National Behavioral Health Quality Framework

National Behavioral Health Quality Framework – Overview

In 2010, the Patient Protection and Affordable Care Act (PPACA—or ACA) charged the U.S. Department of Health and Human Services (HHS) with developing a National Quality Strategy (NQS), the purpose of which is to better meet the promise of providing all Americans with access to health care that is safe, effective, and affordable. In March 2011, the Secretary of HHS reported to Congress on a National Strategy for Quality Improvement in Health Care. Using the NQS as a model, the Substance Abuse and Mental Health Services Administration (SAMHSA) has developed the National Behavioral Health Quality Framework (NBHQF).

By behavioral health, SAMHSA refers to mental/emotional well-being and/or actions that affect wellness. Behavioral health problems include substance use disorders; alcohol and drug addiction; and serious psychological distress, suicide, and mental disorders. Problems that range from unhealthy stress or subclinical conditions to diagnosable and treatable diseases such as serious mental illnesses and substance use disorders are included. These illnesses and disorders are often chronic in nature but people can and do recover from them with the help of a variety of interventions, including medical and psychosocial treatments, self-help, and mutual aid. The phrase “behavioral health” is also used to describe service systems that encompass prevention and promotion of emotional health; prevention of mental and substance use disorders, substance use, and related problems; treatments and services for mental and substance use disorders; and recovery support.

The NBHQF provides a mechanism to examine and prioritize quality prevention, treatment, and recovery elements at the payer/system/plan, provider/practitioner, and patient/population levels. The NBHQF is aligned with the NQS in that it supports the three broad aims of better care, healthy people/healthy communities, and affordable care. However, it was specifically broadened to include the dissemination of proven interventions and accessible care. The latter concept encompasses affordable care, along with other elements of care accessibility, including the impact of health disparities.

The NBHQF provides a mechanism to examine and prioritize quality prevention, treatment, and recovery elements at the payer/system/plan, provider/practitioner, and patient/population levels. The NBHQF is aligned with the NQS in that it supports the three broad aims of better care, healthy people/healthy communities, and affordable care. However, it was specifically broadened to include the dissemination of proven interventions and accessible care. The latter concept encompasses affordable care, along with other elements of care accessibility, including the impact of health disparities.

SAMHSA offers the NBHQF as a guiding document for the identification and implementation of key behavioral health quality measures for use in agency or system funding decisions, monitoring behavioral health of the nation, and the delivery of behavioral health care.

In late 2012, the NBHQF underwent two phases of review and input, involving the nomination and selection of key quality measures that were endorsed by a panel of stakeholders internal to HHS, and a second panel of external stakeholders composed of researchers, consumers, clinicians, and state agency personnel.

Recent calls by the National Quality Forum (NQF) and other bodies for additional behavioral health quality measures have prompted significant growth in the number of measures that are “in the pipeline” for endorsement and use. Most are process measures, focusing primarily on mental health conditions such as depression. In the future, a broadened range of NQF-endorsed behavioral health measures is expected.

SAMHSA also recognizes the importance of looking beyond NQF endorsement for measures that capture the breadth of behavioral health activities addressed by SAMHSA and HHS, particularly those for which the evidence base is not mature or areas in which data collection is still evolving. The field of behavioral health quality measurement is relatively young in its development.

Identifying key behavioral health quality indicators is a complicated endeavor. Considerations include the acceptable level of evidence, the breadth of indicators of quality treatment (e.g., what are the key elements that make up high quality psychosocial treatment for a mental health condition; were clients offered a choice when both medication therapy and “talk” therapy are evidence-based options?), and the lengthy history of anecdotal and evaluative evidence that may not yet have been adequately captured.

SAMHSA, other HHS partners, federal colleagues beyond HHS, and many private sector behavioral health entities are committed to appropriately describing, measuring, and implementing quality behavioral health care. In order to advance this objective, SAMHSA has proposed a set of behavioral health quality measures to be collected and tracked by age, race, ethnicity, and other factors to monitor the impact of health and behavioral health changes across the nation.

With the NBHQF, SAMHSA proposes a set of core measures to be used in a variety of settings and programs, as well as in evaluation and quality assurance efforts. The proposed measures are not intended to be the complete or total set of measures a payer, system, practitioner, or program may want to use to monitor quality of its overall system or the care or activities it provides. Yet, SAMHSA encourages such entities to utilize these basic measures as appropriate as a consistent set of indicators of quality in behavioral health prevention, promotion, treatment, and recovery support efforts across the nation.

