Improving the Quality of Health Care for Mental and Substance-Use Conditions (2006) / Chapter Skim
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5 Coordinating Care for Better Mental, Substance-Use, and General Health
5 Coordinating Care for Better Mental, Substance-Use, and General Health
Pages 210-258
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From page 210... ...
Moreover, mental and/or substance-use (M/SU) problems and illnesses frequently affect and are addressed by education, child welfare, and other human service systems.
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CARE COORDINATION AND RELATED PRACTICES DEFINED Crossing the Quality Chasm notes that the multiple clinicians and health care organizations serving patients in the American health care system typically fail to coordinate their care. That report further states that the resulting gaps in care, miscommunication, and redundancy are sources of significant patient suffering (IOM, 2001)
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, and consensus is often used to arrive at a decision. Disagreements over treatment approaches and philosophies, roles and responsibilities, and ethical questions are common in health care settings.
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Shortell et al.'s clinical integration corresponds to care coordination as addressed in the Quality Chasm report. In the context of co-occurring mental and substance-use problems and illnesses, the Substance Abuse and Mental Health Services Administration (SAMHSA)
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SAMHSA's integrated treatment corresponds to Shortell et al.'s clinical integration; both appear to equate to coordination of care as used in the Quality Chasm report. In this report, we use the Quality Chasm terminology of care coordination and address the coordination of care at the level of the patient.
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. One longitudinal study of patients in both mental health and drug treatment settings found that mental illnesses were as prevalent and serious among individuals treated in substance-use treatment facilities as among patients in mental health treatment facilities.
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. Persons with severe mental illnesses have much higher rates of HIV and hepatitis C than those found in the general population (Brunette et al., 2003; Rosenberg et al., 2001; Sullivan et al., 1999)
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All of these conditions need to be to be detected and treated; however, this often does not happen, and even when it does, providers dealing with one condition often fail to detect and treat the cooccurring illness and to collaborate in the coordinated care of these patients. Failure to Detect, Treat, and Collaborate in the Care of Co-Occurring Illnesses Although detection of some common mental illnesses, such as depression, has increased over the past decade, general medical providers still too often fail to detect alcohol, drug, or mental problems and illnesses (Friedmann et al., 2000b; Miller et al., 2003; Saitz et al., 1997, 2002)
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Absent or poor linkages characterize these separate care delivery arrangements. Numerous demonstration projects and strategies have been developed to better link health care for general, mental, and substanceuse health conditions and related services.
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· Some health care for mental and substance-use conditions and related services are delivered through governmental programs that are separate from private insurance -- requiring coordination across public and private sectors of care. · Nonhealth care sectors -- education, child welfare, and juvenile and criminal justice systems -- also separately arrange for M/SU services.
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Estimates of the proportion of employees receiving M/SU health services through carve-out arrangements with managed behavioral health organizations (MBHOs) vary from 36 to 66 percent, reflecting differences in targeted survey respondents (e.g., employers, MBHOs, or employees)
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. A second obstacle to care coordination is that information about the patient's health problem or illness, medications, and other treatments must now be shared across and meet the often differing privacy, confidentiality, and additional administrative requirements imposed by the different health plans.
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The study notes: "Too often, when individuals with cooccurring disorders do enter specialty care, they are likely to bounce back and forth between the mental health and substance abuse services systems, receiving treatment for the co-occurring disorder serially, at best" (SAMHSA, undated:i)
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. The lesser availability of health insurance for severe mental illnesses and for substance-use treatment also helps explain the involvement of other public sectors (i.e., child welfare and juvenile justice)
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These organizations often refer, arrange for, support, monitor, and sometimes deliver M/SU health services. School mental health services and the child welfare and juvenile justice systems provide access to mental health services for the majority of children (DHHS, 1999)
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In some cases, mental health providers from the school and/or community work on-site in school-based health centers in partnership with primary care providers (Weist et al., 2005)
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. This is not surprising given that the circumstances of children who are the subject of reports of maltreatment and investigated by child welfare services are characterized by the presence of known risk factors for the development of emotional and behavioral problems, including abuse, neglect, poverty, domestic violence, and parental substance abuse (Burns et al., 2004)
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. Data from the NSCAW also indicate that underutilization of needed services can be alleviated when there is strong coordination between local child welfare and public mental health agencies (Hurlburt et al., 2004)
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. Although the majority of prisons and jails screen, assess, and provide treatment for mental illnesses, far fewer prisoners receive treatment for their substance-use problems and illnesses.
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Further, like youths who are not abused or neglected but are placed in child welfare solely to obtain mental health services (discussed in Chapter 1) , children who are not guilty of any offence are similarly placed in local juvenile justice systems and incarcerated solely to obtain mental health services not otherwise available.
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. Because many youths are in juvenile justice systems for relatively minor, nonviolent offenses, there also is a growing sentiment that whenever possible, youths with serious mental illnesses should be diverted from those systems.
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Appendix C contains a description of an array of such support services provided by the Veterans Health Administration to veterans with severe M/SU illnesses. Discharge planning units or similar staff within inpatient facilities, as well as case management staff within outpatient treatment settings or programs, must assess patients for the need for these services, establish referral arrangements, and coordinate the services with the human service agencies providing them.
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This unclear accountability has been acknowledged and addressed in a conceptual model for coordinated care delivery developed by the National Association of State Mental Health Program Directors and the National Association of State Alcohol and Drug Abuse Directors. This model articulates a vision of coordinated care involving primary, mental health, substance-use, and other health and human service providers who share responsibility for delivering care to the full population in need of M/SU health care depending upon the predominance of medical, mental, or substance-use symptoms (SAMHSA, undated)
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. Second, regulations implementing HIPAA also permit health care organizations to implement their own patient consent policies for the release of patient information to other treating providers.15 As a result, health care organizations may adopt even more stringent privacy protections that require participating providers to adhere to additional procedures before sharing patient information with other treatment providers or organizations.
