Summits

Crossing the Quality Chasm: Translating the Institute of Medicine Report for Behavioral Health

March 13-16, 2002
Eldorado Hotel & Spa Santa Fe, NM
Allen S. Daniels, LISW, Ed.D., Program Chair
Hubert A. Mintz, III (Ting), Co-Chair

Introduction
In 2001 the Institute of Medicine (IOM) published, Crossing the Quality Chasm. This report of the Committee on the Quality of Health Care in America followed the 1999 report To Err is Human: Building a Safer Health System. Taken together, these reports identify critical problems with the American health care systems and begin to lay out a strategic direction for the redesign of systems for the 21st century. Over the past several years, it is increasingly clear that the work of the Committee on The Quality of Health Care in America has made a substantial contribution to the evolving health policy debate on the reform of health systems. These reports have gained widespread acceptance and there is interest in using them as blueprints for change.

However, attention to specific issues germane to the delivery of services for mental health and addictive disorders has been limited. This failure to address behavioral healthcare has left a gap in the comprehensive scope of these reports and the agenda for systems change. The importance of mental health and addictive disorders and their impact on health status and health systems are too significant to be left unattended.

In an effort to speak to this gap, the American College of Mental Health Administration (ACMHA) elected to focus the2002 Summit on the “translation” of the Quality Chasm report for the mental health and addictive disorders field. As a small multidisciplinary leadership organization recognized for its success as a neutral convener in the field , the College is in an ideal position to undertake this effort.

ACMHA has an established track record of addressing the pressing issues facing the behavioral healthcare field at its annual Summits. These meetings are working forums that have produced summary reports and have spawned a series of project initiatives. Previous Summit topics and projects have considered:

• The development of practice guidelines for the behavioral health field;
• The crisis in training and workforce development for behavioral healthcare;
• The development and promotion of common performance measures for the behavioral healthcare field; and
• Financing strategies for quality and performance in behavioral healthcare
   

The ACMHA 2002 Summit convened March 14-16, 2002 in Santa Fe, New Mexico. The ninety-two attendees represented diverse stakeholder interests in the field and included leaders from public and private behavioral healthcare systems, administrators and service providers of child/adolescent, adult, elderly, mental health, substance abuse care, consumers, persons in recovery, family members, academicians/ educators, researchers, and other professionals.

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Process
In order to attempt a translation of the IOM report, the ACMHA Summit constructed a framework to involve participants in the assessment, evaluation and analysis of the IOM reports from a behavioral healthcare perspective. The format included both didactic presentations and small working group sessions to examine specific aspects of the Quality Chasm report. Data from the working groups was collected for qualitative analysis.

All of the participants were provided an orientation to the “IOM Quality Chasm Report.” The participants were then randomly assigned to six working groups. Each of the groups met twice over two days for a total of four hours. The groups shared a common task for both day one and day two assignments.

The first day assignment was for each of the groups to conduct a Strengths, Weaknesses, Opportunity, and Threat Analysis (SWOT). Each group was randomly assigned two “Aims” from the “IOM Quality Chasm Report”. None of the groups had the same pair of aims. Data from the discussion for each group was compiled and submitted for analysis. Following the first group session was a one hour debriefing for group leaders which included a review of the day one process and results, as well as planning for the second group assignment.

The second day of the summit began with a facilitated discussion of the group experiences prior to the second small group meeting. Participants were also provided with a review of current initiatives that influence the future of behavioral healthcare. This included material from the Substance Abuse and Mental Health Administration’s current agenda, a report from the National Institute of Mental Health on new funding initiatives, the Surgeon General’s report on Mental Health, and consumer led initiatives.

The second small group session was designed to incorporate the work of the first session on the specific aims with an added focus on the Quality Chasm report’s ten rules. Group membership and leadership remained consistent for both sessions. Each group was assigned five of the ten rules from the “Quality Chasm Report”. The rules were assigned so that each of the aims would have a corresponding match with each of the ten rules. Leaders and participants were provided a matrix that incorporated the six aims and ten rules. (See Table 1 below).

At the conclusion of the second group session, the leaders re-convened for debriefing which focused on developing presentation of materials for a final summation session with the Summit participants. A summary presentation was made by each group and there was a general response discussion by all participants.

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Preliminary Findings and Data Analysis
The participants of the ACMHA Summit met on the last day to discuss their experiences and make recommendations for future directions. The overwhelming consensus of the participants was very favorable. In general, they found that the Qualty Chasm Report was very applicable to the concerns and needs of the behavioral healthcare field. Their more specific recommendations are detailed in the next steps section of this report.

The facilitated group sessions provided a a wealth of information: a consensus report of the participants, and the accumulated data which are available for future analysis. The combination of these provides a framework for the future of this ACMHA initiative. The findings from each of the working groups are rich with analysis and examples from the participants, including a SWOT analysis for each of the six IOM Quality Chasm aims, representing a cogent summary of the application of the aims for behavioral healthcare and a summary of the application of these concepts to the field. Because there were multiple groups examining each aim, there is substantial depth and breadth of resources included in each analysis. These data are further enriched by the vast spectrum of experience of the participants.

The data from the SWOT analysis of each of the six aims have also been used in an examination of the ten rules. The result is a matrix that considers all of the aims and their relationship to each of the ten rules. Together, this level of data can provide a valuable resource for both further translating the IOM report for behavioral healthcare as well as addressing the strategic planning goals of the ACMHA Quality Chasm initiative.

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Next Steps
The overwhelming consensus of the participants of the ACMHA 2002 Summit was that the IOM Quality Chasm framework is immediately relevant and applicable to the concerns of behavioral health systems of care and policy. In addition, the participants affirmed the need to translate the material to the specific behavioral healthcare issues field and to address its integration into the larger general healthcare systems. Furthermore, the participants acknowledged and endorsed the IOM paradigm as a strategic planning blueprint for the redesign of the behavioral healthcare system.

The Summit attendees and College leaders concluded by endorsing this work as an ongoing ACMHA initiative. This effort was seen as a natural continuation and extension of past College efforts, described earlier, to address key quality concerns for the mental health and addictive disorders field.

Based upon the endorsement of the ACMHA members and Summit attendees for the ongoing work of the Quality Chasm Initiative, several next steps are planned. These include:

• meeting with the Institute of Medicine to explore collaborative opportunities for the work of this initiative;
• meeting with other policy and payer stakeholder groups (e.g. SAMHSA, NASMHPD, CMS) to explore collaborative initiatives;
• meeting with and presenting proposals for resource development to funding sources;
• analysis and reporting of the Summit data and dissemination of findings; and
• development of best-practice model programs and field testing of results.

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Table 1
IOM Rules/Aims Matrix

Financing for Positive Results:
Purchasing Quality and Outcomes in Behavioral Healthcare

March 21-24, 2001
Eldorado Hotel & Spa Santa Fe, NM
Pamela S. Hyde, JD, Program Chair
Leighton Y. Huey, M.D. , Co-Chair

Overview
The Santa Fe Summit, held on March 22-24, 2001, was the fifth in a series of annual summits that began in 1997. This year’s Summit was also the second in a two-year Summit process focusing on Education and Training last year and Financing for Positive Results this year. Attendees discussed methods for addressing the decreasing resources available for public mental health and substance abuse services and the increasing requirement that the limited dollars available be spent on those services and interventions that have been proven to work. Ten consumer and family administrators attended this year’s conference, some for the first time.

