If your email inbox looks anything like mine, you probably get your fair share of automated messages, including ones asking you to complete a satisfaction survey from a recent purchase. Usually there’s an effusive subject line like “Tell Us How We Did!” While they can sometimes be annoying, I appreciate a company I do business with seeking feedback on how they can improve their customer experience. Remember, some of the best businesses have made their name (and won awards) based on the quality of how they take care of you!
But did you know that health care does the same thing? Well, kind of. If you stay at least one full night in a hospital, there’s a chance you will be given the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, which is to solicit feedback regarding the patient’s experience. The HCAHPS survey encompasses all aspects of the patient experience, from doctor/nurse communication to hospital cleanliness, as a means to increase transparency and accountability and incentivize improvement of patient care.
On the surface this seems like a good idea, right? Well, one of several caveats is that the HCAHPS is not sent to individuals who were hospitalized for or diagnosed with mental health or addiction issues. But why would this be? Are these individuals not deserving of the best possible care?
Sadly, this is indicative of a much broader issue: our standards on mental health care in America are depressingly, frighteningly low. How can we improve the mental health patient experience if we are not asking anyone with a mental health condition about their care? This lack of attention to what matters to people, especially in the mental health space, means that many needs are overlooked, including safety and quality issues.
In fact, just last week, the only state psychiatric hospital in Montana had its federal funding pulled after multiple reports of demonstrable negligence that led to at least four preventable patient deaths. The state’s governor said staffing shortages were responsible, but the Centers for Medicare and Medicaid Services (CMS) issued repeated requests to improve conditions that went unheeded.
Our mental health system has been fragmented for decades, perpetuating an environment where those in need cannot get access to the level of care or the quality of care they deserve. While quality of care doesn’t get the attention it should (because most people can’t get access), it is always there under the surface as a major issue we have to address. This is another pressure constantly pushing against an already-fractured system, with increasing mental health needs and the looming launch of 988 later this Summer only exacerbating things. This crisis system should be built on standards of quality, but the most vulnerable Americans, the ones who need care the most, don’t know what high-quality mental health care looks like as it’s never been an accessible option for them.
At the root of this problem, federal and state officials have failed to take the steps needed to protect the most vulnerable. Montana is just the latest example, but it also recently came to light that state officials in Colorado (a state that’s been in the media a lot recently for its beleaguered mental health system) hid findings of two patient deaths and a pattern of severely negligent care at its Grand Junction-based psychiatric hospital. The sad truth is that both egregious cases could have been prevented if state leadership had taken steps to provide meaningful oversight and accountability before a crisis occurred.
There are undoubtedly well-intentioned individuals and institutions that are simply ill-prepared to help those struggling with mental health or addiction. President Biden recently called for all Americans to be able to receive three mental health visits per year without a copay, which would be a boon for reducing stigma and identifying those who may be struggling before they find themselves in a life-or-death situation (of course, three visits don’t work if the system is already at capacity). Yet, good intentions will mean nothing without major investments - such as those recently announced by the New York governor - in order to get the desired outcome.
For example, if you were to go in for one of those free visits and have a poor experience, or if you called 988 only to be left on hold, you would likely be turned off to the entire mental health system and experience. That result would be detrimental to everything the mental health community has been working towards for decades.
To prevent these failures from harming patients, there are three ways legislators and regulators should consider improving standards of care:
Data and standards: Every patient who seeks care for a physical ailment expects to be given a slew of numbers, from their Body Mass Index (BMI) to the success rate of a given treatment, partially because there are data-driven systems in place to ensure they receive quality care. Legislators should work with CMS, HHS, and SAMHSA to develop equivalent evidence-based standards of care and ensure that every patient receives the best available treatment. With 988 rolling out, we should also have clear standards on what it looks like to have a full continuum of care that can address the myriad of crises that will occur in our communities.
We also need to make sure that the data we collect informs our efforts. This means we need to know more about a person’s experience with the mental health system – with their care. This means that HCAHPS should consistently be given to people with mental health conditions. How will we know what to change if we don’t ask about it?
Incentives: Mental health services can be expensive, and many practices find little to no reward for costly evidence-based interventions, especially if they are serving populations which may not have access to necessary funds. But in order to enhance the overall quality of care, we need to have consistency in what’s done and how it’s done. Incentivizing providers to take part in programs rooted in the aforementioned evidence-based care will help individuals heal and reduce the present overwhelming need for long-term care all the while helping to ensure quality.
