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TMAP
22
NorthSTAR NorthSTAR IMPLEMENTATION IMPLEMENTATION PLANNING TEAMPLANNING TEAM
12-13-200212-13-2002
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PLANNING MEETING GOALSPLANNING MEETING GOALS
Define specific goals for successful Define specific goals for successful implementationimplementation
Define activities to achieve goalsDefine activities to achieve goalsTroubleshoot barriers to carrying out Troubleshoot barriers to carrying out
activitiesactivitiesAssign activities to achieve goals to team Assign activities to achieve goals to team
membersmembers Identify timeline for completing activitiesIdentify timeline for completing activities
44
CONSULTANTS TO PROCESSCONSULTANTS TO PROCESS
Dr. Steve Shon, TDMHMR Medical Dr. Steve Shon, TDMHMR Medical DirectorDirector
Dr. Ken Altshuler, TDMHMR Board of Dr. Ken Altshuler, TDMHMR Board of Directors & UTSMC ProfessorDirectors & UTSMC Professor
Carole Matyas, ValueOptions V-PCarole Matyas, ValueOptions V-PDr. Lynelle Yingling, DANSA Board ChairDr. Lynelle Yingling, DANSA Board Chair
55
Review of BasicsReview of Basics
Dr. ShonDr. Shon
66
Everyone “Just Doing Their Everyone “Just Doing Their Best”Best”
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TMAP: Aligning the ArrowsTMAP: Aligning the Arrows
88
AlgorithmAlgorithm
“A step by step procedure for
solving a problem or
accomplishing some end.”
Webster’s Dictionary
99
GOALS OF MEDICATION GOALS OF MEDICATION GUIDELINES/ALGORITHMSGUIDELINES/ALGORITHMS
Systematic Approach to Medication ManagementSystematic Approach to Medication Management
Quantifiable and Reliable Outcome MeasuresQuantifiable and Reliable Outcome Measures
Documentation of Medications and OutcomesDocumentation of Medications and Outcomes
Enhance Medication Adherence by PatientsEnhance Medication Adherence by Patients
1010
Clinical Reasons for AlgorithmsClinical Reasons for Algorithms
Facilitate clinical decision-makingFacilitate clinical decision-making Improve quality of careImprove quality of care Make treatment plans consistent across Make treatment plans consistent across
sites and physicianssites and physicians Tailor treatment to individualsTailor treatment to individuals Provide adequate clinical documentationProvide adequate clinical documentation Define where new medications fit for Define where new medications fit for
optimal outcomesoptimal outcomes
1111
Administrative ReasonsAdministrative Reasonsfor Algorithmsfor Algorithms
Accountability for scarce resourcesAccountability for scarce resources Uniform expectations for providersUniform expectations for providers Improve cost efficiencyImprove cost efficiency Predictable costsPredictable costs Define where new medications are cost- Define where new medications are cost-
effectiveeffective Define costs related to specific Define costs related to specific
treatments or outcomestreatments or outcomes
1212
Medication AlgorithmsMedication Algorithms
Three disorder groupsThree disorder groupsMajor depressive disordersMajor depressive disordersSchizophreniaSchizophreniaBipolar disordersBipolar disorders
Strategies (identifying the Strategies (identifying the whatwhat))
Tactics (identifying the Tactics (identifying the howhow)) Specific guidelinesSpecific guidelines Planned revisionsPlanned revisions
1313
DOCUMENTATIONDOCUMENTATION
1414
1515
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PATIENT AND FAMILY PATIENT AND FAMILY EDUCATIONEDUCATION
1717
Educational MaterialsEducational Materials
Patient objectivesPatient objectivesTeaching patients disease managementTeaching patients disease management
Involving patients in treatment choicesInvolving patients in treatment choices
Optimizing treatment benefitsOptimizing treatment benefits
Provider objectivesProvider objectivesOptimizing treatment benefitsOptimizing treatment benefits
Teaching optimal medication useTeaching optimal medication use
Clarifying and documenting clinicalClarifying and documenting clinicaldecision-makingdecision-making
Patient objectivesPatient objectivesTeaching patients disease managementTeaching patients disease management
Involving patients in treatment choicesInvolving patients in treatment choices
Optimizing treatment benefitsOptimizing treatment benefits
Provider objectivesProvider objectivesOptimizing treatment benefitsOptimizing treatment benefits
Teaching optimal medication useTeaching optimal medication use
Clarifying and documenting clinicalClarifying and documenting clinicaldecision-makingdecision-making
1818
The Texas Medication The Texas Medication Algorithm Project (TMAP): Algorithm Project (TMAP): Outcomes for Persons with Outcomes for Persons with
Schizophrenia (SCZ)Schizophrenia (SCZ)
1919
SCZ Adjusted Mean Symptoms SCZ Adjusted Mean Symptoms (BPRS(BPRS1818): All Subjects): All Subjects
41.8
25
30
35
40
45
50
55
Baseline 1 2 3 4
TAUnonALO (n=144)ALO+ED (n=165)
Quarter
BPR
S1
8
2020
SCZ: Sum of Cognition z Scores: All Subjects
00
1
2
Baseline 1st Quarter 3rd Quarter
Sum
of z
Sco
res
TAUnonALGO (n=122)ALGO+ED (n=137)
2121
CognitiveImpairment
PositiveSymptoms
Negative Symptoms
AdaptiveFunction
Cognitive Impairment Predicts Cognitive Impairment Predicts Functional OutcomesFunctional Outcomes
Velligan et al. Schizophr Res 1997;25:21-31.Velligan et al. Schizophr Res 1997;25:21-31.