Keynote speeches by Ron Manderscheid, PhD from CMHS, Eric Goplerud, PhD from SAMHSA, Mary Jane England, MD from the Washington Business Group on Health, and Jim Bixler, MSA, a substance abuse financing consultant from Illinois set the stage with information and challenging questions on Issues affecting public financing of services. Following the keynotes, seven dialogue groups led by national leaders from around the country met to discuss critical questions such as what financing mechanisms work best to assure quality care, how to fund services that are promising but not yet evidenced based, and what is the role of consumer and family-operated services in a system funded to produce positive results.

On the second day of the Summit these dialogue groups attempted to sell their ideas in a rousing “Marketplace of Ideas” designed to raise critical issues about the process of financing public services and the process of determining priorities for funding when public dollars are limited. Charles Ray, MEd (CEO of NCCBH), Ting Mintz (a.consumer administrator from Connecticut) and H.G. Whittington, MD (“living legend”) provided comments as roving reporters followed by further refinement of the ideas that emerged as potential promising efforts for the field. ACMHA members and Summit participants discussed a number of action steps for ACMHA to consider to move issues raised in the Summit forward in the field, including:

• development of a new model for determining the value added of services purchased by public payers;
• a survey of key MH/SA leaders and systems to determine financing mechanisms most promising for assuring quality and creation of case studies about these mechanisms;
• development of a “white paper” about network financing rather than unit or program financing;
• a call to action and action plan for increasing the percentage of consumer and family-operated services funded by public systems; and
• support for a multi-institutional collaborative to fundamentally change pre-professional university training.

Presentations [PDF 117k]:
History and Headlines
Use the Power of Purchasing to Get What You Want
Consumer/Family Services
Financing Evidence-Based Practices
Ideas to Make Promising Practices Proven to Gain Funding
Fixing Unmet Needs: Beyond the Community Reinvestment Approach
New Cost/Value Paradism
Dirty Dozen” Ideas

Changing the Actions, Strategies & Behaviors of Clinicians, Consumers, Families & Organizations: The critical role of education and training

March 15 – 18, 2000
Eldorado Hotel & Spa Santa Fe, NM
Leighton Y. Huey, M.D. , Program Chair
Pamela S. Hyde, JD, Co-Chair

Overview
There was clear, if not overwhelming consensus, that across all disciplines and for adults, children, and families, training and education, for both pre-professional programs and the established behavioral health workforce, are failing the field, and therefore the people we serve. While acknowledging the problem and its scope are important steps, the Summit employed a number of techniques to try to get at the core of the problem, its issues, and possible solutions.

The first day’s panel, moderated by Mary Jane England (Lenore Behar, Jeanette Harrison, Steve Hayes, John Rush, Christina Corp) was a general articulation of the problems posed by an inadequately trained and educated workforce. They provided specific examples of approaches being taken at certain sites around the country, e.g., North Carolina. Varied approaches to training would have to be employed to reach the 75% of the behavioral health workforce representing line staff and the 25% component of the workforce comprised of post-baccalaureate clinicians. Further acknowledged was the problem that pre-professional training programs of all disciplines do not address health care reform and the need to develop new training models to more realistically address contemporary health care issues.

Five dialogue groups served as vehicles to address specific and fundamental core issues associated with the central theme of Training and Education:

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Content and Values: Co-Chaired by Chris Ringwalt and Leighton Huey
This group identified the problems of institutional and professional resistance to including training in the existing structure and an inability to provide incentives to staff for meaningful retraining. The group focused on the problems inherent in the present state of managed care, the relative lack of attention to outcomes, and what should be taught. The group refined and augmented a list of proficiencies and competencies for both the existing workforce and for trainees in pre-professional training programs and they also discussed strategies for their implementation.

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Delivery and Integration: Co-Chaired by Ting Mintz and Beverly Abbott
High quality education and training was the focus of this group as it clearly articulated the problem “Universities are ineffective and largely unchangeable for the delivery of high quality education and training needed in today’s behavioral healthcare world.” They proposed an alternative model to create a non-profit “Corporate Virtual University” that would market and deliver custom-designed, consumer-focused, evidence-based, outcomes-oriented, feedback-driven products desired and needed by a variety of customers, including behavioral healthcare delivery systems, managed care companies, consumers and families, public systems, and possibly universities themselves.

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Process and Change: Co-Chaired by Jeanette Harrison and Sonya Schoenwald
This group considered what processes are necessary for creating effective training and education approaches. It reviewed areas such as relevance, proficiency, multiple vs. single processes, and what these processes should facilitate and represent. There was considerable focus on what would be necessary to establish more relevant practice and how to establish training that would support such practice using economic influences as leverage.

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Socio-Political Issues: Co-Chaired by Wilma Townsend and Areta Crowell
The Socio-Political Dialogue Group identified common goals with a focus on improving the lives of recipients and families, consistent with the value domains outlined in the 1997-1999 ACHMA Summits. Active consumer and family participation in service provision and identification of providers who accept the ACMHA values and evidence-based standards of best practices were also considered to be critical aspects of the reform process. The mismatch between current training/accreditation and what needs to be done was discussed. Strategic steps to eliminate this mismatch include: 1) identifying and convening influential stakeholders, accreditation bodies, training/education systems; 2) determining structure and processes to ascertain points of leverage and potential reform; 3) identifying the framework for pre-service education and training; 4) identifying the various discipline-based academic training bodies; and 5) identifying licensing, certification, credentialing, and continuing education organizations.

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Quality and Costs: Co-Chaired by Christy Beaudin and Sandy Forquer
Within the context of Training and Education, this group centered its discussion around three fundamental questions: 1) What should be the new benchmarks for what constitutes quality in the new healthcare models? 2) What is the research agenda to measure how effective the new models are at achieving the values articulated in the new systems? 3) What does a beginning evaluation of financing these changes and the costs of the new models look like? Quality dimensions were discussed from the perspective of organizational, provider, and consumer domains. Value-driven dimensions included a model of recovery, the restoration of hope, consumer and provider partnerships and application of evidence-based interventions. Models for promoting quality and cost efficiencies were considered as well.

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Debate Forum
The highlight of Summit 2000 was the debate forum orchestrated by Pam Hyde. The formal debate topic was:
Whether participants in pre-professional and post-graduate academic training programs should be reviewed by a national accrediting commission and determined to be proficient in managed care, the application of health care reform principles to actual practice, and qualified to both work in the public sector and to be added to managed care panels at the time of graduation from a similarly accredited, reform-oriented training program.

The two debate teams (Pro with David Shern, Marylou Sudders, Julian Ford; Con with Wilma Townsend, Michael Hoge, Christy Beaudin), in a spirit of good fun and jest, actually managed to offer in depth and penetrating analyses of the debate question.

Three Caucus Groups, representing Prevention (Chair-Chris Ringwalt), Consumers (Chair-Ting Mintz), and Children and Families (Chair-Marsali Hansen) met as well during the course of the Summit to consider and express to the conference participants their important perspectives as related to training and education.

At the Summit 2000 wrap-up, there was agreement that this initiative of training and education reform should go forward as a national agenda across all disciplines. Molly Finnerty, Jeanette Harrison, and Leighton Huey agreed on behalf of ACMHA to author a Call to Action article, Building a National Behavioral Health Training and Education Strategic Agenda: A Workforce Crisis for 2000 and Beyond, which will appear in the June, 2000 edition of Behavioral Healthcare Tomorrow. In addition, based upon the Summit, a number of individuals will be working on a Training and Education White Paper, which will be submitted to professional journals. Finally, there was interest in generating momentum for a Surgeon General’s Report on how the crisis in Training and Education of the behavioral healthcare workforce, its pre-professional training and its post-graduate education, have a direct bearing on care and outcomes in the area of behavioral health.

