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FINAL REPORT OF SANTA FE SUMMIT ’97
Preserving Quality And Value In the Managed Care Equation
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THE CORE SET OF VALUES AND INDICATORS ENDORSED BY ACMHA
Section I: Key Value Themes
Section II: Key Indicators
SECTION I: KEY VALUE THEMES
By the close of the SANTA FE SUMMIT on March 22, the group
accepted these value statements as central. They have been edited to make them as clear as
possible to a broad cross-section of readers.
(1) Consumers and families are at the core of
performance measurement.
The centrality of the concerns of primary consumers was a
consistent theme of the SUMMIT. This value statement is intended to highlight the central
role of primary consumers (which includes families of children and adolescents). The role
of family members of adults was also addressed, with special attention to their needs for
information and involvement to the extent possible.
(2) Consumer/customer choice must be a driving
value for all systems of care, including their design, delivery, evaluation and
accreditation.
Choice is an increasingly important element in the delivery of
mental health and addictive disorders treatment, and it is a concern that cuts across
public and private sectors. In an era of increasingly managed care, choice will sometimes
be limited within a plan or system, but this value statement highlights the high priority
that should be given to the broadest range of choices possible.
(3) Issues of ethnicity, race, age and
developmental status, gender, language, culture, spirituality, disability are consciously
addressed in ensuring access and availability of services.
ACMHA and the SUMMIT participants are concerned that all systems
of care become or remain sensitive to their customers. One size does not fit all in
providing mental health and substance abuse services, and due diligence is required in the
design and delivery of culturally and linguistically competent care.
(4) Mental health and substance abuse delivery
systems must be accountable to both internal and external stakeholders for meeting the
mental health needs of the people they serve in ways that are effective and efficient, and
that accountability must be based on reliable, comparable data.
To be credible, claims of the quality of care given can no longer
rely on assertions of good intent. Data must assist delivery systems to improve, and
provide a meaningful yardstick for comparing costs and outcomes to people outside of those
systems. .
(5) Access to mental health and substance abuse
services must be quick, easy and convenient, and outreach and follow-up must be seen as
part of the access continuum.
Attention to access is not new, but the SUMMIT participants
strongly urge continued attention to the basic issues of ease and speed of access.
Outreach and follow-up are part of an access continuum.
(6) A true public health vision of community
health must drive outcomes measurement, which means that universal access and integrated
primary and behavioral healthcare are the ultimate goal of effective systems.
The participants in Santa Fe recognize the complexity of America=s healthcare systems,
but believe that there must be a vision of true community health at the core of all health
planning and delivery. This value statement is not intended to denigrate carve-out or
specialty care models, but it does reflect the critical importance of coordination. A true
public health vision requires attention to prevention and to the health status of entire
populations, not just risk-adjusted subpopulations or high-risk populations.
(7) Children who have mental health and substance
abuse problems:
-
should be able to receive effective services in
their homes and schools without disruptive removals from either setting;
-
should be able to remain safe and out of trouble
with law enforcement;
-
should remain connected to family and peers while
in treatment;
-
should receive services that are family focused and
health centered.
These value statements are difficult to operationalize, of
course, but they focus attention on the most normalizing aspects of life for children and
adolescents, and away from an over-emphasis on problems and deficits. An orientation
towards families as opposed to individuals is not consistent in any area of health care
delivery today, and purchasers and providers alike face many challenges in making these
value statements have meaning. Nonetheless, ACMHA and the SUMMIT participants view the
family focus for children and adolescents as not only a desirable, but a necessary and
achievable goal.
(8) Adults with mental health and substance abuse problems:
-
should be able to maintain a stable, comfortable
and safe living environment;
-
should be able to engage in chosen, productive
daily activity;
-
should be able to remain safe and out of trouble
with law enforcement;
-
should receive treatment that is consumer-centered
and which maximizes independence and self-care skills;
-
should receive services designed to enhance total
health and maintain social connections and improved quality of life.
