Index
A
Academic Behavioral Health Consortium, 300
Accreditors of M/SU health care organizations, recommendations for, 12, 21, 318, 384–385
Acute stress disorder (ASD), knowledge gaps in treatment for, 152
Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice, 299
Addiction Severity Index (ASI), 160
Administration for Children, Youth, and Families, 13–14, 17–18, 174–180, 374–375, 377–378
Administrative datasets, 155–159
Advance directives, 119–120
Advances in care and treatment, 32–34
Agency for Healthcare Research and Quality (AHRQ), 13–14, 17–18, 22–23, 110, 155, 161, 176–180, 268, 358, 374–375, 377–378, 383
Evidence-based Practice Centers, 164
Evidence Report/Technology Assessment, 71
Integrated Delivery Systems Research Network, 359–360
User Liaison Program, 176–177
Agenda for change, 350–390
Aims of quality health care, 8
Alcohol and Drug Services study, 292
American College of Mental Health Administration (ACMHA), 45–46, 182–183, 300
American Health Information Community (AHIC), 264
American Managed Behavioral Health Association, 183
American Psychiatric Association, 30n, 65, 168
Amphetamine dependence, knowledge gaps in treatment for, 153
Analysis of evidence
organizations and initiatives conducting systematic evidence reviews in M/SU health care, 163–166
strengthening and coordinating mechanisms for, 161–167
Annapolis Coalition on Behavioral Health Workforce Education, 300
Anticipation
of comorbidity, and formal determination to treat or refer, 235–236
Application of the Quality Chasm approach to health care for mental and substance-use conditions, 10–23, 70–72.
See also Recommendations
applicability of the Quality Chasm framework, 72
relationship between M/SU and general health care, 70–72
Association for Medical Education and Research in Substance Abuse (AMERSA), 299
Auditing, to ensure that performance measures have been calculated accurately and according to specifications, 187
B
Behavioral Health Data Standards Workgroup (BHDSW), 272
Behavioral health information management, and the NHII, nationwide summit on, 273–274
Benefits and risks of different treatment, providing information about, 117
Brief Psychiatric Rating Scale (BPRS), 160
Budgeted systems of care, 343
C
Campbell Collaboration, 165
Care coordination and related practices defined, 211–214
care coordination, 213
care integration, 213
collaboration, 212–213
communication, 212
integrated treatment, 213–214
Care delivery
gaps in knowledge about effective, 353–355
need to navigate a greater number of arrangements in health care for mental/substance-use conditions, 66–67
by or through non-health care sectors, 275
Care integration, 213
clinical integration, 213
physician (or clinician) integration, 213
Carve-out services
in Medicaid, 341–342
by private payers, 332–333
Case (care) management, 238–239
Center for Studying Health System Change, The, 278
Center for Substance Abuse Treatment (CSAT), 299
Centers for Disease Control and Prevention (CDC), 13–14, 17–18, 174–180, 374–375, 377–378
centers, institute, and offices of, 175
Centers for Medicare and Medicaid Services, 13–14, 22–23, 174–180, 358, 377–378, 383
Certification Commission for Healthcare Information Technology, 265
Change, need for a sustained commitment to bring about, 315–317
Change agenda, 350–390
knowledge gaps in treatment, care delivery, and quality improvement, 351–355
marketplace incentives leveraging needed, 325–349
review of actions needed for quality improvement at all levels of the health care system, 360–388
strategies for filling knowledge gaps, 355–360
summary, 350–351
Changes in MH/SA service delivery in the VHA, 436–437
Child welfare services, 226–227
increased burden on, 41–44
Childhood conditions, gaps in knowledge about therapies for high-prevalence, 352–353
Chronic Care Model, 83, 121–122, 241–242, 306
Clinical integration, 213
Clinically active (CA) mental health personnel, 292
Clinically trained (CT) mental health personnel, 292
Clinicians
diverse types of health care providers, 278
financial issues, 279
in health care for mental/substance-use conditions, 65–66
less use of information technology among M/SU providers, 276
mode of practice, 65–66
numbers in solo or small practices, 277–278
participating in the NHII, 276–279
reporting individual practice as their primary or secondary place of employment, 309
reporting solo practice as their primary or secondary place of employment, 66
varied reimbursement and reporting requirements, 278–279
Clinicians providing M/SU services, recommendations, 14, 179–180, 361–364, 366
Cocaine dependence, knowledge gaps in treatment for, 153
Cochrane Collaboration, 35, 163
Coding
CPT psychotherapy codes, 156–157
ICD-9 procedure codes, 157–158
coercion and mental illnesses, 104–107
coercion and substance-use illnesses, 107–108
defined, 103n
gaps in knowledge about, 354
recommendations concerning, 12–13, 127–128, 362, 366, 373–374
summary, 108
Collaboration, 212–213
and coordination in policy making and programming, 245–247
defined, 212–213
effective communication, 212
New Mexico’s Behavioral Health Collaborative, a case study in policy coordination, 247
with other agencies, 439–440
recommendations concerning, 16–17, 248–249, 282, 363, 367, 370–371, 374, 379–380, 385
shared decision making, 212
a shared understanding of goals and roles, 212
Collaborative public- and private-sector efforts, establishing, 190–191
Collection of outcome data from patients, 159–160
Collocation and clinical integration of services, 237–238
Combating stigma and supporting decision making at the locus of care delivery, 110–115
endorsing and supporting consumer decision making in organizational policies and practices, 110–114
involving consumers in service design, administration, and delivery, 114–115
Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders, xi, 10
convening, 46
study process, 391–393
Committee on the Future of Emergency Care in the U.S. Health System, 47
Communication
defined, 212
effective, 212
underused sources of, 173–177
Community Mental Health Services (CMHS) Block Grants, 223
Comorbidity, anticipation of, and formal determination to treat or refer, 235–236
Compensated Work Therapy (CWT) program and Compensated Work Therapy/Transitional residence (CWT/TR) program, 476–477
outcome measures, 477
process measures, 476–477
program participation, 476–477
Competencies in discipline-specific and core knowledge
Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice, 299
Annapolis Coalition on Behavioral Health Workforce Education, 300
evaluating, 95–96
interdisciplinary project to improve health professional education in substance abuse, 299–300
little assurance of, 298–300
Competition for enrollees, 339–341
Conceptual framework for decision-making capacity, 93–96
ability to understand, appreciate, reason, and communicate preferences, 93–95
characteristics of the competency evaluator, 95–96
contextual risk-benefit factors, 95
Conceptualizing the aspects of care to be measured, 182–185
difference between the public and private sectors, 183
different types of evidence, 184
more diverse stakeholders, 183
unclear locus of accountability, 184–185
Consequences of failing to provide effective care
demands on the juvenile and criminal justice systems, 42–44
great cost to the nation, 38–41
increased burden on the child welfare system, 41–44
mitigating adverse consequences of M/SU problems and illnesses, 44
M/SU illnesses a leading cause of disability and death, 37–38
serious personal and societal, 37–44
Consolidated Health Informatics (CHI) interagency initiative, 266–267
Constraints on sharing M/SU treatment information imposed by federal and state medical records privacy laws, 405–422
HIPAA privacy regulations, 406–407
information sharing for treatment purposes under state law and HIPAA, 412–417
introduction, 405
North Carolina General Stat. Ann. § 122C-55, 418–422