Likewise, as measurement capacity and quality measures evolve, the NBHQF will also evolve, making it a living document playing a critical role in discussion and implementation of behavioral health quality assurance and monitoring efforts nationwide. To the extent possible, SAMHSA will begin to incorporate these measures and this framework into its own quality assurance tools, such as program evaluations, technical assistance, training, product development, etc. Both the NBHQF and its potential uses are evolving as the field of behavioral health quality assurance changes and matures.

The six NQS goals are: evidence-based practices, person-centered care, coordinated care, healthy living for communities, reduction of adverse events, and cost reductions. The impact of each of those goals will be tracked via a set of core behavioral health quality measures across three targets or domains. The targets are: payers (SAMHSA, other federal agency, state/county, or private payers); providers/practitioners; and general populations (individuals, families, and communities).

Where possible, quality measures included in the NBHQF will:

• Be endorsed by NQF or other relevant national quality entities
• Be relevant to NQS and NBHQF priorities
• Address “high-impact” health conditions
• Promote alignment with attributes across programs that include health and social programs and across HHS
• Reflect a mix of measurement types: outcome, process, cost/appropriateness, and structure
• Apply across patient-centered episodes of care, and
• Account for population disparities.

These were the criteria used in the selection of measures. Also considered were the substantial investments made over the last 10 years by government agencies such as SAMHSA, the Centers for Medicare and Medicaid Services (CMS), the U.S. Preventive Services Task Force (USPSTF), and also by private resources such as NQF and the National Committee on Quality Assurance (NCQA).

These public and private bodies have developed and tested a variety of measures that serve as indicators of the well-being of individuals, families, and communities relative to behavioral health. Some examples are Washington Circle Group’s Healthcare Effectiveness Data and Information Set measures, Treatment Episode Data Sets; SAMHSA’s National Survey of Substance Abuse Treatment Services (N-SSATs) and the National Survey on Drug Use and Health (NSDUH); and NQF's Consensus Standards for Treatment of Substance Use Disorders.

Quality measures for behavioral health conditions should also be derived from data that are compliant with patient privacy protections such as 42 CFR Part 2 (Confidentiality of Alcohol and Drug Abuse Patient Records), the Health Insurance Portability and Accountability Act, institutional review boards, and other policies as applicable. For many behavioral health concepts, measures are still needed or need to be vetted and endorsed. SAMHSA has been working with the Office of the Assistant Secretary for Planning and Evaluation (ASPE), CMS, and NQF, among others to develop, vet, and validate additional measures.

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Examples of Recommended Measures and Identified Gaps

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Next Steps for the National Behavioral Health Quality Framework

The NBHQF is designed to be an evolving guide for national progress toward measuring and improving behavioral health and the quality of care. At this early phase, it is recognized that relatively few acceptable outcome measures exist that are endorsed by NQF or other relevant national entities. As mentioned above, SAMHSA anticipates significant growth in outcome measures available to the field within the next few years. The agency will continue to utilize specific National Outcome Measures (NOMs) currently in use that meet both SAMHSA’s and the field’s requirements to demonstrate progress under health reform. As evidence for new outcome measures accrues, it is expected that SAMHSA and stakeholders will work together to incorporate these improvements in subsequent iterations of the NBHQF.

Over time, it is expected that a rich catalog of behavioral health outcome, process, and structural measures will be endorsed and/or accepted as achieving the appropriate level of evidence by the field and payers.

The areas of prevention, wellness, and recovery deserve special attention within the arena of future development. Prevention and wellness measures are often captured as population-level measures. In addition, SAMHSA is actively engaged in defining and measuring the concept of recovery.

During 2014, SAMHSA will be conducting a pilot test to integrate a recovery measure into existing grantee programs’ data collection efforts: an eight-item recovery instrument originally developed by the World Health Organization, along with items specific to mental health and substance abuse recovery that are currently collected by SAMHSA.

The NBHQF will be refined and updated regularly. The measures matrix in the Exhibit provides an overview of recommended core behavioral health quality measures. When possible, NQF-endorsed measures or existing NOMS are recommended. The Appendix contains recommended supplemental measures capturing additional vulnerable populations perhaps not found within the core measures. Measure concepts are identified to help the reader understand the breadth that measures in the matrix address.

Each of the NBHQF’s six goals has two pages. The first page presents currently available and recommended measures. They are intended to reflect broader concepts addressed by a priority/goal area, and will be updated periodically to represent the state-of-the-art in behavioral health quality measurement. The second page presents future measures that are targeted as important in advancing the quality of behavioral health activities. Additional vetted measures for consideration as supplemental measures are offered in the Appendix.

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Exhibit 1: Recommended and Future Measures

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Appendix: Additional Measures for Consideration

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