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Institute of Medicine (US) Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders. Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series. Washington (DC): National Academies Press (US); 2006.

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Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series.

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2A Framework for Improving Quality


Crossing the Quality Chasm identifies six aims and ten rules for redesigning the nation's health care system to achieve better-quality care. However, health care for mental and/or substance-use (M/SU) conditions in the United States historically has been more separated from general health care relative to other specialties. In addition, there are some significant differences between M/SU and general health care, including the implications of a mental or substance-use diagnosis for patient decision making; the more common use of coerced treatment; greater variation in the types of providers licensed to diagnose and treat M/SU illnesses; the need for linkages with a greater number of health, social, and public welfare systems; a less developed quality measurement infrastructure; less widespread adoption of information technology; and a differently structured marketplace for consumers and purchasers of M/SU health care.

In analyzing these differences, the state of M/SU health care, and the Quality Chasm framework for health care quality improvement, the committee finds that:

  • M/SU health care—like general health care—is often ineffective, not patient-centered, untimely, inefficient, inequitable, and at times unsafe. It, too, requires fundamental redesign.
  • Mental, substance-use, and general illnesses are highly interrelated, especially with respect to chronicity. Improving care delivery and health outcomes for any one of the three depends upon improving care delivery and outcomes for the others.
  • The Quality Chasm recommendations for the redesign of health care are as applicable to M/SU health care as they are to general health care.


Crossing the Quality Chasm (IOM, 2001:6) proposes the following statement of purpose for the U.S. health care system:

…to continually reduce the burden of illness, injury, and disability, and to improve the health and functioning of the people of the United States.

To help achieve this purpose, the Quality Chasm report identifies six dimensions in which the U.S. health care system functions at far lower levels than it could and should, and translates these dimensions into national aims to guide the quality improvement efforts of all health care organizations, professional groups, public and private purchasers, and individual clinicians (see Box 2-1).

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BOX 2-1

The Six Aims of High-Quality Health Care. Safe—avoiding injuries to patients from the care that is intended to help them. Effective—providing services based on scientific knowledge to all who could benefit and refraining from providing (more...)

To further assist quality improvement efforts, the Quality Chasm report specifies an accompanying set of ten rules to guide the redesign of health care so as to accomplish the six quality aims (see Box 2-2).

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BOX 2-2

The Quality Chasm's Ten Rules to Guide the Redesign of Health Care. Care based on continuous healing relationships. Patients should receive care whenever they need it and in many forms, not just face-to-face visits. This rule implies that the health care (more...)

Finally, Crossing the Quality Chasm describes how achieving the six aims and following the ten rules requires a fundamental redesign of health care by health care organizations and delivery systems. This health care redesign must include adopting new ways of delivering care; making effective use of information technologies; managing the clinical knowledge and skills of the workforce; developing effective teams and coordinating care across patient conditions, services, and settings; improving how health care quality is measured; and adopting payment methods that create incentives for and reward good quality—all of which require attention to how workers are educated and deployed. Such changes have implications for all four levels of the health care system: (1) the interactions between patients and their individual clinicians; (2) the functioning of small units of care delivery (“microsystems”), such as interdisciplinary teams or staff located on inpatient units; (3) the functioning of organizations that house the microsystems; and (4) the environment of policy, payment, regulation, accreditation, and similar external factors that shape the environment in which health care organizations deliver care (Berwick, 2002).

In many ways, the delivery of health care for mental and/or substance-use (M/SU) problems and illnesses in the United States has evolved so that these four levels of the system operate very differently from the way they function in general health care. Therefore, focused examination and some specialized efforts will be required to apply the Quality Chasm rules and achieve significant improvements on all six quality aims in the M/SU domain.


