Practice Guidelines in Mental Health and Addiction Services
Gail W. Stuart, PhD, RN, Conference Chair
American College of Mental Health Administration
Practice guidelines in mental health and addiction services were the focus of the 1999 Summit. Approximately 110 individuals attended the three day meeting, including representatives of the Washington Circle Group, the Practice Guideline Coalition, the Children’s Outcomes Roundtable, the Federation of Families for Children’s Mental Health, the Bazelon Center for Mental Health Law, the Center for Outcome Research/Effectiveness, Kaiser Permante, Blue Cross/Blue Shield, and the Menninger Care Systems, along with ACMHA members. Day one of the Summit provided attendees with an overview of the “what” and “why” of practice guidelines and the process and politics of guideline development. Areas of discussion included:
- How the need for guidelines originated
- The scope of guidelines that exist in behavioral health
- The process by which the various guidelines were developed
- Ways in which guidelines can be used or misused
- How guidelines are disseminated, implemented and evaluated in practice.
On day two, participants in the SUMMIT were divided into working groups which met over the next two days in Santa Fe, at the end of which each produced a statement of recommendations and outcomes that could be expected from implementing the recommendations. It was clear at the conclusion of Summit 1999 that much controversy, confusion and contextual issues continue to dominate the behavioral health landscape in relation to evidence-based practice guidelines. These negatively impact consumers, providers, payers and policy makers. It was noted that little evidence exists about effective dissemination or implementation strategies used with practice guidelines in behavioral health. While facilitators and barriers to implementation have been theoretically described little is known about the clinical, financial and ethical issues that emerge when evidence-based behavioral health practice guidelines are implemented in systems of care, including managed care environments. Thus, it was the strong recommendation of those attending Summit 1999 that the issues related to practice guidelines in behavioral health needed continued examination and resolution.
Summit 1999 Recommendations
ACMHA Board met in October, 1999 and reviewed the following Summit 1999 outcomes which are briefly described below:
- A Taxonomy of Building Blocks for informed decision-making in behavioral health assessment and treatment
- A Paradigm for the development of practice guidelines
- Characteristics of a good practice guideline derived from the Key Value Themes
- Strategies for disseminating and implementing practice guidelines
(1) A Taxonomy of Building Blocks for Informed Decision-Making in Behavioral Health Assessment and Treatment
It is possible to conceptualize a number of approaches to standardizing prevention and treatment options in behavioral health. These can be placed in a taxonomy from the most general to the most specific. Those at the top of the triangle provide maximum choice and flexibility, while those at the bottom of the triangle provide for maximum accountability. ACMHA sees this taxonomy as a useful way of informing decision-making in the practice setting. A basic assumption underlying this taxonomy is ACMHA’s belief that emphasis should be placed on preventive, as well as treatment interventions in practice guidelines in order to:
- Assist the presenting person identify family members who should be screened for risk for and/or early signs of mental illness or substance use problems because of genetic, other biological predisposition, or the effect of having a mentally ill family member
- Educate and support the person and family regarding expected comorbid illnesses, relapse management and any other aspects of the disorder necessary for the person and family to become enlightened, empowered consumers
- Identify home, school, workplace and community issues regarding unidentified problems and dysfunction in that setting; sources of stress/conflict that may contribute to the presenting problem; environmental or other conditions that identify another high risk population that needs to be screened; modifications to the home, school, workplace or community that may be needed to reduce morbidity for the person and family and risk for the identified population
- Identify protective factors for each disorder Screen individuals for comorbid medical and behavioral health disorders.
Thus this taxonomy is unique in incorporating prevention as well as treatment options, although it is acknowledged that currently this is an underdeveloped area in most practice guidelines.
(2) Paradigm of Practice Guideline Development
ACMHA further believes that the values and goals of consumers and families, embedded in their communities of care, needs to be the touchstone from which behavioral health practice guidelines are developed. To that end, ACMHA endorses a shift from guideline development often driven by the interests of the health care system, including academia, guilds and payers, to a paradigm in which guidelines are developed in partnership with consumers and families in the context of their community.