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identified screening as critical to the successful treatment of comorbid conditions. Similarly, because of the high prevalence of emotional and behavioral problems among children served by child welfare services, screening has been recommended for children in the child welfare system overall (Burns et al., 2004)
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stated that individuals with cooccurring disorders should be the expectation, not the exception, in the substance-use and mental health treatment systems. SAMHSA and others have concluded that substance-use treatment providers should expect and be prepared to treat patients with mental illnesses, and similarly that mental health care providers should be prepared to treat patients with substantial past and current drug problems (Havassy et al., 2004; SAMHSA, undated)
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Care coordination is the result of collaboration, which exists when the sharing of information is accompanied by joint determination of treatment plans and goals for recovery, as well as the ongoing communication of changes in patient status and modification of treatment plans. Such collaboration requires structures and processes that enable, support, and promote it (IOM, 2004a)
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highlighted "integrated treatment" as an evidence-based approach for co-occurring disorders, defined, in part, as services delivered "in one setting." The report noted that such integrated treatment programs can take place in either the mental or substance-use treatment setting, but require that treatment and service for both conditions be delivered by appropriately trained staff "within the same setting." Others have noted the benefits of integrating behavioral health specialists into primary settings, as well as the reciprocal strategy of including primary care providers at locations that deliver care to individuals with severe mental and substance-use illnesses. This type of collocation facilitates patient follow-through on a referrals, allows for face-to-face verbal communication in addition to or as an alternative to communicating in writing, and allows for informal sharing of the views of different disciplines and easy exchange of expertise (Pincus, 2003)
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provision of knowledge and decision support to enhance the quality, safety, and efficiency of patient care; and (4) support for efficient processes of health care delivery (IOM, 2003b)
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) , the approach continues to be a common component of many mental health treatment services for individuals with other than mild mental illnesses.
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Organizational Support for Collaboration Successfully implementing the above strategies for care coordination requires facilitating structures and processes within treatment settings. Collaboration also often requires changes in the design of work processes at treatment sites, in particular, flexibility in professional roles.
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Nonphysician personnel support patients in the self-management of their illnesses and arrange for routine periodic health monitoring and follow-up. Providing chronic care consistent with this model requires support from health care organizations, health plans, purchasers, insurers, and other providers.
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and an essential feature of successful programs in care coordination (NASMHPD, NASADAD, 2002)
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Practices of Purchasers, Quality Oversight Organizations, and Public Policy Leaders Clinicians and health care organizations will not be able to achieve full coordination of patient care without complementary and supporting activities on the part of federal and state governments, health care purchasers, quality oversight organizations, and other organizations that shape the environment in which clinical care is delivered. As noted earlier, care coordination has been identified by the IOM as one of 20 priority areas deserving immediate attention by all participants in the American health care system.
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For example, NCQA's MBHO accreditation standards address care coordination between M/SU and general health care in Standard QI 10, "Continuity and Coordination between Behavioral Health and Medical Care," which states (NCQA, 2004:91) : The organization collaborates with relevant medical delivery systems or primary care physicians to monitor and improve coordination between behavioral health and medical care.
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The importance of seizing this opportunity is emphasized in the IOM report Leadership by Example: Coordinating Government Roles in Improving Health Care Quality. That report, commissioned by Congress to examine and recommend quality improvement activities in six major federal programs,21 concluded that the federal government must assume a strong leadership role in quality improvement: By exercising its roles as purchaser, regulator, provider of health services, and sponsor of applied health services research, the federal government has the necessary influence to direct the attention and resources of the health care sector in pursuit of quality.
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. This strong model of collaboration and coordination could be strengthened by including on the action agenda items addressing the substance-use problems and illnesses that so frequently accompany mental illnesses, and by including more explicitly in implementation activities the SAMHSA centers and state agencies responsible for planning and arranging for care for co-occurring substanceuse illnesses.
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This group, consisting of 17 members including the heads of 15 agencies, was established in law by the New Mexico legislature effective May 2004 and charged with creating a single behavioral health (mental and substance-use treatment) delivery system across multiple state agencies and funding sources.
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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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· Establish referral arrangements for needed services. Providers of services to high-risk populations -- such as child welfare agencies, criminal and juvenile justice agencies, and long-term care facilities for older adults -- should use valid, age-appropriate, and cul turally appropriate techniques to screen all entrants into their systems to detect M/SU problems and illnesses.
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:8891. American Academy of Child & Adolescent Psychiatry and Child Welfare League of America.
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2004. Juvenile Justice Systems: Improving Mental Health Treatment Services for Children and Adolescents.
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In: Feldman S, ed. Managed Behavioral Health Services: Perspectives and Practice.
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2003. Child Welfare and Juvenile Justice: Federal Agencies Could Play a Stronger Role in Helping States Reduce the Number of Children Placed Solely to Obtain Mental Health Services.
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Managing Managed Care -- Quality Improvement in Behavioral Health. Washington, DC: National Academy Press.
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2005. Improving the Quality of Mental Health and Substance Use Treatment Services for Children Involved in Child Welfare.
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2002. Exclusions and limitations in children's behavioral health care coverage.
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2005. Training behavioral health and primary care providers for integrated care: A core competencies approach.
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2003. Using the chronic care model to improve treatment of alcohol use disorders in primary care settings.
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