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

1. Barriers, Strategies, and Solutions to Increasing Quality in the Public Environment November 3, 2005 King Davis, PhD, Executive Director Hogg Foundation for Mental Health Services, Research, Policy & Education Robert Lee Sutherland Chair in Mental Health & Social Policy School of Social Work The University of Texas at Austin Austin, Texas

2. Quality Convergence Challenge: Intersections Conceptualization Payors Providers Values Science Policy Makers Advocates/Consumers Treatment

3. An Expanded View of Health/MH/SA Uninsured Maternal/ Infant Deaths Literacy Nutrition Anxiety Sickle Cell Low Birth Weight Babies Criminal Justice Marital Stress Diabetes Housing & Homelessness Cardiovascular Disease Periodontal Disease Political Office Voting HIV Asset Accumulation Environmental Pollution Alcohol Abuse Cancer Obesity Graduation Rates Low Income Cocaine Use/Sale Mental Retardation Schizophrenia Depression Bipolar Domestic Violence Homicides Personality Disorder Dementia Capital Punishment Unemployment King Davis, 2003

4. Six Cycles of Quality Efforts • Community Based Care – Pre 1750 • Institutionalization – 1763 -2005 • Deinstitutionalization • Community Mental Health • Managed Health Care • Behavioral HealthCare • [Integrated Health Care]

5. Remaining Barriers to Quality • Human Resource Impediments: • Relationship between quality, race, ethnicity, and class: • Political & economic pressure to maintain state hospitals • States Rights – Control of policy at state level: • Budget as Policy: Absence of a business case • Segregated vs. integrated health: • Absence of knowledge management: • Inconsistent ties between Human Rights and quality: • Change by committee – Policy diffusion • Medicine without science - Conceptualization:

6. Conclusions • Public environments are disproportionately for people of color and the poor; quality is low or absent; • Key resistance to transformation is at the state level – prospective impact on costs, control, and jobs are paramount – must involve state governors/legislators • Evidence based approaches must be adapted to include the 4 populations of color; • Cultural competence offers promise but requires national field testing, cost estimation, educational trials, linkages to licensure, accreditation, and further development; • State governors and legislators have not signed off on key reports and recommendations calling for change;

7. Conclusions (continued) • The future is in integrated health approaches • Change requires major alteration in professional schools and licensure – enormous implications • Need a place to house the responsibility for change to quality • Major contradictions in what is proposed, fund, and support – Medicaid and housing cuts • There is no federal or state sense of urgency to change • Must alter the management of knowledge • Transformation may not survive a new administration

8. Major Recommendations • Convene Governors and Legislators re Vision, Change, Cost, Planning, Future - • Nationalize State Mental Health Systems - 5 years – Federal/State Funding – State Hospital Plans • Develop a National/State Policy to Require Behavioral Health in General Hospital/Primary Care Settings – Open Medicaid/Disproportionate Share Policy/Tele-Health • Integrated Health as the National Policy - • National/State Quality Goals & Standards • National/State Workforce & Training Goals • Implementation Strategy for Tracking Quality Data

9. Minor Recommendations • Release Sub-Reports – New Freedom Report • Increase Research Dollars – Causality • Eliminate Medicaid Reductions in Congress • New Training/Education Grants- Universities • Private Sector Involvement in Policy Changes • New Media Portrayals of Behavioral Health • Broader Concept of Health/MH/SA Issues • Publish Data on Effective MH Hospitals • Tie Accreditation to Quality

10. Contact Information • King Davis, Ph.D. • Executive DirectorHogg Foundation for Mental Health • Robert Sutherland Chair in Mental Health Policy • The University of Texas at Austin • Kingdavis@mail.utexas.edu • 512-471-5041