Use Of Measurement-based Care Research Articles

Implementation of Measurement-Based Care in Mental Health Service Settings for Youth: A Systematic Review.

Measurement-Based Care (MBC) is the systematic use of patient-reported data to inform care decisions and monitor treatment progress. MBC has been shown to improve patient outcomes across medical and mental health treatment settings for adults and youth. While many studies have examined the use of MBC in specific care settings, few have focused on the implementation of MBC among youth populations or across care settings. While a review has shown that use of MBC benefits youth, no published reviews exist that summarize the successful strategies and barriers to implementation models across studies in youth service settings. To address these gaps, the present systematic review (N = 25 studies) focuses on the implementation of MBC across four youth service settings, including outpatient mental health centers, medical centers/pediatric clinics, schools, and clinical psychology training clinics. Results suggest that few studies employ consistent implementation models or strategies to guide efforts. Further, there is significant overlap in the successful strategies employed as well as the barriers to implementation of MBC across youth service settings, at the client, clinician, and organizational levels. Broadly, the authors recommend on the basis of findings that future implementation work in youth service settings: incorporate comprehensive training in the use of MBC for clinicians; incorporate stakeholder feedback into the implementation process for initial and sustained use; employ digital measurement feedback systems to deliver MBC that allow for real-time feedback and continuous technical support; and employ a health equity lens in implementation efforts to help address disparities in access to and use of MBC so that all youth and families may benefit from this evidence-based practice.

Shifting From Best Practice to Standard Practice: Implementing Measurement-Based Care in Health Systems.

There is a high prevalence of untreated depression in adults and youth observed at the population level in the United States, and many who would benefit from treatment do not receive it. One proposed effort to increase access to care is the use of measurement-based care (MBC; repeated use of symptom measures for screening and treatment guidance) by primary care physicians to treat non-complex cases of depression. MBC has been shown to improve patient outcomes compared to care as usual, but there are barriers that need to be addressed at the health system level for effective implementation to occur. Herein we provide an overview of MBC and detail benefits and barriers of MBC implementation. Relevant considerations and guidance for implementing MBC are presented, and a case example of a health system implementing MBC is included. Though issues of reimbursement, limited human and technological resources, and resistance to systemic change are barriers to implementing MBC, effective strategies exist to overcome these barriers. In addition to helping health systems align with changes to value-based care models, effective implementation of MBC can likely improve patient outcomes and result in net financial benefits.

Comprehensive Virtual Treatment for Severe Anxiety in Youth: A Case Report

Anxiety disorders and obsessive-compulsive disorder (OCD) are among the most common mental health conditions in children and adolescents and are associated with various impairments and long-term consequences. Evidence-based treatments exist but are often lacking in elements needed to effectively treat youth with more severe presentations. This case report illustrates a patient’s treatment course in an innovative program for children, adolescents, and young adults with severe anxiety. The program offers a continuum of outpatient, evidence-based care tailored to the severity of the patient’s condition. The case study focuses on “Jane,” an adolescent female with anxiety as well as obsessive-compulsive spectrum disorders, who had previously received extensive treatment without sustained improvement. Through the program’s three treatment phases, Jane and her parents demonstrated consistent engagement and adherence to treatment. Jane showed significant progress, with rapid reduction in symptoms and functional impairment. This case report underscores key elements of this treatment that address gaps in traditional approaches to care, particularly for patients with severe presentations, including the coordinated, team-based approach; the continuum of evidence-based, phased treatment titrated to need; the utilization of virtual individual, group and parent-focused care and between-session coaching to enhance learning generalization; and the use of measurement-based care. Further research is warranted to evaluate the generalizability and long-term outcomes of this program and its potential to transform the treatment landscape for pediatric anxiety and OCD.

Using Measurement-Based Care as a Precision Medicine Strategy for Substance Use Disorders.

