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The Mental Health Quality Forum: An Ecosystem Approach to Quality

J Clin Psychiatry Monograph 2014;20[1]:3–20

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A multidisciplinary panel met twice to identify key issues and opportunities in the management of serious mental illness (schizophrenia, bipolar depression, and major depressive disorder). Panelists worked in small groups set up to simulate mental health “ecosystems,” designed to mimic the inherent tension among stakeholders in real-world mental health care. The meetings were convened by Otsuka America Pharmaceutical, Inc., with the goals of identifying barriers to quality care, designing a blueprint for pilot initiatives for change, and presenting the findings to organizations that can work toward that change.


This monograph summarizes the panelists’ findings and sets the stage for further work toward quality improvement in the care of serious mental illness.


The Mental Health Quality Forum: An Ecosystem Approach to Quality—Part 1: Identifying the Barriers to Quality

The Mental Health Quality Forum was a 2-meeting multidisciplinary panel focused on issues and opportunities in the management of serious mental illness (defined as schizophrenia, bipolar depression, and major depressive disorder). Participants included psychiatric nurses, managed care administrators, a specialty pharmacy provider, a community mental health center director, psychiatrists, a noted health services researcher in mental health, an American Psychiatric Association employer representative, a quality director, and executives from 2 leading mental health advocacy groups. In the initial meeting, panelists worked in small groups designed to simulate mental health “ecosystems,” intended to mimic the inherent tension that often exists between various stakeholders in real-world mental health care. During the course of the meeting, panelists shared their experiences working in mental health to help frame key issues, identified key structures and processes related to quality care for patients diagnosed with serious mental illness, and identified and prioritized key facilitators and barriers related to the delivery of quality care. High-priority issues included needed improvements in the following components of care: care integration, infrastructure/enabling technology, tools to facilitate accountability, quality/performance measures, early screening and intervention best practices, enabling financing structures, consistency in diagnosis between providers, and access to appropriate care. Participants strategically identified methods to resolve these issues and emphasized that the initial focus should be on relatively simple structures and processes (eg, pilot projects) that would be manageable and provide measurable results in the short term. In the long term, the pilot project examples may be used to advocate for larger changes in payment structures, care integration, and societal issues. (J Clin Psychiatry Monograph 2014;20[1]:3–11)

The Mental Health Quality Forum: An Ecosystem Approach to Quality—Part 2: Guiding Development of Pilot Projects to Drive Quality Improvement

The Mental Health Quality Forum, a 2-meeting multidisciplinary panel, focused on issues and opportunities in the management of serious mental illness (SMI). Participants met in small groups designed as mental health “ecosystems” that represented a variety of stakeholders in real-world mental health care. The task of the second meeting was to create a blueprint for pilot initiatives that would effect change in SMI management. The panelists identified 3 areas as key to pilot design: (1) care coordination, (2) quality measures, and (3) enabling financial structures to provide incentives. Participants emphasized that care coordination should include all care providers (including nontraditional and primary care providers) and evaluate each provider’s contribution to care, with determination of treatment overlap and gaps. An expanded, centralized care manager role could be implemented; this person would have broad knowledge of general health care and SMI, as well as traditional case manager connections (to housing, employment, benefits, etc). Panelists discussed several factors that will influence quality measures in SMI, including access to care, clinical processes, patient satisfaction, functional status, and patient engagement, and the measures will impact many stakeholders, including health care professionals, hospitals, network/accountable care organization/plans, and patients and caregivers. Both negative metrics (measures of poor care) and positive metrics (measures of good-quality care) were suggested. Payment for care coordination is currently not widespread, and incentives must support the improvement of overall health. Outcomes that could be tied to incentives include those resulting in cost savings (eg, fewer admissions) and in improved overall health. Participants noted that incentives must include payment for ancillary services (eg, education, training) and payment to non–health care providers (eg, jails, child welfare, housing). Further, providers and payers must be held accountable to the incentives. Considerations in payment redesign include coding for services, differences among states, data acquisition, and utilization. For many individuals with SMI diagnoses, care is currently managed primarily by providers within the mental health system, rather than by primary care providers, yet physical health expenditures are very high in this population. (J Clin Psychiatry Monograph 2014;20[1]:12–20)