Measure Something!

measuring tapeI just returned from the National Council for Behavioral Health Board of Directors annual retreat, which was held this year in beautiful San Juan, Puerto Rico. It is always invigorating to network with colleagues from across the country, receive an update on the innovations of the National Council team, and plan together on how best to advance the cause of behavioral health in the coming year. I travelled 3,008 miles from Phoenix, Arizona to participate. I know that because the distance has been measured and the information is readily available… something that’s traditionally been lacking in the behavioral health care field.

One of the highlights of the 2014 meeting was having consultant David Lloyd, founder of MTM Services, participate. David will receive a Visionary Leadership award at the conference in Washington, DC in May for his tremendous impact on advancing the business practices of community mental health centers nationwide, largely because of his focus on measurement and data-driven performance improvement. When David first began in the behavioral health field, there was very little measurement going on at all (aside from agency financial statements).

Chuck Ingoglia, who introduced David to the board in San Juan, described the early days when the National Council urged member organizations to “measure something!” I first met David in the early 2000s when I had the privilege to partner with him on a speaking road trip across the state of Georgia. At the time, he was already equipping agencies to measure staff productivity as a means of evaluating organizational efficiency. In “How to Deliver Accountable Care,” David targeted the inefficiencies which drive up provider costs, e.g., lack of billable hour standards, redundant paperwork, and meeting culture, but these performance improvement efforts were only possible because of the productivity baseline data that he had helped agencies capture and report.

One of our homework assignments in preparation for the board retreat was to read Michael Porter’s “The Strategy that Will Fix Healthcare.” In the article, the Harvard professor describes the transformation to “value based health care,” which means focusing on improving the outcomes that matter to “patients,” while ensuring costs are kept constant, or lowered. He writes, “Indeed, rigorous measurement of value (outcomes and costs) is perhaps the single most important step…” Continuing, he says, “Wherever we see systematic measurement of results in health care – no matter the country – we see those results [outcomes and cost] improve.”

Porter pointed out that even when health care has measured things, it has tended to focus on process elements, the indicators that are easiest to capture and “least controversial.” This resonated strongly with me. For years, behavioral health agencies have been closely monitored as to whether they have faxed an annual coordination of care sheet to the primary care physician (despite knowing these papers largely went into a black hole, filed to the shredder, etc.) Value-based health care demands we center on the individual and their success in daily functioning. For decades, psychosocial rehabilitation has taught us that the symptoms are not the central issue, but rather how the person is doing with their job, relationships, housing, education, and spirituality… in other words, their day-to-day life. Health care is catching up with this important approach.

As David addressed the board, he talked about his more recent work supporting agencies in reducing the long wait times experienced by many individuals seeking behavioral health services in the past. National Council, motivated by initiatives such as same-day access and same-day medication, has begun exploring the concept of Behavioral Health Centers of Excellence, which would not have been possible without first measuring our results and improving them.

Agencies across the country now participate in SPQM, a data measurement system hosted by MTM Services that allows leadership to monitor utilization management, productivity, the cost of services delivered, no-shows, and cancellations. As a demonstration of his vision and leadership, David described the partnership with the National Council to pair these efforts with a focus on real outcomes by implementing the systematic administration of the DLA-20 (Daily Living Activities Functional Assessment 20-question survey).

The board discussion that ensued touched on how we are now taking this principle to countries, as well. GDP used to be the main measure of national success, but now countries tout Gross Domestic Wellness. The second annual World Happiness Report tells us that the residents of Denmark flourish more than the rest of us (the United States finished just outside the top ten).

In the early 1990s, the Harvard Business Journal published “The Balanced Scorecard – Measures that Drive Performance,” and businesses across the country augmented financial reporting with quality and business metrics, the customer experience, and innovation and learning. In 2008, the Council of State Governments published Dr. Keon Chi’s work onorganizational transformation, which emphasized collaboration, anticipation, and the transparent and public reporting of measurable outcomes.

