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By Robin Jay, BHC Editorial Director

“Fragmented” well describes the healthcare delivery system in the United States, because there isn’t a single national entity or set of policies guiding the healthcare system at the national, state, community, or practice levels. Furthermore, multiple agencies divide state responsibilities, and providers caring for the same patients in a community often don’t work together. As healthcare reform approaches, many experts believe that stakeholders must use the opportunity to restructure chronic care, including substance use disorders. Providers agree that chronic disease contributes considerably to the cost of healthcare and is a significant challenge for those wanting to deliver high-quality, cost-efficient care. The Institute of Medicine reports that mental illness and substance dependence problems are the leading cause of combined disability and death among women, and the second-highest among men.

Overcoming the challenges and costs associated with chronic care will involve the dissemination and implementation of standards promoting a continuum of comprehensive services linked among various agencies, including mental and medical healthcare agencies and treatment providers. A major step forward toward reaching this goal was recently achieved. The Treatment Research Institute (TRI) hosted representatives from 25 states, accrediting bodies and federal agencies at a workshop to discuss the implementation of treatment standards recommended by the National Quality Forum (NQF) — a Congressional charter to work with researchers, academics, policy makers and providers in the drug, alcohol and related fields.

The standards embrace the concept that substance abuse disorders are chronic conditions that can be successfully treated with a continuum of comprehensive services linked between and among various agencies, including mental and medical healthcare agencies and treatment providers. These key stakeholders have supported the continuum of care, cross-agency model for the delivery of substance-abuse treatment ever since the NQF published them in 2007, but retooling a publicly-funded delivery system that’s not geared to this model has been a difficult roadblock to hurdle on the way toward widespread dissemination and restructuring.

During the workshop, which addressed adoption of the NQF standards in state-funded treatment systems, implementation of small-scale pilot programs were presented by representatives of five states. Participants also discussed solutions to overcome barriers in order for states to incorporate the standards. Through a grant from the Open Society Institute, Dr.Mady Chalk, Ph.D., and Richard Rawson, Ph.D., of UCLA are leading a national dissemination/implementation project for the NQF standards.

“With help and technical assistance, state policy makers are ready to begin incorporating the NQF Standards,” says Dr. Chalk of TRI. “When 25 states are represented at an implementation meeting, and seven more are interested and request project materials but are unable to physically attend, it tells me the states are ready to take essential steps toward systems of care that cover the entire treatment continuum, including linkages to other agencies, particularly when the national economy makes this time ripe for lower-cost infrastructure-building.

“Most people did not and do not know what NQF is, that it is chartered by the government, and that once it endorses standards and measures, they have very special legal standards. States needed to understand that. NQF-endorsed standards are considered the gold standard for measurement of healthcare quality, and they are intended to be used by federal and state government and private purchasers for quality improvement and reporting. So it becomes terribly important because states should be using these. These are standards that are intended to applied in all settings.”

Public and private purchasers of care need to be aware that these standards of care should be included in their purchasing agreements. Providers of care need to be equally aware that there are expectations attached to the care they deliver and consumers need to be aware of what they should expect from both purchasers and providers.

“I fully expect that there’s going to be a lot of interaction among providers trying to work with these standards, because they cut across healthcare and specialty care, which is not easy to begin with. Most treatment providers in this country don’t have relationships with the healthcare sector — with primary care — and that’s part of this effort, that’s part of the standards,” says Dr. Chalk. “This may be surprising, but most states do not use standardized tools to do assessment. I was looking at data today actually, and only 20 percent of treatment programs as of 2007 were using medications, yet two of the NQF measures directly talk about use of medications for alcohol, opiates and cigarettes. This is not going to be a simple process.

“What is tremendously important about it is that these standards set the stage. With the introduction of these standards, we have a conceptual framework that has principles and practices that are broken down into domains that are defined; that can be used. The response to the dissemination effort subsequent to the workshop has been huge — it’s been huge. People are going to the website; people are asking us if we could please have a meeting to adapt these for adolescents, could we please have a meeting to adapt these for treatment criminal offenders, and we may be able to do some of that. States are talking about using these as they restructure and reform their systems, as they face the huge budget cuts. And to have standards that they can say, ‘Okay, let me look at my treatment system. Now, how am I going to help my provider move toward these kind of standards, be able to implement these kinds of standards, and what are the implications of that for buyers who need to look what kind of organization they have to be?’”

