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Evidence Based Framework for Behavioral Health

IOM Recommendations Reflect Importance of Improving Quality of Behavioral Health Services

August 3, 2015 / SAMHSA / Behavioral Health / No Comments

By: Pamela S. Hyde, J.D., Administrator, Substance Abuse and Mental Health Services Administration and Richard G. Frank, Ph.D, Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services

The Institute of Medicine (IOM) released a report on July 14, 2015 that is both timely and critical to current efforts to incorporate evidenced-based interventions into everyday care of people with behavioral health issues.  In its report, Psychosocial Interventions for Mental & Substance Use Disorders, the IOM provides a framework for interventions as well as recommendations to the Department of Health and Human Services (HHS) “to support policy, research, and implementation strategies that promote the use of evidence-based psychosocial interventions.”

Studies indicated that evidence-based psycho-social treatments have been under-utilized and as a result, opportunities are missed to effectively treat people with a range of mental disorders.  In addition, accountability systems for ensuring that the highest impact treatments are deployed have been under-developed.  The IOM report represents a call to action for ensuring that appropriate psychosocial interventions take their place alongside other effective health care treatments.

As the nation’s lead public health agency focused on behavioral health, SAMHSA is pleased to see several of the IOM panel’s recommendations align closely with SAMHSA’s existing efforts.  For example, the IOM recommends developing and continuously updating “a portfolio of measures with which to assess the structure, process, and outcomes of care.”  SAMHSA’s quality team has significant experience in these areas, forming federal partnerships and working with measure stewards such as the National Committee for Quality Assurance (NCQA) as well as with the National Quality Forum, groups that work to validate and incorporate key quality measures into health delivery settings.

The IOM report recommends that “federal, state, and private research funders and payers should establish a coordinated effort to invest in research to develop measures for assessing the structure, process, and outcomes of care…”  This recommendation aligns well with the National Behavioral Health Quality Framework (NBHQF), which SAMHSA first published in 2013 and continues to update regularly.  The NBHQF was modeled on the National Quality Strategy (NQS), and was prepared in direct response to the implementation of the Affordable Care Act.  The NBHQF puts forth recommended core and supplemental behavioral health quality measures for payers, facilities/providers/practitioners, and for communities to assess population health.  As the NBHQF evolves, it is ideally positioned to house, maintain, and update measures with input from stakeholders and federal colleagues.

Since 2011, SAMHSA has worked closely with the Assistant Secretary for Planning and Evaluation (ASPE) and the Administration on Healthcare Research and Quality (AHRQ) and has spent over $2 million toward the development of behavioral health quality measures.  In April 2015 eleven more measures were endorsed by NQF, and three are being considered by HHS’ Centers for Medicare and Medicaid Services (CMS) to be added to the Medicaid Adult Core Set.  The measures being considered are largely focused on people with serious mental illness (SMI) with physical health co-morbidities including metabolic conditions, high blood pressure, and tobacco use.   Other measures are being incorporated into the Demonstration Programs to Improve the Quality of Community Mental Health Services authorized by Section 223 of the Protecting Access to Medicare Act (PAMA) of 2014, currently being implemented by SAMHSA, CMS and ASPE.  As providers move to adopt the measures promulgated through the NBHQF, there is a potential to meaningfully impact on the burden of serious physical health co-morbidities often experienced by individuals with serious mental illness and to improve health, morbidity, and mortality outcomes through more effective health care, including care for mental and substance use disorders.

The IOM report also recommends that HHS “expand and enhance existing efforts to support a coordinated process for conducting systematic reviews of psychosocial interventions and their elements based on the IOM’s recommendations for conducting high-quality systematic reviews.”  To this end, the IOM recommends that greater efforts be made to “disseminate guidelines, implementation tools, and methods for evaluating the impact of guidelines on practice and patient outcomes.”

These efforts and recommendations are timely as HHS is redoubling its efforts to pay for value in healthcare rather than volume.  Under new payment arrangements, it is critically important to have measures of all components of care promoting value, including behavioral health, so new payment systems will be effective and can realize the promises of behavioral health parity.  HHS will incorporate these ideas into plans for its continuing work to promote delivery system reform and improvements in cost, quality and access for our nation’s health system.

Finally, the IOM report recommends “support[ing] the use of health information technology (HIT) for quality measurement and improvement of psychosocial interventions.”  SAMHSA has been proactive in identifying behavioral health information technology (IT) needs and working with federal partners and stakeholders to develop solutions.  Since 2011, HIT has been one of SAMHSA’s strategic initiatives with significant work occurring with the HHS Office of the National Coordinator for HIT (ONC) and other federal partners to develop standards, pilot data segmentation software to allow individuals to manage access to confidential information and improve Prescription Drug Monitoring Program (PDMPs).

Realizing the promise of greater integration of behavioral health with health care that maximizes the benefits of developments in medical science and health care delivery requires making use of the full range of effective treatments in a way that appropriately matches interventions to people and their circumstances.  The IOM’s recommendations offer a plan for using a well-designed program of research to support the development of mechanisms that will hold accountable the rapidly evolving health care delivery system providing a balanced set of effective behavioral health interventions for populations served.  SAMHSA and ASPE look forward to continued work with the National Institute of Mental Health and the National Institutes on Drug Abuse and on Alcohol Abuse and Alcoholism to advance the science of behavioral health and move research findings into practice in the field.

SAMHSA and HHS at large wish to thank the IOM panel for the tremendous time and effort required to put together such a comprehensive report.  The upcoming IOM Implementation panel will be critical to the future direction of these efforts.  SAMHSA and other HHS agencies are prepared to collaborate closely with current partners, along with building strong collaborations with others to ensure the success of this framework and better dissemination and implementation of evidence-based practices.