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Delay and Dilution of Measurement-Based Care Undermines Our Field
The behavioral field has long resisted routinely measuring clinical outcomes to improve care. We now at least have a name for this process: measurement-based care or MBC. Delays in adopting MBC are disappointing, as fewer than 20% of clinicians and programs have implemented it, but even more distressing are efforts to get by with diluted models.
MBC is not based on government legislation with rules and guidelines for implementation, so confusion is probably genuine about how its promise is best fulfilled. At this stage of development, it may be most helpful to clarify what the full realization of this idea offers our field. This will be provided here by elaborating the ultimate goal behind each word included in this inelegant label.
Measurement. The measurement of a client’s level of distress with self-report questionnaires is well understood. Some survey tools are longer than others, and some focus on specific disorders (e.g., depression), but experts design them all to be valid, reliable, and sensitive to change for people in care. These measures have cut-off scores for identifying clinical levels of distress. This is the first stage of measurement.
The next measurement question involves prediction—given an initial score, how much change is expected by the end of services? This too is well understood by experts in psychometrics, and it requires a database with pre- and post-scores for a similar population. Knowing how people with each initial score have responded to care enables the calculation of expected final scores for others.
These measurements are more accurately called analytics, and client-level change is readily aggregated at the population level. This level of reporting helps executives determine the comparative success of their clinicians and programs. As suggested, the amount of change for each client is adjusted according to the initial severity level, so aggregate outcomes are also severity-adjusted.
Based. When care is based on data and analytics, clinicians have access to fluctuating levels of clinical distress and risk. Based on this feedback, clinicians can either continue on the same path or change course, but they need actionable feedback that is provided during treatment. The most critical feedback, validated by extensive research, is evidence of whether a client might prematurely end treatment.
While a small percentage of cases show this risk for an abrupt ending of treatment by the client, research shows clinicians rarely identify this risk. On the other hand, many clients want to terminate care after a few sessions because they have improved enough to be satisfied. This helps the clinician who may be uneasy about an early ending—the data aids their understanding of when to stop care.
Care may also be based on aggregate data—over time, we find which clinicians get the best and worst results. A critical factor driving results is therapeutic alliance, and brief alliance measures may enhance clinician feedback. “Common factors” like alliance and empathy drive outcomes more than techniques—in fact, the evidence suggests one mark of a superior clinician is an ability to form alliances with the diverse mix of people seeking care.
Care. Care is a vague term, and appropriately so, because MBC extends beyond its origins in psychotherapy to other clinical services like medication management. Changes in symptoms and distress are relevant for any behavioral health treatment, and this means it should be implemented for substance use disorder (SUD) services as well as mental healthcare. While the clinical measures might be different, the process is the same.
As the field grows within primary care and other medical settings, other adaptations may be on the horizon. Slight technical modifications can be expected since many medical patients warrant help for behavioral issues despite minimal levels of psychological distress. This is also found in general outpatient settings, though perhaps not as broadly. Once again, outcomes must be severity-adjusted.
Administrative simplification is needed in all settings but most urgently in medical ones. MBC was launched initially with clinicians and office staff collecting data and handling other clerical tasks. MBC must ultimately be automated at every step. One possibility is to embed the process in the interactive AI technology that has simplified many customer service interactions.
A Matter of Executive Leadership
MBC is not our norm today due to clinician resistance, cost considerations, and minimal consequences for ignoring the issue during our field’s long history of isolation. As we are steadily integrated into the larger healthcare industry, we will be expected to report clinical performance like other fields. Pressure will grow to expand MBC. Accountability for population health will be a major advance for our field.
Clinicians will ultimately be impressed by how MBC can improve each episode of care, but executives must be the driving force behind adoption today. As value-based care gains ground, MBC can provide the outcomes data for contracts combining costs with outcomes. Payers and consumers will learn to value MBC, but we must first ensure each implementation is geared to realize its full potential.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
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