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Fixing Behavioral Health Care in America - A National Call for Measurement-Based Care in the Delivery of Behavioral Health Services


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Originally Published: 12/07/2015

Post Date: 12/16/2015

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by Issue Brief Released by The Kennedy Forum


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Kennedy Forum | Issue Brief # 2 | Fixing Behavioral Health Care in America - A National Call for Measurement-Based Care in the Delivery of Behavioral Health Services

Summary/Abstract

The Kennedy Forum focus group's second white paper titled  Fixing Behavioral Health Care in America - A National Call for Measurement-Based Care in the Delivery of Behavioral Health Services.

Content

Issue Brief # 2

Fixing Behavioral Health Care in America

A National Call for Measurement-Based Care in the Delivery of Behavioral Health Services

 




Dec 10, 2015
by Patrick J. Kennedy

Measurement-based care is routine practice throughout the medical and surgical fields – from blood pressure cuffs to A1c tests for diabetes. Yet today, only 18% of psychiatrists and 11% of psychologists routinely administer simple measurement tools, such as symptom rating scales, to monitor their patients’ progress.

As a result, millions of patients seeking help for their behavioral health disorders are missing important opportunities to have their treatments adjusted in a timely manner, possibly leading to worsening symptoms that may be going altogether undetected by their providers.

Our latest policy issue brief, “A National Call for Measurement-Based Care in the Delivery of Behavioral Health Services,”
 
underscores how these proven tools can significantly improve outcomes for individuals living with mental illness and addiction in our country.

With Measurement-Based Care, behavioral health providers are empowered to fine-tune treatment plans when patients are not improving, and patients who participate in rating their symptoms are likely to become more knowledgeable about their disorders, attune to their symptoms, and cognizant of the warning signs of relapse or reoccurrence, enabling them to better self-manage their illness and seek treatment without delay.

It is time to make Measurement-Based Care a standard in behavioral health.



Published by The Kennedy Forum

In Partnership with
Advancing Integrated Mental Health Solutions (AIMS) Center, Department of Psychiatry and Behavioral Sciences,
University of Washington; and The Kennedy Center for Mental Health Policy and Research, Satcher Health
Leadership Institute, Morehouse School of Medicine

Kennedy Forum Focus Group Participants:*

Lauren Alfred, The Kennedy Forum   Kevin Middleton, PsyD, MHNet Behavioral Health
Carol Alter, MD, AstraZeneca Pharmaceuticals   Garrett E. Moran, PhD, Westat
Norman B. Anderson, PhD, American Psychological Association   Irvin Muszynski, American Psychiatric Association
Mary Barton, MD, National Committee for Quality Assurance   Theresa Nguyen, LCSW,Mental Health America
Andrew Bertagnolli, PhD, Kaiser Permanente   Samuel Nussbaum, MD, Anthem, Inc.
Brian Boon, PhD, CARF International   Joe Parks, MD, Missouri HealthNet
LTC Mill Brown, Army Behavioral Health Service Line   Laurel Pickering, MPH, NorthEast Business Group on Health
Garry Carneal, JD, The Kennedy Forum   Willa Presmanes, MTM Services
Tim Cheney, Chooper’s Guide   Phil Renner, MBA, Kaiser Permanente
Patrick Conway, MD, Centers for Medicaid & Medicaid Services   Linda Rosenberg, MSW, National Council for Community Behavioral Health Care
U.S. Department of Health and Human Services     Karen Sanders, American Psychiatric Association
Mark Covall, National Association of Psychiatric Health Systems   Lewis G. Sandy, MD, FACP, UnitedHealth Group
Bill Emmet, The Kennedy Forum   Brett Schneider, Walter Reed Medical Center
Charles Engel, RAND Corporation   Michael Schoenbaum, PhD, National Institute of Mental Health
John Fortney, PhD, University of Washington   Jody Silver, Collaborative Support Programs of New Jersey
Margot Friedman, JD, Dupont Circle Communications   Becky Sladek, University of Washington
David Gastfriend, MD, Treatment Research Institute   Gregory Simon, MD, MPH, Group Health Research Insitute
Mary Giliberti, JD, National Alliance on Mental Illness   Jim Spink, Beacon Health Options
David Gitlin, MD, Brigham and Women’s/Faulkner Hospitals   Jurgen Unutzer, MD, MPH, MA, University of Washington
Howard Goldman, MD, PhD, University of Maryland School of Medicine   Jeff Valliere, The Kennedy Forum
Henry Harbin, MD, The Kennedy Forum   Margaret VanAmringe, MHS, Joint Commission
Deborah Heggie, PhD, Magellan Health Services   Thomas Wilson, Trajectory Health Care
Rick Hermann, Tufts University of Medicine   Glenda Wrenn, MD, The Satcher Health Leadership Institute
Patrick Kennedy, The Kennedy Forum   Doug Zatzick, University of Washington School of Medicine
Carolyn Kurtz, JD Accreditation Association for Ambulatory Health Care    
Rick Lee, M3    

