Transcript Can Patient-Centered Care Enhance the Quality of

Can “Patient-Centered Care”
Enhance the Quality of
Behavioral Health Care?
Judith A. Cook, Ph.D.
Professor and Director
Center on Mental Health Services Research & Policy
Department of Psychiatry
University of Illinois at Chicago
Presented at the The Twenty-First Annual Rosalynn Carter
Symposium on Mental Health Policy
Atlanta, GA, November2, 2005
What is Patient-Centered Medical
Care as Defined in the 2001 IOM
Quality Chasm Report?
Respecting pt’s values, beliefs, preferences
Customizing care to the individual pt
Providing patient education
Coordinating & integrating care
Expert management of symptoms
Provision of emotional support to pts
Accommodation of pt’s supporters
What Does Patient-Centered Behavioral
Health Care Look Like?
Self-help/mutual support groups (Recovery, GROW,
Depression & Bipolar Support Alliance)
Peer-to-peer services (Georgia Certified Peer Specialists)
Peer-to-peer education (Bridges, Vision for Tomorrow)
Mental illness self-management (WRAP, Taking Charge)
Self-directed care/$ follows the person models
Person-centered planning
Peer addiction recovery services (AA, Double Trouble)
Advance directives for mental health care (ADMaker)
Employment of people in recovery in traditional programs
Seclusion & restraint reduction/elimination
How to Accomplish Pt-Centered Care?
From Quality Chasm Report:
• View the patient as the source of
control…
“… [by providing patients with] the necessary
information and the opportunity to exercise the
degree of control they choose over health care
decisions…” (2001, p. 61, emphasis added)
Have We Accomplished this Aspect of
Patient-Centered Care in U.S Mental
Health System?
From Presidents’ New Freedom Commission on
Mental Health Achieving the Promise Report…
(2003, p. 28-29)
“Currently, adults with serious mental illnesses…have
limited influence over the care they receive…”
 “The extreme fragmentation of the system of care means
that many consumers of behavioral health services
are…unable to fully participate in their own plans for
recovery.”
 “…consumers and their families do not control their own
care.”
(emphasis added)

What Does the 2005 IOM Report
Recommend?
• “Recommendation 4-1. Build and disseminate the
evidence base better…strengthen, coordinate, and
consolidate the synthesis and dissemination of
evidence on effective M/SU treatments and
services…”
IOM Report on Improving the Quality of Health
Care for Mental and Substance Use Conditions,
2005, p.12
What Is the Evidence Base
for Patient-Centered Care
In Behavioral Health Care?
U.S. Agency for Healthcare Policy &
Research 1992 Evidence Rating Guidelines
Level Ia
Level Ib
Level IIa
Level IIb
Level III
Level IV
evidence from meta-analysis of multiple randomized
controlled trials
evidence from at least 1 randomized controlled trial
at least one well-designed controlled study without
randomization
evidence obtained from at least one other type of
non-controlled, well-designed quasi-experimental
study
evidence obtained from well-designed non-experimental
descriptive studies, such as comparative studies,
correlation studies, and case studies
expert committee reports or opinions &/or clinical
experiences of respected authorities
Consumer-Operated Mental Health
Services: Evidence Base
4 Randomized Controlled Trials (Paulson et al., 1999;
Solomon & Draine, 1999; Kaufmann, 1995; Edmunson
et al., 1982)
Multi-site (N=8) COSP Study (Campbell et al., 2005)
All found COSP services equivalent or superior to control
services
• COSP Evidence Base - Level Ib*
*Level Ib - evidence from at least 1 randomized controlled trial, U.S. Agency for
Healthcare Research & Quality 1992 Evidence Rating Guidelines
Mental Illness Self-Management:
Evidence Base
Illness Self-Management: Wellness Recovery Action
Planning (WRAP) (Vermont Recovery Education
Project, nd; Buffington, 2003)
Significant changes in knowledge of symptoms,
symptom management, use of natural supports,
hopefulness, development of crisis plan
• Self-Management Evidence Base - Level IIb*
*Level IIb - evidence obtained from at least one other type of non-controlled,
well-designed quasi-experimental study, U.S. Agency for Healthcare
Research & Quality 1992 Evidence Rating Guidelines
Seclusion & Restraint Reduction:
Evidence Base
Seclusion & Restraint Reduction (Jonikas et al.,
2004; McCue et al., 2004)
Significant pre-post-reductions in rates of seclusion
&/or restraint following staff/patient training &
ACM planning
• Seclusion & Restraint Reduction Evidence
Base - Level IIb*
*Level IIb - evidence obtained from at least one other type of noncontrolled, well-designed quasi-experimental study, U.S. Agency for
Healthcare Research & Quality 1992 Evidence Rating Guidelines
Advance Directives for Psychiatric
Care: Evidence Base
Psychiatric Advance Directives: (AD-Maker) –
(Backlar, 2000; Southerby et al., 1999; Srebnik et al.,
2004, 2005)
Significant increases in perceived control over mental
health problems, involvement in care, and ability to
express treatment preferences
• Advance Directives Evidence Base - Level IIb*
*Level IIb - evidence obtained from at least one other type of non-controlled,
well-designed quasi-experimental study, U.S. Agency for Healthcare
Research & Quality 1992 Evidence Rating Guidelines
Self-Directed Care: Evidence Base
Self-Directed Care for Mental Health Recovery:
Significantly greater satisfaction than comparison
group with ability to obtain needed services & with
progress toward goal attainment; significant increases
in level of functioning & days in the community
compared to pre-program levels (Teague & Boaz,
2003; Cook & Russell, 2005)
• Advance Directives Evidence Base - Level III*
*Level III-evidence obtained from well-designed non-experimental
descriptive studies, such as comparative studies, correlation studies,
and case studies, U.S. Agency for Healthcare Research & Quality 1992
Evidence Rating Guidelines
Other reasons to expect quality
enhancement from consumercentered care
The Use of Consumer-Directed Mental
Health Care Appears to be Growing
• ECA study (early 1980s) - 4.1% of individuals with a
mental disorder used voluntary support in past year
• MIDUS study (1996) - 18% of ppl with severe mental
illness used formal mental health self-help/mutual aid
group in past year
• In a national survey of states, 40 funded consumeroperated peer/mutual support programs, 38 funded
consumer advocacy programs, 32 states reported
offering self-help programs in state hospitals, & 32
funded drop-in centers (Shaw, 2004).
While Consumer-Centered Care is
Growing the Amount of State
Funding is Fairly Minimal
• In 2002-2003, most states spent less than
one percent of their total annual mental
health budgets on COSP.
• Of 41 states reporting, 1/3 provided less
than $500,000/year and 1/4 spent $200,000
or less/ year. (NASMHPD, 2004).
Is Consumer-Centered Care a
Good Investment for Federal
Policy?
• President’s Commission Report (2003)
noted the need to increase opportunities for
consumer-run services and consumerproviders, enhance access to peer support,
and increase treatment choice and the full
partnership of consumer and providers.
A “Modest Proposal” for Enhancing
Behavioral Health Quality
 Increase level of funding for consumer-centered and
consumer-operated services
 Encourage development of new models of consumercentered care
 Encourage & fund more and more rigorous research on
the effectiveness of consumer-directed care
 Train professionals in these models & require that they
collaborate effectively with consumers & consumerproviders
 Increase consumers’ involvement in all levels of
behavioral health care “transformation”
Is This the Dawning of a New
Day for Quality Behavioral
Healthcare?