Implementing the Quadruple Aim in Behavioral Health Care

Brief review and suggested item(s). As noted, substance use disorders confer an increased risk for early mortality^15,19 and are significantly implicated in disease disability burden worldwide.³⁰ Substance use has also been associated with both the onset^47,48 and exacerbation of mental health diagnoses.^49-51 Further, substance use appears to heighten the risk of violence in the general population⁵² and especially among those with a co-occurring mental illness.^53,54 The County Health Rankings & Roadmaps list alcohol and drug use as key behaviors to address to improve the overall health of a given county,¹³ and the Centers for Medicare & Medicaid Services (CMS) has endorsed initiation and engagement in addiction treatment as one of the measures in its Adult Core Set.⁵⁵

Tobacco use continues to be one of the most significant risk factors for early mortality worldwide, and evidence indicates that it is associated with a lower life expectancy of nearly 10 years.⁵⁶ Unfortunately, rates of tobacco use are even higher among those with severe mental illness relative to the general population, and their rates of smoking cessation are lower.^57,58 Tobacco use is a significant risk factor for the high rates of early mortality in individuals with severe mental illness.¹⁸ Further, a recent meta-analysis noted that, relative to those who continued to smoke, those who ceased smoking had reduced rates of psychological distress and increased quality of life rankings.⁵⁹ Reducing tobacco use is one of the key components of the County Health Rankings & Roadmaps, and medication assistance with smoking and tobacco use cessation is also listed in the CMS Adult Core Set.^13,55

An accumulating body of evidence suggests that single-item measures can adequately detect alcohol^60-62 and drug use disorders.^60-64 McNeely and colleagues recently developed and tested a brief 4-item screen, the Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) tool.^65,66 Preliminary evidence suggests that the TAPS tool can effectively identify the presence of problematic and disordered use of tobacco, alcohol, prescription medications, and other drugs.^65-67 BHD will use the 4 items from the TAPS tool to represent its substance use CD.

Education/Employment Status. This CD assesses the proportion of BHD members who have completed high school, who are in some type of educational or training program, or who are engaged in some type of employment activity (defined as full-time, part-time, supported, sheltered workshop, or as a full-time homemaker).

Brief review and suggested item(s). Research indicates that unemployment is a risk factor for mortality, even after controlling for other risk factors (eg, age, sex, socioeconomic status [SES], health).⁶⁸ Unemployment is associated with poorer physical and mental health in the general population and among those with disabilities.^69-71 Promisingly, evidence suggests that gaining employment or re-employment is associated with better health,⁷² even for individuals with substance use disorders⁷³ or moderate⁷⁴ to severe mental health disorders.^75-78 Some authors have even proposed that, above and beyond the associated health benefits, employment may also help to realize a modest cost savings due to reduced service utilization and disability.^79,80 Employment is a core tenet in the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) model of recovery,⁸¹ and is also listed as an important recovery goal for individuals with behavioral health issues.⁸² BHD collects data on employment status on all the patients it serves as part of its state-mandated reporting requirements and will use this item in the CD data set.⁸³