 

Authors/Editors:

Prepared by: John Fortney, PhD, Rebecca Sladek, MS and Jürgen Unützer, MD from the Advancing Integrated Mental Health Solutions (AIMS) Center, Department of Psychiatry and Behavioral Sciences, University of Washington in conjunction with The Kennedy Forum senior leadership team, including Patrick Kennedy, Henry Harbin, MD, Bill Emmet, Lauren Alfred, and Garry Carneal, JD.

*Note: The Kennedy Forum hosted several focus groups to discuss provider outcomes and accountability issues in the behavioral health field. This list is not exhaustive of all focus group participants. In addition, focus group participation does not mean a formal endorsement of The Kennedy Forum recommendations or this issue brief by the attending organizations.

Executive Summary

Patients with mental health and substance use disorders treated in routine care often experience worse outcomes than patients enrolled in clinical trials that have demonstrated the effectiveness of evidence-based treatments that incorporate routine monitoring with quantifiable measures of patient-reported symptoms. This large gap between routine outcomes and optimal outcomes exists across a wide range of patient populations and treatment settings, including primary care and specialty behavioral health.

A key means of narrowing the gap between actual and optimal outcomes is through clinicians’ routine, systematic use of standardized, patient-reported outcome instruments to determine quantitatively whether their patients are improving. Virtually all randomized controlled trials of outcomes measurement with frequent and timely feedback of results to providers during the clinical encounter found that outcomes were significantly improved compared to usual care across a wide variety of mental health disorders.

Patient-Reported Symptom Rating Scales

Symptom rating scales, a type of patient-reported outcome measure, are focused structured instruments that patients use to report their perceptions about the frequency and/or severity of the psychiatric symptoms they are experiencing. Symptom rating scales can cover a myriad of psycho-social functional Impairments and patient behaviors. A number of diagnostic-specific symptom rating scales exist that have been psychometrically validated to assess the severity of depression, bipolar disorder, anxiety disorders, post-traumatic stress disorder, schizophrenia, and substance use disorders. A number of validated symptom rating scales also exist that can be used for multiple diagnostic groups. These symptom rating scales (e.g., PHQ-9 for depression) are practical to administer, interpretable, reliable, and sensitive to changes in the frequency/severity of psychiatric symptoms and functional impairment over time. Much like using a blood pressure cuff to track treatment outcomes in hypertension, monitoring behavioral health outcomes with a symptom rating scale helps providers determine whether a treatment is working or not.

However, only 18% of psychiatrists and 11% of psychologists in the United States routinely administer symptom rating scales to patients to monitor improvement. With clinical judgement alone, behavioral health providers frequently fail to detect a lack of improvement or a worsening of symptoms in their patients, and this can lead to clinical inertia (i.e. not changing the treatment plan even though the patient is not benefiting from the current treatment).

Routine assessment of symptoms is essential to the provision of evidence-based mental health care. Symptom severity on initial assessment can influence which treatments are initially recommended for some disorders. The lack of symptom improvement within established time periods serves as an important indicator for considering changes to treatment. A standardized and validated means of quantitative measurement is essential for communicating patients’ clinical outcomes across providers and settings of care.

However, standardized symptom rating scales are not a substitute for perceptive clinicians carefully assessing symptoms and are not intended to replace clinical judgment. This issue brief does not recommend the use of quantifiable validated outcomes tools as a substitute for detailed clinician interviews.

The Clinical Impact of Measurement-Based Care

Measurement-Based Care is a key evidenced- based supplement to clinician assessments and interviews of their patients’ symptoms, functioning, and personal goals. Using standardized symptom rating scales is an example of a Measurement-Based Care approach.

Ratings scales are designed to optimize the accuracy and efficiency of symptom assessment in order to improve the detection of patients and/or targeted populations that are not responding to the current clinical interventions. With Measurement-Based Care, providers are empowered to more quickly change or fine-tune treatment plans when patients are not improving. In addition, patients who regularly complete symptom rating scales also are likely to become more knowledgeable about their disorders, attune to their symptoms, and cognizant of the warning signs of relapse or reoccurrence, thus enabling them to better self-manage their illness and seek treatment without delay.

