TABLE 9-5Recommendations for Federal Policy Makers

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. Rule 5. Evidence-based decision making—Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place.
Rule 8. Anticipation of needs—The health system should anticipate patient needs, rather than simply reacting to events.
Recommendation 4-1. To better build and disseminate the evidence base, the Department of Health and Human Services (DHHS) should strengthen, coordinate, and consolidate the synthesis and dissemination of evidence on effective M/SU treatments and services by the Substance Abuse and Mental Health Services Administration; the National Institute of Mental Health; the National Institute on Drug Abuse; the National Institute on Alcohol Abuse and Alcoholism; the National Institute of Child Health and Human Development; the Agency for Healthcare Research and Quality; the Department of Justice; the Department of Veterans Affairs; the Department of Defense; the Department of Education; the Centers for Disease Control and Prevention; the Centers for Medicare and Medicaid Services; the Administration for Children, Youth, and Families; states; professional associations; and other private-sector entities. Aim of effectiveness—providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse, respectively).
Rule 5. Evidence-based decision making (see above).
To implement this recommendation, DHHS should charge or create one or more entities to:
  • Describe and categorize available M/SU preventive, diagnostic, and therapeutic interventions (including screening, diagnostic, and symptom-monitoring tools) and develop individual procedure codes and definitions for these interventions and tools for their use in administrative datasets approved under the Health Insurance Portability and Accountability Act.
  • Assemble the scientific evidence on the efficacy and effectiveness of these interventions, including their use in varied age and ethnic groups; use a well-established approach to rate the strength of this evidence, and categorize the interventions accordingly; and recommend or endorse guidelines for the use of the evidence-based interventions for specific M/SU problems and illnesses.
  • Substantially expand efforts to attain widespread adoption of evidence-based practices through the use of evidence-based approaches to knowledge dissemination and uptake. Dissemination strategies should always include entities that are commonly viewed as knowledge experts by general health care providers and makers of public policy, including the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, the Centers for Medicare and Medicaid Services, the Office of Minority Health, and professional associations and health care organizations.
Recommendation 4-3. To measure quality better, DHHS, in partnership with the private sector, should charge and financially support an entity similar to the National Quality Forum to convene government regulators, accrediting organizations, consumer representatives, providers, and purchasers exercising leadership in quality-based purchasing for the purpose of reaching consensus on and implementing a common, continuously improving set of M/SU health care quality measures for providers, organizations, and systems of care. Participants in this consortium should commit to:
  • Requiring the reporting and submission of the quality measures to a performance measure repository or repositories.
  • Requiring validation of the measures for accuracy and adherence to specifications.
  • Ensuring the analysis and display of measurement results in formats understandable by multiple audiences, including consumers, those reporting the measures, purchasers, and quality oversight organizations.
  • Establishing models for the use of the measures for benchmarking and quality improvement purposes at sites of care delivery.
  • Performing continuing review of the measures' effectiveness in improving care.
Aim of effectiveness (see above).
Rule 5. Evidence-based decision making (see above).
Rule 7. The need for transparency—The health care system should make information available to patients and their families that allows them to make informed decisions when selecting a health plan, hospital, or clinical practice, or choosing among alternative treatments. This should include information describing the system's performance on safety, evidence-based practice, and patient satisfaction.
Recommendation 4-4. To increase quality improvement capacity, DHHS, in collaboration with other government agencies, states, philanthropic organizations, and professional associations, should create or charge one or more entities as national or regional resources to test, disseminate knowledge about, and provide technical assistance and leadership on quality improvement practices for M/SU health care in public- and private-sector settings. All six aims and ten rules.
Recommendation 5-2. To facilitate the delivery of coordinated care by primary care, mental health, and substance-use treatment providers, government agencies, … should implement policies and incentives to continually increase collaboration among these providers to achieve evidence-based screening and care of their patients with general, mental, and/or substance-use health conditions. The following specific measures should be undertaken to carry out this recommendation:
  • DHHS should fund demonstration programs to offer incentives for the transition of multiple primary care and M/SU practices along a continuum of coordination models.
  • Purchasers should modify policies and practices that preclude paying for evidence-based screening, treatment, and coordination of M/SU care and require (with patients' knowledge and consent) all health care organizations with which they contract to ensure appropriate sharing of clinical information essential for coordination of care with other providers treating their patients.
  • The Federal … government should revise laws, regulations, and administrative practices that create inappropriate barriers to the communication of information between providers of health care for mental and substance-use conditions and between those providers and providers of general care.
Rule 10. Cooperation among clinicians—Clinicians and institutions should actively collaborate and communicate to ensure an appropriate exchange of information and coordination of care.
Recommendation 5-4. To provide leadership in coordination, DHHS should create a high-level, continuing entity reporting directly to the secretary to improve collaboration and coordination across its mental, substance-use, and general health care agencies, including the Substance Abuse and Mental Health Services Administration; the Agency for Healthcare Research and Quality; the Centers for Disease Control and Prevention; and the Administration for Children, Youth, and Families. DHHS also should implement performance measures to monitor its progress toward achieving internal interagency collaboration and publicly report its performance on these measures annually. Rule 10. Cooperation among clinicians (see above).
