crossing the quality chasm

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Crossing the Quality Chasm Quality problems occur typically not because of failure of goodwill, knowledge, effort or resources devoted to health care, but because of fundamental shortcomings in the ways care is organized” Trying harder will not work: changing systems of care will! a new HEALTH system for the 21 st century (IOM, 2001)

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Crossing the Quality Chasm. “ Quality problems occur typically not because of failure of goodwill, knowledge, effort or resources devoted to health care, but because of fundamental shortcomings in the ways care is organized” Trying harder will not work: changing systems of care will!. - PowerPoint PPT Presentation

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  • Crossing the Quality Chasm

    Quality problems occur typicallynot because of failure of goodwill,knowledge, effort or resourcesdevoted to health care, but becauseof fundamental shortcomings in theways care is organized

    Trying harder will not work:changing systems of carewill!

    a new HEALTH system for the 21st century (IOM, 2001)

  • The Crossing the Quality Chasm Series

    To Err is Human (1999)

    Crossing the Quality Chasm - A New Health System for the 21st Century (2001)

    Leadership by Example (2002)

    Fostering Rapid Advances in Health Care (2002)

    Priority Areas for National Action (2003)

    Health Professions Education (2003)

    Keeping Patients Safe Transforming the Work Environment of Nurses (2004)

    Patient Safety Achieving a New Standard for Care (2004)

    Quality through Collaboration the Future of Rural Health (2005)

    Improving the Quality of Health Care for Mental and Substance-use Conditions (2005)

  • Six Aims of Quality Health Care Safe avoids injuries from care Effective provides care based on scientific knowledge and avoids services not likely to help

    Patient-centered respects and responds to patient preferences, needs, and values

  • Six Aims (cont.)Timely reduces waits and sometimes harmful delays for those receiving and giving care

    Efficient avoids waste, including waste of equipment, supplies, ideas and energy

    Equitable care does not vary in quality due to personal characteristics (gender, ethnicity, geographic location, or socio-economic status)

  • OVERARCHING CONCLUSION

    It is not possible to deliver safe or adequate healthcare without simultaneous consideration of general health, mental health and substance use issues.

  • Overarching Recommendation 1The aims, rules, and strategies for redesign in Crossing the Quality Chasm apply equally to M/SU health care.

    In particular, Patient Centered Care also applies to M/SU Care.

  • Overarching ConclusionBut.

    Mental and Substance Use Care are different in important ways

  • M/SU Health Care Compared to General Health Care More stigma, coercion & discrimination

    Less patient decision-making

    Diagnosis more subjective

    Less developed QI infrastructure

  • M/SU Health Care Compared to General Health Care More separate care delivery arrangements

    Less use of IT

    More diverse workforce & more solo practice

    Differently structured marketplace

  • Overview The Problem

    Patient Centered Care vs Effective Care

  • Issue 1: Patient-Centered CareHallmark of Ethical CarePatient is the source of control on:information sharing & decision makingCare based on patient needs and valuesCare is transparent to the patientEthical care provides full disclosure/discussion of all care options for patient to decide

  • Issue 2: Effective CareFDA standards of effectivenessDo substance abuse treatments meet those standards?

  • An FDA Perspective

    A Drug is Approved for An Indication

    2 -Randomized Clinical Trials: Often ask for separate investigators

    Placebo Control: Movement to test vs approved medicationTreatment Research Institute

  • TherapiesCognitive Behavioral TherapyMotivational Enhancement TherapyCommunity Reinforcement and Family TrainingBehavioral Couples TherapyMulti Systemic Family Therapy12-Step FacilitationIndividual Drug Counseling

  • MedicationsAlcohol (Disulfiram, Naltrexone, Accamprosate) Opiates (Naltrexone, Methadone, Buprenorphine) Cocaine (Disulfiram, Topiramate, Modafinil) Marijuana (Rimanoban)Methamphetamine Nothing Yet

  • So Given effective options: What if patients dont want them?How can we implement them?

  • Improving the Quality of Health Care for Mental and Substance-Use Conditions Defining and Measuring Quality and Effectiveness

  • Effectiveness, Performance, Quality: Whats the Difference?

  • Effectiveness Patient outcomes following treatment - patient symptoms and function Methods - Usually patient follow-up 6 12 months post discharge. Measures -Patient substance use, employment, crime health, family & social function Recovery.Characteristics Definitive, relevant, but slow, expensive, not management-relevant

  • Performance System function during treatment Indicators of effectiveness. Methods - Examine admin databases for processes and interim results consistent with & indicative of effectivenessMeasures Usually identification, initiation, engagement, retentionCharacteristics - Fast, intuitive, face-valid, management-relevant, but not definitive

  • Performance Indicator Examples Premise 1 Patients who stay in treatment longer are likely to have better outcomes. Premise 2 - Care systems that perform better in engaging and retaining patients longer are likely to have better outcomes Then: Easily collected, analyzed and interpreted measures of the care systems ability to engage and retain patients are one indicator of potential effectiveness.

  • Performance Indicator Examples 1 Initiation = % of patients who need care, that attend at least one session or day2 Engagement - % of patients who initiate, that stay for three days or visits3 Linkage - % of patients who complete early stage of care (ie. detox), that engage in the next stage of care (ie. OPT or Residential).

  • Summary:EffectivenessQualityPerformance

  • Effective Care: Produces favorable patient outcomes. Recovery

  • Quality Care:Uses evidence-based methods, delivered by credentialed staff, within licensed, accredited programs,and meets or exceeds the patients expectations.

