The Ultimate Guide to Demystifying Measurement-Based Care
Table of Contents
Measurement-based care (MBC) is the systematic evaluation of patient reported progress to inform behavioral health treatment. Measurement-based care is a phrase that gets used quite a bit in behavioral health circles as well as the public perspective of healthcare. Most often, the phrase provokes an anxious response from providers, scrutiny from the payers, and a host of questions for consumers. Measurement-based care doesn’t need to be complicated and highly technical. It does require some forethought and planning to be integrated with simplicity and impact. Most often, measurement-based care is used to inform improvements to the patient experience, but that only reflects one goal among many. The fundamentals of measurement-based care are simple: track information that accurately and precisely shows the impact of the care provided in a meaningful correlation. In simpler terms, show how the care provided worked.
While some may be recalling memories of grade school math class: “to get full credit you must show your work”, measurement-based care doesn’t need to be an activating experience.
Most guides to measurement-based care focus on trying to oversimplify measurement-based care claiming that measurement-based care only requires two things:
Routinely collecting brief, validated patient self-report questionnaires
Incorporating the results into treatment.
While starting to approach measurement-based care can be reduced to these two actions, there is more to the process if the results are to be meaningful and sustainable. Measuring self-reports only show part of the story, and in some instances, self-reporting measures have unintended consequences.
A good case in point is the role of only measuring patient satisfaction in pain management. It is well documented that the linking of patient satisfaction scores in healthcare settings to higher reimbursements contributed to the rise in over prescribing of opiate pain medication, which in turn proliferated what has become a country wide pandemic of opiate misuse, abuse, and dependence. Measuring pain is healthcare screening had become referred to by some as “the fifth vital sign”, which is an issue unto itself related to measurement-based care. Numerous articles and documentaries have been produced on this vital public health topic:
________________
Scott K, & Lewis CC (2015). Using measurement-based care to enhance any treatment. Cognitive and Behavioral Practice, 22, 49–59.
- https://www.donoharmfilm.com
- Adams J, Bledsoe GH, Armstrong JH. Are Pain Management Questions in Patient Satisfaction Surveys Driving the Opioid Epidemic? Am J Public Health. 2016 Jun;106(6):985-6. doi: 10.2105/AJPH.2016.303228. PMID: 27153016; PMCID: PMC4880256.
- Scher C, Meador L, Van Cleave JH, Reid MC. Moving Beyond Pain as the Fifth Vital Sign and Patient Satisfaction Scores to Improve Pain Care in the 21st Century. Pain Manag Nurs. 2018 Apr;19(2):125-129. doi: 10.1016/j.pmn.2017.10.010. Epub 2017 Dec 15. PMID: 29249620; PMCID: PMC5878703.
- Mazurenko, O., Andraka-Christou, B. T., Bair, M. J., Kara, A. Y., & Harle, C. A. (2020). Clinical Perspectives on Hospitals’ role in the opioid epidemic. BMC Health Services Research, 20(1). https://doi.org/10.1186/s12913-020-05390-4
Rummans, T. A., Burton, M. C., & Dawson, N. L. (2018). How good intentions contributed to bad outcomes: The opioid crisis. Mayo Clinic Proceedings, 93(3), 344–350. https://doi.org/10.1016/j.mayocp.2017.12.020
Patient satisfaction through self-report is one way to measure care, but it is not the only way, and indeed may not be best the best way to measure effective care, but more on that shortly. Measuring effective care should include more than just the patient experience.
Effective measurement-based care with a centering goal of improving patient experiences should include outcomes that demonstrate the work of the entire organization, not just the patient experience. Rather than just focusing on the patient, we recommend considering measurement-based care from the perspective of all participants in the process. Who qualifies as a participant? Participants include persons being served, the persons producing the service, the persons referring others for care, and community stakeholders.
The rationale for this recommendation is simple. The more aspects of care measured, the better the demonstration of the overall impact of care and the better we can understand what is actually impacting care. When reviewed regularly, exploring this information further can teach us how to improve each aspect of care, and most importantly, how to produce the best outcomes for everyone involved.
