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Improving the Quality of Health Care for Mental and Substance-Use Conditions Improving the Quality of Health Care for Mental and Substance-Use Conditions Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders Board on Health Care Services INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, DC www.nap.edu
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Improving the Quality of Health Care for Mental and Substance-Use Conditions THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by multiple contracts and grants between the National Academy of Sciences and the Substance Abuse and Mental Health Services Administration (SAMHSA) of the Department of Health and Human Services (Contract No. 282-99-0045), the Robert Wood Johnson Foundation (Grant No. 048021), the Annie E. Casey Foundation (Grant No. 204.0236), the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism (Contract No. N01-OD-4-2139), the Veterans Health Administration (Contract No. DHHS 223-01-2460/TO21), and through a grant from the CIGNA Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the view of the organizations and agencies that provided support for this project. Library of Congress Cataloging-in-Publication Data Institute of Medicine (U.S.). Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders. Improving the quality of health care for mental and substance-use conditions / Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders, Board on Health Care Services. p. ; cm.—(Quality chasm series) Includes bibliographical references and index. ISBN 0-309-10044-5 (full book) 1. Substance abuse—Treatment. 2. Community mental health services. 3. Substance abuse—Patients—Services for. I. Title. II. Series. [DNLM: 1. Mental Disorders—therapy. 2. Substance-Related Disorders—therapy. 3. Patient-Centered Care. 4. Quality of Health Care. WM 400 I59i 2006] RC564.I47 2006 362.29—dc22 2005036202 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2006 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.
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Improving the Quality of Health Care for Mental and Substance-Use Conditions “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Advising the Nation. Improving Health.
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Improving the Quality of Health Care for Mental and Substance-Use Conditions THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org
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Improving the Quality of Health Care for Mental and Substance-Use Conditions COMMITTEE ON CROSSING THE QUALITY CHASM: ADAPTATION TO MENTAL HEALTH AND ADDICTIVE DISORDERS MARY JANE ENGLAND (Chair), President, Regis College, Weston, MA PAUL S. APPELBAUM, A.F. Zeleznik Distinguished Professor of Psychiatry; Chairman of the Department of Psychiatry; and Director of the Law and Psychiatry Program at the University of Massachusetts Medical School, Worcester, MA SETH BONDER, Consultant in Systems Engineering, Ann Arbor ALLEN DANIELS, Professor of Clinical Psychiatry and Executive Vice Chair, Department of Psychiatry, University of Cincinnati College of Medicine, and CEO of Alliance Behavioral Care BENJAMIN DRUSS, Rosalynn Carter Chair in Mental Health, Emory University, Atlanta SAUL FELDMAN, Chairman and Chief Executive Officer of United Behavioral Health, San Francisco RICHARD G. FRANK, Margaret T. Morris Professor of Health Economics, Harvard Medical School, Boston, MA THOMAS L. GARTHWAITE, Director and Chief Medical Officer, Los Angeles County Department of Health Services GARY GOTTLIEB, President of Brigham and Women’s Hospital, Boston, and Professor of Psychiatry, Harvard Medical School, Boston, MA KIMBERLY HOAGWOOD, Professor of Clinical Psychology in Psychiatry, Columbia University and Director of Research on Child and Adolescent Services for the Office of Mental Health in the State of New York, New York City JANE KNITZER, Director, National Center for Children in Poverty, New York City A. THOMAS MCLELLAN, Director, Treatment Research Institute, Philadelphia JEANNE MIRANDA, Professor, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles LISA MOJER-TORRES, Attorney in civil rights and health law, Lawrenceville, NJ HAROLD ALAN PINCUS, Professor and Vice Chair, Department of Psychiatry, University of Pittsburgh School of Medicine, and Senior Scientist and Director, RAND–University of Pittsburgh Health Institute, the RAND Corporation ESTELLE B. RICHMAN, Secretary, Pennsylvania Department of Public Welfare, Harrisburg
