ADVERTISEMENT
Let’s Have a Sense of Urgency About Putting Our Knowledge Into Practice
What is worse than an unsolved healthcare problem? Validated solutions never implemented might be worse. Sadly, our field has extensive research knowledge waiting to be put to use, and this is complicated further by the reality that our field is in transition. Our historically independent field is merging into integrated care systems. How agile will these integrated systems be at implementation?
Our field’s declining autonomy can be seen in the acquisition of “carve-out” behavioral payers by health plans and in the transformation of specialty behavioral programs and services into subsidiaries of health systems. However, there is much to celebrate as we integrate into the larger healthcare arena, and high on that list is the possibility that holistic care might become the norm.
There are risks with integration as well, and we might wonder how well integrated systems will transfer our knowledge into practice. Will they have a sense of urgency about putting our research findings into clinical practice? Unfortunately, the US healthcare system has long been deficient in this regard, with a “knowledge transfer” gap averaging 17 years.
Let us contemplate 2 knowledge transfer gaps in behavioral health by reviewing recent studies by integrated care systems. Only debate and speculation are possible at this point, but these studies raise the possibility that transferring knowledge is easier as an autonomous field than as an integrated one.
Is Measurement-Based Care (MBC) On a Near or Distant Horizon?
MBC represents a major knowledge transfer gap. It was validated as improving therapy outcomes over 2 decades ago. Many researchers contributed, but Michael Lambert’s work stands out for crystallizing the components of what we now call MBC. Client self-report measures are the basis for monitoring results and giving actionable feedback to therapists.
Lambert and others consulted in the late 1990s to my company, one of the managed behavioral healthcare organizations (MBHOs) or independent behavioral payers at the time. An MBC program was implemented, and several peer-reviewed articles subsequently described the positive results. However, MBC is only slightly more common today (fewer than 20% of clinicians use it) than it was at that time.
MBC failed to spread across our industry partly because business consolidation soon eliminated MBHOs. Were MBHOs quality improvement juggernauts? They certainly were not, but they were responsible for a single industry and could implement system changes with speed and agility. Are integrated care systems less agile? In terms of MBC, early implementation efforts are not encouraging.
Clinicians from an integrated system recently offered a 10-point plan to improve MBC implementations. At first glance this seems fine, until it becomes clear they are turning the hurdles confronted successfully decades earlier into far greater impediments. A related article bemoans these barriers, asking questions long ago answered. Both articles are preparing us for slow progress. Are integrated systems less agile or are behavioral clinicians less able to drive change in them?
There is reason for some optimism. Companies exist today to help programs install the scientific and technological components needed for MBC. Yet it is fair to worry MBC could be delayed a decade if behavioral programs follow an “implementation science” that is too perfectionistic or incremental.
Can PCPs Boost Motivation Like Therapists?
We have long struggled with unacceptably low treatment rates for addiction, and shifting focus to the primary care setting seems critical. An integrated care system recently described a massive effort to train PCPs on brief interventions that might improve engagement in addiction care. It failed to increase engagement over usual care. The authors suggest “iterative quality improvement efforts.”
The approach they studied is worth trying, but do we not have better alternatives available? For example, motivational interviewing has been used in the addiction field since the 1980s. It is derived from basic therapeutic skills to help people gain motivation for changing self-damaging behaviors. We should consider deploying more psychotherapists to primary care to use these skills.
While integrated care systems use therapists in primary care, more debate is needed about how to use them. Most are providing either brief consultations or full therapy sessions. Asking therapists to do brief motivational interviews is a strong, well-validated alternative. Yet how much autonomy will therapists in primary care be given for new solutions? Iterative improvement may be unduly slow.
Urgency
A sense of urgency is often undermined indirectly through delays and excessively modest goals. Delays are often due to funding, a problem in any setting, but quality experts may routinely stifle a sense of urgency by extolling small, incremental steps. For example, using implementation science may have value, but it can also drive needlessly slow or narrow change.
It must be noted in fairness that hurried deadlines and overly ambitious goals can undermine the very practices one values. Our north star in this is clear: Research has given us important knowledge that should be put to use as soon as possible. It is aggravating to know a better way and not take it.
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.
References
