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Measurement-Based Care in Community Mental Health
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Hello and welcome. I'm Tristan Grindow, Deputy Medical Director and Director of Education for the American Psychiatric Association. I'm pleased that you are joining us for today's SMI Advisor webinar, Measurement-Based Care and Community Mental Health. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Now I'd like to introduce you to the faculty for today's webinar, Dr. Lori Rainey. Dr. Rainey is a board-certified psychiatrist and is principal with Health Management Associates in Denver, Colorado. She's considered a leading authority on the collaborative care model and the bi-directional integration of primary care and behavioral health. Her work focuses on service evaluation, gap analysis, and design and training of multidisciplinary teams to implement evidence-based practices. Her efforts have helped to improve the identification and treatment of mental illness in the primary care setting and have helped improve the health status of patients with serious mental illness and behavioral health settings. Lori, thank you so much for leading today's webinar. Thank you, Dr. Garindo, and good afternoon, everyone. It's a pleasure to be here talking about a subject that is near and dear to my heart, measurement-based care in community mental health centers. I want to start by saying that I have no disclosures, no conflicts as it pertains to this particular presentation. And for today's agenda, I really want us to think about what are effective approaches to measurement-based care? What are ineffective approaches in these settings? I want folks to leave with a list of some of the more common measurement tools for assessing both behavioral and physical symptoms in the community mental health population. And then I want to talk about what you should do with that measurement data. We're going to talk about registries, how you use it to track patients and improve their care. Now, let's start with a definition of measurement-based care. I will refer several times during this talk to a John Fortney and colleagues article that was published in Psych Services back in 2016. But basically, the definition is it's the care, measurement-based care involves a systematic administration. Now, there are words in here that you will see later that are really important, but systematic administration is one of those buzzwords, using symptom rating scales. And when you collect that data, you use the results of those scales to drive clinical decision-making, one, at the patient level, at that individual patient you have there in your office that day, but also you can take and aggregate those symptom rating scales and use that data for professional development for the individual provider, for quality improvement in your clinic, at your clinic level, but also something that we're going to see more and more of is to inform payers about the value of the services that we're delivering. So just a really nice, concise definition focusing on what we're going to do today. Now, let me just start a little bit with what might be some of your, what providers sometimes ask or providers are sometimes concerned about when we start talking about measurement-based care, because many of you know this isn't something that we have done in mental health. We haven't, even though our physical health partners in primary care have been doing A1Cs and blood pressures and all sorts of things for years, measurement-based care in the community mental health center in this setting is actually something quite new, and providers will say things like, well, is this really the right place to be doing this? These tools really can't replace clinical judgment. I know what's going on with my patient because we have a relationship and we're having a conversation, and I don't think these tools can really work with individuals with serious mental illness. You know, we've got to go beyond just the PHQ-9 that we're using in primary care. What can we use for more serious illness in this community mental health setting? And then we just, we don't need these tools. We provide a thorough clinical interview, we do that one-hour psych eval, we're fine. We don't need this. So there's just sometimes a little pushback or concern when we start talking about using these tools. I would encourage you to really think about a somewhat different perspective, about how can these tools really help you? They really allow you to know there's value in the work that you're doing. They really, they help really kind of demonstrate that nuanced human impact, to really be able to see that variation. And we feel undervalued in health care. Well, how might these measurement tools really change that around a little bit, where we're able to demonstrate significant changes and impact of successfully and effectively treating behavioral health conditions? Sometimes there's concern, we're going to miss out on alternative payment structures if we don't have a way to demonstrate our value. So we've got to figure out, how can we use measurement tools to do this? Our primary care colleagues, they get bonuses if X amount of their, X percentage of their patient population has their hemoglobin A1C under control. What if we got a performance bonus, because we had the same thing going on with depression or mania or psychotic symptoms or anxiety? Oftentimes, therapists can experience burnout and hopelessness when they don't see progress. So what if you have examples and signs of that progress really right in front of you as you're looking at your aggregate data? And then the one that gets a lot of attention is, there's so much focus on productivity and not so much focus on quality. Well, let's have quality metrics to actually demonstrate that what we're doing is