Measurement-Based Care Improves Outcome, Helps Clinicians

Measurement-based mental health care significantly improves outcomes, provided that symptom severity data are collected frequently and the results are provided to the clinician shortly before or during the clinical encounter, according to a literature review published September 1 in Psychiatric Services in Advance.

Moreover, the authors of the review said that measurement-based care (MBC) can be used to enhance professional development at the provider level, facilitate practice-level quality improvement, demonstrate the value of mental health services to purchasers and payers, and positively influence reimbursement policy.

MBC is the systematic administration of symptom rating scales and use of the results to drive clinical decision making at the level of the individual patient.

MBC involves, for instance, the frequent measurement of symptoms with valid tools such as the PHQ-9 or GAD-7. These measures are used not just once but are repeated, reviewed weekly, and used to adjust treatment until targeted outcomes are reached. It is an essential component of the collaborative care model, for which the Centers for Medicare and Medicaid Services has recently provided reimbursement codes that will support consultative services provided by a psychiatrist.

John Fortney, Ph.D., of the University of Washington and colleagues reviewed 51 articles on the use of MBC. The results of randomized, controlled trials indicated that frequent and timely feedback of patient-reported symptoms to the provider during the clinical encounter significantly improved outcomes or showed trends toward significance. These findings were robust and consistent across patient groups, providers, and settings.

Settings and institutions from which the articles were drawn included federally qualified health centers, the Veterans Administration, the Department of Defense, and Kaiser Permanente.

Fortney and colleagues also found that not all approaches to structured symptom assessment and feedback improve outcomes. For example, assessing patients once by using a symptom rating scale and alerting clinicians to symptomatic patients does not improve outcomes. A Cochrane review of depression screening trials found that patients with depression who were randomly assigned to be screened did not have better outcomes than patients who were randomly assigned to no screening, according to the report.

Similarly, alerting clinicians to positive screening results and providing them with guideline-concordant treatment recommendations is no more effective than usual care.

“The suboptimal outcomes associated with this approach are likely due to the fact that initial mental health treatment choices are often ineffective,” the researchers wrote. “Thus screening alone is insufficient to improve outcomes without systems in place to monitor treatment response.”

“The time is long overdue for the field of mental health to embrace MBC and live up to the medical testing and treat-to-target principles applied by other medical specialties,” the study authors wrote. “The cost of routinely administering symptom severity scales is minimal, yet the benefits of MBC accrue to all the stakeholders involved, including patients, providers, purchasers, and payers.”

In comments to Psychiatric News, Fortney said MBC has been widely adopted by large integrated systems of care. “Although adoption in other settings has not yet ramped up, incentives are rapidly being put into place that will promote such adoption,” he said. “For example, the National Committee for Quality Assurance announced that depression symptom monitoring and depression response/remission rates will be health plan performance measures for the Healthcare Effectiveness Data and Information Set. Likewise, the Centers for Medicare and Medicaid Services is planning to begin reimbursing clinical practices for delivering collaborative care services, which has measurement-based care as a core component [Psychiatric News, August 5].

“Given the rapid changes being made by accreditation agencies and payers, those health care organizations that have not yet started to develop systems to support measurement-based care should begin identifying tools and protocols that meet their patients’ needs before such systems are imposed from outside their organizations,” Fortney said.

MBC is at the heart of the collaborative care model and advances the ability of clinicians to provide robust treatment for patients, said Lori Raney, M.D., chair of the APA Work Group on Integrated Care.

MBC is “absolutely necessary for reporting outcomes to payers in the changing health care environment where value-based purchasing is the wave of the future,” she told Psychiatric News. “It has personally changed my practice in a very positive way, and I look forward to the development of more sophisticated measurement tools as we move forward in our understanding of the importance of this process.” ■