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Improving the Quality of Health Care for Mental and Substance-Use Conditions JEFFREY H. SAMET, Professor of Medicine and Social and Behavioral Sciences and Vice Chair for Public Health, Boston University Schools of Medicine and Public Health and Chief, General Internal Medicine at Boston Medical Center TOM TRABIN, Consultant in behavioral health care and informatics, El Cerrito, CA MARK D. TRAIL, Chief of the Medical Assistance Plans, Georgia Department of Community Health, Atlanta ANN CATHERINE VEIERSTAHLER, Nurse, advocate, and person with bipolar illness, Milwaukee, WI CYNTHIA WAINSCOTT, Chair, National Mental Health Association, Cartersville, GA CONSTANCE WEISNER, Professor, Department of Psychiatry, University of California, San Francisco, and Investigator, Division of Research, Northern California Kaiser Permanente Study Staff ANN E. K. PAGE, Study Director and Senior Program Officer, Board on Health Care Services REBECCA BENSON, Senior Project Assistant (11/03–11/04) RYAN PALUGOD, Senior Project Assistant (11/04–1/06) Board on Health Care Services JANET M. CORRIGAN, Director (11/03–5/05) CLYDE BEHNEY, Acting Director (6/05–12/05) JOHN RING, Director (12/05–) ANTHONY BURTON, Administrative Assistant TERESA REDD, Financial Associate
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Improving the Quality of Health Care for Mental and Substance-Use Conditions Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: ALLEN DIETRICH, Dartmouth Medical School, Hanover, New Hampshire MICHAEL FITZPATRICK, National Alliance for the Mentally Ill, Arlington, Virginia HOWARD GOLDMAN, University of Maryland at Baltimore School of Medicine MICHAEL HOGAN, Ohio Department of Mental Health, Columbus TEH-WEI HU, University of California, Berkeley School of Public Health EDWARD JONES, PacifiCare Behavioral Health, Van Nuys, California DAVID LEWIS, Brown University Center for Alcohol and Addiction Studies, Providence, Rhode Island
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Improving the Quality of Health Care for Mental and Substance-Use Conditions JOHN MONAHAN, University of Virginia School of Law, Charlottesville GAIL STUART, Medical University of South Carolina College of Nursing, Charleston MICHAEL TRUJILLO, University of New Mexico School of Medicine, Albuquerque WILLIAM WHITE, Port Charlotte, Florida Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by FLOYD BLOOM, The Scripps Research Institute and Neurome, Inc., La Jolla, California, and JUDITH R. LAVE, University of Pittsburgh, Pennsylvania. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
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Improving the Quality of Health Care for Mental and Substance-Use Conditions Foreword Improving the Quality of Health Care for Mental and Substance-Use Conditions represents the intersection of two key developments now taking place in health care. One is the increasing attention to improving the quality of health care in ways that take account of patients’ preferences and values along with scientific findings about effective care. The second important development comes from scientific research that enables us to better understand and treat mental and substance-use conditions. New technologies such as neuroimaging and genomics, for example, enable us to observe the brain in action and examine the interplay of genetic and environmental factors in mental and substance-use illnesses. These advances are potentially valuable to the more than 10 percent of the U.S. population receiving health care for mental and substance-use conditions; the many millions more who need but do not receive such care; and their families and friends, employers, teachers, and policy makers who encounter the effects of these illnesses in their personal lives, in the workplace, in schools, and in society at large. This report puts forth an agenda for capitalizing on these two developments. Using the quality improvement framework contained in the predecessor Institute of Medicine report Crossing the Quality Chasm: A New Health System for the 21st Century, it calls for action from clinicians, health care organizations, purchasers, health plans, quality oversight organizations, researchers, public policy makers, and others to ensure that individuals with mental and substance-use health conditions receive the care that they need to recover. Importantly, the report’s recommendations are not directed solely to clinicians and organizations that specialize in the delivery of health care for mental and substance-use conditions. As the report notes, the link be-
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Improving the Quality of Health Care for Mental and Substance-Use Conditions tween mental and substance-use problems and illnesses and general health and health care is very strong. This is especially true with respect to chronic illnesses, which now are the leading cause of illness, disability, and death in the United States. As the committee that conducted this study concluded, improving our nation’s general health and the quality problems of our general health care system depends upon equally attending to the quality problems in health care for mental and substance-use conditions. The committee calls on primary care providers, other specialty health care providers, and all components of our general health care system to attend