Improving the Quality of Health Care for Mental and Substance-Use Conditions (2006) / Chapter Skim
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, put forth a strategy for improving health care overall -- a strategy that has attained considerable traction in the United States and other countries. However, health care for mental and substanceuse conditions has a number of distinctive characteristics, such as the greater use of coercion into treatment, separate care delivery systems, a less developed quality measurement infrastructure, and a differently structured marketplace.
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In so doing, it details the actions required to achieve those ends -- actions required of clinicians; health care organizations; health plans; purchasers; state, local, and federal governments; and all parties involved in health care for mental and substance-use conditions. MILLIONS OF AMERICANS USE HEALTH CARE FOR MENTAL OR SUBSTANCE-USE CONDITIONS Each year, more than 33 million Americans use health care services for their mental problems and illnesses1 or conditions resulting from their use 1Whenever possible, this report uses the words "problems" and illnesses," as opposed to "disorders," for reasons explained in the full report.
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received mental health treatment in an inpatient or outpatient setting in 20032 (SAMHSA, 2004a) , and more than 6 percent of American children and adolescents aged 517 had contact with a mental health professional in a 12-month period according to the 19981999 National Health Interview survey (Simpson et al., 2004)
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Many people with these conditions require only a shortterm intervention to help them cope successfully with a less severe M/SU problem, such as anxiety or distress caused by loss of a loved one, loss of a job, or some other life-changing event; to help them change their unhealthy behaviors, such as heavy drinking or drug experimentation; or to prevent their condition from worsening. People with mental illnesses -- such as severe anxiety, depression, posttraumatic stress disorder, or a physiologic dependence on alcohol or some other drug -- require treatments of longer duration.
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to the application of specific models for treating depression in primary care (Pirraglia et al., 2004) and providing supported housing for homeless persons with mental illness (Rosenheck et al., 2003)
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citizens, people with alcohol dependence were found to receive care consistent with scientific knowledge only about 10.5 percent of the time (McGlynn et al., 2003)
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. Because of limitations of insurance for mental health care, some families resort to placing their severely mentally ill children in the child welfare system, even though the children are not neglected or abused, to secure mental health services otherwise unavailable (GAO, 2003)
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As a result, the Annie E Casey Foundation, the CIGNA Foundation, the National Institute on Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse, The Robert Wood Johnson Foundation, the Substance Abuse and Mental Health Services Administration (SAMHSA)
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Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clini cian to clinician or from place to place.
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The com mittee will examine both environmental factors such as payment, benefits coverage and regulatory issues, as well as health care organization and delivery issues. Based on a review of the evidence, the committee will develop an "agenda for change." To respond to this charge, IOM convened the Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders.
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To implement this overarching recommendation and achieve success in quality improvement, the committee proposes that the agenda for change embodied in recommendations 3.1 through 9.2 below be undertaken by clinicians; organizations; health plans; purchasers; state, local, and federal governments; and all other parties involved in M/SU health care. Foremost, consumers of health care for M/SU conditions face a number of obstacles to patient-centered care that generally are not encountered by consumers of general health care.
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· Health plans and direct payers of M/SU treatment services should: For persons with chronic mental illnesses or substance-use de pendence, pay for peer support and illness self-management programs that meet evidence-based standards. Provide consumers with comparative information on the quality of care provided by practitioners and organizations, and use this information themselves when making their purchasing decisions.
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should strengthen, coordinate, and consolidate the synthesis and dissemina tion of evidence on effective M/SU treatments and services by the Substance Abuse and Mental Health Services Administration; the Na tional Institute of Mental Health; the National Institute on Drug Abuse; the National Institute on Alcohol Abuse and Alcoholism; the National Institute of Child Health and Human Development; the Agency for Healthcare Research and Quality; the Department of Justice; the De partment of Veterans Affairs; the Department of Defense; the Depart ment of Education; the Centers for Disease Control and Prevention; the Centers for Medicare and Medicaid Services; the Administration for Children, Youth, and Families; states; professional associations; and other private-sector entities. To implement this recommendation, 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)
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Dissemina tion 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, the Office of Minority Health, and professional associations and health care organizations. Recommendation 4-2.
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To increase quality improvement capacity, DHHS, in collaboration with other government agencies, states, phil anthropic 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. Recommendation 4-5.
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To facilitate the delivery of coordinated care by primary care, mental health, and substance-use treatment providers, government agencies, purchasers, health plans, and accreditation orga nizations should implement policies and incentives to continually in crease collaboration among these providers to achieve evidence-based screening and care of their patients with general, mental, and/or substance-use health conditions. The following specific measures should be undertaken to carry out this recommendation: · Primary care and specialty M/SU health care providers should transition along a continuum of evidence-based coordination models from (1)
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all health care organizations with which they contract to ensure appropriate sharing of clinical information essential for coordina tion of care with other providers treating their patients. · Organizations that accredit mental, substance-use, or primary health care organizations should use accrediting practices that assess, for all providers, the use of evidence-based approaches to coordinating mental, substance-use, and primary health care.
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To realize the benefits of the emerging National Health Information Infrastructure (NHII) for consumers of M/SU health care services, the secretaries of DHHS and the Department of Veterans Affairs should charge the Office of the National Coordinator of Health Information Technology and the Substance Abuse and Men tal Health Services Administration to jointly develop and implement a plan for ensuring that the various components of the emerging NHII- including data and privacy standards, electronic health records, and community and regional health networks -- address M/SU health care as fully as general health care.
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National associations of purchasers -- such as the National Association of State Mental Health Program Directors, the National Association of State Alcohol and Drug Abuse Directors, the National Association of State Medicaid Directors, the National Association of County Behavioral Health Directors, the American Managed Behavioral Healthcare Association, and the national Blue Cross and Blue Shield Association -- should decrease the burden of vari able reporting and billing requirements by standardizing requirements at the national, state, and local levels. Recommendation 6-4.
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Recommendation 7-1. To ensure sustained attention to the develop ment of a stronger M/SU health care workforce, Congress should au thorize 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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Licensing boards, accrediting bodies, and pur chasers should incorporate the competencies and national standards established by the Council on the Mental and Substance-Use Health Care Workforce in discharging their regulatory and contracting re sponsibilities. Recommendation 7-3.
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In addition, there are many gaps in knowledge about effective treatment, especially for children and adolescents, and there is a paucity of information about the most effective ways to ensure the consistent application of research findings in routine clinical practice. To fill these knowledge gaps, the committee recommends the formulation of a coordinated research agenda for quality improvement in M/SU health care and the use of more-diverse research approaches.
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Recommendation 9-2. Federal and state agencies and private founda tions should create health services research strategies and innovative approaches that address treatment effectiveness and quality improve ment in usual settings of care delivery.
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2003. Child Welfare and Juvenile Justice: Federal Agen cies Could Play a Stronger Role in Helping States Reduce the Number of Children Placed Solely to Obtain Mental Health Services.
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2004. Testimony before the Institute of Medicine Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders.
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Hart Research Associates Inc.
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2003. Use of substance abuse treatment services by persons with mental health and substance use problems.
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