Precision medicine prioritizes characterization of individual patient parameters to optimize care and this review evaluates measurement-based care (MBC) as a strategy for doing so in the treatment of substance use disorders (SUD). Measurement-based care refers to the systematic use of validated assessments to inform diagnosis and treatment planning, with varying frequency of assessments. Despite the seemingly obvious grounds for the use of MBC in treating SUD, systematic implementation to date has been limited. Thus, the goal of this review is to evaluate efforts to date and to stimulate greater consideration of MBC models in addictions programs. Data from two published randomized controlled trials and findings from pragmatic clinical research highlight the potential utility of MBC in the SUD treatment settings. Despite these findings, the existing literature indicates the high need for larger-scale clinical trials and quality improvement programs. Potential barriers to the implementation of MBC for SUD are outlined at the patient, provider, organization, and system levels, as well as the challenges associated with the use of MBC programs for clinical research. Critical thinking considerations and risk mitigation strategies are offered toward advancing MBC for SUD beyond the current nascent state. Collectively, the existing data confirm that MBC is a suitable and promising strategy for applying a precision medicine approach in SUD treatment, warranting further implementation efforts and scientific inquiry.

Integration of Measurement-Based Care for Youth Depression and Suicidality Using VitalSign6.

Depression and suicidality are prevalent in youth and are associated with a range of negative outcomes. The current study aimed to evaluate a measurement-based care (MBC) software (VitalSign6) tool to improve the screening and treatment of depression and suicidality in youth aged 8-17 years within a rural, underserved population. To assess for depression and suicidality, the Patient Health Questionnaire-2 was administered as an initial screen, and the Patient Health Questionnaire-9 Modified for Adolescents (PHQ-9-A) was administered if the initial screen was positive. Data were collected at medical clinics over one year, and descriptive statistics and t-tests or Wilcoxon-Mann-Whitney tests were conducted. A total of 1,984 youth were initially screened (mean age of 13 years; 51.6% female); 24.2% screened positive for depression, and 14.9% endorsed suicidality. Of those who screened positive, the mean PHQ-9-A score was 12.8; 66.9% had PHQ-9-A scores in the moderate to severe range, and 44.2% endorsed suicidality. Almost half of the youth who screened positive for depression had at least one follow-up assessment, and about one quarter achieved remission 4 months after initial screening. Adolescents (12-17 years) had higher PHQ-9-A scores, higher suicidality, and more follow-up assessments than younger youth (8-11 years). Younger youth had higher rates of remission. The widespread use of MBC was feasible in this setting. It is important to utilize MBC to identify and treat youth with depression and suicidality and to do so in younger populations to improve their trajectory over time; VitalSign6 is one tool to help achieve these goals.

Measurement-Based Care for Depression: Personalized Management Approaches for Optimized Treatment Outcomes

Use of measurement-based care (MBC) in depression includes the systematic administration of validated clinical measurement tools to guide the screening, assessment, treatment, and monitoring of clinical outcomes in patients with depression. In clinical practice, MBC can be used to screen for and assess severity of depressive symptoms, and guide treatment selection and change in type of treatment when clinical improvement is insufficient. In addition to identifying depressive symptoms, MBC can also help detect co-existing psychiatric conditions to inform more precise treatment selection. Furthermore, the MBC approach entails regular assessments of symptom severity, adherence, and side effects, which facilitates timely and vigorous dose adjustments of antidepressants to improve clinical outcomes. MBC can also be used to monitor specific symptoms that are associated with poor depression outcomes to allow acute-phase prognostication of treatment outcomes. The authors conclude that the MBC approach has many evidence-based benefits compared to the usual care and should be incorporated into the clinical care of patients with depression. [ Psychiatr Ann. 2023;53(9):395–399.]

Measurement-based care for suicidal youth: Outcomes and recommendations from the Services for Teens At Risk (STAR) Center.

Measurement-based care has demonstrable benefits, but significant implementation barriers slow dissemination in real-world clinical settings, especially youth behavioral health care. Here, we describe use of measurement-based care in a specialty clinic offering a continuum of outpatient care for suicidal youth. We characterize strategies used to facilitate measurement-based care in this population and ways in which challenges to implementation have been addressed. We examined adherence to measurement-based care procedures relative to treatment engagement data from electronic medical records, as well as data from clinicians regarding acceptability and utility of measurement-based care. Results suggest that measurement-based care is both feasible and acceptable for use with suicidal youth. Here we provide future directions in measurement-based care in this, and other, behavioral health settings.

