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SUMMARY MANAGING MANAG E D CARE QUALITY IMPROVEMENT IN BE HAVIORAL H EALTH Margaret Ecimuncis, Richard Frank, Michael Hogan, Dennis McCarty, Rhoncia Robinson-Beale, and Constance Weisner, Editors Committee on Quality Assurance and Accreclitation Guiclelines for Managed Behavioral Health Care Division of Neuroscience and Behavioral Health Division of Health Care Services INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. 1997

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NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, DC 20418 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 report has been reviewed by a group other than the authors according to procedures ap- proved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. Support for this project was provided by the Center for Substance Abuse Treatment of the Sub- stance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Servlces. This Summary is available in limited quantities from the Institute of Medicine, Division of Neu- roscience and Behavioral Health, 2101 Constitution Avenue, N.W., Washington, DC 20418. The complete volume of Managing Managed Care: Quality Improvement in Behavioral Health, from which this Summary is extracted, is available for sale from the National Academy Press, Box 285, 2101 Constitution Avenue, N.W., Washington, DC 20055. Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area), or visit the NAP's on-line bookstore at http://www.nap.edu. Copyright 1997 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 image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.

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COMMITTEE ON QUALITY ASSURANCE AND ACCREDITATION GUIDELINES FOR MANAGED BEHAVIORAL HEALTH CARE JEROME H. GROSSMAN* (Chair), Chairman anc3 Chief Executive Officer, Health Quality LEC, Boston, MA, anc3 Scholar-in Resicience, Institute of Medicine, National Academy of Sciences. Washington, DC ROBERT BOORSTIN, Mental Health Advocate, Washington, DC JOHN J. BURKE, Executive Vice President, Value Behavioral Health EAP Services, Falls Church, VA M. AUDREY BURNAM, Senior Behavioral Scientist, Co-Director. Drug Policy Research Center, RAND, Santa Monica, CA BARBARA CIMAGLlO, Director, Illinois Department of Alcoholism anc3 Substance Abuse, Chicago, IL MOLLY JOEL COYE,* Executive Vice President, Strategic Development, HealthDesk Corporation, Berkeley, CA LYNNE M. DeGRANDE, President, DeGrancie anc3 Associates, Senior Consultant, Employee Assistance Program, General Motors, Detroit, MI RICHARD G. FRANK, Professor of Health Economics, Department of Health Care Policy, Harvard Medical School, Boston, MA JOHN E. FRANKLIN, JR., Associate Professor of Psychiatry, Northwestern University Medical School, Chicago, IL MICHAEL F. HOGAN, Director, Ohio Department of Mental Health, Columbus, OH DENNIS McCARTY, Director, Substance Abuse Group, Institute for Health Policy, Heller Gracluate School, Brancleis University, Waltham, MA J. MICHAEL McGINNIS, Former Deputy Assistant Secretary for Health, Scholar-in-Resicience, Commission on Behavioral anc3 Social Sciences and Eclucation, National Acaclemy of Sciences, Washington, DC Resigned from committee service, August 1996) RHONDA J. ROBINSON-BEALE, Senior Associate Medical Director, Coorclinatec3 Behavioral Health Management, Health Alliance Plan, Southfielc3, M! ALEX R. RODRIGUEZ, Vice President anc3 Medical Director, National Account Consortium, Inc., Stamford, CT ~Member, Institute of Medicine. . . .

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STEVEN S. SHARFSTEIN, President, Medical Director, and Chief Executive Officer, The Sheppard Pratt Health System, Baltimore, MD DONALD L. SHUMWAY, Co-Director, Self-Determination for People with Developmental Disabilities, Institute on Disability, University of New Hampshire, Durham, NH CONSTANCE WEISNER, Senior Scientist, Alcohol Research Group, Western Consortium for Public Health and School of Public Health, University of California at Berkeley, Berkeley, CA Institute of Medicine Staff MARGARET EDMUNDS, Study Director CARRIE INGALLS, Research Associate THOMAS WETTERHAN, Project Assistant/Research Assistant AMELIA MATHIS, Project Assistant TERRI SCANEAN, Administrative Assistant EUGENE LEE, Student Intern MOLLA DONALDSON, Senior Program Officer, Division of Health Care Services CONSTANCE PECHURA, Director, Division of Ne Behavioral Health IV uroscience and

