1. 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

2. 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

3. 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

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

5. 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.

6. 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

7. 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.

8. 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

9. 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 (
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

11. 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

12. 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

13. VA’s Electronic Health Record

14. 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

15. 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)

16. 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

17. 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

18. 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

19. 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

20. 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