effective. Productivity is important, but actually at the end of the day, the real question is, did the patient get better or not? And then just, there's sometimes a concern about loss of unique individual level in a data-driven system, and how do we think through that as we begin aggregating data and demonstrating the effect? I want to just point out one thing. So this Fortney paper that I've talked about really came from extensive work by the Kennedy Forum, and I encourage you all to go to that website and take a look at the work that they did. But one of, some of the nuances we're actually finding in the literature on measurement-based care is that behavioral health providers only detect about 19% of the patients who are actually worsening. So we're talking to patients, we're using our judgment, we're trying to get a feel for whether someone's getting worse, just kind of using this subjectively. And we're actually missing, in many, many cases, that patients are actually getting worse. And if you were actually tracking it with a tool, you would see that much clearer. And then detection is even lower for those whose symptoms are not improving as expected. So we don't know that people are getting better. And oftentimes, the patients don't know that they're getting better. And I'll tell you, a change in a PHQ-9 from 18 to 14, patients may not think they're getting better, and yet you're able to show them that and really demonstrate that they are and that things are getting better. So we miss things when we don't measure these symptoms and really think about what that might look like. The other thing to really think about with using these tools is there's a lot of interest in integration, so how do we get mild to moderate behavioral health conditions treated in primary care, save the specialty care setting for the more moderately severe to severe illness. One of the things, and this is called step care, this is a process called step care, and what we know is these tools can actually help us sort through whether or not the person is on the right, is receiving the right level of care, and can be either stepped up or can be stepped down. We need to remember on step care, getting referred to specialty behavioral health is not a one-way street to the right. As patients are getting better, we should be able to step them back down to primary care. Being able to say to a primary care provider, this patient's PHQ-9 has gone from 21 down to 9. We want to step their care back and support you as we move on those symptoms down, hopefully to remission if we can. And if you do this, if you have this process, what you begin doing is saving the right hand side of the screen for me. I'm a psychiatrist. Give me the more severe patients to see face to face, and let me help support primary care with the less severe patients. And this is really a way to address the psychiatric workforce shortage, and these tools can really help you. People will say to me in integrated settings, how do I know if this person should be treated in primary care or behavioral health? And now we're starting to have some tools to actually help us do that. So when you look at progress over time, the patient on the upper left-hand side of the screen, very nice response to treatment. The patient on the right-hand side of the screen, really kind of all over the place And if I'm looking at these scores in a primary care setting, I'm going to say, this person needs a higher level of care. This person needs to be stepped up to the right-hand side of that step care ladder I showed you on the previous slide. Maybe they have a substance use problem. Maybe they have a personality disorder and need a round of DBT. Maybe they are not taking their medications on a regular basis or don't have transportation, not showing up for clinic and getting the care that they need. So you can see how the tools in this particular example help you figure out where along the spectrum a patient needs to be. Now the payers have their own perspective, right? I had a payer literally tell me behavioral health is a black hole. We pour money in and we don't get anything in return. And they are really starting to expect outcomes. We're seeing this in a number of places. We're seeing it's written into state performance metrics. For me, in my community mental health center, we actually had a withhold. I think it was a 5% withhold until we could actually demonstrate that 50% of our patients with schizophrenia on second-generation antipsychotics that actually had a test for diabetes, like a hemoglobin A1c. We're also seeing in states like New York, when you're doing integrated care in a primary care setting, they actually want to know what percent of your patients had a drop of 50% or more in PHQ-9 scores of those patients that are being seen in primary care and are receiving a bonus payment for the collaborative care model. So we're really starting to see this. And we want them to open more codes. We want them to pay us more. We want to be part of value-based payment and catch up with the rest of medicine. We're going to have to really begin to demonstrate our value by demonstrating outcomes. And this move from value-based to two-value-based payment, it'll be interesting maybe during the Q&A if some of you are already there to maybe describe a little bit about what that's been for you. It's a little of an unknown. You don't know if you're going to reach those performance metrics or not, so it makes people sometimes a little anxious. But it's really where the rewards, performance bonuses, and potentially new codes will be in the future. So I would sort of say measurement-based care is a win for everyone. It's a win for the payer. They get something for their money. It's a win for the provider. You can actually see how you're doing. And it's a win for the patient because if they're not getting