Greater Separation from Other Components of the Health Care System

M/SU health care differs from other specialty and nonspecialty health care in many ways. One of these is its greater degree of separation, both structurally and functionally, from other components of the health care system. This separation is historical in origin. Because of poor understanding of the biological aspects of M/SU illnesses and the lack of any medical treatments, care for individuals with these illnesses initially was viewed as a social rather than a medical problem. Specific therapies for mental illnesses were rarely mentioned in the medical literature before 1800. Sick individuals were often treated by ministers and women, rather than by doctors (Grob, 1994). Substance-use “disorders” similarly were viewed as manifestations of intellectual weakness or moral inferiority. In the early nineteenth century, for example, when alcoholism was beginning to be understood as a disease, “drunkards, along with unwed mothers, and those suffering from venereal disease, were routinely denied admission to America's earliest hospitals on the grounds that they were unworthy of community care” (White, 1998:4). Even when alcohol and other substance-use illnesses began to be recognized as biological diseases, medical treatment initially had little to offer, and most recovery assistance came from “mutual support” societies that were not part of health care (White, 1998).

Although understanding of the biological aspects of these illnesses and effective treatments has since greatly improved, the greater separation of M/SU health care from the rest of the system persists. This is manifested in part by society's continuing reliance on public-sector delivery systems and funding for M/SU care (Hogan, 1999; Mark et al., 2005); the resulting existence of a separate administration for these illnesses within federal (the Substance Abuse and Mental Health Services Administration [SAMHSA]) and state governments; frequent calls for the integration of health care services for mental and substance-use conditions with each other and with primary health care (Bazelon Center for Mental Health Law, 2004; DHHS, 2001; Jenkins and Strathdee, 2000; Minkoff, 2001; Torrey et al., 2002), and the separate purchase of M/SU health care by public- and private-sector purchasers. The separate purchasing of M/SU health care in most individuals' health insurance plans is known as “carving out” these services (Grazier and Eselius, 1999). “Carved-out” M/SU health care plans can be provided by companies separate from the main insurer or by subsidiaries of the primary insurer. Mental health care is even more separated from general health care for children and adolescents; they frequently receive mental health care through their schools, not through their primary health care provider (Burns et al., 1995; Kessler et al., 2001).

Some of these separations can have salutary effects, for example, by fostering recognition of and support for specialized knowledge of M/SU problems and illnesses and treatment expertise, and attenuating problems related to the adverse selection of individuals with M/SU illnesses in insurance plans. Moreover, some M/SU health care organizations involve individuals recovering from M/SU illnesses in the administration and delivery of services, providing a strong source of recovery support for others with these illnesses. At the same time, however, separation of those with M/SU problems and illnesses from the mainstream population might nurture the residual stigma and discrimination faced by some of these individuals (Corrigan et al., 2001, 2002; Kolodziej and Johnson, 1996). It can also pose obstacles to the coordination of M/SU health care services with each other and with general health care (IOM, 1997). Individuals needing these services often must interact with separate delivery systems to receive health care for general, mental, and substance-use conditions. These multiple delivery arrangements frequently have unreliable or nonexistent linkages with each other, creating opportunities for discontinuity of care. Chapter 5 addresses in greater detail these separation issues and the resulting need for better coordination of care, while Chapter 8 contains a more detailed discussion of the benefits and difficulties of carve-outs.

Additional Differences

Beyond the structural and functional separation discussed above, there are many other ways in which M/SU health care is distinctive. These differences, briefly summarized in Table 2-1 and in the text that follows, can have significant implications for efforts to apply the Quality Chasm aims and rules and are discussed more fully in succeeding chapters.

TABLE 2-1. Differences Between General Health Care and Health Care for Mental and Substance-Use Conditions .


Differences Between General Health Care and Health Care for Mental and Substance-Use Conditions .

Consumer Role

Consumers of M/SU health care face a number of obstacles not generally encountered by consumers of general health care. Shame, stigma, and discrimination still experienced by some consumers of M/SU services may prevent them from seeking care (Peter D. Hart Research Associates, Inc., 2001; SAMHSA, 2004) and nourish both their own and providers' doubts about their competence to make decisions on their own behalf (Bergeson, 2004; Leibfried, 2004; Markowitz, 1998; Wright et al., 2000). These attitudes create obstacles to consumers' exercising the control of which they are capable over health care decisions that affect them and to their managing their illnesses effectively. Moreover, coerced treatment, which is common in substance-use health care and also seen (though less frequently) in mental health care for those with more severe mental illnesses, raises the question of how patients subjected to such treatment can make decisions about their care. As the locus of most M/SU treatment has shifted to the community, new mechanisms for pressuring or compelling individuals with these illnesses to undergo treatment have evolved, including coercion from the criminal justice and welfare systems, schools, and workplaces (Monahan et al., 2003, 2005; Sterling et al., 2004; Weisner et al., 2002).

