IOM Daniels England Slides 020306

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

Improving the Quality of Health Care for Mental and Substance-Use Conditions A Report in the Quality Chasm Series

The Crossing the Quality Chasm Series: 

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) www.nap.edu

Crossing the Quality Chasm: 

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)

Six Aims of Quality Health Care : 

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

Six Aims (cont.): 

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)

Ten Rules for Achieving the Aims: 

Ten Rules for Achieving the Aims Old Rules Care is based on visits. Professional autonomy drives variability. Professionals control care. Information is a record. Decisions are based upon training and experience New Rules 1. Care is based upon 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.

Ten Rules for Achieving the Aims : 

Ten Rules for Achieving the Aims 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. New Rule Safety is a system responsibility. Transparency is necessary. Needs are anticipated. Waste continuously decreased. Cooperation among clinicians is a priority.

Achieving Aims and Rules Requires : 

Achieving Aims and Rules Requires 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.

Study Sponsors : 

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

Charge to the IOM: 

Charge to the IOM Explore the implications of the Quality Chasm report for the field of mental health and addictive disorders; Identify barriers and facilitators to achieving significant improvements along all six dimensions examining 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, develop an “agenda for change.”

Committee expertise: 

Committee expertise M/SU, and general healthcare Public and private sector M/SU healthcare delivery Primary care Consumer issues Care coordination Ethics Economics Medicaid Racial and ethnic disparities in care Child M/SU care Geriatrics Informatics Systems engineering

COMMITTEE ON CROSSING THE QUALITYCHASM: ADAPTION TO MENTAL HEALTH AND ADDICTIVE DISORDERS : 

COMMITTEE ON CROSSING THE QUALITYCHASM: ADAPTION TO MENTAL HEALTH AND ADDICTIVE DISORDERS MARY JANE ENGLAND (Chair) - Regis College, Weston, MA. PAUL APPELBAUM - University of Massachusetts Medical School SETH BONDER - Consultant in Systems Engineering, Ann Arbor ALLEN DANIELS - Alliance Behavioral Care, Cincinnati BENJAMIN DRUSS - Emory University, Atlanta SAUL FELDMAN - United Behavioral Health, San Francisco RICHARD FRANK - Harvard Medical School THOMAS GARTHWAITE - Los Angeles County Dept of Health Services GARY GOTTLIEB - Brigham and Women’s Hospital & Harvard Medical School KIMBERLY HOAGWOOD - Columbia University & NY Office of Mental Health JANE KNITZER - National Center for Children in Poverty, New York.

COMMITTEE ON CROSSING THE QUALITYCHASM: ADAPTION TO MENTAL HEALTH AND ADDICTIVE DISORDERS : 

COMMITTEE ON CROSSING THE QUALITYCHASM: ADAPTION TO MENTAL HEALTH AND ADDICTIVE DISORDERS THOMAS MCLELLAN - Treatment Research Institute, Philadelphia. JEANNE MIRANDA - UCLA. LISA MOJER-TORRES - Attorney in civil rights and health law, Lawrenceville, NJ. HAROLD PINCUS - University of Pittsburgh School of Medicine, and RAND - U. Pittsburgh Health Institute ESTELLE RICHMAN - Pennsylvania Department of Public Welfare JEFFREY SAMET - Boston University Schools of Medicine and Public Health and Boston Medical Center TOM TRABIN - Consultant in behavioral healthcare and informatics, El Cerrito, CA. MARK TRAIL - Georgia Department of Community Health. ANN CATHERINE VEIERSTAHLER - Nurse, advocate, person with bipolar illness. Milwaukee, WI CYNTHIA WAINSCOTT Chair, National Mental Health Association, Cartersville, Georgia. CONSTANCE WEISNER - University of California, SF, and Northern California Kaiser Permanente.

Two Phenomena Central to the Committee’s Work and Findings: 

Two Phenomena Central to the Committee’s Work and Findings Co-occurrence of mental, substance-use, and general health conditions The differences in M/SU health services delivery compared to general health care

Mental and substance-use conditions: 

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/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

Consequences of the status quo: 

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” > 9,000 children placed in juvenile justice system solely to receive MH care

Mental, substance-use, & general health : 

Mental, substance-use, & general health CONCLUSION Improving care delivery and outcomes for any one depends upon improving care and outcomes for the others. 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.

