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IMPROVING MENTAL
HEALTH CARE
Commitment to Quality
This page intentionally left blank
IMPROVING MENTAL
HEALTH CARE
Commitment to Quality

Edited by

Barbara Dickey, Ph.D.

Lloyd I. Sederer, M.D.

Washington, DC
London, England
Note: The authors have worked to ensure that all information in this book
concerning drug dosages, schedules, and routes of administration is accurate as of
the time of publication and consistent with standards set by the U.S. Food and Drug
Administration and the general medical community. As medical research and
practice advance, however, therapeutic standards may change. For this reason and
because human and mechanical errors sometimes occur, we recommend that
readers follow the advice of a physician who is directly involved in their care or the
care of a member of their family. A product’s current package insert should be
consulted for full prescribing and safety information.

Books published by American Psychiatric Publishing, Inc., represent the views and
opinions of the individual authors and do not necessarily represent the policies and
opinions of APPI or the American Psychiatric Association.

Copyright © 2001 American Psychiatric Publishing, Inc.

ALL RIGHTS RESERVED

Manufactured in the United States of America on acid-free paper

04 03 02 01 4 3 2 1
First Edition

American Psychiatric Publishing, Inc.

1400 K Street, N.W.
Washington, DC 20005
www.appi.org

Library of Congress Cataloging-in-Publication Data

Commitment to improving quality in mental health care : concepts and case
reports / edited by Barbara Dickey, Lloyd I. Sederer.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-88048-963-4 (alk. paper)
1. Mental health services--United States--Standards. 2. Health care reform--
United States. I. Dickey, Barbara. II. Sederer, Lloyd I.
[DNLM: 1. Mental Health Services--standards. 2. Quality Assurance,
Health Care. 3. Health Care Reform. 4. Quality of Health Care--standards.
WM 30C7267 2001]
RA790.6 .C575 2001
362.2’02’1873--dc21
2001027945

British Library Cataloguing in Publication Data

A CIP record is available from the British Library.
To patients and others who have shown us the way.
This page intentionally left blank
 Contents
About the Editors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xix
R. Heather Palmer, M.B.B.Ch.

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xxi
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiii
Barbara Dickey, Ph.D.
Lloyd I. Sederer, M.D.

I
Challenges

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

1 The President’s Advisory Commission on Consumer

Protection and Quality in the Health Care Industry . . . . . . . . . . . . . 5
Steven S. Sharfstein, M.D.

2 Maintaining Professional Ethics in a

Changing Health Care System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Steven M. Mirin, M.D.

3 Quality of Care in an Era of Wall Street Medicine. . . . . . . . . . . . . . 37

Lloyd I. Sederer, M.D.

4 Can Managed Care Deliver Quality? . . . . . . . . . . . . . . . . . . . . . . . 49

Mary Durham, Ph.D.

5 Role of Academic Medical Centers in Achieving Quality . . . . . . . 61

Linda S. Godleski, M.D.
Allan Tasman, M.D.
 II
Quality Measurement

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

6 Measuring Quality: An Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Barbara Dickey, Ph.D.

7 Risk Adjustment of Clinical Outcome Data . . . . . . . . . . . . . . . . . . . 89

Sebastian Lorenz, M.D., M.P.A
Lloyd I. Sederer, M.D.

8 Building Partnerships in Accountability:

Consumer Satisfaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Jean Campbell, Ph.D.
Kimberlee Einspahr

9 Toward a National Report Card:

Measuring Consumer Experiences . . . . . . . . . . . . . . . . . . . . . . . . . 115
Susan V. Eisen, Ph.D.
Brian Clarridge, Ph.D.
Vickie Stringfellow
James A. Shaul, M.H.A.
Paul D. Cleary, Ph.D.

10 Practical Steps Toward Quality Improvement:

A Public-Sector Example . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Astrid Beigel, Ph.D.
Christine Torre

11 The American Psychiatric Association’s

Agenda for Evidence-Based Quality . . . . . . . . . . . . . . . . . . . . . . . 151
Deborah A. Zarin, M.D.
Joyce C. West, Ph.D., M.P.P.
Claudia Hart

12 Status of National Efforts to Improve

Accountability for Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Ronald W. Manderscheid, Ph.D.
Marilyn J. Henderson, M.P.A.
David Y. Brown
 III
Case Reports

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181

13 Intensive
Psychiatric Community Care in the
Department of Veterans Affairs. . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Robert A. Rosenheck, M.D.
Michael S. Neale, Ph.D.

