Since 2000, when the Institute of Medicine (IOM) began a series of publications describing the "quality chasm" in U.S. health care, there has been no lack of analyses and reports setting forth recommendations, blueprints, and strategies for changing mental health care. In 2003 the President's New Freedom Commission report was released, and 2005 saw the publication of the Federal Action Agenda by the Substance Abuse and Mental Health Services Administration as well as IOM's Improving the Quality of Health Care for Mental and Substance-Use Conditions. What seems most needed now is a synthesis and integration of these complementary but differing recommendations for change.
Such a synthesis—From Study to Action: A Strategic Plan for Transformation of Mental Health Care—was recently published by the Partnership for Health Care Change with support from the Center for Mental Health Services and the California Institute for Mental Health. The Partnership is affiliated with the department of psychiatry at the University of Cincinnati. The synthesis report is based on the work of a 13-member committee with representatives from federal and state mental health agencies, academic medicine, managed care, and private health plans.
The 34-page synthesis lays out a "crosswalk" that demonstrates congruence between six problems and solutions identified as critical in the IOM's 2005 report on mental health and substance abuse treatment (for example, ensuring a patient-centered system and improving workforce capacity) and the five focus areas set forth in the Federal Action Agenda for transformation (for example, coordination of community-based services and dissemination of evidence-based practices). The document also weaves in findings from the IOM's quality chasm series and the President's New Freedom Commission on Mental Health.
However, the monograph notes that "Change cannot be initiated or sustained on the basis of findings and recommendations alone…. One missing element from these reports has been a model for understanding and organizing transformative systems change." Four models are described to help policy makers and providers develop strategies for change. The models include the four levels of the health care system derived from the work of Donald Berwick, the four levers of change outlined in the IOM's 2001 Crossing the Quality Chasm, the three vectors of change developed by the California Institute for Mental Health, and the four quadrants of experience—personal, group, interior, and exterior—derived from the work of John Ott and Associates.
The four models have two common features: all depict systems as being complex, and all emphasize that successful change is implemented on multiple levels simultaneously. Change initiatives often fail when they focus on a single system component. For example, Berwick's model of the health care system outlines four functional levels that change together or do not change at all. The first level—the experiences of individuals, families, and communities—is the organizing principle for change. However, attention must be paid to the settings where services are provided (microsystems), the larger systems that support these settings (macrosystems), and the external environment of government regulations and policies.
In synthesizing recent recommendations from many sources for transforming mental health care, the report notes that "perhaps the greatest level of congruence is found in the centrality of person-centered care." The report emphasizes that the "most fundamental issue in the redesign of the mental health service delivery system is the need to fully embrace and effect the principles of person-centered care. This requires all levels of the health care system adopt the patient-centered aim and associated rules. These aims and rules must not only be incorporated into the mission and vision of the system, but must drive daily business and clinical practice."
Acknowledging that person-centeredness is a "fuzzy concept," the report concludes by asking specific questions, including "What will the new system look like?" Berwick's model is used to describe some attributes of the new system. In the area of consumers and families, self-care and self-advocacy will be central, and consumers and families will identify the education, training, and supports that they need to be effective in these roles. When differences arise between patients' wishes and providers' expertise, they will be "resolved with a shared commitment to sharing of information, transparency, safety, and effective care." In the microsystem of the treatment setting, "the role of the provider or clinician shifts away from being an authority figure to being an advocate for each patient's decision-making consistent with the individual and family's culture and preferences…. The goal is to provide evidence-based care and help facilitate self-management of mental and substance use conditions consistent with the preferences of the individual."
At the macrosystem level of a patient-centered system, organizations that provide care will ensure that patients and families are meaningfully involved in the design of care Also, insurers and purchasers will promote peer support and evidence-based programs or illness self-management, while removing coverage exclusions and restrictions and shifting purchasing strategies to an emphasis on quality rather than cost. Finally, in Berwick's "external environment," state and federal policy makers will redraft laws and regulations to eliminate barriers to communication and coordination between providers, ensure that resources are provided for quality improvement and measurement, and promote the installation of electronic health information systems.
