According to reports issued by the President's New Freedom Commission on Mental Health and the Institute of Medicine, the delivery of mental health care in the United States requires radical improvement and reform. To help identify promising innovations in behavioral health care, the authors of this report interviewed experts in the field of mental health and substance abuse. Based on their suggestions, the authors selected and described 17 practices—all related to purchasing and quality improvement—being implemented by states in behavioral health care. Many of the projects result from the increasing demands placed on state agencies to meet needs with a reduced budget, leaving states with little choice but to increase efficiency and effectiveness. The innovations fall into six categories: enhancing consumer-centered care, criminal justice/mental health collaboration, system integration, the use of performance incentives, quality improvement, and other promising practices.
Building on the foundation laid by the President's New Freedom Commission on Mental Health and the Institute of Medicine—calling for radical reform and improvement of the mental health and substance abuse systems of care—this report identifies 17 innovations being implemented by states in behavioral health care. By describing and disseminating these innovations—all related to purchasing and quality improvement of mental health and substance abuse care—the authors of this report hope to acknowledge the work of many leaders in the field while assisting states in the task of translating policy into effective practice.
To identify promising projects, the authors interviewed 21 experts in the field and surveyed the mental health and substance abuse directors in all 50 states. Their suggestions led to the 17 projects included in the report. When requesting nominations, the authors asked for practices that:
- increase cost effectiveness;
- improve access;
- lead to improved clinical outcomes (although innovations in direct clinical care were not sought);
- enhance patient-centeredness;
- reduce disparities; or
- reduce fragmentation of care.
The projects reviewed are in various stages of implementation and evaluation. Some are worthy of review and consideration by other states although they have not yet accomplished all their goals. There are rarely perfect solutions to complex social problems, and other states and counties can learn from mistakes made in early innovations. This information can help the field move forward by informing state and county decision makers about their peers' efforts and the trends in the field, so that they, in turn, can more knowledgeably consider their own options in designing or modifying existing policies and programs.
The 17 innovations fall into the following six categories:
Enhancing consumer-centered care. Generally, individuals with mental illness receive care in a location, modality, and amount dictated by professionals. In consumer centered care, services are more explicitly tailored to the needs of individuals, delivered in a way that is sensitive to their needs and allows for greater control, in terms of the type of services received, location, and provider.
Criminal justice/mental health collaboration. Jails and prisons have become a de facto component of the nation's inpatient behavioral health system, housing more individuals with mental health and substance abuse needs than do psychiatric hospitals. Programs that utilize criminal justice diversion and re-entry strategies can help to avoid unnecessary criminalization and extended incarceration of non-violent adult and juvenile offenders with mental illnesses.
System integration. To combat issues of fragmentation, some states have initiated projects that provide for a coordinated system of care and a blended funding arrangement. Integrating service systems, however, is a massive undertaking, involving multiple players, agencies, legislative mandates, providers, structures, and funding sources.
Using performance incentives. Many states use contracting methods that either reimburse costs or set fixed prices. More recently, however, states have begun developing ways of using performance incentives. In human services, performance can be defined in relation to services performed by the contractor or to outcomes achieved by clients.
Quality improvement. While all the innovations are intended to improve quality, the projects in this section are explicitly intended to improve the way in which particular state agencies perform their own functions or encourage their contracted providers to perform. The ultimate goal is to improve the care clients receive, as well as their clinical and functional outcomes.
Other significant projects. Four innovations stood alone in their areas of concern, yet seemed worthy of mention by virtue of their apparently successful approaches to issues that challenge nearly all mental health and substance abuse agencies.
Highlights of the Case Studies
- In New Jersey, Consumer Connections recruits, trains, and supports consumers of mental health services to be providers of mental health services as volunteers, or as full or part-time paraprofessionals or professionals within the mental health and human service systems. These services are available at no charge to consumers of mental health services in New Jersey. Since inception, the program has had 850 graduates. Of these, 65 percent to 70 percent are currently working in mental health care, substance abuse treatment, or other human service settings throughout the state.
- The Criminal Justice Coordinating Center of Excellence was initiated to develop programs throughout Ohio to help keep people with mental disorders out of jail and in treatment. Working with the National GAINS Center for Evidence-Based Programs in the Justice System, the program has developed a model to encourage communities to approach jail diversion systematically.
- The Washington Medicaid Integration Partnership is a comprehensive approach that blends funds for behavioral health, primary care, and long-term care services in a county-based system. The 5,000 adult Medicaid enrollees in the county have access to care coordinators, primary care providers, specialty care, and drug and alcohol services. By bringing all the services under one roof, the project planners hope to provide a "medical home" for clients where they will be cared for by a stable team of professionals they know and trust. In the long run, the project leaders believe that focusing on preventive care and services is likely to save money, as well as improve lives.
- For 2003 through 2005, the Kentucky Department for Mental Health and Mental Retardation Services designated 1 percent of total state general funds for use as performance incentives. This amount was increased to 10 percent for the fiscal year 2005–06. While the program has not yet been formally evaluated, preliminary internal review suggests that there has been improvement in the integrity of data collection and greater awareness of responsibility for using best practices and achieving quality outcomes.
- The Iowa Department of Public Health, Division of Behavioral Health and Professional Licensure, is working with the Network for the Improvement of Addiction Treatment (NIATx) to improve access and retention within the addiction treatment field. Using the NIATx model, Iowa has worked with local addiction service providers to decrease wait time to outpatient services. One agency reduced wait times by an average of 56 percent, while admissions increased by 186 percent. The state agency is now working to disseminate the NIATx principles to all addiction service providers in Iowa.
- The Creating Homes Initiative (CHI) partners the Tennessee Department of Mental Health and Developmental Disabilities with local communities to create permanent housing options for Tennesseans with mental illness and co-occurring disorders. Using a grant from the Centers for Medicare and Medicaid Services, CHI has provided greater access to information and services about available housing options and reduced stigma surrounding mental illness through community education and social marketing efforts. By late 2005, CHI had successfully created 4,288 affordable, safe, permanent, quality housing options in consumers' chosen communities. Most importantly, the state reports a 95 percent reduction in the rate of re-hospitalization for consumers residing in CHI housing.
Many of the projects described in this report result in no small part from the demands placed on state agencies to meet an increased need for services with a reduced budget. Many states have little choice but to try to improve performance and increase efficiency and effectiveness. They have sought to accomplish these goals by adopting approaches from other parts of the health care system, like performance-based contracting, and projects from the private sector, like primary care integration and chronic disease management.
While careful reporting on the results of these efforts is crucial to the design of new initiatives, evaluations are often funded insufficiently or not at all. Yet, in the absence of competent studies, state policymakers cannot be sure which innovations are worthy of consideration. New models of evaluation are needed—ones that can document change and report on a set of standard and comparable measures.
By facilitating local efforts, sharing best practices, and reporting on the outcomes of innovations wherever possible, states can act as "incubators" of promising practices. Disseminating details about current innovations, including accomplishments and challenges, is one vital component of this approach.
S. B. Perlman and R. H. Dougherty, State Behavioral Health Innovations: Disseminating Promising Practices, The Commonwealth Fund, August 2006