Summit 2000 serves as a lead-in to Summit 2001, with Pam Hyde as Program Chair and Leighton Huey as Co-Chair, which will consider the financing of workforce improvement through training and education initiatives.

Practice Guidelines in Mental Health and Addiction Services

Gail W. Stuart, PhD, RN, Conference Chair
American College of Mental Health Administration

Introduction
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.

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Summit 1999 Recommendations
ACMHA Board met in October, 1999 and reviewed the following Summit 1999 outcomes which are briefly described below:

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 derived from the Key Value Themes
4. Strategies for disseminating and implementing practice guidelines

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(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.

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(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

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(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.

1. Practice guidelines should be developed in partnership with recipients, consumers, family members, people in recovery, and a wide range of disciplines and organizations.
2. Practice guidelines should be clear, educational and fully available to recipients, consumers, families, people in recovery, all mental health providers, and all payers.
3. Practice guidelines should be a toolbox of options, and not prescriptive in nature.
4. Practice guidelines should be flexible and accommodate consumer choice as well as consumer values, goals and desired outcomes.
5. Practice guidelines should be sensitive and responsive to the individual’s environment, ethnicity, culture, gender, sexual orientation, and socio-economic status.
6. Practice guidelines should be based on scientific evidence of efficacy, effectiveness and established best practices in the field.
7. Practice guidelines should be reviewed and updated regularly.
8. A prevention framework and public health paradigm should be incorporated into every practice guideline.
9. 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.
10. Practice guidelines should produce positive clinical outcomes that are sensitive to time for quality improvement.

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ACMHA Key Value Themes

1. Consumers and families are at the core of performance measurement.
2. Consumer/customer choice must be a driving value for all systems of care, including their design, delivery, evaluation and accreditation.
3. Issues of ethnicity, race, age and developmental status, gender, language, culture, spirituality, disability are consciously addressed in ensuring access and availability of services.
4. 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.
5. 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.
6. 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.
7. 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.
8. 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.

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(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.

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Significance
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.

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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
Integra, Inc.
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
ValueOptions, Inc.
Veterans Health Administration
West Virginia Office of Behavioral Health Services

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References

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.

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Persons J.B. (1999). Using Evidence-Based Methods in a Private Practice. Behavioral Healthcare Tomorrow, Special Report: Quality & Accountability, June, 45-47.

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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.

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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
Email: stuartg@musc.edu

A. John Rush, MD
Co-Chair, Practice Guidelines Santa Fe Summit, 2000
Professor of Psychiatry
University of Texas Southwestern Medical Center
Dallas, Texas

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

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Abstract
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.

Overview

With the Santa Fe Summit 1997, the American College of Mental Health Administration brought together consumers and other mental health stakeholders with a focus on ensuring accountability in a churning healthcare marketplace. The first summit sparked a remarkably broad effort that has created a set of core indicators for the field, an accountability framework that is at once both focused and doable.

Santa Fe Summit 1998 was organized around the theme of integration of mental health and other services. Presentations and discussions focused on the concept of integration, its history, current experiences and the essential elements necessary to preserve quality, accountability and value as we make decisions about mental healthcare in the context of integration.

Conference content consisted of three main elements. The first was an information session, where presenters focused on the issues of integration as they pertain to mental health mental health and primary care, and issues of integration in the field of children’s mental health. The second part of the conference consisted of presentations of two actual case studies from the field–developing stories of attempts to integrate mental health service and substance abuse services in the public and private sectors. The third aspect was a simulation designed to have participants experience the challenges of incorporating the values and measures developed from Summit 1997 within the context of the current emphasis on integration and the “real world” pressures that exist in the healthcare market today.

From this combination of information and experience, several major themes surfaced:

The rest of this document contains copies of the papers presented, copies of the overheads from the case studies of integration attempts in the public and private sector, the simulation material and a synthesis of the “discussions about learnings” from the six workgroups in the simulation. Within each segment, more detail is presented about the ideas and strategies that emerged.

Presentations on Integration
The first sessions focused on presentations dealing with various aspects of integration. The papers presented and included in this document deal with “Issues of Integration” and “Integrating Primary Care and Mental Health Care”. The key themes and strategies that emerged from these presentations are inherently compatible with the values identified in Summit 1997.

Key Values/Summit 97

Themes/Strategies/Summit 98

Key Values/Summit 97

Themes/Strategies/Summit 98

Key Values/Summit 97

Themes/Strategies/Summit 98

There are no easy answers to questions about when to integrate, with whom to integrate and how to integrate services with mental healthcare Decisions should be guided by desired outcomes and by issues of quality and value for our healthcare dollars.

Case Studies
Two case studies of developing integration models were presented, one from the private sector and one from the public sector. In the former, Delta Airlines is undertaking a major effort to integrate mental health and substance abuse services with physical healthcare for it employees through training and education for supervisors and employees, standardizing delivery of healthcare, destigmatizing mental health issues and empowering consumers. They are doing so because they believe this will result in a healthier workforce, higher quality care, prevention of costly emotional and physical problems and increased safety for the consumer.

The County of San Diego, in California, has been working on a massive redesign of services in both the adult/older adult area and services to children and their families. This was presented as a work in progress, illustrating the complexity of implementing change, and the challenges of developing consumer involved integrated services.

In both situations, those involved are making an investment in the future that they believe will result in a better quality, more cost effective healthcare service delivery system. These are truly developing stories: perhaps worth revisiting after they have been operating long enough to have done some evaluation of their effectiveness.

Simulation
The simulation exercise was designed to stimulate discussion of issues of values, price and integration in the context of the real world marketplace of mental healthcare. A copy of the material given to workgroup participants is included in this summary. The key learnings from this experience are highlighted below:

The participants in the Santa Fe Summit 1998 on Integration recognized that the concepts of integration and how to preserve quality and incorporate accountability in the “integration movement” are elusive. In the fast changing and highly competitive healthcare marketplace, decisions are made with relatively little information. Clear thinking about functionality, outcomes and the primary interests and concerns of consumers often takes a backseat to decisions about structure, price and the “survival instincts” of purchasers and providers.

The College has developed a set of structure, process and outcome measures that are focused and driven by as set of axiomatic core values for mental health services for adults, children and families. Our challenge is to provide the leadership for incorporating these values into our policy, purchasing, structural, programmatic and fiscal decisions about integrated healthcare service delivery.

Issues of Integration
Colette Croze

The Myth of Integration
Both public and private healthcare systems treat integration as a much too simple concept, acting as if it’s self-explanatory and homogeneous–as if one size fits all . Integration is not a single objective: rather, it involves multiple objectives and is multi -dimensional , depending on the population which is served. It is not a single product, but may actually be a product line and definitely requires several product platforms. or delivery systems, for accomplishing the clinical objectives implied by integration.

Current models for integrating health and behavioral health benefits frequently address one or more of the following dimension of integration:

Rarely do they actually engineer a specific clinical strategy to effect integration at the patient and practitioner level.

There also appears to be confusion among three activities: subsuming mental health under health; combining mental health and health: and integrating mental health and health. In public insurance, there’s currently only one model for integration of health and mental health services in which Medicaid purchases management of a single benefit package (in which mental health is included along with medical/surgical benefits). through a single premium, from a single primary contractor or health plan, thereby assuming that singularity equals integration. In almost no case does that commercial health plan deliver the mental health benefit through an integrated approach–most health plans purchase mental health benefits management from a carve out company. Is this integration? Integrated benefits, integrated health plans, integrated financing–none of these automatically guarantees integrated care through collaborative treatment.