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Preface introducing a report that aciciresses such a complex anc3 dynamic issue as managed behavioral health care is a Jaunting task. The charge to the Committee on Quality Assurance anc3 Accreditation Guidelines for Man- agec3 Behavioral Health Care was to develop a framework to guide the development, use, anc3 evaluation of performance indicators, accreclita- tion stanciarcis, anc3 quality improvement mechanisms. The framework could then be used to assist in the purchase and delivery of the most effec- tive managed behavioral health care at the lowest appropriate cost for consumers of publicly anc3 privately financed care. There were numerous challenges in addressing this charge. The com- mittee was operating in a rapidly changing environment in which mul- tiple efforts by accreditation organizations, government agencies, con- sumer groups, anc3 other interested parties were uncler way to develop re- port carcis, performance indicators, anc3 other measures of behavioral health care quality. The committee members chose to take an evicience- basec3 approach to their task, but they found that the research base anc3 the development of quality assurance anc3 accreditation stanciarcis are far less advanced in behavioral health care than in other areas of health care. Discussions among committee members clearly indicated a great cli- versity in opinions anc3 experiences. The committee, however, believed that its charge to create a framework for assessing quality assurance anc3 accreditation guidelines was best served by the development of recom v

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v! PREFACE menciations broac3 enough to allow various stakeholcler groups to make them more specific to their own needs anc3 circumstances, as appropriate. This report fulfills this charge anc3 provides a framework that will be useful anc3 enduring. In abolition, this report possibly for the first time weaves together in a single place the many complex issues, concepts, anc3 chal- lenges involved in assuring quality in behavioral health care in a way that is accessible to a broac3 audience. To accomplish its task, the committee began by developing the State- ment of Principles incluciec3 in Chapter ~ of the full report. These prin- ciples served to guide anc3 unite the committee anc3 are the outcome of intensive discussion anc3 consensus-builcling across a rich diversity of views anc3 perspectives. As a primary care physician listening to the workshop presentations anc3 deliberations, it was sometimes unclear to me whether or not mental health anc3 substance abuse problems really presented unique challenges. For example, many of the presentations anc3 discussions emphasized the importance of viewing mental health anc3 substance abuse problems as chronic, relapsing conditions that c30 not differ significantly from other health problems, such as diabetes anc3 heart disease. Other presentations, however, emphasized key differences, such as greater needs for integration of services, a large percentage of substance abuse problems being dealt with in the publicly funciec3 Meclicaic3 system, anc3 the emergence of so-called "carve-out" companies providing behavioral health care, among other ex- amples. Thus, the committee has tried throughout the report to uncler- score a critical distinction between the unique aspects of the structure of behavioral health care delivery and the nature of the disorders themselves, which are not unique, but can range from a single episode of illness to chronic, recurrent, anc3 disabling conditions. From early on in its deliberations, the committee was cleterminec3 to be scrupulous in separating eviclence-basec3 research results from informa- tion based on current clinical strategies or best practices. Thus, the body of the report includes findings that were rigorously grounciec3 in the research literature. However, the committee felt that this report could not go for- warc3 without expressing the strong clinical judgments that this is an excit- ing time in research, that rapid progress is being made in the diagnosis and treatment of behavioral health conditions, anc3 that there is an increasing recognition of the importance of continuing care as a way to prevent or ameliorate relapses. Although the report covers a wide range of topics anc3 issues in this