relationship between federal and state privacy laws, 407–409
state laws governing mental health records, 409–411
state laws governing the confidentiality of substance abuse records, 411
state medical records confidentiality laws, 409
Consumer decision making in organizational policies and practices, 110–114
continuing education, 111
leadership and policy practices, 110–111
tolerance for “bad” decisions, 111–114
Consumer role
in health care for mental/substance-use conditions, 61
providing them real choices, 116–117
as service providers, 114–115
Content of continuing education, 306
Contextual risk-benefit factors, 95
Continuing advances in care and treatment, enabling recovery from mental and substance-use conditions, 4–5, 32–34
Continuing education, 111
content of, 306
financing, 307–308
inadequacy of, 305–308
methods, 306–307
organizational support, 308
Continuity of care among outpatients
with psychotic diagnoses, 481
with PTSD diagnosis, 478
Continuous healing relationships, 9
Continuum of linkage mechanisms, 236
Co-occurring mental, substance-use, and general health problems and illnesses, 214–217
co-occurrence with general health conditions, 215–217
co-occurring mental and substance-use problems and illnesses, 214–215
Cooperation among clinicians, 9
in health care, 58
Coordinated care for better mental, substance-use, and general health, 210–258
care coordination and related practices defined, 211–214
difficulties in information sharing, 232–233
failed coordination of care for co-occurring conditions, 214–218
numerous, disconnected care delivery arrangements, 218–232
recommendations concerning, 17, 248–250, 364, 368
structures and processes for collaboration that can promote coordinated care, 233–247
summary, 210–211
Cost to the nation, 38–41
decreased achievement by children in school, 39–41
decreased productivity in the workplace, 39
Council on Social Work Education, 302
Council on the Mental and Substance-Use Health Care Workforce, recommendations for, 20–21, 317–318, 382–383, 386
Counseling, 295
Counselor education, paucity of content on substance-use care in, 302–303
CPT psychotherapy codes, 155–157, 178
insight oriented, behavior modifying and/or supportive psychotherapy, 156
interactive psychotherapy, 156
Criminal justice system, 43–44, 227–229
involvement, 439
Critical role of the workforce and limitations to its effectiveness, 288
workforce shortages and geographic maldistribution, 289
Cross-agency research efforts, recommendations concerning, 22–23, 358, 383
Crossing the Quality Chasm: A New Health System for the 21st Century, ix, xi, 1–2, 11, 30, 44–48, 56–59, 65, 70, 72, 77–78, 108, 111–112, 116–118, 123, 185, 211, 213–214, 229, 260, 278–279, 353, 392
Customization, based on patient needs and values, 9, 78
in health care, 58
D
Dangerousness, risk of, 100–103
Data access, need to balance privacy concerns with, 274–275
Data availability, 359
Data interchange, 266
Data standards, 17–18, 262–263, 265–267, 374–375
knowledge representation, 266
recommendations for, 19, 281, 371
terminologies, 266
Davies Award, The, 274
Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care, 263
Decision Support 2000+, 270–271
Decision-making abilities of individuals, xii, 93–100
conceptual framework, 93–96
Decision-making abilities of individuals with and without M/SU illnesses, 96–100
among people with substance-use illnesses, gaps in knowledge about, 354
effects of substance use on decision making and compulsive behavior, 99–100
impaired decision making by individuals not mentally ill or using substances, 100
mental illnesses, 96–98
Decision-making support
providing all M/SU health care consumers with, 116–122
providing consumers with real choices, 116–117
providing decision support to all patients, 117–118
providing information about the benefits and risks of different treatment, 117
providing stronger decision support mechanisms for individuals with significantly impaired cognition or diminished self-efficacy beliefs, xii, 118–120
supporting illness self-management practices and programs, 120–122
Deference to the patient as the source of control, 9
in health care, 58
Demands on the juvenile and criminal justice systems, 42–44
criminal justice, 43–44
juvenile justice, 42
Department of Defense (DoD), 13–14, 177–180, 377–378
Department of Education, 13–14, 177–180, 377–378
Department of Health and Human Services (DHHS), 13–14, 177–180, 211n, 377–378
recommendations for, 14–15, 17–18, 370, 374–375, 378–380
Department of Justice, 13–14, 161, 164–165, 177–180, 377–378
Department of Labor, 88
Department of Veterans Affairs (VA), 13–14, 18–19, 22–23, 177–180, 189–193, 358, 377–378, 380–381, 383, 426
patients diagnosed with mental health and substance abuse disorders, 432–433
quality measurement and quality management in the VA, 424–425, 440–446
VA health service use, 468–470
VA MH/SA services among veterans who used any MH/SA care, 471–472
Diagnostic methods
for mental/substance-use conditions, 64–65
improving, 167–169
Differences between general health care and health care for mental and substance-use conditions
in decision-making ability, 96–97
in health care for mental/substance-use conditions, 62–64
in the marketplace for health care for mental/substance-use conditions, 69–70
between the public and private sectors, 183
Disability-adjusted life years (DALYs), 37
Disconnected care delivery arrangements, 218–232
frequent need for individuals with severe mental illnesses to receive care through a separate public-sector delivery system, 223–224
involvement of non-health care sectors in M/SU health care, 224–232
separation of health services for M/SU conditions from each other, 222–223
separation of M/SU health care from general health care, 219–222
unclear accountability for coordination, 231–232
Discrimination by health care providers, gaps in knowledge about preventing unintentional, 354
Discrimination impeding patient-centered care, 79–92
adverse effects on patients’ ability to manage their care and achieve desired health outcomes, 81–84
relationship between stigma and discriminatory policies, 87–92
stigma affecting clinician attitudes and behaviors, 84–87
Discrimination in health insurance coverage, 88–90
coverage of mental health care, 88–89
coverage of substance-use health care, 89–90
Discriminatory policies, 87–92, 122–126
minimizing risks in involuntary treatment, 125
needed research, 125–126
potential lifetime ban on receipt of food stamps or welfare for felony drug conviction, 91–92
preserving patient-centered care and patient decision making in coerced treatment, 124
restrictions on access to student loans for some drug offenses, 90–91
transparent policies and practices for assessing decision-making capacity and dangerousness, 123–124
Dissemination of the evidence, 169–180
conclusions and recommendations, 177–180
key efforts, 171–173
key factors associated with successful, 170
National Institutes of Health, 172
professional associations, 173
recommendations concerning, 13–14, 177–180, 377–378
Substance Abuse and Mental Health Services Administration, 171–172
underused sources of communication and influence, 173–177
Veterans Health Administration, 172–173
Diversity of providers, in health care for mental/substance-use conditions, 10, 68–69
Domiciliary Care for Homeless Veterans (DCHV) program, 475–476
outcome measures, 476
patient characteristics, 475
process measures, 475–476
program participation, 476
program structure, 475
Drug Evaluation Network System (DENS), 273
Duke University, 120
E
Educational institutions. See also Professional education and training;
recommendations for, 21, 318, 386
Effective communication, 212
gaps in knowledge about delivering, 353–355
Effectiveness, 448–451
evaluating, 158
knowledge gaps in, 153
of performance measures, and measure sets and policies, 188–189
relative, of different treatments alone and in combination, 353
Efficacious treatments, 151.