We’ve seen many other fields travel quickly down this path, with informed consumers making choices based upon quality and experience. Crisis Access, LLC’s companies have been publishing online performance dashboards since the mid-2000s (including Crisis & Access Line, Access to Services, and Intensive Service Referral Linkages). Health care, and especially behavioral health care, have lagged far behind, seemingly unaware of the sea of change that is occurring, but pioneers like David Lloyd and MTM Services continue to blaze a bright new trail and offer tremendous support for agencies looking for a partner on the journey of improved outcomes.

Is Suicide Really a Choice?

iceAfter multiple trips down the hall, I dumped the last bucket of ice into the bathtub, then topped it off with cold water.  Just a couple hours earlier, I had completed my first marathon in New York’s Central Park, finishing fifteen minutes north of three hours. My legs cramped badly in the last half-mile, and after returning to our hotel, my friend Michael and I thought it would be a good idea to do what the professionals do to expedite recovery: take an ice bath.

With his teasing encouragement to go first, I stepped into the tub and quickly sat down, immersing my body in the ice and water up to my neck… Jesus! I have always tried to avoid the cold, but the pain I encountered upon entering the tub was instantly and completely unbearable. I don’t really recall the specific nature of the pain, but the memory is vivid. I was filled with an all-consuming terror that I would not be able to get out of the water fast enough. In the next moment, I was thrashing in the water, desperate to escape the acute pain I was experiencing.

That type of reaction is hard-wired in all of us. Our immediate response to acute pain is physiological: our pupils dilate and eyelids widen, our heart rate and blood pressure spike, our breathing quickens. It is part of our body’s built-in defense system, and in a micro-second we are into fight-or-flight mode. I didn’t choose whether to exit the ice bath; my primal reaction was to simply GET OUT.

Last year, at the American Association of Suicidology annual board meeting, I challenged a friend of mine regarding the relative absence of survivors of suicide attempts at the meeting, and told him how incongruous I thought it was. “What if the American Cancer Association meetings lacked survivors of cancer?” I asked. He replied that such a comparison was inappropriate. “Individuals choose to die by suicide; no one chooses cancer.”

Perhaps we have all thought about suicide in this same way, but I’m not sure how helpful or even how accurate that frame actually is. In “A Darkness Visible,” one of our most skilled American authors, William Styron, expresses his frustration with finding the words to adequately convey the utterly crippling nature of his suicidal depression.

Depression is a disorder of mood, so mysteriously painful and elusive in the way it becomes known to the self — to the mediating intellect– as to verge close to being beyond description. It thus remains nearly incomprehensible to those who have not experienced it in its extreme mode.

Styron says that for those of us who have not experienced this kind of darkness, it is extraordinarily difficult to grasp how much like physical pain this anguish can be. Our more typical life experiences of disappointment and sadness, grief and loss, and the normal ups and downs of being human do not provide any accurate translation.

When my friend talked about choice, I relayed my experience with the ice bath. I told him I didn’t go through a decision-making algorithm on the benefits and drawbacks of leaving the tub, nor did I white-board potential solutions. Like any animal in pain, I instinctively bolted away from the source of it. No one needed to offer me the idea of exiting the tub, because that idea had already filled every neural pathway of my mind. (Many who have experienced psychic anguish are offended by the concept that someone who mentions suicide might give them an idea that they have not already had.)

My example references an acute pain, but extend that into a chronic day-over-day anguish that blinds the person to the possibility of a better day tomorrow. Perhaps people do not choose suicide so much as they finally succumb because they just don’t have the strength, supports, resources, hope, etc. to hold on any longer.

Recently, I have been offering a multiple choice question to audiences. Suicide is preventable:

A.  Never in Those Truly Intent on Suicide
B.  Sometimes, but Only in Advance of Acute Risk
C.  Always, but Only in Advance of Acute Risk
D.  Always, Even Up to the Last Moment

The idea that “suicide is a choice” is central to our disbelief that we could actually save everyone. But, we know we can extend and strengthen a person to hold on, even in spite of desperate pain.

