CAN PSYCHIATRY CROSS THE QUALITY CHASM?
Vol 2 #6
Alan Eppel MB, FRCPC
Patients, family members and family physicians all too frequently express dissatisfaction with the quality of psychiatric care. Accessibility to care and continuity of care are two of the major quality dimensions that are most often cited as deficient.
Patients and family members complain of not knowing how to access the system and are often subjected to long waiting times. Patients admitted to hospital in many cases have limited follow-up care.
Family physicians find access systems to psychiatric care bewildering in the array of different programs all with differing admission and exclusion criteria.
In a Canadian community health survey carried out in 2012 almost 1.9 million people endorsed having a mental illness. Almost one third of these reported that their needs were only partially met or not met at all.
The same report noted that patients hospitalized in Ontario with a psychiatric disorder do not have timely access to follow-up upon discharge. Less than 33% had a follow-up appointment with a physician within seven days of leaving hospital. This compares with 44% of cardiac patients who were followed up within seven days. Thirty day readmission rates to psychiatric units in Ontario average around 12%. This may reflect inadequate or delayed follow-up care.
Patients and family physicians are often frustrated by not having access to psychiatric to intermediate and long-term psychiatric follow-up which is often vital for patients with serious mental illness such as major depression, bipolar disorder, PTSD, obsessive compulsive disorder, psychoses, eating disorders, developmental disorders, substance abuse, dementing illnesses, and certain personality disorders.
Patients are frequently dissatisfied with the quality of the interpersonal aspects of care: the need to be treated with compassion, dignity and respect; the need to have ongoing two-way communication with physicians and nurses; the need to participate in treatment decisions.
Because of poor coordination and deployment of resources inpatient admissions are often brief and ineffective. The focus is often on crisis management, risk assessment, pharmacological interventions and early discharge.
In many cases patients complain of the lack of psychotherapeutic input. The missed opportunity to work through feelings and emotions related to their illnesses.
Similarly follow-up care is often limited to a mechanistic focus on symptoms and pharmacological management. The psychological, relational and social dimensions of care are often forgotten.
The Institute of Medicine
In a landmark report in 2001 the Institute of Medicine identified the following dimensions of quality of care:
Safety: avoiding injuries to patients from the care that is intended to help them.
Effectiveness: providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit.
Patient-centered: providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.
Timely: reducing waits and harmful delays .
Efficiency: avoiding waste, in particular waste of equipment, supplies, ideas, and energy.
Equitability: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.
In addition the report outlined ten rules to guide improvements in healthcare that included:
Care based on continuous healing relationships.
Customization based on patient needs and values.
Patient as the source of control. Patients should be given the necessary information and the opportunity to exercise the degree of control they choose over health care decisions. The health system should be able to accommodate differences in patient preferences and encourage shared decision making.
Patients should have complete access to their own medical information.
Evidence-based decision making. Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place.
source: IOM, 2001.
WHAT IS REQUIRED
The concept of “Patient-Centred Care” was originally put forward by the Picker Commonwealth Program for Patient-Centered Care, which later became The Picker Institute. These ideas were developed by Dr. Harvey Picker and his wife Jean beginning in 1986.
Access to care needs to be in the form of “One Stop Shopping” i.e. centralised, quick and relevant. Treatment silos need to broken down and coordinated or integrated.
Services should be based on needs not diagnosis.
There should be continuity of care and coordinated transitions from one level of care to another.
Treatment should be evidence-based and delivered safely to minimize potential side effects are harms. This requires critical evaluation of treatment studies and outcomes.
Treatment interventions should embrace Recovery principles, quality of life in addition to symptom resolution.
Treatment should be multimodal including pharmacological, psychotherapeutic and social interventions.
Crossing the Quality Chasm: A New Health System for the 21st Century. IOM. Washington, DC. National Academy Press. 2001.
Institute of Medicine. Psychosocial interventions for mental and substance use disorders: a framework for establishing evidence-based standards. Washington (DC): National Academies Press 2015.
Improving the Quality of Health Care for Mental and Substance-Use Conditions: Institute of Medicine Quality Chasm Series. 2006. http://www.nap.edu/catalog/11470.html
Patient-Centred Care: What does it Take? Commonwealth Fund. October, 2007.
Taking Stock: A Report on the Quality of Mental Health and Addictions Services in Ontario. An HQO/ICES Report. Toronto, Health Quality Ontario and Institute for Clinical Evaluative Sciences; 2015.