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FINAL REPORT OF SANTA FE SUMMIT ’97
Preserving Quality And Value In the Managed Care Equation
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BACKGROUND/INTRODUCTION
About the College. The American College of Mental Health Administration (ACMHA)
was founded in 1979 to advance the field of mental health and substance abuse
administration and to promote the continuing education of clinical professionals in the
areas of administration and policy. An elected Board of Directors governs the College, and
its membership includes leaders in the field from the private and public sectors, a broad
range of disciplines, as well as academicians, researchers and consumers.
In March of 1996, ACMHA's Board of Directors voted to build on its diversity to serve
as a neutral forum for development of consensus on challenging issues facing the field of
mental health and substance abuse treatment and prevention. ACMHA made this commitment
real by choosing to host a series of behavioral health summits: collegial efforts to bring
together key leaders on targeted subjects. To that end, we will host the SANTA FE SUMMIT
ON BEHAVIORAL HEALTH annually at least until the year 2000.
SANTA FE SUMMIT 1997. The first SUMMIT was devoted to outcomes/performance
measurement, and this document is the result of that initial venture. Leaders from all
sectors of the mental health and substance abuse field were invited to attend a working
meeting in March, 1997 to see if consensus could be reached on core performance measures
for mental health and substance abuse care. Many in the College are concerned that
continued proliferation of measures and strategies has the potential to sap both energy
and resources from the field. Throughout our work, ACMHA has pushed for simplicity and
relevance. In our view, a multitude of technically elegant but uncollectible or ultimately
irrelevant measures will fail to move the system forward. Measuring those things that are
important to consumers and purchasers, and which can be collected accurately is our goal.
This work takes to heart the folk-adage that "the excellent should not be the enemy of the
good."
Approximately 100 individuals accepted the challenge to participate, including
representatives of the Washington Business Group on Health, the American Managed
Behavioral Healthcare Association (AMBHA), the National Alliance for the Mentally Ill
(NAMI), the National Committee on Quality Assurance (NCQA), the Institute of Medicine
(IOM), the Substance Abuse and Mental Health Administration (SAMHSA), the Council on the
Accreditation of Rehabilitation Facilities (CARF), the National Mental Health Association
(NMHA), along with ACMHA members. The College was assisted by an unrestricted educational
grant from the Eli Lilly Company to ensure that travel, scholarships for consumers, and
other conference needs could be met.
Participants in the SUMMIT were divided into five working groups reflecting the domains
targeted by those in attendance: PREVENTION, ACCESS (what NCQA refers to as
"availability of care"), PROCESS/PERFORMANCE (what NCQA refers to as
"appropriateness of care"), OUTCOMES (what NCQA refers to as
"outcomes of care"), and STRUCTURE (what NCQA refers to as
"systems"). Each workgroup met over the course of two days in Santa Fe, at the
end of which each produced a statement of core values for the domain, provisional
indicators to capture success in that domain, possible measures and needed next steps.
Participants (and in some cases individuals who were unable to be in Santa Fe, but who
wanted to be involved in the work) have continued to refine the work begun at the SUMMIT
through conference calls, mailings, FAXes, electronic bulletin boards and other
mechanisms. The volunteer time commitment alone is an astonishing tribute to the mental
health and substance abuse communities.
The moderators of the workgroups met in Washington, DC, June 29-30, 1997, to review
materials to be included in the first draft of the recommendations of the SUMMIT. Also
invited were several primary consumers of mental health services; the College is committed
to have the maximum consumer participation possible. This meeting identified several areas
that needed additional work, and so ACMHA revised its original time frame for release of
the report. The document you see has been through numerous revisions.
NEXT STEPS. The College will widely distribute the recommendations that have
emerged from the SANTA FE SUMMIT. No document reflects complete consensus among all
participants in every area, but we remain interested in seeking the greatest consensus
that is feasible. The College has no expectation that this document can supplant the
outstanding work of other organizations and groups that have tackled these same issues. We
have benefited from the work of , and in some cases the collaboration with, with the
Center for Mental Health Services Mental Health Statistics Improvement Project’s
Consumer Report Card initiative, the Commission on Accreditation of Rehabilitation
Facilities (CARF), the National Committee on Quality Assurance (NCQA), the Managed
Behavioral Healthcare Association (AMBHA) , the National Association of State Mental
Health Director’s Research Institute, the National Alliance for the Mentally Ill
Round Table, and the Academy for State Health Policy’s QISMC project—among
others. We do, however, hope that the SANTA FE SUMMIT and these core indicators will help
to coalesce some of these diverse efforts, and further the cause of issue refinement and
focus to the benefit of all.
As this document goes to press, ACMHA is planning a follow-up mini-SUMMIT in April of
1998, to which a group of decision-makers will be invited to review this report and
strategize about how to achieve the next steps. Following this meeting, SANTA FE SUMMIT
’98 will build on this work on performance measurement and outcomes to look at
purchasing value in integrated systems.