These are some basic principles of the NQF standards discussed at the workshop:

• Treatment of substance use disorders involves a continuum of care and a long-term perspective based on a chronic care model for individuals who are more severely ill
• Although access and availability are significant factors in delivery, in addition the standards are based on the six aims for high-quality treatment identified in the IOM report, “Crossing the Quality Chasm” (2001)
• Treatment of severe substance use disorders requires comprehensive services with multiple
• interventions
• Treatment should be coordinated with general and mental healthcare settings (as appropriate)
• Treatment should incorporate the NIDA Principles of Addiction Treatment and the approach identified in the NIAAA clinician’s guide

NQF Domains:

• Identification of Substance Use Disorder, including screening/case finding and diagnosis and assessment
• Initiation and Engagement in Treatment, including brief interventions, support for engagement in treatment by healthcare professionals as well as specialty clinicians, and withdrawal management
• Therapeutic Interventions to Treat Substance Use Conditions, including psychosocial
• interventions and pharmacotherapy (e.g., interventions identified in the National Repository of Evidence-based and Promising Practices [NREPP])
• Continuing Care Management, including extended monitoring and regular contact with a treatment professional (whether in person or by telephone), risk assessment, and recovery management support.

What can providers, facilities and other behavioral healthcare stakeholders do to help states move forward toward implementation of NQF Standards? “We are continuing our activities to help states identify how they will adapt these standards. Last week, we sent out a questionnaire to all the participating states, asking them what they are going to do with the next step. We will then use that to formulate some assistance. We can do it beginning in January of 2010. In addition, we would hope that states would then begin talking with us about how they can work with their providers. The whole issue of how treatment providers can be assisted to work on implementation of these standards, as well as function under healthcare reform — which includes parity and new treatment benefits in the healthcare reform packages that are in legislation now — is a large project, much larger than this dissemination effort. There are several of us, TRI and several other organizations, talking about what needs to happen to be able to assists providers to be able to function.”

Funding permitting, the next steps involve getting more help to states, possibly through peer-led learning communities based on common approaches to adapting, disseminating or piloting NQF standards. A webinar and webcast will be developed for members of such major national associations as ASAM, State Associations of Addiction Services (SAAS), the National Council for Community Behavioral Health Care and others. Developing evaluation models that measure outcomes from NQF-related pilots is also a priority, according to Chalk.

For an NQF summary of standards, visit www.tresearch.org. The following is a complete transcript of our interview with Dr. Mady Chalk:

BHC: Dr. Chalk, for those who may be listening to this who are not familiar with the NQF, give a brief overview about what it is and why the treatment standards were developed in the first place, especially if they were identified way back in ’05.

MC: Well, they were identified but then they have to go through a year-long process of developing them from the workshop, from the information gathered in the workshop, which includes asking the entire field to submit ideas for standards and measures. And each process takes a good year. That’s why they weren’t published until 2007.

But the reason they were needed was to improve the effectiveness, efficiency and cost-effectiveness of treatment by assuring consistent implementation of proven administrative, organizational and, ultimately, clinical practices. The NQF is a nonprofit membership organization chartered by the government, which first began under President Clinton. [It was] created to implement a national strategy for healthcare quality measurement and reporting. So when you go to their website, you end up seeing all kinds of conditions. You’ll see cardiac conditions; you’ll see issues related to diabetes and all kinds of other disorders, cancer and, ultimately, substance-use disorders are included of health.

BHC: So what was the impetus that got the representatives from 25 states to the workshop in September?

MC: The impetus was that the regulations indeed had not been disseminated widely and that the Robert Wood Johnson Foundation and Center for Substance Abuse Treatment — which originally funded the NQF effort — decided that they wanted them disseminated. And so, they funded TRI to move toward widespread dissemination.

BHC: So then they convened there in Pennsylvania?

MC: TRI invited state directors. We did a number of dissemination activities. The culmination was September, but in May of this year, TRI met with the executive directors and the board chairs for all of the major national associations and did a dissemination activity with them. Subsequently, we invited all state directors.

Originally we were going to have two meetings, one on the east coast and one on the west coast, and had asked UCLA to collaborate with us in that effort. However, most states responded to the east coast meeting. Maybe it was timing — I don’t know what the reasons were — so we ended up consolidating everything into one meeting in September, and we invited state directors and we invited the accrediting bodies, whom we had met with individually. All the national accrediting bodies — there are about five that accredit substance use treatment programs. And we are very concerned that their accrediting standards and measures work with the national quality form standards.

