Barriers, Strategies, and Solutions to Increasing Quality in the Public Environment November 3, 2005 King Davis, PhD, Executive Director Hogg Foundation for Mental Health Services, Research, Policy & Education Robert Lee Sutherland Chair in Mental Health & Social Policy School of Social Work The University of Texas at Austin Austin, Texas

Quality Convergence Challenge: Intersections Payors Providers Policy Makers Advocates/Consumers Science Conceptualization Treatment Values

An Expanded View of Health/MH/SA Cardiovascular Disease Depression Sickle Cell Schizophrenia Periodontal Disease Diabetes HIV Alcohol Abuse CancerObesity Bipolar Personality Disorder Dementia Homicides Domestic Violence Unemployment Environmental Pollution Low Birth Weight Babies Low Income Asset Accumulation Voting Political Office Marital Stress Criminal Justice Cocaine Use/Sale Housing & Homelessness Nutrition Literacy Maternal/ Infant Deaths Mental Retardation Uninsured Graduation Rates Anxiety Capital Punishment King Davis, 2003

Six Cycles of Quality Efforts Community Based Care – Pre 1750 Community Based Care – Pre 1750 Institutionalization – Institutionalization – Deinstitutionalization Deinstitutionalization Community Mental Health Community Mental Health Managed Health Care Managed Health Care Behavioral HealthCare Behavioral HealthCare [Integrated Health Care] [Integrated Health Care]

Remaining Barriers to Quality Human Resource Impediments: Human Resource Impediments: Relationship between quality, race, ethnicity, and class: Relationship between quality, race, ethnicity, and class: Political & economic pressure to maintain state hospitals Political & economic pressure to maintain state hospitals States Rights – Control of policy at state level: States Rights – Control of policy at state level: Budget as Policy: Absence of a business case Budget as Policy: Absence of a business case Segregated vs. integrated health: Segregated vs. integrated health: Absence of knowledge management: Absence of knowledge management: Inconsistent ties between Human Rights and quality: Inconsistent ties between Human Rights and quality: Change by committee – Policy diffusion Change by committee – Policy diffusion Medicine without science - Conceptualization: Medicine without science - Conceptualization:

Conclusions Public environments are disproportionately for people of color and the poor; quality is low or absent; Public environments are disproportionately for people of color and the poor; quality is low or absent; Key resistance to transformation is at the state level – prospective impact on costs, control, and jobs are paramount – must involve state governors/legislators Key resistance to transformation is at the state level – prospective impact on costs, control, and jobs are paramount – must involve state governors/legislators Evidence based approaches must be adapted to include the 4 populations of color; Evidence based approaches must be adapted to include the 4 populations of color; Cultural competence offers promise but requires national field testing, cost estimation, educational trials, linkages to licensure, accreditation, and further development; Cultural competence offers promise but requires national field testing, cost estimation, educational trials, linkages to licensure, accreditation, and further development; State governors and legislators have not signed off on key reports and recommendations calling for change; State governors and legislators have not signed off on key reports and recommendations calling for change;

Conclusions (continued) The future is in integrated health approaches The future is in integrated health approaches Change requires major alteration in professional schools and licensure – enormous implications Change requires major alteration in professional schools and licensure – enormous implications Need a place to house the responsibility for change to quality Need a place to house the responsibility for change to quality Major contradictions in what is proposed, fund, and support – Medicaid and housing cuts Major contradictions in what is proposed, fund, and support – Medicaid and housing cuts There is no federal or state sense of urgency to change There is no federal or state sense of urgency to change Must alter the management of knowledge Must alter the management of knowledge Transformation may not survive a new administration Transformation may not survive a new administration

Major Recommendations Convene Governors and Legislators re Vision, Change, Cost, Planning, Future - Convene Governors and Legislators re Vision, Change, Cost, Planning, Future - Nationalize State Mental Health Systems - 5 years – Federal/State Funding – State Hospital Plans Nationalize State Mental Health Systems - 5 years – Federal/State Funding – State Hospital Plans Develop a National/State Policy to Require Behavioral Health in General Hospital/Primary Care Settings – Open Medicaid/Disproportionate Share Policy/Tele-Health Develop a National/State Policy to Require Behavioral Health in General Hospital/Primary Care Settings – Open Medicaid/Disproportionate Share Policy/Tele-Health Integrated Health as the National Policy - Integrated Health as the National Policy - National/State Quality Goals & Standards National/State Quality Goals & Standards National/State Workforce & Training Goals National/State Workforce & Training Goals Implementation Strategy for Tracking Quality Data Implementation Strategy for Tracking Quality Data

Minor Recommendations Release Sub-Reports – New Freedom Report Release Sub-Reports – New Freedom Report Increase Research Dollars – Causality Increase Research Dollars – Causality Eliminate Medicaid Reductions in Congress Eliminate Medicaid Reductions in Congress New Training/Education Grants- Universities New Training/Education Grants- Universities Private Sector Involvement in Policy Changes Private Sector Involvement in Policy Changes New Media Portrayals of Behavioral Health New Media Portrayals of Behavioral Health Broader Concept of Health/MH/SA Issues Broader Concept of Health/MH/SA Issues Publish Data on Effective MH Hospitals Publish Data on Effective MH Hospitals Tie Accreditation to Quality Tie Accreditation to Quality

Contact Information King Davis, Ph.D. King Davis, Ph.D. Executive Director Hogg Foundation for Mental Health Executive Director Hogg Foundation for Mental Health Robert Sutherland Chair in Mental Health Policy Robert Sutherland Chair in Mental Health Policy The University of Texas at Austin The University of Texas at Austin