While the current attention to integration is laudable, the provision of integrated healthcare may be a second order goal, after the field has developed the clinical and financial technology and approaches for delivering health and mental health services collaboratively. Currently, in both the commercial and public sector. there is no experience base which points to successful models for integrating health and mental healthcare.

Most purchasers treat “buying integrated benefits management from HMOs” the same as buying benefits management which clinically integrates health and mental health services. The two are not one and the same and. it’s possible that achieving integrated clinical care does not require that coverage be provided by integrated health plans. It’s also possible that, although many purchasers have adopted the goal of “integration”. the technology of achieving this goal has yet to be developed.

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Specific Integration/Coordination Objectives
As stated above, there are many ways to operationalize the goal of “integration of health and mental health”. Demonstrating the multidimensional nature of integration, its objectives could include any of the following:

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Development of Integrated Models
If one were developing an integrated model, the sequence of considerations would be as follows:

This is very complicated product development and successful approaches will require adherence to that biological and architectural principle: ” form follows function”. In this case, form (organizational configuration) and financing must follow the clinical objectives, not the other way around.

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Obstacles to Integration
The stigma attached to mental illness, the lack of parity between health and mental health benefits and the current realities of medical practice all present obstacles to integration. Consider just the realities of practice:

Payers’ Opportunities to Facilitate Integration/Collaboration
Payers have opportunities to facilitate collaborative care through their purchasing practices, if they attend specifically to the issue and set expectations for their care management organizations:

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Integrating Primary Care and Behavioral Care
New Models for Integration

If integration is not well-suited to a one-size fits all approach, purchasers must be clearer about the specific clinical objectives they wish to accomplish through integrated benefits management. For example. using the above-described approach for choosing an integrated model (among an integrated product line), the payer could specify the populations for whom it wanted collaborative treatment and the components of the clinical process which were to be delivered in a collaborative manner; it could also identify performance standards and indicators which would demonstrate that this integration occurred. The purchaser could preserve the integrity of a comprehensive mental health benefit package by contracting separately with health plans and with mental health plans, but could withhold a portion of each plans capitation payments as an incentive pool which would be released only if the integration performance indicators were met. This would create a codependence between the health and mental health plans around integrated care since they would need to collaborate in order to receive the incentive payments.

Whatever purchasing strategy they choose, payers can move the field forward on the issue of integration if they adopt two principles: form follows function; measurement, not anecdote.

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H. G. Whittington, M.D.
Introduction

Last year at the Summit, we found it relatively easy to arrive at a consensus about values. It became clear in the process that many of the desirable outcomes fell beyond the scope of traditional behavioral health services, such as housing, economic security, employment, safety, and general health services. This meeting is the first step at asking how we might, as a concerned subculture of behavioral health policy formulators, pursue the laudable values and beliefs which we all support.

We agreed on the DESIRABILITY of certain outcomes.

Today we begin to discuss the FEASIBILITY of implementing our values in the real world: the task of being PRAGMATIC IDEALISTS: ACHIEVING THE ATTAINABLE WHILE PURSUING THE IDEAL.

FEASIBILITY has several components:

Last year I cited the PARABLE of the Sand Canyon Ruin to demonstrate how beliefs and values, not matter how vigorously pursued, cannot cope with changing circumstances in the absence of effective technology. Last summer in revisiting the ruin, I discovered, nearby, a modem relic: a three-story residence, replete with religious symbolism incorporated in its architecture, standing uncompleted and abandoned. In this instance, the beliefs/values were wedded with advanced technology-and the project still came to naught because the necessary capital was lacking.

We all live hemmed in by this trinity of FAITH/VALUES, TECHNOLOGY, AND CAPITAL/RESOURCES. To ignore the constraints imposed on our attempts to be PRAGMATIC IDEALISTS is to ensure unanticipated and undesirable consequences in our efforts at human betterment (Dorner, 1996). To summarize one component of error in complex organizations, at the onset of a change process there is a balanced mixture of ASSESSMENT, REFLECTION, and ACTION. Over time, as initial apparent successes come unraveled, ACTION steadily increases in frequency, while assessment and reflection decline precipitously. Most of us in this room are action oriented, and will put the Santa Fe Summit recommendations into play. For example, my Managed Behavioral Healthcare Organization, Comprehensive Behavioral Care, has adopted the Summit as the basis for our corporate Quality Management Plan, which will provide an opportunity to assess and reflect if we don’t get too absorbed in acting to observe and think! The Santa Fe Summit, this year and for some years to come, will provide a wonderful opportunity to ASSESS and REFLECT, correcting and refining our initial efforts.

In my presentation today, I will focus on one aspect of the implementation of the value expressed in the Summit Report, the integration of behavioral health and general medical care.

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The integration of behavioral and primary care is not a new idea.

Enough history. My question is this: when an idea that has so much face validity is adopted and implemented by so many bright and idealistic people and yet has apparently not liven up to the self-evident good that seems apparent, why are we once again jumping on the integration bandwagon? Sol Feldman, in his presentation tomorrow, will undoubtedly give us all ample reason to consider carefully the answers.

My job is a bit less prescient that Sol’s, however: to explore why we might want to integrate medical and behavioral health care, how we might go about it, and what the impact on the recipients of our services might be. I will use the over two-decades old trinity of National Health Care reform to organize the remainder of this presentation:

Would integration of behavioral healthcare and medical care increase accessibility, quality, or affordability of behavioral health services?

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Accessibility
The existing system of care appears to perpetuate under-utilization of behavioral health services. Physicians still do not recognize, in about half of their patients, the existence of psychiatric morbidity (Higgins, 1994); chemical dependency is underrecognized as well, and even when identified is not likely to result in an appropriate referral.

As well, there are different cognitive norms between the medical and behavioral health subcultures: physicians do not perceive relationship problems as worthy of professional intervention, while many if not most behavioral health professionals view them as appropriate for treatment services, broadly defined. For example (Kimball and Snowden, 1997), HMO patients with a self-referral option appear to enter mental health treatment because of relationship problems at a higher rate than their physician-referred counterparts. This disparity in world-views (and it appears that patients’ perceptions are closer to the behavioral health subculture’s than the medical) has important, although unanswered, implications:

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Now, could the skill of primary care physicians in the recognition and management of behavioral disorders be enhanced through “integration” of behavioral and medical health services? The efforts to increase physician competency in this area generally have fallen short of true integration, but rather have adopted strategies that incorporate one or more of the following approaches:

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Quality
As with accessibility, there are many assertions that integration would improve quality, but few of them are supported by empirical data.

At this point in the presentation, I have just made a transition from one method of value assessmentempirically verified improvements in one or more outcomes-to appraisal of compliance with consensual standards of good and accepted practice. That transition is perilous for the entire process that we are engaged in. The hazard of consensus, of course, is that it is only the codification of the conventional wisdom of the moment, which only occasionally withstands the tests of time, advancing technology, and rigorous assessment of outcomes. For example, a little over ten years ago the Prudential Insurance Company, under Mary Jane England’s leadership spite of my timorous counsel of caution and gradualism–, essentially accepted that then available outcome data did not support the general or predictable superiority of 28-day residential treatment over intensive outpatient for chemical dependency. She was encouraged by a rather eccentric California psychiatrist who shall remain nameless-not out of discretion, but because I don’t remember his name–, who was a strong advocate of intensive outpatient treatment, already in full steam on the west coast. This action in full opposition of the consensus of the experts on chemical dependency treatment-followed by an equally radical re-appraisal of the value of residential treatment for emotionally and behaviorally disturbed adolescents-resulted in the ability to afford a major expansion of outpatient services without crippling co-payments, a significant advance in accessibility.

