November 2006

Grant Results

SUMMARY

In March 2005, the Institute of Medicine (IOM) issued a report, Improving the Quality of Health Care for Mental and Substance-Use Conditions. It presents an agenda for strengthening mental health and substance abuse treatment and care.

The report was the product of an IOM committee charged with examining the implications of a 2001 institute report, Crossing the Quality Chasm: A New Health System for the 21st Century, for the treatment of mental health and addictive conditions.

Key Recommendations

  • "Health care for general, mental and substance-use problems and illnesses must be delivered with an understanding of the inherent interactions between the mind/brain and the rest of the body."
  • "The aims, rules and strategies for redesign set forth in Crossing the Quality Chasm should be applied throughout [mental and substance-use] health care on a day-to-day operational basis, but tailored to reflect the characteristics that distinguish care for these problems and illnesses from general health care."

Funding
The Robert Wood Johnson Foundation (RWJF) supported this unsolicited project with a grant of $189,000.

 See Grant Detail & Contact Information
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THE PROBLEM

The 2001 report from the Institute of Medicine (IOM), Crossing the Quality Chasm: A New Health System for the 21st Century, laid out an ambitious agenda for redesigning the health care sector. It addressed six areas for improvement: safety, effectiveness, timeliness, patient-centered care, efficiency and equity.

However, the report does not directly address the special issues of quality of care for mental and addictive disorders. According to the project director, four key principles underlying the report's recommendations pose challenges for mental health and substance abuse care:

  • Care systems must consciously redesign themselves to achieve quality. For mental health, however, the definition of a "care system" may need to be broadened. Care for individuals diagnosed with a serious and persistent mental illness, an addictive disorder or serious emotional disturbances often involves extensive interaction among the specialty mental health care system, the general health care system and numerous social systems, such as housing, criminal justice and the public schools.
  • Care delivery should involve a team-based approach. For mental health and addictive conditions, this requires coordination across multiple specialties, including primary care providers, psychiatrists, psychologists, social workers and nurses. To be successful, efforts to coordinate care across specialties must take into account the conceptual and operational differences among fields and identify incentives for working across disciplines.
  • Care must be client-centered and responsive to patients' needs. However, for individuals with a compromised ability to actively engage in decision-making, the concept of client-centered care may need to be expanded to provide adequate protection for those receiving treatment.
  • Care delivery systems must apply scientific knowledge to practice. However, although there is a clear evidence base for many areas of behavioral health, there remain common practices for which evidence of efficacy is limited and consists of case studies or other qualitative data.

In March 2002, the American College of Mental Health Administration — the national organization for mental health and substance abuse administrators — convened a summit of more than 90 leaders in the field of behavioral health care to consider the relevance and application of the Crossing the Quality Chasm report for behavioral health (the provision of mental health and substance abuse services).

The consensus of the attendees was that the report had significant potential for reform of the behavioral health field, and that its conceptual framework was immediately relevant and applicable to the concerns of behavioral health systems of care and policy.

As a follow-up to this summit, the college began coordinating with the IOM on a workshop to develop an agenda for change.

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RWJF STRATEGY

For more than two decades, RWJF has systematically sought to improve health by reducing the harmful effects of substance-use disorders and addictions. Early work centered on addiction prevention efforts. Since 2003, programming has focused on improving the quality of treatment for those with substance-use disorders and addictions.

RWJF also has a long-standing interest in improving health care quality. It supported the IOM in developing Crossing the Quality Chasm and a conference about it. See Grant Results on ID# 046718.

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THE PROJECT

In March 2004, the Institute of Medicine established a 22-member committee to explore the implications of the Crossing the Quality Chasm report for the treatment of mental and addictive disorders and develop an agenda for improving the quality of that care.

Representatives from academia, advocacy organizations, state and federal agencies, along with health care providers and consumers served on the committee. See Appendix 1 for a list of committee members.

The committee commissioned 15 papers providing in-depth reviews of key issues. (The papers, which are available from the project director, are listed in the Bibliography.) It met seven times between April 2004 and June 2005, receiving testimony from a wide range of stakeholders in the mental health and addiction fields.

Committee members also reviewed leading reports in the mental health and substance-use fields, including:

Other Funding

In addition to RWJF, six organizations contributed funds to the project. For a list of other funders and amounts contributed, see Appendix 2.

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RECOMMENDATIONS

The committee produced a report, Improving the Quality of Health Care for Mental and Substance-Use Conditions, which offers a set of recommendations, including two it termed "overarching":

  • "Health care for general, mental and substance-use problems and illnesses must be delivered with an understanding of the inherent interactions between the mind/brain and the rest of the body."
  • "The aims, rules and strategies for redesign set forth in Crossing the Quality Chasm should be applied throughout [mental and substance-use] health care on a day-to-day operational basis, but tailored to reflect the characteristics that distinguish care for these problems and illnesses from general health care."

