Fragmentation Impeding Effectiveness of Care

Areport from the Institute of Medicine (IOM) of the National Academies offers a first-time comprehensive strategy to improve health care for people with mental illness and alcohol or drug problems by linking them with high-quality care in the overall U.S. health system.

The report, called “Improving the Quality of Health Care for Mental and Substance-Use Conditions,” was released last month and outlined key roles for government officials, clinicians, health care organizations, health plans, and insurance purchasers.

The authors found that, as with general health care, the delivery of high-quality interventions is inconsistent, and poor care has serious consequences that range from lost productivity to suicide. The private and publicly funded report found that more than 33 million Americans use health care services for mental health and substance abuse treatment annually, and that successful, cost-effective treatments exist.

“To the extent that we fragment care between general health care and mental health services we reduce the overall effectiveness of health care,” said Paul Appelbaum, M.D., chair of the Department of Psychiatry at the University of Massachusetts and a member of the committee that prepared the study, in an interview with Psychiatric News.

Health services for mental health and substance abuse conditions have been isolated not only from other components of the health system but also from each other, Appelbaum said, despite the fact that many people have psychiatric conditions, including problems with alcohol or drugs.

The report's recommendation for a “multidimensional approach” goes beyond previous research findings that have focused on service improvements that could be made to various components of mental health, substance abuse, and general health care, Appelbaum said.

To make collaboration and coordination of care the norm, service providers should link relevant areas of their own organizations and form ties with other providers, said the report.

The report encourages government agencies, purchasers, health plans, and accrediting groups to create incentives and policies to increase collaboration among all health care providers. The Department of Health and Human Services (HHS) should lead these efforts by establishing a permanent, highlevel mechanism to foster greater coordination across the department's mental, substance use, and general health care agencies.

A broad range of providers licensed to diagnose and treat mental illnesses and substance abuse has spawned varied training levels and therapeutic approaches. The result is that the overall workforce has an uneven distribution of the knowledge and skills necessary to provide consistent, high-quality services, according to the report.

While the report specifically avoided identifying models of better integration, Appelbaum said, it requested that Congress authorize and fund a component called the Council on the Mental and Substance-Use Health Care Work Force to create plans that help professionals improve the quality of the care they provide.

“The quality-of-care movement in health care has been late in coming to mental health, but it is revolutionizing how people think about delivering those services,” Appelbaum said.

Information Sharing: Next Wave

Effective care also hinges on the ability of health professionals to obtain and share information quickly on a patient's health and potential treatments, the report said. It urged federal and state governments to revise laws, regulations, and administrative practices that hinder such information sharing.

Among the few potential drawbacks to the systemic changes advocated in the report, Appelbaum said, are possible abuses that come with increased access to patient information. But the technological safeguards exist to control this risk, he said.

An information technology system under development, called the National Health Information Infrastructure (NHII), will make the exchange of health information easier. But such efforts have dealt inadequately with health care for psychiatric problems, including substance use, said the report. It urged HHS and the Department of Veterans Affairs to take steps to ensure that NHII will comprehensively address such conditions. Additionally, federal and state governments, purchasers, and foundations should offer incentives to clinicians and groups who treat these problems to invest in the information technology needed to fully participate in NHII.

Improve Coordination

The report called for HHS to gather and disseminate scientific evidence on effective services for mental and substance-use conditions. The department should lead efforts to develop an infrastructure to measure and improve the quality of mental health care, including treatment for substance use. It encouraged HHS to work with the private sector to create a private, nonprofit organization able to identify and put into practice quality measures in these areas.

Charles Curie, M.A., administrator of the Substance Abuse and Mental Health Services Administration, said in a statement on the IOM report that his agency intends to work within HHS and other agencies and organizations to“ expand capacity for treatment that is science based, responsive to the individual needs of consumers, and culturally relevant.”

“Improving the Quality of Health Care for Mental and Substance-Use Conditions” is posted at<www.nap.edu/catalog/11470.html?onpinewsdoc110120005>.▪