See also Self-efficacy
Efficacy-effectiveness gap, 151–153
Efficient health care, 8, 57, 453
Electronic health records (EHRs), 17–18, 238, 259, 264–265, 279, 374–375
and personal health records, 272
recommendations for, 19–20, 281, 371–372, 375, 381–382
Employee assistance programs (EAPs), 230–231
Ensuring National Health Information Infrastructure (NHII) benefits to persons with mental and substance-use conditions, 259–285
summary, 259–260
Epidemiological Catchment Area (ECA) study, 101–103
EQUIP project, 261
Equity for minorities, 453–454
Evidence
improving the production of, 151–167
Evidence base and quality improvement infrastructure, 140–209
applying quality improvement methods at the locus of care, 193–194
better dissemination of the evidence, 169–180
improving diagnosis and assessment, 167–169
improving the production of evidence, 151–167
problems in the quality of care, 141–151
public-private strategy for quality measurement and improvement, 195–196
strengthening the quality measurement and reporting infrastructure, 180–193
Evidence base gaps, 151–160
better capture of mental and substance-use health care data in administrative datasets, 155–159
collection of outcome data from patients, 159–160
efficacious treatments, 151
the efficacy-effectiveness gap, 151–153
knowledge gaps in treatment for M/SU conditions, 152–153
studies other than randomized controlled trials, 154–155
Evidence of decision-making capacity, 93–100
conceptual framework, 93–96
decision-making abilities of individuals with and without M/SU illnesses, 96–100
Evidence Report/Technology Assessment, 71
Evidence-based decision-making, 9
in health care, 58
Evidence-based Practice Centers (EPCs), 164
Experience of Care and Health Outcomes (ECHO) Survey, 160
External providers, formal agreements with, 239–240
F
Faculty development
inadequacy of, 303
recommendations concerning, 21, 318, 383
Failed coordination of care for co-occurring conditions, 214–218
co-occurring mental, substance-use, and general health problems and illnesses, 214–217
failure to detect, treat, and collaborate in the care of co-occurring illnesses, 217–218
Failure to treat and prevent problems in the quality of care, 144–147.
See also Consequences of failing to provide effective care
failure to prevent, 146–147
failure to treat, 144–146
FDA. See U.S. Food and Drug Administration
Federal Employees Health Benefit Program (FEHBP), 331
Federal policy makers, recommendations for, 377–383
Federal privacy law, 407–409
Felony drug conviction, potential lifetime ban on receipt of food stamps or welfare for, 91–92
Female veterans, 454
Financing, 279
continuing education, 307–308
methods for mental health/substance-use care, 326
of M/SU health care research, recommendations for, 387–388
recommendations for health care, 22, 344, 372, 375
Flexibility, in professional roles, 242
Food Stamp Program, 91
Formal agreements, with external providers, 239–240
Framework for improving quality, 56–76
aims and rules for redesigning health care, 57–59
applying the Quality Chasm approach to health care for mental and substance-use conditions, 70–72
distinctive characteristics of health care for mental/substance-use conditions, 59–70
summary, 56–57
Front-line experience, 425, 454–456
G
Gaps in knowledge, 355
General medical/primary care providers, 293–294
Global Appraisal of Individual Needs (GAIN), 160
Global Assessment of Functioning (GAF) scale, 160, 482
improvement after inpatient discharge, 482
improvement during outpatient treatment, 482
National Mental Health Program Performance Monitoring System, 160
Government Performance and Results Act (GPRA), 272–273
Government purchasing, 2
dominance of, 326–327
H
HCPCS codes, 178
Health care
anticipation of needs, 58
based on continuous healing relationships, 58
Health Care for Homeless Veterans (HCHV) program, 475–476
outcome measures, 476
patient characteristics, 475
process measures, 475–476
program participation, 476
program structure, 475
Health care for mental/substance-use conditions, 59–70
consumer role, 61
diagnostic methods, 64–65
differences between general health care and health care for mental and substance-use conditions, 62–64
differences in the marketplace, 69–70
greater diversity of types of providers, 68–69
greater separation from other components of the health care system, 59–61
information sharing and technology, 68
integrating into the NHII, 279–283
mode of clinician practice, 65–66
need to navigate a greater number of care delivery arrangements, 66–67
quality measurement infrastructure, 67–68
solving the problems of, xi
Health care organizations, 13–14, 177–180, 377–378
Health care provider and organization strategies, 234–243
anticipation of comorbidity and formal determination to treat or refer, 235–236
linking mechanisms fostering collaborative planning and treatment, 236–240
organizational support for collaboration, 240–243
screening, 234–235
Health care providers, diverse types of, 278
Health Insurance Portability and Accountability Act (HIPAA), 13–14, 68, 158, 177–180, 232–233, 377–378, 405
privacy regulations, 68, 406–407
Health maintenance organizations (HMOs), 277–278, 310
Health of the Nation Outcome Scales (HoNOS), 160
Health plans and purchasers of M/SU health care, recommendations for, 369–372
Health Privacy Project, 405
Health professional education in substance abuse, interdisciplinary project to improve, 299–300
Health Resources and Services Administration (HRSA), 268, 299
Healthplan Employer Data and Information Set (HEDIS), 155, 183–184, 186–187, 221, 271
High quality health care, six aims of, 57
Higher Education Act, 90
High-prevalence childhood conditions, gaps in knowledge about therapies for, 352–353
High-risk populations, 17
I
ICD-9 procedure codes, 155, 157–158
Illness self-management practices and programs
gaps in knowledge about, 355
impaired, 82–83
Improving care, ix
using information technology, 261–262
Improving diagnosis and assessment, 167–169
Improving the production of evidence, 151–167
filling the gaps in the evidence base, 153–160
gaps in the evidence base, 151–153
strengthening and coordinating mechanisms for analyzing the evidence, 161–167
Information infrastructure
initiatives for health care for M/SU conditions, 270–275
relationship to quality, 260–262
Information sharing
difficulties in, 232–233
technology, in health care for mental/substance-use conditions, 68
for treatment purposes under state law and HIPAA, 412–417
Information technology (IT), 2, 307
improving care using, 261–262
less use among M/SU providers, 10, 276
Information technology (IT) initiatives
balancing privacy concerns with data access, 274–275
care delivered by or through non-health care sectors, 275
