What do the US, Myanmar, and Liberia all have in common? They are the only countries in the world who do not commonly use the metric system of measurement. Instead of kilos, liters, and meters, we measure in pounds, gallons, and yards (i.e., the English system). No big deal, right? Well, consider that in May 1999 the $123 million Mars Climate Orbiter was lost when it veered off course and burned up in the Martian atmosphere. A week later, NASA revealed the cause: One part of the orbiter’s navigation system was speaking in English units and another in metric. The lesson seems clear: use wisdom when choosing a measuring stick.
In the fields of science and medicine, we have an objective measurement system based on a universal physical constant (speed of light). In the field of integrated health care delivery, there is no objective system of measurement, no gold standard to follow. All of the measuring tools we use today are rooted in certain values and beliefs about what makes integrated care work. They are the products of fallible humans striving to do the best they can with what they have. Yes, some of these beliefs are supported by evidence or widely practiced; but none of them can lay claim to be the only road to Rome.
That said, how do you measure integration? What stick(s) are in your tool bag for evaluating your integrated care service? There are several benefits for implementing a regular system of collecting and analyzing data points that reflect upon your service. First, that data can indicate successes and gaps in your service. Are you reaching enough patients? Do all the medical providers participate in your service? Second, you can demonstrate value to stakeholders (e.g., funders, payers, decision-makers). Are you seeking a grant? Data from your measurement system will strengthen your position. Third, data can reveal the individual performance of clinicians and staff. Are you a manager or supervisor? What data do you need to evaluate your subordinates? Fourth, you can advance the science of integration by measuring your service and reporting your results.
If you’re like most of us in this field, then research and evaluation training is something you have had to pick up along the way in your career. I have learned that developing a culture of quality improvement in your clinic really helps to generate energy and support for measuring an integrated care service. Seek out champions among your colleagues who are also interested in data collection and analysis. Also, find ways to make your measurement a regular part of the clinic workflow. Identify data points that you are already collecting and then imagine new ones that want to collect in the future. Finally, remember that you cannot measure everything and not everything should be measured. Start small with your plan, stick with it, and grow over time.
What should you measure? I recommend using the RE-AIM framework to guide your decision-making process on data points. For example, if you want to know if your integrated care service is reaching the target patient population, then you may want to count the number of patients screened, the number of positive screenings, and the number who needed treatment actually receiving that treatment. If you want to determine the effectiveness of your service, then consider measuring patient outcomes like symptom reduction (e.g., PHQ-9, GAD-7), functional improvement, quality of life, and care utilization (e.g., number of visits, hospital admissions). If you want to measure how often your medical providers are engaging in the integrated care model, then look at measuring the number of same-day referrals (e.g., warm handoffs), formal referrals, the number of clinicians who referred last month, and the number of team huddles or meetings with a behavioral health provider. There are many other operational and financial data points you can measure.
Remember to be judicious and pragmatic when choosing the right data points for your organization. Once you start analyzing your data, look for care gaps and prioritize the gaps that are most important for addressing first. Once you choose the most important gaps, then describe how clinical practice will change using tools like a process map. Then, engage your team in making the change and continuing your measurement plan. At that point, you can repeat the cycle over and over. Your measurement plan will likely change over time, especially as new policies and practices emerge. But you and your team will be ready to craft new sticks for new metrics.
Gold, S. B., & Green, L. A. (Eds.). (2018). Integrated Behavioral Health in Primary Care: Your Patients Are Waiting. Springer.