Best Practices in Mental Health Reform: Discussion Paper

• Return to Table of Contents
• Previous Section
• Next section

7. Best Practices that Achieve Integration and Accountability

7.1 Core Services and Supports

Among the core services and supports within a reformed system of care, case management and assertive community treatment (see Chapter 1, Literature Review, ANMH) have the most relevance to the creation of an integrated system of care. In these models of care delivery, accountability is clearly established at a local level, and continuity of care and access to comprehensive services are given priority. Assertive community treatment is the most comprehensive approach, combining in one team the elements of crisis intervention, treatment and individual support. It also has demonstrated economic effectiveness by reducing use of expensive inpatient hospitalization.

In response to criticisms about being too coercive and neglecting rehabilitation needs, the ACT model has undergone thoughtful analysis (Diamond, 1995) and has evolved, e.g., by adding supplemental vocational interventions (Chandler et al., 1996). Psychosocial rehabilitation and assertive community treatment should not be viewed as incompatible alternatives. Still, assertive community treatment is a relatively intensive intervention that is appropriate only for those who are at high risk and are unable to benefit from less costly services and supports. Clinical case management approaches can serve clients with less severe problems. With the move to supported housing, employment and education there is great potential to reduce the proliferation of separate agencies dealing with only one aspect of a consumer's needs. They can be replaced with multi-faceted individual support programs which have the capacity to assist with living, learning and working needs.

7.2 System Level Strategies

The system strategies that are critical for integration and accountability are governance, funding and evaluation (see Chapters 9 and 10, Literature Review, ANMH).

Mental Health Authorities

Mental health authorities, which create single envelope funding and are responsible for administrative, clinical and fiscal aspects of care delivery for a designated geographic area, perform many of the functions needed in an integrated mental health system. They play a major role in defining the target population and implementing gatekeeping procedures. Accountability for system performance is decentralized to a level where there is greater knowledge about local conditions. Responsibility for ensuring delivery of comprehensive services and maximizing economic efficiency is given to the authority which can use multiple tools (including training, management information systems, etc.) to achieve its goals (Hoge et al., 1994).

The coordination roles of clinical case management approaches (at an individual level) and mental health authorities (at a systems level) can extend beyond the formal mental health sector. A number of best practice programs demonstrated the feasibility and benefit of partnerships with other service sectors such as housing, social services and private employers. The strategies and tools that would be used to create incentives and partnerships are somewhat different but are more likely to be implemented if authorities and case management programs provide a unified presence that can advocate for and create these opportunities.

Fiscal Strategies

A number of fiscal levers and incentives can be used to promote cost containment, transfer resources from institutional to community care, encourage the implementation of best practices, and increase accountability. Prospective payment ³ , capitation ⁴ and performance contracts ⁵ all have the potential to contribute to more integrated care delivery if they are used appropriately (see Chapter 9, Literature Review). Few of these innovations were nominated as best practices in Canada but they were the focus of a recent policy workshop aimed at increasing knowledge of alternative fiscal strategies. Mental health economists from the UK (Martin Knapp) and the US (Richard Frank) were asked to discuss experiments in their respective countries. Workshop participants from across Canada discussed the applicability of these experiences to our context. (Clarke Institute of Psychiatry, 1997).

One of the lessons learned from system change in other countries has been the importance of defining and protecting the budgets that are allocated for persons with severe mental illness. For example, in England the establishment of various new forms of commissioning and funding have created a "leakage" of resources that were formerly available for the severely mentally ill population. There has been a gap between "priority rhetoric" and "priority reality". A study comparing the plans of local purchasers with their actual implementation showed that mental health was often a top priority in the plans, but got bumped to lower priorities in the allocation of money (Knapp, 1997). The government is now considering methods of separating and "ring fencing" mental health budgets under new authorities that would have responsibility for health/mental health and social services (United Kingdom Green Paper, 1997).

In the US there are a number of situations where the separation of community and institutional care budgets has retarded the shift to community-based care and the implementation of best practice innovations. Dr. Frank summarized these issues with the statement "Fragmented financing results in distorted and fragmented care (Frank, 1997). Giving an authority control over a consolidated funding envelope begins to remedy this problem, in part by discouraging cost shifting and by localizing, within one body, the full consequences of decision making.

The introduction of competition among provider agencies as a fiscal mechanism to improve quality and efficiency has had generally disappointing results in the US and UK. Frank (1997) points out that few places seem able to meet the requirements for meaningful quality competition. The following were identified as necessary in order to best meet these requirements:

• information available to consumers so that they can make informed choices.
• a reliable way of determining which service is better than another.
• information that spans the various dimensions of quality.
• a feasible set (at least 3 or 4) of alternative providers who can also deliver the service, in order to have choice.

There also are potential problems when competition is set up using fixed budgets or capitation payments because enormous incentives are created to reduce access for the most severely ill people. Encouraging competition can also interfere with collaboration and information sharing among agencies that need to work together in order to achieve systems of care. The introduction of competition at a higher level, i.e. among those who are running regional systems of care, appears to have had more success when a particular set of conditions have been in place (Frank, 1997).

Incentive grants and contracts can be valuable means of changing systems. In the UK the Mental Health Challenge Fund and Mental Illness Specific Grant have been effective mechanisms to encourage health and social services to improve services (United Kingdom Green Paper, 1997). In Ohio, Local Mental Health Boards were paid bonuses for serving the seriously mentally ill and were made fiscally responsible for public mental health hospital use. These fiscal mechanisms had dramatic positive effects in a short period of time (Frank, 1997; also see Literature Review, Chapter 9, ANMH; Frank and Goldman, 1989).