for health care for mental/substance-use conditions, 270–275
information infrastructure initiatives for health care for M/SU conditions, 270–275
private-sector initiatives, 274
SAMHSA initiatives, 270–274
unique characteristics of M/SU services with implications for the NHII, 274
Innovations
key factors associated with successful adoption of, 170
NIATx, 195
within psychiatry, 167
Inpatients
care measures for, 480–481
improvement after discharge, 482
satisfaction measures, 481
specialized (residential) PTSD programs for, 478
Institute of Medicine (IOM), ix–xi, 8–10, 30, 32, 44, 211n, 220, 243, 245, 260, 267, 279, 425
Instructional directives, psychiatric, 119
Insurance coverage, more limited for M/SU conditions, 7, 328–329
Integrated Delivery Systems Research Network (IDSRN), 359–360
data availability, 359
management authority to implement a health care intervention, 359
research expertise, 359
Integrated treatment, 213–214
defined, 213–214
integrated programs, 214
integrated systems, 214
Interactions between the mind/brain and the rest of the body, 11, 71–72, 361, 365, 369, 373, 377, 384, 386
Interactive psychotherapy, 156
Interdisciplinary Project to Improve Health Professional Education in Substance Abuse, 301, 303–304
Interventions to improve decision-making capability, 98
Involuntary treatment, minimizing risks in, 125
J
Jamison, Kay Redfield, 112–113
Joint Commission on Accreditation of Healthcare Organizations (JCAHO), 157, 244
Jost, Timothy Stoltzfus, 405–422
Justice systems, 227–230
Juvenile justice system, 42, 229–230
K
Keeping Patients Safe: Transforming the Work Environment of Nurses, 307
Knowledge about effective care delivery
coercion into treatment, 354
demonstrations of illness self-management programs, 355
gaps in, 353–355
potential modification of certain public policies, 354
preventing unintentional discrimination by health care providers, 354
providing patient-centered care, 353–354
understanding decisional capacity among people with substance-use illnesses, 354
Knowledge about effective treatments
gaps in, 351–353
medication treatments for certain substance dependencies, 352
optimal pharmacotherapy for psychosis, 352
prevention and treatment of PTSD, 352
prevention studies, 353
relative effectiveness of different treatments (alone and in combination), 353
therapies for high-prevalence childhood conditions, 352–353
therapies for other population subgroups, 353
treatment of multiple conditions, 351
Knowledge about quality improvement practices for M/SU health care, recommendations about disseminating, 15, 196, 379, 387
Knowledge gaps in treatment for M/SU conditions, 152–153, 351–355
acute stress disorder, 152
amphetamine dependence, 153
cocaine dependence, 153
gaps in treatment knowledge, 351–355
marijuana dependence, 153
posttraumatic stress disorder, 152
psychotic illnesses, 153
relative effectiveness of different treatments, 153
shortcomings in public policy, 355
therapies for children and older adults, 152
therapies for other population subgroups, 153
treatment of multiple conditions, 152
Knowledge representation, 266
L
Leadership, 242–243
and policy practices, 110–111
Leadership by Example: Coordinating Government Roles in Improving Health Care Quality, 245, 250
Linkage of the VA with the Department of Defense (DoD) and other mental health, medical, and social service systems, 424, 437–440
collaborative relationships with other agencies, 439–440
criminal justice involvement, 439
cross MH/SA system use, 437–438
primary care and specialty medical services, 438–439
transition from DoD to VA, 437
Linkages with community and other human services resources, 231
Linking mechanisms fostering collaborative planning and treatment, 236–240
case (care) management, 238–239
collocation and clinical integration of services, 237–238
the continuum of linkage mechanisms, 236
formal agreements with external providers, 239–240
recommendations concerning, 16, 248, 282, 363, 367
shared patient records, 238
M
MacArthur Research Network on Mental Health and the Law, 113
MacArthur Violence Risk Assessment Study, 102
Making Health Care Safer: A Critical Analysis of Patient Safety Practices, 307
Managed behavioral health organizations (MBHOs), 67, 220, 222, 243–244, 327–328, 332–335
Management authority, to implement a health care intervention, 359
Marijuana dependence, knowledge gaps in treatment for, 153
Market and policy structures
budgeted systems of care, 343
direct public purchase of behavioral carve-out services in Medicaid, 341–342
effects on quality, 339–343
private payer direct procurement of carve-out services, 342
quality distortions in the purchase of health plan services through competition for enrollees, 339–341
traditional Medicaid programs, 342
Marketplace for mental and substance-use health care, 1, 326–329
dominance of government purchasing, 326–327
financing methods for mental health/substance-use care, 326
frequent direct provision and purchase of care by state and local governments, 329
more limited insurance coverage, 328–329
purchase of M/SU health insurance separately from general health insurance, 327–328
Marketplace incentives to leverage needed change, 325–349
characteristics of different purchasing strategies, 330–337
conclusions and recommendations, 343–346
effects of market and policy structures on quality, 339–343
procurement and the consumer role, 337–339
summary, 325
Marriage and family therapy, 296
Measurement and reporting infrastructure
analyzing and displaying the performance measures in suitable formats, 187–188
auditing to ensure that performance measures have been calculated accurately and according with specifications, 187
conceptualizing the aspects of care to be measured, 182–185
ensuring calculation and submission of the performance measures, 186–187
maintaining the effectiveness of performance measures and measure sets and policies, 188–189
necessary components of a quality, 181–189
pilot testing the performance measure specifications, 186
translating quality-of-care measurement concepts into performance measure specifications, 185–186
traditional programs, 342
Medical Expenditure Panel Survey, 330
Medication, xii
treatments for certain substance dependencies, gaps in knowledge about, 352
Mental and substance-use health problems and illnesses, ix–x
Americans annually receiving care for, 2–4, 30–32
among veterans and nonveterans in the general population, 428–429
and general health care, 70–72
a leading cause of disability and death, 37–38
mitigating adverse consequences of, 44
Mental and substance-use health services, clinicians in solo or small practices, 277–278
Mental and substance-use health services for veterans