This is simply another plea that we continue ASSESSMENT and REFLECTION as we go forward with this process. The joy of the scientific endeavor is that proving oneself wrong in initial hypotheses is a victory as much as proving correctness-and the humbling experience contributes to enormous personal growth!

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Affordability
Since the dollars available for behavioral health services are finite, we must assume a zero sum scenario and ask if any innovation, within a fixed number of dollars, will increase accessibility and/or quality. For this presentation, I believe that we should look at all health-care dollars as the “pot” of money, since the allocation between physical and behavioral health is fungible and ever-shifting. As I suspect Sol will be discussing tomorrow, this area presents the greatest potential hazard to our constituency, as general health care systems may seek reduction of behavioral healthcare costs to “balance the budget on the backs of the mentally ill,” as Mary Jane once so passionately accused an HMO.

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Models for Integration
Perhaps it is time now to ask, what is “integration” anyway? Particularly with such an emotionally charged word, we probably should pay a little attention to what we are undertaking, rather that accepting the unalloyed social good of the abstract concept of integration. Probably the most appropriate definition is, “having all its parts combined into a harmonious whole; coordinating diverse elements.” Using this broader definition, which helps protect us from overly concrete ecumenical enthusiasm, harkens back, of course, to earlier concepts of case management or care coordination. That effort is to various degrees in some disrepair across the country, as the earlier expectations have been dimmed by cost-benefit concerns; as well, case management in the proprietary sector is a code word, often, for utilization management. Yet, at least for high-complexity, high-risk cases, it continues to have an honored place in our armanentarium of care integration.

David Mechanic, who has contributed so richly over the years to the intellectual capital of the behavioral health enterprise, has published a recent article entitled “Approaches for Coordinating Primary and Specialty Care for Persons With Mental Illness” (Mechanic, 1997). He proposes, and reports the limited outcome data, on the following models:

I commend the article to you in its entirety, and will not attempt to parrot it here. Rather, I would like to cite a few words as a segue-way into my long-awaited conclusion:

“The more we learn, the more we appreciate the importance of sensitive management of communication and psychosocial issues across all areas of disease. Patient communication and behavioral health practice is intrinsic to good medicine, more broadly defined, and there is need to integrate such concerns centrally into all aspects of medical education. Managed care and the evaluation of primary care responsibilities may provide the incentives for reappraisal of educational needs.”

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Conclusions
Attempts to assure that all health care is combined into a harmonious whole, and/or all of its diverse parts coordinated, have been numerous, motivated by concerns for patient welfare, and implemented by well-intentioned professionals for three decades without the emergence of a consensually accepted model or strong demonstration of either clinical or social utility. A CULTURAL MATERIALIST might say that is because we lack the TECHNOLOGY to implement our aspirations.

We have focused on structural and process reform WITHIN THE SYSTEM, AS WE DEFINE THE SYSTEM. Conspicuously absent has been attention to factors not entirely inside our community of perceptions and interests:
Although integration is clearly seen as the solution of the moment, the term is used to mean a myriad of different things, we are often not clear on what definition is being used in any particular discussion, more is assumed about the concept than is really known and we do not as yet have any specific models that have emerged to guide us in our thinking and planning.
It is easier to talk about integration than it is to do it. Simply creating integrated administration, financing and/or benefits does not necessarily result in integrated care. Whether we are talking about integrating separate organizational structures, different funding streams, physical and mental health services, or a wide range of health and human services as is often true in the field of children’s mental health, actually implementing a successful integrated system requires consumer involvement at all levels, a clear focus on outcomes, sustained leadership, broad-based commitment, and can be costly, at least during the initial stages.
The integration we are striving for is functional integration; integration in practice so that the service delivery system appears seamless to the consumer. Creating a common language for practice guidelines and outcome measurement can help move us in this direction. Financial incentives to work together have proven successful in the past, New knowledge that links mental health and physical health may create even stronger technological and professional incentives for integrating care.
The current competitive healthcare marketplace frequently does not allow the careful reflection and the focus on integration and the values and outcomes that were identified in Summit 1997. As conference participants tried to apply these principles during the simulation, they found themselves focusing more on producing a product for the purchaser that would be acceptable, with greater emphasis on price than on consumer involvement and issues of integration, access and accountability.
Consumers and families are at the core of performance measurement
Consumers/customer choice must be a driving value for all systems of care, including their design, delivery, evaluation and accreditation.
Sustained models start with the consumer, empower consumers and/or are consumer driven
The term “integration” is used in many different ways. Presenters discussed the various definitions and the need to define integration from the client/service perspective.
No matter how integration is defined or implemented, it is valuable only if it adds value to the healthcare equation and produces a seamless service system for the consumer.
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
Issues of ethnicity, race, age and developmental status, gender and language. culture, spirituality and/or disability are consciously addressed in assuring access and availability of services.
Successful integrated systems incorporate the “three A’s” of good service delivery-Affability, Accessibility, Ability
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.
A true public health vision of community health must drive outcome measurement, which means that universal access and integrated primary and mental health and substance abuse care are the ultimate goal of effective systems.
Desired outcomes should drive the change process.
In thinking about integration, form should follow function; integration should occur functionally and in practice, structure becomes less important
There has been a long history of attempts to integrate all health care, and health and human services, without the emergence of a consensually accepted model or documented successful outcomes.
Integrated administration, integrated financing and integrated benefits do not necessarily result in integrated care
Capable, sustained leadership is key to successful integration
Implementing and sustaining successful integration requires careful planning and continuous assessment and reflection avoiding -‘the logic of failure”– when things start to falter action increases, while assessment and reflection decrease
Under the pressure of trying to develop a presentation with very little time and information, values, integration issues and outcome measures took a backseat to developing a product at a competitive price
Different stakeholders emphasize different values Consumers took for choice and seamless services; clinicians stress quality treatment and service, purchasers focus upon price and cost effectiveness, providers need to maintain a viable business The key values identified in Summit 97 need to be operationalized for all stakeholders.
Price forced a discussion of balancing reality and values Responses to the competitive process need to be structured in such a way that it will be possible to incorporate and operationalize key values. If not, one should be willing to walk away from the business
In the marketplace it is important for both purchasers and providers to be clear about integration expectations. There is a difference between buying an integrated benefits system and buying a benefits system that integrates services.
It was difficult to focus on the concept of integration in the competitive procurement process. Incorporating key values, integrated outcome measurements and consumer input are ways of encouraging functional integration to occur following a successful contract procurement.
geographic
financial
organizational
identification of clinical risk factors which trigger the need for a psychiatric assessment
identification of medical use patterns or physical conditions which can serve as “warning signals” for the need for psychiatric intervention
appropriate identification of the mental health needs of HMO members
appropriate treatment of persons with psychiatric disorders by primary care practitioners
appropriate referrals of persons with more extensive psychiatric needs to specialty mental health practitioners
appropriate levels and types of consultation across primary and specialty care (e.g. mental health)
for whom is care to be integrated?
Specify the population(s)
what part of the care delivery process is to be integrated? (screening, intake, diagnosis, treatment, referral?)
Identify the clinical functions to be impacted what strategies will be employed to do this?
Describe the clinical interventions
what delivery system will yield the greatest likelihood of successfully implementing these strategies?
Construct the product platform
what financing method(s) will incentivize clinical practice in the desired directions?
Choose a financing method
what organizational configuration will best support and facilitate all of the above?
Develop an organizational framework to support the integrated functions
Very few primary or specialty medical care practitioners have any training in/exposure to mental health problems or psychiatric conditions
Very few primary care practitioners spend extensive time with their patients (or look for issues that the patient doesn’t specifically present)
Very few primary care practitioners conduct wholistic/comprehensive assessments on their patients, unless there’s a specific reason for doing so
Patient consent is required for any collaborative activities. Health plan members may not want their HMO communicating with their mental health providers; MBHO members may not want their mental health provider communicating with their health plan
All mental health services are not offered at the same level of complexity and intensity. It may be true that HMOs can successfully provide “primary mental health services”. but that only MBHOs can provide both primary and specialty mental healthcare.
Establish specific “bridge” protocols for provider-level collaboration across the health/mental health boundary

