As we look across the quality chasm, we find that the people we serve are dying 25 years earlier than expected.4 Many suffer from metabolic disorder. Children are stuck unnecessarily on waiting lists or in hospitals. Our work itself increasingly has been ignored by medicine and the government. Yet many in the field still cling to the belief that if we “do more of the same, we are going to get different results.”
Alternately, far too often we fall into the trap of “blaming” someone or some larger problem for poor quality. Inaction often is accompanied by statements such as “if only we could…” or “we can't change because….” The result is that new programs are added on top of existing ones, and nothing is done while we wait for someone or something to make the needed changes.
During the past several years, however, there has been increasing recognition in general healthcare and other sectors that a significant level of change and improvement does not require overall reengineering of systems, privatization of providers, or all new staff. Instead, improving quality requires small actions, focused project measurement, leadership committed to change, working together, and systematic efforts to make improvements.
Recent years have seen significant attention focused on improving service quality and care coordination, particularly between mental and physical health providers, for individuals with depression. Depression affects 10 to 14 million Americans every year, and exerts a detrimental impact on quality of life, functioning, and work productivity. Often the initial treatment for depression is within primary care.5 There is a clear business case for the need to improve the quality of care. Several guidelines for the early identification, treatment, and follow-up for depression in primary care settings have been developed during the past decade, and these generally have been found to be effective. However, as one recent report indicated, “For a variety of reasons, guideline based primary care for depression remains the exception rather than the rule.”6 In other words, turning knowledge into practice takes more than guidelines. Several of the large national depression collaboratives funded by the Robert Wood Johnson Foundation and the federal Health Resources and Services Administration have shown how to make this leap from guidelines to practice change.
Existing guidelines for a wide variety of mental and substance use conditions, along with major advances in pharmacologic and psychotherapeutic treatments, hold great promise for providing a framework for improving behavioral health outcomes. But the promise has yet to be realized for most patients. Efforts by funders to promulgate guidelines and require their use are necessary, but they are not sufficient unto themselves. For instance, a Substance Abuse and Mental Health Services Administration study conducted by Horgan et al reviewed managed care screening and treatment practice guidelines in primary care settings.7 In this study, 51% of the managed care plans distributed practice guidelines, and yet there was little if any systematic follow-up on these measures.
Stigma, the nature of behavioral health conditions, irrelevant professional education, high staff turnover in public programs, and the lack of consistent leadership are some of the barriers we face to implementing effective quality improvement programs. There is also a much larger set of issues that includes the financing, administration, organization, and design of the delivery system. Many efforts at reform have called for changes in reimbursement and financing systems, as if these would solve quality problems by themselves. Changing incentives works to change behavior, but it has become clear that such changes must be accompanied by additional change at the organizational and practice levels. The use of the chronic care model, for example, has been shown to be efficacious8 but, as Pincus and colleagues note, “because of inherent differences in behavioral health care, the chronic illness care model must be customized to…plans and payers, practices, providers (behavioral health and primary care), and patients.”9
So, how can we work our way out of this? The answer, nationally and within states, is to begin the work one project at a time, using consensus-based practice guidelines, training staff, sharing our results with each other, and implementing systemic approaches to support and make the needed practice changes. What is needed is an approach that pushes clinical practice to its boundaries, identifies barriers, and then stands ready to address needed system changes on a local basis. We can't afford to wait for the larger changes in financing and organization of the system to occur.
There are models for the type of systemic change we need. The Pittsburgh Regional Health Initiative and the Institute for Clinical Systems Improvement (in Minneapolis/St. Paul) are examples of important local efforts. One of the broadest efforts, designed to look at the health of the community as a whole, is the Kansas City Area Community Healthcare Initiative. All of these are notable in the collaboration they have created among providers, health plans, academic institutions, government, and business, and it is likely that their systemic approaches have been pivotal in their success. As Daniels et al suggest, these community collaboratives may be a key to the transformation of the behavioral health field.10