America’s veterans, 427–432
development of MH/SA quality measurement and quality management in the VA, 424–425, 440–446
experience with performance evaluation in the Department of Veterans Affairs, 423–482
front-line experience, 425, 454–456
introduction to the Department of Veterans Affairs in American mental health care, 426–427
linkage of the VA with the Department of Defense and other mental health, medical, and social service systems, 424, 437–440
performance measures used by the Northeast Program Evaluation Center in the evaluation and monitoring of VA mental health programs, 475–482
population characteristics of veterans who used VA services, 464–467
quality of VA MH/SA care, 425, 446–454
status among veteran and nonveteran users of mental health services, 429–430
summary, 423–425
tables, 464–474
treatment of MH/SA in the VA, 424, 432–437
U.S. veterans, 424
VA health service use, 468–470
VA MH/SA services among veterans who used any MH/SA care, 471–472
veterans treated for mental health diagnosis in the VHA, by specialty, 473
workload of specialized VA mental health programs, 474
Mental Health: Culture, Race, and Ethnicity, 290
Mental health and substance-use treatment information
constraints on sharing imposed by federal and state medical records privacy laws, 405–422
HIPAA privacy regulations, 406–407
information sharing for treatment purposes under state law and HIPAA, 412–417
introduction, 405
North Carolina General Stat. Ann. § 122C-55, 418–422
relationship between federal and state privacy law, 407–409
state laws governing mental health records, 409–411
state laws governing the confidentiality of substance abuse records, 411
state medical records confidentiality laws, 409
Mental health care
discrimination in health insurance coverage of, 88–89
introduction to the Department of Veterans Affairs in, 426–427
Mental Health Corporations of America, 274
Mental health intensive case management (MHICM), 479–480
appropriateness of admissions, 479
outcomes, 480
program structure, 479
treatment process, 480
Mental Health Parity Act, 88n
Mental Health Statistical Improvement Project (MHSIP), 269–271, 283
survey, 160
Mental illnesses, 96–98
ability of interventions to improve decision-making capability, 98
difference in decision-making ability, 96–97
poor decision-making abilities better predicted by cognitive than by psychotic symptoms, 97–98
summary, 98
Multi-Agency INitiative on Substance abuse TRaining and Education for AMerica (Project MAINSTREAM), 300
Multiple conditions, gaps in knowledge about treating, 351
N
National Advisory Council on Nurse Education and Practice (NACNEP), 287, 316–317
National Alliance for the Mentally Ill (NAMI), 109
National Association of Alcohol and Drug Abuse Counselors (NAADAC), 302–304
National Association of State Alcohol and Drug Abuse Directors (NASADAD), 158, 232
National Association of State Mental Health Program Directors (NASMHPD), 158, 187, 232
National Committee for Quality Assurance (NCQA), 186, 244
Healthplan Employer Data and Information Set, 155, 183–184, 186–187, 221, 232–233, 271
National Committee on Vital and Health Statistics, 267
National Compensation Survey, 88
National Coordinator. See Office of the National Coordinator of Health Information Technology
National Epidemiologic Survey on Alcohol and Related Conditions, 214
National Health Information Infrastructure (NHII), 18–19, 260, 280, 380–381
activities under way to build, 262–268
data standards, 265–267
electronic health records, 264–265
a secure interoperable platform for exchange of patient information across health care settings, 267–268
National Health Information Infrastructure (NHII) benefiting persons with mental and substance-use conditions, 259–285
activities under way to build a national health information infrastructure, 262–268
building the capacity of clinicians treating mental and substance-use conditions to participate in the NHII, 276–279
information technology initiatives for health care for mental/substance-use conditions, 270–275
integrating health care for mental and substance-use conditions into the NHII, 279–283
need for attention to mental and substance-use conditions in the NHII, 268–270
National Health Interview survey, 3
National Healthcare Quality Report, 180
National Institute of Child Health and Human Development, 13–14, 177–180, 377–378
National Institute of Mental Health (NIMH), 13–14, 22–23, 172, 177–180, 222, 358, 377–378, 383
Outreach Partnership Program, 109
National Institute on Alcohol Abuse and Alcoholism (NIAAA), 13–14, 22–23, 172, 177–180, 214, 222, 303, 358, 377–378, 383
National Institute on Drug Abuse (NIDA), 13–14, 22–23, 172, 177–180, 222, 358, 377–378, 383
National Institutes of Health (NIH), 32, 172, 222
National Inventory of Mental Health Quality Measures, 180
National Library of Medicine, 267
National Mental Health Program Performance Monitoring System, 160
National Quality Forum, 14–15, 182, 195–196, 370, 378–379
National Quality Measurement and Reporting System (NQMRS), 182
National Registry of Evidence-based Programs and Practices (NREPP), 163–164, 310
National Research Council, 154, 357
National Survey of Child and Adolescent Well-Being (NSCAW), 226
National Survey on Drug Use and Health, 145
National Treatment Plan Initiative, 87
Nationwide summit on behavioral health information management, and the NHII, 273–274
Network for the Improvement of Addiction Treatment (NIATx), 194–195, 360
the innovation initiative, 195
the single state agency initiative, 195
the treatment provider initiative, 194–195
New Freedom Commission on Mental Health, 218, 220, 246, 282, 289, 391
New Mexico’s Behavioral Health Collaborative, case study in policy coordination, 247
Non-health care sectors
child welfare services, 226–227
employee assistance programs, 230–231
involvement in M/SU health care, 224–232
justice systems, 227–230
linkages with community and other human services resources, 231
schools, 225–226
North Carolina General Stat. Ann. § 122C-55, 418–422
Number of Americans annually receiving care, 30–32
Nursing education, paucity of content on substance-use care in, 302
O
Office of Minority Health, 13–14, 177–180, 377–378
Office of the National Coordinator of Health Information Technology (ONCHIT), 17–18, 263, 268, 282, 374–375
Organizational support
for collaboration, 240–243
for continuing education, 308
facilitating structures and processes at treatment sites, 240–242
flexibility in professional roles, 242
leadership, 242–243
Organizations
conducting systematic evidence reviews in M/SU health care, 163–166
providing M/SU health care, recommendations for, 365–368
Outcome measures, 476–477, 479–480
the Global Assessment of Functioning scale, 482