M/SU Health Care Compared to General Health Care : 

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

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

Improving the Quality of Health Care for Mental and Substance-Use Conditions Contents The nature of the quality problem in M/SU health care Chasm framework for QI Supporting patient decision making and preferences Strengthening the evidence base and QI infrastructure Coordinating care Ensuring the NHII benefits persons with M/SU needs Increasing workforce capacity Using marketplace incentives for QI A comprehensive agenda for change Constraints on information sharing by federal & state laws, organization practices

Six Problems in the Quality of M/SU Health Care --- and their solutions : 

Six Problems in the Quality of M/SU Health Care --- and their solutions

A Users Guide to the Quality ChasmBerwick (2002): 

A Users Guide to the Quality Chasm Berwick (2002) “…in its current form and environment, American healthcare is incapable of providing the public with the quality of health care it deserves.” 4-Level Systems Framework A: experience of patients and communities B: microsystems of care C: health care organizations D: policy, payment, regulation and accreditation

Slide22: 

Experience of Patients and Communities Microsystems of Care where care occurs Health Care Organizations where microsystems are housed External Environment of Care policy / financing / regulation True North Roadmap for Implementing the IOM’s Quality Chasm Report

Problem 1. Obstacles to Patient-Centered Care : 

Problem 1. Obstacles to Patient-Centered Care Stereotypes of impaired decision-making and dangerousness, and lack of understanding of drug dependence Residual stigma and discrimination by health care providers in public policy Wrongful application of coercion

Rules for Patient-Centered Care: 

Rules for Patient-Centered Care The patient is the source of control Customization based on patient needs and values Anticipation of needs Shared knowledge and the free-flow of information The need for transparency

Stereotypes, stigma and discrimination:: 

Stereotypes, stigma and discrimination: Lessen patient ability to manage their illness and achieve recovery; Encourage non-therapeutic clinician attitudes and behaviors that hamper patients’ illness self-management efforts; and Promote discriminatory public policies that create barriers to recovery.

Lessened patient ability to manage their illness and achieve recovery: 

Lessened patient ability to manage their illness and achieve recovery Stigma pathway to decreased outcomes: Stigma → ↓ self-esteem → ↓ self efficacy ↓ ↓ health outcomes/recovery ← ↓ ability to manage chronic illness

Non-therapeutic clinician attitudes and behaviors : 

Non-therapeutic clinician attitudes and behaviors “We believe that the majority of physicians and other health care providers must fundamentally change their approach toward their patients, an approach revealed through the use of that “special voice.” Sadly, far too many professionals have a manner of speaking to us as if we are slightly stupid children. It’s that voice that reminds us that we aren’t really partners in care with our health care providers. . . . . It’s that voice that reminds us that health care providers still think of themselves as taking care of us, instead of working with us. It’s the voice of learned helplessness.” Bergeson, 2004

Discriminatory public policies create barriers to recovery: 

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 Penalties in addition to criminal sanctions for non-alcohol substance convictions: Decreased access to student loans Potential lifetime ban on food stamps and welfare

Remedies to achieve patient-centered care : 

Remedies to achieve patient-centered care Combat stigma & support decision making at locus of care; Organizational leadership and policies In-service education and orientation of clinicians Tolerance for “bad” decisions Involve consumers in design, administration and delivery of care; Provide decision making support to consumers; including peer support and advance directives

Remedies to achieve patient-centered care: 

Remedies to achieve patient-centered care Support illness self-management programs and practices; Make transparent policies for determining decision-making capacity and dangerousness; Preserve patient decision-making in instances of coercion.

Problem 2: Weak measurement & improvement infrastructure: 

Problem 2: Weak measurement & improvement infrastructure 1998 - mental health care identified as an aspect of health care not well addressed by existing quality measures and measure sets (The President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry). 2003 - the first National Healthcare Quality Report continues to identify mental illness as a clinical area lacking “broadly accepted” and “widely used” measures of quality. Of 107 measures of the effectiveness of health care, only 7 addressed mental health: (3 on treatment of depression in adults, 1 suicide, and 3 management of delirium and confusion in nursing homes and home health). None address substance-use. The only measure pertaining to children was that for suicide (AHRQ, 2003). 2004 - No additional measures of the quality of mental health care were included in the second annual National Healthcare Quality Report, and measures of substance-use health care remain absent (AHRQ).