The preceding value statements about adults speak to consumers= concerns about
self-determination and dignity. In the field, we are coming to grips with consumers= demands for real power
in mental health and substance abuse service design, delivery and evaluation. While the
concerns of families of adults who have severe and persistent mental illnesses have
legitimate (and all-too-often ignored) needs for information and involvement in the care
of their loved ones, the ultimate authority must remain with the adult consumer. These
statements also reflect a concern that persons who do not have ready access to appropriate
care for mental and addictive disorders can too easily fall prey to incarceration,
homelessness and other social problems that could be prevented.
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SECTION
II: THE KEY INDICATORS
The SANTA FE SUMMIT workgroups generated mountains of paper and
logged hundreds of collective hours of conference calls. In order for this report to
receive wide distribution, that level of detail is impossible, the following indicators
are much abbreviated and every effort has been made to keep the language simple and
unambiguous. The indicators are grouped by four of the domains (OUTCOMES, PROCESS, ACCESS,
and STRUCTURE).
The domain of PREVENTION is addressed in a separate section
[Section IV], and there is a special section on outcomes for a risk-adjusted group of
children and adolescents [Section III].
ACMHA is using the definitions of indicators and measures
developed as part of CARF=s Strategic Outcomes Initiative.
An INDICATOR is a@ Domain (e.g.,
effectiveness, efficiency or satisfaction; either process or outcome) or variable used to
point to program quality or performance.
A MEASURE is a ASpecific instrument or
data element used to quantify or calibrate an indicator.
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A.
OUTCOME INDICATORS
The outcome indicators are broken into two sections: the first
three indicators are appropriate for all populations, both the commercially insured
and working populations, as well as persons with serious and persistent mental or
addictive disorders. The remaining measures are seen as relevant primarily for individuals
with serious disorders. The measures used to assess performance are different for the two
populations.
ALL ADULTS:
O-I-1. Adults [including those with serious and
persistent mental or chemical dependency disorders] reside in their own homes or living
arrangements of their own choosing.
ACMHA believes that the ability to choose and maintain a stable
home environment is a useful indicator of the effectiveness of services for people with
mental health and substance abuse disorders. Both types of disorders can expose the
individual to the risk of homelessness, transience, or serial supervised living
environments. This indicator is intended to capture individuals who are hospitalized, in
jail for reasons directly related to their mental illnesses, or homebound. For employed
populations, the measures can be less rigorous, but ACMHA believes that it should be part
of a core set of domains.
O-I-2. Adults [including those with serious and
persistent mental or chemical dependency disorders] are working.
For employed and commercially insured populations, absences from
work and missed productivity are important indicators. For persons with serious and
persistent mental and addictive disorders, this is increasingly seen as an essential
element of recovery models. For some individuals, Awork@ may be understood as
meaningful daily activities (including job training, volunteer work, etc.), but consumer
participants successfully urged the College to keep the language focused on WORK. Again,
different measures are appropriate, but the indicator is part of the core set.
O-I-3. Adults [including those with serious and
persistent mental or chemical dependency disorders] have good physical health and report
good mental health [psychological well being].
It is vital that both general health and mental health be
assessed in determining the effectiveness of interventions. Behavioral health services for
all populations need to be integrated with primary health care to guarantee the best
outcomes. There will be different measures for different population groups, but the value
of general health is sufficient to place this indicator in the core set for all
populations.
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INDICATORS FOR ADULTS WITH SERIOUS AND PERSISTENT
DISORDERS:
O-I-4. Adults with serious and persistent mental
or chemical dependency disorders report feeling safe.
The issue of safety was highlighted in the work of the SUMMIT.
Persons with serious disorders can be at unusual risk for victimization, and often report
feeling unsafe because of the reduced social and economic status that often accompanies a
chronic illness. Consumers also express concerns about being victimized by public
institutions and practices that deprive them of free movement and choices.
O-I-5. Adults with serious and persistent mental
or chemical dependency disorders avoid trouble with the law.
Obviously, people with mental and addictive disorders can commit
crimes and have criminal responsibility for the consequences of their actions. This
indicator seeks to address the dangers of the use of jails and prisons as a de facto
alternative to viable community services.