Pharmacotherapy for Depression and Anxiety in the Primary Care Setting

The prevalence of mental health disorders is rising with the coronavirus of 2019 pandemic, and millions of Americans reside in areas with mental health professional shortages. Primary care providers have an opportunity to provide care for commonly occurring mental health disorders. Using a holistic conceptualization of recovery in mental illness, this report provides evidence-based guidance for initiation, titration, and discontinuation of pharmacotherapy for mild to moderate depression and anxiety in the primary care setting. The use of measurement-based care, selection of appropriate class and agent for individual candidates, and patient education are addressed. Best practices for troubleshooting, titration, and referral are discussed.

Educating Mental Health Trainees About Measurement-Based Care: A Scoping Review.

Measurement-based care (MBC) refers to the routine use of symptom rating scales to guide treatment decisions. Although effective, it is an underused approach to enhance patient care. A significant barrier to integration of MBC is insubstantial foundational training. This scoping review aims to survey the literature on MBC educational curricula for mental health trainees. Investigators searched Ovid Medline, PsycINFO, Embase, Cochrane Central, and Ebsco CINAHL through June 2021 to select records that described studies of MBC educational programs for undergraduate, graduate, or postgraduate learners in mental healthcare. From 1270 unique records, 1263 were excluded in abstract/title and full-text screening. This scoping review included seven articles, of which most were empirical or case studies and took place in the USA. These curricula involved many delivery formats, including lectures and in-service training. Measured learner outcomes include those that are learner-focused (i.e. learner reaction, or attitudinal/behavioral change) and organizational-focused (i.e. increased clinical use of MBC). Mechanisms of positive outcomes are posited to include enhanced stakeholder support and continual curriculum improvement. MBC curricula can be taught in various formats to diverse learners in mental healthcare. Contextual factors, such as dedicated resources, MBC champions, supervisor training, online measurement feedback systems, simple measures, and gathering and disseminating feedback may facilitate curricular success by fostering stakeholder support and continual program improvement. To address literature gaps, future research in MBC education should involve educational frameworks in designing curriculum and address the use of quality improvement approaches in the implementation of MBC education.

A Survey of Behavioral Health Care Providers on Use and Barriers to Use of Measurement-Based Care.

Despite robust evidence for efficacy of measurement-based care (MBC) in behavioral health care, studies suggest that adoption of MBC is limited in practice. A survey from Blue Cross-Blue Shield of North Carolina was sent to behavioral health care providers (BHCPs) about their use of MBC, beliefs about MBC, and perceived barriers to its adoption. The authors distributed the survey by using professional networks and snowball sampling. Provider and clinical practice characteristics were collected. Numerical indices of barriers to MBC use were created. Ordered logistic regression models were used to identify associations among practice and provider characteristics, barriers to MBC use, and level of MBC use. Of the 922 eligible BHCPs who completed the survey, 426 (46%) reported using MBC with at least half of their patients. Providers were more likely to report MBC use if they were part of a large group practice, had MBC training, had more weekly care hours, or practiced in nonmetropolitan settings. Physicians, self-reported generalists, more experienced providers, and those who did not accept insurance were less likely to report MBC use. Low perceived clinical utility was the barrier most strongly associated with less frequent use of MBC. Although evidence exists for efficacy of MBC in behavioral health care, less than half of BHCPs reported using MBC with at least half of their patients, and low perceived clinical utility of MBC was strongly associated with lower MBC use. Implementation strategies that attempt to change negative attitudes toward MBC may effectively target this barrier to use.

A modified measurement-based care approach to improve mental health treatment engagement among racial and ethnic minoritized youth.

