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Readers Write: The Key Ingredient to Improving Outcomes in Behavioral Health: Measurement-Based Care
The Key Ingredient to Improving Outcomes in Behavioral Health: Measurement-Based Care
By Jason Washburn, PhD
Jason Washburn, PhD is a professor at Northwestern University Feinberg School of Medicine in Chicago, IL.
The burden of mental disorders is well known. Mental disorders are common, resulting in significant disability and contribute to — and complicate — chronic health conditions. Most mental disorders are untreated, and the COVID-19 pandemic has only further highlighted significant disparities in access to treatment. Effective pharmacologic and psychological treatments are available, yet outcomes in routine practice are often weaker than what is found in randomized controlled trials.
Measurement-based care (MBC) can improve the outcomes of routine mental health practice. MBC involves routinely and systematically evaluating mental health symptoms, ideally before or during a clinical encounter, to both inform and direct mental health treatment. For example, in 2015, a randomized controlled study of MBC in the treatment of depression found a much higher remission rate among the MBC group compared to usual treatment (73.8% vs. 28.8%).
What accounts for the impact of MBC on outcomes? MBC can help providers track the response of their patients to treatments, alert providers to when patients need to adjust treatment, and aid clinical decision making. For example, MBC can facilitate changes in dosage and medications, improve case conceptualization, identify the need to change treatment modality and targets, or to increase or decrease service frequency and intensity. MBC can also facilitate communication between patients and providers, improving the therapeutic relationship and shared decision making.
Patients like MBC. Patients accept MBC practices and report that it improves their care. When implemented correctly, providers also like MBC, recognizing its many benefits and utility in treating patients. Although providers often express fears about the burden of MBC, successful implementation of MBC usually results in little to no barriers or burdens for providers.
Despite the clear benefits of MBC, routine use of MBC remains rare. The available evidence suggests that less than 20% of psychiatrists, psychologists, and master’s level providers use any meaningful level of MBC. Why do so few providers use MBC?
Concerns with the practicality of implementing MBC is one of the primary barriers to utilization of MBC. Practical concerns can include the time required to complete measures, the administrative burden of administering measures, and disruptions to patient flow and processes. Another barrier is the reliance of providers on clinical judgment. Even when providers recognize that MBC is likely to improve their treatments, providers may fall back on their clinical judgemnt when the infrastructure for MBC is not available. Unfortunately, clinical judgment is not always accurate: One study found that providers were only able to accurately detect deterioration in their patients 21.4% of the time.
Although adoption of MBC has been slow, technological solutions hold promise for accelerating the integration of MBC into routine mental health care. Many – if not all – of the perceived and actual barriers associated with MBC can be addressed through technology infrastructure that supports fully automated MBC systems. Automated MBC systems can be integrated into existing clinical workflows, including the electronic health record, providing a seamless experience for both the patient and the provider.
Accelerating the adoption of MBC, especially through automated systems that provide access to outcome data at the individual and organizational level, will not only improve care, but increase access to care. Given that MBC is associated with faster response to treatment (e.g., 4.5 weeks in MBC group vs. 8.1 weeks in usual care), the increased efficiencies gained in using MBC allows for greater throughput of patients and increased access. By monitoring remissions rates, MBC can also help to identify when patients no longer need a specific level of care, facilitating quicker transitions to lower levels of care and termination, thereby increasing access for new patients to enter the system.
The available evidence is clear: MBC holds promise in improving mental health care. To actualize the potential of MBC, however, providers and the organizations that support them must make MBC a routine expectation in the provision of mental health treatment.
Hi Jason. Thanks for the thoughtful article. I believe that clinical decision support for behavioral health – which tracks physical health CDS by 20+ years – is a huge opportunity for BH outcomes and quality of care. In turn, I really like the insight you have that MBC could be a foundation for that. I think that the best opportunity for MBC would be in high-intensity services for the SMI population where the cost of treatment is high, reporting to managed care organizations and administration is stringent, and there is a great incentive to facilitate the quicker transitions you mention. These services include FACT, ACT, youth programs, crisis services, integration with law enforcement, etc. The other interesting thing about these services is that they are implemented with a set care team which could facilitate adoption. Overall, I agree with your observations and how MBC could provide great leverage to much-needed capacity and care. I’d be interested to know if there are any frameworks/quality measures that you respect/envision.
