Barriers, Strategies, and Barriers, Strategies, and Solutions to Increasing Solutions to Increasing Quality in the Public Quality in the Public EnvironmentEnvironment

November 3, 2005November 3, 2005

King Davis, PhD, Executive DirectorKing Davis, PhD, Executive DirectorHogg Foundation for Mental Health Services, Research, Policy Hogg Foundation for Mental Health Services, Research, Policy

& Education& EducationRobert Lee Sutherland Chair in Mental Health & Social PolicyRobert Lee Sutherland Chair in Mental Health & Social Policy

School of Social WorkSchool of Social Work

The University of Texas at AustinThe University of Texas at AustinAustin, TexasAustin, Texas

Quality Convergence Quality Convergence Challenge: IntersectionsChallenge: Intersections

PayorsProviders

Policy Makers Advocates/Consumers

Science

Conceptualization

Treatment

Values

An Expanded View of Health/MH/SA

CardiovascularDisease

Depression

Sickle Cell

Schizophrenia

PeriodontalDisease

Diabetes

HIV

Alcohol Abuse

Cancer Obesity

Bipolar

PersonalityDisorder Dementia

HomicidesDomestic Violence

Unemployment

EnvironmentalPollution

Low BirthWeightBabies

Low Income

AssetAccumulation

VotingPoliticalOffice

Marital StressCriminalJustice

Cocaine Use/Sale

Housing &Homelessness

NutritionLiteracy

Maternal/Infant Deaths

MentalRetardation

Uninsured

GraduationRates

Anxiety

CapitalPunishment

King Davis, 2003

Six Cycles of Quality Six Cycles of Quality EffortsEfforts

Community Based Care – Pre 1750Community Based Care – Pre 1750 Institutionalization – 1763 -2005Institutionalization – 1763 -2005 Deinstitutionalization Deinstitutionalization Community Mental HealthCommunity Mental Health Managed Health CareManaged Health Care Behavioral HealthCareBehavioral HealthCare [[Integrated Health CareIntegrated Health Care]]

Remaining Barriers to Remaining Barriers to QualityQuality

Human Resource Impediments: Human Resource Impediments: Relationship between quality, race, ethnicity, Relationship between quality, race, ethnicity,

and class:and class: Political & economic pressure to maintain state Political & economic pressure to maintain state

hospitalshospitals States Rights – Control of policy at state level:States Rights – Control of policy at state level: Budget as Policy: Absence of a business caseBudget as Policy: Absence of a business case Segregated vs. integrated health:Segregated vs. integrated health: Absence of knowledge management:Absence of knowledge management: Inconsistent ties between Human Rights and Inconsistent ties between Human Rights and

quality:quality: Change by committee – Policy diffusionChange by committee – Policy diffusion Medicine without science - Conceptualization:Medicine without science - Conceptualization:

ConclusionsConclusions Public environments are disproportionately for Public environments are disproportionately for

people of color and the poor; quality is low or people of color and the poor; quality is low or absent;absent;

Key resistance to transformation is at the state Key resistance to transformation is at the state level – prospective impact on costs, control, and level – prospective impact on costs, control, and jobs are paramount – must involve state jobs are paramount – must involve state governors/legislatorsgovernors/legislators

Evidence based approaches must be adapted to Evidence based approaches must be adapted to include the 4 populations of color;include the 4 populations of color;

Cultural competence offers promise but requires Cultural competence offers promise but requires national field testing, cost estimation, national field testing, cost estimation, educational trials, linkages to licensure, educational trials, linkages to licensure, accreditation, and further development;accreditation, and further development;

State governors and legislators have not signed State governors and legislators have not signed off on key reports and recommendations calling off on key reports and recommendations calling for change;for change;

Conclusions (continued)Conclusions (continued) The future is in integrated health approachesThe future is in integrated health approaches Change requires major alteration in Change requires major alteration in

professional schools and licensure – enormous professional schools and licensure – enormous implicationsimplications

Need a place to house the responsibility for Need a place to house the responsibility for change to quality change to quality

Major contradictions in what is proposed, Major contradictions in what is proposed, fund, and support – Medicaid and housing cutsfund, and support – Medicaid and housing cuts

There is no federal or state sense of urgency to There is no federal or state sense of urgency to changechange

Must alter the management of knowledgeMust alter the management of knowledge Transformation may not survive a new Transformation may not survive a new

administrationadministration

Major Major RecommendationsRecommendations

Convene Governors and Legislators re Vision, Convene Governors and Legislators re Vision, Change, Cost, Planning, Future -Change, Cost, Planning, Future -

Nationalize State Mental Health Systems - 5 Nationalize State Mental Health Systems - 5 years – Federal/State Funding – State Hospital years – Federal/State Funding – State Hospital PlansPlans

Develop a National/State Policy to Require Develop a National/State Policy to Require Behavioral Health in General Hospital/Primary Behavioral Health in General Hospital/Primary Care Settings – Open Care Settings – Open Medicaid/Disproportionate Share Policy/Tele-Medicaid/Disproportionate Share Policy/Tele-HealthHealth

Integrated Health as the National Policy -Integrated Health as the National Policy - National/State Quality Goals & Standards National/State Quality Goals & Standards National/State Workforce & Training GoalsNational/State Workforce & Training Goals Implementation Strategy for Tracking Quality Implementation Strategy for Tracking Quality

DataData

Minor RecommendationsMinor Recommendations Release Sub-Reports – New Freedom ReportRelease Sub-Reports – New Freedom Report Increase Research Dollars – CausalityIncrease Research Dollars – Causality Eliminate Medicaid Reductions in CongressEliminate Medicaid Reductions in Congress New Training/Education Grants- UniversitiesNew Training/Education Grants- Universities Private Sector Involvement in Policy ChangesPrivate Sector Involvement in Policy Changes New Media Portrayals of Behavioral HealthNew Media Portrayals of Behavioral Health Broader Concept of Health/MH/SA IssuesBroader Concept of Health/MH/SA Issues Publish Data on Effective MH HospitalsPublish Data on Effective MH Hospitals Tie Accreditation to QualityTie Accreditation to Quality

Contact InformationContact Information

King Davis, Ph.D.King Davis, Ph.D. Executive DirectorExecutive Director

Hogg Foundation for Mental HealthHogg Foundation for Mental Health Robert Sutherland Chair in Mental Health Robert Sutherland Chair in Mental Health

PolicyPolicy The University of Texas at AustinThe University of Texas at Austin Kingdavis@mail.utexas.eduKingdavis@mail.utexas.edu 512-471-5041512-471-5041