Strategic Objective 4
Strategic Objective 4 strives to bring the knowledge and findings derived from the previous Strategic Objectives to practice, to improve the reach and quality of existing services, and to develop novel evidence-based services.
Strategic Objective 4: Strengthen the Public Health Impact of NIMH-Supported Research
The previous objectives focused on the development of new diagnostics and new therapeutics that will transform mental health care in the future. Unfortunately, the pace of discovery science is not a good match for the urgency of the public health need. The increasing prevalence of autism, the persistently high rates of suicide, the mental health needs of service members and veterans, the treatment delays experienced by youth with early psychosis, and the chronic disability and early mortality of serious mental illnesses are among the problems that demand a rapid response. Fortunately, we need not wait for the distant future to see research impact public health. A lesson from the NIMH Recovery After an Initial Schizophrenia Episode (RAISE) project is that services research can speed implementation of evidence-based care for early psychosis in community settings by optimizing the organization and delivery of current treatments. In the new mental health care landscape, there should be many opportunities to improve outcomes with new financing and care delivery models, with services provided outside the traditional health care systems (in schools, in community settings, at workplaces, and online), and with care integration. NIMH’s role is to support the science that capitalizes on these opportunities, providing the best evidence about how to organize care to ensure the best outcomes.
How can NIMH strengthen the public health impact of its research? One approach involves partnering with payers (e.g., Medicaid, commercial insurers), regulators (e.g., U.S. Food and Drug Administration), and local, state, and Federal decision makers to determine what research will provide the requisite evidence for improving outcomes in the world of practice. A second approach develops new modes of health care service delivery, for example, the expansion of developmentally focused team-based care as in the RAISE project. A third approach, based on the learning health care system concept, builds a feedback loop between practice and research so that each encounter with a person receiving care yields data that are used to improve the care system on an ongoing basis.
The next 10 years will see more change in the mental health ecosystem that will affect how we provide care. Technological advances such as real-time availability of health information, remote sensing of health status over time, and a fundamental shift in how individuals interact with the health care system and providers (e.g., email, texting, online social networks) have the potential to improve an individual’s care experience. Yet strategic questions must be answered for technology’s promise to materialize. What are the critical targets for improving the care delivery system and improving mental health outcomes in diverse populations (e.g., sex, gender, age, race, ethnicity)? How can research contribute to creating and using new tools to address those targets? In what new ways can health care data be leveraged to address pressing patient, provider, and system-level needs? Which research methods are best suited for assessing public health impact? These complex questions demand us to ask: what partnerships must exist to address these questions efficiently and effectively? For stakeholders, a learning mental health care (LMHC) system provides the necessary forum for collaboration and shared responsibility. For those receiving care, LMHC means that care decisions are more frequently based on data, the practice of care will be subject to ongoing improvements based on broader arrays of information, and lessons learned will be shared across providers and patient networks. In LMHC, the consumers of care are at the center and are engaged as full partners in the process.
To improve evidence-based services that reach the broadest population, NIMH will employ the following strategies:
Right now, research can reveal opportunities to improve care. At all levels, and across sectors, leverage points exist to optimize the current standard of care. Local innovations have the promise to improve system outcomes, but are understudied and thus lack an evidence base that is sufficient to promote scale-up. In other situations, existing mental health services have limited effectiveness and need target-based approaches to improve delivery of high-quality and efficient care. Particularly within the area of serious mental illnesses, we need research on the impact of alternative strategies to provide and pay for care in public and private health systems (e.g., accountable care organizations, bundled payment mechanisms, performance-based financing). To implement this strategy, NIMH will support research to:
- Employ existing real-world data collection systems to identify strategies for improving access, quality, and equity of mental health services in diverse populations.
- Identify, validate, and scale up innovative programs currently in use that improve mental health services for underserved populations.
- Optimize financing models for adults and children with serious mental illnesses to provide efficient and effective care in public and private health care systems.
The delay between research and practice is too long, and limitations in uptake of effective mental health interventions are widespread. We need large-scale change that broadly improves public health. Research to improve the dissemination, adoption, implementation, and sustainability of evidence-based interventions can reduce the lag between research discovery and clinical practice, radically alter the quality of care provided for people, and reduce disparities in access and quality of care for underserved and diverse populations. Dissemination and implementation research requires expanded partnerships with stakeholders who oversee the provision and financing of care, as well as those who directly benefit from evidence-based approaches (e.g., service users and caregivers). By necessity, these partnerships must leverage complementary efforts of other Federal agencies (e.g., SAMHSA, Centers for Medicare & Medicaid Services) and institutions with common interests and activities (e.g., PCORI, state agencies, private and public health care systems). To effect this strategy, NIMH will support research to:
- In partnership with key stakeholders, develop and validate strategies for implementing, sustaining, and continuously improving evidence-based practices.
- Build models to scale up effective interventions for use in public and private primary care, specialty care, and other systems.
- Develop decision support tools that increase the effectiveness and continuous improvement of mental health interventions in public and private primary care, specialty care, and other systems.
Evidence suggests that current service delivery models are inadequately organized to meet the needs of the U.S. population. New models of service delivery that move beyond traditional care systems and address challenges posed by an insufficient workforce and limited capacity for monitoring and following up care (e.g., drawing from lessons learned in global mental health research conducted in low- and middle-income countries) could significantly improve the impact of mental health services on population health. We must circumvent the traditional shortcomings of mental health care by developing and testing novel components of care across multiple settings where mental health services are needed, and use advanced tools to better reach the population and deliver immediate, appropriate, and progressively improving care. To implement this strategy, NIMH will support collaborative research to:
- Develop systems-level strategies in nontraditional mental health care settings using technology and other approaches to identify, support, and monitor the effectiveness of care for individuals with mental illnesses.
- Develop and validate service delivery models that provide responsive and preemptive evidence-based supports for individuals throughout the course of illness.
- Develop and validate coordinated medical decision-making models that bridge multiple social and medical care settings to integrate the appropriate care for people with serious mental illnesses and multiple chronic conditions.
Tools available to improve mental health services have shifted rapidly toward approaches that emphasize team-based care, systems integration, technological developments, data aggregation, and new financing models. The next generation of investigations will require a range of platforms to study the prevalence of mental illnesses, quality of care, practice variations, and the impact of new innovations on access, efficiency, clinical outcomes, and epidemiologic indicators. New research designs, measures, and statistical approaches will be needed to support rapid testing of system improvement efforts and to facilitate analysis of complex data arising from the growing digital enterprise. To achieve high-impact public health research, new training models will be required that embrace new opportunities, including advanced information and communication technologies, and assessment and analytic strategies for complex data. Finally, we need to harness new opportunities afforded by citizen-centered science and crowdsourcing. These approaches provide collective expertise and evidence to help shape research questions and optimally answer them. To implement this strategy, NIMH will support research to:
- Develop assessment platforms within service systems that allow ongoing monitoring of mental illness prevalence, service access, quality, efficiency of care, and outcomes in diverse populations and settings.
- Develop valid and reliable measures of treatment quality and outcomes that can be feasibly applied at the person, clinic, system, and population levels.