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In our first blog post on March 3rd, 2023, we reported on efforts by the Primary Care Behavioral Health Special Interest Group (PCBH SIG) to advance the understanding of screening and outcome measurement in demonstrating the value of the integrated model of service delivery. Since that time a Measurement-Based Care (MBC) workgroup was created to continue this work within CFHA. The following blog post and ongoing work is written by members of the MBC Workgroup.

As healthcare makes a shift toward value-based care, the field of integrated behavioral health requires a framework that guides clinics, clinicians, and health systems to choose outcomes that connect to effective measurement while simultaneously demonstrating value to the system at large.

To advance the field of integrated care, we must come to a consensus on the following questions:

• What metrics demonstrate integrated behavioral health providers’ impact on primary care services?
• Which validated tools do we need to demonstrate impact?
• Which MBC strategies are best for our primary care patient population?
• How do we prepare our healthcare systems and providers to utilize an MBC approach?

The only shared consensus on screening and outcomes currently is that there is no shared consensus. To move forward, the MBC Workgroup proposes establishing a framework for screening and outcome measurement.

The Framework

Unlike physical health conditions, mental health conditions cannot be measured through blood draws and lab work. Without this, the value of integrated behavioral health programming relies on alternative outcome measures that demonstrate the impact of care provided.

One opportunity lies in the role of behavioral health screening in primary care which: 1) At a population level, identifies individuals at risk for mental health disorders, and 2) Provides a quantitative measure that demonstrates the impact of BH intervention once identified. Many approaches to behavioral screening exist across health systems, including universal vs. targeted screening and workflows such as administering the “behavioral health “vitals” (ex: depression and anxiety screeners). The value of routine behavioral health screening, universally and for targeted at-risk populations, is the gathering of data to inform treatment and tracking over time as well as to destigmatize addressing behavioral health in the primary care setting. For more on the challenges and experiences of behavioral health screening within CFHA, see our last blog post.

Another opportunity lies in measuring the medical outcomes of patients with comorbid conditions who are receiving integrated behavioral health services. The value in this approach is the direct implication of the benefit of the integrated model of care. For instance, amongst populations with comorbid depression and diabetes, can we demonstrate a clinically significant reduction in A1c amongst patients receiving PCBH interventions? Or, for patients with comorbid anxiety and hypertension, can we demonstrate clinically significant improvement in blood pressure?

Ideally, the answer isn’t one or the other, but both. By using validated assessments to demonstrate improvement in mental health along with physical health indicators to demonstrate improvement in overall wellness, the value of PCBH becomes clear to the patient (they feel better), the system (more appropriate utilization of resources and monetary incentives from payors), and the payor (decreased total cost of care).

Standardization of Concepts and Evidence-Based Tools

This work is not easy and requires standardized workflows and organizational population level screening and rescreening goals, with dedicated quality assurance (QA) resources to help support the data review.  We are all at different levels of implementation and maturity when it comes to adopting a routine approach to measuring outcomes.  Change cannot begin until we have baselines for what we know and what we do so that we can set new goals for expansion and improvement.

As a part of building that baseline understanding, the MBC workgroup has developed an operational definition of Measurement-Based Care.

Measurement-Based Care (MBC) involves the routine evidence-based practice of using quantitative data over time to guide and inform patient-centered treatment decisions. In Integrated Care, MBC describes using reliable, valid data sources, such as patient-reported progress and outcomes of functioning and health behaviors, in a collaborative manner with patients and their care team to continually monitor and inform treatment.

Operationally, MBC is often described as comprising of the following three core components to improve treatment outcomes:

• Routine & frequent administration (e.g., before each encounter) of validated outcome measures (e.g., symptom, functioning, or process measures).
• Practitioner(s) and patient review of that data; and
• Shared decision-making and a collaborative re-evaluation of the treatment, informed by the data.

Measurement-Based Care for Your Context

The first step in the MBC process is to formalize expectations for how to administer, review, and discuss measurement tools with your patients and care teams.  How do we use this to inform treatment and treatment planning?  We must develop rubrics to guide the treatment team, then go back to our MBC process and evaluate impact. As a field these rubrics would guide us with addressing common barriers to implementing MBC such as the following challenges:

• Identifying preferred integrated BH measures that would fit well within an MBC approach to integrated care (e.g., brief, or feasible measures that can be administered routinely and frequently for a real time, collaborative, feedback discussion by provider and patient to make any necessary changes in treatment)
• Determining whether to use validated measures that track symptoms, functioning, health-related quality of life, and/or wellness
• Training clinical teams in routine outcomes measurement, not just screening
• Identifying what BH measures have established norms with non-clinical and clinical populations that can also identify “on” or “off-track” patients during care
• Utilizing fidelity measures for the integrated behavioral health program and primary care team
• Identifying measures that are evidence-based (i.e., have been investigated by a randomized controlled trial) within an MBC approach and have demonstrated improvement in outcomes vs. routine or treatment-as-usual care

Once these processes are in place, we may be able to really start to evaluate, “Is what we are doing working.”  And truthfully, the ultimate definition of “working” is “are patients getting better?”  What is “better?” That’s the question we are all trying to answer. For an MBC approach that focuses on “patient directed” outcome measures, the patient’s goals are crucial to understand, as well as how an individual patient defines “getting better” —may it be certain lifestyle changes, changes in psychological symptoms, changes in bio- markers, or quality of life changes, etc.

Aligning with Primary Care System Goals

We also suggest aligning MBC processes with primary care goals in the context of integrated care. In a recent report by the National Academies of Sciences, Engineering, and Medicine (NASEM) on Implementing High-Quality Primary Care, health centers are encouraged to move towards outcomes that include overall patient engagement and connection with the health system, with the theory being as patients become more engaged with the health system, health outcomes (e.g., A1C scores) will improve. Despite all the advances in technology, medicine is still fundamentally a human endeavor, and despite the sophisticated diagnostic tools of modern medicine, the conversations between patient and doctor remain the primary diagnostic tool.

A core component of a measurement-based care approach is the role of collaboration and patient-directed feedback. We aspire to guide the standardization of an approach to measurement in integrated behavioral health models of service delivery (PCBH in particular) that improves fidelity and quality across the field and aligns with other initiatives like the call from NASEM.

Acknowledgements

Blog authors: Amanda Brooks, Kelli Bosak, and Meghan Fondow, with editing/contributions by Brian DeSantis, Bill Sieber and Dave Haddick

MBC Workgroup: Amanda Brooks, Kelli Bosak, Meghan Fondow, Bill Sieber, Dave Haddick, Brian DeSantis, Sara Green-Otoro, Chris Hunter, Meghan Fondow, Stanley Lieberson

References

Barber & Resnick, 2021; Scott & Lewis, 2015; Kearney et al., 2015; Peterson et al., 2018; Lewis et al., 2019; Ofri, 2017.