Despite high levels of need, racial and ethnic minoritized (REM) youth are much less likely than their White peers to engage in mental health treatment. Concerns about treatment relevance and acceptability and poor therapeutic alliance have been shown to impact treatment engagement, particularly retention, among REM youth and families. Measurement-based care (MBC) is a client-centered practice of collecting and using client-reported progress data throughout treatment to inform shared decision-making. MBC has been associated with increased client involvement in treatment, improved client-provider communication, and increased satisfaction with treatment services. Despite its promise as a treatment engagement strategy, MBC has not been studied in this capacity with REM youth or systematically modified to address the needs of culturally-diverse populations. In this article, we propose a culturally-modified version of MBC, Strategic Treatment Assessment with Youth (STAY), to improve treatment engagement among REM youth and families. Specifically, STAY is designed to target perceptual barriers to treatment to improve treatment retention and ultimately, client outcomes. The four STAY components (i.e., Introduce, Collect, Share, and Act) are based on an existing MBC practice framework and modified to address perceptual barriers to treatment among REM youth. The clinical application of this model is presented via a case example. Finally, future research directions to explore the use of MBC as a treatment retention strategy with REM client populations are provided. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Sustainability of the Collaborative Chronic Care Model in Outpatient Mental Health Teams Three Years Post-Implementation: A Qualitative Analysis.

Our goal was to investigate the sustainability of care practices that are consistent with the collaborative chronic care model (CCM) in nine outpatient mental health teams located within US Department of Veterans Affairs (VA) medical centers, three to four years after the completion of CCM implementation. We conducted qualitative interviews (N = 30) with outpatient mental health staff from each of the nine teams. We based our directed content analysis on the six elements of the CCM. We found variable sustainability of CCM-based care processes across sites. Some care processes, such as delivery of evidence-based psychotherapies (EBPs) and use of measurement-based care (MBC) to guide clinic decision-making, were robustly maintained or even expanded within participating teams. In contrast, other care processes-which had in some cases been developed with considerable effort-had not been sustained. For example, care manager roles were diminished in scope or eliminated completely in response to workload pressures, frontline care needs, or the COVID-19 pandemic. Similarly, processes for engaging Veterans more fully in decision-making had generally been scaled back. Leadership support in the form of adequate team staffing and time to conduct team meetings were seen as crucial for sustaining CCM-consistent care. Given the potential impact of leadership turnover on sustainability in mental health, future efforts to implement CCM-based mental health care should strive to involve multiple leaders in implementation and sustainment efforts, lest one key departure undo years of implementation work. Our results also suggest that implementing CCM processes may best be conceptualized as a partnership across multiple levels of medical center leadership.

1.96 Implementation of Measurement-Based Care for Youth in Behavioral Health and Substance Use Clinics: An Examination of Barriers and Facilitators

Research has demonstrated that patient outcomes improve with the use of measurement-based care (MBC). Despite this, there has been limited implementation of MBC in behavioral health and substance use disorder (SUD) clinics. The current study aims to explore barriers and facilitators in the MBC implementation for youth in a child behavioral health clinic and an adolescent SUD clinic. We also aim to examine similarities and differences in barriers and facilitators between these clinics.

Organization-level variation in therapists' attitudes toward and use of measurement-based care.

Despite significant interest in improving behavioral health therapists' implementation of measurement-based care (MBC)-and widespread acknowledgment of the potential importance of organization-level determinants-little is known about the extent to which therapists' use of, and attitudes toward, MBC vary across and within provider organizations or the multilevel factors that predict this variation. Data were collected from 177 therapists delivering psychotherapy to youth in 21 specialty outpatient clinics in the USA. Primary outcomes were use of MBC for progress monitoring and treatment modification, measured by the nationally-normed Current Assessment of Practice Evaluation-Revised. Secondary outcomes were therapist attitudes towards MBC. Linear multilevel regression models tested the association of theory-informed clinic and therapist characteristics with these outcomes. Use of MBC varied significantly across clinics, with means on progress monitoring ranging from values at the 25th to 93rd percentiles and means on treatment modification ranging from the 18th to 71st percentiles. At the clinic level, the most robust predictor of both outcomes was clinic climate for evidence-based practice implementation; at the therapist level, the most robust predictors were: attitudes regarding practicality, exposure to MBC in graduate training, and prior experience with MBC. Attitudes were most consistently related to clinic climate for evidence-based practice implementation, exposure to MBC in graduate training, and prior experience with MBC. There is important variation in therapists' attitudes toward and use of MBC across clinics. Implementation strategies that target clinic climate for evidence-based practice implementation, graduate training, and practicality may enhance MBC implementation in behavioral health.