2222
HOSPITALIZATIONS FOR SCZHOSPITALIZATIONS FOR SCZ
ALGOALGO
PatientsPatients 165165
% Admits% Admits 3.0% 3.0%
# Admitted# Admitted 5 5
Days/Pt.Days/Pt. 1.481.48
# of Admits# of Admits 6 6
TAUTAU
PatientsPatients 300300
% Admits% Admits 8.7% 8.7%
# Admitted# Admitted 26 26
Days/Pt.Days/Pt. 3.843.84
# of Admits# of Admits 36 36
2323
The Texas Medication The Texas Medication Algorithm Project (TMAP): Algorithm Project (TMAP):
Outcomes for Persons Outcomes for Persons with Bipolar Disorder with Bipolar Disorder
(BPD)(BPD)
2424
BPD Adjusted Mean BPD Adjusted Mean Manic/Hypomanic Symptoms (CARS-Manic/Hypomanic Symptoms (CARS-
M): All SubjectsM): All Subjects
11.0
0
2
4
6
8
10
12
14
Baseline 1 2 3 4
CAR
S-M
TAUnonALGO (n=124)ALGO+ED (n=141)
Quarter
2525
The Texas Medication The Texas Medication Algorithm Project (TMAP): Algorithm Project (TMAP): Outcomes for Persons with Outcomes for Persons with Major Depressive Disorder Major Depressive Disorder
(MDD)(MDD)
2626
MDD Adjusted Mean SymptomsMDD Adjusted Mean Symptoms(IDS-C(IDS-C3030): All Subjects): All Subjects
2727
http://www.mhmr.state.tx.us/centraloffice/medicaldirector
Official TMAP/TIMA/CMAP
Internet Sites
Official TMAP/TIMA/CMAP
Internet Sites
2828
Goals for NS TMAP Goals for NS TMAP ImplementationImplementation
Develop a clear implementation planDevelop a clear implementation planBegin changes with incorporating medical Begin changes with incorporating medical
records used with TMAP by summerrecords used with TMAP by summerBegin with computerized versionBegin with computerized version
2929
Activities to Achieve GoalsActivities to Achieve Goals
Initial workgroup [VO, Dr. Shon, Dr. Initial workgroup [VO, Dr. Shon, Dr. Altshuler, DANSA ED + PAC] review Altshuler, DANSA ED + PAC] review TDMHMR implementation guides for TDMHMR implementation guides for appropriateness/adaptationappropriateness/adaptation
VO meet with Dr. Altshuler to plan VO meet with Dr. Altshuler to plan electronic requirementselectronic requirements
VO pilot with 1 or 2 providers to refine the VO pilot with 1 or 2 providers to refine the process before full implementationprocess before full implementation
3030
Barriers & How To OvercomeBarriers & How To Overcome
Startup costStartup cost Ongoing cost of medsOngoing cost of meds Mental mindsetMental mindset Training large number Training large number
of private providers [1 of private providers [1 day of training initially]day of training initially]
Develop a uniform Develop a uniform plan with a large plan with a large number of providers number of providers
Possible software grantPossible software grant Long-term reduced medsLong-term reduced meds Careful planningCareful planning Possibly minimize time Possibly minimize time
required by using required by using teleconferencingteleconferencing
Pilot first & streamlinePilot first & streamline
3131
Assignment of Specific TasksAssignment of Specific Tasks
Share implementation guides with Share implementation guides with initial workgroup for review & possible initial workgroup for review & possible modificationmodification
Meet to plan electronic requirementsMeet to plan electronic requirements
DavidDavid
[to Carole, [to Carole, DANSA DANSA PAC, Dr. PAC, Dr. Altshuler]Altshuler]
David, David, Carol, Dr. Carol, Dr. AltshulerAltshuler
3232
TimelineTimeline
Spring Spring 20032003
SummerSummer20032003
Fall Fall 20032003
Plan for implementation definedPlan for implementation defined
Pilot project fully implemented and Pilot project fully implemented and evaluatedevaluated
Plan for complete NS Plan for complete NS implementation definedimplementation defined
3333
Next Step to SuccessNext Step to Success
3434
Demonstration of Software Demonstration of Software ResourceResource
Dr. AltshulerDr. Altshuler