The Ethel & James Flinn Foundation
The publication of this action plan—the work of a distinguished panel of 25 mental health experts who served as the project steering committee—is the first phase of a multiyear effort to improve the quality of mental health care in Michigan by encouraging physicians to adopt best-practice or evidence-based practice (EBP) in the prescription and monitoring of drugs for people with major depression, bipolar disorder, and schizophrenia. The steering committee’s charge was to select the guidelines/algorithms best suited for Michigan and create a research-based plan aimed at encouraging their use.
Reliable and rapidly accumulating research demonstrates that the mental health care Americans receive is not always grounded in science or generally recognized best practices. Further, the lag between the discovery of new treatments and their routine incorporation into patient care is often unacceptably long. The best practice- and evidence-based tools advocated here—guidelines and algorithms—overcome both problems by summarizing treatment options in a way that reflects the state of scientific research or the expert opinion of practitioners in the field.
Funding for this project was provided by the Ethel and James Flinn Foundation of Detroit, which contracted with Public Sector Consultants Inc. of Lansing to manage the project.
After a careful review of available options, the steering committee recommends that the Texas Implementation of Medication Algorithms (TIMA) guidelines be appropriately modified for use in Michigan. The TIMA guidelines are scientifically sound, field-tested, and regularly updated. Equally important, they are part of a larger program of care that includes evaluation and measurement and the education and support of patients and families.
Research sponsored by and made available to the Steering Committee indicates that the action plan would be successful to the degree that it embodies the following principles:
- The guidelines/algorithms must be easy to use and part of a broader education and disease management approach.
- Differences in knowledge and needs among psychiatrists, primary care physicians (PCPs), and consumers must be part of the plan.
- The plan should be rolled out over time, with pilot programs to enlist opinion leaders and early adopters.
Elements of the Plan
The action plan itself offers both general recommendations and specific tactics associated with seven different strategic areas. The two general recommendations are:
- Pilot Programs. The steering committee and its leadership successor team should implement the EBP action plan by supporting and sponsoring three to six pilot programs at locations around Michigan over the next three years. The pilot programs, which would be designed to implement and test the efficacy of the EBP guidelines and algorithms, would be based upon the strategies and tactics described below. To the degree possible, all three conditions (major depression, bipolar disorder, and schizophrenia) would be included in each pilot, which would also cover public and private systems of care and accommodate the differing needs of primary care physicians and psychiatrists. The committee notes that state hospitals, university consortia, and private mental health practices that are university affiliated would be logical pilot program candidates.
- Leadership Team. To maintain the continuity and momentum of this effort and facilitate the establishment and ongoing operations of pilot programs there should be established in Michigan a leadership team with the following components:
- A “committee of the whole” composed of current steering committee members that will meet once or twice annually to review progress in the implementation of the report, suggest mid-course corrections, and serve as “ambassadors” for the project within Michigan.
- An “executive committee,” composed of volunteers from the steering committee and including both public- and private-sector participation that will provide oversight and assistance in a number of areas, especially in the critical area of funding. This group would meet more regularly, perhaps every other month.
- A “project coordination group” charged with staffing the project and doing the day-to-day work of implementation—including meeting with potential funders, developing requests for proposals (RFPs), evaluating proposals for local pilot programs, and coordinating the activities of the pilot programs that are established.
The two recommendations create a framework within which this EBP project can proceed in Michigan and reflect the committee’s belief that EBP principles are best advanced by means of local pilot programs guided by state-level leadership. A table outlining the roles and responsibilities of the leadership team and the pilot programs is included in the report as Appendix A.
The following strategies and tactics indicate the work the pilot programs must accomplish.
Strategies for the Packaging and Distribution of Guidelines and Algorithms
Tactic 1: The leadership team should oversee the reformatting and disseminating to the pilot programs of Michigan-specific guidelines and algorithms based upon the Texas (i.e., TIMA) model.
Tactic 2: The reformatted guidelines/algorithms should be available in both short and long versions and disseminated to accommodate differing needs and uses.