better, we're then prompted to do something about that lack of change or lack of improvement over time. So I really would hope at the end of this webinar, people are really able to embrace what this looks like overall. So let's dig into this a little bit. Now, this is a study that changed, that personally changed my practice of psychiatry. I picked up the Green Journal one day, and I found this article. And I was a little bit blown away because in this article, this is actually a group of psychiatrists. You know, psychiatrists, I just kept thinking when I was seeing my patients, I really knew what was going on. Before PHQ-9s and such, I tried to develop kind of a scale of one to ten, how do you think you're doing? I was struggling to figure out what was going on with patients and making sure I could quantitate it. So in this particular study, they gave a group of psychiatrists, half of them got a tool and half of them didn't. And the tool at this time that they actually gave them was the HAM-D. It's a little long. We don't use it that much clinically, but it's a great research tool. And what they found was a couple of things. One is more patients reached response, and they reached it a heck of a lot faster in four and a half weeks instead of eight weeks to actually get to that response and remission. It was quite an impressive drop if the patient was administered the HAM-D on a routine basis versus just trying to figure out as the patient's talking to you what's going on. And then, again, it happened with both response and it happened with remission. So it was an impressive study, and I came away from this study. I had a private practice at the time in addition to my work in the mental health center. I took a clipboard and I stuck it on the chair outside of my office. I had a PHQ-9, a GAD-7, and an Audit C on it, gave it out to the appropriate patients because I wanted to be like this. And what we found was people had a greater response, shorter time to response, and they ended up on higher doses of antidepressants. And even though they were on higher doses of antidepressants, it was basically the same dropout rate on both sides and the same side effects. What it really does is it pushes you to increase the dose, change the medicine, use some sort of adjunctive treatment. It really pushes you to do something different. And it's the same on primary care. If a person's hemoglobin A1c is at 9.5%, that internal medicine or primary care doc is going to keep pushing until they get that hemoglobin A1c below 7. So this tool made a difference in my practice. And then the following year, again, the Kennedy Forum work came out, and this was an extensive body where they literally looked at the world's literature on measurement-based care for behavioral health conditions. They had hundreds of studies. If you go and look in the back, look at the references in this article, they had all these studies. There's a lovely supplement, actually, and the link for it is at the bottom here. But they had all of these tools. They looked at these tools to figure out, you know, what is it that we actually have for measurement-based care? And it was actually quite impressive. The other thing that they found, in addition to giving us a supplement full of tools we can use for measurement, is they figured out some things, what's effective measurement-based care and actually what's ineffective measurement-based care. So the one thing that they found is that one-time screening doesn't change outcomes. And this is a reminder, because this is the U.S. Preventative Services Task Force recommendation, is screening and the measurement, typically, and even for adhedus and other measures, is that you have at least annual screening. But what we know is one-time screening, they had 500 patients, 250 got screened, 250 didn't, and at the end of the day, their outcomes were the same. It has to be different. On the next slide, I'm going to show you what's different. Assessing the symptoms infrequently, when I'm in primary care practices, I'll ask, how often do you check the PHQ-9? I'll say, oh, whenever the patient comes in or whenever the PCP thinks about it or, you know, it's just infrequent. There's no systematic way of doing it. And the other thing is giving providers these numbers. So if your insurance company mails you a PHQ-9, you fill it out, mail it in to your provider, they look at it, go, either who's this person or I haven't seen this person in years. So that doesn't really change outcomes to see that out. So what is actually needed for it to be effective? What does it take to get effective measurement-based care? So number one is that word systematic, the systematic administration of these tools. I tell folks that when patients first come in and they're depressed, absolutely a PHQ-9 every time for an anxiety disorder, every visit. When they're in primary care, if I've got a care manager, I can give it to them every two weeks. But at a minimum, I'm like, PHQ-9 once a month, CAD-7 once a month. We do this with Vanderbilt. Every time these kids come in, it has to be very systematic with specific intervals. And that is new and different to primary care, and it's new and different for us. So it's not just catch-as-catch-can, or if I think about it, it's in our protocol how we're going to do it. Remember that measurement-based care is not a substitute for clinical judgment. We actually listed that early on as one of the concerns around it. People can fill out a tool in a way where you kind of look at it and go, well, they put a zero down on the PHQ-9, but they're sitting here sobbing, and I'm a little worried they might be suicidal. Now, I'm going to use my clinical judgment. I had a patient with schizophrenia. We were given the PHQ-9 as just a regular tool, and this actually happened. His score was 20. I saw it before he came in. I'm like, oh