to the mental and substance-use health care needs of those they serve. Dealing equally with health care for mental, substance-use, and general health conditions requires a fundamental change in how we as a society and health care system think about and respond to these problems and illnesses. Mental and substance-use problems and illnesses should not be viewed as separate from and unrelated to overall health and general health care. Building on this integrated concept, this report offers valuable guidance on how all can help to achieve higher-quality health care for people with mental or substance-use problems and illnesses. To this end, the Institute of Medicine will itself seek to incorporate attention to issues in health care for mental and substance-use problems and illnesses into its program of general health studies. Harvey V. Fineberg, MD, PhD President, Institute of Medicine
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Improving the Quality of Health Care for Mental and Substance-Use Conditions Preface The charge to the Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders was broad, encompassing health care for both mental and substance-use conditions, the public and private sectors, and the comprehensive range of issues addressed in the 2001 Institute of Medicine report Crossing the Quality Chasm: A New Health System for the 21st Century. The committee was pleased to be asked to address this breadth of issues. Despite the frequent co-occurrence of mental and substance-use conditions, studies and reports that address both are unusual, as are those that cut across both the public and private sectors. We are grateful to our sponsors for having the vision to recognize the need for this study. Although the committee at times found the different histories, vocabularies, and other characteristics of these groups of illnesses and delivery systems challenging, we also acknowledged the unique strengths that each brought to the study, respected each others’ positions, and reached consensus on issues that have traditionally been characterized by great disharmony. Having expertise in both mental and substance-use health care and the perspectives of the public and private sectors at the table was essential to the committee’s efforts to craft a strategic agenda for improving the quality of health care for mental and substance-use conditions for all. The committee hopes that joint mental and substance-use studies and public–private partnership initiatives will become routine. Although the focus of this study was on solving the problems of health care for mental and substance-use conditions—some of which are more complex than those associated with general health care—the committee also recognized its strengths. Health care for mental and substance-use condi-
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Improving the Quality of Health Care for Mental and Substance-Use Conditions ing the American Academy of Family Physicians; Gerry Schmidt, Clinical Affairs Consultant to NAADAC (the Association for Addiction Professionals); Ruth Hughes from the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Center for Mental Health Services Human Resources Work Group Alliance; Carolyn Russell, Director of the Florida Self-Directed Care Program; Jonathan Stanley, Assistant Director of the Treatment Advocacy Center; Linda Rosenberg, President and CEO of the National Council for Community Behavioral Healthcare; Frank Ghinassi, representing the National Association of Psychiatric Health Systems; Robert Sheehan, President of the National Association for Children’s Behavioral Health; Michael B. Harle, representing Therapeutic Communities of America; Ronald J. Hunsicker, President and CEO of the National Association of Addiction Treatment Providers, Inc.; Marvin D. Seppala, representing the Partnership for Recovery; Wesley Sowers, President of the American Association of Community Psychiatrists; Robert Booth, Executive Director of the American Board of Examiners in Clinical Social Work; Mara Shrek, also representing the American Board of Examiners in Clinical Social Work; Elizabeth J. Clark, Executive Director, and Mickey J. W. Smith, Senior Policy Associate, both of the National Association of Social Workers; William F. Northey, Professional Development and Research Specialist at the American Association for Marriage and Family Therapy; Sandra Talley, President of the American Psychiatric Nurses Association; Thomas W. Nolan, Senior Fellow at the Institute for Healthcare Improvement; David H. Gustafson, Principal Investigator, Network for the Improvement of Addiction Treatment, University of Wisconsin-Madison; Vijay Ganju, Director of the Center for Mental Health Quality and Accountability at the National Association of State Mental Health Program Directors Research Institute, Inc.; Robert Johnson, representing the National Association of State Alcohol and Drug Abuse Directors; Howard B. Shapiro, Executive Director of the State