From Study to Action: A Strategic Plan for Transformation of Mental Health Care is available on the Web site of the Partnership for Health Care Change at www.healthcarechange.org
Variations in Medicare drug plans: An analysis by the Kaiser Family Foundation has found significant variation in Medicare drug plans. The study looked at 152 drugs in plans offered by 14 organizations; the plans account for 1,222 of the 1,429 available packages. The most restrictive formulary covers 64 percent of the drugs, and the least restrictive covers 97 percent; no plan covers all 152 drugs. Cost-sharing varies considerably: for example, an enrollee could pay from $17 to $66 for Zoloft and from $15 to $100 for Namenda (for Alzheimer's disease). "Without careful consideration," the report notes, "beneficiaries may find themselves paying hundreds, if not thousands, of dollars more." Plans vary significantly in the frequency with which they restrict access to specific drugs through quantity limits, prior authorization, and step therapy. Four of the plans use these tools for less than 10 percent of covered drugs, while 13 plans do so for 25 percent or more. The potential impact of the variations is heightened by the fact that beneficiaries are generally locked into a plan for the entire year in which they enroll, whereas plans can change their formularies throughout the year. In releasing the study, Kaiser Foundation President Drew E. Altman said, "The drug law was designed to encourage competition among plans, and in that respect, it is working. But because there are big differences from plan to plan, choice matters…. What's not yet clear is how well people with Medicare can sort through all these differences to make informed decisions." The complete study is available on the Kaiser Family Foundation Web site at www.kff.org/medicare/7489.cfm.
"How-to" advocacy Web site: The Advocacy Center Web site of the Depression and Bipolar Support Alliance (DBSA) provides a comprehensive guide to advocating for mental health care. The fully indexed site describes a variety of ways that individuals can become involved in advocacy activities. Along with a detailed explanation of the legislative process, the site provides links to government Web sites for conducting research and monitoring legislation. The site also provides tips on how to communicate with legislators and their staff (by letter and telephone and in person) and a list of key messages and talking points. Visitors can download a mail-in voter registration form and sign up for DBSA's Advocacy E-Newsletter as well as for "Mega-Vote," a weekly e-mail service informing advocates about how members of Congress are voting on key legislation. The Advocacy Center can be found at www.dbsalliance.org.
State substance abuse data from SAMHSA: A new report from the Substance Abuse and Mental Health Services Administration provides state-level analyses of data from the 2004 National Survey on Drug Use and Health. The two states with the largest increases in past-month alcohol use among 12- to 20-year-olds were California and Wisconsin. Michigan and South Carolina showed the largest decreases. Eight states were in the top fifth for both underage and binge drinking: Iowa, Massachusetts, Montana, New Hampshire, North Dakota, Rhode Island, South Dakota, and Wisconsin. No state had a statistically significant increase in current drug use in any age group. The estimates show that past-month use of any illicit drug in 2003-2004 among persons aged 12 and older ranged from a low of 5.8 percent in Mississippi to a high of 11.8 percent in Alaska. West Virginia had the highest rate of serious psychological distress in the past year among persons aged 18 and older (12.7 percent), and Hawaii had the lowest rate (7.1 percent). Increases in serious psychological distress were noted in ten states—Arizona, California, Florida, Illinois, Iowa, New Jersey, Pennsylvania, Texas, West Virginia, and Wyoming. The full report is available at www.oas.samhsa.gov.
NMHA Web site for Mental Health Awareness Month: For more than 50 years the National Mental Health Association has sponsored Mental Health Awareness Month in May. This year the focus is on the mind-body connection through the promotion of mental wellness and overall health for all Americans, regardless of age or background. NMHA has developed a series of mental health tips and suggestions to help Americans achieve physical and mental well-being. Fact sheets address managing workplace stress, balancing the demands of work and home, understanding childhood depression, improving the mental health of older adults, caring for an aging parent, and improving family mental health. More information is available on NMHA's Web site at www.nmha.org.