Phil Klassen MD FRCPC Vice-President, Medical Affairs Ontario Shores Centre for Mental Health Sciences Assistant Professor, University of Toronto Quality.

Phil Klassen MD FRCPCVice-President, Medical AffairsOntario Shores Centre for Mental Health SciencesAssistant Professor, University of Toronto

Quality Standard for Schizophrenia

Introduction1. Project scope

2. Panel composition and selection

3. Methods for the development of quality statements– Identification of key areas for quality improvement – Prioritization of key areas– Review of evidence for each prioritized key area– Drafting of quality statements– Finalization of quality statements

4. Prioritization of key areas for quality statements– Results of topic prioritization survey– Potential guidelines for inclusion– Prioritization of key areas from survey and potential guidelines

• Concise sets of 5-15 strong (“must do”), measurable, evidence-based statements guiding care in a topic area

• Developed in topic areas identified as having high potential for better quality care in Ontario

• Each quality statement accompanied by quality indicator(s)

• Every quality standard will be accompanied by a plain language summary for patients and caregivers

• Strong emphasis on implementation through a variety of vehicles (monitoring/reporting, QBPs, Quality Improvement Plans, etc.)

• Strong emphasis on partnerships to support development and implementation

Quality standards – what are they?

Population and Topic Scope

• Adults aged 18-65 suffering from schizophrenia• From the ER/hospital admission to discharge

• Community treatment for next iteration

In Scope

• Adolescents and the elderly• Not specifically about first episode psychosis• Not specifically about concurrent disorders

Out of Scope

Panel Composition

High Level Timeline

Schizophrenia Quality Standard and QBP Clinical Handbook

High Level Timeline

May 2015 June 2015 July 2015 Aug. 2015 Sept. 2015 Oct. 2015 Nov. 2015 Dec. 2015 Jan. 2016 Feb. 2016 Mar. 2016 Apr. 2016 May 2016 June 2016 July 2016 Aug. 2016

Implementation Phase

Populating the Clinical Handbook Template

July 15

Submit Panel

Membershipto MOH

(August 14) August 2015

Topic Prioritization

Survey Sent to Panel

December 2015

2016

July 15

Expert Panel Established

August 16

Ready For Final Posting

May 2016

Develop Implementation

Plan

March 2016

Quality Standard document drafted

April 16 - July 16

Approvals & EditingPhase

July 2016 - August 2016

Production & Publication

Phase

July 16

Ministry Notification

April 2016

Expert Panel Meeting 4(if necessary)

February 2016

Draft Quality

Indicators

February 16

Expert Panel Meeting 3

October 2015 - April 2016

Development PhaseMay 15 - October 15

Scoping & Planning

October 15

Expert Panel Meeting 1

(September 30)

December 2015

Draft Quality

Statements

December 15

Expert Panel Meeting 2

(December 03)

Method Overview

Identification of Key Areas

Prioritization of Key Areas

Review of Evidence

Drafting Quality

Statements

Finalization of Quality

Statements

• Current activities are focused on review of evidence and drafting quality statements.

• Expert group meeting to discuss scheduled December 3, 2015.

DRAFT QUALITY STATEMENTS(FOR REVIEW AND DISCUSSION PURPOSES)

Primary Key Areas

Secondary Key Areas

Support for carers & family

members

Patient education

Transition to community / ACT

teams

Assessment

Supporting healthy eating &

exercise

Supporting smoking cessation

Early intervention

Treatment of substance

misuse

Monitoring for adverse events

to treatment

Engagement

CBT

Self-management

Monitoring patient health

Management of acute risk

Supporting adherence to

treatment

Choice of pharmacological

treatment

Alternative therapies

Peer support

Non-response to treatment

Services for people in crisis

Training & education of

HCPs

Access to psychiatrist

Psychosocial interventions

Neurocognitive training

Draft Quality Statements

Adults with schizophrenia who are assessed as inpatients in a hospital setting for a mental health diagnosis undergo a comprehensive, multidisciplinary assessment.

Definition: Assessment should be both comprehensive and multidisciplinary, undertaken by health care professionals with expertise in the treatment of people with schizophrenia. The assessment should address the following domains:

– Current and identified sources of distress, including risk of harm to self or others– Family/developmental (social, cognitive and motor development and skills, including coexisting

neurodevelopmental conditions) and education history, including history of trauma/adversity– Social history (accommodation, culture and ethnicity, leisure activities and recreation, and

responsibilities for children or as a carer), social networks, and history of intimate relationships– Occupational and educational (attendance at college, educational attainment, employment and

activities of daily living) history, and economic status– Medical history and full physical examination to identify physical illness (including organic brain

disorders) and prescribed drug treatments that may result in psychosis, and history of substance misuse

– Assessment of self-identified goals and aspirations as regards outcome of mental health care

Draft Quality Statements

Adults with schizophrenia who are assessed in a hospital setting for a mental health diagnosis are assessed for substance misuse.