Outpatient care measures, 481
all VA PTSD treatment, specialized and non-specialized, 478
continuity of care among outpatients with psychotic diagnoses, 481
continuity of care among outpatients with PTSD diagnosis, 478
improvement during treatment, 482
service utilization and continuity of care, 478, 481
Outpatient programs (specialized for PTSD), 477–478
costs, 478
patient characteristics, 477–478
workload, 478
Outreach Partnership Program, 109
P
Partnerships
public-private, 189–193
researchers and stakeholders, 23, 358, 388
Pastoral counseling, 296
Patient activation, 83–84
Patient as the source of control, 78
Patient characteristics, 475, 477–478
Patient decision making, 12
preserving in coerced treatment, 124
Patient Health Questionnaire, 235
Patient information, exchanging across health care settings, a secure interoperable platform for, 267–268
Patient needs and values, customization based on, 9
Patient Outcomes Research Team (PORT) Pharmacotherapy Guidelines, for patients with schizophrenia, adherence to, 33, 482
Patient-centered care, xii, 8, 57, 77, 451–452
actions supporting, 108–128
anticipation of needs, 78
combating stigma and supporting decision making at the locus of care delivery, 110–115
customization based on patient needs and values, 78
eliminating discriminatory legal and administrative policies, 122–126
gaps in knowledge about providing, 353–354
the need for transparency, 78
obstacles to, 11
the patient as the source of control, 78
preserving in coerced treatment, 124
providing decision-making support to all M/SU health care consumers, 116–122
recommendations concerning, 11–12, 126–128, 361–362, 365–366, 369, 384
rules helping to achieve, 78–79
shared knowledge and the free flow of information, 78
Patients’ ability to manage their care and achieve desired health outcomes
adverse effects on, 81–84
decreased self-efficacy, 82
diminished self-esteem, 81
impaired illness self-management, 82–83
weakened patient activation and self-determination, 83–84
Patients’ decision-making abilities and preferences supported, 77–139
actions supporting patient-centered care, 108–128
coerced treatment, 103–108
evidence countering stereotypes of impaired decision making and dangerousness, 92
rules helping to achieve patient-centered care, 78–79
stigma and discrimination impeding patient-centered care, 79–92
summary, 77–78
Peer support programs, xii, 118–119
Performance measures
analyzing and displaying in suitable formats, 187–188
ensuring calculation and submission, 186–187
pilot testing specifications for, 186
public-sector efforts to develop, test, and implement, 192–193
recommendations for, 17–18, 374–375, 380
Performance Measures Advisory Group (PMAG), 157
Performance measures used by the National Mental Health Program Performance Monitoring System, 480–481
inpatient care measures, 480–481
inpatient satisfaction measures, 481
outpatient care measures, 481
population coverage, 480
Performance measures used by the Northeast Program Evaluation Center in the evaluation and monitoring of VA mental health programs, 475–482
adherence to PORT Pharmacotherapy Guidelines for patients with schizophrenia, 482
Compensated Work Therapy and Compensated Work Therapy/Transitional residence programs, 476–477
Health Care for Homeless Veterans and Domiciliary Care for Homeless Veterans programs, 475–476
mental health intensive case management, 479–480
outcomes on the Global Assessment of Functioning scale, 482
PTSD performance monitors and outcome measures, 477–479
Personal health records (PHRs), 264n, 272
Personal Responsibility and Work Opportunity Reconciliation Act, 91
Pharmacotherapy for psychosis, 5
gaps in knowledge about optimal, 352
Physicians
integrating, 213
paucity of content on substance-use care in education of, 300–301
Poor care, hindering improvement and recovery for many with mental and substance-use conditions, 5–6, 35–36
Poor decision-making abilities, better predicted by cognitive than by psychotic symptoms, 97–98
Populations
coverage issues, 480
gaps in knowledge about therapies for other subgroups, 353
high-risk, 17
Posttraumatic stress disorder (PTSD)
inpatient care (generalized and specialized programs), 479
knowledge gaps in treatment for, 152
Posttraumatic stress disorder (PTSD) performance monitors and outcome measures, 477–479
all PTSD inpatient care (generalized and specialized programs), 479
inpatient/residential programs (specialized PTSD programs), 478
outcomes, 479
outpatient care measures (all VA PTSD treatment, specialized and non-specialized), 478
outpatient programs (specialized PTSD outpatient programs), 477–478
Practices of purchasers, quality oversight organizations, and public policy leaders, 243–247
collaboration and coordination in policy making and programming, 245–247
purchaser practices, 243–244
quality oversight practices, 244–245
President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry, 180
President’s New Freedom Commission on Mental Health, 218, 220, 246, 282, 289, 391
Prevention studies
failure of, 146–147
gaps in knowledge about, 352–353
Primary care, and specialty medical services, 438–439
Privacy concerns, 17–18, 374–375
need to balance with data access, 274–275
Private payer direct procurement, of carve-out services, 342
Private-sector initiatives, 274
The Davies Award, 274
Mental Health Corporations of America, 274
Procedure codes, 13–14, 174–180, 377–378
ICD-9, 157–158
Process measures, 475–477
Procurement, and the consumer role, 337–339
Professional associations, 13–14, 166, 173, 177–180, 377–378
Professional education and training, 294–304
deficiencies in, 297–304
inadequate faculty development, 303
little assurance of competencies in discipline-specific and core knowledge, 298–300
paucity of content on substance-use care, 300–303
summary, 303–304
variation in amounts and types of, 294–297
Program participation issues, 476–477
integrated, 214
Project MAINSTREAM. See Multi-Agency INitiative on Substance abuse TRaining and Education for AMerica
Proxy directives, psychiatric, 119–120
Psychiatric instructional directives, 119
Psychiatric nursing, 295
Psychiatric proxy directives, 119–120
innovation within, 167
Psychologist education, paucity of content on substance-use care in, 301
Psychology, 294–295
Psychosocial rehabilitation, xii, 5, 296
Psychotherapy
insight oriented, behavior modifying and/or supportive, 156
interactive, 156
Psychotic illnesses, knowledge gaps in treatment for, 153
Public and publicly funded programs
recommendations for, 22, 346, 372, 376
requiring submission of jointly agreed-upon public- and private-sector measures in, 191–192
Public policy
gaps in knowledge about potential modification of, 354