VALUES. The participants in Santa Fe and the members of the College share a
strong investment in a value-driven process, and this may be the chief legacy of the first
SUMMIT. Whatever methodological or other weaknesses of this work (and they are inevitable,
given the state of the art), there was no debate about the need to anchor outcomes
measurement in core service values and the primacy of the consumer of those services.
CAVEATS. While we are proud of the leadership provided by ACMHA in this effort,
we are cognizant of the complexity of this field of inquiry. Benchmarking, quality
improvement, and outcomes measurement in mental health and substance abuse are an emerging
area of concentration. Many of the issues with which the SUMMIT participants grappled
proved too burdensome to measure, too complex to quantify, or inadequate in other ways.
Lest we lose the richness of some of those discussions, we have included a section in this
report that addresses issues needing further study and measures reviewed but not chosen.
After lengthy debate, we have moved the MEASURES section to a less prominent section of
the report, reflecting the lack of consensus and the need for more rigorous validation
efforts.
We made special efforts to address children and family issues. A subgroup of
participants in the SANTA FE SUMMIT have produced a special section on OUTCOMES for
children with serious emotional disorders; this work occurred after the Santa Fe meeting.
There are references to the special needs of children and their families’ needs in
each of the major sections of the report, but we acknowledge that the report has not
adequately addressed these concerns.
In the area of PREVENTION, ACMHA deferred to a work-in-progress that preceded the
SUMMIT. The National Mental Health Association, along with the Center for Substance Abuse
Prevention, was already in the process of convening a panel of experts and advocates in
this area, and so we have merged our process with theirs. The PREVENTION Section is
provided to us by that NMHA workgroup, and we are grateful to Rob Gabriele and the NMHA
for this significant contribution.
YOUR ASSISTANCE. We hope that people from diverse sectors will continue to
grapple with the technical and other barriers that hamper progress in assuring quality in
mental heath and substance abuse treatment. At the end of this document is a form for
comment on the work of the SUMMIT. Please be as detailed as possible in your responses,
which should be sent to ACMHA at the address on the form.
ABOUT THIS DOCUMENT: The report is presented, in
some measure, in priority order. There was greatest consensus about the VALUES, and we
believe that this statement of core values is one of the greatest contributions to the
field of this work. Somewhat less robust was consensus around core INDICATORS, but we
think this is a meaningful set around which to focus debate and further refinement. We
feature two special sections: one on CHILDREN’S OUTCOMES and another on PREVENTION.
There was least agreement about the MEASURES that are useful to provide the data on the
indicators; in some areas we have been prescriptive about measures that seemed most
promising, but in other areas we have offered options. Our most controversial elements are
those that suggest items pulled from larger, validated instruments. Recommending subsets
of existing instruments is a controversial action: there are validity and reliability
issues, not to mention copyright and legal liabilities. ACMHA does not recommend use of
any instrument or part of an instrument unless the user has addressed the legal and
scientific issues. We believe that the mental health and substance abuse field needs
to focus its energies on achieving consensus on measures in the near term.
USING THIS REPORT: This document is not intended so much as a cook-book
as a set of guidelines and principles. We hope that readers and users will help support
the driving vision of this work, which is to coalesce energy around a limited number of
core indicators and measures—all born out of a vision of quality care.
FORMAT: The format of the report is as follows:
THE CORE SET: VALUES AND INDICATORS ENDORSED BY ACMHA.
Section I: Key value themes. These are the consensus value statements generated
in Santa Fe.
Section II: Key Indicators. We are using the CARF definition of an indicator:
A
domain or variable used to point to program quality or performance.
SPECIAL FOCUS REPORTS:
Section III: Outcomes measures for children with serious emotional disorders.
This report was submitted by a sub-group of SUMMIT participants, and then modified based
on feedback from a SAMHSA/CMHS funded children’s expert panel. Although following the
format of the main report, it is in some senses a stand-alone product.
Section IV: A Framework for Incorporating Prevention. This is a special
submission to ACMHA from the National Mental Health Association’s prevention
workgroup, and includes selected materials from a larger report to be released by NMHA.
FUTURE DEVELOPMENT:
Section V: Key Measures. There is a measure or measures for most of the
Indicators. We are using the CARF definition of a measure: A specific instrument or
data element used to quantify or calibrate an indicator. ACMHA believes that the
recommended measures require additional work, and will work with leaders in behavioral
health to insure that the refinement occurs.
Section VI: Issues considered but not included. These are elements that were
generated by the workgroups but not included in the core recommended set.
ACKOWLEDGEMENTS and SUPPORTING DOCUMENTS:
Acknowledgements and List of Participants: This effort has required the work of
many people and organizations. We hope the listing is complete, and apologize for any
unintentional omissions.
Appendices: The appendices include a variety of supporting documents and tables
that were collated or developed for the SANTA FE SUMMIT by HSRI.
Editor’s Note: Comments from the Program Chair.
For additional copies of the report or for other information on SANTA FE SUMMIT or the
American College of Mental Health Administration, please contact:
Lawrence A. Heller, PhD, Executive Director
The American College of Mental Health Administration
7625 West Hutchinson Avenue
Pittsburgh, PA 15218-1248
VOICE: 412.244.0670 FAX: 412.244.9916
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