Millions of Americans today receive health care for mental or substance-use problems and illnesses. These conditions are the leading cause of combined disability and death among women and the second highest among men.

Effective treatments exist and continually improve. However, as with general health care, deficiencies in care delivery prevent many from receiving appropriate treatments. That situation has serious consequences — for people who have the conditions; for their loved ones; for the workplace; for the education, welfare, and justice systems; and for the nation as a whole.

A previous Institute of Medicine report, Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001), put forth a strategy for improving health care overall — a strategy that has attained considerable traction in the United States and other countries. However, health care for mental and substance-use conditions has a number of distinctive characteristics, such as the greater use of coercion into treatment, separate care delivery systems, a less developed quality measurement infrastructure, and a differently structured marketplace. These and other differences raised questions about whether the Quality Chasm approach is applicable to health care for mental and substance-use conditions and, if so, how it should be applied.

This new report examines those differences, finds that the Quality Chasm framework can be applied to health care for mental and substance-use conditions, and describes a multifaceted and comprehensive strategy for doing so and thereby ensuring that: Individual patient preferences, needs, and values prevail in the face of residual stigma, discrimination, and coercion into treatment; The necessary infrastructure exists to produce scientific evidence more quickly and promote its application in patient care; Multiple providers' care of the same patient is coordinated; Emerging information technology related to health care benefits people with mental or substance-use problems and illnesses; The health care workforce has the education, training, and capacity to deliver high-quality care for mental and substance-use conditions; Government programs, employers, and other group purchasers of health care for mental and substance-use conditions use their dollars in ways that support the delivery of high-quality care; Research funds are used to support studies that have direct clinical and policy relevance and that are focused on discovering and testing therapeutic advances.

The strategy addresses issues pertaining to health care for both mental and substance-use conditions and the essential role of health care for both conditions in improving overall health and health care. In so doing, it details the actions required to achieve those ends — actions required of clinicians; health care organizations; health plans; purchasers; state, local, and federal governments; and all parties involved in health care for mental and substance-use conditions.