Tactic 3: The guidelines/algorithms should be tailored specifically for use with information technology, the Internet, local networks, and PDAs.
Tactic 4: Existing disease management tool kits available for treatment of major depression, bipolar disorder, and schizophrenia should be collected and analyzed, and, if necessary, new tool kits should be developed for use in the pilot programs.
Tactic 5: The newly formatted Michigan algorithms should be updated regularly.
Strategies for Physician Education
Tactic 1: The leadership team and pilots should develop strong, consistent messages as to explain the value of guidelines and algorithms. These should be focused on critical issues such as expected outcomes and physician autonomy and, whenever possible, be accompanied by stakeholder endorsements.
Tactic 2: As part of a commitment to being “centers of excellence,” one or more state medical schools should adopt and teach guidelines/algorithms as part of the medical school curriculum and in residency training programs.
Tactic 3: The leadership team and pilot programs should explore ways of offering Continuing Medical Education (CME) credit for conferences, training programs, and regional sessions devoted to evidence-based mental health care and the use of guidelines and algorithms.
Tactic 4: The leadership team and pilot programs should work together to develop site-specific physician training programs for each pilot program.
Strategies for Consumer Education
Tactic 1: The leadership team and pilot programs should develop materials and methods for improving patient-physician communication on the nature, importance, value, and use of guidelines and algorithms during individual treatment sessions—that is, on a “one-to-one” basis.
Tactic 2: Pilot programs and the leadership team should collaborate on a broader program of consumer education and awareness through the use of public service announcements, and, most especially, by employing existing advocacy groups as messengers to their constituents.
Tactic 3: The leadership team should evaluate the need to conduct further research into consumer needs and preferences as well as the possibility of offering consumer education tailored to specific subgroups or settings—for example, CMH settings.
Strategies for Ongoing Physician Support
Tactic 1: The leadership team and pilot programs should devise mechanisms to support and assist clinicians in the treatment of specific cases and patients.
Tactic 2: The leadership team and individual pilots should mutually develop support mechanisms to help with administration and logistics of the pilot itself.
Tactic 3: The leadership team should work with payers to develop prescriber profiles and make them available to prescribers and researchers, while remaining sensitive to privacy issues. As part of this process, the group should encourage as much as possible movement toward universal use of electronic medical records.
Strategies to Develop Incentives for Change
Tactic 1: The leadership team and pilots should develop nonfinancial incentives for the adoption of guidelines and algorithms.
Tactic 2: The leadership team should offer CME credit as an incentive as well as an educational opportunity.
Tactic 3: The leadership team should approach payers to secure their buy-in for: (1) paying or creating rewards for guideline/algorithm adherence and (2) increasing reimbursement to improve the quality of care and reporting.
Tactic 4: The leadership team should work with the Michigan Department of Community Health to ensure that contracts with providers reflect EBP principles.
Strategies for Evaluation and Measurement
Tactic 1: The leadership team, working with representatives from the pilot programs, should develop multidimensional evaluation and measurement techniques that assess adherence to and variation from guidelines, effectiveness of guidelines, consumer and physician satisfaction, cost, and variations among prescribers.
Tactic 2: The leadership team and the local pilot programs should work together to establish registries of persons with the conditions of interest (depression, bipolar disorder, and schizophrenia), while remaining sensitive to privacy issues.
Strategies for Stakeholder Buy-in
Tactic 1: The leadership team should assist pilot programs in developing EBP buy-in at each site through informational outreach efforts.
Tactic 2: The leadership team should identify a suitable contractor to coordinate marketing efforts to consumer advocacy groups and other groups with an interest in mental health care.
Tactic 3: The leadership team should encourage current steering committee members to serve as active ambassadors for EBP, the use of guidelines and algorithms in mental health care, and the pilot program process.
Tactic 4: The leadership team should serve as a liaison to private foundation and corporate funders, within Michigan and nationally, and develop strategies for engaging their support for the project.
A copy of the full report is available below.