Improving the Quality of Health Care for Mental and SubstanceUse Conditions

1
Improving the Quality of Health Care for Mental
and Substance-Use Conditions

• A Report in the Quality Chasm Series
• Ann Page RN, MPH
• Study Director
• Institute of Medicine

2
The Crossing the Quality Chasm Series

• To Err is Human (1999)
• Crossing the Quality Chasm - A New Health System
  for the 21st Century (2001)
• Leadership by Example (2002)
• Fostering Rapid Advances in Health Care (2002)
• Priority Areas for National Action (2003)
• Health Professions Education (2003)
• Keeping Patients Safe Transforming the Work
  Environment of Nurses (2004)
• Patient Safety Achieving a New Standard for
  Care (2004)
• Quality through Collaboration the Future of
  Rural Health (2005)
• Improving the Quality of Health Care for Mental
  and Substance-use Conditions (2005)

3
Crossing the Quality Chasm

• Quality problems occur typically not because of
  failure of goodwill, knowledge, effort or
  resources devoted to health care, but because of
  fundamental shortcomings in the ways care is
  organized
• Trying harder will not work
• changing systems of care
• will!

a new HEALTH system for the 21st century (IOM,
2001)
4
Six Aims of Quality Health Care

• Safe avoids injuries from care
• Effective provides care based on scientific
  knowledge and avoids services not likely to help
• Patient-centered respects and responds to
  patient preferences, needs, and values

5
Six Aims (cont.)

• Timely reduces waits and sometimes harmful
  delays for those receiving and giving care
• Efficient avoids waste, including waste of
  equipment, supplies, ideas and energy
• Equitable care does not vary in quality due to
  personal characteristics (gender, ethnicity,
  geographic location, or socio-economic status)

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Ten Rules for Achieving the Aims

• Old Rules
• Care is based on visits.
• Professional autonomy drives variability.
• Professionals control care.
• 4. Information is a record.
• 5. Decisions are based upon training and
  experience.

• New Rules
• Care is based on continuous healing
  relationships.
• 2. Care is customized to patient needs and
  values.
• 3. The patient is the source of control.
• 4. Knowledge is shared and information flows
  freely.
• 5. Decision making is evidence-based.

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Ten Rules for Achieving the Aims

• New Rule
• Safety is a system responsibility.
• Transparency is necessary.
• Needs are anticipated.
• Waste is continuously decreased.
• Cooperation among clinicians is a priority.

• Old Rules
• Do no harm is an individual clinician
  responsibility.
• Secrecy is necessary.
• The system reacts to needs.
• Cost reduction is sought.
• Preference for professional roles over the system.

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Six Critical Pathways for Achieving Aims and
Rules

• News ways of delivering care
• Effective use of information technology (IT)
• Managing the clinical knowledge, skills, and
  deployment of the workforce
• Effective teams and coordination of care across
  patient conditions, services and settings
• Improvements in how quality is measured
• Payment methods conducive to good quality

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Study Sponsors

• Annie E. Casey Foundation
• CIGNA Foundation
• National Institute on Alcohol Abuse and
  Alcoholism
• National Institute on Drug Abuse
• Substance Abuse and Mental Health Services
  Administration
• Robert Wood Johnson Foundation
• Veterans Health Administration

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Charge to the IOM

• Explore the implications of the Quality Chasm
  report for mental health and substance-use
  conditions
• Examine barriers and facilitators to
  significantly improving quality ? including
  environmental factors such as payment, benefits
  coverage and regulatory issues, as well as health
  care organization and delivery issues.
• Based on the evidence, develop an agenda for
  change.

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Two Findings Critical to an Agenda for Change

• Co-occurrence of mental, substance-use, and
  general health conditions
• The differences in M/SU health services delivery
  compared to general health care

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Mental and substance-use conditions

• Pervasive
• More than 33 million Americans treated annually
• 20 of all working age adults (18-54)
• 21 of adolescents
• Millions more fail to receive care
• Frequently intertwined
• 15 - 40 co-occurrence of M and SU illnesses
• Often influence general health
• frequently accompany chronic illnesses e.g.,
  cancer, diabetes, and heart disease
• 20 of heart attack patients suffer from
  depression, tripling risk of death
• associated with leading causes of outpatient
  visits e.g., headache, fatigue and pain

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Mental, substance-use, general health

• CONCLUSION
• Improving care delivery and outcomes for any one
  of the above depends upon improving care and
  outcomes for the other two.
• OVERARCHING RECOMMENDATION
• Health care for general, mental, and
  substance-use problems and illnesses must be
  delivered with an understanding of the inherent
  interactions between the mind/brain and the rest
  of the body.

