In many ways, insurers, clinicians, and even consumers & families may have put the cart in front of the horse. What do I mean by that?
Simply stated, across the country those looking for “quality” in children’s mental health services may be putting the quality cart up front, and flogging a weary horse to push quality up a steep hill. Who are the horses? Not just clinicians, but the clinical service delivery systems that have to work together to pull the cart up the quality hill. So let’s stop for just a minute and think about what we our vision would be for a quality-driven clinical service system for families with children with significant mental health challenges:
A Vision for Quality Mental Health Services for Children and Families
In this system, imagine that the child and family walk into an office, where a cheerful receptionist greets the everyone by name. The client is handed a tablet computer with a brief survey comprised of checkboxes and dropdown menus asking questions related to the patient’s current well-being and follow-up questions since the last visit. Data from this survey are transmitted directly to the clinician, enabling him/her to know exactly why the patient is in the office today and allowing ensuing discussion of treatment to be streamlined and targeted. Doctors and patients alike are given helpful prompts by the system, not just to avoid medical errors, but also to remind all parties when the client needs a blood test or examination. Clients also receive personalized summary reports for their own records, and referring doctors and other health care team members are kept fully in the loop with frequent and regular status reports, thus ensuring better coordination among different health care providers. Billing is done automatically, but always based on family’s income and ability to pay. Complicated mental health problems are addressed by the necessary combination of team expertise and support – psychotherapeutic, medical, educational, social, and community, with carefully constructed, solid bridges built for each family to help them help their child succeed, regardless of income or ethnic background.
This system would incorporate everything that our current systems lack:
- This health care setting not only serves clients, but also serves the community. Every member of the staff feels the desire to give back to the community, and to be accountable to the community.
- This health care setting includes all of the necessary team members to address the child’s and family’s needs, including an accurate and comprehensive diagnosis, assessment of child & family strengths, research-guided therapy and rehabilitation, and provision of ancillary support.
- The health care operation serves a diverse socioeconomic community, including patients capable of full payment through those reliant on Medicaid
- The office runs on a comprehensive software system, with 21st century capacities: capable of electronic billing, creating a newsletter and reminders that can be e-mailed directly to clients, comprehensive reports and records immediately available to the family and referring professionals, and other documents needed to inform and guide current treatment
- Within the software system, crucial information is shared virtually immediately among all team members (including the family), as well as schools and other providers, such that all stakeholders invested in the child’s (and societal) well-being receive the necessary information and feedback to apply optimal methods, employ corrective steps when needed, and achieve optimal outcomes.
Such a system must be structured to maximize three essential elements: 1) the family’s personal and interpersonal experience of the services delivery; 2) the scientific rigor and effectiveness of all services offered; and 3) aligning all procedures with the right “the patient comes first” values within a sustainable business model: let’s see what these entail:
1) Maximizing the personal and interpersonal experience for families and clinicians
- a) procedures for engaging the child and family; b) procedures for developing agreed-upon and shared understanding of problem; c) use of collaborative problem-solving model, d) ongoing problem identification, open discussion, and working out problems together; ie., a true partnership vs. “doctor knows best”; e) user-friendly and rigorous assessments that also serve to track ongoing optimizing of process and outcome, with a collaborative feedback system between clinician and family; two-way communication focused on problem solving and improvement; f) minimal paper work or computer entry; all data input/paperwork are incentivized and provide feedback to persons giving it; g) assessments are adaptable for current standard of practice, DSMIV, ethical standards, and billing systems; h) interpersonal processes measured from multiple informants, with feedback shared with all in collaborative process; i) helpful reminders to clinician, child, and family for completion of necessary assessments and feedback; j) ongoing ease of access to services, with caring, knowledgeable individuals “in-the-loop” about the family’s needs, available 24/7; k) a safe environment to discuss billing issues, financial worries, impact on child and family; l) all complex, sequenced activities are assisted by computer aids or other supports; m) decision-aids to families and clinicians about choices that are available to them; m) access to community and social supports outside of traditional medical model, with the clinical system providing active linkages to these additional services; n) child /family assessments, with individual child/family prognosis, treatment, and outcomes presented to the family based on references to research-based standards; o) the child & family’s experience & perceptions of quality and efficiency is sought, and used to further maximize and improve individual care and larger system; p) treatments are tailored to individual families, with emphasis on child & family input, choice, and control; q) all clinical processes are transparent to families, with active educational efforts directed at all steps of assessment and intervention, and their rationale. An active mentoring/coaching approach by the treatment team is critical, rather than a “trust me, the doctor knows best” approach; r) impact of the amount of time spent with families and perceived time pressures is monitored; and s) there is ongoing going communication about families’ needs; these are shared among team members via systematic feedback with the entire problem-solving team (including families, who are the most key members of the team;