Establish mental health-specific performance standards and measures which are consistently applied to both HMOs and MBHOs

Establish targeted “integration/collaboration” objectives which are then operationalized through specific performance indicators. Move beyond our current reliance on anecdotes to chronicle efforts at integration since “the plural of anecdote is not data”.

Is the technology available to attain the goal?
Do the resources exist to capitalize the necessary processes?
Is there reasonable evidence that achievement of a goal would yield empirically demonstrated benefits?
If so, what is the value of the benefit, computed as the outcome enhancement expressed quantitatively divided into the cost? For example, if intervention A results in a 20% increase in interpersonal contacts over a base period, and the cost is $500 a month, might that money be better spent in increasing the proportion of pre-school children receiving a full schedule of immunizations?
Would the implementation process be socially acceptable in the present economic and political milieu? For example, when I published the first medical necessity rating scale in 1966, it was met with thundering indifference; it is now occasionally cited as a forerunner of our present system of rationing care.
On February 5, 1963, John F. Kennedy delivered a message to Congress which said, ” I propose a national mental health program to assist in the inauguration of a wholly new emphasis and approach to care for the mentally ill … We need a new type of health facility, one which will return mental health care to the mainstream of American medicine ….
This proposed a structural approach: build a facility with an open medical staff and they will come. We did not, in general, have open medical staffs; and private practitioners did not come.
Interestingly, psychiatrists have rejoined, perhaps unfortunately, the mainstream of American medicine to a considerable extent-with, some of us feel, a consequent loss of many of the attributes that made psychiatry particularly useful to society! Capitalism is indeed wondrous in its workings
Over the years, national policy had been directed toward the “psychitriatizing” of medicine, with generous federal grants:
General practitioners were subsidized to enter psychiatric residencies; they came out as psychiatrists, however, and rarely combined family and psychiatric medicine in their practices.
Training opportunities were developed for practicing physicians, ranging from didactic to sensitivity groups, to increase their sensitivity to, and comfort in dealing with, psychiatric problems.
We subsidized the development of psychosocial training in family practice residencies, utilizing predominately clinical psychologists as faculty, with more success. While Family Practitioners have not notably expanded their scope or expertise in the management of behavioral health problems, they may be marginally better gatekeepers, and more sophisticated brokers for behavioral health services on behalf of their patients.
Most recently, the Depression, Assessment, Recognition, and Treatment project has developed good training materials for non-psychiatric practitioners, as well as useful treatment guidelines for practitioners.
And, independent of national policy or financial incentives, non-psychiatric physicians continue routinely to prescribe over 70% of all psychoactive medications dispensed (if antipsychotics are excluded, the proportion of antidepressant and anti-anxiety agents is even higher). And, the National Comorbidity Study ( Kessler et al, 1994) shows that while only half of the one-fifth (20%) of the community population having a mental disorder in a 12 month period sought any form of professional service, only half received care from the behavioral health specialty sector, with most of the remaining receiving their care exclusively from primary care physicians. In this context, then, behavioral healthcare is significantly integrated into general medical practice.
In 1966, as Director of Psychiatry for the City and County of Denver, I located mental health teams in each of the Neighborhood Health Centers in the Denver General Hospital’s catchment area. In addition to the usual suspectspsychiatrists, psychologists, and social workers-masters prepared psychiatric nurses and indigenous non-professionals were charged with a sub-area of about 40,000 population, and encouraged to work closely with the physicians and other health workers in the Neighborhood Health Centers. This consanguinity model did not produce uniformly stellar results-just as marriages and other relationships do not necessarily prosper with consanguinity! Admittedly, there was some improved communication: but the reality was that, in general, the mental health types and the medical types did not particularly like each other, or feel greatly compelled to relate differently than they had before collocation.
The first generation of federally approved HMOs were all integrated models, with employed staff-model mental health professionals. While a few large HMOs, such as Kaiser, Harvard Community Health Plan, and Puget Sound, have “kept the faith,” most have “carved back out’ the behavioral health components.
Accessibility
Quality
Affordability