Last year, I had the pleasure of meeting Major General Mark Graham and his wife Carol, who tragically lost two sons, Kevin and Jeff, in the military within seven months of one another. One died as a result of an IED in Iraq; the other was taken by suicide. You expect courage from leaders in the army, but I was so inspired by the choice this couple made to speak out about their pain and make themselves vulnerable in order to help and support others. Their choice demonstrates bravery to the tenth power.

In his appearances, Maj. General Graham speaks of Rabbi Kushner’s famous book “When Bad Things Happen to Good People,” in which the author highlights a study done regarding how much pain one can endure and for how long. Individuals were timed on how long they could hold their feet in a tub of ice water, first by themselves, and then with another individual in the room with them. The study found they could persevere almost twice as long when they were not alone. Kushner’s conclusion: “The mere presence of at least one caring person doubles the endurance of an individual.”

I think it’s a fair statement that almost no one chooses cancer. We simply would never frame someone’s struggle with such a disease in that fashion.  Why should suicide be any different? Yes, the individual did something: they pulled a trigger or they took an overdose. But I would argue that all of us react to pain, instinctively and immediately. The vast majority of us can only remain in a tub of ice water for so long. Imagine living day after day with extreme psychological pain and anguish.

Many of us have considered the phrase “committed suicide” as an inappropriate way to talk about the deaths of individuals who, despite their most tenacious efforts, could no longer endure unbearable pain. Perhaps Maj. General Graham has a better focus. I haven’t heard him talk about choice; he talks about sitting with the person in pain and helping them hold on. That’s even better.

*Note: Also, see my YouTube TED-style TALK at the 2014 National Council for Behavioral Health Conference in Washington, DC, “Everything we knew about suicide was wrong.”

What’s the Best New Year’s Resolution?

health word cloudNearly half of Americans made a New Year’s resolution over the past week. I did. I pledged to return to the Six Gap Century road race in north Georgia, which means I’ll need to spend a lot more time on my road bike in 2014. In fact, many people’s resolutions revolve around health and wellness, and the top ten year over year include losing weight, getting fit, eating better, and quitting smoking.

Resolutions for improving health aren’t limited to individuals. A recent Forbes article highlighted Obamacare’s focus on prevention and wellness, and if you’ve been in a Walgreens in the past year, you’ve probably heard, “Be well,” at the register. It’s the spirit of our time.

It turns out that these are all great goals to have. A meta-analysis by Holt-Lunstad et. al. surveyed 148 studies of mortality risk in 2010 and quitting or decreasing smoking was #2 in the list of effective means to reduce mortality. Increasing physical activity (#5) and losing weight (#6) were also positively correlated. Abstaining from excessive drinking and getting an annual flu shot, while not your typical New Year’s resolution, were also helpful (#3 and #4, respectively).

But the #1 most significant action one can take to improve mortality odds and health outcomes? The one neglected by many of us in our New Year’s resolution? Have more friends. Research shows that a stronger social network of family, friends, and relationships is really good for your health.

Make no mistake: lifestyle changes and improvements in health and wellness are important, particularly for individuals with Serious Mental Illness (SMI). A 2006 research study of six states by the National Association of State Mental Health Program Directors (NASMHPD) found a decreased average life span of 25-30 years compared with the general population.  And it’s not that healthcare leaders and policy makers aren’t doing a lot to tackle the problem. There has been tremendous focus since USA Today brought the disparity to the public’s attention, explaining that those with diagnoses like Schizophrenia, Bipolar Disorder, and Major Depressive Disorder are dying at the average age of 50, while most Americans are living into their late 70s. You’d have to look to countries like Afghanistan for a comparably low life span, where professional primary care and preventive services are unavailable at levels in Western countries.

Typically, our analysis of mortality rates for individuals with SMI has been based on medical conditions, rather than the root causes. While suicide was an issue cited in the USA Today report, the larger challenge was preventable diseases. Individuals were 3 to 5 times more likely to have heart disease, diabetes, and respiratory problems like COPD, and obesity was a very significant issue. A very large percentage of these individuals also smoke. Quickly, many policy makers called for systems change.

