The President's New Freedom Commission on Mental Health declared in 2003 that the U.S. mental health system was “fragmented and in disarray.”1 The Institute of Medicine's (IOM)
Crossing the Quality Chasm report in 2001 raised serious concerns about the quality of general healthcare delivery systems. Both reports call not just for systems reform but for a more profound transformation to address the identified problems. As the 2005 IOM report on behavioral healthcare states:
"Departures from known standards of care, variations in care in the absence of care standards, failure to treat M/SU [mental and substance use] problems and illnesses, and lack of coordination are of concern for many reasons. While they may often represent ineffective care, there is evidence that they can also threaten patient safety…. The high prevalence and adverse consequences of M/SU problems and illnesses, the availability of many efficacious treatments, and the widespread delivery of poor-quality care are increasingly being recognized by consumers, purchasers, care providers, and policy makers."
The report goes on to discuss the problems with collaboration in the field:
"Collaboration by mental, substance-use and general health care clinicians is especially difficult because of…(1) the greater separation of mental and substance-use health care from general health care; (2) the separation of mental and substance-use health from each other; (3) 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 (4) the location of services needed by individuals with more severe M/SU illnesses in public sector programs apart from private sector health care."2
It's not that we haven't tried to improve quality in behavioral health services. Most professionals and administrators seek to maintain and improve quality all the time. The challenge lies in implementing collaborative and systemic approaches to improvement.
The most profound change in the field during the past two decades has been the movement to managed care—a systemic but not collaborative change. It initially was driven by efforts to control costs, but after costs were under control, managed behavioral healthcare organizations (MBHOs) increasingly promised and delivered some levels of improved quality. While costs, standardization of services, and utilization reporting improved, it is fair to say that many consumers experienced reductions in care and did not perceive any improvements in quality.
Most current approaches to quality improvement include accreditation and performance measurement activities. These both are essential, but not sufficient, to ensure system quality. Many providers maintain some form of accreditation and have documented their procedures, undergone reviews, hired quality improvement staff, and operated active quality improvement projects. In fact, accreditation standards and processes have improved dramatically in the past decade. They are more focused on outcomes, use such innovations as “tracer methodology,” and focus on consumers' perceptions of care. Most health plans and managed care organizations (MCOs) also meet some form of NCQA, URAC, or other accreditation organization's standards. But, again, these are systemic, not collaborative, efforts.
For more than a decade, public and private behavioral health purchasers have proposed various performance measures for their systems. However, purchasers have had mixed success in implementing and actually using these measures. MBHOs have made major improvements in reporting on utilization and process measures such as re-admission rates and postdischarge follow-up. According to a recent study, public systems that have achieved notable success in performance measurement include the:
Connecticut Department of Mental Health and Addiction Services;
Ohio Department of Mental Health;
Oklahoma Department of Mental Health and Substance Abuse Services; and
Washington Mental Health Division.3
Yet for all the success these states have had in measuring and documenting performance, few could identify consistent efforts of providers or their own staffs to use the data for quality improvement. It is increasingly apparent that data are necessary but not sufficient for quality improvement.
The behavioral health “delivery system” requires that consumers navigate among multiple providers, that information be shared, and often that services be delivered at multiple locations. Categorical funders often still require that consumers and providers alike patch together needed services. Delivering high-quality services in this context is difficult enough, and significant professional, organizational, and “cultural” barriers have limited collaboration in the past. Staff in many public-sector programs have little experience with private clinicians and primary care systems. Case managers may have received little training in care coordination and, even if they have, they may be operating from old models. Psychiatry largely has been marginalized in the medical field and to some degree also in mental health practice.