Crossing the Quality Chasm

“Quality problems occur typicallynot because of failure of goodwill,knowledge, effort or resourcesdevoted to health care, but becauseof fundamental shortcomings in theways care is organized”

Trying harder will not work:changing systems of carewill!

a new HEALTH system for the 21st century (IOM, 2001)

The Crossing the Quality Chasm SeriesTo Err is Human (1999)

Crossing the Quality Chasm - A New Health System for the 21st Century (2001)

Leadership by Example (2002)

Fostering Rapid Advances in Health Care (2002)

Priority Areas for National Action (2003)

Health Professions Education (2003)

Keeping Patients Safe – Transforming the Work Environment of Nurses (2004)

Patient Safety – Achieving a New Standard for Care (2004)

Quality through Collaboration – the Future of Rural Health (2005)

Improving the Quality of Health Care for Mental and Substance-use Conditions (2005)

Six Aims of Quality Health Care

1. Safe – avoids injuries from care

2. Effective – provides care based on scientific knowledge and avoids services not likely to help

3. Patient-centered – respects and responds to patient preferences, needs, and values

Six Aims (cont.)

4. Timely – reduces waits and sometimes harmful delays for those receiving and giving care

5. Efficient – avoids waste, including waste of equipment, supplies, ideas and energy

6. Equitable – care does not vary in quality due to personal characteristics (gender, ethnicity, geographic location, or socio-economic status)

OVERARCHING CONCLUSION

It is not possible to deliver safe or adequate healthcare without simultaneous consideration of general health, mental health and substance use issues.

Overarching Recommendation 1

The aims, rules, and strategies for redesign in Crossing the Quality Chasm apply equally to M/SU health care.

In particular, “Patient Centered Care” also applies to M/SU Care.

Overarching Conclusion

But….

Mental and Substance Use Care are different in important ways……

M/SU Health Care Compared to General Health Care

• More stigma, coercion & discrimination

• Less patient decision-making

• Diagnosis more subjective

• Less developed QI infrastructure

M/SU Health Care Compared to General Health Care

• More separate care delivery arrangements

• Less use of IT

• More diverse workforce & more solo practice

• Differently structured marketplace

Overview

The Problem

Patient Centered Care vs

Effective Care

Issue 1: Patient-Centered CareHallmark of Ethical Care

• Patient is the source of control on:

– information sharing & decision making

• Care based on patient needs and values

• Care is transparent to the patient

• Ethical care provides full disclosure/discussion of all care options – for patient to decide

• FDA standards of effectiveness

• Do substance abuse treatments meet those standards?

Issue 2: Effective Care

An FDA Perspective

A Drug is Approved for “An Indication”

2 -Randomized Clinical Trials: Often ask for separate investigators

Placebo Control: Movement to test vs approved medication

Treatment Research Institute

• Therapies– Cognitive Behavioral Therapy– Motivational Enhancement Therapy– Community Reinforcement and Family Training– Behavioral Couples Therapy– Multi Systemic Family Therapy– 12-Step Facilitation– Individual Drug Counseling

• Medications– Alcohol (Disulfiram, Naltrexone, Accamprosate)

– Opiates (Naltrexone, Methadone, Buprenorphine)– Cocaine (Disulfiram, Topiramate, Modafinil)

– Marijuana (Rimanoban)

– Methamphetamine – Nothing Yet

So…

Given effective options: • What if patients don’t

want them?

• How can we implement them?

Improving the Quality of Health Care for Mental and Substance-Use

Conditions

Defining and Measuring Quality and Effectiveness

Effectiveness, Performance, Quality: What’s the Difference?

Effectiveness – Patient outcomes following treatment - patient symptoms and function

Methods - Usually patient follow-up 6 – 12 months post discharge.

Measures -Patient substance use, employment, crime – health, family & social function “Recovery”.

Characteristics – Definitive, relevant, but slow, expensive, not management-relevant

Performance – System function during treatment – “Indicators” of effectiveness.

Methods - Examine admin databases for processes and interim results consistent with & indicative of effectiveness

Measures – Usually identification, initiation, engagement, retention

Characteristics - Fast, intuitive, face-valid, management-relevant, but not definitive

Performance Indicator Examples

Premise 1 – Patients who stay in treatment longer are likely to have better outcomes.

Premise 2 - Care systems that perform better in engaging and retaining patients longer are likely to have better outcomes

Then: Easily collected, analyzed and interpreted measures of the care system’s ability to engage and retain patients are one indicator of potential effectiveness.

Performance Indicator Examples

1 – Initiation = % of patients who need care, that attend at least one session or day

2 – Engagement - % of patients who initiate, that stay for three days or visits

3 – Linkage - % of patients who complete early stage of care (ie. detox), that engage in the next stage of care (ie. OPT or Residential).

Summary:

Effectiveness

Quality

Performance

Effective Care: Produces favorable patient outcomes.

“Recovery”

Quality Care:Uses evidence-based methods,

delivered by credentialed staff,

within licensed, accredited programs,

and meets or exceeds the patient’s expectations.

High Performance Systems:Identify those who need care;

Initiate care for those who need it;

Engage and retain those who initiate across modalities and between primary and specialty types of care.

Other “Indicators” of Quality

Licensing – indicates safety, legitimacy

Accreditation – indicates contemporary standards of care

Credentials –indicates proficiency in accepted practices

Satisfaction –indicates appeal and value

Evidence Based Practices – indicates use of state of the art care, professionalism

Mechanisms for Coordinating Care

• Inter-agency sharing agreements for patient information with patient consent.– Co-location of services– Shared patient records

• Higher level policy coordination

– Uniform record standards– Uniform information protection

standards.

A Differently Structured Marketplace

• Government is major purchaser,

• Carve-out purchases

• Private insurance avoids covering or offers more-limited coverage

Strategies • Purchasers offering enrollees a choice of health plans should use one or more

tools for reducing adverse selection of individuals with M/SU conditions: – risk adjustment, – payer “carve-outs,” – risk-sharing or mixed-payment contracts, and – benefit standardization across the health plans

• Congress and state legislatures should enact coverage parity.

• Reorient State procurement to give greatest weight to quality.

• Use M/SU health care quality measures in procurement and accountability processes.

• State and local governments should reduce emphasis on grant-based systems of financing and increase use of funding mechanisms that link some funds to measures of quality.