Implementing the Quadruple Aim in Behavioral Health Care
Although some organizations may have access to claims data or may function as self-contained health systems (eg, the Veterans Health Administration [VHA] ), others may not have access to such data. In the absence of claims data, patient self-report of service utilization has been used as a proxy for actual agency records.157 Although concordance between medical and/or agency records and patient self-report has been variable,157 evidence generally suggests that rates of agreement are higher the shorter the recall time interval.158,159 BHD does not have access to comprehensive claims data and has therefore chosen to use 5 dichotomously scored (yes/no) questions—related to medical inpatient, medical ED, psychiatric inpatient, psychiatric ED, and detoxification use in the last 30 days—to represent the CD of acute service utilization.
The Second Aim: Quality of Care
Safety
Safety is defined as avoiding injuries to patients from the care that is intended to help them.
Brief review and suggested item(s). As noted in “Crossing the Quality Chasm,” the IOM’s seminal document, “the health care environment should be safe for all patients, in all of its processes, all the time.”160 The landmark Harvard Medical Practice Study in 1991 found that adverse events occurred in nearly 4% of all hospital admissions and, among these, over a quarter were due to negligence.161 Other estimates of adverse events range as high as 17%.162 Indeed, a recent article by Makary and Daniel estimated that medical errors may be the third leading cause of death in the United States.163 Unfortunately, research on safety in the mental health field has lagged behind that of physical health,164 with evidence indicating that research in nonhospital settings in mental health care may be particularly scarce.165 In a study of adverse events that occurred in psychiatric inpatient units in the VHA system between 2015 and 2016, Mills and colleagues found that of the 87 root cause analysis reports, suicide attempts were the most frequent, and, among safety events, falls were the most frequently reported, followed by medication events.166 Another report on data collected from psychiatric inpatient units in the VHA revealed that nearly one-fifth of patients experienced a safety event, over half of which were deemed preventable.167 These numbers likely represent an underestimation of the true volume of safety events, as another study by the same research group found that less than 40% of safety events described in patient medical records were documented in the incident reporting system.168 BHD will utilize the total number of complaints and incident reports submitted within a given time frame as its “safety” metric in the CD data set.
Wait Time for Service
The CD is defined as the length of time between the date a patient first contacted BHD for services and the date of their first clinical service.
Brief review and suggested item(s). “Timeliness” was listed among the 6 aims for improvement in “Crossing the Quality Chasm” in 2001, and it remains no less relevant today.160 For example, evidence indicates that access to primary care is inversely related to avoidable hospitalizations.169 One study found that, of patients hospitalized for cardiovascular problems, those who had difficulty accessing routine care post discharge had higher 30-day readmission rates.170 Among VHA patients, longer wait times are associated with more avoidable hospitalizations and higher rates of mortality.171 Longer wait times appear to decrease the likelihood of attending a first appointment for individuals with substance use172,173 and mental health disorders.174 Importantly, longer wait times are associated with lower ratings of the patient experience of care, including perceptions of the quality of and satisfaction with care,175 and may be associated with worse outcomes for individuals in early intervention for psychosis treatment.176 For the purposes of the CD data set, BHD will monitor the length of time between the date a patient first contacted BHD for services and the date of their first clinical service.