my gosh, what's wrong? He's usually a very happy guy, and he pops it, and he's happy and smiling, but he's put a 20 on the tool. So I had to use my clinical judgment to say, you know, he's not severely depressed. Maybe he's interpreting this tool in a different way. So it does not take the place of clinical judgment. It's not, I wish it was exactly like hemoglobin A1C, but it's not that close, but it's close enough that we can actually get in the ballpark and start using it. We use these tools to drive clinical decision-making at the patient level. It really helps overcome that clinical inertia. So one of the biggest things we see is underdosing, as you saw in that article we saw before, and particularly in primary care, it's probably the number one reason for the care not being as effective. Everyone stops at 50 to 75 milligrams or so off when psychiatrists will push to 200 in a heartbeat. So we really use those tools to keep going, and the other thing is to really think about is letting the patient fill out the scales if it's appropriate. So having someone alone in the quietness of the waiting room, have an MA, having people ask the questions can change things up sometimes. You got to make sure their literacy level is right, they can read it, understand it, and if they do have some pushback, sure, go ahead and read the questions to them. But I really like leaving them alone and letting them do it, and what the research shows is it's equivalent to sitting there and asking them the questions, and on some level I think it might even be better to let them do it. The best choice for a tool is brief, easy to score, clinicians like it, patients like it, you don't need a whole bunch of administrative tasks and clinician time to do it, to score it, and it's going to be very helpful if it's non-proprietary, meaning like PHQ-9 or other tools, it's out there, it's available, it's free, you don't have to pay for it. So you may say, well, how about we do the HAM-D, that's what we just saw in that study, and I'm going to say, well, how about we do the PHQ-9, it's nine questions versus 30 questions, it's quicker, easier to score, actually the patient can score it. So these are some things you need to think about when you're thinking about those tools. The other thing is, is that there are screening tools and there are measurement tools, and it's a really good day if the screen and measurement tools are the same thing, and here's sort of an example of commonly used tools that you can use in your study. Now some of these are screening and some of these are measurement. Remember what I said before, it's great if it's both, so the PHQ-9 is both a screening tool for depression, and if they have depression or dysthymia, it's actually a great measurement tool. You can see here I have some other screening tools. One thing to say about the postnatal depression screening tool, the EDINBURG, is it is a screening tool, not validated for measurement. What we're starting to see in OBGYN clinics are they're just passing out the PHQ-9, because if the EDINBURG's positive, then they have to give them a PHQ-9 if they want a measurement tool. For anxiety disorders, the GAD-7 for anxiety, the PCL-5 really will allow you to track those PTSD symptoms in kids. There's a tool called the SCARED. For psychotic disorders, we're going to talk about this a little bit more in a minute, it's a little more tricky. We don't have the world's best tools for this. We're going to go over that in a minute. And then for substance use, there are things like the AUDIT-C. C actually stands for consumption. If someone has a substance use problem, you're actually looking for reduction in consumption. The BAM is the Brief Addiction Monitor. Again, you can look at changing scores on that. That's a nice measurement tool. DEF and CRAF are more screening tools. So just to think about what's a measurement and a screening tool, I'd really rather go there first if I can. Here's an example. Here's the PHQ-9. Hopefully everyone has seen this. I am not a fan of the PHQ-2, and I would say to folks, as much as you can, you're not doing suicide screening if you're asking the PHQ-2. It's only the first two questions. So I push every primary care clinic, everyone I know, stay away from the PHQ-2, and really go for the 9. Plus, you get all this other great information. The trigger on the PHQ-9 is a score of 10 or above, and at that point, we tell folks to kind of get activated. We're beyond kind of the mild symptoms, really getting into moderate symptoms. The GAD-7 is another tool that I like to use quite frequently, and again, there's the GAD-2, which is the first two questions. I like to just go ahead and ask all seven, and again, a score of more indicates a possible diagnosis. Oh, just for a moment, going back to the PHQ-9. A score of less than five is remission, and remission is the Holy Grail. That's where we want to go. That's where we want to drive down that score for our patients. Children and adolescents, we have plenty of tools. My child psychiatrist in my clinic always got the Vanderbilt. He was doing measurement-based care way before any of us were. But there are plenty of tools to also look for this in kids. Now I want to go to the SMI tools because this is where it gets a little tricky. And just before this talk, very thankful that Dr. Staramelli and colleagues at University of Washington actually came out with this very nice new article on measuring symptoms in patients with bipolar disorder. They were doing a lot of work in rural, actually primary care clinics, where they were trying to figure out how to help primary care providers think about measuring symptoms. And so for mania, the Altman self-rating mania scale, brief, easy to score, self-administered. That's kind of the tool. And they did a lot of looking at the tools. That's the one that kind of came out