- Measurement-Based Care and Patient-Centered Mental Health Care
- Do Consumers Value Provider Performance, and is There More at Play?
- NQF: National Quality Forum Takes Action for Mental Health Awareness Month with Release
- Author notes
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Measurement-Based Care and Patient-Centered Mental Health Care
Help us improve our web calendar. The indicators should have a national- or regional-level focus, or otherwise be used to assess the performance among organizations or providers. Indicators from 31 programs in 11 countries and two cross-national programs were compiled, yielding total measures. The final framework comprised 17 domains and 80 subdomains. Each indicator specified an objective numerator and denominator drawn from an identifiable dataset—as required by the selection criteria noted above. There was considerable variability in the numbers and types of indicators, programs and datasets.
The numbers of total measurable indicators per country ranged from 3 to , which is explained only in part by the range of 1—7 programs per country. Supplementary Table S1 online gives lists of the programs from which the indicators were drawn, demonstrating the wide scope of the data sources used. The gray literature review did not yield any indicators for Ireland and Taiwan that met the inclusion criteria.
Do Consumers Value Provider Performance, and is There More at Play?
After condensing the indicators in this way, 80 total subdomains were identified. The numbers of indicators per domain and subdomain were also highly variable, and we found broad types of measurable indicators within each domain.
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For example, both adequate medication dosage and medication reconciliation are found in the Evidenced-Based Pharmacotherapy domain; the former measures compliance to clinical standards, whereas the latter is a system-level practice. Similarly, the Outcome Assessment domain which contains 72 total indicators, the greatest number contains subdomains, including examples as diverse as mortality rates, employment status and the Global Assessment of Functioning scale.
Examples of each subdomain are listed in the online Supplementary Table S2 for illustrative purposes. Several aspects of this analysis provide important insights into the state of quality measurement worldwide, and the provisional organization of these data represents a meaningful step toward developing an international framework for mental health quality indicators. No single program contained indicators in all domains, further emphasizing the need for a comprehensive, shared scheme for international measurement.
This finding echoes the results of two recent literature reviews arising from the IIMHL project, which reviewed numerous US [ 9 ] and international [ 10 ] mental health quality measurement programs, but still identified significant gaps in the scope of every program. A significant methodological contribution of this effort is its inductive approach to organize mental health measures. By deriving categories and examples of quality indicator measures through a compilation of the existing programs, this stage of the IIMHL project has generated an organized list of measures that is maximally broad in scope, thus allowing future efforts to proceed from the most inclusive basis possible.
Quality indicators have complicated origins, as each guideline for measurement is a product of the goals, context and time from which it came.
The priorities and influences of these performance measurement programs will vary under the influence of broader cultural factors, and the framers, providers and consumers coming from a given culture or health-care system may not be fully aware of how their context impacts the ways they measure quality. One important motivation of a structured framework approach such as this, derived from a comprehensive inventory of international measures, is to attempt to avoid these potential biases by providing an inclusive global perspective on the state of quality measurement.
The relative frequencies of indicators per domain may give a sense of how different measures have been prioritized or an indication of which measures are actually measurable. For example, despite the recent popularity of the recovery movement in mental health [ 13 ], the recovery domain in this sample has among the fewest measurable indicators.
It is important to note, however, that no strong conclusions can be drawn from these counts. In many cases, these frequencies may simply reflect the feasibility of measurement: outcome assessment and symptom assessment are likely easier to quantify than culture issues or perceptions of care. It is also important to note that high numbers of indicators in particular domains do not necessarily indicate greater coverage of topics within those domains.
In many cases, different indicators were capturing quite similar measurement concepts with different approaches or minor variants in numerator or denominator definition e. That said, on a more straightforward level, these frequencies do give an important sense of which areas are in need of further quality measure development. There are several limitations to this study. Language issues may have hampered the collection of indicators from countries, for example, translations were done by the IIMHL partners who provided the indicators themselves, creating a somewhat onerous step for participating members.
More broadly, the first step of obtaining measures from representatives in peer countries depended on those representatives for thoroughness and rigor, and while they were asked to submit a broad collection of measures, individuals may have gone about their selection processes differently. In terms of the organization of the indicators, the system of domains that was created is inherently subjective and rests in part on a priori assumptions about the organization of quality measures.
That said, this provisional categorization was not the primary goal of this effort, and the study methodology allowed for flexible adjustments to these categories as the data were analyzed. In addition, it should be noted that these measures have not been subjected to a validation process. In fact, a key component of a research agenda for quality improvement in mental health is evaluation of the reliability, validity and utility of quality indicators.
Ultimately, each country needs to determine its own priorities, amidst the reality of what is feasible, given available data and resources. It is likely that national programs of quality measurement will develop ways to create composite measures or dashboards to compress the information in ways that can be directly acted upon to improve quality. Several of the next key steps of the Clinical Leaders project in Phase II will proceed from these data.
Now that the performance indicators have been collected and grouped, the IIMHL Clinical Leaders Group will rate this sample for validity, importance and feasibility, with a goal to propose a consensus list of mental health quality indicators that could be collected by each of the participating countries. At the same time, country networks are forming to further discuss data infrastructures and explore implementation strategies that will allow for the comparison of performance measures across countries in the future.
The ultimate goal is to enable quality measurement initiatives that will help to transform mental health services worldwide. Finally, we will explore whether implementation of MBC increases primary care team communication and function related to the care of mental health conditions. MBC has significant potential to improve mental health care but it represents a major change in practice. Understanding factors that can support MBC implementation is essential to attaining its potential benefits and spreading these benefits across the health care system.