  • High Performance Systems:Identify those who need care; Initiate care for those who need it;Engage and retain those who initiate across modalities and between primary and specialty types of care.

  • Other Indicators of Quality Licensing indicates safety, legitimacyAccreditation indicates contemporary standards of careCredentials indicates proficiency in accepted practicesSatisfaction indicates appeal and valueEvidence Based Practices indicates use of state of the art care, professionalism

  • Mechanisms for Coordinating CareInter-agency sharing agreements for patient information with patient consent.Co-location of servicesShared patient records Higher level policy coordinationUniform record standardsUniform information protection standards.

  • A Differently Structured Marketplace Government is major purchaser, Carve-out purchases Private insurance avoids covering or offers more-limited coverage

  • Strategies Purchasers offering enrollees a choice of health plans should use one or more tools for reducing adverse selection of individuals with M/SU conditions: risk adjustment, payer carve-outs, risk-sharing or mixed-payment contracts, and benefit standardization across the health plans

    Congress and state legislatures should enact coverage parity.

    Reorient State procurement to give greatest weight to quality.

    Use M/SU health care quality measures in procurement and accountability processes.

    State and local governments should reduce emphasis on grant-based systems of financing and increase use of funding mechanisms that link some funds to measures of quality.

    The Quality Chasm report well documented that quality problems occur typically not because of failure of goodwill, knowledge, effort or resources devoted to health care, but because of fundamental shortcomings in the ways care is organized. It concluded that trying harder will not work: changing systems of care will!

    To help change the system, the chasm report articulated:

    six aims for quality health care,

    ten rules that redesigned healthcare should follow to achieve the Aims, and

    priority components of the health care system that should be the focus of redesign efforts.

    In the next few slides, I will briefly review the Quality Chasm Aims, Rules, and redesign principles, which served as the analytic framework for this present study on improving the quality of health care for mental and substance-use conditions.These reports began with the landmark report, To Err is Human, which garnered national attention, not only within the healthcare system, but within the public at large, when it called attention to the estimated 44,000 98,000 Americans who die every year from errors in health care delivered in hospitals alone.

    While this report was groundbreaking and very effective in calling attention to the need for improvements in the quality of our health care system, it was the IOMs second report on health care quality: Crossing the Quality Chasm - A New Health System for the 21st Century which outlined a comprehensive strategy for achieving the improvements needed a strategy which has gained considerable traction in the healthcare system.The six dimensions of good quality care as articulated in the Quality Chasm framework are (Refer to slide) Consideration of the high rates of co-occurrence of general, mental and SU problems and illnesses lead to the committees first conclusion and recommendation: (refer to slide) . . .

    . . . and underpin all of the committees more detailed recommendations.

    The second issue pervading the committees work was the ways in which mental and SU healthcare differs from general health care.

    Specifically, what aspects of M/SU healthcare might require that the Quality Chasm approach be modified?

    The eight issues in this slide are those differences identified by the committee. The evidence about them and recommendations for improving the quality of mental and SU healthcare in the presence of these distinctive characteristics are addressed in each of the reports nine chapters (next slide).The second issue pervading the committees work was the ways in which mental and SU healthcare differs from general health care.

    Specifically, what aspects of M/SU healthcare might require that the Quality Chasm approach be modified?

    The eight issues in this slide are those differences identified by the committee. The evidence about them and recommendations for improving the quality of mental and SU healthcare in the presence of these distinctive characteristics are addressed in each of the reports nine chapters (next slide).The first set of problems examined by the report are those that interfere with the delivery of patient-centered care - which the Quality Chasm report states should be guided by the above rules (refer to slide).

    In these studies it is very important to keep in mind the phrase Compared to What? To maximize the accountability and performance of treatment it will be very important to keep reasonable comparisons in mind. As legislators you are obliged to ask what else could be done what are the most cost effective options?This report is the tenth in a series of reports produced by the Institute of Medicine on how to improve the quality of the nations health care.The committee first recommends that sharing of information between providers treating the same patient become more routine. Clinicians should discuss with each patient the importance of sharing diagnoses and medications and other therapies between providers treating co-occurring conditions to enable collaborative care between clinicians. The report acknowledges that information on M/SU conditions is sensitive and that sharing this information is often addressed by federal and state laws and individual organization practices. The report calls on state and federal entities and organizations implementing additional information policies to re-examine their policies and practices on information sharing to ensure that they are not inappropriately interfering with coordinating care.

    Second, because one cant coordinate what one doesnt know about, three areas are recommended for targeted screening.

    1. Consistent with the recommendations of the US Preventive Services Task Force, screening for alcohol misuse by all adults, including pregnant women, should be routine.2. In addition, the report recommends screening for a co-occurring mental or substance-use problem at the time of an individuals initial presentation with either condition. 3. Because of the high prevalence of M/SU problems among children served by child welfare services and entrants into the criminal and juvenile justice systems, screening is recommended for entrants into all of these systems.

    With respect to evidence-based coordinationlinkage mechanisms (next slide):The feasibility of many of the changes called for in the preceding slides depends on how accommodating the marketplace is to them, particularly with respect to the ways in which purchasers of mental and/or substance-use (M/SU) health care exercise their marketplace roles.

    The M/SU health care marketplace has some unique features that distinguish it from the general health care marketplace. These include: (refer to slide).

    Attending to these differences is essential if the marketplace is to promote quality improvement in M/SU health care. The committee recommends five ways of strengthening the marketplace to this end and presents strategies for accomplishing each of these.