Since behavioral healthcare focuses on more than just physical symptoms of an issue, (i.e., changes in knowledge, understanding, as well as to cognition, emotional regulation, and/or behavior), measuring effective care should include the contexts in which the results of treatment are experienced. In other words, the mental health and well-being is best measured not just through patient satisfaction, but the changes experienced in relationship to oneself and with others in one’s daily life. Thus, pursuing more measurement from other sources is indicated.
The truth is that all organizations measure their care in some way, but they may not correlate the measurements to effective care directly. All organizations measure how much labor they expend to produce care. All organizations measure how much they invest in their staff to maintain highly trained providers who produce the care. Some organizations track employee retention and turnover rates, while others track compassion satisfaction and compassion fatigue of staff. All organizations track a wide variety of financial information to include but definitely not limited to payments, whether directly from the persons served or other payer sources such as reimbursements from insurance companies.
All licensed providing organizations must keep compliance to regulatory standards of care, which include adherence to documented policies and procedures required by rule and law. Some Organizations pursue formalized accreditation for standards of care, such as the most common industry standards of accreditation granted by The Joint Commission (TJC) or the Council on Accreditation of Rehabilitation Facilities (CARF), each of which maintains that outcomes should be measured in order to meet accreditation compliance. Any organization that has been credentialed with a third-party payer (whether through public funding sources such as Medicaid or contractual negotiations with commercial insurance providers) agree to maintain records of care which include a variety of measurements. All organizations are making diagnoses, utilize treatment plans to track progress and response to care, and providing continue care recommendations once the treatment is complete.
More focused towards persons served, all organizations are screening persons to ensure they are the right provider to meet someone’s needs. All organizations are conducting initial assessments during the admission process to ensure they are the right level of care to meet a person’s needs. Most organizations track who the referral source of the person in care was to ensure continuity of care and collaborative treatment. Many organizations, especially those in behavioral health, ask for records from previous care experiences, as well as interviews with family members loved ones supporting the person seeking care, All of these examples include measurements of one type or another, and all of this information can be, and some may argue must be, included in measurement-based care.
So, we return to the fundamentals of measurement-based care. What should we be measuring to show our work? We recommend three areas of inquiry for measurement:
- The Process – this includes all aspects of the care process from preadmission to admission, and beyond. Items such as person served demographic data, wait times, admission conversion and denial rates, referral rates to other providers and the types of providers referred to. Next, processes to measure are focused on the actual care itself: what medications were utilized and to what effect, what treatment methodologies were engaged – evidenced based strategies, practice-informed methods, or a combination of both; how was the treatment delivered and by what types of professionals for what services rendered. How often were the treatment plans evaluated, modified, and measured for effect, and who was involved in the treatment plan evaluation process. Things such as measuring how involved was the person receiving care and their family in the decision-making process to change treatment plans and how those involved informed of changes to the treatment plan(s). Included in the process category would be organizational measurements to include organizational quality improvement impacts, organizational health measures, and organizational functioning metrics.
- The Outcomes – this includes measuring the impact of the care more focused on there persons served, but should include measurements to those connected to the persons served (i.e., family. Loved ones, the community = population health). This would include reduction of symptoms or changes to diagnostic criteria for treatment, resolution of treatment plans and goals, improvements to health and functioning, and improvement to quality of life. The often-unstated overall goal of most approaches therapy is not to need therapy, so, what has changed or helped someone need lower levels (to no levels) of professional services in order to achieve the highest quality of living?
- The Experience – this includes a focus of the person served, but should include those supporting the person served. Experiences such as ease of access to care, inclusion of family/loved ones/natural supports in treatment, satisfaction with care, and measuring of respect of culture / identity.
With these three areas of measurement, an organization can effectively demonstrate how the care was produced, delivered, and what the outcomes and impact were for those involved.
