The “Usual Care” Quality Conundrum: A Call to Action

Abstract

The synthesis of current knowledge about specialty outpatient children’s mental health care in this article provides a sobering reminder that we have effectively been ‘‘asleep at the wheel’’ when it comes to comprehensive evaluation of the quality of mental health services being provided to children and families. In this new age of health care reform, this is a travesty that cannot stand. We cannot be complacent and be steamrolled into accepting anything less than the rigorous evaluation of what is being provided to youth and families in ‘‘usual care’’ settings. The fact that this selective review focuses primarily on services provided in specialty outpatient mental health settings is precisely why readers should pay attention. It is of grave concern to me that this is exactly the type of care that will be supported by health care reform initiatives. A chilling pall comes over this reader as the authors detail the ineffectiveness of usual care. I can’t help but ask the question––If usual care is ineffective, what will be supported in health care reform? Actually, that’s a rhetorical question because it is precisely ‘‘usual care’’ that will likely be supported in health care reform. And if that doesn’t get your attention and make you want to review this article with great care and attention to the macro level of quality children’s mental health care, then you are in the wrong business. Usual care should be radically broadened to include a robust family partner component along with access to family-driven respite care and innovative mobile crisis response options, to name but a few key ingredients that go far beyond the typical outpatient care scenario. Garland, et al. shines a bright light into the dark corners of traditional mental health delivery. They note that 68 % of the care in the studies reviewed were clinic based. A sobering reminder of how fragile our current mental health services are is the finding that ‘‘a third of the directors with site-specific budget data indicated that their agency ran at a budget deficit.’’ This is so important for advocates to understand. For us, ‘‘what works’’ goes far beyond usual care. It involves the active participation of community groups and families and initially may cost more. Yet, a third of Clinic Systems Project (CSP) cited in the article ran at a deficit and the largest funding source was Medicaid, which has what I consider to be narrowly fundable criteria, i.e., ‘‘usual care.’’ Are you starting to get the picture? If we allow policy makers to just fund what we do now, (i.e., usual care) without doing rigorous quality checks, then we are doomed to a mediocre at best mental health service delivery system. We need a system that evaluates and supports services beyond usual care if we are going to make significant improvements. Garland et al. (2013) identify studies that show that the majority of children receiving community-based ‘‘usual care’’ do not show clinical improvement. We need much more research to find examples of excellence and promote them so that funders can see the impact––clinically, financially and overall improvement in the family and community. The article also talks about promising strategies, including integration of behavioral health with services such as primary care and education. Traditional outpatient care is dead in my opinion. It’s just that those practicing it Improving community-based mental health care for children: Translating knowledge into action, by Ann F. Garland, Rachel HaineSchlagel, Lauren Brookman-Frazee, Mary Baker-Ericzen, Emily Trask, Kya Fawley-King.