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Measurement-Based Care (MBC) can Fundamentally Reconfigure Outpatient Services
The demand for psychotherapy in the US exceeds available clinicians. When latent demand or unrecognized need is included, this shortage increases. Yet neither funding to expand the workforce nor a national strategic plan is forthcoming. Fortunately, innovative solutions are available by combining existing technologies. We can improve care access while ensuring quality.
First, we must clarify the problem. It is not providing more therapy. It is meeting people’s needs, some of which get met with therapy. People do not really want therapy. They want improvement.
Giving people what they want starts with measurement. Care should routinely include the monitoring of improvement. Our field rests on science, but we do not use scientific methods to monitor services. Measurement by itself is a modest change, but measurement-based care (MBC) is a set of technologies that can reconfigure our outpatient systems with access and quality as co-equal drivers.
MBC started with therapists using brief client self-report questionnaires, analyzed at each session to show clinical change compared to benchmarks. We can now expand to new settings and services—for example, brief interventions in primary care. We can use our existing workforce and measure improvement with shorter visits. We can touch more people while routinely monitoring clinical results.
Building a New System
Today, we can automate and expand the MBC process. Outpatient systems can use automated systems to collect ratings of client distress, which are then analyzed with algorithms that trigger a range of suggested interventions. We have interactive devices (e.g., phones, bots) and advanced analytics that can assess clinical needs in a given population, monitor progress with services, and flag early warnings.
An underused feature of MBC is clinician ratings. Aggregate outcome scores are a reasonable measure of clinician performance. Results for all clinicians tend to mirror a bell curve, with most achieving acceptable outcomes. A very small percentage are below average and would merit more support or monitoring. The public should know we have effective clinicians providing care.
We might rebrand our services by focusing on what people care about most: results. The public has mixed perceptions of therapy. Marketing experts remind us that people want solutions, not products. We can leverage this in 2 ways: 1) by spreading the good news about real-world therapy outcomes; 2) by stressing that multiple pathways are available to achieving desired improvements.
Patient self-report measures are the lab tests of behavioral healthcare. However, too many people have had the experience of not getting meaningful results after completing them, and this lack of feedback extinguishes interest or support for the process. Fortunately, over the past decade digital therapeutics have been reversing this. They routinely use such measures and provide rapid feedback.
Self-reported distress ratings can be monitored for every type of service modality as long as data are collected. MBC needs devices to gather and transmit data, and it then functions as a guidance system supporting all types of care. This includes visits with therapists of any duration in any setting. We can modify our services for better access, and then assess the results with MBC.
Improvement is the priority. For example, placing therapists in primary care for brief interventions is sensible. Some people are likely to respond well. MBC monitors continuously and flags some for additional services. Moving therapists into primary care is not enough. MBC highlights using effective clinicians and monitoring progress. Even the best clinicians and therapies benefit from monitoring.
Finding People to Lead
MBC experts could readily adapt their systems and services as described here. What is missing? Executives are needed to buy and run them. Therapists are needed to modify their clinical work in recognition of the need to expand access. This would likely involve brief interventions, but whatever the adjustment, it means being guided by data in the process.
Healthcare is procedure-focused, while the model outlined here is solution-focused. Not only is the outcome the real product (not the service), but the therapist is the biggest driver of change (not the techniques). Yet not every case goes well, and so MBC provides guidance. Created as a guide for therapy, it is readily adapted for services more broadly.
Why would clinicians want to follow the path described here? One motivator—fear—should be growing in response to mounting public outrage over poor access to care. It should be a wake-up call that clinical workforce funding is elusive, while lower cost options attract sizable investments. Digital solutions abound. Behavioral coaches are on the rise. Therapists may be defending their professional turf soon.
We also need adventure seekers. We can make good strides in solving our access problems with the people and tools we have available. However, we need executives and clinicians to create new career paths in healthcare. As healthcare consolidates, most of us will eventually be working for multispecialty healthcare organizations. Success in this new setting will demand new ideas and new roles.
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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