Many of the things that you say are correct, however:
1. Most electronic health records and patient portals do a poor job of integrating patient reported outcome measures in their systems and workflows
2. Those that do have some integration typically include only a few scales used in primary care such as the PHQ9 or GAD7 and not the breadth of measures needed for other psychiatric conditions
3. Available measures were designed and tested in specific research contexts and may not be sufficiently generalizable or sensitive to change to be used in other contexts. The PHQ9 and GAD7 are more focused on symptom frequency (days in the past two weeks) for example rather than symptom severity.
4. Many measures that may be useful are either proprietary (with costs that are prohibitive for routine clinical care) or have cumbersome processes to obtain authorization for use. The PROMIS measures were supposed to address such issues but have not gained widespread clinical adoption.
5. The reliability of self report scales is limited in serious mental illness including psychosis and mania.
6. Even for widely accepted self rated scales, there are limitations to the evidence of their reliability and reliability in historically under-represented demographic groups.
7. Similar limitations hold for clinician-rated scales, even ones that are viewed as a “good standard.” As but one example, the C-SSRS (in its multiple manifestations) includes compound questions that are even confusing for clinicians to answer. Plus there is no evidence that the “risk levels” correlated with the triage points tool are correlated with actual risk of death by suicide. Yet the Joint Commission and others are wedded to its use as a “evidence based tool”. In fact, it is just as evidence based (based on a substantial body of epidemiological work) and clearer to patients and clinicians to ask about suicidal thoughts and behaviors in a more traditional manner: wish for death y/n; thoughts of suicide y/n; suicidal plans (including method) y/n if y what are the plans? Suicidal intent y/n; suicide preparations y/n; past suicide attempts including aborted or interrupted attempts y/n and if y describe. These have been part of suicide risk assessment for decades (long before the C-SSRS) and are widely recommended in clinical practice guidelines. Thus, while structured consistent systematic assessment is important, there is nothing magical about tools such as the C-SSRS.
8. Similarly, there is nothing magical about specific score thresholds on other rating scales just as a lab test can be right on the threshold of normality. Yet people seem to be more rigid about interpreting scores from mental health measures in an either/or fashion.
9. Unfortunately, however, the most insidious and dangerous issue with so-called measurement based care is presaged by the closing words and by Nathaniel Weiss’ remarks i.e. the negative consequences for patients of these measures in terms of being prematurely terminated from care, losing disability benefits (and with it Medicare coverage), losing community mental health based housing (based on disability status), and other untoward consequences. Many people, especially those with serious mental illnesses, have very brittle illness, just like a brittle diabetic. No one would think of terminating a brittle diabetic from care just because their glucose levels are under control by one or more glucose measurements. So why are we even discussing the “benefits” of “measurement based care” in making quicker transitions and terminations of care for those with psychiatric disorders for whom we know that a stable consistent therapeutic alliance is just as important (if not more so) than in other clinical contexts. Perhaps, in addition to the other barriers to using patient reported outcomes in mental health treatment, clinicians are being understandably cautious in trying to protect their patients from even greater harm and outright discrimination and victimization by insurers and others.
I appreciate your thoughts, Concerned Clinician. It strikes me that many of your comments, appropriately, describe the choke chain of measurement based care. There are so many questionnaires as you note, and so few are effective. And the spectre of prematurely pushing a brittle patient with schizophrenia out of a wrap-around program because they haven’t decompensated for several weeks makes no sense.
I do believe, however, that there is great promise in MBC. Specifically around driving more considered and equitable reimbursement. I work with care teams that treat serious mental illness. And like many/most high-intensity care teams, they are scraping and clawing for funding. This makes sense in some regard because these high-intensity teams are infrastructure / pure cost. They don’t generate meaningful revenue and therefore have to constantly justify their existence. I believe that having measurement based care – lets just call it metrics – can change that by correlating care to operational improvement, better outcomes, and lower unnecessary utilization. And using that to improve funding of these high-quality wrap-around teams. (Not to mention using this information to drive better communication and respect within the provider organization.)
I understand and appreciate your points that there are a lot of hurdles to getting there, but I am a believer in the longer-term path/strategy of driving change through better visibility of the metrics and MBC.