The report also offered 26 other recommendations in seven categories:

  1. Supporting patient decision-making abilities and preferences for treatment and recovery.
  2. Strengthening the evidence base and quality improvement infrastructure.
  3. Coordinating care for better mental, substance-use and general health.
  4. Ensuring that the national health information infrastructure benefits persons with mental and substance-use conditions.
  5. Increasing workforce capacity for quality improvement.
  6. Using marketplace incentives to leverage needed change.
  7. Formulating an agenda for addressing knowledge gaps in treatment, care delivery and quality improvement.

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LESSONS LEARNED

  1. Make joint mental health and substance-use studies the norm. Although many people suffer from both mental and addictive disorders, collaboration between these two fields typically has not occurred. It took the committee's 22 experts in both fields several meetings over a period of months to learn each other's vocabularies, concerns, therapeutics, evidence bases and strengths. In the end, all committee members increased their appreciation of the interconnectedness of mental and substance-use issues, and the implications of this interconnectedness for clinical care and health policy. The experience also led them to agree that future grant awards for either mental health or substance use should require expertise in and participation by researchers in both fields. (Project Director)

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AFTER THE GRANT

The committee's chair and other members made around a dozen presentations on the report to various professional organizations, including the National Association of State Mental Health Program Directors. The report was also the focus of the Twenty-First Annual Rosalynn Carter Symposium on Mental Health Policy in Atlanta in 2005.

The project director cites the following as evidence that the report's recommendations have provided a stimulus and agenda for change:

  • Saul Feldman, Ph.D., one of the report's committee members, is on California's Proposition 63 Oversight Committee and is infusing the report's recommendations into that process. (Proposition 63, passed in 2004, expands mental health services in California.)
  • The offices of Congressmen Patrick Kennedy (D-R.I.) and Jim Ramstad (R-Minn.) held a meeting of key mental and substance use health care stakeholders in April 2006 to explore the potential of developing federal legislation supporting several core recommendations from the report.
  • The Johns Hopkins University Department of Psychiatry and Behavioral Sciences, the National Mental Health Association and the Academic Behavioral Health Consortium have sponsored a two-day conference in October 2006 to inaugurate a formal alliance, a chief goal of which is to pursue the agenda described in the report.

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GRANT DETAILS & CONTACT INFORMATION

Project

Implications of Crossing the Quality Chasm Report for the Treatment of Mental and Addictive Disorders

Grantee

National Academy of Sciences-Institute of Medicine (Washington,  DC)

  • Amount: $ 189,000
    Dates: December 2003 to January 2005
    ID#:  048021

Contact

Ann E. Page, R.N.
(202) 334-2165
aekpage@nas.edu

Web Site

http://www.nap.edu/catalog/11470.html

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APPENDICES


Appendix 1

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders

Mary Jane England, M.D. (Chair)
President
Regis College
Weston, Mass.

Paul S. Appelbaum, M.D.
Chair, Department of Psychiatry
Director, Law and Psychiatry Program
University of Massachusetts Medical School
Worcester, Mass.

Seth Bonder, Ph.D.
Consultant in Systems Engineering
Ann Arbor, Mich.

Allen Daniels, Ed.D.
Professor of Clinical Psychiatry
Executive Vice Chair, Department of Psychiatry
University of Cincinnati College of Medicine
Cincinnati, Ohio

Benjamin Druss, M.D., M.P.H.
Rosalynn Carter Chair in Mental Health
Emory University
Atlanta, Ga.

Saul Feldman, Ph.D.
Chairman and Chief Executive Officer
United Behavioral Health
San Francisco, Calif.

Richard G. Frank, Ph.D.
Professor of Health Economics
Harvard Medical School
Boston, Mass.

Thomas L. Garthwaite, M.D.
Director and Chief Medical Officer
Los Angeles County Department of Health Services
Los Angeles, Calif.

Gary Gottlieb, M.D., M.B.A.
President
Brigham and Women's Hospital
Professor of Psychiatry
Harvard Medical School
Boston, Mass.

Kimberly Hoagwood, Ph.D.
Professor of Clinical Psychology in Psychiatry
Columbia University
Director of Research on Child and Adolescent Health
State of New York
New York, N.Y.

Jane Knitzer, Ed.D.
Director
National Center for Children in Poverty
New York, N.Y.

A. Thomas McLellan, Ph.D.
Director
Treatment Research Institute
Philadelphia, Pa.

Jeanne Miranda, Ph.D.
Professor, Department of Psychiatry and Biobehavioral Sciences
University of California
Los Angeles, Calif.

