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Improving the Quality of Health Care for Improving the Quality of Health Care for Mental and Substance-Use ConditionsMental and Substance-Use Conditions

““America will not have a high-quality health system if equal attention is not America will not have a high-quality health system if equal attention is not given to mental health issues and substance use problems…” given to mental health issues and substance use problems…”

Mary Jane EnglandMary Jane England

Frances M. Murphy, M.D., M.P.H.Frances M. Murphy, M.D., M.P.H.

Office of the Deputy Under Secretary for HealthOffice of the Deputy Under Secretary for Health

For Health Policy CoordinationFor Health Policy Coordination

November 3, 2005November 3, 2005

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Health Care Provider Health Care Provider Organizations should:Organizations should:

• Have policies to enable and support all actions required of clinicians

• Involve patients/families in design, administration, and delivery of services

• If serving a high risk population, screen all entrants for M/SU problems

• Involve leadership and staff in developing the NHII

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• Strengths: • U.S. leader in mental health care and research• Integrated national healthcare system• Full Continuum of Care: screening, health promotion and

disease prevention, outpatient care, acute hospital care, and long-term care

• Comprehensive electronic health records• VA system supports parity

• Challenges:• Variability in access and quality of services across the

country • Lack of integration of mental health and primary care• Increased projected workload and demand for mental health

services

VA’S Mental Health System VA’S Mental Health System Prior to Transformation ?Prior to Transformation ?

4

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024

Fiscal Year

In T

hous

ands

Mental Health Outpatient Stops

Overall Veteran Enrollment

Mental Health Bed Days of Care

What Can We Expect in the Future?What Can We Expect in the Future?

Mental Health Utilization ProjectionsMental Health Utilization Projections

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Overarching RecommendationOverarching Recommendation

• The aims, rules, and strategies for redesign set forth in Crossing the Quality Chasm should be applied on a day-to-day operational basis but tailored to reflect the characteristics that distinguish care for M/SU problems and illnesses from general health care.

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Events Leading to VA Health Events Leading to VA Health System TransformationSystem Transformation

• Transformation of VA Healthcare

• “Vision for Change” and “Journey for Change”• Motivational force and culture change• Organization-wide reorganization • Full continuum of care including prevention• Emphasis on evidence-based care• Healthcare quality, safety and performance

measurement • Crossing the Quality Chasm: A New Health System for the

21st Century• President’s New Freedom Commission Report

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Recommendation 3.1Recommendation 3.1

• To promote patient-centered care, organizations providing M/SU treatment services should support the decision making abilities and preferences for treatment and recovery of persons with M/SU problems and illnesses

• Policies that implement informed, patient-centered participation and decision-making in treatment, illness self management, and recovery plans.

• Involving patients and families• Incorporating informed, patient centered decision-making

active participation in treatment and recovery plans, advance directives and informed decision making.

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Recommendation 3-1Recommendation 3-1

• VA is embracing new approaches to care:• Recovery Model

• Development of National VA Recovery Plan

• Peer Support programs• Veteran and Family Centered

• Encourage establishment of Medical Center Consumer Councils

• Advance Directives

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Personal Health RecordsPersonal Health Records

• Patient centered tool supports informed decision-making, self-management and expression of treatment preferences in achieving optimal health

• My HealtheVet Mental Health Portal (www.myhealth.va.gov)• Health Information and Veteran Education• Mental Health Screening• Disease Management dialogues and Self-Tracking tools

• Enhancing the Internet-based, secure Personal Health Record to include mental health.

• Provides veterans with copies of key parts of their VA health information

• E-Prescribing• Messaging

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Recommendation 4-2Recommendation 4-2

• Organizations should:• Increase use of valid reliable patient

questionnaires or other patient assessment instruments to assess the progress and outcomes systematically and reliably

• Use measures of process and outcomes of care to continuously improve the quality of care they provide

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Recommendation 5-1Recommendation 5-1

• Organizations should:• Make collaboration and coordination of patients’

M/SU care the norm by providing effective linkages within their own organizations and between providers of mental health and S/U treatment.

• Routine sharing of information on patients’ problems and pharmacologic and non-pharmacologic treatments

• Valid, age appropriate screening of co-morbid mental health, substance-use, and general health

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VA’s Electronic Health RecordVA’s Electronic Health Record

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Clinical RemindersClinical Reminders

Contemporary Expression of Practice Guidelines

• Time & Context Sensitive

• Reduce Negative Variation

• Create Standard Data

• Acquire health data beyond care delivered in VA

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VA Sets the U.S. Benchmark for 18 VA Sets the U.S. Benchmark for 18 Comparable IndicatorsComparable Indicators

Clinical Indicator VA 2003 Medicare 03 Best Not VA or Medicare

Advised Tobacco Cessation (VA x3, others x1) 75 62 68 (NCQA 2002)

Beta Blocker after MI 98 93 94 (NCQA 2002)

Breast Cancer Screening 84 75 75 (NCQA 2002)

Cervical Cancer Screening 90 62 81 (NCQA 2002)

Cholesterol Screening (all pts) 91 NA 73 (BRFSS 2001)

Cholesterol Screening (post MI) 94 78 79 (NCQA 2002)

LDL Cholesterol <130 post MI 78 62 61 (NCQA 2002)

Colorectal Cancer Screening 67 NA 49 (BRFSS 2002)

Diabetes Hgb A1c checked past year 94 85 83 (NCQA 2002)

Diabetes Hgb A1c > 9.5 (lower is better) 15 NA 34 (NCQA 2002)

Diabetes LDL Measured 95 88 85 (NCQA 2002)

Diabetes LDL < 130 77 63 55 (NCQA 2002)

Diabetes Eye Exam 75 68 52 (NCQA 2002)

Diabetes Kidney Function 70 57 52 (NCQA 2002)

Hypertension: BP < 140/90 68 57 58 (NCQA 2002)

Influenza Immunization 76 P 68 (BRFSS 2002)

Pneumocooccal Immunization 90 P 63 (BRFSS 2002)

Mental Health F/U 30 D post D/C 77 61 74 (NCQA 2002)

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““VA’s integrated health care VA’s integrated health care information system, including its information system, including its framework for using performance framework for using performance measures, is considered one of the measures, is considered one of the

best in the nation”best in the nation”

Institute of Medicine

“Leadership by Example”

October 2002

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Recommendation 5-2Recommendation 5-2

• To facilitate the delivery of coordinated care by primary care, mental health and substance-use treatment providers • Enhancing M/SU staff at Community-Based

Outpatient Clinics• Collocation of mental health, S/U, primary care

services (Level 3)• Performance Measure established

• Collaborative Care Pilots• Delivery of MH, SU, and primary healthcare

through clinically integrated practices

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Recommendation 5-3Recommendation 5-3

• To ensure the health of persons for whom they are responsible, organization should: 1)coordinate their services with those of other human-services agencies; 2) establish referral arrangements for needed services. • Large provider of Homeless Veterans services

• Performance Measures established• VA-HUD collaborations• Grant and Per Diem program with non-profit providers

• Supported Employment and CWT• State collaborations• Transition services for incarcerated veterans

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Workforce DevelopmentWorkforce DevelopmentAcademic Affiliations and TrainingAcademic Affiliations and Training

83,115 Total Trainees (Academic Year 2003)

29,179 Medical Residents 16,740 Medical Students 37,196 Associated Health Trainees

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SummarySummary• Mental Health transformation is a journey• The IOM report gives us an excellent roadmap

for improving the quality of healthcare in MH and SUD

• Health Care Organizational transformation requires a systems approach and a strategic plan

• Transformation requires culture change