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M/SU Health Care Compared to General Health Care

• Increased stigma, discrimination, coercion
• Patient decision-making ability not as
  anticipated / supported
• Diagnosis more subjective
• A less developed quality measurement
  improvement infrastructure

• More separate care delivery arrangements
• Less involvement in the NHII and use of IT
• More diverse workforce and more solo practice
• Differently structured marketplace

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• Six Problems in the Quality of M/SU Health Care ?
  and Their Solutions

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Problem 1 Threats to Patient-Centered Care

• Residual stereotypes
• impaired decision-making
• dangerousness
• drug dependence as solely volitional
• Resulting stigma and discrimination
• by health care providers
• in public policy
• Wrongful application of coercion

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Evidence Contradicts Stereotypes

• Great diversity in decision-making capacity
  (DMC).
• DMC more affected by cognitive ability than
  psychotic symptoms DMC can be improved with
  interventions.
• Inappropriate to make conclusions about DMC based
  on diagnosis.
• Vast majority of individuals with mental
  illnesses and no concurrent substance use are at
  no greater risk of violent behavior than those
  without M/SU illnesses.
• Contribution of people with mental illnesses to
  violence is small.
• Drug dependence reflects neurological changes
  not simply volitional.
• Patients can have a voice even when care is
  coerced.

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Stereotypes, stigma and discrimination impair
quality by

• Lessening patient ability to manage their illness
  and achieve recovery
• Encouraging non-therapeutic clinician attitudes
  and behaviors and
• Fostering discriminatory public policies that
  create barriers to recovery.

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Lessened patient ability to manage illness
achieve recovery

• Stigma pathway to decreased outcomes
• Stigma ? ? self-esteem ? ? self efficacy ?
• ? ability to manage ? ? health outcomes /
• chronic illness
  recovery

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Discriminatory public policies create barriers to
recovery

• Insurance discrimination
• Less benefit coverage especially for children
  and SU
• Higher co-pays
• Loss of child custody solely to secure coverage
• Punishment added to criminal sanctions for
  non-alcohol substance convictions
• Decreased access to student loans (revised
  per 2005 Budget bill)
• Potential lifetime ban on food stamps and welfare
  

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Problem 2 Weak quality measurement improvement
infrastructure

• Inefficient production of the evidence base
• Treatments not codified and captured in
  administrative datasets
• Outcome measurement not widely applied
• Evidence not mined from observational and other
  non-RCT study designs
• Dissemination of advances often fails to use
  effective strategies and available resources
  e.g., CDC
• Performance measurement for M/SU health care
  receives insufficient attention in the private
  sector public sector efforts have not yet
  achieved consensus.
• QI methods not permeating day-to-day operations
  of providers of M/SU services.

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Fivepart strategy to strengthen the QM/I
Infrastructure

• Fill gaps in the evidence base via
• Alternate study designs
• Standardizing and coding interventions for
  capture in administrative data sets
• Outcome measurement
• Coordinating initiatives analyzing the evidence
• Evidence-based approaches to disseminate
  evidence
• Improved diagnosis and assessment
• An infrastructure to measure report on quality
  
• Quality improvement practices at locus of care.

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Problem 3 Poor linkages across separations in
care

• Greater separation of M/SU specialty care from
  general health care
• Separation of mental and substance-use health
  care from each other
• Societys reliance on the education, child
  welfare, and other non-health care sectors to
  deliver M/SU care and
• Location of services needed by individuals with
  more severe illnesses in public sector programs
  apart from private sector.
• Unclear accountability for coordination

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Mechanisms for Coordinating Care

• Routine sharing of patient information between
  providers with patient knowledge and consent.
• Targeted screening of patients for comorbid
  mental, substance-use, and general medical
  problems.
• Evidence-based coordinationlinkage mechanisms
• High level policy coordination mechanisms that
  achieve and model collaboration at the federal
  and state levels.