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PREFACE Vi! field, it might be useful to highlight some of the issues that the committee could not address fully and that will require ongoing consideration by feel' eral anc3 state agencies, as well as a number of other stakeholcier groups. Four key areas seem to be important areas for further work by others. First, there are complex and often overlapping systems of regulation and ac- creclitation, which result in different data requirements, specifications, anc3 timetables. In abolition, there are compelling needs to ensure the quality anc3 integrity of the various measures used by many different organizations. This complexity presents real challenges to purchasers, consumers, pro' vipers, anc3 practitioners of behavioral health care. This report describes the complexity anc3 presents general recommendations to be consiclerec3 by the variety of regulatory agencies anc3 accreditation organizations (e.g., the utility of external audits anc3 quality improvement mechanisms). Whether or not the current system requires mollification anc3 how such mollification should be approached, however, was beyond the scope of our work. The second key area involves questions regarding the analysis anc3 re' porting of the many different types of quality assessment (e.g., report carols, patient satisfaction measures, anc3 other evaluations) anc3, further, how to use such measures to develop accurate anc3 appropriate case~mix anc3 risk adjustment models. To aciciress these questions, the committee believes that further development of analytical tools is necessary anc3 that this evi' clence base needs to be expanclec3 before cletailec3 recommendations can be macle. In abolition, development of such tools will require collaboration among various components of the public anc3 private sectors. The public' anc3 private~sector entities involved might find it fruitful to consider ways to foster these collaborations. Third, there is a general need to develop strategies to aciciress the com' plexities of the Meclicaic3 population, particularly as they relate to people with mental health anc3 substance abuse problems anc3 to the Revolution of responsibility for this population from the federal government to the states. A comprehensive survey of the states anc3 an analysis of the specific needs of the mental health anc3 substance abuse segment of Meclicaic3-coverec3 health care anc3 the variety of needs across states were beyond the committee's charge. Yet, this theme was expressed at many of the com' mittee's workshops anc3 in its deliberations, anc3 further work seems neces' sary to understand the complex needs of this population, particularly as they relate to strategies to integrate services across social services agencies and health care proviclers.

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. . . vile PREFACE The fourth area relates to the variety of health care practitioners, of' ten working simultaneously, who are involved in treating mental health anc3 substance abuse problems. Clearly, tensions exist among some of these groups of practitioners, but there is also a great need to integrate care across the various disciplines when a patient is being treated by a team of practi' tioners. This situation is an excellent example of a systemic problem that contributes importantly to the fragmentation of services cliscussec3 in the report anc3 that this committee could not solve. However, the variety of practitioners involved also presents special problems for measuring quality in managed behavioral health care, anc3 these problems could benefit from further research to design specific approaches to handle the tensions anc3 to aciciress the need for integration of treatment services. The entire health care system is changing rapidly, anc3 behavioral health care is no exception. During the spring anc3 summer months of 1996 when the committee met, Congress cieliberatec3 anc3 then passed a com' promise mental health parity bill, consumer groups challenged the capac- ity of accreditation organizations to measure quality, anc3 researchers re' ported that psychotherapy hac3 been found to produce changes in brain function similar to those seen with medications. While the report was be' ing reviewed, President Clinton announced the formation of a federal ad' visory commission on the quality of health care. Thus, the issues consic3' erec3 by the committee are timely anc3 seem to reflect some fundamental policy questions, some of which will continue to be clebatec3 over the next clecacle anc3, possibly, longer. As one who has been fortunate to participate on a number of Institute of Medicine committees, ~ must close with a personal statement. The sub' ject matter, the committee anc3 its generous participation in lively anc3 informative meetings as well as in writing the report, anc3 the {OM staff particularly the study director, who kept the work on track anc3 synthe' sized anc3 balanced the multiple streams of input have macle this effort one of the most satisfying in which ~ have participated in the past 15 years. Jerome Grossman, M.D., Chair Committee on Quality Assurance and Accreditation Guidelines for Managed Behavioral Health Care

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Acknowledgments The committee would like to acknowledge the contributions of many inclivicluals and organizations to the committee's work. The committee expresses cieep appreciation to all the inclivicluals and groups who contributed to the public workshops. The speakers in the work- shops were Don Austin, John Bartlett, Linda Bresolin, Ray Bridge, Catherine Brown, Reginald Cedar Face, Robert Cole, William Dennis Derr, Elizabeth Edgar, Robert Egnew, Michael Faenza, Daniel Fisher, Julia Puebla Fortier, Ann Froio, Donald Galamaga, Susan Goldman, Sybil Goldman, Sarah Gotbaum, Elizabeth Haciley, Laura Lee Hall, Judith Hines, Michael Jeffrey, Linda Kaplan, Randall Maciry, Ron Manclerscheic3, David Mee-Lee, Raphael Metzger, Margaret O'Kane, Peter Panzarino, Mark Paris, Mark Parrino, Geoffrey Reed, Gwen Rubinstein, Paul Schyve, Golnar Simpson, Tim Slaven, Sarah Stanley, Tom Trabin, Robert Valciez, Rita Vanclivort, and Grace Wang. Many inclivicluals who were not speak- ers also participated by asking the workshop speakers Questions. and they are listed in Appenclix D. ~, The committee thanks Don Steinwachs and Thomas McLellan and his colleagues Mark Belcling, James McKay, David Zanis, and Arthur Alterman for contributing their papers, which were used by the commit- tee in preparing this report and which appear as Appenclixes to this report. The committee expresses appreciation to Don Detmer and Ed Perrin, who servecl, respectively, as liaisons to the Institute of Meclicine (IOM) IX

