Crossing the Quality Chasm
“Quality problems occur typically
not because of failure of goodwill,
knowledge, effort or resources
devoted to health care, but because
of fundamental shortcomings in the
ways care is organized”
Trying harder will not work:
changing systems of care
will!
a new HEALTH system for the 21st century (IOM, 2001)
The Crossing the Quality Chasm Series
To 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 socioeconomic 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 Care
Hallmark 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
Issue 2: Effective Care
• FDA standards of effectiveness
• Do substance abuse treatments meet
those standards?
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 grantbased systems of financing and increase use of funding
mechanisms that link some funds to measures of quality.