shortcomings in, 355
Public policy leaders, practices of, 243–247
Publicly budgeted systems of care, 336–337
Public-private leadership and partnership to create a quality measurement and reporting infrastructure, 189–193
continuing public-sector efforts to develop, test, and implement new performance measures, 192–193
establishing collaborative public- and private-sector efforts, 190–191
requiring submission of jointly agreed-upon public- and private-sector measures in public and publicly funded programs, 191–192
strategy for quality measurement and improvement, 195–196
Purchasers of M/SU services
practices of, 243–244
recommendations for, 22, 345, 372, 376
Purchase of M/SU services
direct, of carve-out services by group payers, 332–333
of M/SU health insurance separately from general health insurance, 327–328
of services by carve-out organizations, 334–335
of services in traditional Medicaid programs, 335–336
through competitive insurance markets, with competition for enrollees, 330–332
Purchasing strategies, 330–337
publicly budgeted systems of care, 336–337
Q
Quality Chasm in health care for mental and substance-use conditions, 29–55
continuing advances in care and treatment enabling recovery, 32–34
gaps in knowledge about how to improve, 355
numbers of Americans annually receiving care, 30–32
poor care hindering improvement and recovery for many, 35–36
scope of the study, 47
serious personal and societal consequences of failing to provide effective care, 37–44
a strategy to improve overall health care, crossing the Quality Chasm, 44–46
summary, 29–30
ten rules to guide the redesign of health care, 9, 58
Quality distortions in the purchase of health plan services through competition for enrollees, 339–341
Quality Enhancement Research Initiative, 173
Quality improvement
at all levels of the health care system, review of actions needed for, 360–388
at the locus of care, 193–194
Network for the Improvement of Addiction Treatment, 194–195
recommendations for, 22, 344–345, 372
workforce capacity for, 286–324
Quality management, in the “new VA,” expansion of, 443–446
Quality measurement and quality management in the VA, 424–425, 440–446
evaluation and monitoring of specialized VA MH/SA programs, 441–443
expansion of quality management in the “new VA,” 443–446
Quality measurement and reporting infrastructure, 1, 180–193
in health care for mental/substance-use conditions, 67–68
necessary components of, 181–189
need for public-private leadership and partnership to create, 189–193
Quality of care problems, 141–151
failure to treat and prevent, 144–147
unsafe care, 147–151
variations in care due to a lack of evidence, 143–144
Quality of VA MH/SA care, 425, 446–454
effectiveness, 448–451
efficiency, 453
equity minorities, 453–454
female veterans, 454
patient-centered care, 451–452
safety, 447–448
timeliness, 452–453
Quality oversight organizations, practices of, 244–245
R
Recommendations, 126–128, 177–180, 317–319
for accreditors of M/SU health care organizations, 12, 21, 318, 384–385
for clinicians, 361–364
for clinicians providing M/SU services, 14, 362, 366
concerning coerced treatment, 12–13, 362, 366, 373–374
concerning collaboration, 16–17, 363, 367, 370–371, 374, 379–380, 385
concerning coordinating care for better mental, substance-use, and general health, 17, 248–250, 364, 368
concerning cross-agency research efforts, 22–23, 358, 383
concerning dissemination of the evidence, 13–14, 377–378
concerning faculty development, 21, 318, 383
concerning linking mechanisms to foster collaborative planning and treatment, 16, 363, 367
concerning patient-centered care, 11–12, 361–362, 365–366, 369, 384
concerning research designs, 15–16, 387
on coordinating care for better mental, substance-use, and general health, 248–250
for the DHHS, 14–15, 370, 378–379
about disseminating knowledge about quality improvement practices for M/SU health care, 15, 379, 387
for educational institutions, 21, 318, 386
for electronic health records, 19–20, 371–372, 375, 381–382
for federal policy makers, 377–383
for funders of M/SU health care research, 387–388
for health care financing, 22, 344, 372, 375
for health plans and purchasers of M/SU health care, 369–372
for institutions of higher education, 386
for organizations providing M/SU health care, 365–368
for performance measures, 17–18, 374–375, 380
for public and publicly funded programs, 22, 346, 372, 376
for purchasers, 22, 345, 372, 376
for quality improvement, 22, 344–345, 372
regarding public-private leadership and partnership to create a quality measurement and reporting infrastructure, 19, 364, 368, 371, 375
for state policy makers, 373–376
for workforce capacity for quality improvement, 20–21, 382–383, 386
Redesigning health care, 57–59
care based on continuous healing relationships, 9, 58
continuous decrease in waste, 9, 58
cooperation among clinicians, 9, 58
customization based on patient needs and values, 9, 58
deference to the patient as the source of control, 9, 58
evidence-based decision-making, 9, 58
recommendations for, 11, 72, 365, 369
safety as a system property, 9, 58
shared knowledge and the free flow of information, 9, 58
six aims of high quality health care, 57
Regional health information organizations (RHIOs), 275
Reporting. See Measurement and reporting infrastructure
Research designs, 357–359
recommendations concerning, 15–16, 196, 387
Research expertise, 359
Restrictions on access to student loans for some drug offenses, 90–91
Risks. See also Benefits and risks of different treatment
of dangerousness, 100–103
in involuntary treatment, minimizing, 125
Rules to guide the redesign of health care, 9, 58
S
Safety in health care, 8, 57, 447–448
heightened concerns, and need for multiple actions, 150–151
School achievement by children, 39–41
Screening, 234–235
Self-efficacy, 81
Self-esteem, diminished, 81
Separate public-sector delivery system, 1
frequent need for individuals with severe mental illnesses to receive care through, 223–224
Separation of health care system components for mental/substance-use conditions, 60–61
from each other, 59–61, 222–223
from general health care, 219–222
Serious personal and societal consequences of failing to provide effective care for mental and substance-use conditions, 6–7
Service design, administration, and delivery
consumer participation in service design and administration, 114
consumers as service providers, 114–115
involving consumers in, 114–115
Service utilization and continuity of care, 478, 481
Services Accountability Improvement System (SAIS), 272–273
Shared decision making, 212
Shared knowledge in health care, and the free flow of information, 9, 58, 78
Shared patient records, 238.