This paradigm requires that consumers and families be involved in all critical steps of guideline development including:
* scientific and research funding and services research
* defining goals, scope, target audience, data, methods and endorsement
* guideline derived quality measures and outcome assessments
* systems adoption, implementation, evaluation and adaptation
(3) ACMHA’s Characteristics of Good Behavioral Health Practice Guidelines:
ACMHA endorses the Institute of Medicine’s eight attributes of a good practice guideline (Institute of Medicine, 1990). It builds on and expands upon these attributes by further identifying ten characteristics of good behavioral health practice guidelines based on ACMHA’s Key Value Themes developed at the Santa Fe Summit 1997. The characteristics are as follows.
- Practice guidelines should be developed in partnership with recipients, consumers, family members, people in recovery, and a wide range of disciplines and organizations.
- Practice guidelines should be clear, educational and fully available to recipients, consumers, families, people in recovery, all mental health providers, and all payers.
- Practice guidelines should be a toolbox of options, and not prescriptive in nature.
- Practice guidelines should be flexible and accommodate consumer choice as well as consumer values, goals and desired outcomes.
- Practice guidelines should be sensitive and responsive to the individual’s environment, ethnicity, culture, gender, sexual orientation, and socio-economic status.
- Practice guidelines should be based on scientific evidence of efficacy, effectiveness and established best practices in the field.
- Practice guidelines should be reviewed and updated regularly.
- A prevention framework and public health paradigm should be incorporated into every practice guideline.
- Practice guidelines should identify process and outcome measures, including engagement in the treatment process, adherence, continuity of care, symptom reduction, enhanced quality of life, improved functional ability, integration of medical, psychiatric and substance abuse treatment, and improved social status related to employment, housing, school.
- Practice guidelines should produce positive clinical outcomes that are sensitive to time for quality improvement.
ACMHA Key Value Themes
- Consumers and families are at the core of performance measurement.
- Consumer/customer choice must be a driving value for all systems of care, including their design, delivery, evaluation and accreditation.
- Issues of ethnicity, race, age and developmental status, gender, language, culture, spirituality, disability are consciously addressed in ensuring access and availability of services.
- Mental health and substance abuse delivery systems must be accountable to both internal and external stakeholders for meeting the mental health needs of the people they serve in ways that are effective and efficient, and that accountability must be based on reliable, comparable data.
- Access to mental health and substance abuse services must be quick, easy and convenient, and outreach and follow-up must be seen as part of the access continuum.
- A true public health vision of community health must drive outcomes measurement, which means that universal access and integrated primary and behavioral healthcare are the ultimate goal of effective systems.
- Children who have mental health and substance abuse problems: should be able to receive effective services in their homes and schools without disruptive removals from either setting; should be able to remain safe and out of trouble with law enforcement; should remain connected to family and peers while in treatment; should receive services that are family focused and health centered.
- Adults with mental health and substance abuse problems: should be able to maintain a stable, comfortable and safe living environment; should be able to engage in chosen, productive daily activity; should be able to remain safe and out of trouble with law enforcement; should receive treatment that is consumer-centered and which maximizes independence and self-care skills; should receive services designed to enhance total health and maintain social connections and improved quality of life.
(4) Strategies for Disseminating and Implementing Practice Guidelines
Significant difficulties exist in relation to evidence-based guideline dissemination and implementation. Successful implementation of practice guidelines requires an understanding of basic knowledge dissemination and technology acceptance techniques. Involvement in the development or selection of practice guidelines is likely to enhance the likelihood of their acceptance. While no single effective strategy for implementation currently exists, a number of methods can be employed to enhance the likelihood of success. These include:
Prompting – the use of forms or computer screens to prompt practitioners regarding the use of practice guidelines. These tools should prompt and make it easy for the user to determine the best treatment for the presenting situation and should be decision-supports rather than decision-makers.
Academic Detailing – the provision of limited data in a simple format, provided one-to-one, with frequent follow-up. This is a “sales” approach built on a behavioral change model.
Consumer Activation – the provision of information directly to beneficiaries directly via mail, handouts, educational sessions, web sites, and other information resources. This approach assumes that once consumers and their families know what is “best practice” as communicated by a clinical practice guideline, they will begin to question practitioners about it and request that practitioners use the recommendations with themselves.