2) Maximizing scientific effectiveness
- a) Identification and ongoing implementation of evidence-based, “best practices”; b) creation of culture of the need for ongoing improvement among all staff; c) commitment to and completion of ongoing training in EBPs; d) ongoing assessment of clinical quality processes by patient, by clinician, by treatment type, with feedback and correction to clinicians and clinical staff; e) collaborative problem solving among clinicians and scientists; consumers, with commitment by all to scientific method; f) comparing outcomes across clinicians and clinics, referencing processes and national standards, and giving improvement feedback and assistance where needed; g) ensuring rigorous data collection so that every family, every clinician, every procedure, and every practice setting contributes to improved knowledge and scientific understanding; h) ongoing process to identify most important knowledge gaps in clinical procedures
3) Maximizing optimal alignment between key values, systems/structures, human processes, science-based procedures, outputs, and sustainability and dissemination
- a) Mission, appropriate values, and a strategic planning process drive all decisions; b) this system must use a “social business” model – delivering a high quality, much needed product at affordable cost where all costs are covered in a sustainable business model, and secondly, the products and services provide value-added to society, both short- and long-term; c) business model involves simultaneous promotion of public health values, with transparency of all budgeted funds and income; d) business model must be tailored to local markets; e) those who devote funds to start up and develop such programs must receive return on principal, and perhaps a small return on the investment.
Unanswered Questions about Quality Mental Health Services
Members of the REACH Institute, along with a group of like-minded individuals, are now pursuing the active study of what this type of quality costs.
Several questions to be asked and answered. Please weigh in with your own views, and respond to our initial answers:
Q1) Can it be done?
Answer: Yes, these technologies are now available to us.
Q2) Would you want this for yourself and your family?
Answer: Most certainly.
Q3) Can we afford it?
Answer: That’s the big question. We think so, if we take a population-based approach, and share costs across all income levels, using a sliding scale based on income and ability-to-pay.
Q4) What other elements of “quality” are needed, and are there any elements I have mentioned that you would feel are superfluous or not needed?
Your thoughts?
pj
Peter S. Jensen, M.D.
President & CEO, The REACH Institute &
Professor of Psychiatry & Co-Chair
Division of Child Psychiatry & Psychology,
Mayo Clinic – Rochester
6 Comments
Dr. Jensen,
It seems clear to me that much of the cost of poor mental health care for children is not obvious to the public.
There are enormous costs to society for undiagnosed and untreated psychiatric disorders in children (manic-depressive disorders, psychosis, anxiety disorders, attentional disorders, depression) and related personality disorders.
Financial costs include school failure, juvenile justice costs, probation costs, substance abuse related costs and losses, future costs from criminal justice, police and security costs, costs related to violence and property destruction, teen pregnancy costs, homelessness, failed families, domestic violence cost, lost work time and productivity for families and businesses, costs related to chronic pain, costs to health care of poorly tracked and treated co-morbid disorders or those caused by certain medications, and the costs associated with child neglect and abuse.
Emotional and societal losses also include the loss of the creativity and talents of children with psychiatric disorders. A large percentage of these children are very bright. Society losses their future contributions to the future. Instead, we tend to pay their “tuition” in jail and prison to become very talented and bright criminals. The losses to substance abuse and suicide are significant.
The impact on families is enormous. Lost work and income, legal fees, monies spent on poor diagnosis and treatment, broken families and marriages, impacted siblings and extended families, and more.
To ignore the mental health needs of children is like ignoring childhood cancer. The near and far future costs are enormous.
I would think that if we had even just 10% of the monies spent on the down-stream agencies to create and sustain a quality mental health system for children, the savings to society would be monumental and the positive outcomes incredible.
Tom Roseland, MS, MSN, FNP-C
I think what you describe is what is needed for ALL of health care reform, not just quality mental health care! As a nurse, I feel like we keep trying to invent the ideal health care system and never get there. Do we have the technologies available to us? Yes, technically we probably do, BUT the ways they are being implemented is preventing us from using them effectively and efficiently. (“good enough” for most of the time is not quality).