Ultimately, there are three critical areas to focus on when measuring behavioral health care regardless of which area of care we are measuring. We want to measure changes in knowledge, emotions, and behaviors. By keeping these three critical areas in mind, we can measure change over time in a very meaningful way that can be translated from data points through narrative to demonstrate not only what has changed, but how things changed.
The temptation of most approaches to measurement-based care is to focus only on the individual receiving the treatment. We think this leaves so much opportunity to measure important influences to a change process. Hence why we are advocating measurement-based care practices that focus on the person served, those connected to the person served, including the organizations and care systems providing the treatment.
Now, comes the second greatest challenge of measurement-based care. We’ll discuss the greatest challenge shortly, but for now, let’s press on.
Reliability and validity of measurements. Reliability is a property of a measure that refers to its precision, or the degree to which multiple observations of a given phenomenon yield identical results. Validity is a property of a measurement that refers to its accuracy, or the degree to which observations reflect the true value of a phenomenon.
To illustrate, let’s use the classic example, the bullseye example.
In the three figures below, the bulls-eye of the target represents the true underlying risk of disease in a population and the holes in the target represent multiple objective measurements of the risk. In the first figure, the measure is reliable – it measures nearly the same value each time. But the measure in Figure 1 is not valid – the average of the scores is not close to the true underlying risk. In the second figure, the scores are not very reliable – there is a lot of variability in the scores, but they center around the true risk value, so they are valid (at least on average). In the third figure, the measure is both reliable and valid.
The term “precision” is often used in relation to reliability, while the term, “accuracy” is used to describe validity.
Behavioral health, differently than other aspects of care focused on physical health, has an inherent challenge. There aren’t as many uniform reliable and valid measurements available to use or to compare one care experience to another. For most conditions in behavioral health, there aren’t national standards or agreed upon methodologies for care. Where there are agreed upon standards, referred to often as “generally accepted standards” in legalese, the diagnostics used to assess conditions often contain such subjective experience interpretations that uniform measurements that are both reliable and valid become quite challenging, and some would argue, even impossible. Is there just one way to treat depression, anxiety, addiction, or trauma? Is there just one goal for a behavioral health care experience? What exactly should measure and what tool can help us measure the right things, in the right frequency, with a reliable, valid tool that show meaningful results.
Learning to understand what makes reliable and valid measurements can be challenging but is not an insurmountable task. Standardized measurements that have been designed and tested There are a variety of standardized measures to choose from, but understanding which apply to your organization takes some effort.
Here is a list of free, brief validated instruments as a sample:
The Clinically Useful Anxiety Outcome Scale (CUXOS)
Generalized Anxiety Disorder Screener (GAD-7)
Hamilton Rating Scale for Anxiety (HAM-A)
Liebowitz Social Anxiety Scale Clinician-Report (LSAS-CR)
Liebowitz Social Anxiety Scale Self-Report (LSAS-SR)
Panic Disorder Severity Scale (PDSS)
Fear Questionnaire (FQ)
Penn State Worry Questionnaire (PSWQ)
Social Phobia Inventory (SPIN)
Worry and Anxiety Questionnaire (WAQ)The Clinically Useful Depression Outcome Scale (CUDOS)
Hamilton Rating Scale for Depression (HAM-D)
The Inventory of Depressive Symptoms and the Quick Inventory of Depressive Symptoms (IDS and QIDS)
Patient Health Questionnaire-9 (PHQ-9)
Eating Disorder Diagnostic Scale (EDDS)
Sick, Control, One, Fat, Food Screening Tool (SCOFF)
Altman Self-Rating Mania Scale (ASRM)
Bech-Rafaelsen Mania Scale (MAS)
Young Mania Rating Scale (YMRS)
National Institutes of Health Patient Reported Outcomes Measurement Information System (PROMIS)
Patient Health Questionnaires (PHQ)
Recovery Assessment Scale (RAS)
Borderline Evaluation of Severity over Time (BEST)
Columbia-Suicide Severity Rating Scale (C- SSRS)
