In Brief
While the clinical eye of an experienced and astute provider is invaluable, even the most seasoned physician will not always be able to look at you and know if you’ve gained 10 pounds, let alone if your blood pressure has gone up or your temperature is high. And yet, all of these readings are central to your health and essential in guiding the care that you are provided.
If your new medication is reducing your blood pressure but all of a sudden you’ve gained a bunch of weight, your health care provider will likely make adjustments to your treatment plan. Alternatively, when your fever breaks and your temperature starts to go down, even if you’re still in your pajamas and feeling crummy, you can see the light at the end of the tunnel and know that you are on the mend.
That’s why every time you see your primary care provider you step on the scale then sit still while the blood pressure cuff tightens around your arm. If you’ve gone in because you’re sick, you’ll probably also get your temperature read. Of course, in the days of the pandemic, sick or not, you’ll often get it read before you even enter the building.
Knowing these markers for your health and being able to track changes is just as important for mental health care, where measurement-based care has been shown to improve client outcomes.
What is Measurement-Based Care?
Measurement-based care may sound complex and technical, but it is actually quite simple. It requires only two things: routinely collecting brief, validated patient self-report questionnaires and incorporating the results into treatment. The questionnaires must have established scoring thresholds and be sensitive in measuring symptoms as well as changes in symptoms over time.
Questionnaires are often given at the beginning of treatment to offer a baseline and to track client progress over the treatment period. This allows for a celebration of victories when certain symptoms improve and adjustments in treatment when symptoms deteriorate or problematic symptoms arise.
Mental health issues are complex and multifaceted. DSM V criteria can span multiple unique symptoms for one diagnosis. As such, it’s not always clear when a person is improving in certain aspects of functioning and staying stagnant or declining in others. Self-report questionnaires can track these symptoms with more specificity and precision, highlighting progress and recognizing shifting problem areas.
Clinicians can track multiple symptoms for a variety of mental health issues including residual symptoms, which can increase the likelihood of relapse or recurrent episodes. They can also monitor the side effects of medications. For example, a medication for depression may improve mood while inadvertently increasing insomnia. Measurement-based care can also track overall functioning and quality of life, readiness for change, and the therapeutic alliance, which is central to treatment outcomes.
As a society, we need to improve our mental health outcomes, which are far poorer in real-world settings than those achieved in randomized clinical trials. These trials have a leg up due to their use of regular measurement of symptom severity coupled with algorithm-based treatment adjustments. If anything, the systematic measurement of therapeutic outcomes can steer your clinical ship in the right direction while accounting for real-world complexities. And there is no reason that these practices cannot be implemented more widely in mental health treatment.
Measurement-based care has been shown to improve outcomes in psychotherapy and medication management in part because mental health professionals are often not able to accurately detect symptom deterioration or lack of substantial improvement. Used in conjunction with clinical judgment, measurement-based care offers a lifeline for clinicians to overcome treatment inertia and adjust clinical decisions appropriately.
Benefits of Measurement-Based Care
Measurement-based care offers benefits to clients, clinicians, and practices alike. In addition to supporting more effective and efficient treatment, it also allows practices to offer value-based care. The following sections explain these benefits in more detail.
Improves Care Experience
Beyond improving outcomes in psychological disturbances, relationship issues, social functioning, and quality of life, clients who complete symptom ratings throughout treatment report feeling more respected and engaged in the treatment process. In addition, they report a greater sense of ownership in treatment decisions.
Measurement-based care also accelerates symptom improvement and offers clients a better understanding of their diagnoses, symptoms, and therapeutic endpoints. For example, one study exploring measurement-based care for clients with depression found that the clients who used standardized measures gained a better understanding of their experience with depression after learning how to quantify their symptoms.
The recognition of a specific set of symptoms that other people experience can also break down the stigma associated with mental illness and provide a sense of connection to combat the feeling of being alone in one’s struggles.
Restores Joy in Practice
Burnout is a significant problem in the mental health field. Measurement-based care is meant to improve the clinician experience by enhancing treatment outcomes while providing insight into treatment progress, facilitating the development of a treatment focus, and reducing the worsening of client symptoms.
It can save clinicians time by clearly displaying relevant symptoms each time they pull up the client record. It also streamlines the assessment process and assists clinicians in developing differential diagnoses. If you’re prescribing medications, patient-reported symptom measures can help optimize medication response.
Beyond providing a boost for direct client care, measurement-based care also supports care coordination in multi-provider teams and across clinical spaces.
Demonstrates Value
Mental disorders are on the rise in the United States and come at a great social and financial cost to our society. Nevertheless, mental health providers remain under-compensated compared to physical health providers.
Low reimbursement levels may be a reflection of payor perceptions that mental health treatment is a low return on investment. Client outcome data can be used to demonstrate the value of mental health treatment.