When considering the adoption of similar approaches in Canada, it needs to be recognized that there are administrative costs associated with the establishment of incentives and contracts. While this is not an inherent disadvantage, the critical question is whether the increased administrative costs are balanced by greater quality and efficiency in the delivery of services and supports. The costs of monitoring contracts can be reduced when obligational rather than adversarial climates are developed. It is also essential that the effects of fiscal incentives be monitored. Several examples were given of unintended negative consequences that prompted revisions in how these fiscal mechanisms were used. Cautions were also raised by both mental health economists about tying funding to program outcomes. This practice is hampered by the difficulties in defining and measuring mental health outcomes. Furthermore, it can create the same problems with selection bias as does competition.

Recommendation 2 Each region should develop strong mechanisms (e.g. assertive community treatment teams and a Mental Health Authority) for service integration with clearly designated responsibility for all aspects of care and sufficient influence to bring together the four solitudes, i.e. Community Mental Health Programs, provincial psychiatric hospitals, general hospitals and consumer and family initiatives.

Recommendation 3 The creation and protection of a separate, single funding envelope that combines various funding streams for the delivery of mental health care is an essential component of system reform. Greater use of incentive contracts and grants as levers for change is warranted.

Performance Indicators

As central government decentralises responsibilities to regional administrative bodies, there is a need to develop more explicit frameworks for accountability so that some measure of control can be exerted to build and maintain integrated systems of care across regions. This requires the development of performance indicators that spell out the form, quantity and quality of inputs, outputs and outcomes that are expected. Performance indicators are operationally defined, indirect measures of selected aspects of a system that give an indication of how well it conforms with its intended purpose (Glover and Kamis-Gould, 1996). A checklist of best practices is an important first step to developing a consensus about standards and criteria for measuring system performance. But it is not a report card, i.e. it does not spell out how to measure and compare functioning. The setting of explicit goals and indicators is a prerequisite for systems change and for evaluation, and should be tackled within each province or region.

A recent UK report by Huxley and Hughes (1997) provides valuable definitions and guidelines for such activity. They emphasize that the selection of appropriate indicators and benchmarks is only one step of a process that must include understanding existing procedures and creating links between benchmarking, continuous improvement and evaluation. As there are many problems associated with the definition of performance indicators for mental health, it is critical that the process of planning and implementation not be imposed from above, but instead be viewed as a dynamic and iterative process that involves selection, monitoring and refinement of indicators. To build an integrated system of care, provinces should take a lead role in the development of accountability frameworks. The use of round tables which routinely solicit input from regions and major stakeholder groups may be a useful tool to address this task. Although responsibility for monitoring program performance may be delegated to regional bodies, a high degree of uniformity regarding expectations and indicators will be required. As discussed in Chapter 10, Literature Review (ANMH), good system wide evaluation also depends upon the existence of a valid, reliable information database that is client linked, rather than based upon episodes of care.

The desirable features of performance indicators for mental health defined by Glover and Kamis-Gould (1996) are listed in Table 2. Access, delivery and outcome indicators need to be defined for each level of mental health care (i.e. individual, program, region and population), and should reflect the thinking of multiple stakeholders, including consumers and families. Huxley and Hughes (1997) provide examples of the types of benchmarks that might be used for each of 12 cells in a Benchmarks Applied to Behavioural Health and Social Care (BABS) Matrix. Forth and Nasir (1996) compile examples of outcome indicators that have been used at each level of care ⁶ . The checklist of best practices (Tables 1A, 1B) provides a basis for defining the set of service delivery indicators. For example the ratio of intensive case managers per 100,000 population can be used as one indicator of the implementation of assertive community treatment. Comparisons with progressive jurisdictions can be used to establish benchmark levels.

It would be worthwhile to explore whether agreement could be reached across provinces and territories about some performance indicators and benchmarks. Could we agree that there should be targets for the balance of funding between institutional and community services ⁷ , and also what those ratios should be? Can we achieve common ways of defining and assessing consumer and family involvement in governing services?  Would the widespread utilization of a national system of accreditation for community programs be a means of assuring quality?⁸ These are worthwhile objectives but should not supersede or interfere with individual provincial/territorial efforts to establish targets and benchmarks within an ongoing accountability framework. 

Recommendation 4 The setting of explicit, operational goals and performance indicators within each province/territory is a prerequisite for systems change and for evaluation. The possibility of achieving a national consensus about selected issues should be explored.

Endnotes

3. Prospective payment is a fiscal strategy that puts the client at the centre of the funding policy. The level of payment per client is predetermined based on illness characteristics and needs of the client and is independent of the actual cost of providing services. Prospective payment is aimed at cost containment and uses rewards and risk to encourage efficiency. (Back to text)

4. Capitation is a needs-based form of prospective payment wherein providers receive a preset fee per enrolled client in exchange for delivery of a defined range of services in a specified period of time. Because the fee remains fixed regardless of the client's level of use of services, the provider assumes risk and responsibility for costs exceeding the capitated amount. (Back to text)

5. Performance (incentive) contracts link funding to program and system performance. Payments are tied to aggregate measures of program performance to promote goals such as improved quality, contained costs, new service developments and increased care for previously neglected populations.  (Back to text)

6. Other valuable materials on performance domains and indicators include the Framework for Planning and Evaluation of Community-Based Health Services in Canada (Wanke, Saunders, Pong and Church, 1995) and Standards for Comprehensive Health Services (Canadian Council on Health Services Accreditation, 1996). (Back to text)

7. Policy makers should take into account differences regarding what is included in the envelope.
(Back to text)

8. Standards for Comprehensive Health Services (Canadian Council on Health Services Accreditation, 1996 draft)  to text