At the same time, the long-standing history of individuals in recovery from substance-use illnesses helping to teach others about their illness and recovery strategies and supporting them in the recovery process is an advantage that consumers of substance-use health care services have when attempting to make informed health care choices and manage their illnesses. Mental health care is following in these footsteps; peer support programs are an emerging component of public-sector mental health services. Evidence shows that seeing or visualizing those similar to oneself successfully performing activities typically increases one's belief in one's own ability to perform those activities successfully (Bandura, 1997) and facilitates successful management of one's own chronic illness (Lorig et al., 2001) (see Chapter 3).

Diagnostic Methods

Compared with general health care, relatively few laboratory, imaging, or other physical findings can be used to diagnose mental illnesses or substance dependence.1 Accurate diagnosis instead relies primarily on clinical interviews with patients or their caregivers regarding the patient's symptoms and a clinician's application of expert, but still subjective, judgment. Moreover, different types of clinicians vary in the breadth, depth, and theoretical basis of their training (see Chapter 7). As a result, individuals with the same symptoms presenting to different mental health clinicians can receive very different diagnoses (Eaton et al., 2000; Kramer et al., 2000; Lefever et al., 2003; Lewczyk et al., 2003; McClellan, 2005; Mojtabai, 2002). In children, diagnoses may have an even greater range of variability because clinicians are greatly dependent upon parents' perceptions of the nature of the presenting problem. Subjectivity in diagnosis is also manifest in the different diagnoses received by individuals who are members of ethnic minorities (Bell and Mehta, 1980, 1981; Mukherjee et al., 1983). Criteria for accurately diagnosing M/SU problems and illnesses are found in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, now in its revised fourth edition (DSM-IV-TR). However, adherence to these guidelines is not uniform (Rushton et al., 2004), nor is training on the appropriate use of this manual required for professional credentialing.

Mode of Clinician Practice

A substantial proportion of mental health clinicians report that “individual practice” is either their primary or secondary2 employment setting (Duffy et al., 2004) (see Table 2-2).

TABLE 2-2. Percentage of Clinically Trained Specialty Mental Health Personnel Reporting Solo Practice as Their Primary or Secondary Place of Employment .


Percentage of Clinically Trained Specialty Mental Health Personnel Reporting Solo Practice as Their Primary or Secondary Place of Employment .

Among primary care and specialist physicians who are self-employed or employees of physician-owned medical groups,3 psychiatrists are most likely to work in solo practices or small groups. Fully 85 percent practice in groups of one to three clinicians, compared with 53 percent of physicians overall, 54.9 percent of pediatricians, and 62.7 percent of internists (Cunningham, 2004).

Individual practice may be an impediment to the delivery of high-quality M/SU health care for multiple reasons. As described in Chapter 6, the size of health care provider organizations is related to the uptake of information technologies. Use of electronic health records, for example, is typically found in larger health care organizations (Brailer and Terasawa, 2003). Moreover, as articulated in Crossing the Quality Chasm, “Today, no one clinician can retain all the information necessary for sound, evidence-based practice. No unaided human being can read, recall, and act effectively on the volume of clinically relevant scientific literature” (IOM, 2001:25). Clinicians in solo practice must assume all the burden of investigating, analyzing, purchasing, and maintaining decision support technologies, which can be prohibitively expensive when there is no economy of scale to be achieved.

