December 19, 2018

Let’s put measurement-based care in behavioral health treatment

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Dr. Cara Lewis reflects on using implementation science to integrate patient-reported symptoms into behavioral health care

Cara C. Lewis, PhD, is an associate investigator at Kaiser Permanente Washington Health Research Institute’s MacColl Center for Health Care Innovation and affiliate faculty of psychiatry and behavioral sciences at the University of Washington School of Medicine.

Imagine a primary care visit where no one takes your blood pressure. Instead, your provider looks you up and down and makes a mental note of her impression of what your blood pressure might be. Or she privately concludes in your chart that your blood pressure is likely fine because you don’t mention it as an issue during your interaction. Silly, right? And unlikely, since basing care on reliable assessments — a.k.a. “measurement-based care” — is widespread in most health care.

Yet a version of this irrational scenario plays out every day at far too many behavioral health visits — around 8 in 10 — where providers deduce how their patients are feeling. A more accurate and patient-centered approach is available:

· systematically giving each patient a brief validated symptom assessment before or during every visit;

· having the patient and provider review the data together; and

· then using that evaluation — and trends relative to prior ones — to inform discussion between the patient and provider, including about which direction future treatment should take.

This systematic patient-centered practice can transform behavioral health care. It can surface points when it might be time for a patient to switch providers or medications, change dosing, add psychotherapy — or stop treatment because it has achieved its goals. Measurement-based care can also help teams coordinate care and help clinics to know when additional training or staffing might be needed.

That’s why my colleagues and I wrote “Implementing Measurement-Based Care in Behavioral Health: A Review” in JAMA Psychiatry. We wrapped our arms around the evidence for implementing measurement-based care in behavioral health. Our narrative review of this field was informed by implementation science, which studies how to integrate evidence-based care, including measurement-based care, into routine care.

Our work isn’t done

We offer up implementation strategies — and we give a call to the field: Our work isn’t done yet. We acknowledge that implementation can be done better — more effectively and efficiently — if we fill in some gaps in our research, including mechanisms of change and algorithms for psychotherapy.

We found barriers to implementing measurement-based care across patients, providers, organizations, and systems. Implementation science provides strategies to address these barriers at these multiple levels.

We offer a 10-point research agenda to advance the integration of measurement-based care into behavioral health. If we address these knowledge gaps about this integration, we’ll be able to do a better job of supporting its implementation, continuation, and scaleup. Measurement-based care is standard in behavioral health at Kaiser Permanente Washington, and we hope to see it spread widely.

My co-authors were Dr. Greg Simon and Elena Navarro of Kaiser Permanente Washington Health Research Institute and 10 other colleagues from 9 other institutions. We’re grateful to the National Institute of Mental Health for supporting this work through grant R01MH103310.

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