O-I-6. Adults with serious and persistent mental
or chemical dependency disorders maintain a social support network.
The presence of social supports is well documented as enhancing
the quality of life for persons with serious and persistent mental and addictive
disorders, and these networks can play a pivotal role in relapse prevention and recovery.
O-I-7. Adults with serious and persistent mental
or addictive disorders are able to manage their daily lives.
Consumers frequently report concerns about managing their daily
lives effectively, including symptom management and conflict resolution. This indicator
can help assess the effectiveness of a system=s most basic
interventions.
O-I-8. Adults with serious and persistent mental
or addictive disorders report a positive quality of life.
Quality of life is the ultimate test of any health care
intervention, and this indicator fits with the others as part of a comprehensive core set.
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B.
PROCESS INDICATORS
The process indicators are designed to reflect on a system=s performance in serving
the needs of the individuals it serves. The essential role of the consumer in all aspects
of care is highlighted in this section, reflecting emerging practice for both privately
and publicly insured populations.
P-I-1. Consumers actively participate in decisions
concerning their treatment.
This is a bedrock performance issue for ACMHA, and reflects the
value statements of the SUMMIT. Consumers are essential partners in all aspects of the
therapeutic enterprise. In the case of individuals under 18, Aconsumer@ should be understood to
include family members or guardians actively participating in treatment. [See special
section on children and adolescents in Section III.)
P-I-2. Consumers who receive inpatient services*
receive face-to-face follow up care within seven days of discharge. [*@Inpatient
services@ are defined as A24-hour, medically supervised services for a primary mental or
substance abuse diagnosis.]
There is face validity in the field for the importance of
follow-up care for individuals whose mental and addictive disorders are so severe as to
require intensive and restrictive levels of care. Failure to engage persons in ambulatory
follow-up care after discharge from inpatient treatment is a powerful signal that
continuity of care is not present.
P-I-3. Consumers with mental health and addictive
disorders are engaged in treatment.
While it is possible that a single treatment or assessment visit
is needed, the norm would be that continuing care is expected with a valid mental illness
or substance abuse diagnosis. Failure to continue in regular treatment is especially
highly correlated with successful outcomes for persons with substance abuse disorders and
persistent mental health conditions.
P-I-4. Consumers receive adequate information to
make informed choices.
This indicator is inextricably tied to indicator P-I-1 and
indicator P-I-3 ; active participation in treatment can only be achieved when
consumers are provided with useful information about those choices.
P-I-5. Consumers receive mental health inpatient
services in a voluntary, non-coercive manner.
Some persons with mental illnesses may require involuntary
hospitalization to protect themselves or others from harm. However, a well functioning
service delivery system should be able to minimize unplanned, coercive hospital admissions
through care management and effective alternative treatment resources. High rates of
involuntary hospitalization may indicate inadequacies in ambulatory care services that are
less intrusive/restrictive.
P-I-6. Consumers are satisfied with the services
they receive.
Consumers of substance abuse and mental health services (and
their families and guardians) are the best resources for determining whether or not
systems are meeting their needs and expectations. It is especially important that clients
with these disorders receive services that preserve the dignity and respect of the
individual and family.
P-I-7. The system of care assumes responsibility
for continuous and integrated care appropriate to the needs of children and families.
[Also see Section IV, special section on children.]
Children with mental health and substance abuse problems are
likely to be involved with many systems: schools, child welfare agencies, primary care and
pediatric specialty care, juvenile justice and others. Children=s disorders often tend
to have periodic changes and care can become episode-driven without consistency.
Coordination and integration of care is essential across the developmental span.
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C.
ACCESS INDICATORS
The Access indicators identified by the SUMMIT reflect an attempt
to move to more meaningful indicators of access than counts of phone rings or drop
rates--although these have been useful proxies for access in systems that can track these
data. The methodological issues in collecting and analyzing these data are considerable.
A-I-1. Consumer experiences of treatment (both
positive and negative) are assessed on dimensions of appropriateness, timeliness and
sensitivity of services delivered. [Also addressed in P-I-6]
Customer satisfaction is another bedrock indicator. The
methodologies for measuring this variable are numerous, and need to also include measures
of dissatisfaction.