The Suicide Behaviors Questionnaire – Revised (SBQ-R)
Impact of Event Scale-Revised (IES-R)
Los Angeles Symptom Checklist (LASC)
The Post-Traumatic Stress Disorder Checklist – Civilian Version (PCL-C)
The Trauma History Screen (THS)
The Trauma History Questionnaire (THQ)
For a full listing of these and other free, brief validated instruments, please see: Beidas, R. S., Stewart, R. E., Walsh, L., Lucas, S., Downey, M. M., Jackson, K., Fernandez, T., & Mandell, D. S. (2015). Free, brief, and validated: Standardized instruments for low-resource mental health settings. Cognitive and Behavioral Practice, 22(1), 5–19. https://doi.org/10.1016/j.cbpra.2014.02.002
In the Joint Commission Standards, under the standards for Care Treat Services (CTS the following standards must be met by a TJC accredited organization:
Standard CTS.03.01.09 – The organization assesses the outcomes of care, treatment, or services provided to the individual served
– EP 1 – The organization uses a standardized tool or instrument to monitors the individual’s progress in achieving his or her care, treatment, or service goals
– EP 2 – The organization gathers and analyzes the data generated through standardized monitoring, and the results are used to inform the goals and objectives of the individual’s plan for care, treatment, or services as needed
– EP 3 – The organization evaluates the outcomes of care, treatment, or services provided to the population(s) it serves by aggregating and analyzing the data gathered through the standardized monitoring effort
The outcome measurement list provided by The Joint Commission includes but is not exclusive to some of the following:
ACORN Adult Outcome Questionnaire (ACORN Adult)
ACORN Child Outcome Questionnaire (ACORN Child)
ACORN Recovery Outcome Questionnaire (ACORN Recovery)
BASC-3 Flex Monitor (BASC-3 FM)
BH-Works Behavioral Health Screen (BHS)
BH-Works Behavioral Health Screen – ED version (BHS – ED version)
Behavior and Symptom Identification Scale-24 (BASIS-24)
Better Outcomes Now (BON)
Brief Addiction Monitor (BAM)
Brief Situational Confidence Questionnaire (BSCQ)
Child and Adolescent Service Intensity Instrument (CASII) (CASII)
Columbia Suicide Severity Rating Scale (C-SSRS)
Daily Living Activities-20 Functional Assessment (DLA-20)
Developmental Assets Profile (DAP)
ERP Health Outcome Tracking Tool (ERP Platform)
Early Childhood Service Intensity Instrument (ECSII)
Eating Disorder Examination Questionnaire (EDE-Q)
Emotion Dysregulation Inventory (EDI)
Generalized Anxiety Disorder 7-item (GAD-7)
INSIGHT Addiction (INSIGHT Addiction)
INSIGHT Behavioral (INSIGHT Behavioral)
INSIGHT Detox (INSIGHT Detox)
Mirah Measurement Based Care Solution (Mirah MBC Solution)
OpenFIT (Feedback Informed Treatment Made Simple) (OpenFIT)
Outcome Rating Scale (ORS)
Patient Health Questionnaire (PHQ)
Personal Wellbeing Index – Adult (PWI-A)
Promoting Recovery in Organizations Survey (PRO Survey )
RECOVERY 20/20 (RECOVERY 20/20)
Rating of Outcome Scale (ROS)
Recovery Capital Index® (RCI)
RecoveryTrack® (RecoveryTrack® )
Session Rating Scale (SRS)
Standard Child and Adolescent Needs and Strengths (CANS) Comprehensive (Standard CANS Comprehensive)
Trac9: Addiction Recovery Assessments (Trac9.com)
Treatment Outcome Package (TOP)
So, how do pick the right standardized measurement? Let’s turn again to The Joint Commission’s standards and practices for clarity:
Criteria for a tool to be considered a standardized instrument
The choice of an instrument(s) belongs to the accredited organization; however, any instrument used must meet the criteria listed below for routine outcome measures:
- Well-established psychometric properties (i.e., reliability and validity)
- Documented sensitivity to change (i.e., the ability to detect true/meaningful changes over time)
- Use as a repeated measure (i.e., can reliably detect change from administration to administration)
- Has established norms (i.e., the instrument can distinguish between populations that need or do not need services)
One of the challenges organizations learn (sometimes quickly, and sometimes slowly) is that not all standardized tools are intended or designed to be used as a repeated measure beyond a certain or prescribed frequency. While well intended, early adopters of measurement-based care ended up trying to use standardized tests that weren’t designed to measure results with beyond a certain frequency of testing. They ended up using tools more frequently than they were designed to measure change, thus not being able to accurate and precisely measure the changes they intended to track.
