Improving the Quality of Health Care for Mental and Substance-Use Conditions “America will not have a high-quality health system if equal attention is not given to mental health issues and substance use problems…” Mary Jane England Frances M. Murphy, M.D., M.P.H. Office of the Deputy Under Secretary for Health For Health Policy Coordination November 3, 2005

Health Care Provider 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

VA’S Mental Health System Prior to Transformation ? 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

What Can We Expect in the Future? Mental Health Outpatient Stops Overall Veteran Enrollment Mental Health Bed Days of Care Mental Health Utilization Projections

Overarching 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.

Events Leading to VA Health System 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

Recommendation 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.

Recommendation 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

Personal 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

Recommendation 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

Recommendation 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

VA’s Electronic Health Record

Clinical Reminders Links Reminder With the Action With Documentation Contemporary Expression of Practice Guidelines Time & Context Sensitive Reduce Negative Variation Create Standard Data Acquire health data beyond care delivered in VA With the Action With Documentation

VA Sets the U.S. Benchmark for 18 Comparable 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 (NCQA 2002) Cervical Cancer Screening 90 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 61 (NCQA 2002) Colorectal Cancer Screening 67 49 (BRFSS 2002) Diabetes Hgb A1c checked past year 85 83 (NCQA 2002) Diabetes Hgb A1c > 9.5 (lower is better) 15 34 (NCQA 2002) Diabetes LDL Measured 95 88 85 (NCQA 2002) Diabetes LDL < 130 77 63 55 (NCQA 2002) Diabetes Eye Exam 68 52 (NCQA 2002) Diabetes Kidney Function 70 57 Hypertension: BP < 140/90 58 (NCQA 2002) Influenza Immunization 76 P 68 (BRFSS 2002) Pneumocooccal Immunization 63 (BRFSS 2002) Mental Health F/U 30 D post D/C 61 74 (NCQA 2002)

Institute of Medicine “Leadership by Example” October 2002 “VA’s integrated health care information system, including its framework for using performance measures, is considered one of the best in the nation” Institute of Medicine “Leadership by Example” October 2002

Recommendation 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

Recommendation 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

Workforce Development Academic Affiliations and Training 83,115 Total Trainees (Academic Year 2003) 29,179 Medical Residents 16,740 Medical Students 37,196 Associated Health Trainees

Summary 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