on top. For depression, the PHQ-9 hasn't been used very much. More complicated tools have. But they're actually saying it'd be really nice if we could get a little more research on using the PHQ-9 for depression. Again, very simple tool. And then if you want to do both mania and depression, there is the bipolar inventory of symptoms scale, which if I remember correctly, might be clinician-administered. Schizophrenia, again, it's a little tough. If you look at the pharmacology studies, most of them use the PANS, the positive and negative symptoms scale. They're looking at changes in the PANS over time. There's also the brief psychiatric rating scale, which is picking up on psychosis. And we're going to talk for a minute about functional assessments, because it's so hard sometimes with the direct symptoms. What about functioning in patients with psychotic disorders? And then I had mentioned the BAM for substance use disorders. And I just want to point to the quote on the right out of a study from Kumari and colleagues in 2017. There are a lot of different scales out there to measure the positive and negative symptoms of schizophrenia. And just finding something easy that helps us really understand severity and psychopathology really has yet to be developed. So maybe there's some folks out there in the audience today who have had some other things they are using or are thinking about this in their particular practice. In the meantime, though, we do have these scales. And again, these are the scales that are used to measure medication effects in many, many, many of the drug trials that go on. Some functional measures. So, okay, well, if you have schizophrenia, if you have a psychotic disorder, if you have bipolar disorder, what are those other things that we can look at? And here are just some examples. I'm not going to go through these except to say, you know, community tenure, which basically means you're not in a hospital. What's your quality of life? Are you employed or not? Really looking at disability. And so it's really, you know, it's a bit of a really looking at functional status instead of symptoms. And just, you know, the functional status will be a measure of what's going on psychologically for folks. So just something to think about given the absence. It's a perfect tool. Now, the other thing in community mental health you guys are aware of is really measuring the physical symptoms is just front and center in our field right now. And cardiovascular disease is really what we can effectively measure and track in the community mental health center. It gets a little trickier with preventative health, mammograms, pap smears, colonoscopies. We can always encourage and refer our patients, but these are actually the things every day in our office. We can get blood draws. We can ask about smoking. We can weigh our patients. We can slap on a blood pressure kit, draw blood for both A1Cs, and to be able to now calculate the risk factors. I have a little app on my phone to do that calculation based on cholesterol levels. These are the HEDIS metrics that you are more and more and more in your setting gonna be held to. These are national quality form standards. And look at what's starting to pop up. Diabetes screening and schizophrenia. Remember, that's the one I was held to in my practice four or five years ago. You know, what's really happening with your patients with schizophrenia and other conditions? Metabolic monitoring in children. These are very important measures and you may be given a performance bonus or you may can have a withhold of funds until you begin to prove that you're able to meet some of these metrics. So I would say this list in particular, take this list seriously and think about how can we do this in our patient population? Now, the process for measurement-based care really requires you to think about your workflow. We had to work this out in our clinic. How are we gonna screen? Once you screen, how do I get to the diagnosis and the treatment? I need to measure response over time. Remember, in a systematic way, I've got to put this data somewhere. I have to track it. And if the person's not getting better, I need to adjust treatment as needed. And then really being able to feedback those results to patients, to my community, to my clinic, to my colleagues. How do we begin to do that? So this takes time and it takes working out a workflow. I was talking to someone who was spending a lot of time on their workflow just trying to figure out how to get BMI, how to get patient's weight as they were coming into the clinic. So you really do have to think about what this looks like. You have to sort of figure out, okay, now which tools am I gonna use? Am I gonna use the BAM and the PANS and the PHQ-9 and the GAD-7 and maybe the Audit-C? What am I gonna use? How often am I gonna repeat them? Is the minimum requirement in my clinic gonna be once a month? Is it gonna be every visit? Is it gonna be every six months? And when am I gonna screen and when am I gonna measure? Very specific around that. Who's gonna give the tool and by what means? Are we gonna give it on a tablet, on a kiosk, on a piece of paper? Are we gonna do it written? Are we gonna do it verbally? How are we gonna administer? Who's gonna put those results in the EMR? Where's it gonna be located? I've had people put it in a vital sign column. I've had people put it, have its own distinct field, but it's under the Wellness tab. You gotta remember to go over there in whatever your EMR is. So where is it gonna be? And everyone needs to know where it's gonna be. How is it gonna be used? Can you graph it? Can you show it to the patient? You know, what are you gonna do on the individual patient level? And then who on your team is gonna be responsible for aggregating that data for whatever those needs are? So let's say we wanna know in our