BHC: And so, one of the things that took place at this workshop was that some of the states presented on small-scale, pilot implementations?

MC: First of all, most people did not and do not know what NQF is — that it is chartered and that once it endorses standards and measures, they have very special legal standards. And the states needed to understand that. NQF-endorsed standards are considered the gold standard for measurement of healthcare quality and they are intended to be used by federal and state government and private purchasers for quality improvement and reporting.

So it becomes terribly important because states should be using these as they begin to purchase [and] continue to purchase care. And the federal government may begin using these — as far as I know, Medicare could use them; Medicaid could use them. These are standards that are intended to applied in all settings.

BHC: Once states come on board and understand that they need to comply with these NQF standards, are the major providers and payers on board with what those standards are and how to enforce them?

MC: Well that’s the next step. You asked whether any state had adopted them. All are piloting them. There are many treatment providers and programs that are piloting individual standards that are among the eleven that the NQF defined. However, what the NQF said quite specifically … is that these need to be adopted in whole, not piecemeal. Not ‘one or another,’ because they are supposed to support a system that covers the full continuum of care. One state has made the effort to adopt them at the state level for state use ultimately.

This is going to be quite a process. This is not something that’s going to happen overnight. So they adopted them and then the next step was the question you just asked. Their next step has been to put out the standards on their website and invite comment by all appropriate stakeholders. And that means the counties.

The state is California. It was the state of California that had the foresight to go ahead and adopt the standards because the report tells states and large purchasers how to adopt them. They’ve put them out and they continue to be out for comment by stakeholders. And in California, the counties are the major purchasers of care, as opposed to the state. And so they will get to comment, as will the providers.

Now, I fully expect that there are going to be a lot of discussions among providers trying to work with these standards, because they cut across healthcare and specialty care, which is not easy to begin with. Most treatment providers in this country don’t have relationships with the healthcare sector — with primary care — and that’s part of this effort. That’s part of the standards.

This may be surprising, but most states do not use standardized tools to do assessment. And as I was looking at things (at data today, actually), only 20 percent of treatment programs as of 2007 were using medications. And two of the measures directly talk about use of medications for alcohol, opiates and cigarettes. So this is the reason I think this is not going to be a simple process.

What is tremendously important about it is that these standards set the stage. With the introduction of these standards, we have a conceptual framework that has principles — practices that are broken down into domains that are defined, that can be used, and the response to the dissemination effort subsequent to the meeting has been huge — it’s been huge. People are going to the website. People are asking us if we could please have a meeting to adapt these for adolescents. Could we please have a meeting to adapt these for treatment criminal offenders? And we may be able to do some of that.

States are talking about using these as they restructure and reform their systems, as they face the huge budget cuts. And to have standards that they can say, “Okay, let me look at my treatment system. Now how am I going to help my provider move toward these kind of standards, be able to implement these kinds of standards, and what are the implications of that for buyers who need to look what kind of organization they have to be?”

BHC: Dr. Chalk, is there any correlation between these standards and the concept of the Patient-Centered Medical Home that Medicare is going to test in 2010 with the concept of integrating care, including the primary care provider?

MC: The NQF document specifically talks about the context being the six aims set out by the Institute of Medicine’s “Crossing the Quality Chasm” report, so that patient- centered and Medical Home or some patient-centered version of Medical Home in substance abuse treatment systems are clearly part of this.

BHC: And so for the C-levels, the medical directors, the facilities, etc., who may be listening to this from across the country, what can they do to help either learn about these standards or help their states move forward with them?

MC: We are continuing our activities to help states identify how they will adopt these standards. Yesterday, we sent out a questionnaire to all the participating states, asking them what they are going to do with the next step. We will then use that to formulate some assistance. We can do it beginning in January of 2010.

In addition, we would hope that states would then begin talking with us about how they can work with their providers. The whole issue of how treatment providers can be assisted to work on implementation of these standards, as well as function under healthcare reform — which includes parity and new treatment benefits in the healthcare reform packages that are in legislation now — is a large project, much larger than this dissemination effort. There are several of us, TRI and several other organizations, talking about what needs to happen to be able to assist providers to be able to function.
 

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