Need to Use Rating Scales Effectively

Measuring patient-reported symptoms has the potential to improve outcomes, but not all approaches are effective. For example, assessing patients once for depression using a symptom rating scale (i.e. screening) does not by itself improve outcomes. Research also has shown that feeding back outdated symptom severity data to providers outside the context of the clinical encounter is not clinically actionable, and therefore, is not considered to be effective Measurement-Based Care for improving patient-specific outcomes.

To inform clinical decision making, data from symptom rating scales must be current, accurate, interpretable and easily available during the clinical encounter. For example, many pharmacotherapy and psychotherapy treatments targeta specific diagnosis (e.g., mood stabilizers for bipolar disorder, prolonged exposure therapy for posttraumatic stress disorder), and rating scales that are diagnostic-specific are often clinically actionable. As noted above, the vast majority of randomized controlled trials with timely feedback of diagnostic-specific, patient-reported symptom severity to the provider demonstrated the effectiveness of Measurement Based Care compared to usual care.

Expert Consensus Supporting Measurement-Based Care

For at least 20 years, leaders in the behavioral health field have been calling for the routine use of symptom rating scales to inform clinical decision making. Consensus exists too that Measurement-Based Care can also be used to improve outcomes at the provider and clinical levels, and also inform payers about the value of behavioral health services.

Without the systematic monitoring of symptoms, providers may miss opportunities to improve their treatments over time and clinical practices miss opportunities to evaluate quality improvement activities. In addition, when aggregated across all patients in a clinical practice or healthcare system, symptom rating scale data can be used to demonstrate the value of behavioral health services to payers, thereby helping to inform the development of reimbursement policies of payers. The failure to use symptom rating scales to demonstrate to payers and other stakeholders the effectiveness of behavioral health treatment may contribute to the chronic underfunding of behavioral health services in the United States. In other words, there are secondary gains to be made with Measurement-Based Care beyond improving the outcomes of individual patients.

Empirical Evidence Supporting Measurement-Based Care

Most randomized controlled trials with frequent and timely feedback of patient-reported symptoms to the provider during the clinical encounter significantly improved outcomes or trended towards significance. In the context of research and clinical practice, Measurement-Based Care has been found to be effective across a wide range of patient populations (e.g., adults, children), diagnoses, and treatment types (e.g., marriage counseling, individual psychotherapy, and pharmacotherapy). A meta-analysis of 27 randomized controlled trials enrolling patients with a variety of behavioral health disorders found that Measurement-Based Care programs that incorporated symptom rating scales into the clinical encounter in a systematic fashion promoted more effective care.

Feasibility

Symptom rating scales are feasible to administer in a range of clinical settings and are highly acceptable to patients and providers who have used them in a measurement-based practice setting. Measurement-Based Care can be incorporated into routine care regardless of the characteristics of the patient population, or the treatment philosophy and training background of providers.

Patients usually perceive symptom rating scales to be efficient, complementary to their provider’s clinical judgment and used as evidence that their providers are taking their behavioral health problems seriously. In addition, most providers who use these tools find symptom rating scales helpful in monitoring response to treatment and prompting treatment adjustments such as change in antidepressant dose, adding or switching medications, starting psychotherapy, or asking more questions about suicide.

Despite the evidence for effectiveness, acceptability, feasibility, and professional endorsement of Measurement-Based Care, limited adoption has occurred of this approach to outcomes measurement for both specialty behavioral providers and primary care providers who treat mental health and substance use disorders.

Case Examples

The issue brief describes a number of different examples where Measurement-Based Care Programs have been successfully implemented outside of a research study. Table 1 highlights programs that have been implemented in both the public and private sectors for a range of mental health and substance use disorders.

The Benefits

The routine use of Measurement-Based Care will improve the effectiveness of treatment whether pharmacological or psychosocial for millions of patients seeking help for their mental health and substance use disorders. The time is long overdue for the field of mental health to embrace the concept of Measurement-Based Care and live up to the standard set by other medical specialties.

The Kennedy Forum strongly endorses the following policy:

All primary care and behavioral health providers treating mental health and substance use disorders should implement a system of Measurement-Based Care whereby validated symptom rating scales are completed by patients and reviewed by clinicians during encounters. Measurement-Based Care will help providers determine whether the treatment is working and facilitate treatment adjustments, consultations, or referrals for higher intensity services when patients are not improving as expected.

Measurement-Based Care may appear similar, but it is not equivalent, to performance measurement and provider profiling. While performance measurement and profiling focus on the results obtained by clinical organizations (e.g., a clinic or group practice) and by individual clinicians, respectively, Measurement-Based Care involves the systematic use of symptom rating scales to inform clinical decision making for individual patients at the level of the clinician-patient encounter.

