At this point in the evolution of the mental health treatment system, I was surprised to read this headline-Less Than A Third Of People With Serious Behavioral Disorder Receive Evidence-Based Treatment. In a recent report to congress, the federal Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC) reported that although effective evidence-based treatment practices (EBPs) exist, they are not widely in use.
In 2016, of the 10 million adults in the United States who were living with serious mental illness (SMI), only 32% received medication management and only 19% received support for illness self-management. Of the seven million children and youth who experienced a serious emotional disturbance (SED) less than 5% received multi-systemic therapy or therapeutic foster care, and about 7% received functional family therapy.
To me, the disconnect is that we now have about 90% of the population insured, and we have behavioral health parity in commercial, marketplace, and Medicaid managed care plans. So why the poor system performance? To answer that question, I turned to my colleagues at OPEN MINDS. As you can imagine, the reason for the poor mental health system performance is complex and various. From our team’s perspective, there appear to be five key drivers.
Provider organizations don’t typically mandate the use of decision support tools-and leave consumer treatment offerings up to individual clinical professionals
Consumer treatment plans most often come down to decisions being made by individual clinical professionals. Often EBPs are not included as part of a clinical professional’s initial education and training and there is a lack of continuing education around EBPs for front-line staff (see Disseminating Evidence-Based Mental Health Practices and Barriers and Bridges to Evidence Based Clinical Practice). This, coupled with the scarcity of decision support tools, leaves them to make treatment decisions without considering the available EBPs.
OPEN MINDS Senior Associate and former chief executive officer of a community mental health center, Bob Dunbar, explained that when his organization was implementing EBPs, some of the most important steps were related to staffing:
Key to successful implementation was employment of EBP trainers responsible for educating staff about EBPs and team leaders about how to supervise, evaluate, and coach their staff on EBPs. Neither bachelor, or graduate level direct service staff received education on EBPs while in school. Also important was employment of staff willing to learn EBPs and, to an extent, loss of staff who just could not change or adapt long standing clinical practices to EBPs, such as assertive community treatment.
Provider organization teams don’t feel a sense of “ownership” for individual consumer outcomes-unless they are in “medical home” type of arrangements
In a “siloed” system, there isn’t a lot of incentive for individual clinical professionals or provider organization managers to focus on individual consumer costs and outcomes. As we move towards a more integrated, value-based financing system, programs and practices that are proven to improve outcomes and lower costs will be more appealing to payers. And the performance expectations of value-based purchasing arrangements will likely be demand that more provider organizations invest in standardized treatment protocols. OPEN MINDS Senior Associate and former health plan executive Darryl Donlin noted:
Health plans have concerns that these EBPs should be occurring already and some are conflicted about having to fund their start up or incentivize their use. A savvy provider organization will embrace the use of EBPs, show evidence of it, and take their outcomes to a health plan to get higher reimbursements or preferred network status.
There is lack of management knowledge among provider organization executives about how to bring EBPs to scale-and how to fund that development
Developing an EBP structure requires an initial investment to design the program, train and hire new staff, and build an operational structure to document and measure the program’s outcomes. OPEN MINDS Senior Associate Annie Medina and former hospital chief operating officer noted that many provider organizations do not have the operational infrastructure they need to support the use of EBPs:
If physical health care is behind when it comes to technology, behavioral health still hasn’t invented the wheel. Because meaningful use didn’t apply in the same way to behavioral health, there are still facilities using paper. It’s impossible to offer up-to-date best practice information when provider organization managers can’t even find out what was done at the last visit. We know that the adoption of best practices in the field is only a few years shy of two decades. New technologies should shorten that timeframe—but if the field doesn’t even have the basic tech, they definitely can’t make the shift to EBPs effectively.
OPEN MINDS Senior Associate, and former mental health center chief executive officer, George Braunstein went on to explain that even if provider organizations do use some elements of EBPs, they have been unable to meet all the documentation and training requirements to have a fully implemented EBP model:
Many provider organizations have partially implemented some of the well-known EBP approaches. So they may have successful service delivery practices, but do not fully document and measure the impact. These organizations could fully develop these EBPs with some additional assistance to find an efficient way to implement the missing elements such as training and designing efficient workflows.
Health plans don’t always pay for all service elements in EBPs
Funding for this investment can be difficult to obtain. EBPs require some program elements to make them successful, that may not be reimbursable under a fee-for-service (FFS) model. As OPEN MINDS Senior Associate and formed health plan executive Darryl Donlin pointed out:
Health plans will only pay for licensed clinicians and not for “clinical extenders” or paraprofessional, which have proven to be very effective; however due to the benefit plan designs health plans must abide by, they cannot use them. There are ways around this through creative bundle payments. This is a real opportunity—designing VBR arrangements based on EBPs.
Stigma affects the use of EBPs in two different ways. First, there is the inherent stigma that we see associated with mental illness, which prevents many consumers from accessing the services that they need. This is particularly true in systems without strong integration and care coordination. Ms. Medina explained:
Part of the reason there is such a gap in the use of EBPs has to do with the history of mental illness. We’re quick to demonize it, and often treat it as something to be controlled instead of treated. Stigma is a commonly cited reason as to why people don’t seek care, or feel like they’re not getting adequate care – and this includes stigma from health care professionals. You can’t treat who you don’t see. We fear what we don’t know, we have trouble knowing what we can’t see, and mental illness is primarily unseeable.
Second, among many clinical professionals working in the mental health field, there is an associated stigma with using EBPs. There are many real and perceived barriers to using EBPs—a belief that evidence-based practices are bad for the therapeutic relationship; that they are too structured and technique focused; and that they don’t actually lead to better outcomes. It is the job of executive teams of provider organizations to develop training and education programs to overcome these biases and build a culture that focuses on EBP as the model of care. Like any organizational culture change, it is important to get “buy-in” from your team and to consistently support the use of EBP as part of your strategy to improve care for consumers. As Mr. Braunstein noted:
Using EBPs as standard operating procedure for services requires a cultural change within the organization. Many organizations know they need to change, but will need to make it a priority as part of more robust strategic plan that does not build on existing practices. The tools are available, organizations need to have the will to make those changes and focus on the necessary follow-up to assist with implementing those changes.
How do we solve this problem? A complex set of problems requires a complex set of solutions, and those solutions at the service delivery level need to be focused on changing clinical practices and organizational culture.
Looking to incorporate evidence-based practices as part of a new service line? Join OPEN MINDS Senior Associate, Joseph P. Naughton-Travers on June 6 for his session, Are You Developing A New Service Line? A Round Table Discussion on Service Line Development, at The 2018 OPEN MINDS Strategy & Innovation Institute.