Feedback – the provision of regular, timely, easy to read and understandable information about the use of practice guidelines and the outcomes related to them in terms of reduced outliers, increased consistency with best practices, improved consumer outcomes, etc. Such information could be system, program or provider specific. Benchmarking can be useful in analyzing the effects of guideline implementation.
Behavioral Change – the marketing of the desired change with simplicity, clarity, and repetition. This process involves identifying barriers to change in the system or organization, and involving leaders in the development and ownership of change. These opinion leaders or champions then assist with communicating the benefits of practice guidelines and convince others to use them as well.
Efficacy/Quality Improvement Initiatives – the utilization of practice guidelines as an efficiency initiative and integrating their use into daily organizational operations. Automation of medical records and a relational data base can assist this process, as can linking practice guidelines to the measurement of outcomes.
Simplification – the initiation of guideline implementation with those that are both feasible and relatively acceptable. Early success and a focus on the providers’ needs will advance subsequent adherence with more extensive guidelines and will minimize their initial burden to the overall system.
Incentives and Sanctions – the use of both positive and negative incentives to entice providers to change. These may include focusing on increasing (positive) or decreasing (negative) items such as time, money, status, autonomy, public recognition or censure, promotion, demotion, disciplinary action, or job loss.
While these strategies for disseminating and implementing practice guidelines have been described in the literature, little evidence exists regarding their actual use or outcomes associated with them.
After reviewing these outcome products from Summit 1999, the ACMHA Board endorsed the need to continue this important work and address some of the dilemmas related to practice guidelines that continue to dominate the behavior health care field. This conference took the next step and built upon the work previously done by ACMHA, a neutral forum in the mental health field.
Table 1. Directory of Behavioral Practice Guidelines
American Academy of Child & Adolescent Psychiatry
American College of Obstetricians and Gynecologists
American Medical Directors Association
American Psychiatric Association
American Psychological Association
American Society of Addiction Medicine
American Society of Consultant Pharmacists
Apollo Managed Care
Association for Ambulatory Behavioral Healthcare
Comprehensive Behavioral Care, Inc.
ComPsych Behavioral Health Corporation
Expert Consensus Guideline Series
First Mental Health
Horizon Behavioral Services
Institute for Clinical Systems Integration
Institute for Healthcare Quality
International Association of Psychosocial Rehabilitation Services
International Society for the Study of Dissociation
Magellan Health Services
Managed Behavioral Healthcare Organizations
MCC Managed Behavioral Care, Inc.
National (Australian) Health and Medical Research Council
National Clearinghouse For Alcohol and Drug Information
National Community Mental Healthcare Council
National Institutes of Health (NIH) Consensus Development Conference Statements
New Zealand Guidelines Group
The Oak Group
Practice Guidelines Coalition
Preferred Clinical Practices Guide of Behavioral Health Network of Vermont
The Psychological Association
Texas Medication Algorithm Project
U.S. Agency for Health Care Policy and Research (AHCPR)
U.S. Preventive Service Task Force
Veterans Health Administration
West Virginia Office of Behavioral Health Services
American College of Mental Health Administration. (1998). Preserving Quality and Value in the Managed Care Equation. Pittsburgh, PA: American College of Mental Health Administration.
Battisda, R.N., & Hodge, M.J. (1993). Clinical Practice Guidelines: Between Science and Art. CMAJ, 148, 385-389.
Bauer, M.S. (1998). Clinical Practice Guidelines: The Academic Emperor in Search of Clinical Practice Clothes. Submitted.
Bauer, M.S., Callahan, A.M., Jampala, C., et al. (1999). Clinical Practice Guidelines for Bipolar Disorder from the Department of Veterans Affairs. Journal of Clinical Psychiatry, 60, 9-21.
Bilsker, D. & Goldner, E.M. (1999). Teaching Evidence-Based Practice in Mental Health. Evidence-Based Mental Health, 2(3), 68-69.
CHAMPUS National Quality Management Project: Side-by-Side Comparison of Mental Health Practice Guidelines. Beaverton, OR: Science Applications International. 1994.
Citrome, L. (1998). Practice Protocols, Parameters, Pathways, and Guidelines. Administration and Policy in Mental Health, 25(3), 257-269.