Understanding Veteran Suicide Risk and Mitigation Strategies During the COVID-19 Pandemic

U.S. Veterans experience a significantly higher risk for suicide compared to the general population. Understanding the challenges associated with coronavirus disease 2019 (COVID-19) enables providers to mitigate the risk of suicide among Veterans. Evidence supports access and utilization of U.S. Department of Veterans Affairs (VA) mental health services as they are a protective factor associated with lower suicide rates. During the ongoing COVID-19 pandemic, the VA has worked to further decrease deaths by suicide in the Veteran population by rapid expansion of current interventions and implementation of new evidence-based interventions. These interventions include mental health and coaching applications, consistent use of measurement-based care across multiple disciplines, and greater use of telehealth services. Through these efforts, despite increased risk for suicide due to additional stressors from COVID-19, suicide rates among Veterans are decreasing. [Journal of Psychosocial Nursing and Mental Health Services, 60(12), 25-29.].

Implementation strategies to promote measurement-based care in schools: evidence from mental health experts across the USA

BackgroundDespite an established taxonomy of implementation strategies, minimal guidance exists for how to select and tailor strategies to specific practices and contexts. We employed a replicable method to obtain stakeholder perceptions of the most feasible and important implementation strategies to increase mental health providers’ use of measurement-based care (MBC) in schools. MBC is the routine use of patient-reported progress measures throughout treatment to inform patient-centered, data-driven treatment adjustments.MethodsA national sample of 52 school mental health providers and researchers completed two rounds of modified Delphi surveys to rate the relevance, importance, and feasibility of 33 implementation strategies identified for school settings. Strategies were reduced and definitions refined using a multimethod approach. Final importance and feasibility ratings were plotted on “go-zone” graphs and compared across providers and researchers to identify top-rated strategies.ResultsThe initial 33 strategies were rated as “relevant” or “relevant with changes” to MBC in schools. Importance and feasibility ratings were high overall for both survey rounds; on a scale of 1 to 5, importance ratings (3.61–4.48) were higher than feasibility ratings (2.55–4.06) on average. Survey 1 responses resulted in a reduced, refined set of 21 strategies, and six were rated most important and feasible on Survey 2: (1) assess for readiness and identify barriers and facilitators; (2) identify and prepare champions; (3) develop a usable implementation plan; (4) offer a provider-informed menu of free, brief measures; (5) develop and provide access to training materials; and (6) make implementation easier by removing burdensome documentation tasks. Provider and researcher ratings were not significantly different, with a few exceptions: providers reported higher feasibility and importance of removing burdensome paperwork than researchers, providers reported higher feasibility of train-the trainer approaches than researchers, and researchers reported higher importance of monitoring fidelity than providers.ConclusionsThe education sector is the most common setting for child and adolescent mental health service delivery in the USA. Effective MBC implementation in schools has the potential to elevate the quality of care received by many children, adolescents, and their families. This empirically derived, targeted list of six implementation strategies offers potential efficiencies for future testing of MBC implementation in schools.

Gender differences in the PTSD symptoms of polytraumatized youth during isolated phases of trauma-focused cognitive behavioral therapy.

Gender differences in the development and severity of PTSD have long been observed, but much less is known about gender differences within the context of trauma-focused treatment. This study investigated gender differences in the PTSD symptoms of polytraumatized youth during Trauma-focused Cognitive Behavioral Therapy (TF-CBT). The sample included child welfare-involved youth ages 7-18 (N = 138) who experienced a mean of 4.78 types of trauma and received TF-CBT at a trauma treatment clinic. Mixed ANOVA analyses assessed gender differences in PTSD symptoms from baseline to termination of treatment. PTSD symptoms were then mapped according to the phase of treatment, and factorial ANOVAs examined gender differences during isolated phases of TF-CBT. Potential interactions with sexual violence history were considered. Significant reductions in overall PTSD, intrusive, avoidance and arousal symptoms were found from baseline to termination of TF-CBT for the entire sample, although females reported higher symptom levels across all PTSD symptom domains. Significant gender differences were also revealed during some, but not all, phases of treatment, with variations among PTSD symptom domains noted. Findings suggest TF-CBT is effective in reducing PTSD in youth with poly-trauma exposure, irrespective of gender. Gender differences in symptom severity were revealed, however, and indicate the need to attend to gender within the context of treatment. Findings also suggest the use of measurement-based care, and specifically attending to symptom fluctuation in PTSD symptom domains during treatment, can help inform clinical decision making and individualize treatment. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Measurement-based Care in the Adolescent Partial Hospital Setting: Implementation, Challenges, & Future Directions