psychiatric medical team what percent of our patients have had a screen for diabetes and of those that have been screened, how many of those patients have diabetes, have a hemoglobin A1C less than nine. We're gonna be looking at percentages and comparing them across their clinic. It's really, really important to have role clarity as you're sorting through the workflow and how you're gonna do measurement-based care. This is in my clinic, actually, and I had my trusted medical assistance. This is a little outdated. We called it the pink sheet, where we actually were tracked and knew and had all the list of vital signs, labs, tobacco, last PCP visit, those sorts of things. If they had a PH, if it was appropriate for them to have a PHQ-9. And we really had someone in the workflow to help me do it. This is not, for the administrators out there, this is not something to just give to the clinical staff to do. You need to really think about who on the team, you know, what are those tasks that don't require an MD? Who on the team could actually help do this? Because adding more and more tasks without adding folks to help do it doesn't settle very well with folks who are potentially seeing a lot of patients and seeing them back-to-back. So this is my medical assistant, Jamie, and she got all these things done and prepped and ready to go before the patient came in. We would set goals, and again, this is that work of your team. You know, in your clinic, you can say our goal is glucose control or blood pressure control, and there are health behaviors we also want to target. And so you have those goals in your clinic and among your staff, and then you commit to some targets. What is this going to look like in my clinic? What targets do we want to reach? Because if you don't hit your targets, you want to come back and take a look at what's going on and see what do we need to do differently, and that's kind of in a PDSA cycle. We'll talk about it in a minute. Now, you need to be able to track your data, and most people track their data. You can track it in an Excel spreadsheet. You can track it on a piece of paper, making hash marks if you need to, but a registry is typically, again, it's a systematic way of collecting data. It's held in a central database, and you have a purpose for it. So you've actually set the data fields that you want. You saw my pink sheet. That was how I was actually starting a registry, at least on the individual patient level, for my patients, but it's in that central database, and a lot of people do modify Excel spreadsheets, especially if you know how to work the formulas on Excel spreadsheets, and they serve very different purposes. They can be used on the individual patient level. They can be used for risk stratification. They can be used for research. They can be used for clinic, you know, overall outcomes in your clinic. What they do at the individual patient level is really make sure no one falls through the cracks. If you have a list of patients' names and a list of things that are supposed to be occurring, and there is a blank, there is a care gap, you can see that. You just glance your eyes over a registry, and I'll show you this in a minute. You can actually see where those care gaps are, so it really is the antidote to people being lost to follow-up or falling through the cracks. It's really hard to fall through the cracks if I've actually kept a list of who I've seen, who I started on a second-generation antipsychotic, who I'm getting a hemoglobin A1C on, who is doing three months that didn't get it, because all of a sudden now I've got a gap, so it really does help with that, and by doing that, it helps you with your metrics, especially if you're reporting to a payer, because if you lose track of someone, sometimes you get stuck aggregating their last score, which is probably not their best score, so it's really good for tracking. It lets us know who needs attention, who's at high risk, who's at lower risk, so you can stratify your patients a little bit. You can put reminders in there, so we have one for primary care every two weeks that cues you to give the patient a call and see how they're doing, maybe repeat a rating scale. It really helps facilitate communication, and to help choose the initiative that's most likely to have an impact, so if everyone's blood pressure's doing just fine, but I've got a lot of high hemoglobin A1Cs, maybe the focus would become on diabetes, maybe you do staff training around that, and that becomes more of your focus. Here's just an example of a registry, and what you're really looking, in this particular registry, we're measuring change, two crucial data points if you're treating, for instance, depression, or a drop in the PHQ-9 of 50%. That is what the FDA requires to get a new antidepressant approved, so that 50% reduction in symptoms for depression and anxiety and many other things, and as I mentioned before, remission is a PHQ-9 less than five, it's also a GAD-7 less than five, so they kind of track along with those same metrics, and you can see on here, you can see which patients are gradually, their scores are moving down, you can see how long they've been in treatment, you can see who's stuck, you can see who's been lost to follow-up, and actually often use the registry for flagging, person needs to go to primary care, person needs to have some escalation in treatment, or change in treatment, more intensive treatment, this person's a safety risk, your registry can really provide a lot of information and a lot of tracking, this would be great for a therapist to actually be tracking their caseload and really looking at what's going on, same for one of your psychiatric medical staff, again, tracking, knowing what's going on with your caseload, and then these numbers can be aggregated by administration or your IT folks, so that you can actually