Associations of Addiction Services; Pamela Greenberg, Executive Director of the American Managed Behavioral Healthcare Association; Melissa M. Staats, Executive Director of the National Association of County Behavioral Health Directors; Mark Willenbring, Director of the Division of Treatment and Recovery Research at the National Institute on Alcohol Abuse and Alcoholism; John A. Paton, representing the Software and Technology Vendor’s Association; Lisa Teems, representing the Employee Assistance Programs Alliance; Joan M. Pearson, Principal, Towers Perrin; Dale A. Masi, President and CEO of Masi Research Consultants, Inc.; Neal Adams, Medical Director for Adult Services, California Department of Mental Health; Pamela S. Hyde, Secretary of the New Mexico Human Services Department; Joy M. Grossman at the Center for Studying Health System Change; Patricia A. Taylor, Executive Director of Faces & Voices of Recovery; Kevin D. Hennessey, Science to Service Coordinator at SAMHSA;
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Improving the Quality of Health Care for Mental and Substance-Use Conditions Sarah A. Wattenberg, Public Health Advisor at SAMHSA; and staff of the Greater Los Angeles Veterans Healthcare Center EQUIP project and their sponsors at the Veterans Administration Health Services Research & Development Service and Quality Enhancement Research Initiative. Several national experts on topics relevant to the committee’s work also provided invaluable assistance by preparing commissioned papers on the issues under study. We thank Scott Y. H. Kim, MD, PhD, from the University of Michigan Medical School, for his paper on “Impact of Mental Illness and Substance-Related Disorders on Decision-Making Capacity and Its Implications for Patient-Centered Mental Health Care Delivery”; Elyn R. Saks, JD, from the University of Southern California Law School, and Dilip V. Jeste, MD, from the University of California-San Diego, for their papers on “Capacity to Consent to or Refuse Treatment and/or Research: Theoretical Considerations” and “Decisional Capacity in Mental Illness and Substance Use Disorders: Empirical Database and Policy Considerations”; Judith Cook, PhD, from the University of Illinois-Chicago, for her paper on “‘Patient-Centered’ and ‘Consumer-Directed’ Mental Health Services”; Ellen Harris, JD, and Chris Koyanagi of the Judge David L. Bazelon Center for Mental Health Law, for their paper on “Obstacles to Choice: Statutory, Regulatory, Administrative and Other Barriers That Impede Consumer-Directed Care in Mental Health”; Constance M. Horgan, ScD, and Deborah W. Garnick, ScD, both of Brandeis University, for their paper on “The Quality of Care for Adults with Mental and Addictive Disorders: Issues in Performance Measurement”; Christina Bethell, PhD, of the Oregon Health and Science University School of Medicine, for her paper on “Taking the Next Step to Improve the Quality of Child and Adolescent Mental and Behavioral Health Care Services: Current Status and Promising Strategies for Quality Measurement;” Robert Rosenheck, MD, of the Veterans Administration Northeast Program Evaluation Center, for his paper “Mental Health and Substance Abuse Services for Veterans: Experience with Performance Evaluation in the Department of Veterans Affairs”; Benjamin C. Grasso, MD, Executive Director of the Institute for Self-Directed Care, for his paper on “The Safety of Health Care for Individuals with Mental Illness and Substance Use Disorders”; Susan Stefan, JD, from the Center for Public Representation, for her paper on “Patient-Centered Care/Self-Directed Care: Legal, Policy and Programmatic Considerations”; Mark D. Weist, of the University of Maryland School of Medicine, Carl E. Paternite, PhD, of Miami University (Ohio), and Steven Adelsheim, MD, of the University of New Mexico Health Sciences Center, for their paper “School-Based Mental Health Services”; John Landsverk, PhD, of the Child and Adolescent Services Research Center at Children’s Hospital-San Diego, for his paper “Improving the Quality of Mental Health and Substance Abuse Treatment Services for Children Involved in Child Welfare”; Nancy Wolff, PhD, of Rutgers
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Improving the Quality of Health Care for Mental and Substance-Use Conditions University, for her paper “Law and Disorder: The Case Against Diminished Responsibility”; Joseph J. Cocozza, PhD, of the National Center for Mental Health and Juvenile Justice and Policy Research Associates, Inc., for his paper “Juvenile Justice Systems: Improving Mental Health Treatment Services for Children and Adolescents”; John A. Morris, MSW, of Comprehensive NeuroScience, Inc. and the University of South Carolina School of Medicine, Eric N. Goplerud, PhD, of George Washington University Medical Center, and Michael A. Hoge, PhD, of Yale University School of Medicine, for their paper “Workforce Issues in Behavioral Health”; and Timothy S. Jost, JD, of Washington and Lee