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Evidence-based coordinationlinkage mechanisms

• Clinical integration of services
• Co-location of services
• Shared patient records
• Case management
• Formal agreements with external providers

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Problem 4 Lack of involvement in the National
Health Information Infrastructure

• Involvement needed in design of
• Electronic health records (EHRs)
• Platform for the exchange of info across clinical
  settings
• Data standards

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M/SU care falling behind in IT

• In AHRQs 2004 awards of 139 million in grants
• and contracts to promote the use of health
• information technology, health care for M/SU
• conditions was not strongly represented in either
  the
• applicants or awardees.
• Of the nearly 600 applications for funding, only
  a
• handful had any substantial behavioral health
• content, and of the 103 grants awarded, only one
• specifically targeted M/SU health care.

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Problem 5 Insufficient Workforce Capacity for QI

• Greater variation in M/SU workforce and its
  education / training
• Across-the-board deficiencies in education e.g.,
  re substance use no core knowledge across
  disciplines
• Variation in licensure /credentialing/continuing
  education doesnt assure competency
• More solo practice impedes knowledge and
  technology uptake
• Limited preparation for Internet and other
  communication technologies for service delivery

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Greater diversity licensed to diagnose and treat

• General health care
• Physicians
• Advanced practice nurses
• Physician assistants

• M/SU health care
• Psychiatrists
• Psychologists
• Counselors
• Guidance
• Addiction
• Pastoral
• Other
• Marriage and family therapists
• Social Workers
• Others

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Problem 6 of 6 A Differently Structured
Marketplace

• Dominance of government (state and local)
  purchasers,
• Frequent purchase of insurance for M/SU health
  care separately from other health care (i.e.,
  carve-out arrangements),
• Tendency of private insurance to avoid covering
  or to offer more-limited coverage to individuals
  with M/SU illnesses, and
• Government purchasers greater use of direct
  provision and purchase of care rather than
  insurance arrangements.

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Improving M/SU health care requires action by

• Clinicians
• Health care organizations
• Health plans
• Purchasers
• State policy officials

• Federal policy officials
• Congress
• Accrediting bodies
• Institutions of higher education
• Funders of research

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Recommendation 4-1. To better build and
disseminate the evidence base,

• DHHS should strengthen, coordinate, and
  consolidate the synthesis and dissemination of
  evidence on effective M/SU treatments and
  services by SAMHSA, NIMH, NIDA, NIAAA, AHRQ, DOJ,
  et al. public and private sector entities.

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To implement this, DHHS should charge or create
one or more entities to

• Describe and categorize available M/SU
  preventive, diagnostic, and therapeutic
  interventions (including screening, diagnostic,
  and symptom-monitoring tools) and develop
  individual procedure codes and definitions for
  these interventions and tools for their use in
  administrative datasets approved under the Health
  Insurance Portability and Accountability Act.
• Assemble the scientific evidence on the efficacy
  and effectiveness of these interventions,
  including their use in varied age and ethnic
  groups use a well-established approach to rate
  the strength of this evidence, and categorize the
  interventions accordingly and recommend or
  endorse guidelines for the use of the
  evidence-based interventions for specific M/SU
  problems and illnesses.
• Substantially expand efforts to attain widespread
  adoption of evidence-based practices through the
  use of evidence-based approaches to knowledge
  dissemination and uptake. Dissemination
  strategies should always include entities that
  are commonly viewed as knowledge experts by
  general health care providers and makers of
  public policy, including the Centers for Disease
  Control and Prevention, the Agency for Healthcare
  Research and Quality, the Centers for Medicare
  and Medicaid Services, . . . and professional
  associations and health care organizations.

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Recommendation 4-3. To measure quality better,

• DHHS, in partnership with the private sector,
  should charge and financially support an entity
  similar to the National Quality Forum to convene
  government regulators, accrediting organizations,
  consumer representatives, providers, and
  purchasers exercising leadership in quality-based
  purchasing for the purpose of reaching consensus
  on and implementing a common, continuously
  improving set of M/SU health care quality
  measures for providers, organizations, and
  systems of care.