See also Constraints on sharing imposed by federal and state medical records privacy laws
Shared understanding of goals and roles, 212
Single state agency initiative, of NIATx, 195
Social work, 295
paucity of content on substance-use care in education for, 301–302
Software and Technology Vendors’ Association (SATVA), 271, 273–274
Solo practice, 309–310
clinically trained specialty mental health personnel reporting individual practice as their primary or secondary place of employment, 309
Specialized VA MH/SA programs, 434
evaluation and monitoring of, 441–443
Specialty medical services, and primary care, 438–439
Specialty mental health providers, 291–292
clinically active (CA) or clinically trained (CT) mental health personnel, 292
Specialty substance-use treatment providers, 292–293
Stakeholders, 435–436
more diverse, 183
Stanford University, 83
State and local governments, 165–166
frequent direct provision and purchase of care by, 329
State data infrastructure grants, 271
State laws
governing mental health records, 409–411
governing the confidentiality of substance abuse records, 411
State medical records confidentiality laws, 409
State Outcomes Measurement and Management System, 183
State policy makers, recommendations for, 373–376
State privacy law, 407–409
Stereotypes of impaired decision making and dangerousness, 92–93
evidence countering, 92
evidence of decision-making capacity, 93–100
harmful stereotypes of impaired decision making and dangerousness, 92–93
risk of dangerousness, 100–103
Stigma, 79–92
affecting clinician attitudes and behaviors, 84–87
pathway to diminished health outcomes, 81
Strategies for filling knowledge gaps, 355–360
Agency for Healthcare Research and Quality’s Integrated Delivery Systems Research Network, 359–360
Network for the Improvement of Addiction Treatment, 360
research designs, 357–359
Strategies to improve overall health care, 8–10, 44–46
six aims of high quality health care, 8
ten rules to guide the redesign of health care, 9
Strong information infrastructure
improving care using information technology, 261–262
as vital to quality, 260–262
Structures and processes for collaboration that can promote coordinated care, 233–247
health care provider and organization strategies, 234–243
practices of purchasers, quality oversight organizations, and public policy leaders, 243–247
Student loans, 90–91
Substance Abuse and Mental Health Services Administration (SAMHSA) initiatives, 13–14, 17–19, 22–23, 32, 60, 158, 171–172, 177–180, 189–193, 270–274, 291, 358, 374–375, 377–378, 380–381, 383
Alcohol and Drug Services study, 292
Behavioral Health Data Standards Workgroup, 272
Center for Substance Abuse Treatment, 299
Drug Evaluation Network System, 273
EHRs and personal health records, 272
mental health Decision Support 2000+ and statistics improvement program, 270–271
National Treatment Plan Initiative, 87
nationwide summit on behavioral health information management and the NHII, 273–274
Recovery Community Services Program, 115
state data infrastructure grants, 271
substance abuse information system, 272–273
Uniform Reporting System, 272
Substance Abuse Prevention and Treatment (SAPT) Block Grants, 223, 337
Substance-use health care. See also Mental and substance-use health problems and illnesses
discrimination in health insurance coverage of, 89–90
professional training on, 300–303
treatment counseling, 296–297
Systems, integrated, 214
T
Temporary Assistance for Needy Families (TANF), 91, 354
Terminology issues, 86–87, 266
Therapies for children and older adults, knowledge gaps in, 152
Therapies for high-prevalence childhood conditions, gaps in knowledge about, 352–353
Therapies for other population subgroups, gaps in knowledge about, 153, 353
Timely health care, 8, 57, 452–453
To Err Is Human: Building a Safer Health System, 44, 45n
Tolerance for “bad” decisions, 111–114
Traditional Medicaid programs, 342
Transforming Mental Health Care in America , 246
Transition from DoD to VA, 437
Transparency, 9
in policies and practices for assessing decision-making capacity and dangerousness, 123–124
Treatment, failure of, 144–146
Treatment knowledge, 351–355
about effective care delivery, 353–355
about effective treatments, 351–353
gaps in effective, 351–353
about how to improve quality, 355
Treatment of mental health and substance abuse in the VA, 424
administrative organization, 434–435
changes in MH/SA service delivery, 436–437
patients, administration, relationships with other federal agencies, stakeholders, and changes, 432–437
relationships with other federal departments, 435
specialized MH/SA programs, 434
stakeholders, 435–436
VA patients diagnosed with mental health and substance abuse disorders, 432–433
Treatment of multiple conditions, knowledge gaps in, 152
Treatment process, 480
Treatment provider initiative, of NIATx, 194–195
Treatment sites, facilitating structures and processes at, 240–242
U
Unclear accountability, 184–185
for coordination, 231–232
Underused sources of communication and influence, 173–177
Agency for Healthcare Research and Quality, 176–177
Centers for Disease Control and Prevention, 174–176
Uniform Reporting System (URS), 272
Unquiet Mind, An, 112–113
Unsafe care, 147–151
heightened safety concerns and need for multiple actions, 150–151
medication errors, 148–149
seclusion and restraint, 149–150
U.S. Bureau of Justice Statistics, 7
U.S. Food and Drug Administration (FDA), 162, 353
U.S. Government Accountability Office (GAO), 7, 41, 89, 149
U.S. Preventive Services Task Force, 163, 234, 357
U.S. Surgeon General, 32, 290, 391
Use levels
of the Internet and other communication technologies for service delivery, 310–311
of VA mental health services, 431–432
of VA services, 430–431
User Liaison Program (ULP), 176–177
V
VA. See Department of Veterans Affairs
Variations in care, due to a lack of evidence, 143–144
Variations in the workforce treating M/SU conditions, 288–294
in amounts and types of education, 294–297
counseling, 295
general medical/primary care providers, 293–294
insufficient workforce diversity, 290
in licensure and credentialing requirements, 304–305
marriage and family therapy, 296
pastoral counseling, 296
psychiatric nursing, 295
psychiatry, 294
psychology, 294–295
psychosocial rehabilitation, 296
social work, 295
specialty mental health providers, 291–292
specialty substance-use treatment providers, 292–293
substance-use treatment counseling, 296–297
Varied reimbursement and reporting requirements, 278–279
Veterans. See also Mental and substance-use health services for veterans
female, 454
mental health and substance abuse disorders among veterans and nonveterans in the general population, 428–429
mental health and substance abuse status and use of VA services, 427–432
MH/SA status among veteran and nonveteran users of mental health services, 429–430
quality measurement and quality management in the VA, 424–425, 440–446
treated for mental health diagnosis in the VHA, by specialty, 473
use of all VA services, 430–431
use of non-VHA M/SU treatment services, 437–438
use of VA mental health services, 431–432
who used VA services, population characteristics of, 464–467
Veterans Health Administration (VHA), 160, 172–173, 181, 427
administrative organization, 434–435
Quality Enhancement Research Initiative, 173
Violent behavior. See Dangerousness
W
Waste in health care, continuous decrease in, 9, 58
Weakened patient activation and self-determination, 83–84
Wellness Recovery Action Plan (WRAP), 121
Workforce
capacity for quality improvement, 2, 286–324
chronology of well-intentioned but short-lived initiatives, 312–315
critical role and limitations to its effectiveness, 288
greater variation in the workforce treating M/SU conditions, 288–294
inadequate continuing education, 305–308
insufficient diversity of, 290
more solo practice, 309–310
need for a sustained commitment to bring about change, 315–317
problems in professional education and training, 294–304
recommendations for, 20–21, 317–319, 382–383, 386
summary, 286–288
use of the Internet and other communication technologies for service delivery, 310–311
variation in licensure and credentialing requirements, 304–305
Workforce shortages and geographic maldistribution, 289
Workload, 478
of specialized VA mental health programs, 474
Workplace productivity, 39
World Bank, 37
World Health Organization, 37