A simple example is using the Patient Health Questionnaire (PHQ-9). While it may seem obvious, using this questionnaire more than every two weeks invalidates the test, since the test asks a person to report on their experience over the past two weeks.
The lesson is simple. Take the time to ensure you are picking tools that will help you measure what you want to understand, and make sure those tools can be used effectively to produce reliable and valid results with a frequency that will show your work. Most importantly, ask for help. There are a wealth of resources on measurement based care and even more people devoting themselves to facilitating measurement base care programs in collaboration with providers. Two amazing resource for those interested in learning more about outcomes measurement for substance use disorder treatment , for exmaple, are the National Association of Addiction Treatment Provider’s (NAATP) Outcomes Measurement Toolkit and their Foundation For Recovery Science & Research FoRSE Outcomes Program. The NAATP Outcomes Measurement Toolkit provides a pathway to building an outcomes measurement program with all of the experience and considerations mapped, while the FoRSE Outcomes Program provides a pathway to large scale data collection and comparison.
________________
Measurement-based care – standardized tools and instruments: Behavioral Health: Care Treatment and services CTS. The Joint Commission. (n.d.). https://www.jointcommission.org/standards/standard-faqs/behavioral-health/care-treatment-and-services-cts/000002332/
Now, lets circle back to the greatest challenge of measurement-based care: getting started. While it may seem overwhelming, getting started is actually pretty simple. The good news is you are already equipped with most of what you need and the best news is you are already likely practicing a similar process.
Choose
Choose something to measure. When you are first getting started, it is best to choose something specific that can be measured, such as a symptom of an issue. Choose a brief, validated outcome measure that is connected to your treatment goals and objectives. These measures will be unique to each provider and practice. If you care focuses on several larger goals, such as addiction recovery, then pick a specific aspect of early recovery to measure. Measuring the reduction of cravings or urges to use substances is one example. If your care addresses depression and/or anxiety disorders, you may want to select symptom measures for those specific concerns. There is no one right answer for the selection, so choose the measures that align with your treatment goals, the population you serve, and be sure to pick something that shows your work.
Hone
Once you’ve chosen something to measure and something to measure with (i.e. a brief, validated, standardized measure), hone in on how you want the information to be used. Be specific on how you want to integrate the information gathered into the care process and how the information gathered can show your work. Think through how you’ll integrate the information into treatment planning, compliance considerations, organizational metrics for demonstrating the value of your care and service. There is a tendency for most people focus mostly on improving outcomes for patients, a benefit of practicing measurement-based care is it allows you to show your work to others, if you hone how to properly use the data. Qualifying for grants and negotiating better reimbursement rates with payers are two examples. Be sure to consider how collecting these measurements of change show your work in ways to improve every aspect of your organization.
Engagement
Engagement means getting everyone in the organization involved. This includes developing plans for informing providers, staff, stakeholders, and especially the persons served your plans, and process for implementing and integrating measurement-based care. If you engage some of the resources referenced above, there are systems and processes recommended for informed consent, for example. Engagement should include clarity on collecting and storing the information gathered, how collaboration of using the information gathered will take place and examining the results over time to improve the care process for a specific person served and the organizations overall care and treatment services. Everyone in the organization should be able to understand who is involved, what is being measured, where the measures are being employed, when the measures will be deployed and the results processed, and why the information is being measured to include how to share the results of the information gathered. Most important, engagement needs to include sharing how this information is being used to improve the care process. Engagement is literally showing your work in every step.