ABSTRACT In this paper, we describe the process of implementing measurement-based care (MBC) in the adolescent partial hospital program setting. First, we outline the rationale for incorporating MBC in this treatment setting. Second, we describe the partial hospital setting in which implementation took place, including the patient population, treatment providers, and structure of programming. Next, we outline the initial implementation of standardized assessments into our programming, including key initial considerations and challenges during implementation. We describe the importance of considering the primary symptom presentations of the patient population when selecting assessment tools, the importance of leveraging existing electronic health record tools to efficiently track and record data collection, and the ability to integrate assessments into clinical workflows. Fourth, we present data describing compliance with implementation, patient outcomes, and providers’ attitudes toward and knowledge of MBC following implementation. We found after the initial implementation period, compliance was high. We also found providers had an overall positive perception of the use of MBC, reporting they perceived it to be helpful to both their clinical practice and patient outcomes. Finally, we discuss future directions for best utilizing standardized assessments in intensive treatment settings.

Measurement-based care in integrated health care: A randomized clinical trial.

Introduction: Many suggest that the next step for integrated care is widespread implementation of measurement-based care (MBC). Although the measures most associated with MBC are standardized, no randomized clinical trial has demonstrated their use to improve psychotherapeutic outcomes with embedded behavioral health providers in integrated care. Two evidence-based MBC systems have been studied in a variety of behavioral health environments, but neither system has been investigated in integrated health care. Addressing this gap in the literature, the present study evaluated the use of MBC, specifically the Partners for Change Outcome Management System, in three integrated care sites. Method: Using a randomized design within routine care, treatment as usual (TAU; n = 133) was compared using the Outcome Rating Scale (ORS) and Patient Health Questionnaire-9 (PHQ-9) with a feedback condition (n = 147) in which behavioral health providers had access to patient-generated outcome (ORS only) and alliance information at each session. Results: Patients in the feedback condition demonstrated significantly more improvement than those in the TAU condition posttreatment on the ORS. Patients in the feedback condition also achieved significantly more clinically significant change as measured by both the ORS and PHQ-9. Feedback condition patients also attended significantly more sessions and dropped out significantly less that TAU patients. Discussion: Although our findings need to be replicated, this study offers evidence that the improved outcomes and reduced dropouts associated with MBC in traditional behavioral health centers also occur in integrated care settings. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Improvements to PTSD quality metrics with natural language processing.

As quality measurement becomes increasingly reliant on the availability of structured electronic medical record (EMR) data, clinicians are asked to perform documentation using tools that facilitate data capture. These tools may not be available, feasible, or acceptable in all clinical scenarios. Alternative methods of assessment, including natural language processing (NLP) of clinical notes, may improve the completeness of quality measurement in real-world practice. Our objective was to measure the quality of care for a set of evidence-based practices using structured EMR data alone, and then supplement those measures with additional data derived from NLP. As a case example, we studied the quality of care for posttraumatic stress disorder (PTSD) in the United States Department of Veterans Affairs (VA) over a 20-year period. We measured two aspects of PTSD care, including delivery of evidence-based psychotherapy (EBP) and associated use of measurement-based care (MBC), using structured EMR data. We then recalculated these measures using additional data derived from NLP of clinical note text. There were 2 098 389 VA patients with a diagnosis of PTSD between 2000 and 2019, 72% (n=1 515 345) of whom had not previously received EBP for PTSD and were treated after a 2015 mandate to document EBP using templates that generate structured EMR data. Using structured EMR data, we determined that 3.2% (n=48 004) of those patients met our EBP for PTSD quality standard between 2015 and 2019, and 48.1% (n=23 088) received associated MBC. With the addition of NLP-derived data, estimates increased to 4.1% (n=62 789) and 58.0% (n=36 435), respectively. Healthcare quality data can be significantly improved by supplementing structured EMR data with NLP-derived data. By using NLP, health systems may be able to fill the gaps in documentation when structured tools are not yet available or there are barriers to using them in clinical practice.