look and see how the clinic is doing over time, here is an example of toggling the registry, so that the highest scores, the people that are having the biggest struggles, actually come to the top, and then you can focus your attention on this, I'm working with a clinic where the therapists are monitoring their patients, and if their patients aren't getting better, they're sitting down and reviewing their caseload with a psychiatrist to see, hey, is there anything else we can do, do we need to bump up this person's meds, this person is only in therapy, they really don't wanna be on meds, maybe we can show them this data and convince the patient to do this combination of therapy and medication, maybe we need to be really focusing on a substance use problem, but you're gonna actually use this to sit down and have a focused caseload review, so again, focusing your attention on the people that aren't getting better by toggling your registry can be extremely helpful, and again, so what might the metrics be, so now we're gonna aggregate the data, we wanna report to Medicaid, Medicare, Anthem, Cigna, we wanna report to our payer on how we're doing in our clinic, we're hoping for a performance bonus or hoping to share in any cost savings that are with the result of our great numbers, and so here's some examples of things that could potentially, there are process metrics, you know, that a patient had at least two contacts a month or a patient had they were reviewed if they weren't getting better, the outcome metrics that I mentioned before, those reductions in symptoms, they're very specific National Quality Forum standards, 710 and 711, they're right in there, patient and provider satisfaction, you can always monitor that, I'm not sure that a payer might not pay for that, but that's important for you to know, again, the functional measures we talked about earlier and certainly a payer's gonna wanna know about reduction in emergency room visits, 30-day readmissions, these are all things that we can help, we can have some impact on and they're ultimately gonna drive down costs, so this is just sort of an example of metrics that you can report on, some more of these metrics, now here is, we're kind of now looking at the physical health measurements we were talking about before, here's a registry now for a patient to really look at all of those cardiovascular risk factors that we were talking about earlier and again, tracking and aggregating this data over time is extremely important, you can use this data, this is what we had, we had a dashboard, we could actually show the patient, we could come up with these wellness report cards, again, aggregating the data now becomes a central focus of what we're trying to do and how we're gonna try to direct patient care, the other thing is to really have, is to share your aggregate results, so this is a clinic, this is a Indian Health Service clinic that I've worked in for years and across the top, ABCD are the actual providers, so you can always decide are we gonna do this blinded or unblinded when you're really hearing providers to each other, in this case, they gave up a number, on the left are all the different, I think these are different measures that the federal government requires, but all these different measures are on the left, how's the clinic doing, what's the goal, how's each individual provider, so every time the provider goes to the bathroom or the break room, they get to take a glance at this and they actually see where they are, this can be in a friendly way, can be friendly competition, it can be just a way for the whole clinic to get behind what is going on, because there's not a single provider here whose results depend on them alone, it's really a team and keep that in mind, if we're just rewarding providers, primary care or psychiatric team with performance bonuses or gift cards or whatever it is, you're really forgetting there's a team that works behind those performance metrics and to really think about what that would be, these guys would have pizza parties when they reach certain goals, and all the things on the left that turn to green, that was actually a time of celebration, you can also use it as a time to change the goals, maybe you wanna up it a little bit, so there's all kinds of interesting ways, the carrot, the stick, you can be punished for your scores being low, you can be encouraged to get them higher, but I'll tell you, if everyone's looking at each other and docs in particular don't like to be outliers, but they start to look at each other, a little friendly competition can sometimes start, you can see results in a clinic really begin to improve, you can also see on here where you need to focus your attention, so for instance, for the colorectal screen on this particular one, kind of across the board, everyone's having trouble for the mammograms, for the pap smears, for the tobacco cessation, for the different things that are on here, you can actually see where they're struggling and you can see where they're doing just fine, so that actually points out to you, hey, this is where we need to put some resources, here's another, I'm sorry about that, here's another just example of using just to look across these numbers and identify those gaps in care, so again, here's two psychiatrists and three primary care providers in a clinic, they have two goals, everyone gets asked about smoking, yeah, 100% is your goal, and then cessation advised, so for those who are smoking, we want a 38 or 50% rate of really advising those patients around nicotine replacement or something, and if you look across this, you can see of all providers, they're not meeting this goal, 38% is across all providers, a few PCP2 is doing a little better than the rest, and if you look at cessation advised, again, just carry your eyes across it and you can see only one