Does the extension of psychosocial services-as opposed to pharmacological intervention for the symptoms of situational disturbance, such as insomnia or anxiety, which can be rendered by general physiciansresult predictably in the prevention of more serious mental health disorders (Mrazek and Haggerty, 1994)? If so, intervention can be seen as having a preventive effect, a desirable social goal.
If, on the other hand, the psychosocial services only offer palliation-relief of tension-which is no more effective than medication, and do not prevent the development of more serious disorders, then affording such services is a waste of the health care dollar.
There is, of course, considerable evidence that early intervention does result in a decrease in absenteeism and an increase in work productivity; this would suggest that such a benefit should properly be funded by employers under an employee assistance benefit.
Continuing Medical Education utilizes a cognitive model which has Questionable efficacy in modifying physician behavior (Stoudmire, 1996).
The development of integrated training and clinical guidelines, such as the publication of the Quick Reference Guide for Clinicians entitled Depression in Primary Care.- Detection, Diagnosis, and Treatment (Agency for Health Care Policy and Research, 1993) clearly has face validity, and has been perceived as useful by primary care physicians.
The use of patient-report screening instruments has been proposed for many years, and research confirms that they would increase recognition of mental disorders in the physician’s office. While research continues to show their usefulness, and even that while increasing primary care visits they do not increase the use of psychotrophic medications or rate of hospitalization (Mazonson et al, 1996), such instruments are little utilized in routine medical practice. Chemical dependency instruments, which exist in great variety, are also not routinely utilized, even in settings, such as the offices of obstetricians, where there is considerable preventive potential.
There is limited research indicating some enhancement of outcomes through collaboration:
One study of collaboration between the primary care and behavioral health provider on the outcomes of treatment of depression (Katon et al, 1995) showed, when compared with patients treated without such collaboration, improved rates of compliance (75.5 % Vs 50.0%), more patients helped by antidepressants (88.1% Vs 63.3%), and a greater likelihood of rating the quality of care as good to excellent (93.0 % Vs 75.0%). However, no differences were noted with “minor depression.”
While other authors believe that the PCP may be able to enhance medication compliance (Lin et al, 1995; Faloon et al, 1996), data is impressionistic and far from convincing.
Certainly, we all have experienced the untoward effects of the primary care physician’s and the psychiatrists prescribing medication in ignorance of what the other is doing. Because of this, the state of Texas, in its Medicaid reform, has mandated communication between the behavioral health provider and the primary care physician concerning diagnosis, medication, and treatment planning and results (although, not mandating reciprocal communication from the PCP to the BHP). As a subcontractor for HMOs in San Antonio, Fort Worth, Austin, Lubbock, and the Houston metropolitan area, CompCare has achieved modest success in increasing written communication between the BHP and the PCP. The value of this process, however, has not been demonstrated; but it is clear that the costs of care administration have been increased-since these dollars can only come out of the amount used to purchase behavioral health services, the cost-benefit ratio is critical to determine before we blindly perpetuate superstitious, bureaucratic behavior forever.
Enhanced early recognition and referral for appropriate treatment of major mental disorders would certainly be a strong reason for integrating services. The NIMH Epidemiologic Catchment Area Study, Four Sites, demonstrated that the lag between age of onset and first diagnosis of major depression ranges from 6.7 to 13.5 years, depending upon age of onset. Yet, we cannot empirically demonstrate that this creature called ‘integration” would measurably shorten that interval.
The dearth of hard data, however, has not deterred NCQA from codifying some elements of integration in their Standards for the Accreditation of Managed Behavioral Healthcare Organizations. Ql 7.2, “Collaboration with medical providers,” mandates consultation with PCPs, other healthcare practitioners, and relevant medical delivery systems in the selection of clinical issues to study and analyze. Ql 1.5 directs that the Ql committee include structured input from representatives of relevant medical delivery systems or other health care practitioners. Ql 6.2 requires that the BHO has mechanisms to inform primary care physicians about the diagnosis, treatment, and referral of behavioral health disorders commonly seen in primary care. Again, this has implications for the costs of health care delivery. Indeed, our own Summit last year affirmed, in the statement of values, that integration of behavioral healthcare and medical care adds value.
Use of the PCP as gatekeeper was designed to prevent the unnecessary or frivolous utilization of behavioral health services. By now the literature is replete with data that such a strategy may reduce access to outpatient services by behavioral health professionals, the patients did not go away, and often received unnecessary inpatient services or over-utilized general medical services as a consequence. Whenever the PCP operates with a global capitation, so that any specialty services are deducted from his monthly payments per enrolled member, the disincentives for early and appropriate referral increase prohibitively.
The “medical offset” hypothesis, postulated on two decades of research-which is often imperfectly understood and applied-has never, in my experience, been a convincing argument for a non-psychiatric medical professional: our colleagues simply have not observed, in their experience as practitioners or administrators, that improved access to behavioral health services reduces general medical care costs. And, indeed, there is no empirical data from a naturalistic practice environment that supports this hypothesis; moderate effects noted in atypical or specialized environments, or with special populations such as somatizing or system-abusing patients, simply have not held up in the ebb and flow of every-day clinical life. (Shulberg, 1997) The clearest yield, actually, was overlooked by many in the reading of the classical McDonald-Douglas study of integrated EAP and behavioral health services: immediately following the identification and referral to treatment of a chemically-dependent employee, the general medical costs of the spouse and dependent children declined precipitously.
The utilization of PCPs as primary providers of behavioral health services, including such approaches as guideline-directed treatment of major depression, has been research extensively (Nazareth et al, 1996; King, 1996; Schuylberg, 1996; Katon et al, 1996; Brody et al, 1997). Efficacy has been variable, and no data was presented on cost comparisons with utilization of the behavioral health provider.
Long-term cost reductions from improved early recognition and referral for appropriate treatment, since almost all behavioral health problems first present in the PCP’s office, represent a theoretical yield that would, unfortunately, be obscured by the rapid movement of members from one organized system to another, as well as the movement of providers in and out of care management systems due to network restriction, exclusion based on provider profiling, and provider resignations based on fee or contract disputes.
Mainstreaming
The liaison/collaboration model
New practitioner models
Independent carveouts
Functionally integrated carveouts
Extended care models
The CONSUMER is, after all, the one most concerned with having the diverse parts of the system coordinated into a harmonious whole.
The PURCHASER, broadly defined, controls decisions about allocation of resources that results in incentives and disincentives for the coordination of the system of care into a harmonious whole.

We might well focus our future efforts, then, on the following endeavors:

But we must also, in a society that does not like boundaries, work on defining much more precisely the components of “behavioral health,” and delineating the implications of service system design and payment mechanisms. We have pretended too long, for obvious reasons, that the worried well-the common cold of behavioral health-are entitled to a disproportionately large share of the health care dollar, to purchase a “store-boughtened friend” with whom to discuss their emotional distress over life’s unavoidable unpleasantness. Nor can we any longer pretend that every one who chooses to get drunk or stoned is the victim of an illness. Nor that everyone who is sad is “depressed.” Nor that intra-species aggression and predation is always the result of a brain disorder. This lumping together of all human misery under the illness rubric demeans and erodes our public image and credibility. The imprecision of our diagnostic categories evokes memories of the humors and the wandering womb. Our psychotherapies and counseling are so imprecise and rendered so promiscuously for all human distress, as to remind us of the panaceas of the last century, bleeding and purging. Nor should we forget the admonition of Action of Mental Health (Joint Commission, 1961) that the major unfinished business of our activities is effective treatment and rehabilitation of major mental illness. As is true for individual adolescents, our adolescent field must decide what we cannot do, in order to devote our full energy and resources to that which only we can do well. As the father of seven adolescents over four decades, and as one who had an inordinately prolonged adolescence myself, I am painfully aware of the anger and pain that such an acceptance of limits entails. But not to do so engenders an eternity of unrealized promise. But for today, let’s focus on one aspect of improvement, the reform of the competitive environment.

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Reform of the Competitive Environment
Managed care companies compete on the basis of price. As this competition continues to erode margins-indeed, no un-subsidized behavioral health managed care company has yet demonstrated a capacity to yield a sustained profit in excess of that yielded by many less risky investments-managed care companies have limited ways to remain viable:

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WITH THE HEAVY DEBT BURDEN OF THE NEW MANAGED BEHAVIORAL HEALTHCARE MONOLITHS, THESE PRESSURES HAVE INCREASED EXPONENTIALLY: ESTIMATES OF THE MONTHLY COSTS OF DEBT SERVICE ALONE RANGE FROM $0.15 PER MEMBER PER MONTH TO $0.48 PMPM.

Clearly, it does not require a clairvoyant to predict the turmoil of these next few years, which will have a disastrous effect on consumers when, not if, the next economic downturn occurs. When a labor surplus again develops, companies will be less impelled to compete for employees on the basis of benefits, and usually mental health benefits are the most vulnerable to cost-saving measures (with the exception of the larger companies with highly professional human resource departments).

IT IS TIME NOW, THEN, FOR US TO DEVELOP A CONSENSUS ABOUT THE STANDARD BENEFIT PACKAGE TO BE OFFERED AS A MINIMUM BY ALL MANAGED CARE COMPANIES. SUPPLEMENTS WOULD STILL BE OFFERED FORPURCHASE,BUTWITHINDEFINEDBENEFITMENUS-MUCHASNOW EXISTS FOR MEDICARE SUPPLEMENTAL PLANS.

Managed care companies would then compete on price and service, with regulatory oversight to guard against fraud and abuse.

Undoubtedly, any uniform national benefit design would be lower that our hopes and expectations. But, I believe it is a better platform to build from than the present PARITY platform, which is more form than substance.

Unless the initiative is national, as states have found however when they have acted independently, the usual competitive forces will be inhibited since the “playing field” is not level.

Another state approach is to define certain diagnoses as “like any other illness.” This sound like good social policy, since it should promote private sector services for major mental illnesses that otherwise would be a public sector responsibility. It is, however, vulnerable to manipulation because psychiatric diagnoses are so fungible. NO PLAN BASED ON DIAGNOSTIC CATEGORIES CAN BE FAIRLY ADMINISTERED AT THIS TIME IN HISTORY: we lack the technology to substantiate psychiatric diagnoses. With the advance of the neurosciences and genetic research, we undoubtedly will have such capability in the future-which will raise many ethical and social justice issues.