Historically, a Grand Canyon-sized chasm existed between “silos” delivering these services; care was fragmented. That is all changing, and we are seeing the most fundamental administrative and organizational changes in the public behavioral healthcare system since deinstitutionalization. The 2010 Milbank Memorial Fund report “Evolving Models of Behavioral Health Integration in Primary Care” provided a basic road map.

The Chronic Care Model (also, called the Planned Care approach) has been shown to yield the strongest outcomes and dramatically improves care coordination, active follow-up, and training so individuals can self-manage their own illnesses. Care is closely and fully integrated, care teams are prepared and proactive and engage in productive interactions with individuals receiving services who are informed and activated. In this fully integrated model, behavioral health is a routine part of medical care. Mental health staff members are not coming from a specialty niche, but are members of the core care team.

Consensus believes, and nearly 80 randomized clinical trials suggest, that the planned care model is a really good “resolution” for our healthcare system.  There are also many health plans focused on important elements (using the out-of-vogue term “disease management”) like healthy eating, increased physical activity, and smoking cessation.

The integrated care movement continues to transform the way behavioral health, primary care, and specialty medical services are delivered and managed. But how much effort are we spending on the problem that can give the greatest outcome?

There are a few prophets out there we should listen to. Rick Brush is a former Cigna executive who launched Collective Health. He contends that perfect healthcare service delivery might solve 30% of the life-span disparity, but the stronger challenges are the social determinants of health. Similarly, Emory researcher Benjamin Druss points to the importance of non-medical factors, such as a history of abuse and/or neglect, past trauma, environmental stressors, poverty and, again, social supports and connectedness (Robert Wood Johnson Foundation, “Mental Disorders and Medical Comorbidity,” 2011).

Social supports and friends seems to be a greater challenge for men. It’s not uncommon for a woman to report having coffee with a close friend they have known since second grade, and they seem more apt to expand their network over the course of their lifetime. Thomas Joiner has written about the opposite proclivity in the male gender (Lonely at the Top). His Interpersonal Theory of Suicide proposes that one of the two required elements for suicide risk is feeling, “I am alone;” what he calls thwarted belongingness.

For those with Serious Mental Illness, improving social networks is a stark challenge. When I was at Magellan Health Services, our team reviewed nearly 20,000 Health Risk Assessments for those being served in the most intensive behavioral healthcare services. We developed a social supports algorithm that considered the answers to three questions:

1) Do you have someone to talk with about your problems (besides a professional)?

2) Do you have someone to go out with for a movie or meal?

3) Do you live alone?

Forty-one percent reported rarely or never for the first two questions and also shared that they lived alone (see Slide Deck Presentation). These are the same individuals struggling with multiple chronic health conditions, and we have rarely focused on the link between improving health and improving social supports. While coaching on diet, exercise, and smoking cessation, as well as better care coordination, will make a difference, we must concentrate our efforts attending to those for whom “friends just can’t be found” (from the old Simon & Garfunkel song).

One Health is a company working to tackle this challenge by bringing social networking and other online self-management supports to individuals with SMI, but it’s time for direct service healthcare leaders to innovate in this area as well. Former SAMHSA administrator Charlie Curie is fond of saying that people with mental illness want the same things the rest of us do: a job, a safe place to live, and a date on Friday night…the friends who will provide the supports that actually promote health, wellness, and longer life.

Of course, there are many positive things happening regarding integration, and the related challenges are sufficiently great, that it’s easy to say we should wait. I recently had lunch with my friend and national peer leader Eduardo Vega. His reply was germane. “It’s not so much that we don’t see the glass as half-full; it’s just that we’re really thirsty.”

Perhaps it’s time for a new New Year’s resolution, one that may make the most difference of all.

*Note: David would like to acknowledge the Magellan Health Services Regional Behavioral Health Authority where he was responsible for the integrated care program from 2010 to 2013. Eduardo Vega is the Mental Health America of San Francisco executive director and a member of several national leadership groups, including the National Action Alliance for Suicide Prevention. 

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