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Participants in this consortium should commit to

• Requiring the reporting and submission of the
  quality measures to a performance measure
  repository or repositories.
• Requiring validation of the measures for accuracy
  and adherence to specifications.
• Ensuring the analysis and display of measurement
  results in formats understandable by multiple
  audiences, including consumers, those reporting
  the measures, purchasers, and quality oversight
  organizations.
• Establishing models for the use of the measures
  for benchmarking and quality improvement purposes
  at sites of care delivery.
• Performing continuing review of the measures
  effectiveness in improving care.

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Recommendation 4-4. To increase quality
improvement capacity

• DHHS, in collaboration with other government
  agencies, states, philanthropic organizations,
  and professional associations, should create or
  charge one or more entities as national or
  regional resources to test, disseminate knowledge
  about, and provide technical assistance and
  leadership on quality improvement practices for
  M/SU health care in public- and private-sector
  settings.

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Recommendation 5-2. To facilitate the delivery of
coordinated care by primary care, mental health,
and substance-use treatment providers,

• government agencies, . . . should implement
  policies and incentives to continually increase
  collaboration among these providers to achieve
  evidence-based screening and care of their
  patients with general, mental, and/or
  substance-use health conditions.

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The following specific measures should be
undertaken to implement this recommendation

• DHHS should fund demonstration programs to offer
  incentives for the transition of multiple primary
  care and M/SU practices along a continuum of
  coordination models.
• Purchasers should modify policies and practices
  that preclude paying for evidence-based
  screening, treatment, and coordination of M/SU
  care and require (with patients knowledge and
  consent) all health care organizations with which
  they contract to ensure appropriate sharing of
  clinical information essential for coordination
  of care with other providers treating their
  patients.
• Federal . . . governments should revise laws,
  regulations, and administrative practices that
  create inappropriate barriers to the
  communication of information between providers of
  health care for mental and substance-use
  conditions and between those providers and
  providers of general care.

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Recommendation 5-4. To provide leadership in
coordination. . . .

• DHHS should create a high-level, continuing
  entity reporting directly to the Secretary to
  improve collaboration and coordination across its
  mental, substance-use, and general health care
  agencies, including the Substance Abuse and
  Mental Health Services Administration the Agency
  for Healthcare Research and Quality the Centers
  for Disease Control and Prevention and the
  Administration for Children, Youth, and Families.
  
• DHHS should implement performance measures to
  monitor its progress toward achieving internal
  interagency collaboration and publicly report its
  performance on these measures annually.

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Recommendation 6-1. To realize the benefits of
the National Health Information Infrastructure
for M/SU health care

• The secretaries of DHHS and the Department of
  Veterans Affairs should charge the Office of the
  National Coordinator of Health Information
  Technology and SAMHSA to jointly develop and
  implement a plan for ensuring that the various
  components of the emerging NHIIincluding data
  and privacy standards, electronic health records,
  and community and regional health
  networksaddress M/SU health care as fully as
  general health care.

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As part of this strategy

• DHHS should create and support a mechanism to
  engage M/SU health care stakeholders in the
  public and private sectors in developing
  recommendations for the data elements, standards,
  and processes needed to address unique aspects of
  information management related to M/SU health
  care. These recommendations should be provided to
  the appropriate standards-setting entities and
  initiatives working with the Office of the
  National Coordinator of Health Information
  Technology.
• Federal grants and contracts for the development
  of components of the NHII should require and use
  as a criterion for making awards the involvement
  and inclusion of M/SU health care.
• The Substance Abuse and Mental Health Services
  Administration should increase its work with
  public and private stakeholders to support the
  building of information infrastructure components
  that address M/SU health care and coordinate
  these information initiatives with the NHII.
• Policies and information technology
  infrastructure should be used to create linkages
  (consistent with all privacy requirements) among
  patient records and other data sources pertaining
  to M/SU services received from health care
  providers and from education, social, criminal
  justice, and other agencies.

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Recommendation 6-4.

• (The) Federal . . .government . . . should
  encourage the widespread adoption of electronic
  health records, computer-based clinical
  decision-support systems, computerized provider
  order entry, and other forms of information
  technology for M/SU care by

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• Offering financial incentives to individual M/SU
  clinicians and organizations for investments in
  information technology needed to participate
  fully in the emerging NHII.
• Providing capital and other incentives for the
  development of virtual networks to give
  individual and small-group providers standard
  access to software, clinical and population data
  and health records, and billing and clinical
  decision-support systems.
• Providing financial support for continuing
  technical assistance, training, and information
  technology maintenance.
• Including in purchasing decisions an assessment
  of the use of information technology by
  clinicians and health care organizations for
  clinical decision support, electronic health
  records, and other quality improvement
  applications.