A-I-2. Service denials, terminations, or refusals
are assessed.
Denials, terminations or refusals for services (adjusted for
benefits included in a service plan) can serve as a barometer of access. [Serious concerns
have been raised about this indicator, because of the issue of the clinical
appropriateness of some denials, e.g. the denial of a request for a more restrictive
level of care than is indicated for a child, a request for a specific medication that is
contraindicated medically, etc.]
A-I-3. Penetration rates demonstrate benchmarked
levels of service delivery to like populations.
The attempt here is to insure that services are at expected
levels, neither significantly higher nor lower than is the norm.
A-I-4. Access to a full range of services is
demonstrable.
Easy access to a narrow range of services is not genuine access.
(As the folk-adage puts it: AIf all you have is a hammer, everything looks like a nail.@) This indicator would
encompass referral linkages and other strategies to offer a comprehensive array. This
would have to be risk-adjusted for benefit packages that have limited scope.
A-I-5. Children and their families receive the
appropriate services that they need, when they need them.
This indicator and A-I-6 below were developed and proposed to the
SUMMIT process by a group of child and adolescent experts convened by SAMHSA in late 1997.
This indicator overlaps somewhat with other ACCESS indicators, but the special emphasis on
child and family indicators is seen as essential.
A-I-6. Children and their families are being
assessed for and offered services at appropriate levels.
This indicator seeks to highlight the importance of both
penetration and proper matching of children and families to needed levels of care. Of
special concern are children being under-identified and hence under-served, as well as
children being over-served, for example in the instance of over- or inappropriate
utilization of out-of-home placements, restrictive settings , etc.
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D.
STRUCTURE INDICATORS
The structure indicators lend themselves more to
traditional accreditation and survey techniques, as opposed to true Aoutcome@ indicators, but are
included as relevant to the over-all initiative.
S-I-1. The organization=s structure is
consistent with the delivery of mental and addictive disorder treatment, with effective
consumer and professional representation in policy making.
In integrated systems, it is important to ensure that the special
needs of persons with mental and addictive disorders are addressed by the structure. The
involvement of consumers and professionals in policy is essential in all environments,
whether private or public, managed or fee for service.
S-I-2. Consumer rights are clearly defined and
procedures for resolution of complaints and grievances are in place and easy to use.
This is an essential element in most current certification
protocols. ACMHA is especially concerned that measures reflect the system=s capacities and
performance in making complaint and grievance processes genuinely non-threatening and
responsive.
S-I-3. Staffing levels are appropriate for
delivery of the array of services and provide for meeting the diverse needs of the
individuals served, including linguistic and cultural competence.
The issue of staffing is enormously complex, and is not
responsive to a one-size-fits-all mentality. Of special concern here is the
cultural/linguistic element of this indicator.
S-I-4. Data on clients is secure, available only
to those who need to know.
Confidentiality remains an especially vexing concern in the
mental and addictive disorders field, not least of all because of federal and state laws
regulating access to consumer information.
S-I-5. There are appropriate linkages to other
service systems with which consumers need to interact.
Persons with addictive and mental disorders frequently require
services from more than one specialty service, and often need services from other social
support systems. In the instance of children, adolescents and their families, this is even
more of a need.
S-I-6. There is continuity of care within the
organization and effective integration with external care-giving systems.
This indicator is a close corollary to S-I-5, but an
indicator of both internal and external continuity of care is important.
S-I-7. There is a single, fixed point of
responsibility for each client.
All populations need this simple structural support. Consumers
and families with complex service needs are better served when there is a single reference
point.
S-I-8. There is a quality assurance system in
place to examine adverse clinical events.
Systems need to be able to assess their own vulnerability to
incidents such as suicide, aggressive acts and other high risk incidents.
S-I-9. Consumers and families are educated about
their rights, the array of services available to them, and likely outcomes of treatment
interventions.
ACMHA is concerned here with improving the
effectiveness of systems= communications with their service users. Again, this
is a measure with high relevance for
all populations.
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