Recommendation 6-1. To realize the benefits of the emerging National Health Information Infrastructure (NHII) for consumers of M/SU health care services, the secretaries of DHHS and the Department of Veterans Affairs should charge the Office of the National Coordinator of Health Information Technology and the Substance Abuse and Mental Health Services Administration to jointly develop and implement a plan for ensuring that the various components of the emerging NHII—including data and privacy standards, electronic health records, and community and regional health networks—address M/SU health care as fully as general health care. As part of this strategy:
  • DHHS should create and support a continuing mechanism to engage M/SU health care stakeholders in the public and private sectors in developing consensus-based recommendations for the data elements, standards, and processes needed to address unique aspects of information
  • management related to M/SU health care. These recommendations should be provided to the appropriate standards-setting entities and initiatives working with the Office of the National Coordinator of Health Information Technology.
  • Federal grants and contracts for the development of components of the NHII should require and use as a criterion for making awards the involvement and inclusion of M/SU health care.
  • The Substance Abuse and Mental Health Services Administration should increase its work with public and private stakeholders to support the building of information infrastructure components that address M/SU health care and coordinate these information initiatives with the NHII.
  • Policies and information technology infrastructure should be used to create linkages (consistent with all privacy requirements) among patient records and other data sources pertaining to M/SU services received from health care providers and from education, social, criminal justice, and other agencies.
All six aims and ten rules.
Recommendation 6-4. (The) Federal … government … should encourage the widespread adoption of electronic health records, computer-based clinical decision-support systems, computerized provider order entry, and other forms of information technology for M/SU care by:
  • Offering financial incentives to individual M/SU clinicians and organizations for investments in information technology needed to participate fully in the emerging NHII.
  • Providing capital and other incentives for the development of virtual networks to give individual and small-group providers standard access to software, clinical and population data and health records, and billing and clinical decision-support systems.
  • Providing financial support for continuing technical assistance, training, and information technology maintenance.
  • Including in purchasing decisions an assessment of the use of information technology by clinicians and health care organizations for clinical decision support, electronic health records, and other quality improvement applications.
All six aims and ten rules.
Recommendation 7-1. To ensure sustained attention to the development of a stronger M/SU health care workforce, Congress should authorize and appropriate funds to create and maintain a Council on the Mental and Substance-Use Health Care Workforce as a public–private partnership. Recognizing that the quality of M/SU services is dependent upon a highly competent professional workforce, the council should develop and implement a comprehensive plan for strengthening the quality and capacity of the workforce to improve the quality of M/SU services substantially by:
  • Identifying the specific clinical competencies that all M/SU professionals must possess to be licensed or certified and the competencies that must be maintained over time.
  • Developing national standards for the credentialing and licensure of M/SU providers to eliminate differences in the standards now used by the states. Such standards should be based on core competencies and should be included in curriculums and education programs across all the M/SU disciplines.
  • Proposing programs to be funded by government and the private sector to address and resolve such long-standing M/SU workforce issues as diversity, cultural relevance, faculty development, and continuing shortages of the well-trained clinicians and consumer providers needed to work with children and the elderly, and of programs for training competent clinician administrators.
  • Providing a continuing assessment of M/SU workforce trends, issues, and financing policies.
  • Measuring the extent to which the plan's objectives have been met and reporting annually to the nation on the status of the M/SU workforce.
  • Soliciting technical assistance from public–private partnerships to facilitate the work of the council and the efforts of educational and accreditation bodies to implement its recommendations.
All six aims and ten rules.
Recommendation 7-3. The federal government should support the development of M/SU faculty leaders in health professions schools, such as schools of nursing and medicine, and in schools and programs that educate M/SU professionals, such as psychologists and social workers. The aim should be to narrow the gaps among what is known through research, what is taught, and what is done by those who provide M/SU services.
Recommendation 9-1. The secretary of DHHS should provide leadership, strategic development support, and additional funding for research and demonstrations aimed at improving the quality of M/SU health care. This initiative should coordinate the existing quality improvement research efforts of the National Institute of Mental Health, National Institute on Drug Abuse, National Institute on Alcohol Abuse and Alcoholism, Department of Veterans Affairs, Substance Abuse and Mental Health Services Administration, Agency for Healthcare Research and Quality, and Centers for Medicare and Medicaid Services, and it should develop and fund cross-agency efforts in necessary new research. To that end, the initiative should address the full range of research needed to reduce gaps in knowledge at the clinical, services, systems, and policy levels and should establish links to and encourage expanded efforts by foundations, states, and other nonfederal organizations. All six aims and ten rules.

From: 9, An Agenda for Change

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

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