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x ACKNOWLEDGMENTS Board on Health Care Services anc3 the National Research Council's Com- mittee on National Statistics (CNSTAT). The committee is particularly grateful to the members of the liaison panel, who raised many questions for the committee's consideration anc3 helped to identify materials for the committee's review. All of the mem- bers are listed in Appendix E. The members who were especially active in responding to requests for information were Linda Bresolin, Peggy Clark, Judith Emerson, Elizabeth Haciley, Judith Hines, Linda Kaplan, Anne Kilguss, Yvonne Lewis, Mark Paris, Mark Parrino, Clarke Ross, Gwen Rubinstein, Paul Schyve, Claire Sharcia, Tom Trabin, Jeanne Trumble, Robert Valclez, anc3 Margaret Van Amringe. Organizations that submitted written comments for the committee's review are listed in Appendix F. The committee is grateful to several inclivicluals who proviclec3 techni- cal comments on preliminary cirafts of sections of the report. They include Gary Chase, Peggy Clark, Denise Dougherty, Lynn Ethereclge, Joe Frisino, Susan Goldman, Judith Katz-Leavy, Kathleen Lohr, Hal Luft, David Mactas, Ron Manclerscheic3, Clarke Ross, Hector Sanchez, Eugene Schoener, Paul Schyve, Claire Sharcia, Lisa Simpson, anc3 Tim Slaven. The committee could not have accomplished its task without the in- sightful anc3 tireless support of the study director, Margo Ecimuncis. Dr. Eclmuncls' extraordinary skills in planning and managing the study, imagi- native guidance of the committee's activities, anc3 writing or editing nu- merous sections of the report proviclec3 an anchor for the committee throughout the study. Other members of the IOM professional staff also proviclec3 invaluable help. Constance Pechura cievelopec3 the idea for the study with the spon- sor anc3 proviciec3 guidance throughout, including descriptions of the IOM process anc3 identification of resources anc3 materials. Molla Donaldson attenclec3 committee meetings anc3 reviewed ciraft sections of the report. Marilyn Field was responsive to many questions anc3 reviewed ciraft sec- tions of the report. Linda Bailey anc3 Jane Durch helped to coordinate this study with the IOM study on public health performance monitoring, as slid Jeff Koshel, study director for the CNSTAT effort on performance partnership grants. The professional staff were supported by the efforts of Carrie Ingalls, research associate; Thomas Wetterhan, project assistant/research assistant; Amelia Mathis, project assistant; Terri Scanlan, aclministrator; and Eu- gene Lee, a summer student intern from the Massachusetts Institute of Technology. Other IOM and National Acaclemy of Sciences staff who

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ACKNOWLEDGMENTS Xt were helpful at a variety of stages include Carolyn Fulco, Carlos Gabriel, Kate-Louise Gottfriec3, Linda Kilroy, Lauren Leveton, Cathy Liverman, Luis Nunez, Dan Quinn, Mary Lee Schneiciers, anc3 Andrea Solarz. During report review, Claudia Carl anc3 Mike Eclington proviciec3 valuable direct tion anc3 technical assistance. The extensive commentary anc3 suggestions macle by the copy editor, Michael Hayes, are gratefully acknowlecigec3. Finally, support for this study was provided by the U.S. Department of Health anc3 Human Services, Substance Abuse anc3 Mental Health Ser' vices Administration (SAMHSA), anc3 its three centers: the Center for Substance Abuse Treatment (CSAT), the Center for Mental Health Ser' vices (CMHS), anc3 the Center for Substance Abuse Prevention (CSAP). David Mactas, the Director of CSAT, the leac3 agency for the study, cle' scribed the sponsor's goals for the study at the committee's first meeting. For their helpful responses to the staffs inquiries anc3 requests throughout the study, the committee thanks Macly Chalk, Director of Managed Care Initiatives at CSAT anc3 the government's project officer; Eric Gopleruc3, Director of SAMHSA's Managed Care Initiative; Jeff Buck, Acting Direct tor of the CMHS Office of Policy anc3 Planning; Nancy Kennedy, Man' aged Care Coordinator for CSAP; anc3 Ron Manclerscheic3, Chief of the Survey Analysis Branch for the CMHS Division of State anc3 Community Systems Development.

