Sylvia B. Perlman, Richard H. Dougherty
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:
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.
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.