Need to Navigate a Greater Number of Care Delivery Arrangements

As discussed above, the ways in which M/SU and other health care providers are separated are more numerous and complex than is the case for other health care generally. Not only is M/SU care separated from general health care, but health care services for mental and substance-use conditions are separated from each other despite the high rate of co-occurrence of these conditions. Also distinctive are the location of services needed by individuals with more severe mental and substance-use illnesses in public-sector programs apart from private-sector health care, and reliance on the education, child welfare, and juvenile and criminal justice systems to deliver M/SU services for many children and adults. These disconnected care delivery arrangements necessitate numerous patient interactions with different providers, organizations, and government agencies. They also require multiple provider “handoffs” of patients for different services, and the transmittal of information to and joint planning by all these providers, organizations, and agencies if coordination is to occur. Yet effective structures and processes to ensure coordination of care across clinicians and organizations are not in place. This situation is exacerbated by the widespread failure of general medical, mental health, and substance-use health care providers to look for and respond to co-occurring conditions, as well as legal and organizational prohibitions on sharing M/SU information. These issues are discussed more fully in Chapter 5.

Quality Measurement Infrastructure

The infrastructure required to measure, analyze, publicly report on, and improve the quality of M/SU health care is less well developed than that for general health care. As a result, less measurement of the safety, effectiveness, and timeliness of M/SU health care has taken place (AHRQ, 2003; Garnick et al., 2002) (see Chapter 4). This situation exists for several reasons. For example, multiple organizations and initiatives have put forth different core measurement sets and different approaches to identifying aspects of M/SU health care delivery to be measured. This problem is due in part to the fact that conceptualizing a framework for M/SU health care is more complex than is the case for general health care. The larger number of disciplines licensed to diagnose and treat M/SU problems and illnesses can require the involvement of a greater number of stakeholder groups in a consensus process. Further, as noted above, consumers have been more active in shaping the delivery of M/SU health care than that of general health care, again with implications for the numbers and diversity of stakeholders involved in a consensus process. Moreover, although general health care is delivered in both the private and public sectors, M/SU health care in the public sector serves a population with a clinical profile much different from that of those treated in the private sector—more often those with severe and chronic illnesses. Measures that may be meaningful to private-sector stakeholders may be less useful to those in the public sector, and vice versa.

The separation of M/SU and general health care also has sometimes created confusion about which entity is accountable for the quality of care that can be delivered through multiple arrangements (primary or specialty care, a general or a “carved out” health plan, school-based programs, etc.). For example, measures of M/SU quality required of comprehensive managed care organizations seeking accreditation are often not required of managed behavioral health organizations (MBHOs) seeking accreditation from the same organization.4 Moreover, to produce many performance measures, data about the patient's entire illness—from detection to ongoing treatment—is required. When M/SU patients are served by arrangements such as carved-out managed behavioral health plans or employee assistance programs separate from their general health care plan or from each other, difficulties in linking the necessary data produced by different organizations can make many performance measures infeasible (Garnick et al., 2002).

Information Sharing and Technology

The need to share patient information across providers so that care can be coordinated is widely acknowledged as necessary to effective and appropriate care. This need was acknowledged most recently in regulations governing the privacy of individually identifiable health information under the authority of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Under HIPAA regulations, the routine sharing of information for treatment, payment, or health care operations is permissible without requiring patient consent. These regulations have provided some consistency with respect to the sharing of information on general health conditions and care, but much less so for M/SU health care.

HIPAA itself requires that regulations promulgated to implement its privacy provisions not supersede any more stringent provisions of state law pertaining to patient privacy. Each of the 50 states (and the District of Columbia) has a number of statutes that specifically govern aspects of mental health records. Many of these statutes and regulations are more stringent than the HIPAA requirements, and the variation among them is great (see Appendix B). Moreover, separate federal laws govern the release of information pertaining to an individual's treatment for alcohol or drug use. These federal laws are also superseded by state laws, which are more stringent. The preamble to the HIPAA privacy regulations recognizes the constraints of substance-use confidentiality laws and states that wherever one is more protective of privacy than the other, the more restrictive should govern. This means that clinicians providing treatment to the many individuals with co-occurring mental, substance-use, and general health problems and illnesses need to comply with multiple regulations and laws governing the release of information, as well as policies prescribed by the organization or organizations under whose auspices they provide care. This situation inhibits or at least confounds communications between M/SU and general health care providers. The need for an appropriate balance between privacy concerns and sharing of clinically relevant information among providers is addressed in Chapters 5 and 6.