Evaluation
Evaluation is essential. Evaluate not only the results for improving the care for each person served, but also the process of your efforts. Are there ways to improve the measurement-based care process as you grow? Assuredly, you’ll encounter the lessons of experience referenced earlier about measuring the process, the outcomes, and the experience. One of the barriers practitioners often encounter is learning how to practice measurement-based care efficiently and authentically. Evaluating means regularly exploring how consistently each aspect of the engagement is going, can be informed and improved. In other words, evaluation means demonstrating integrity of your own process to ensure the results are what you want them to be, and when they aren’t, you can respond by learning what to improve and more importantly, considering how to improve. Just remember, evaluation is a process, not an event.
Revise
Revise, revise, revise! Once you’ve evaluated, you can then revise your measurement-based care practices, which really means, you can revise your approach to any part of the care and services. This could include revising a treatment plan, revising the way we understand a person, or the way we engage communication with a stakeholder. Revising is where measurement-based care can really help an organization understand its true impact. Amending systems and processes is a constant in behavioral healthcare, as we strive to meet the evolving needs and goals of those we serve.
Show Your Work
Show your work means sharing the results. Measurement-based care always includes sharing how things are changing, whether the results support our goals, or inform how we strive to achieve them. For a person in care, showing your work means celebrating changes throughout their change process, however small or large the change is. For organizations, showing your work means sharing information about how everyone’s contribution supports the care and services through the lives impacted, showing how your organization is improving, and celebrating the delivery of the mission, vision, and values as they evolve.
CHEERS to showing your work through measurement-based care! Still not convinced? Still fearful of the costs and investment? Fear not, as you likely have some of the resources in place already. Most likely, you are using an electronic health record system, which is filled with all sorts of useful technologies, systems, and tools already that can help you build a measurement-based care approach. While you may need education and training, the initial investment has already been made. Now, it’s just a matter of focusing your efforts on capitalizing that investment. Take some time to explore the resources you already have access to could support your measurement-based care initiative. Then, you can take a little more time to learn how to tap into the information you already have as a starting point. You can then decide what other resources you may want to employ to help you deliver the best care possible, which is informed by showing your work through measurement-based care.
By following these guidelines, you can create strong and impactful processes, systems, improve client outcomes, while simultaneously positioning your organization for the future of behavioral healthcare and measurement based, value driven care.
If you’re ready to take the next steps, there are 3 ways that we can support your journey.
Unlock the full potential of your behavioral health business with our tailored business optimization services. Our expert solutions drive clinical excellence, boost financial performance, streamline operations, enhance client outcomes, and maximize the potential of your most valuable asset—your people. Transform your business into a thriving enterprise that delivers exceptional clinical care, while ensuring sustainable growth with the help of our behavioral health consulting firm.
Empower your business to navigate the ever-changing behavioral health industry with confidence. Our mental health consulting services are designed to assist you at every stage of your journey, from start to finish. With our behavioral health consulting services, get expert guidance and industry insights to navigate regulatory complexities, identify growth opportunities, optimize operations, and make informed decisions that drive success.
Revolutionize your behavioral healthcare business with the power of data-driven strategies. Unlock valuable insights from diverse sources – integrated quantitative and qualitative analysis, measurement-based practices, operations and finances, revenue cycle management, and payor rates to fuel informed decisions that drive unparalleled success. Our comprehensive approach, powered by cutting-edge analytics and industry expertise, optimizes client outcomes, propels operational efficiency, and ignites financial performance.
Contact us at C4 Consulting at (866) 329-7170 or hello@c4-consulting.com.
Additionally, you can reach our Chief Marketing Officer and Senior Consultant, Christopher Bennett directly at (619) 481-2141 or cbennett@c4-consulting.com.
We look forward to partnering with you to make a meaningful impact in the behavioral health sector.
Thank you for choosing the Ultimate Measurement Based Care Guide!