Definition: The use of alcohol, tobacco, prescription and non-prescription medication and illicit drugs should be discussed with the individual, and carer if appropriate. The possible interference of substance misuse with the therapeutic effects of both pharmacological and non-pharmacological treatments should be discussed.

Draft Quality Statements

Adults with schizophrenia are offered peer support during their hospitalization by a trained peer support worker who has recovered from psychosis or schizophrenia and remains stable.

Definition: Peer support programs may include information and advice about:• Psychosis and schizophrenia• Effective use of medication• Identifying and managing symptoms• Accessing mental health and other support service• Coping with stress and other problems• What to do in crisis• Building a social support network• Preventing relapse and setting personal recovery goals

Draft Quality Statements

Caregivers of adults with schizophrenia who are assessed in a hospital setting for a mental health diagnosis are offered access to relevant and appropriate carer-focused training and education.

Definition: Carer-focused training and education is designed to improve caregivers’ experience and reduce burden and may include:• Psychoeducation• Support groups• Self-help interventions

Draft Quality Statements

Adults with schizophrenia who are assessed in a hospital setting for a mental health diagnosis undergo physical health assessments focusing on problems common in people with schizophrenia.

Definition: Physical health interventions should measure:• Weight/body mass index/waist circumference• Pulse and blood pressure• Fasting blood glucose• Lipid panel (total cholesterol, low-and high-density lipoprotein, cholesterol, triglycerides)• Extrapyramidal symptoms and signs• Overall physical health

Draft Quality Statements

Adults with schizophrenia who are assessed in a hospital setting for a mental health diagnosis are offered combined physical health and healthy eating interventions.

Definition: Behavioural interventions that combine support for healthy eating and physical exercise should be considered for initiation in the acute care setting. Such interventions may follow a psychoeducation/information-based approach and provide information and support for how to increase levels of physical activity and healthy eating.

Draft Quality Statements

Adults with schizophrenia who are assessed in a hospital setting for a mental health diagnosis are offered help to reduce or stop smoking through behavioural or pharmacological interventions.

Definition: A range of interventions to help reduce or stop smoking should be considered for initiation in the acute care setting. These may include:• Behavioural support• Pharmacotherapy

– Nicotine replacement therapy products (e.g. transdermal patches, gum, inhalation cartridges, sublingual tablets, or spray)

– Varenicline– Bupropion

Draft Quality Statements

Adults with schizophrenia who have failed to respond to treatment with at least two antipsychotic medications including a second-generation antipsychotic medication are offered clozapine.

Draft Quality Statements

Adults with schizophrenia who are assessed in a hospital setting for a mental health diagnosis are offered individual cognitive behavioural therapy for psychosis in addition to oral antipsychotic medication.

Definition: Cognitive behavioural therapy (CBT) for psychosis should be delivered on a one-to-one basis over at least 16 planned sessions and should be delivered according to a treatment manual. CBT psychosis can be initiated during all phases of psychosis (including the initial phase, the acute phase, or the recovery phase) and should be delivered by professionals with an appropriate level of competence who, wherever possible, receive regular supervision by the relevant specialists.

Draft Quality Statements

Adults with schizophrenia who are assessed in a hospital setting for a mental health diagnosis are offered family intervention in addition to oral antipsychotic medication. Family members of adults with schizophrenia are also offered family intervention.

Definition: The term ‘family’ can describe members of the individual’s family or caregivers who live with or are in close contact with an adult with schizophrenia.

Family intervention should:• Include the person with psychosis or schizophrenia if practical• Be carried out for between 3 months and 1 year• Include at least 10 planned sessions (these may or may not be part of the acute setting and planning for

subsequent sessions should be part of the discharge planning)• Take account of the whole family’s preference for either single-family intervention or multi-family group

intervention• Take account of the relationship between the main carer and the person with psychosis or schizophrenia• Have specific supportive, educational or treatment function and include negotiated problem solving or crisis

management work

Draft Quality Statements

Transition to the Community:

Adults with schizophrenia are assessed prior to discharge to determine further levels of care and linkage with primary care or community care support.

Adults with schizophrenia discharged from a hospital setting are scheduled a follow-up appointment with a psychiatrist within X days of discharge.

Additional Areas for Draft Quality Statements

1. Recovery

2. Trauma-informed care

3. Early intervention

4. Polypharmacy and LAI

5. Other non-pharmacological interventions– Art therapy– Social skills training– Psychoeducation– Supportive therapy– Mindfulness – Motivational interviewing– Cognitive remediation

Key Next Steps

• Further refinement of draft quality statements and review of evidence

• Expert group meeting – December 3, 2015

[email protected]

QUESTIONS?