The primary benefit of Measurement-Based Care is improved clinical outcomes for each individual patient and targeted populations. A secondary benefit is the potential to use aggregated symptom rating scale data to enhance professional development, facilitate practice and program level quality improvement, and positively influence payer purchasing decisions and reimbursement policies.

Stakeholder Adoption

Patients and Patient Advocacy Groups

The use of symptom severity scales has many benefits for patients by:

  • Patient Feedback. Completing symptom rating scales and reviewing the information with providers validates the way patients are feeling and can ameliorate the self-blame that some patients experience.
  • Patient Engagement. Using symptom rating scales empowers patients by giving them a new role in their treatment by helping them communicate with their providers and making them feel more involved in clinical decision making.
  • Patient Knowledge. By completing symptom rating scales patients get specific feedback that can help them more fully understand their disorder and changes in their symptom severity over time.
  • More Effective Treatment Approach. Sharing the results of symptom rating scales helps providers determine when treatments are not working and leads to the delivery of more effective treatment for patients.

Given these benefits, patients, family members, and patient advocacy groups should demand that Measurement-Based Care be implemented in their provider’s clinical practice. Patients can be a catalyst for change by asking their providers to start using symptom severity scales so they can better describe their symptoms during encounters and follow their own progress over time.

Providers and Provider Organizations

The use of symptom severity scales also has many benefits for providers by:

  • Treatment Focus. Streamlining assessments by focusing the discussion on symptoms identified as most severe by the patient.
  • Earlier Feedback. Completing symptom rating scales can help patients recognize improvement early in the course of treatment that they might not notice without symptom rating scales. Patient recognition of even small decreases in symptom severity may help them feel more optimistic and hopeful, and to maintain better adherence to the treatment plan.
  • Clinical Effectiveness. Encouraging providers to objectively assess the effectiveness of various treatments or treatment components, and also using this information to become a more effective clinician.
  • Quality. Helping clinical practices evaluate quality improvement efforts.
  • Value-Based Care. Creating an evaluation platform that can be used by providers, practices, and healthcare systems to demonstrate to payers that the services they deliver are effective.

While the potential exists for using aggregated symptom rating scale data to make comparisons between providers, some providers may not be comfortable reconciling their personal assessment of their effectiveness with objectively measured outcome data. Moreover, it can be challenging to adequately adjust for potential case mix differences in the patients of different providers. Therefore, payers and quality assurance organizations should be cautioned against using Measurement-Based Care to penalize or reward providers based solely on these types of aggregated outcome data. At the same time, providers should be held accountable if their patients are experiencing poor outcomes, and the providers are not revising treatment plans, getting additional consultation or referring their patients to higher or appropriate levels of care.

Payers

The use of symptom rating scales also has many benefits for payers by:

  • Transparency. Promoting transparency and accountability. Under the Mental Health Parity and Addiction Equity Act, payers are held accountable to offer equivalent benefits for behavioral health and physical health. Symptom rating scale data can be aggregated across patient populations and provider groups to make outcomes more transparent and enable payers to observe treatment outcomes. However in all cases, appropriate case mix adjustments must be made when comparing providers or provider groups across diverse practice and population settings.
  • Value-Based Care. Aggregating patient outcomes data at the provider or provider organization level will give payers some of the information they need to assist in the identification of providers who are generating the best outcomes.
  • Quality Provider Networks. Identifying providers who are using state of the art quality improvement programs to measure actual patient outcomes.
  • Payer Reimbursement. Creating incentives by payers, such as private insurance companies, state and federal government purchasers (e.g., Medicaid, Medicare, Tricare, and Veterans Health Administration) and self-insured employers, to encourage providers and health care systems to use Measurement-Based Care, including reimbursement for using validated tools.
  • Actionable Measures. Seeking input from provider organizations to help select validated symptom rating scales that their providers believe best inform their clinical decision making. Further, requiring providers to use rating scales that are not perceived to have clinical utility may result in the reporting of outcomes data that have not been clinically verified for accuracy.

Regulatory Agencies and Accreditation Organizations

Regulators and accreditors should develop objective quantifiable performance measures for health care systems, managed care organizations, and other health insurance arrangements that support the adoption of Measurement-Based Care.

Researchers

While there are dozens of disease-specific symptom rating scales and some multi-diagnostic tools that have been empirically validated and are routinely used in clinical care, future research should focus on improving these standardized scales to make them more focused and brief, as well as more reliable and sensitive to change.

Final Thoughts

We encourage you to join The Kennedy Forum and others to improve behavioral health services through Measurement-Based Care. The wide spread implementation of symptom rating scales for behavioral health services can improve both clinical and financial outcomes on many levels. This Measurement-Based Care approach can actively engage patients to more closely monitor their health status, provide critical feedback loops to providers, and support value-based purchasing initiatives.


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