Measurement-Based Care for Improving Mental Health

Chapter 5:

Scales for Measuring Mental Health: How They Work

To effectively illustrate the power of using questionnaires and scales, consider several applications related to body dysmorphic disorder (BDD). According to Cleveland Clinic, BDD is a disorder where preoccupation with an imagined or very slight defect with one’s body can affect an individual’s ability to attend school, work or function in social or home settings. Clinicians use a mix of questionnaires and scales to screen, assess and monitor the progress of BDD patients.

Screening

The Body Dysmorphic Disorder Questionnaire (BDDQ) is available for researchers, clinicians and those patients who wonder if they have BDD. The questionnaire takes up to 5 minutes to administer and assists in identifying patients that require further diagnosis using the BDD Diagnostic Module. BDDQ versions cater to teens and adults. The questionnaires’ responses have no comparative element as opposed to rating scales since they are either yes or no.

Assessment

The assessment provides patients and providers with an indication of the severity or frequency of symptoms. The Body Dysmorphic Disorder Diagnostic Module, also known as BDDD, is based on the DSM-5 diagnostic criteria for BDD. It evaluates appearance preoccupations and repetitive behaviors of clinical significance, uses specifiers to identify patients with either insight specifiers or muscle dysmorphia, and aids differentiation from an eating disorder.

Monitoring

To identify changes in patient health with treatment, a clinician uses another type of scale, such as the Yale-Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS). BDD-YBOCS is an example of a scale used commonly to measure the progress of patients diagnosed with BDD. The scale features a series of 12 semi-structured items to assess the severity of BDD during the previous week and asks patients to respond to and rate items. They rate these items like “I check my appearance (e.g., in mirrors, by taking photos of myself or by touching with my fingers)” or “I avoid situations because of my appearance.”

The clinician can identify whether the patient’s health worsens or improves when comparing patient data from week to week over time. Tracking health this way over a period — especially when viewed across patient populations — aids clinicians and researchers in identifying which interventions support best outcomes and developing effective evidence-based practices.

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Chapter 6:

Choosing the Right Measures

Devising the right system for measurement in mental healthcare is challenging but vital for health screening, assessment of treatment progress and monitoring whether maintenance of patient progress is evident. The proper measures aid researchers in identifying whether an intervention is of value to particular populations. Data also helps decrease unwarranted variation in care treatment and diagnosis, which, according to Wolters Kluwer, accounts for at least 25%, and possibly up to 65%, of the unnecessary costs in care delivery.

The Importance of Outcome Measures in Mental Healthcare: Key Things to Know

Importantly, focusing on outcome versus process measures can provide valuable insights for improving mental health. Process measures focus on an action that a patient or physician performs at a given point in time. For instance, a patient process-measure could be taking medication while a physician process-measure could be recording temperature or administering a blood test. Process measures tell only a part of the story, focusing on what was performed and not the outcome. Outcome measures differ from process measures in that they explain the results of steps taken. Using behavioral health outcome measures, a physician can determine the deterioration or improvement of patient conditions when changes occur and better ensure treatment has its intended effect. Data from outcome measures also helps with quality monitoring and tracking progress at the aggregate level.

How are Mental Health Outcomes Measured?

In behavioral health, outcome measures are necessary because they indicate whether patients are improving due to the treatment, and both patients and providers can track and report outcome measures. Patient outcome measures are collected through patient-self reporting that typically involves completing forms, with results called “patient-reported outcomes measures (PROMs)” or “patient-reported symptom rating.” According to the National Institutes of Health (NIH), mental health outcome measures must be reliable and valid, sensitive to change, comparable across relevant client service types and groups, and meaningful to clinicians and their clients.

A wide range of mental health outcome measures helps gauge the patients’ mental wellness. Some standard outcome measures in behavioral health include cognitive performance, physical and social activity, and behavioral experiences.

An outcome-based approach to mental health is beneficial to providers, patients, healthcare systems and society in the following ways:

• Enables providers to track and monitor patient potential backsliding and improvements
• Offers meaningful insights into the patient’s state of mind
• Assesses clinical effectiveness of the healthcare system and providers
• Demonstrates desired changes occurring from a patient’s perspective
• Helps procure funding and support payment

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Chapter 7:

Measurement-Based Care in the VA: How it Works

Measurement-based care is impacting mental health outcomes within the VA. The VA has been rolling out MBC principles to establish a behavioral health standard in treatment planning and setting recovery goals.

Measurement-based care for behavioral health at the VA uses a “collect, use and share” foundation that works as described below:

When the VA initiated its MBC in mental health initiative, an interagency task force on veterans and military agreed to an initial pilot of four measures for the measurement-based care program. The four measures are:

• (PCL-5) PTSD Symptom Checklist for PTSD assessment
• (BAM-R) Brief Addiction Monitor for substance use and risk together with recovery factors assessment
• (PHQ-9) Patient Health Questionnaire for depression assessment
• (GAD 7) Generalized Anxiety Disorder for anxiety assessment

After the pilot, the VA conducted a survey comprising 230 mental health providers across nearly 50 VA medical centers. The study aimed to assess attitudes and self-reported use of various measurement-based care components. The adoption of the MBC tools at the VA was high: about 58% of the providers recorded collecting at least one measure for at least half of their patients and provided positive feedback on using such utility.

The survey revealed a high acceptance of treatment planning, with 72% indicating that they always explained their results to the patients while 65% used the results as part of shared decision making. However, only 37% indicated using scores when discussing a patient with another healthcare provider.

The authors of the VA pilot program study note measurement-based care using patient-reported data shows improved treatment outcomes for patients with mental illness, from better engagement to faster response to treatment. Yet, despite these benefits of MBC and the availability of validated measures for use specifically by mental health practitioners, the approach is still adopted to a lesser degree than in other clinical areas.

The VA also acknowledges that the adoption of measurement-based care is lower in mental healthcare because it is a “pretty big adjustment” in clinical practice. As a result, the VA is rolling out MBC in phases to study the best ways to put it into practice.

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Chapter 8:

Tips for Adopting Measurement-Based Care Within Your Practice

Approaches to transitioning toward measurement-based care vary. Some providers find it useful to think about the data they are using in different categories and then stagger adoption.

As Dr. Jennifer Birdsall, chief clinical officer for CHE Behavioral Health Services, notes in “Understanding Outcome Measurement: Mental Health Experts Share Insight,” sometimes it’s helpful to first think about data as a means to be collaborative with patients about their care, looking for opportunities to discuss particular measures as a signal of whether symptoms are getting worse or improving.

As comfort with this data use grows, then focus can begin to include making use of aggregate data applications. Birdsall notes this trend information can be invaluable: “I can look at it as, ‘We have really good outcomes for depression and anxiety, but for our patients with substance abuse disorders, we don’t. Why is that? Do we need to look at our programming?’ These insights are really impactful to me as a clinical leader.”

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Chapter 9:

What to Consider When Implementing Outcome Measurement Tools

Implementing outcome measures alone does not improve patient care. Rather, clinicians must establish systems that guide usage. Here are some tips on how you can better implement measurement-based care within your organization:

• Use digital solutions; for instance, you can screen, assess and track patients more seamlessly using software programs
• Incorporate an outcome-measures approach in communicating progress
• Integrate process improvement consistently to make collaboration on patient health decisions easier

Also, check out Proem, which provides a variety of tools for incorporating measurement-based care into behavioral health practice. Proem’s solutions support data collection to track each patient’s health journey and validate outcomes for providers, payers and researchers.

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