Finally, while use of electronic health records, decision support, and other information technology applications is growing in general health care, their use in M/SU health care is more limited.

Greater Diversity of Types of Providers

Although the diagnosis and treatment of general health conditions are typically limited to physicians, certain advanced practice nurses, and physician assistants,5 M/SU health care clinicians include psychologists, psychiatrists, other specialty or primary care physicians, social workers, psychiatric nurses, marriage and family therapists, addiction therapists, psychosocial rehabilitation therapists, sociologists, and a variety of counselors (e.g., school counselors, pastoral counselors, guidance counselors, and drug and alcohol counselors) (see Chapter 7). In addition to having differing education, training, and therapeutic approaches, these clinicians may not be educated in clinical practice guidelines for evidence-based care, receive training in their use, understand them, or be motivated to apply them (Manderscheid et al., 2001). As a result, some clinicians may be more committed to “schools” of practice than to evidence-based eclecticism (Jackim, 2003). Also, differences in educational curriculums make it difficult to credential providers in the large number of therapies in current use.

Differences in the Marketplace

State and local governments play a larger role in purchasing and delivering M/SU health care compared with general health care (Hogan, 1999). In 2001, Medicaid (a state-administered program) and other state and local government programs together paid for 52 percent of all M/SU health care in the United States, with Medicaid, the largest payer, representing more than a quarter of all spending on mental health care (Mark et al., 2005). Medicaid funds pay primarily for mental health care; the major source of funds for substance-use health care is federal block grants to states, which states use to purchase or provide services directly. Moreover, M/SU spending accounts for approximately 30 percent of all state and local spending (excluding Medicaid) for health care but represents only 4 percent of health care spending in the private sector. Between 1991 and 2001, annual spending by private insurers for substance-use treatment did not keep pace with inflation and declined in real dollars. In 1991, private insurers paid for 24 percent of all substance-use health care; in 2001 they paid for 13 percent (Mark et al., 2005). In general health care, payers are more often private insurers or the Medicare program.

The greater financial attention to M/SU health care in the public sector has several ramifications. First, because of the larger role of state and local governments, there is greater variability in how M/SU health care can be accessed and how providers are selected and reimbursed, as well as in the reporting requirements associated with the various local and state programs. Second, the greater visibility and financial consequences of M/SU health care in the public as compared with the private sector may explain why leadership on some quality improvement initiatives, such as reduction in the use of restraints, performance measurement, and consumer-oriented health care, is more often found in the public than the private sector.

Moreover, although access to M/SU health care for some individuals has improved over the past decade (Kessler et al., 2005; Mechanic and Bilder, 2004), there are still unique obstacles to accessing these services. Insurers continue to impose greater limits on M/SU health care coverage by requiring higher copayments and deductibles, limiting benefits (Bureau of Labor Statistics, 2003), and excluding coverage altogether if an injured individual was under the influence of alcohol or some other drug (Cimons, 2004). These cost and insurance issues are a leading reason reported by consumers for not receiving needed M/SU treatment (SAMHSA, 2004).

Further, individuals with substance-use illnesses themselves may impede their access to care in the marketplace. Individuals with substance-use problems and illnesses who do not experience recovery on their own typically do not seek treatment until their condition becomes so severe that they must do so, or they are compelled by workplace problems, criminal offenses, and the like (Weisner and Schmidt, 2001). In a 2001 national survey of individuals in recovery from alcohol or other drug illnesses and their families, 60 percent reported that denial of “addiction” or refusal to admit the severity of the problem was the greatest barrier to their recovery. Embarrassment or shame was the second most frequently cited obstacle (Peter D. Hart Research Associates, Inc., 2001). This is unfortunate because, as noted in Chapter 1, evidence shows that interventions delivered to patients with substance-use problems and illnesses can reduce substance use (Bernstein et al., 2005; Fleming et al., 1997).


