Quality-Improvement Efforts: Will Psychiatry Be Left Behind?
What will it take to bring the entire field of mental health treatment into line with the general movement for quality improvement throughout medicine?
That's the question posed by researchers at RAND and the UCLA Semel Institute for Neuroscience and Human Behavior Health Services Research Center in an article in the May Health Affairs.
The response they offered describes three broad reforms that are necessary to accelerate the process of quality improvement in mental health. Among their suggestions:
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Developing quality-improvement measures applicable to a diverse set of disorders, patients, and service settings.
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Improving the infrastructure for providing evidence-based psychotherapy and psychosocial interventions.
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Promoting innovation in financial incentives for demonstrating quality improvement in mental health care.
Lead author Kavita Patel, Ph.D., an associate natural scientist at RAND in Santa Monica, Calif., and colleagues noted that a 2004 report by the Agency for Healthcare Research and Quality on the state of quality measurement in medical practice, only four of 179 quality indicators were related to mental health care.
“Efforts to include mental health in broader quality-improvement initiatives face such barriers as condition- and treatment-related social stigma and regulations concerning privacy,” they said. “These barriers are often exacerbated by system factors specific to mental health, such as the broad array of provider specialty types and agencies providing services and characteristics of the market, such as financing limitations.”
Patel and colleagues described the following three broad reforms necessary to address barriers to quality improvement:
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Developing generalizable quality-improvement resources. The activities that community practices often use in quality-improvement efforts, such as screening, provider feedback, and reminder systems, have not demonstrably improved outcomes in mental health care. To support communitywide quality improvement for mental health care, such programs must be made more widely generalizable. This can be done by expanding implementation of quality-improvement programs across a range of psychiatric disorders, tailoring them to diverse age and sociocultural groups, and adapting them for a spectrum of settings, particularly those outside of traditional research environments.
“Doing this will likely increase community and public health systems' confidence to integrate quality-improvement initiatives into their own care delivery contexts,” the researchers noted. “This also has the potential to reduce fragmentation in the mental health system.”
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Improving the infrastructure for providing evidence-based psychotherapy and psychosocial interventions. Patel and colleagues stated that for the broad range of psychotherapy practitioners—including psychologists and social workers—there are no uniform licensure or certification requirements obligating these providers to have competence in such evidence-based psychosocial treatments as cognitive-behavioral therapy (CBT) and interpersonal psychotherapy (IPT) and no easy way for consumers or health care providers to identify clinicians who deliver the treatments. (Psychiatry residents are currently required by the Accreditation Council for Graduate Medical Education to demonstrate competency in five psychotherapies, including CBT and IPT.)
“Leadership. .is central to achieving widespread use of evidence-based psychotherapies.”
“Leadership, especially at the level of professional organizations and training institutions, is central to achieving widespread use of evidence-based psychotherapies,” they said.
“Professional organizations can play a role by developing resources available to members to support evidence-based psychotherapies and providing training during annual national and regional meetings. Academic training programs similarly can lay a foundation by routinely exposing trainees to a variety of evidence-based psychotherapies and requiring competency in at least one form of evidence-based therapy, while learning how to evaluate the evidence for that therapy.”
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Promoting innovation in financial incentives for quality improvement in mental health care. Patel and colleagues noted that a variant of pay-for-performance—the innovation currently attracting the most interest in medicine—that could have particular relevance to mental health is the realignment of financial incentives to reflect patients' preferences for treatments and outcomes.
“This strategy has been adopted by some health plans and consumer advocacy groups but has not yet been extensively described in the literature or formally evaluated,” they noted. “Developing a better understanding of patients' preferences could inform risk-adjustment models by explaining additional sources in variance around mental health spending.”
“What Is Necessary to Transform the Quality of Mental Health Care” is posted at<http://content.healthaffairs.org/cgi/content/abstract/25/3/681?rss=1>.▪
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Published online: 2 June 2006
Published in print: June 2, 2006
Notes
In a recent report by the Agency for Healthcare Research and Quality on the state of measuring quality in medical practice, only four of 179 quality indicators were related to mental health care.
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