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Contents SUMMARY introduction, 1 Description of the Study, 6 Statement of Principles, 9 Terminology Used in This Report, 13 Trencis in Managed Care, 14 Challenges in Delivery of Behavioral Health Care, 17 Structure, 23 Access, 26 Process, 28 Outcomes, 34 Findings and Recommendations, 36 Concluding Observations, 52 References, 52 The contents of the entire report, from which this Summary is extracted, are listed below. ACRONYMS SUMMARY . . . x`~` 1

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xlv 1 INTRODUCTION Terminology Used in This Report Consumers and Families Practitioners Purchasers The Managec3 Care Industry Statement of Principles Organization of the Report 2 TRENDS IN MANAGED CARE The Changing Health Care System Concerns with Managec3 Care in the Public Sector Behavioral Health in the New Marketplace Health Care Quality Prevention Quality Improvement and Quality Assurance Ethical Issues in Managec3 Behavioral Health Care Summary 3 CHALLENGES IN DELIVERY OF BEHAVIORAL HEALTH CARE Extent and Impact of Behavioral Health Problems The Role of Primary Care Special Issues for Quality in Behavioral Health Care Developments in the Private Sector Quality and Consumer Protection Challenges Variability at the State Level Historical Perspective on Systems Summary: System Integration 4 STRUCTURE Practitioner Issues Meclicaicl Medicare Substance Abuse Service Systems Mental Health Treatment Wraparouncl Services Managec3 Behavioral Health Care Industry CONTENTS

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CONTENTS XV Workplace Services U.S. Department of Defense anc3 U.S. Department of Veterans Affairs Care anc3 Services for Children anc3 Adolescents Care anc3 Services for Seniors Indian Health Service Cultural Competence Rural Health anc3 Managed Care Summary of Structural Issues 5 ACCESS Importance of Assessing Access Measures of Access Need anc3 Access Needs of Special Populations Measuring Access to Services Within Managed Care Organizations Summary 6 PROCESS Quality anc3 Accountability Quality Management in Behavioral Health Care Performance Measurement in the Public Sector Accreditation Information Infrastructure for Quality Measurement Role of Government in Quality Assurance Summary 7 OUTCOMES Definitions of Success General anc3 Specific Measures of Outcomes Links Among Structure, Process, anc3 Outcomes Performance Indicators as Outcomes Measures Efficacy anc3 Effectiveness Outcomes anc3 Quality Improvement Criteria for Evaluating Outcomes Measures Summary 8 FINDINGS AND RECOMMENDATIONS 1. Structure and Financing 2. Accreditation

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xv! 3. Consumer Involvement 4. Cultural Competence 5. Special Populations 6. Research 7. Workplace 8. Wraparound Services 9. Children and Adolescents 10. Clinical Practice Guidelines 11. Primary Care 12. Ethical Concerns GLOSSARY APPENDIXES CONTENTS A Biographies B Commissioned Paper: Can the Outcome Research Literature Inform the Search for Quality Indicators in Substance Abuse Treatment?, A. Thomas McLellarr, Mark Be7Jir~g, lames R. McKay, David Zarris, arid Arthur I. Attermarr C Commissioned Paper: Consumer Outcomes and Managed Behavioral Health Care: Research Priorities Dorrald M. Steir~quachs D Public Workshop Agendas and Participants E Liaison Panel Members F Organizations that Submitted Written Statements to the Committee INDEX