University School of Law, for his paper on “Constraints on Sharing Mental Health Treatment Information Imposed by Federal and State Medical Records Privacy Laws.” In addition, Jennifer Kraszewski, graduate student at The George Washington University, and Craig Bremmer, Senior Research Associate at the Institute for Health Policy and Health Services Research at the University of Cincinnati Medical Center, collected and analyzed information pertaining to accreditation and performance measurement in health care for mental and substance-use conditions, respectively. At the Institute of Medicine, Karen Adams, PhD, provided expert consultation and advice on self-efficacy, patient activation, and other aspects of patient-centered care. Danitza Valdivia once again provided ever-ready and gracious assistance regardless of the task or timeline, and Bill McLeod and the staff of the George E. Brown Library provided sustained professional support in the location and retrieval of voluminous reference materials. Rona Briere of Briere Associates, Inc. provided expert copy editing, and Alisa Decatur excellent proofreading and manuscript preparation assistance. Finally, we thank the Annie E. Casey Foundation, CIGNA Foundation, the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute on Drug Abuse (NIDA), The Robert Wood Johnson Foundation, SAMHSA within the U.S. Department of Health and Human Services, and the Veterans Health Administration (VHA) of the Department of Veterans Affairs for their support for the application of the Quality Chasm framework as a tool for improving the quality of health care for mental and substance-use conditions, for their leadership in calling for a study to address the intertwined issues of mental health and substance use, and for their financial support for this study. We also are especially grateful to key personnel within these agencies and organizations who spearheaded efforts to get this study under way and provided ongoing data, information, and support and encouragement throughout the committee’s efforts. We especially thank Ronald W. Manderscheid, PhD, Chief of the Survey and Analysis Branch in the Center for Mental Health Services, and Mady Chalk, PhD, Director of the Division of Services Improvement in the Center for Substance Abuse Treatment, both within SAMHSA; Constance Pechura, PhD,
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Improving the Quality of Health Care for Mental and Substance-Use Conditions and Victor A. Capoccia, PhD, both Senior Program Officers at The Robert Wood Johnson Foundation; Rhonda Robinson Beale, MD, Senior Vice President and Chief Medical Officer at CIGNA Behavioral Health; Frances M. Murphy MD, MPH, Deputy Under Secretary for Health, Department of Veterans Affairs; Stephen W. Long, Executive Officer, NIAAA; Wilson M. Compton, Director, Division of Epidemiology, Services and Prevention Research, and Jerry P. Flanzer, PhD, Senior Health Science Administrator, both of NIDA; and Patrick McCarthy, PhD, Vice President, Systems and Service Reform, the Annie E. Casey Foundation.
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Improving the Quality of Health Care for Mental and Substance-Use Conditions Contents SUMMARY 1 1 THE QUALITY CHASM IN HEALTH CARE FOR MENTAL AND SUBSTANCE-USE CONDITIONS 29 More Than 33 Million Americans Annually Receive Care, 30 Continuing Advances in Care and Treatment Enable Recovery, 32 Poor Care Hinders Improvement and Recovery for Many, 35 Failure to Provide Effective Care Has Serious Personal and Societal Consequences, 37 A Charge to Cross the Quality Chasm, 44 Scope of the Study, 47 Organization of the Report, 47 2 A FRAMEWORK FOR IMPROVING QUALITY 56 Aims and Rules for Redesigning Health Care, 57 Distinctive Characteristics of Health Care for Mental/Substance-Use Conditions, 59 Applying the Quality Chasm Approach to Health Care for Mental and Substance-Use Conditions, 70 3 SUPPORTING PATIENTS’ DECISION-MAKING ABILITIES AND PREFERENCES 77 Rules to Help Achieve Patient-Centered Care, 78 How Stigma and Discrimination Impede Patient-Centered Care, 79 Evidence Counters Stereotypes of Impaired Decision Making and Dangerousness, 92
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Improving the Quality of Health Care for Mental and Substance-Use Conditions Coerced Treatment, 103 Actions to Support Patient-Centered Care, 108 4 STRENGTHENING THE EVIDENCE BASE AND QUALITY IMPROVEMENT INFRASTRUCTURE 140 Problems in the Quality of Care, 141 Improving the Production of Evidence, 151 Improving Diagnosis and Assessment, 167 Better Dissemination of the Evidence, 169 Strengthening the Quality Measurement and Reporting Infrastructure, 180 Applying Quality Improvement Methods at the Locus of Care, 193 A Public–Private Strategy for Quality Measurement and Improvement, 195 5 COORDINATING CARE FOR BETTER MENTAL, SUBSTANCE-USE, AND GENERAL HEALTH 210 Care Coordination and Related Practices Defined, 211 Failed Coordination of Care for Co-Occurring Conditions, 