Prob. 2: Weak measurement & improvement infrastructure: 

Prob. 2: Weak measurement & improvement infrastructure Clinical assessment and treatment practices not yet standardized and classified for use in the administrative datasets; Outcome measurement not widely applied in spite of the reliable and valid instruments; Dissemination of advances often fails to use effective strategies and available resources; e.g., CDC; Performance measurement for M/SU health care has not received sufficient attention in the private sector, and public sector efforts have not yet achieved consensus. QI methods not yet permeating day-to-day operations of providers of M/SU services.

Five–part strategy to build the QM/I Infrastructure: : 

Five–part strategy to build the QM/I Infrastructure: Filling gaps in the evidence base via: Alternate study designs Administrative data sets Outcome measures Coordination of initiatives analyzing the evidence Evidence-based approaches to disseminating evidence; Improving diagnosis and assessment; Building the infrastructure for measuring and reporting quality; and Supporting quality improvement practices at the locus of health care.

Problem 3: Poor linkages across separate care delivery: 

Problem 3: Poor linkages across separate care delivery greater separation of M/SU specialty care from general health care; separation of mental and substance-use health care from each other; society’s reliance on the education, child welfare, and other non-health care sectors to secure M/SU services for many children and adults; and location of services needed by individuals with more severe M/SU illnesses in public sector programs apart from private sector health care.

Mechanisms for Coordinating Care: 

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 coordination–linkage mechanisms High level policy coordination mechanisms that achieve and model collaboration at the Federal and state levels.

Evidence-based coordination–linkage mechanisms: 

Evidence-based coordination–linkage mechanisms Clinical integration of services Co-location of services Shared patient records Case (care) management Formal agreements with external providers

Problem 4: Lack of involvement in the National Health Information Infrastructure (NHII): 

Problem 4: Lack of involvement in the National Health Information Infrastructure (NHII) Electronic Health Records with decision support Platform for the exchange of info across clinical settings Data standards

M/SU care falling behind in IT: 

M/SU care falling behind in IT In AHRQ’s 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.

Actions needed: 

Actions needed 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 NHII address M/SU health care as fully as general health care Related activities by private sector and purchasers

Problem 5. Insufficient Workforce Capacity for QI: 

Problem 5. Insufficient Workforce Capacity for QI Much 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 doesn’t assure competency More solo practice impedes knowledge and technology uptake Limited preparations for use of the Internet and other communication technologies for service delivery

Remedy : 

Remedy Sustained national attention as has been provided for the physician and nursing workforce. Creation of an ongoing, federally funded public–private Council on the Mental and Substance–use Health Care Workforce Council to collaborate with institutions of higher education, licensing bodies, accrediting bodies, purchasers, and other private sector initiatives such as AMERSA and the Annapolis Coalition

Problem 6: Differently Structured Marketplace : 

Problem 6: 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., use of “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.

Strategies : 

Strategies Purchasers that offer enrollees a choice of health plans should use one or more tools for reducing adverse selection of individuals with M/SU conditions: risk adjustment, payer “carve-outs,” risk-sharing or mixed-payment contracts, and benefit standardization across the health plans Congress and state legislatures should enact coverage parity. Reorient State procurement to give greatest weight to quality. Use M/SU health care quality measures in procurement and accountability processes. State and local governments should reduce the emphasis on the grant-based systems of financing and increase the use of funding mechanisms that link some funds to measures of quality.

Improving M/SU health care requires action by:: 

Improving M/SU health care requires action by: Clinicians Health care organizations Health plans Purchasers State policy officials Federal policy officials Accrediting bodies Institutions of higher education Funders of research

IOM Workshop Questions: 

IOM Workshop Questions What are the implications of the IOM report for the protagonist problem? What do you think they could do? What changes can you do when you return to your home institution that reflects the quality chasm report?