Improving the Quality of Child Mental Health Care

Mar 11, 2013, 9:00 AM, Posted by

Bonnie Zima, MD, MPH, an alumna of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program (1989-1991), published a study this month that appeared in a special supplement of Pediatrics with articles by RWJF Clinical Scholars on child health quality. Pediatrics is the official journal of the American Academy of Pediatrics. Zima is a professor-in-residence in child and adolescent psychiatry at the University of California in Los Angeles (UCLA) and associate director of the UCLA Center for Health Services & Society.


Human Capital Blog: Why did you decide to review the new child mental health quality measures?

Bonnie Zima: This paper was written to stimulate discussion about the need for a paradigm shift for quality measurement for children that more closely aligns research with the accelerated pace of quality measure development. 

These are exciting times for those who believe that the quality of child health care can be improved through measurement and public reporting. However, this direction also raises questions about how to improve our methods and data infrastructure to monitor the quality of care received in real-time and to link adherence to quality indicators to clinical outcomes that are meaningful to parents, child advocates, providers, agency leaders and policy-makers.

HCB: Why did you focus on child mental health?

Zima: We focused on child mental health care because quality measurement poses additional challenges that can be used as a stimulus to improve future measure development.

Some of the areas for future research include development of a stronger evidence base to support nationally recommended care processes in community-based populations; models of care coordination across multiple care sectors that often have discrete funding streams, such as specialty mental health, public health, education, child welfare, and juvenile justice; and the development of interventions that more flexibly align service delivery with children’s clinical needs, especially for those with co-morbid mental and physical health conditions.

HCB: Could you provide a thumbnail sketch of the paper?

Zima: The paper provides a brief summary of recent federal health policies that are driving the accelerated development and refinement of pediatric quality measures; the selection process of two parallel national initiatives to recommend and/or endorse pediatric quality measures; the few quality measures related to child mental health yielded from these processes; and the strength of evidence supporting them. Within this context, we also provide an update on the development of new quality measures in the Agency for Healthcare Research & Quality Pediatric Quality Measures Program, which is related to child mental health care, and early lessons learned from this pioneering work.

HCB: What were your main findings?

Zima: Although the process of quality measure selection varied in the Children’s Health Insurance Program Reauthorization-funded development of the initial core set of measures and National Quality Forum’s Patient Outcomes (Phase III): Child Health and Child Health Measures Projects, only nine unique measures of the quality of child mental health care were recommended and/or endorsed. For these measures, the age ranges varied in the specification, such that one was restricted to children aged 0-5 years, two were restricted to ages 13-18 years, and six included all or most child age groups. 

The focus of concern also ranged from specific to general problem areas. Two measures focused on depression, two on attention-deficit/hyperactivity disorder, one on risk behaviors, one on suicidality, and three on general problem areas. 

Overall, the strength of the evidence supporting the child mental health quality measures was variable. None of the measures was supported by research using randomized clinical trials to examine their relationship between adherence and outcomes. This finding is consistent with adult mental health and substance abuse quality-of-care measures.

HCB: So where do we go from here?

Zima: As a starting point, it is important to acknowledge that the shared vision of these federal health policies is to have a quality-driven health care system for children. High priority is placed on equally valuing the perspectives of multiple stakeholders during the process of bringing this vision to fruition.

As we move forward on the feasibility testing of new or refined quality measures, this next phase stimulates more questions. How should we address the constraints of the existing data infrastructure? At the state and provider levels, how do we enhance the capacity to capture data that links measure adherence to improved care and meaningful outcomes?  How do we harness technologies and methodological advances to reduce agency, provider and parent and/or youth burden to do this? How do we access, combine and align multiple data sources in such a way they are HIPAA-compliant and capitalize on their unique strengths? How do we bring to scale promising approaches to engage community partners in examining the clinical validity of child mental health quality measures, support further refinement, and sustain their use? 

To advance this important national dialogue, RWJF’s support for this special edition on pediatric health care quality is a significant contribution. The methodological rigor of the research also exemplifies the outstanding training provided in the RWJF Clinical Scholars program as well as the rich network of national health care leaders it has developed.

Also read a Q&A with RWJF Clinical Scholars program alumnus Lawrence Kleinman, MD, MPH, (1990-1992) about the special supplement in Pediatrics.

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.