More detailed analyses of the above issues are presented in the following chapters. As a result of these analyses, the committee made an overall finding and formulated an overarching recommendation concerning the relationship between M/SU and general health care. In addition, the committee made two overall findings and formulated a second overarching recommendation pertaining to the feasibility of applying the Quality Chasm framework to M/SU health care.

Relationship between M/SU and General Health Care

In conducting its work, the committee, like many expert panels before it, was confronted by the “destructive,” “artificial, centuries old separation of mind and body” that was criticized in the 1999 Surgeon General's Report on Mental Health (DHHS, 1999:Preface and p. x). Since that report was released, evidence for the effects of mental and substance-use problems and illnesses on each other and on general health and health care continues to accumulate (Bush et al., 2005; Katon, 2003; Kroenke, 2003). Depression and anxiety disorders are strongly associated with somatic symptoms, such as headache, fatigue, dizziness, and pain, that are the leading cause of outpatient medical visits and often medically unexplained (Kroenke, 2003). Similarly, substance-use problems and illnesses contribute to the misdiagnosis, difficult management, and poor outcomes associated with many of the most pervasive medical illnesses in this country, such as chronic pain, sleep disorders, breast cancer, hypertension, diabetes, pneumonia, and asthma (Howard et al., 2004; Rehm et al., 2003; Saitz et al., 1997). A substantial portion of individuals with chronic physical illnesses also have a comorbid M/SU problem or illness. A nationally representative survey of Americans found that among respondents with the four most common chronic general illnesses (hypertension, arthritis, asthma, and ulcers), the loss of whole or partial work days was confined largely to those to those who had a co-occurring mental condition (Kessler et al., 2003).

Examining in detail the effect of just one type of mental illness (depression) on one general health care condition (heart attack), a recent Agency for Healthcare Research and Quality (AHRQ) Evidence Report/Technology Assessment found that approximately one in five patients hospitalized for a heart attack suffers from major depression, and that the evidence is “strikingly consistent” that post–heart attack depression significantly increases one's risk of death from heart-related or other causes. Patients with depression are about three times more likely to die from a future heart attack or other heart problem. Fully 60–70 percent of individuals who become depressed when hospitalized for a heart attack continue to suffer from depression for 1–4 or more months after discharge, and during the first year following a heart attack, those with major depression can experience a delay in returning to work, worse quality of life, and worse physical and psychological health (Bush et al., 2005:5).

Overall Finding. Mental, substance-use, and general illnesses are highly interrelated, especially with respect to chronic illness and injury. Improving care delivery and health outcomes for any one of the three depends upon improving care delivery and outcomes for the others.

Overarching Recommendation 1. 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.

Applicability of the Quality Chasm Framework

As a result of its analyses (contained in the succeeding chapters), the committee made the following two overall findings:

Overall Finding. M/SU health care—like general health care—is often ineffective, not patient-centered, untimely, inefficient, inequitable, and at times unsafe. It, too, requires fundamental redesign.

Overall Finding. The Quality Chasm recommendations for the redesign of health care are as applicable to M/SU health care as they are to general health care.

In light of the above findings, the committee makes the following recommendation:

Overarching Recommendation 2. The aims, rules, and strategies for redesign set forth in Crossing the Quality Chasm should be applied throughout M/SU 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 following chapters describe how to implement these overarching recommendations.


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Substance use, but not dependence, can be detected by laboratory tests.


Many mental health practitioners work in multiple settings. For example, 60 percent of full-time psychiatrists reported working in two or more settings in 1998, as did 50 percent of psychologists in 2002, 20 percent of full-time counselors, and 29 percent of marriage/family therapists. Rates were higher for part-time counselors (Duffy et al., 2004).


Residents and employees of hospitals, universities, medical schools, government, and health maintenance organizations (HMOs) are excluded.


Personal communication, Philip Renner, MBA, Assistant Vice President for Quality Measurement, National Committee for Quality Assurance, March 22, 2005.


Dentists, chiropractors, and podiatrists also are licensed to diagnose and treat, but typically within proscribed domains.

Copyright © 2006, National Academy of Sciences.
Bookshelf ID: NBK19826


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