14 A National Strategy to Reduce

Depression and Suicide in England. . . . . . . . . . . . . . . . . . . . . . . . . 193
Rachel Jenkins, M.A., M.B., Bchir, M.D.(Cantab), F.R.C.Psych.

15 The Texas Medication Algorithm Project . . . . . . . . . . . . . . . . . . . . 201

William V. Rago, Ph.D., M.B.A.
Steven P. Shon, M.D.

16 Improving the Quality of Community-

Based Services for Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
Mary E. Evans, R.N., Ph.D., F.A.A.N.

17 Improved Emergency Access for Medicaid Clients:

A Colorado Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Paula M. Dahl, M.B.A., C.P.H.Q.
Sandra L. Forquer, Ph.D.

18 Improving Employment Outcomes for People

With Severe Psychiatric Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . 235
Deborah R. Becker, M.Ed.
Robert E. Drake, M.D., Ph.D.

19 Matching Substance Abuse Patients to Services . . . . . . . . . . . . . 241

Grant R. Grissom, Ph.D.

20 Adverse Drug Reactions:

An Interdisciplinary Team Approach . . . . . . . . . . . . . . . . . . . . . . . 251
Carlos A. Zarate Jr., M.D.
Arthur Siegel, M.D.
Lloyd I. Sederer, M.D.

21 High-Risk Medicaid Enrollees and a

Community-Based Support Program . . . . . . . . . . . . . . . . . . . . . . . 265
Deborah Nelson, Ph.D.
Donna Zeh, L.I.C.S.W.
Kathleen Bennett, M.D.
22 Increasing Consumer Involvement in Treatment . . . . . . . . . . . . . 275
Susan V. Eisen, Ph.D.
Barbara Dickey, Ph.D.
Lloyd I. Sederer, M.D.

23 Improving the Detection of Mental

Disorders by Primary Care Clinicians. . . . . . . . . . . . . . . . . . . . . . . . 285
Richard C. Hermann, M.D., M.S.
Paul Erickson, M.D.
Robert Joseph, M.D., M.S.
David H. Bor, M.D.

24 Reducing the Incidence of Restraint and Seclusion. . . . . . . . . . . 297

Paul Plasky, M.D., Ph.D.
Catherine Coakley, M.S., R.N., C.

25 Using Dialectical Behavior Therapy in the

Treatment of Borderline Personality Disorder . . . . . . . . . . . . . . . . . 307
Daniel Potenza, M.D.
Patricia Carty, M.S.

26 Reducing the Risk of Falls for Elderly Patients . . . . . . . . . . . . . . . . . 315

Geraldine Nelson, M.S., R.N.

Afterword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
 About the Editors

B arbara Dickey, Ph.D., is Associate Professor of Psychology in the Depart-

ment of Psychiatry at Harvard Medical School and The Cambridge Hos-
pital. She has been active in hospital quality improvement efforts and has a
long academic career in health services research. She has published widely
in the fields of outcome research, homelessness, and the effects of managed
care on costs and outcomes for people with serious mental illness. She is
leading a research study of the quality of care for adults with schizophrenia,
comparing the treatment and outcomes of people in managed care with
those of people whose care is not managed. With Dr. Sederer, she coedited
Outcomes Assessment in Clinical Practice.

Lloyd I. Sederer, M.D., was Medical Director and Executive Vice Presi-
dent of McLean Hospital at the time this book was being prepared. In this
role, he directed the hospital’s clinical services, including its special empha-
sis on clinical quality assessment and quality improvement. He is now
Director of the Division of Clinical Services at the American Psychiatric
Association in Washington, DC. Dr. Sederer is Associate Professor of Clin-
ical Psychiatry at Harvard Medical School and has published 10 books and
over 125 articles, reviews, chapters, and monographs. He has consulted
nationally and internationally on clinical care and service delivery, quality
improvement, risk management, and the regulation and reimbursement of
medical care.

xi
This page intentionally left blank
 Contributors

Deborah R. Becker, M.Ed.