Most modern medical care uses objective measurement to guide and evaluate treatment. For example, blood pressure measurement is routinely used to screen for hypertension, to determine if treatment is indicated, and to guide treatment including behavior-focused efforts. By contrast, modern mental health care typically uses subjective clinician assessment as the most common tool for guiding both psychotherapy and pharmacotherapy treatment decisions. Although reliable and valid patient reported outcome measures PROM for mental health conditions are available, their use to guide treatment beyond screening and initial evaluation is relatively infrequent [ 1 , 2 , 3 , 4 , 5 , 6 , 7 ].
Routine use of PROM to track patient symptoms, guide treatment decisions and facilitate communication between patients and providers is referred to as measurement-based care MBC. There are three critical elements to MBC: 1 collection of information using psychometrically-sound self-report instruments repeatedly over the course of treatment; 2 use of that information to guide treatment decisions; and, 3 sharing the information with patients and others on the health care team to support collaborative treatment decision-making.
NQF: National Quality Forum Takes Action for Mental Health Awareness Month with Release
The evidence for MBC is strong when it is used over time in a systematic way to adjust treatment pharmacotherapy or psychotherapy rather than simply fed back to providers or patients monitoring alone [ 8 , 9 , 10 , 11 ]. In addition to its potential benefit to individual patient outcomes, MBC can improve treatment fidelity [ 9 , 10 , 12 ], improve patient-provider communication [ 13 , 14 ], and increase patient engagement [ 15 ]. At the clinic and program level, MBC can support treatment team communication about mental health conditions [ 16 , 17 ] and can facilitate quality improvement QI efforts [ 18 ] by providing patient outcome data that can be monitored in response to systematic changes in clinical operations.
At the population level, MBC can improve the programmatic efficiency of care by identifying patients in need of more treatment and reducing the number of sessions for patients who have improved [ 9 ]. Further, MBC does not require new staffing and, while a MBC approach requires providers to alter their clinical practice, it does not add time to patient encounters [ 11 ]. As a result, while MBC improves the outcomes of care, it can also increase clinician efficiency [ 11 ]. Despite these benefits and calls for the implementation of standard systems of MBC in mental health practice, few health care systems have adopted it as a standard of care [ 11 , 19 , 20 ].
In fact, it is the norm for mental health providers in all clinic settings to rely heavily on clinical interviews focused on the individual experience of patients ideographic assessment rather than using standardized instruments that allow comparison to a normative group nomothetic assessment [ 5 , 6 , 21 ]. Beginning in , the U. The initiative has occurred in phases. In the first phase, leadership representing the broad scope of VA mental health care agreed on a set of standards that would define successful implementation.
Having laid this groundwork, the next phase included a set of activities that have become standard in the VA system for supporting practice change initiatives. This national support included: developing educational materials for providers and patients, engaging volunteer programs throughout the system to begin implementation, supporting a community of practice for engaged sites, and, upon request, brief coaching for implementation problem-solving. That stage was recently completed with evidence of increased use of PROM throughout the healthcare system.
Educational materials, web-based community of practice discussion, and expert consultation remain available. The next phase requires every facility to implement MBC in at least one clinical program. Coincident with these policy changes the Joint Commission is also now requiring the use of MBC in some behavioral health programs such as addiction and residential services [ 27 ].
Beginning in , the program integrated mental health services into primary care clinics system-wide [ 28 ] using both care managers in a collaborative care model [ 29 , 30 ] and embedded behavioral health providers BHPs in an integrated primary care model [ 31 ]. Collaborative care models of primary care treatment for depression provided early, evidence-based examples of how MBC can improve communication, collaboration, and quality of care [ 7 , 29 , 32 ].
While MBC is a core component of care management, embedded BHPs have typically relied on PROM only as part of an initial assessment; follow-up assessments are most often idiographic [ 5 , 6 , 21 ]. For instance, measures may be collected using pen and paper but not transcribed into the electronic medical record.
Thus, the data are unavailable for communication, team decision-making, and program improvement efforts. Further, in PCMHI, where providers are intended to be fully integrated members of primary care, this partial use of MBC limits the ability of the rest of the primary care team to coordinate with and support mental health treatments and presents a barrier to interdisciplinary team function [ 34 ].
Team communication is a crucial component of team development and is thought to be critical to establishing high performance health care delivery teams [ 20 , 34 , 35 ]. The implementation of MBC has the potential to provide a pathway to improved communication about mental health conditions, allowing professionals from medical and mental health disciplines to work in a more fully integrated manner [ 36 , 37 ].
In summary, while MBC has significant potential to yield improved patient care and interdisciplinary practice, it is a complex practice that has proven to be challenging to fully implement. Therefore, the current protocol will seek to determine if external facilitation EF when combined with an internal QI team will improve the implementation of MBC practice as compared to sites receiving only standard national support. External facilitation, an evidence-based, multi-faceted process of interactive problem-solving and support [ 38 , 39 ], can incorporate multiple other discrete implementation strategies, e.
Engaging stakeholders and involving them in implementation processes is a core component of facilitation [ 43 , 44 ] and is critical for implementation success [ 45 , 46 ].
QI teams in this study will be composed of local stakeholders who will share responsibility for implementation efforts, thus acting as internal facilitators. This study employs a quasi-experimental multiple case study design [ 47 ], using mixed methods to accomplish the study aims. In addition to addressing the two primary aims, the study is designed to explore factors that may affect successful implementation. Conceptual frameworks guiding study design. RE-AIM is a useful framework for evaluating implementation interventions because it addresses issues related to real-world settings and assesses multiple dimensions Reach, Effectiveness, Adoption, Implementation, and Maintenance.