Good intentions, but few results: part one in a two-part series about improving the quality of behavioral health services.

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. (2)

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.

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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.

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)