Research Assistant Professor of Community and Family Medicine, Dart-
mouth Medical School, Hanover, New Hampshire
Astrid Beigel, Ph.D.
Mental Health District Chief, Quality and Outcome Division, Los Angeles
County Department of Mental Health, Los Angeles, California
Kathleen Bennett, M.D.
Senior Medical Director, Boston Medical Center/HealthNet Plan, Boston,
Massachusetts
David H. Bor, M.D.
Associate Professor of Medicine, Harvard Medical School, Boston, Massa-
chusetts; and Chief of Medicine, Cambridge Health Alliance, Cambridge,
Massachusetts
David Y. Brown
Consultant, Center for Mental Health Services, Substance Abuse and
Mental Health Services Administration, U.S. Department of Health and
Human Services, Rockville, Maryland
Jean Campbell, Ph.D.
Director, Program in Consumer Studies and Training; and Research As-
sistant Professor, Missouri Institute of Mental Health, St. Louis, Missouri
Patricia Carty, M.S.
Director, Community Support Services, Mental Health Center of Greater
Manchester, Manchester, New Hampshire
Brian Clarridge, Ph.D.
Senior Research Fellow, Center for Survey Research, University of Massa-
chusetts, Boston, Massachusetts

xiii
 xiv I MP ROVI N G M ENT AL H E ALTH C ARE

Paul D. Cleary, Ph.D.

Professor of Medical Sociology, Department of Health Care Policy, Har-
vard Medical School, Boston, Massachusetts
Catherine Coakley, M.S., R.N., C.
Nurse Director, Bipolar and Psychotic Disorders Program, McLean Hos-
pital, Belmont, Massachusetts
Paula M. Dahl, M.B.A, C.P.H.Q.
Executive Director, National Networks Quality Assurance, ValueOptions,
Virginia Beach, Virginia
Robert E. Drake, M.D., Ph.D.
Andrew Thomson Professor of Psychiatry and Community and Family
Medicine, Dartmouth Medical School, Hanover, New Hampshire
Mary Durham, Ph.D.
Vice President/Research, Kaiser Foundation Hospitals; and Director,
Center for Health Research, Northwest and Hawaii, Kaiser Permanente,
Portland, Oregon
Kimberlee Einspahr
Multisite Interviewer Coordinator, Consumer Operated Services Project
(COSP), and Senior Research Lab Technician, Missouri Institute of Men-
tal Health, St. Louis, Missouri
Susan V. Eisen, Ph.D.
Director, Department of Mental Health Services Research, McLean Hos-
pital, Belmont, Massachusetts; and Associate Professor of Psychology,
Harvard Medical School, Boston, Massachusetts
Paul Erickson, M.D.
Assistant Professor of Psychiatry, Harvard Medical School, Boston, Mas-
sachusetts; and Acting Chief of Psychiatry, Cambridge Health Alliance,
Cambridge, Massachusetts
Mary E. Evans, R.N., Ph.D., F.A.A.N.
Professor, Director of Research, and Director of Doctoral Program, Col-
lege of Nursing, University of South Florida, Tampa, Florida
Sandra L. Forquer, Ph.D.
Vice President for Education Services, Comprehensive Neuroscience, Inc.,
White Plains, New York; and former Executive Director, Colorado Health
Networks, Colorado Springs, Colorado
Contributors xv

Linda S. Godleski, M.D.

Associate Professor, Department of Psychiatry and Behavioral Sciences,
University of Louisville School of Medicine; and Chief of Mental Health
and Behavioral Science Services, Mid-South Health Care Network, De-
partment of Veterans Affairs, Louisville, Kentucky
Grant R. Grissom, Ph.D.
President, PsyberMetrics, Inc., Langhorne, Pennsylvania
Claudia Hart
Director and former Associate Director, Office of Quality Improvement
and Psychiatric Services, American Psychiatric Association, Washington,
DC
Marilyn J. Henderson, M.P.A.
Assistant Branch Chief, Survey and Analysis Branch, Center for Mental
Health Services, Substance Abuse and Mental Health Services Administra-
tion, U.S. Department of Health and Human Services, Rockville, Mary-
land
Richard C. Hermann, M.D., M.S.
Assistant Professor of Psychiatry, Harvard Medical School, Boston, Mas-
sachusetts; and Director of Quality Management, Department of Psychia-
try, Cambridge Health Alliance, Cambridge, Massachusetts
Rachel Jenkins, M.A., M.B., Bchir, M.D.(Cantab), F.R.C.Psych.
Professor and Director, World Health Organization Collaborating Center
for Research and Training for Mental Health, Institute of Psychiatry, De
Crespigny Park, London, United Kingdom
Robert Joseph, M.D., M.S.
Assistant Professor of Psychiatry, Harvard Medical School, Boston, Mas-
sachusetts; and Director of Consultation-Liaison Psychiatry, Department
of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts
Sebastian Lorenz, M.D., M.P.A.
Head, Clinical Resource Management Unit, President’s Staff, Inselspital
Bern University Hospital, Bern, Switzerland
Ronald W. Manderscheid, Ph.D.
Chief, Survey and Analysis Branch, Division of State and Community De-
velopment, Center for Mental Health Services, Substance Abuse and Men-
tal Health Services Administration, U.S. Department of Health and
Human Services, Rockville, Maryland
 xvi I MP ROVI N G M ENT AL H E ALTH C ARE