Lisa Mojer-Torres, J.D.
Attorney in Civil Rights and Health Law
Lawrenceville, N.J.

Harold Alan Pincus, M.D.
Professor and Vice Chair, Department of Psychiatry
University of Pittsburgh School of Medicine
Senior Scientist and Director
RAND-University of Pittsburgh Health Institute
Pittsburgh, Pa.

Estelle B. Richman, M.A.
Secretary
Pennsylvania Department of Public Welfare
Harrisburg, Pa.

Jeffrey H. Samet, M.D., M.P.H., M.A.
Professor of Medicine and Social and Behavioral Sciences
Vice Chair for Public Health
Boston University Schools of Medicine and Public Health
Chief, General Internal Medicine
Boston Medical Center
Boston, Mass.

Tom Trabin, Ph.D., M.S.M.
Consultant in Behavioral Health Care and Informatics
El Cerrito, Calif.

Mark D. Trail, M.A.
Chief, Medical Assistance Plans
Georgia Department of Community Health
Atlanta, Ga.

Ann Catherine Veirstahler, R.N., S.C.S.J.A.
Nurse, Advocate and Person with Bipolar Illness
Ancilla Convent
Milwaukee, Wis.

Cynthia Wainscott
Chair
National Mental Health Association
Cartersville, Ga.

Constance Weisner, Dr.P.H., M.S.W.
Professor, Department of Psychiatry
University of California, San Francisco
Investigator, Division of Research
Northern California Kaiser Permanente
San Francisco, Calif.


Appendix 2

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

Other Funders

  • Substance Abuse and Mental Health Services Administration of the Department of Health and Human Services, $346,000
  • CIGNA Foundation, $25,000
  • Annie E. Casey Foundation, $50,000
  • National Institute on Drug Abuse, $100,000
  • National Institute on Alcohol Abuse and Alcoholism, $100,000
  • Veterans Health Administration, $450,000

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Books

Institute of Medicine. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington: National Academy Press, 2006. Available online.

Commissioned Papers

Bethell C. "Taking the Next Step to Improve the Quality of Child and Adolescent Mental and Behavioral Health Care Services: Current Status and Promising Strategies for Quality Measurement," commissioned by the IOM Committee on Crossing the Quality Chasm, 2004.

Cocozza JJ. "Juvenile Justice Systems: Improving Mental Health Treatment Services for Children and Adolescents."

Cook J. "'Patient-Centered' and 'Consumer-Directed' Mental Health Services," July 2005. Available online.

Grasso BC. "The Safety of Healthcare for Individuals with Mental Illness and Substance Use Disorders."

Harris E and Koyanagi C. "Obstacles to Choice: Statutory, Regulatory, Administrative and Other Barriers That Impede Consumer-Directed Care in Mental Health."

Horgan CM and Garnick DW. "The Quality of Care for Adults with Mental and Addictive Disorders: Issues in Performance Measurement," confidential draft to the IOM Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders. Revised January 10, 2005.

Kim SYH. "Impact of Mental Illness and Substance-Related Disorders on Decision-Making Capacity and Its Implications for Patient-Centered Mental Health Care Delivery."

Landsverk J. "Improving the Quality of Mental Health and Substance Abuse Treatment Services for Children Involved in Child Welfare."

Morris JA, Goplerud EN and Hoge MA. "Workforce Issues in Behavioral Health," commissioned by the Institute of Medicine and the Center for Mental Health Services, 2004.

Rosenheck R. "Mental Health and Substance Abuse Services for Veterans: Experience with Performance Evaluation in the Department of Veterans Affairs."

Saks ER and Jeste DV. "Capacity to Consent to or Refuse Treatment and/or Research: Theoretical Considerations." Behavioral Sciences & the Law, 24(4): 411–429, 2006. Abstract available online.

Saks ER and Jeste DV. "Decisional Capacity in Mental Illness and Substance Use Disorders: Empirical Database and Policy Considerations." Behavioral Sciences & the Law, 24(4): 607–628, 2006. Abstract available online.

Stephan S. "The Application of the Concepts of Patient Centered Care and Self-Directed Care to Individuals with Psychiatric Disabilities: Legal, Policy and Programmatic Considerations," October 2006. Abstract available online.

Weist MD, Paternite CD and Adelsheim S. "School-Based Mental Health Services," commissioned by the Institute of Medicine, Board on Health Care Services, Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders Committee, 2005.

Wolff N. "Law and Disorder: The Case Against Diminished Responsibility," commissioned by the Board of Health Care Services, Crossing the Quality Chasm: Adaptation to Mental Health and Addiction Disorders. Institute of Medicine, 2004.

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Report prepared by: Robert Crum
Reviewed by: Robert Narus
Reviewed by: Molly McKaughan
Program Officer: Constance M. Pechura