214 Numerous, Disconnected Care Delivery Arrangements, 218 Difficulties in Information Sharing, 232 Structures and Processes for Collaboration That Can Promote Coordinated Care, 233 6 ENSURING THE NATIONAL HEALTH INFORMATION INFRASTRUCTURE BENEFITS PERSONS WITH MENTAL AND SUBSTANCE-USE CONDITIONS 259 A Strong Information Infrastructure Is Vital to Quality, 260 Activities Under Way to Build a National Health Information Infrastructure, 262 Need for Attention to Mental and Substance-Use Conditions in the NHII, 268 Information Technology Initiatives for Health Care for Mental/Substance-Use Conditions, 270 Building the Capacity of Clinicians Treating Mental and Substance-Use Conditions to Participate in the NHII, 276 Integrating Health Care for Mental and Substance-Use Conditions into the NHII, 279 7 INCREASING WORKFORCE CAPACITY FOR QUALITY IMPROVEMENT 286 Critical Role of the Workforce and Limitations to Its Effectiveness, 288 Greater Variation in the Workforce Treating M/SU Conditions, 288
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Improving the Quality of Health Care for Mental and Substance-Use Conditions Problems in Professional Education and Training, 294 Variation in Licensure and Credentialing Requirements, 304 Inadequate Continuing Education, 305 More Solo Practice, 309 Use of the Internet and Other Communication Technologies for Service Delivery, 310 Long History of Well-Intentioned but Short-Lived Workforce Initiatives, 312 Need for a Sustained Commitment to Bring About Change, 315 8 USING MARKETPLACE INCENTIVES TO LEVERAGE NEEDED CHANGE 325 Key Features of the Marketplace for Mental and Substance-Use Health Care, 326 Characteristics of Different Purchasing Strategies, 330 Procurement and the Consumer Role, 337 Effects of Market and Policy Structures on Quality, 339 Conclusions and Recommendations, 343 9 AN AGENDA FOR CHANGE 350 Knowledge Gaps in Treatment, Care Delivery, and Quality Improvement, 351 Strategies for Filling Knowledge Gaps, 355 Review of Actions Needed for Quality Improvement at All Levels of the Health Care System, 360 APPENDIXES A Study Process and Committee Membership 391 B Constraints on Sharing Mental Health and Substance-Use Treatment Information Imposed by Federal and State Medical Records Privacy Laws 405 C Mental and Substance-Use Health Services for Veterans: Experience with Performance Evaluation in the Department of Veterans Affairs 423 INDEX 483
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Improving the Quality of Health Care for Mental and Substance-Use Conditions Tables, Figures, and Boxes TABLES 2-1 Differences Between General Health Care and Health Care for Mental and Substance-Use Conditions, 62 2-2 Percentage of Clinically Trained Specialty Mental Health Personnel Reporting Solo Practice as Their Primary or Secondary Place of Employment, 66 4-1 Organizations and Initiatives Conducting Systematic Evidence Reviews in M/SU Health Care, 163 7-1 Estimated Number of Clinically Active (CA) or Clinically Trained (CT) Mental Health Personnel and Rate per 100,000 Civilian Population in the United States, by Discipline and Year, 292 7-2 Percentage of Clinically Trained Specialty Mental Health Personnel Reporting Individual Practice as Their Primary or Secondary Place of Employment, 309 9-1 Recommendations for Clinicians, 361 9-2 Recommendations for Organizations Providing M/SU Health Care, 365 9-3 Recommendations for Health Plans and Purchasers of M/SU Health Care, 369 9-4 Recommendations for State Policy Makers, 373
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Improving the Quality of Health Care for Mental and Substance-Use Conditions 9-5 Recommendations for Federal Policy Makers, 377 9-6 Recommendations for Accreditors of M/SU Health Care-Organizations, 384 9-7 Recommendations for Institutions of Higher Education, 386 9-8 Recommendations for Funders of M/SU Health Care Research, 387 FIGURES 3-1 The stigma pathway to diminished health outcomes, 81 5-1 The continuum of linkage mechanisms, 236 8-1 Financing methods for mental health/substance-use care in 2001, 326 BOXES S-1 The Six Aims of High-Quality Health Care, 8 S-2 The Quality Chasm’s Ten Rules to Guide the Redesign of Health Care, 9 2-1 The Six Aims of High-Quality Health Care, 57 2-2 The Quality Chasm’s Ten Rules to Guide the Redesign of Health Care, 58 3-1 Rules for Patient-Centered Care, 78 4-1 Some of the Knowledge Gaps in Treatment for M/SU Conditions, 152 4-2 Key Factors Associated with Successful Dissemination and Adoption of Innovations, 170 4-3 Centers, Offices, and Institute of the Centers for Disease Control and Prevention, 175 4-4 The Network for the Improvement of Addiction Treatment (NIATx), 194 5-1 New Mexico’s Behavioral Health Collaborative: A Case Study in Policy Coordination, 247 6-1 Improving Care Using Information Technology, 261 7-1 Workforce Shortages and Geographic Maldistribution, 289 7-2 Insufficient Workforce Diversity, 290
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