APPENDIX

Methods: Identification of Key Areas

• Topic Prioritization Survey– Aimed to engage panel members to identify key areas for quality

improvement– Modelled on NICE’s method of stakeholder engagement during their

Quality Standard development process

Methods: Prioritization of Key Areas

• Clinical epidemiologist (CE) summarizes key areas identified in topic survey, along with areas identified through scoping exercise

• Panel will prioritize up to 10 key areas for quality statement development

• Considerations for prioritization:

1. Potential to improve health outcomes or health resources

2. Variation in current practice

3. Maintenance of important current standards of care

Methods: Review of Evidence

• CE will identify recommendations or statements from relevant guidelines (such as NICE or NICE-accredited guidelines, guidelines used in current practice, or those otherwise identified through scoping exercise) that may support potential quality statement development

Summary of relevant

recommendations and guidance

statements

• If limited or no evidence exists for key area, the CE will conduct an evidence review using the most appropriate review method

Evidence review

• If there is no evidence, the panel may wish to:• Use expert consensus• Note prioritized key area for future

consideration

Establishment of consensus

For each prioritized area:

Methods: Review of Evidence

• Identification and Inclusion of Clinical Guidelines– Identify relevant guidelines covering the population(s) and setting(s) of

interest– Use the AGREE II instrument to select 4–5 highest quality clinical

guidelines, including at least 1 contextually relevant (Canadian) guideline

Appraisal of Guidelines for Research & Evaluation II

1) Scope and Purpose

2) Stakeholder Involvement

3) Rigour of Development

4) Clarity of Presentation

5) Applicability

6) Editorial Independence

Methods: Review of Evidence

• Acceptable Evidence Threshold– The recommendations or statements identified from relevant guidelines

will be examined by the CE to determine whether they meet an acceptable evidence threshold

– Suggested thresholds:• Moderate to high quality of evidence for diagnostic or therapeutic

interventions• Expert consensus is sufficient when quality of evidence is low for

certain principles, processes, or system-level interventions

Methods: Drafting of Quality Statements

• Up to 15 quality statements will be drafted, based on either recommendations from relevant guidelines or an evidence review

• Quality statements are not verbatim restatements of the relevant recommendations from source guideline(s)

• One quality statement may map to recommendations from one or more guidelines, and/or may be derived by rewording one or more recommendations into a single statement

Methods: Finalization of Quality Statements

• The panel will agree up to 15 quality statements for publication within the quality standard and clinical handbook

Key Areas Identified by Topic Prioritization Survey

Topic Areas

Early intervention: Early intervention may improve clinical outcomes, such as admission rates, symptoms and relapse

Services for people in crisis: Crisis resolution and home-treatment teams to support people in crisis

Support for carers and family members: Family-based interventions; family psychoeducation; family education

Non-pharmacological interventions: Cognitive behavioural therapy; alternative therapies; neurocognitive training; psychosocial interventions

Promoting physical health: Education and interventions to encourage healthy eating and exercise; assessment and treatment of substance misuse; supporting smoking cessation; improving medical care and monitoring of physical health and metabolic parameters

Pharmacological interventions: Choice of antipsychotic treatment (drug and route; access, use and monitoring of clozapine); supporting adherence with treatment; partial or non-response to antipsychotic treatment; monitoring of adverse events

Transition to the community: Supportive and knowledgeable staff to ease transition; strategies and methods to facilitate care transition

Peer support: Support from people with lived experience can help individuals with schizophrenia

Training and education of healthcare providers: Specialized training for all providers who care for people with schizophrenia

Access to psychiatrist: Access to psychiatric care is often limited

Other Key Topic Areas

Topic Areas

Assessment: Psychiatric assessment; comprehensive multidisciplinary assessment; physical health assessment to identify co-existing or comorbid conditions

Management of risk: Management of individuals at immediate risk to themselves or others during an acute episode

Patient education: Improved patient understanding of the assessment process, their diagnosis, and treatment options

Engagement: Experience of staff in working with people from diverse ethnic and cultural backgrounds

Self-management: Self-management to promote recovery and empower individuals

Out of scope

Emergency department or inpatient setting (including transition to community)

• People in the criminal or youth justice systems• Pre-natal and post-natal support• Support of people with learning difficulties• Prevention of psychosis in those at higher risk• People with PTSD symptoms• Transition from youth to adult care

In scope?

Services for people in crisis

Transition to the community / ACT teams

Early intervention services

Promoting physical health

Encouraging healthy eating and exercise

Monitoring of patient health status

Supporting smoking cessation

Treatment of substance misuse

Support for carers and family members

Access to psychiatrist

Engagement(e.g., First Nations,

immigrants/ refugees)

Training and education of HCPs

Self-management Peer support

• Improving community attitudes (reducing stigma)• Access to primary care• Supportive housing/assisted living• Supporting employment• Community integration

Management of acute risk

Patient education

*BLUE indicates identified by topic prioritization survey

Non-pharmacological interventions

Cognitive behavioural therapy

Alternative therapies

Psychosocial interventions

Neurocognitive training

Assessment

Psychiatric assessment

Comprehensive multidisciplinary

assessment

Physical health assessment (for co-existing conditions)

Pharmacological interventions

Choice of antipsychotic medication

Supporting adherence to antipsychotic

medication

Monitoring for adverse events

Partial- or non-response to anti-

psychotic medication