Steven M. Mirin, M.D.

Medical Director, American Psychiatric Association, Washington, DC
Michael S. Neale, Ph.D.
Associate Director, Veterans Affairs Northeast Program Evaluation Cen-
ter, West Haven, Connecticut
Deborah Nelson, Ph.D.
Vice President of Quality Management and Clinical Services, Beacon
Health Strategies, Woburn, Massachusetts
Geraldine Nelson, M.S., R.N.
Program Director, Behavioral Medicine, Caritas Norwood Hospital, Nor-
wood, Massachusetts; and former Nurse Director, Geriatric Program,
McLean Hospital, Belmont, Massachusetts
R. Heather Palmer, M.B.B.Ch.
Professor of Health Policy and Management and Director of the Center
for Quality of Care Research and Education, Harvard School of Public
Health, Boston, Massachusetts
Paul Plasky, M.D., Ph.D.
Associate Psychiatrist, McLean Hospital, Belmont, Massachusetts
Daniel Potenza, M.D.
Vice President of Medical Services, Mental Health Center of Greater
Manchester, Manchester, New Hampshire
William V. Rago, Ph.D., M.B.A.
Special Assistant to the Commissioner, Texas Department of Mental
Health and Mental Retardation, Austin, Texas
Robert A. Rosenheck, M.D.
Director, Veterans Affairs Northeast Program Evaluation Center, West
Haven, Connecticut; and Professor of Psychiatry and Public Health, Yale
School of Medicine, New Haven, Connecticut
Steven S. Sharfstein, M.D.
President and Medical Director, Sheppard Pratt Health System; Clinical
Professor of Psychiatry, University of Maryland, Baltimore, Maryland; and
Member of the President’s Advisory Commission on Consumer Protection
and Quality in the Health Care Industry, Washington, DC
James A. Shaul, M.H.A.
Project Director, Department of Health Care Policy, Harvard Medical
School, Boston, Massachusetts
Contributors xvii

Steven P. Shon, M.D.

Medical Director, Texas Department of Mental Health and Mental Retar-
dation, Austin, Texas
Arthur Siegel, M.D.
Chief of Internal Medicine and Member of the Pharmacy and Therapeu-
tics Committee, McLean Hospital, Belmont, Massachusetts
Vickie Stringfellow
Assistant Study Director, Center for Survey Research, University of Mas-
sachusetts, Boston, Massachusetts
Allan Tasman, M.D.
Professor and Chairman, Department of Psychiatry and Behavioral Sci-
ences, University of Louisville School of Medicine, Louisville, Kentucky
Christine Torre
Mental Health Analyst, Pequic Division, Los Angeles County Department
of Mental Health, Los Angeles, California
Joyce C. West, Ph.D., M.P.P.
Director, American Psychiatric Practice Research Network, American
Psychiatric Institute for Research and Education; and former Associate Di-
rector for Research, Office of Quality Improvement and Psychiatric Ser-
vices, American Psychiatric Association, Washington, DC
Carlos A. Zarate Jr., M.D.
Chief, Mood Disorders Research Program, National Institute of Mental
Health, Bethesda, Maryland
Deborah A. Zarin, M.D.
Director, Technology Assessment Program, Agency for Healthcare Re-
search and Quality, Rockville, Maryland; former Deputy Medical Director,
American Psychiatric Association; and Director, Office of Quality Im-
provement and Psychiatric Services, American Psychiatric Association,
Washington, DC
Donna Zeh, L.I.C.S.W.
Director of Clinical Management, Beacon Health Strategies, Woburn,
Massachusetts
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