Executive Summary

Whether you are at the state, county, or fiscal intermediary level, you are under tremendous pressure to prove that the services purchased with taxpayer dollars have positive outcomes and are used in the most efficient way possible.

The Institute for Medicine (IOM) report Crossing the Quality Chasm: A New Health System for the 21st Century makes the following recommendation:

"Government programs, employers, and other group purchasers of health care for mental and substance-use conditions use their dollars in ways that support the delivery of high-quality care."

During tight budget cycles, social services and health care are frequently the first thing to be cut because they are a large part of state budgets and the people served by these dollars are not well represented in the vocal minority that are heard by legislators and other elected officials. In these times, it is imperative that we stretch every dollar as far as it can go to provide both efficient and effective services.

In Crossing the Quality Chasm, the IOM identifies six aims of high quality health care, all of which apply to substance abuse treatment as well:

The Six Aims of High-Quality Health Care

• Safe: avoiding injuries to patients from the care that is intended to help them.
• Effective: providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse, respectively).
• Patient-centered: providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.
• Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care.
• Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy.
• Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

The STAR-SI initiative and other NIATx projects inform the lessons offered in this toolkit on how to achieve the six aims of high-quality health care in substance abuse and mental health treatment—without completely disrupting the system of care.

NIATx System-Level Toolkit Components

• Tools for providing technical assistance and training to providers
• Strategies for making changes to purchasing, payment, licensing and accreditation, and data collection mechanisms
• Case studies
• Interactive assessments
• Promising practices
• Data management tools

States and other purchasers of treatment services that have implemented these tools have improved the efficiency and effectiveness of the services they deliver. In some cases, better data management and reporting have supported increases in funds directed to their services. Most states have found that developing a collaborative relationship with providers facilitates system-wide change. Process improvement projects have contributed to increases in employee satisfaction and reduced staff turnover. As STAR-SI grantees can attest, the benefits of implementing a system wide process improvement effort are clear:

"New York has integrated process improvement as a core element of our statewide strategic destinations. We have included PI and, in particular, STAR-SI, as an approved evidence-based practice that we are committed to spreading throughout our wide-ranging prevention, treatment, and recovery system. We collaborated with our providers on the development of a web-based data reporting system that provides real-time feedback to them so that they can more accurately assess their progress on change projects. This "state change project" was implemented in less than four months."—New York

"STAR-SI has created a different relationship with our providers. Now, we simply call a provider when a data metric is down and ask them to conduct an analysis and develop a countermeasures plan."—Florida

"A major challenge facing the SSA has been to redesign the agency after a major staff reduction, i.e., from 146 positions to 80. We were concerned about how we could maintain our site visit-based provider monitoring system and training infrastructure. With PI, we are finding that we are able to conduct performance monitoring much more efficiently and with provider buy-in. Our STAR-SI Learning Collaborative forms the core of a new training infrastructure that providers like and is much more cost efficient." —South Carolina