Utilizing the data collected from patient questionnaires, a practice can zoom in and out from individual clients or clinician caseloads to population and practice-based data, tracking trends over time and supporting the quality of an organization as a whole.
Measurement-based care is, therefore, a win-win in that it supports improved client outcomes while also creating a platform for providers, practices, and healthcare systems to demonstrate that the services they deliver are effective.
As payors are increasingly shifting from fee-for-service to value-based models, there is also an increasing demand for accurate outcome measures. Measurement-based care supplies empirical data to payors that can ultimately change the narrative of mental health treatment and bring it up to speed with reimbursement rates for physical health treatment.
Implementing & Integrating Measurement-Based Care
It can be overwhelming to figure out how to implement new systems of care, particularly when most mental health providers and practices already have so much on their plates. It sounds like it would require a prohibitive amount of resources, infrastructure, and training to make it work, right? Absolutely wrong, it turns out. Implementing measurement-based care in your practice is actually quite simple and can be accomplished in a few concrete steps using the acronym SOCCER.
Select
S stands for Select brief, validated outcome measures that are connected to your treatment goals and objectives. These measures will be unique to each provider and practice. If you are a practice focusing on OCD and anxiety disorders, you may want to select symptom measures for those specific disorders, while if you’re a psychodynamic therapist focusing on mild-to-moderate mental health issues, you may elect to track the therapeutic alliance. There is no one right answer for the selection, so choose the measures that align with your treatment goals.
Operationalize
O stands for Operationalize. This means that clinicians are to develop a standard for how they expect each client’s symptoms to improve over time using their treatment model. This may be different for every client, but what is important is that the clinicians are able to see when a client is lagging behind their expected progress. They can then make adjustments to support better outcomes.
Collect
C stands for Collect your outcome measures at regular intervals, ideally weekly. These can be completed by clients between sessions or at the start or end of each session depending on the measures and what works best for your model of care.
Collaborate
C stands for Collaborate with your clients to review the results of their assessments in your sessions, answer questions and make sense of the changes. This is where measurement-based care can really contribute to the clinical process. Having illuminated their specific symptoms and any changes they may not have previously noticed, measurement-based care allows clients to reflect on their experience, coping strategies, challenges, and personal recovery goals. Clinicians can capitalize on this additional information and client engagement to promote rich discussions and enhanced self-reflection.
Examine
E stands for Examine the trend in progress over time, both at the client and practice levels, to see if it matches your expectations. When your expectations are not being met, you can consider changes towards improved outcomes.
Respond
R stands for Respond to results by celebrating even the smallest improvements and adjusting treatment when appropriate to address symptom stagnation or deterioration. In addition to regularly collecting the measurements, responding to the data collected is a cornerstone of measurement-based care.
Overcoming Obstacles in Measurement-Based Care
We can all agree that the last thing busy clinicians need is more paperwork. Using technology, patient questionnaires can be embedded in the electronic health record thus reducing the burden of paperwork on clinicians and offering easy-to-use access to clients.
Rather than sorting through a stack of paperwork or manually scoring questionnaires and mentally charting progress over time, electronic health records make it possible for measures to be scored, charted, visualized, and tracked automatically. These days, clinicians can simply pull up a client’s record to view their symptoms, scores, and changes over time.
The question then becomes what to do with that information. Many mental health professionals were not trained in incorporating self-report questionnaires in their workflow. However, once they realize that they are simply accessing information that they wouldn’t be able to accurately collect with the naked clinical eye, they can incorporate that knowledge into their regular clinical practice, regardless of their theoretical background or approach. It’s just like giving a swimmer goggles and fins: they can keep doing what they’re doing but swimming will all of a sudden become a whole lot easier.
Given all of the benefits of measurement-based care, you’d think that nearly every mental health provider would be using it. Although it has been successfully implemented in public, private, specialty, and primary care practices, still only around 18% of psychiatrists and 11% of psychologists use it.
And the truth is, implementing measurement-based care cannot happen without an initial investment. Measures need to be selected and integrated into the electronic health record, and clinicians need to develop a standard practice for incorporating the information into their workflow. There are also upfront costs and organizational requirements that can be tough to muster up even though the investment is worthwhile.
Improving Mental Health Care is Possible
Ultimately, we’re all in this field for the same reason. We care about mental health, recognize its significance, and believe in high-quality support and treatment that reduces difficult and painful symptoms and promotes wellbeing.
Backed by decades of research, measurement-based care improves mental health outcomes, tracks changes that aren’t perceptible to the clinical eye, and promotes a strong therapeutic alliance. In any health-related field, when there is a clear practice that promotes significantly better outcomes, it only makes sense to adopt it.
As the days of manual charting and bound manila folders become an anachronism, measurement-based care becomes more and more of a no-brainer.