I do worry about confidentiality of information as I see some information being readily available that is not needed to provide quality care (but then again, so much private mental health info is being shared via Twitter, and facebook and other social networking sites that maybe it doesn’t really matter?)
But also, maybe we have to find ways to demonstrate these concepts on small scales and then expand them to larger groups?
Instead what I see happening is the opposite, buisness models are being built that are driving large scale populations further AWAY from cost effective quality by competiton for the same $.
Keep asking these questions – I hope others have answers
Peter,
I certainly agree with Tom Roseland that much of the cost of untreated and inadequately treated MH problems in children is unseen by the general public. I would also add that these secondary costs are ignored by bureaucrats and by insurance executives, all of whom are watching only their own bottom line. The problem goes beyond “cost” and “quality” to “efficiency”.
We have limited resources, both in manpower and in financial resources. I think it will take an integrated health system, where the artificial barrier between health and mental health is dissolved, to be able to create efficient high quality delivery of MH services. The two drivers are obviously linked, since effective treatment (quality) is much more efficient than inadequate or inappropriate treatment. Your efforts with the Reach Institute clearly try to address the manpower shortage by improving the training for primary care physicians, especially pediatricians.
I would like to see the rise and expansion of integrated clinic systems that are driven by quality and efficiency rather than by cost. I don’t think that will happen with our current fee-for-service system Probably our best models for this “capitated” system are the VA and Kaiser Permanente, both of which are large enough to shift resources to meet unexpected needs. Unfortunately, smaller and start-up integrated systems of care would not have that flexibility and would have trouble surviving financially in our current system of financing health care.
The system you propose is complex, involving a complex structure with multiple feedback loops. As you suggest, it is probably soluble with available technology.
The outputs of the system are various levels of improvement of mental health, though somewhat hazy as to the levels of effectiveness with current knowledege, still undoubtedly worth while in terms of limiting human costs and those to society.
What concerns me most are the inputs to the system you propose. Who gets in, how and when are they identified, what incentives are required to capture them? If current knowledge is any guide, then we can assume that only the tip of the iceberg gets into the current system, and that most MH problems are not identified by the system, or are captured late into the process of development, when treatment is less effective.
The solution? (1) It starts with ante-natal health care screening, followed by (2)continuous longitudinal epidemiologic survey, followed by (3)early pediatric/psychiatric entry into the treatment system.
In other words, it seems essential as Eisenberg suggested, to see what or who is pushing drowning victims into the river upstream rather than just having elaborate resucitation measures in place downstream. Really early identification (hence ante- and early post-natal screening)are key to lowering future costs of illness and utilizing the most effective preventive measures.
Current research suggests that valid DSM-4 diagnoses can be made as early as 2 years of age. Research also suggests that much of the “continuum of reproductive casualty” is known, including alcohol, tobacco, and drugs ingested in the first trimester of pregnancy. How can these not be part of a truly effective system of Mental Health care?
I totally agree with Dr. Conners. The approach I have outlined is within the grasp of our current technology and most likely, even with the reach of our current payment systems, if the business model is carefully structured.
As he notes, I think that earlier intervention and prevention are essential, though unfortunately, our society does not yet give much heed to these issues or seem willing to pay for them. Until the political will is generated to move in that direction, we’ll have to do what society is willing to pay for, and advocate for even better solutions.
Envisioning the ideal mental health service system provides a productive exercise toward designing future service delivery programs. And clearly technology has a role in improving services in the future. However, there are additional technologies that can play a critical role in improving mental health care that are not mentioned in your vision, and are not typically included in standard care systems. These technologies include medical screenings to establish a biological basis for diagnosis and treatment decisions. Symptoms of emotional and behavioral disorders are known to be associated with medical conditions such as thyroid disorders, anemia, toxic metal poisoning, nutritional deficiencies, and others. In spite of these known associations, medical screening for these conditions are not typically conducted as part of routine psychiatric diagnostic procedures. Additional technologies in functional brain imaging show promise for supporting psychiatric diagnosis and treatment decisions that are even less often included in clinical service systems. These are some of the major deficits in our current poor quality clinical care systems that I would propose be included in any vision of a quality mental health system.