers, and a medical records librarian was established to write a plan for utilization review. The committee struggled for several months to develop a plan that included a chart-review checklist that would be useful for reviewing charts in a community mental health center, and that organized the results of sample review in a way that would lead to the improvement of services. However, when all items thought to be relevant to good client care were included, the checklist was very long and involved. It was clear that no comprehensive list could be developed that would cover the range of issues and problems. The committee concluded that the general chartreview checklist, with its accompanying sample review of charts, had been the outgrowth of fuzzy concepts about the specific goals of utilization review. The committee spent several more months in study sessions to clarify the issues and after a final, rather drastic revision, developed a plan based on a problem-oriented method of review. The plan was adopted for use in 1972, and in early 1974 the Area A Community Mental Health Center also adopted the same basic model. During the struggles to develop the final plan at the Area B center, we identified several issues we believe are important in establishing a utilization review model for community mental health centers. These issues include breadth of participation, comprehensiveness of review areas, problem focus using documented studies, 1
D. C.
and
Community
VOLUME
et al., “Developing
Riedel
Evaluation
in Community Psychiatry, Vol.
26
NUMBER
a System
Mental Health 22, August 1971,
3 MARCH
1975
for
Utilization
Review
Centers,” Hospital pp. 229-232.
&
165
range of information sources, implementation of studies, and feedback of findings and recommendations. The first issue involves the formation of a utilization review committee. In a community mental health center, with its professional and indigenous workers, its expanded areas of service, and its goal of active community participation in policy-making and services, a broad representation of staff, programs, and community members is mandatory. All programs and disciplines should be represented on the committee, and center staff not on the committee should be used on subcommittees or individually as needed. Staff from contract agencies that provide services to center clients, members of the center’s community advisory board, or other community representatives should be involved in the utilization review process as consultants and subcommittee members, rather than as committee members. Committee activities should include a review of any aspect of the center’s functions that could result in recommendations for changes beneficial to the client, institution, or community. Thus anything related to direct client care or to indirect services, including community consultation and education, administrative issues, or staff training and development cah be a valid subject for review. Evaluation of activities related to such concepts as catchment-area responsibility, accessibility, comprehensiveness of services, community maintenance, continuity of care, and primary prevention can therefore be a legitimate and important part of the review process. We recommend a problem-issue review approach patterned after medical-care evaluation studies.2 Documented studies should be done on particular issues or problem areas. The topics for study should be chosen because of their importance to effective services and to the center’s functioning, because they represent a recurrent problem in a particular pattern of client care, or because they constitute the basis for Medicare or other review requirements. Some study topics appropriate to community mental health centers include the development of treatment standards, with a review of each major therapeutic modality and indications for its use; review of cases of brief and extended duration of treatment; quality and appropriateness of treatment plans for clients; staffing patterns of programs as they relate to quality of services; intake procedures; continuity of care; interprogram relationships; the use of medication in tlient care; and evaluation of consultation activities in the schools. Studies of some topics need to be continuing while others can be time-limited. Sources of information for the studies can include clinical and statitical material in the center’s data bank, interviews and responses to questionnaires, data 2
J.
C. A. Goldberg,
Evaluation
the American 383-387.
166
Studies:
Medical
Needleman, A Utilization
Association,
HOSPITAL
and
S. L. Weinstein,
Review
Vol.
Requirement,”
220,
& COMMUNITY
April
“Medical Journal 17, 1972,
PSYCHIATRY
Care
of pp.
from community sources, and problem-centered chart review. When chart review is used, groups of cases, rather than individual cases, should be examined in order to gather data about patterns of care and recurring problems. STUDIES
BY SUBCOMMITTEES
The studies should be carried out by subcommittees, each of which should include at least one member of the review committee as well as representatives from various programs and disciplines. The subcommittee chairman can be either a committee member or a staff member who is qualified for the position. Broad staff participation in subcommittees allows those with interest and skill in a given area to contribute and relieves committee members of carrying the full burden of implementation of studies. After the review committee assigns a subcommittee to study a topic, the subcommittee members must present a study plan for approval. It should include such information as a statement of the study dimensions, the proposed period of investigation, and the method of data collection. The subcommittee’s report to the full committee at the completion of its study should include, among other things, the actual period of investigation, study procedures and data used, recommendations and actions to be taken, programs and staff involved in recommendations and actions, and dates for discussing findings and recommendations with the appropriate individuals. After approval by the review committee, the subcommittee should be responsible for providing feedback to the appropriate persons and following up on action taken on the recommendation. It then should complete a summary form about actions taken and dates of action and return the completed form to the committee for final review. The entire committee should then be responsible for any additional implementation or action relating to the recommendations. Specific mechanisms, such as those already mentioned, need to be developed for implementing recommendations. Responsibility for the implementatiori needs to be clearly defined and should include participation by staff and community representatives as well as committee members. Feedback of findings to appropriate programs, staff, administrators, and community boards or agencies and implementation of recommendations are crucial aspects of utilization review. Committees have too often fallen into the trap of having spent a lot of time in the review process and then having inadequate mechanisms for acting on recommendations. We feel the utilization review model presented here allows maximum productivity for the time invested. We hope these guidelines can be adapted in other community mental health centers and can be modified for use at other mental health or psychiatric facilities.R