Gilbert, D.A., Altshuler, K.Z., Rago, W.V., Shon, S.P., Crismon, M.L., Toprac, M.G., & Rush, A.J. (1998). Texas Medication Algorithm Project: Definitions, Rationale, and Methods to Develop Medication Algorithms. Journal of Clinical Psychiatry, 59(7), 345-351.
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Institute of Medicine, Field, M.J., & Lohr, K.N. (Eds.). (1990). Clinical Practice Guidelines: Directions for a New Program, Washington, DC: National Academy Press
Katz, D.A. (1999). Barriers Between Guidelines and Improved Patient Care: An Analysis of AHCPR’s Unstable Angina Clinical Practice Guideline. Health Services Research, 34(1), 377-389.
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Leape, L.L. (1990). Practice Guidelines and Standards: An Overview. Quality Review Bulletin, 16, 42-49
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Merz, S.M. (1993). Clinical Practice Guidelines: Policy Issues and Legal Implications. The Joint Commission Journal on Quality Improvement, 19(8), 306-312
National Quality of Care Forum. (1993). Bridging the Gap Between Theory and Practice: Exploring Clinical Practice Guidelines. The Joint Commission Journal on Quality Improvement, 19(9), 384-400.
Noonan, D., Coursey, R., Edwards, J.B., Frances, A., Fritz, T., Henderson, M.J., Krauss, A., Leibfried, T., Manderscheid, R.W., Minden, S., & Strosahl, K. (1998). Clinical Practice Guidelines. Journal of the Washington Academy of Sciences, 85(1), 114-124.
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Sachs, G.S., & Gaughan, S. (1999). Clinical Practice Guidelines: Praise and Problems. Journal of Clinical Psychiatry, 60(1), 7-8.
Shon, S.P., Toprac, M.G., Crismon, M.L., & Rush, A.J. (1999). Strategies for Implementing Psychiatric Medication Algorithms in the Public Sector. Journal of Practical Psychiatry and Behavioral Health, January, 32-36.
Smith, T.E. & Docherty, J.P. (1998). Standards of Care and Clinical Algorithms for Treating Schizophrenia. Schizophrenia, 21(1), 203-220.
Thomas, L. (1999). Clinical Practice Guidelines. Evidence-Based Nursing, 2(2), 38-39.
VanAmringe, M., & Shannon, T.E. (1992). Awareness, Assimilation, and Adoption: The Challenge of Effective Dissemination and the First AHCPR-Sponsored Guidelines. QRB, December, 397-404.
Weiden, P. & Dixon, L. (1999). Guidelines for Schizophrenia: Consensus or Confusion? Journal of Practical Psychiatry and Behavioral Health, January, 26-31.
Practice Guidelines in Mental Health and Addiction Services:
Contributions from the American College of Mental Health Administration
Gail W. Stuart, PhD, RN
Chair, Practice Guidelines Santa Fe Summits, 1999 and 2000
Professor, Colleges of Nursing and Medicine
Medical University of South Carolina
College of Nursing
99 Jonathan Lucas Street
PO Box 250160
Charleston, South Carolina 29425
Phone – 843-792-4627; Fax – 843-792-2104
A. John Rush, MD
Co-Chair, Practice Guidelines Santa Fe Summit, 2000
Professor of Psychiatry
University of Texas Southwestern Medical Center
John A. Morris, MSW, CHE
President, American College of Mental Health Administration
Professor, Neuropsychiatry & Behavioral Science
University of South Carolina School of Medicine
Columbia, South Carolina
Santa Fe Summits 1999 and 2000 Workgroups
Practice guidelines have proliferated in mental health and addiction services with over forty organizations developing guidelines in the field. However much confusion, controversy and contextual issues remain, particularly regarding effective dissemination or implementation strategies and the clinical, financial, political and ethical issues that emerge when evidence-based behavioral health practice guidelines are implemented in systems of care. The American College of Mental Health Administration (ACMHA) has focused on these problems in their 1999 and 2000 Santa Fe Summits and produced a number of specific outcomes that contribute to thinking in the field. These include: 1) a taxonomy of building blocks for informed decision-making in behavioral health assessment and treatment; 2) a paradigm for the development of practice guidelines; 3) characteristics of a good practice guideline; 4) strategies for disseminating and implementing practice guidelines; and 5) areas in need of future research.