APA Starts Transformation Of Vision Into Reality

A vision, no matter how noble, will remain just that without a detailed map that shows how that vision can be achieved. Last spring, in response to the report of the President’s New Freedom Commission on Mental Health, APA developed the “Vision Statement for the Mental Health System” in the United States, which describes themes that are crucial to fixing a mental health system that is dysfunctional and deteriorating.

At its meeting last month in Washington, D.C., the APA Board of Trustees adopted a report that takes seven core themes of the vision statement and outlines steps that APA needs to take to help make the vision of an effective and caring mental health system a reality.

The seven themes are each accompanied by objectives that must be met if the system is to be reformed, along with more than 90 detailed strategies for fulfilling those objectives.

The plan, or roadmap, was developed by the Work Group to Actuate the Vision Statement, which was chaired by APA’s immediate past president, Paul Appelbaum, M.D. Appelbaum stressed that the work group’s report is a “living plan” for APA’s advocacy efforts and will likely change based on legislative and regulatory developments and other changes affecting the mental health care system. It could also be modified based on feedback from APA members who review the document, he noted.

The first of the themes is “creation of an effective system for delivering mental health care,” and the report identifies the following seven objectives as critical in creating such a system:

• A full continuum of community-based services that are easily available to every patient and adequately funded. Such a system would seamlessly allow patients to move to appropriate levels of care without financial or other barriers. One of the five strategies under this objective is, for example, to develop a model of care and guidelines for funding based on the core principles of the Community Mental Health Act of 1963, including a nationwide catchment-area system. Another strategy for achieving this objective is to encourage the appropriate level of social support necessary to maintain patients outside the hospital, including establishment of residential and vocational services.

• Full integration of treatment for substance use disorders and other psychiatric services regardless of venue, including primary care settings as appropriate. There must be adequate reimbursement for these services by public insurance programs and third-party carriers.

• Creation of innovative programs to provide psychiatric care to underserved areas and populations and development of services for groups with particularly complex needs (such as children, the elderly, incarcerated persons, and ethnic and racial minorities).

• Early detection and treatment of targeted high-risk groups before they develop psychiatric morbidity. Early interventions should emphasize wellness and prevention.

• Prevention, screening and referral, and treatment services provided in nontraditional settings such as correctional facilities, schools, and workplaces. Employers should be made aware of the cost savings that derive from early and effective treatment of psychiatric disorders.

• Availability of both inpatient and less-restrictive outpatient commitment for patients who are unable to make capable decisions about treatment and need to be involuntarily involved in treatment.

• Availability of community assessments that specify the type and quantity of services needed for a given population in a given area, for example, inpatient beds, residential units, crisis services, clinic treatment slots.

The second theme in achieving APA’s vision for a mental health system involves the crucial issue of putting in place health insurance that no longer discriminates against the provision of appropriate coverage for mental health treatment. These are the objectives that will govern APA’s strategies in this area, most of which are already high on APA’s agenda:

• Health insurance coverage for all Americans that provides parity for psychiatric and general medical disorders. An example of one of the seven strategies in this section is to use an evidence-based approach to persuade insurance purchasers that it is critical that they provide nondiscriminatory coverage for mental disorders with adequate reimbursement for such services.

• Clear coordination of responsibility among federal, state, and private-sector agencies so that no person who needs care is left untreated.

• Development of funding systems that take into account the unique needs of persons with mental disorders, including needs for outreach, case management, and support in residential services, among others. Access to such services must extend to persons with chronic and episodic disorders.

• Reimbursement that adequately reflects the costs of delivering psychiatric care.

• Removal of structural barriers, such as carveouts and prescription restrictions and policies such as utilization review that limit effective access to evaluation and treatment.

• Reduction of barriers to early treatment by eliminating managed care systems and arbitrary requirements related to severity of health conditions.

The third theme emphasizes the need to develop a psychiatric workforce that is sufficient to meet the country’s needs for comprehensive mental health services. These are the objectives subsumed under this goal:

• Identification of psychiatric manpower requirements for underserved populations, especially those at both ends of the age spectrum.

• An increase in the number of general psychiatrists and subspecialists to levels adequate to deal with unmet needs.

• An increase in minority representation in psychiatry and its subspecialties.

• Removal of structural obstacles—such as inadequate reimbursement for graduate medical education positions—to recruitment of adequate numbers of psychiatrists in shortage subspecialties.

• Facilitation of treatment of children and adolescents by general psychiatrists when child and adolescent psychiatrists are unavailable and development of educational programs to enhance general psychiatrists’ knowledge in this area.

• Provision of sufficient training to primary care physicians to enable them to fulfill their responsibilities in the care of persons with mental disorders.

“Moving toward a patient-centered, culturally competent mental health care system” is the fourth theme in actuating APA’s vision, and the following objectives are described:

• Every psychiatrist receives adequate exposure to concepts of culturally competent, collaborative, patient- and family-centered care and is capable of implementing these approaches.

• Development of cultural sensitivity standards and models for psychiatry so that communities can develop patient-centered systems of care within models of comprehensive community mental health care.

• Patients are empowered, educated, and actively involved in all aspects of their treatment.

• Wide availability of mechanisms such as psychiatric advance directives and of systems to ensure the effective implementation of these directives.

• Adoption of requirements for patient participation in psychiatric care.

• Increased awareness of the value of including family members and others in the patient’s natural support system as part of treatment.

The fifth theme involves the stubborn issue of reducing the stigma attached to mental illness and its treatment. Critical objectives are to increase knowledge of professionals and the public on the causes, prevention, and effective treatment of mental disorders and to form partnerships to fight stigma with like-minded organizations.

Any reformed system must guarantee that the mental health care it makes available is of high quality. These are among the objectives that will lead to improving the quality of care:

• Acceptance of outcome-based management models that include measures of patient satisfaction.

• Enhancement of evidence-based preventive care, with a focus on wellness and protective factors that would reduce the number of at-risk persons needing services.

• Identification, implementation, and dissemination of program and service-delivery models and best practices for specific groups.

The report’s sixth theme is improving the quality of mental health care. Among the objectives to be achieved:

• An emphasis on high-quality care and patient safety.

• Acceptance of outcome-based management models, including patient-satisfaction measures.

• Enhancement of evidence-based preventive care.

• Identification and implementation of effective programs and best practices for specific groups.

The last of the seven themes underlying a reformed health care system is promoting research on mental disorders. This, APA maintains, will require the following:

• Definition of the scope and fiscal requirements for a future mental health research agenda upon which key stakeholders agree.

• Expansion of federal and private research funding to a level commensurate with the proportion of disability attributable to psychiatric disorders.

• Creation of a long-term plan for increases in federal funding for research on mental disorders so that smooth and predictable levels of growth in research can occur and research programs can be sustained.

• Development of a cadre of young psychiatric researchers to pursue investigations of the etiologies and treatments of mental disorders.

The Board sent the report to Medical Director James H. Scully Jr., M.D., to prepare cost estimates for carrying out the dozens of strategies outlined. Scully and the Board will then prioritize the objectives and strategies in light of available resources and APA’s goals.

APA’s publication, “A Vision for the Mental Health System,” is posted online at www.psych.org/news_room/press_releases/visionreport040303.pdf. ▪