Training: Many well-intentioned medical professionals - from Emergency Department nurses to primary care physicians - have not received adequate training in trauma-informed, evidence-based interventions for mental health. Improving training for medical providers will be beneficial to all. In addition, mental health providers need to also be trained to work in setting outside mental health centers – to better be where people are – in schools, primary care, and more. To be most successful in raising the bar for how we address mental health in all settings, training will be a key element.
It’s heartening to see the growing activity and participate in the discussions being had about mental health. At the same time, it’s hard not to become frustrated by pointing out the same fragmented system and health care gaps over and over. Developing an effective and equitable mental health care system will involve a focus on improving quality of care, as well as quantity. Each of us is entitled to a higher standard of care - one that is simply the best - and none of us should be forced to settle for anything less.
I'm a retired mental health provider (LPC). In my experience, most patient feedback, for both inpatient and outpatient treatment, is not considered and patients who complain are often labelled as resistant, hostile, or difficult. The most responsive system I worked in was run by a tribal health care organization. Tribal members had direct access to board members in their communities and let them know if they were satisfied with medical care, mental health and addiction treatment. Our programs and staff were expected to improve our services to meet the needs of the community - and because mental health services were highly valued, we had resources to do so. We used some of Scott Miller's material - not necessarily to rate every session, but to help our counselors develop a framework for assessing their work and staying client-focused. I think that there's an understandable but unfortunate tendency for therapists to blame clients for poor outcomes or premature termination of treatment, often because most mental health programs are not staffed to provide adequate clinical supervision. For instance, it may be hard for a therapist to be aware of their reactions to certain clients, or difficulties they may have with particular diagnoses or issues - unless they have good supervision. Some people are difficult, hostile or resistant, but it's our role as mental health providers to do our very best to form a trusting relationship and help that person engage & get the best possible benefit from treatment.
Dr. Miller an excellent share here and one that has been on a loop in my mind since starting as a volunteer crisis counselor. I question if the outcome I've achieved with someone in crisis raises to a standard of care? Is it quality? Does an evidence based standard of care for a crisis intervention exist? Yes I've helped people ride out suicidal ideation to safety. Yet to your point, is the MH infrastructure in place to continue what I just did with them for an hour?
"Sadly, this is indicative of a much broader issue: our standards on mental health care in America are depressingly, frighteningly" This sentence went yard and overshadows my limited insight in the MH domain.
I came up though marketing, advertising, and CME working for pharma launching drugs, helping set up clinical trials, running advisory panels, and more. All of this was done based on a building of data/evidence from the basic science of a molecule through to clinical trials based on standards of care and outcomes. None of it was left to chance since the FDA demanded evidence prior to approval. And Mr. Cynical me will say my working with pharma in 20/20 hindsight is not my proudest memory, they do what they do for dollars.
In this fragmented MH system offering quality is the critical part of the battle. How do standardize quality care in MH when fragmentation is only getting more fractured with technology bringing application after application to MH. Have these new applications run trials to measure outcomes? How do their outcomes compare to standards of care for treating MH? Can that even be done?
Those I've helped in crisis intervention when we've closed our chat have the option of completing a survey. Of my 1,798 conversations I'm at about 8% who've left a comment about my efforts. This self reporting is not an outcome, though I do bask in validations, since it is immediately post chat--they liked me. My idea of an outcome would be, did they find additional help/support? Were they able to find good quality of continued care? Are the larger issues and fears they had which manifest itself in the immediate crisis were addressed? Which begs the question, can we take quality and quantify it so there are measures? Can we?????
I may be all off here since MH is beyond my IQ and expertise. A lower A1C can be measured easily with an associated outcome. The molecule that achieved that has data to prove it. Perhaps there is no reasonable way to show positive outcomes in MH similar to A1C.
You've shared negative outcomes in MH. The negative is a measure of what is not there. What is there, in that institution, or ED, or app, or service? What are the MH nutritional labels with each. I know how much salt is in my quarter pounder. Do I know if that thing will help my MH?
IDK All I do know is thank you for the thoughts, the space to share, things to consider, and achieve.