I hope that these observations and thoughts will contribute to the reflective process of this and future Santa Fe Summits, and look forward to the vigorous debate that will ensue. I will be really disappointed if we go home this time with so much agreement-it will suggest to me that we have dodged the big issues upon which the future of the mental health venture, a component of the centuries-old human betterment movement, will hinge.

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Bibliography
Agency for Health Care Policy and Research. Depression in Primary Care: Detection, Diagnosis, and Treatment. U.S. Government Printing Office, Washington, DC, 1993.

Brody DS, Khallq AA, Thompson TL. Patients’ perspectives on the management of emotional distress in primary care settings. J Gen Intern Ed 12:403-406) 1997.

Dorner, Dietrich: The Logic of Failure. Addison-Wesley, Reading, Massachusetts, 1996.

Fraser J Scott. Prof Psychol 27:335, 1996,

Higgins ES. A review of unrecognized mental illness in primary care. Prevalence, natural history, and efforts to change the course. Arch Fam Med 3:908-917@ 1994.

Joint Commission on Mental Illness and Health: Action for Mental Health. Basic Books, New York, 1961.

Katon W et al: Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA 273: 1026-1031, 1995.

Katon W et al. A multifaceted intervention to improve treatment of depression in primary care. Arch Gen Psychiatry 53:924-932, 1996.

Kessler RC, McGonagle KA, Zhao S, et al. Arch Genl Psychiatry 51:8-19, 1994.

Kimball JM, Snowden LR. Problem type and referral to HMO mental health treatment. Adm Policy Ment Health 24:399-409, 1997.

King M, Nazareth I. Community care of patients with schizophrenia: the role of the primary health care team. Br J Gen Pract 46:231-237, 1996.

Lin EH et al. The role of the primary care physician in patients’ adherence to antidepressant therapy. Med Care 33:67-74, 1995.

Mazonson PD et al.- J Am Board Fam Pract 9:336-345,1996.

Mechanic D: Approached for coordinating primary and specialty care for persons with mental illness. Genl Hosp Psychiat 19:395-402, 1997.

Mrazek PJ, Haggerty RJ, Eds. Reducing Risks for Mental Disorders. Frontiers for Preventive Intervention Research. National Academy Press, Washington, D.C., 1994.

Nazareth I. King M, Tai SS. Monitoring psychosis in general practice: a controlled trial. Br J Psychiatry 169:475-482, 1996.

Nickels MW, McIntyre JS: Psychaitr Serv 47:522-526, 1996. “The integration of mental health care and primary medical care enhances the quality of patient care and may improve the overall cost-effectiveness of a health care system.” Not data provided to support this assertion.

Penner N. Group Health Cooperative of Puget Sound: toward integrated care, a pioneering provider’s first steps in integrating medical and behavioral health services. Behav Hlth Mgt 16:24, 1996.

Schulberg HC et. al. All that glitters is not always gold: medical offset effects and managed behavioral health care. Arch Fam Med Jul-Aug:334339 1997.

Schulberg HC et al. Treating major depression in primary care practice. Eight-month clinical outcomes. Arch Gen Psychiatry 53:913-919,1996.

Stoudemire A. Psychosomatics 37:502-508, 1996. “…evidence indicates that not only are psychiatric disorders underrecognized in primary care settings, but also that treatment is often inadequate and accompanied by less than optimal outcomes…Strategies for the develoment and implementation of these educational training modules will also be discussed [in Part II].”

Tews J et al. Improving the management of patients with schizophrenia in primary care: assessing learning needs as a first step. Can J Psychiatry 41:617-622, 1996. From southern Alberta.

Tiemens BG. Ormel J, Simon GE: Occurrence, recognition, and outcome of psychological disorders in primary care. AM J Psychiatry 153:636-644, 1996. From Netherlands. “Recognition of psychological disorders was not associatedwith better outcome. Recognition is a necessary but not a sufficient condition for delivery of treatment according to clinical guidelines. Increasing recognition is likely to improve outcomes only if general practitioners have the skills and resources to deliver adequate interventions.”

Voelker R. Quality standards intend to bring psychiatry, primary care into closer collaboration. JAMA 277:366, 1997. Discusses NCQA standards.

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Addendum
Stoudemire A- Psychosomatics 37:502-508, 1996 “…evidence indicates that not only are psychiatric disorders underrecognized in primary care settings, but also that treat3nent is often inadequate and accompanied by less than optimal outcomes … Strategies for the development and implementation of these educational training modules will also be discussed [in Part III].”

Tews J et al. improving the management of patients with schizophrenia in primary care: assessing learning needs as a first step. Can J Psychiatry 41:617-622, 1996. From southern Alberta.

Nichels MW, McIntyre JS: Psychiatr Serv 47:522-526, 1996. “The integration of mental health care and primary medical care enhances the quality of patient care and may improve the overall cost-effectiveness of health care system.” Not data provided to support this assertion.

Penner N. Group Health Cooperative of Puget Sound: toward integrated rare, a pioneering provider’s first steps in integrating medical and behavioral health services. Behav Hlth Mgt 16.-24, 1986.
Tiemens BG, Ormel J, Simon GE.- Occurrence, recognition and outcome of psychological disorders in primary care. Am J Psychiatry 152:636-644, 1996. From Netherlands. “Recognition of psychological disorders was not associated with better outcome. Recognition is a necessary but not a sufficient condition for delivery of treatment according to clinical guidelines. Increasing recognition is likely to improve outcomes only if general practitioners have the skills and resources to deliver adequate interventions.”

EDUCATION AND EMPOWERMENT OF THE CONSUMER. In somewhat belated recognition of this self-evident truth, the College just last year began to reach out actively for consumer involvement, believing that it is time to move beyond the adversarial relationship that has so often characterized cross-cultural exchanges, to a true partnership and community of interest. We have a great deal to learn about how to work together effectively. I have no doubt that future Santa Fe Summits will focus on this vitally important area.
REFORM OF THE COMPETITIVE ENVIRONMENT in order to enhance coordination between various components of the healthcare system to produce an harmonious whole. I would like to end with a few thoughts about how an organization such as ours, acting as a public trust, could promote a national debate-not only by our pronouncements, but by emboldening the key opinion-setters in this room to end our attempts to accommodate to a system that is corrupt at its core.
They can restrict benefits such as exclusions by diagnosis, chronicity, or annual or lifetime benefit maximums
They can reduce utilization by increasing co-payment levels
They can reduce provider reimbursements still further
They can utilize ever-less well-trained, and hence less pricey, providers
They can become more efficient in the provision of the non-clinical aspects of their operations: information and referral, utilization review, provider services, claims payment.
They can reduce their sales commissions. In years past, 3% of premium was a not unusual commission, even higher when brokers were involved. The company that I work with, focusing heavily in the private sector, HAS discontinued commissions for sales personnel, considered a departure bordering on sacrilege by many!

ACMHA Report
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ACMHA Process Group Indicators & Proposed Measures
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ACMHA Process Group Indicators & Proposed Measures
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Comparison of Performance Indicators
NCQA/BMAP, ACMHA, NASMHPD/NASADAD/APWA
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Additional Information

• Background and Introduction
• The Core Set: Values and Indicators endorsed by ACMHA
• Special Reports
• Future Development
• Acknowledgements and supporting documents