provider, PCP2, actually is reaching this goal, so again, aggregating this data, being able to look at it, is extremely important, and then you use that data for two things, one is if people aren't getting better, let's step back and ask why not, why aren't we getting the screening done, if we're not getting blood pressures done because we're expecting the psychiatrist to put the blood pressure cuff on the patient themselves, and that's actually what we used to do, I had the patient trying to slip into the Walmart blood pressure cuff while I was trying to talk to him and it got a little confusing in there until I got my MA as part of my workflow, but you take a step back and say, hey, why isn't this working, and do something different, and you can do these in very short cycles and depend on what you find, it's a lovely opportunity for educating staff around what to do next, put a new workflow in place, see if things get better, keep going until you get it right, until you get it where you want it to be so that you can be proud of your work and also knowing that your patients are getting better. Now, my last slide is really coming back around as I promised to value-based payment. We are, I do a lot of work with state Medicaid agencies and others across the nation. We are seeing, again, in a lot of places, this new focus of attention on behavioral health, and some of that, it's great, people figured out, I mean, we could have told them this years ago, I guess, but folks have certainly figured out that behavioral health conditions absolutely impact physical health conditions and can double or triple the total cost of care. So now there's much more focus on behavioral health and folks wanting effective behavioral health. So the different ways of using value-based payment are assigning, you're actually put at risk. So if you don't reach certain metrics, money can be withheld or money can be taken away. That's kind of upside and downside risk. Performance bonuses, again, if you reach these metrics, if 50% of your patients reach remission, great, you get a bonus. That's, you know, getting into the bonus pool is good. Another pool that's really nice is shared savings. So if all your hard work in behavioral health ends up saving the system money, you split it with the insurance company or you split it with, or split it or have some percentage that comes back to you. The Holy Grail is probably just total capitation, all mental health, all physical health, all in one bucket. And then you're able to move resources around and really cover all the health care expenditures. And then if there are ways because you're using, you have quality metrics that you could potentially get a case rate. So thinking about for first episode psychosis, there was an article recently about thinking, you know, what does that case rate look like? How do we, you know, we know these services are having an impact. How do we assign a case rate to that so we can actually pay for it? Because as you guys know, a lot of services that we do around, especially patients with more severe illness, it's very difficult to actually pay for their services because there's not necessarily a CPT code. It's more of a care management code. We also are seeing this with health homes for the SMI population, organizing around the physical health of those patients, things like ACT teams, again, where there are non-billable services. If we can demonstrate improvement, we're keeping people out of the hospital, we're reducing psychiatric symptoms, they're picking up their antipsychotics more frequently, they're reaching remission for depression, they're going to the emergency room less. If we can begin to demonstrate these, maybe it then gives us the data that we need in order to be able to look at, you know, participating in a value-based payment arrangement. And we've talked a lot about this, and folks keep saying, well, we've been talking for several years about value-based payment. It's not here yet, but I will tell you across the nation, it is absolutely starting. And again, I'd be curious if anybody on the phone has had experiences with this and would like to share that. With that, I'd like to stop and turn this back over to you, Dr. Garindo, for discussion. Thank you.
Video Summary
In this video, Dr. Lori Rainey discusses measurement-based care in community mental health centers. Measurement-based care involves systematic administration of symptom rating scales to drive clinical decision-making and improve patient outcomes. Dr. Rainey emphasizes the importance of using brief, easy-to-score tools that are non-proprietary. She provides examples of measurement tools for depression, anxiety, psychotic disorders, and substance use disorders. Dr. Rainey also highlights the need to measure physical symptoms and shares examples of cardiovascular risk factors that can be tracked. She discusses the importance of developing a workflow that includes screening, diagnosis, treatment, and measuring response over time. Dr. Rainey suggests using registries to track and aggregate data, ensuring that no patients fall through the cracks. She explains how data from registries can be used to identify gaps in care, set goals, and monitor outcomes. Dr. Rainey encourages clinics to share aggregated results with providers and use them to guide quality improvement efforts. She also discusses the potential of value-based payment models for behavioral health and the importance of demonstrating outcomes and cost savings. Overall, Dr. Rainey encourages clinics to embrace measurement-based care as a win for patients, providers, and payers.
Keywords
measurement-based care
symptom rating scales
patient outcomes
depression
anxiety
substance use disorders
registries
value-based payment models
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
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