Contents

• The National Academies
• Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders
• Reviewers
• Foreword
• Preface
• Acknowledgments
• Summary
  • ABSTRACT
  • MILLIONS OF AMERICANS USE HEALTH CARE FOR MENTAL OR SUBSTANCE-USE CONDITIONS
  • TREATMENT CAN BE EFFECTIVE
  • QUALITY PROBLEMS HINDER EFFECTIVE TREATMENT AND RECOVERY
  • DEFICIENCIES IN CARE HAVE CONSEQUENCES FOR THE NATION
  • A STRATEGY HAS BEEN DEVELOPED TO IMPROVE OVERALL HEALTH CARE
  • THE QUALITY CHASM STRATEGY IS APPLICABLE TO HEALTH CARE FOR MENTAL AND SUBSTANCE-USE CONDITIONS
  • REFERENCES
• 1. The Quality Chasm in Health Care for Mental and Substance-Use Conditions
  • MORE THAN 33 MILLION AMERICANS ANNUALLY RECEIVE CARE
  • CONTINUING ADVANCES IN CARE AND TREATMENT ENABLE RECOVERY
  • POOR CARE HINDERS IMPROVEMENT AND RECOVERY FOR MANY
  • FAILURE TO PROVIDE EFFECTIVE CARE HAS SERIOUS PERSONAL AND SOCIETAL CONSEQUENCES
  • A CHARGE TO CROSS THE QUALITY CHASM
  • SCOPE OF THE STUDY
  • ORGANIZATION OF THE REPORT
  • REFERENCES
• 2. A Framework for Improving Quality
  • AIMS AND RULES FOR REDESIGNING HEALTH CARE
  • DISTINCTIVE CHARACTERISTICS OF HEALTH CARE FOR MENTAL/SUBSTANCE-USE CONDITIONS
  • APPLYING THE QUALITY CHASM APPROACH TO HEALTH CARE FOR MENTAL AND SUBSTANCE-USE CONDITIONS
  • REFERENCES
• 3. Supporting Patients' Decision-Making Abilities and Preferences
  • RULES TO HELP ACHIEVE PATIENT-CENTERED CARE
  • HOW STIGMA AND DISCRIMINATION IMPEDE PATIENT-CENTERED CARE
  • EVIDENCE COUNTERS STEREOTYPES OF IMPAIRED DECISION MAKING AND DANGEROUSNESS
  • COERCED TREATMENT
  • ACTIONS TO SUPPORT PATIENT-CENTERED CARE
  • REFERENCES
• 4. Strengthening the Evidence Base and Quality Improvement Infrastructure
  • PROBLEMS IN THE QUALITY OF CARE
  • IMPROVING THE PRODUCTION OF EVIDENCE
  • IMPROVING DIAGNOSIS AND ASSESSMENT
  • BETTER DISSEMINATION OF THE EVIDENCE
  • STRENGTHENING THE QUALITY MEASUREMENT AND REPORTING INFRASTRUCTURE
  • APPLYING QUALITY IMPROVEMENT METHODS AT THE LOCUS OF CARE
  • A PUBLIC–PRIVATE STRATEGY FOR QUALITY MEASUREMENT AND IMPROVEMENT
  • REFERENCES
• 5. Coordinating Care for Better Mental, Substance-Use, and General Health
  • CARE COORDINATION AND RELATED PRACTICES DEFINED
  • FAILED COORDINATION OF CARE FOR CO-OCCURRING CONDITIONS
  • NUMEROUS, DISCONNECTED CARE DELIVERY ARRANGEMENTS
  • DIFFICULTIES IN INFORMATION SHARING
  • STRUCTURES AND PROCESSES FOR COLLABORATION THAT CAN PROMOTE COORDINATED CARE
  • REFERENCES
• 6. Ensuring the National Health Information Infrastructure Benefits Persons with Mental and Substance-Use Conditions
  • A STRONG INFORMATION INFRASTRUCTURE IS VITAL TO QUALITY
  • ACTIVITIES UNDER WAY TO BUILD A NATIONAL HEALTH INFORMATION INFRASTRUCTURE
  • NEED FOR ATTENTION TO MENTAL AND SUBSTANCE-USE CONDITIONS IN THE NHII
  • INFORMATION TECHNOLOGY INITIATIVES FOR HEALTH CARE FOR MENTAL/SUBSTANCE-USE CONDITIONS
  • BUILDING THE CAPACITY OF CLINICIANS TREATING MENTAL AND SUBSTANCE-USE CONDITIONS TO PARTICIPATE IN THE NHII
  • INTEGRATING HEALTH CARE FOR MENTAL AND SUBSTANCE-USE CONDITIONS INTO THE NHII
  • REFERENCES
• 7. Increasing Workforce Capacity for Quality Improvement
  • CRITICAL ROLE OF THE WORKFORCE AND LIMITATIONS TO ITS EFFECTIVENESS
  • GREATER VARIATION IN THE WORKFORCE TREATING M/SU CONDITIONS
  • PROBLEMS IN PROFESSIONAL EDUCATION AND TRAINING
  • VARIATION IN LICENSURE AND CREDENTIALING REQUIREMENTS
  • INADEQUATE CONTINUING EDUCATION
  • MORE SOLO PRACTICE
  • USE OF THE INTERNET AND OTHER COMMUNICATION TECHNOLOGIES FOR SERVICE DELIVERY
  • LONG HISTORY OF WELL-INTENTIONED BUT SHORT-LIVED WORKFORCE INITIATIVES
  • NEED FOR A SUSTAINED COMMITMENT TO BRING ABOUT CHANGE
  • REFERENCES
• 8. Using Marketplace Incentives to Leverage Needed Change
  • KEY FEATURES OF THE MARKETPLACE FOR MENTAL AND SUBSTANCE-USE HEALTH CARE
  • CHARACTERISTICS OF DIFFERENT PURCHASING STRATEGIES
  • PROCUREMENT AND THE CONSUMER ROLE
  • EFFECTS OF MARKET AND POLICY STRUCTURES ON QUALITY
  • CONCLUSIONS AND RECOMMENDATIONS
  • REFERENCES
• 9. An Agenda for Change
  • KNOWLEDGE GAPS IN TREATMENT, CARE DELIVERY, AND QUALITY IMPROVEMENT
  • STRATEGIES FOR FILLING KNOWLEDGE GAPS
  • REVIEW OF ACTIONS NEEDED FOR QUALITY IMPROVEMENT AT ALL LEVELS OF THE HEALTH CARE SYSTEM
  • REFERENCES
• Appendixes
  • Appendix A Study Process and Committee Membership
  • Appendix B Constraints on Sharing Mental Health and Substance-Use Treatment Information Imposed by Federal and State Medical Records Privacy Laws
  • Appendix C Mental and Substance-Use Health Services for Veterans: Experience with Performance Evaluation in the Department of Veterans Affairs

This study was supported by multiple contracts and grants between the National Academy of Sciences and the Substance Abuse and Mental Health Services Administration (SAMHSA) of the Department of Health and Human Services (Contract No. 282-99-0045), the Robert Wood Johnson Foundation (Grant No. 048021), the Annie E. Casey Foundation (Grant No. 204.0236), the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism (Contract No. N01-OD-4-2139), the Veterans Health Administration (Contract No. DHHS 223-01-2460/TO21), and through a grant from the CIGNA Foundation.

Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the view of the organizations and agencies that provided support for this project.

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.