Information Center Bulletin
Volume 1, No. 2 Winter 1997-98

CMHS Project Develops Performance Indicators For Managed Behavioral Health Care

Although managed care is in the process of being analyzed, researched, and scrutinized, no one really knows how it's playing out for public mental health care. One of the surest ways to remove much of the guesswork is to provide the right tools to those who actually deliver those services on a day-to-day basis.

County mental health authorities bear the legal and fiscal responsibility for 70 percent of the U.S. population receiving publicly funded mental health care. And county mental health authorities must swiftly be able to gauge how well the rapid shift to managed care is taking place. To meet this need, the federal Center for Mental Health Services (CMHS) sponsored a project to develop performance indicators for managed care to help county mental health authorities tease apart what is working-and what is not.

"We saw an important information gap at the county level where a number of systems-such as mental health, substance abuse, housing authorities, and social welfare-often converge," says Roger Straw, Ph.D., the former CMHS official who helped get the project rolling. "We were very fortunate others recognized the need for this information as well, and were willing to collaborate with use on performance indicators."

These performance indicators are a joint effort between the Evaluation Center@HSRI, a CMHS technical assistance center at the Human Services Research Institute, and the National Association of County Behavioral Health Directors. "The performance indicators require field-testing," says Stephen Leff, Ph.D., the Evaluation Center's director and principal investigator. "Once they are tested, counties will have a straightforward guide to measure how well their systems are performing in a managed care environment."

Leff acknowledges that a number of performance indicators for managed care are being developed by leading private and public organizations in the mental health field. Among them are the American Managed Behavioral Health Association, the National Commission on Quality Assurance, the College of Mental Health Administrators, and CMHS with its highly regarded "Consumer-Oriented Mental Health Report Card"-all with a slightly different spin. In fact, Leff says these various efforts are a bit like "everyone coining their own money."

"If everyone makes their own money, then it's very hard to have a market and everyone's money becomes devalued," Leff says. "Recognizing that, many organizations are working to integrate the various performance indicators. In the long run, I think there'll be a consensus on core measures everyone needs to use, and that different organizations will add measures that are useful for their particular purpose."

The county performance indicators are distinct, Leff adds, in part because they address the needs of counties that are integrating multiple systems. "So one thing that sets these performance indicators apart is that they track what's going on in, say, admissions to state hospitals and jails to determine if the mental health program really is working and not just cost- or care-shifting."

Public vs. Private Sector

Public sector and private sector managed care needs vary. Most notably, people who receive services in the public sector have a higher degree of disability and use a broader array of continuous services. In the private sector, people tend to use targeted services, such as outpatient mental health care, and use them much more sporadically.

As a result, some managed care performance standards should automatically be built into the public sector that aren't necessarily measured in the private sector, says Robert Egnew, M.S.W., M.PH., president of the National Association of County Behavioral Health Directors (NACBHD).

"For example, there should be 24-hour telephone access. What's more, the person receiving the call should be trained in mental health, and have the language and cultural skills that meet the population's needs," Egnew says. "And we can't just wait for people-such as the homeless who have serious mental illnesses-to walk in the door. So we need outreach services. Key public agencies also need to have memoranda of understanding to clarify responsibilities and linkage mechanisms. In addition, we need a grievance process to protect consumers' rights, and we need a provider appeals process in case payment for services is denied."

The managed care performance indicators for counties developed for CMHS by NACBHD and the Evaluation Center do that, and more. "We've framed five performance indicators for managed care that we believe are important to monitor in the public sector, although some are also applicable in the private sector," Egnew says.

The performance indicators target five areas:

• Utilization (e.g., tracking the number of clients from different Medicaid populations, mode of service, and various benchmarks);
• Access (e.g., timely service, convenient location, array of appropriate services, adequate linkages to other agencies, and linguistic and cultural competence);
• Consumer satisfaction (e.g., outreach services, instant feedback, and the right to choose one's provider);
• Systems integration (e.g., tracking other systems, such as juvenile justice, education, and social welfare to determine if mental health programs are effective); and
• Functionality (e.g., ability to keep a job, to live independently, and to develop adept psychosocial skills).

"We believe these performance indicators will give community-based providers not only the nuts-and-bolts tools to work effectively in a managed care environment," Egnew says, "but also equip them to have a pulse on exactly what's going on in the system so they can provide services that truly meet consumers' wants and needs."

These performance indicators for managed county mental health care are a "work in progress" and are available on the Information Center's Web site. For a hard copy of the complete document, contact the Evaluation Center@HSRI.

For more information, contact Lawrence Woocher at 617-876-0426, or Robert Egnew at 408-755-4509. The Information Center's Web site address is mentalhealth.samhsa.gov/.

Information Center Bulletin
Volume 1, No. 2
KEN98-0057