44
Recommendation 7-1. To ensure sustained attention
to the M/SU health care workforce

• Congress should authorize and appropriate funds
  to create and maintain a Council on the Mental
  and Substance-Use Health Care Workforce as a
  publicprivate partnership

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The Council should develop and implement a
comprehensive plan for strengthening the quality
and capacity of the workforce by

• Identifying the specific clinical competencies
  that all M/SU professionals must possess to be
  licensed or certified and the competencies that
  must be maintained over time.
• Developing national standards for the
  credentialing and licensure of M/SU providers to
  eliminate differences in the standards now used
  by the states. Such standards should be based on
  core competencies and should be included in
  curricula and education programs across all the
  M/SU disciplines.
• Proposing programs to be funded by government and
  the private sector to address and resolve such
  long-standing M/SU workforce issues as diversity,
  cultural relevance, faculty development, and
  continuing shortages of the well-trained
  clinicians and consumer providers needed to work
  with children and the elderly, and of programs
  for training competent clinician administrators.

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Cont.

• Providing a continuing assessment of M/SU
  workforce trends, issues, and financing policies.
• Measuring the extent to which the plans
  objectives have been met and reporting annually
  to the nation on the status of the M/SU
  workforce.
• Soliciting technical assistance from
  publicprivate partnerships to facilitate the
  work of the council and the efforts of
  educational and accreditation bodies to implement
  its recommendations.

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Recommendation 7-3. The federal government should
support the development of M/SU faculty leaders
. . .

• in health professions schools, such as schools of
  nursing and medicine, and in schools and programs
  that educate M/SU professionals, such as
  psychologists and social workers.

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Rec. 9-1. DHHS should provide leadership,
strategic development support, and additional
funding for RD on improving care quality.

• This initiative should coordinate the existing
  quality improvement research efforts of the NIMH,
  NIDA, NIAAA, DVA, SAMHSA, AHRQ, and CMS, and
  develop and fund cross-agency efforts in
  necessary new research.
• To that end, the initiative should address the
  full range of research needed to reduce gaps in
  knowledge at the clinical, services, systems, and
  policy levels and should establish links to and
  encourage expanded efforts by foundations,
  states, and other nonfederal organizations.

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Rec 9.2 Federal and (other) agencies . . . should
create . . . research strategies . . . that
address treatment effectiveness and quality
improvement in usual settings of care delivery.

• To that end, they should develop new research and
  demonstration funding models that
• encourage local innovation,
• Include research designs in addition to
  randomized controlled trials
• are committed to partnerships between researchers
  and stakeholders and
• that create a critical mass of interdisciplinary
  research partnerships involving usual settings of
  care.

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SUMMARY DHHS to charge or create entities to

• Coordinate the identification of evidencebased
  practices
• Develop procedure codes for administrative data
  sets
• Use evidencebased approaches to disseminate and
  promote uptake of evidence-based practices
• Assure use of general health care opinion leaders
  (e.g., CDC, AHRQ) in dissemination
• Fulfill essential quality measurement and
  reporting functions
• Provide leadership in quality improvement
  activities and
• Improve coordination among federal agencies.

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Summary cont. Federal Government also should

• Revise laws, rules, other polices that obstruct
  sharing of information across providers
• Fund demonstrations to transition to
  evidence-based care coordination
• Ensure that the emerging NHII addresses M/SU
  health care
• Authorize and fund an ongoing Council on the
  Mental and Substance-Use Health Care Workforce
  similar to the Council on Graduate Medical
  Education (Congress)
• Support M/SU faculty leaders in health profession
  schools
• Provide leadership, development support and
  funding for RD on QI in M/SU health care.

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Consequences of the status quo

• M/SU conditions the leading cause of disability
  /death for American women the second for
  American men
• Considerable workplace burden from absenteeism,
  presenteeism, disability days, and critical
  incidents
• gt 9,000 children placed in juvenile justice
  system solely to receive MH care