Reducing suffering from psychiatric disorders is the purpose of mental health care. The quickest route to recovery is for clinicians to thoroughly assess the magnitude of symptoms from psychiatric disorders and treat according to evidence-based guidelines. Patient-reported symptom rating scales offer a quick and structured assessment of psychiatric symptoms and provide a mechanism for monitoring response to treatment (The Kennedy Forum, 2015). Measurement-based care (MBC) uses symptom rating scales to consistently track patient outcomes over time and inform clinical decision making (Scott & Lewis, 2015). The purpose of the current article is to (a) provide an overview of MBC and relevant screening tools; (b) examine the clinical use of MBC, including its relevance to evidence-based clinical guidelines and empirical support; and (c) detail the benefits and challenges of MBC implementation.
Although MBC is customary in medical disease management, it is not standard practice in psychiatry (Harding, Rush, Arbuckle, Trivedi, & Pincus, 2011). Less than 20% of mental health clinicians routinely use symptom rating scales to measure symptoms and track response to treatment (Lewis et al., 2015). Treatment decisions in psychiatry are customarily guided by patients' subjective report of symptoms and clinician preference, creating considerable variabilities in practice. Lack of standardized outcome measures and non-specific clinical practice guidelines may contribute to poorer patient outcomes (Harding et al., 2011).
Many symptom rating scales have been developed and empirically validated for use in psychiatry; however, little evidence exists to support the superiority of one rating scale over another. Considering most treatment modalities in psychiatry are aimed at treating a patient's diagnosis, it is clinically relevant to use rating scales that are diagnostic- and symptom-specific. However, monitoring patient symptoms alone is not sufficient to improve outcomes. Evidence from research trials reveals that use of symptom rating scales, in conjunction with evidence-based clinical practice guidelines (e.g., medication algorithms), results in superior patient outcomes (Harding et al., 2011).
In addition to improved patient outcomes, patients and providers reported satisfaction with using MBC during the clinical encounter (Steinfeld, Franklin, Mercer, Fraynt, & Simon, 2016). Patients described feeling more engaged in the treatment process and more knowledgeable of their symptoms (Fortney et al., 2016). Providers are encouraged to objectively monitor the effectiveness of their treatments and incorporate feedback to improve practice (The Kennedy Forum, 2015). Considering its ease and flexibility of use, MBC is gaining attention as a framework to guide clinical practice and improve the quality of mental health care.
Organizations will look to MBC as a method for evaluating quality improvement efforts and demonstrating the value of their services to payers (Fortney et al., 2016). As the evidence supporting MBC continues to grow, several national organizations have recommended its use in practice, including the American Psychiatric Association (APA; 2016) and Substance Abuse and Mental Health Services Administration (SAMHSA) (The Kennedy Forum, 2015). Its broad acceptability, effectiveness, and feasibility make MBC instrumental in improving the quality of mental health services. Due to its growing support, the current literature review was conducted to examine MBC.
What Measures Are Used for Measurement-Based Care?
Numerous psychiatric symptom rating scales have been developed and empirically validated to assess symptom severity for most psychiatric disorders (Harding et al., 2011). Patient-reported symptom rating scales may be preferred to clinician-administered rating scales and are equivalent in their ability to detect treatment response and remission (Fortney et al., 2016). In addition to symptom severity, rating scales can also be used to assess overall functioning and various quality of life domains, such as appetite and sleep. Diagnostic-specific symptom rating scales are commonly used because many treatment modalities, including psychotherapy and pharmacotherapy, are specific to diagnosis (Fortney et al., 2016). Diagnostic-specific symptom rating scales can be of value in clinical practice because the results can be used to monitor patient response to treatment and inform clinical decision making.
Considering the variety of available rating scales, it is important to use those that are clinically and practically relevant and that cause minimal burden to the patient and clinician (Morris & Trivedi, 2011; Zimmerman, Young, Chelminski, Dalrymple, & Galione, 2012). One of the most commonly used patient-reported symptom rating scales seen in practice and research is the nine-item Patient Health Questionnaire (PHQ-9) for depression. The PHQ-9 is a brief, well-validated self-report rating scale with one question for each symptom of major depressive disorder (Katzelnick et al., 2011). The tool is sensitive to changes in depressive symptoms and severity, and useful in monitoring response to treatment (Katzelnick et al., 2011). Morris and Trivedi (2011) and Zimmerman et al. (2012) agreed that it is not practical to comprehensively capture all mental health symptoms during the clinical encounter, and suggested that clinicians focus on clinically relevant symptoms of specific disorders—most commonly depression and anxiety. Implementation of MBC for depression and anxiety could potentially facilitate the transition to more comprehensive MBC in mental health care (Zimmerman et al., 2012).
Research examining the use of MBC across various populations and treatment settings demonstrated that treatment informed by MBC significantly improved patient outcomes (Fortney et al., 2016). Several large pragmatic trials established the effectiveness of MBC and its feasibility of use in clinical practice, including the Sequenced Treatment Alternatives to Relieve Depression (STAR*D), the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-D), and the Texas Medication Algorithm Project (TMAP) (Fortney et al., 2016; Guo et al., 2015). Even on a smaller scale, studies demonstrated significant improvements in patient outcomes with MBC. Guo et al. (2015) observed that outpatients with depression who were randomly assigned to receive MBC (n = 61) had significantly higher response and remission rates than those who were assigned to receive treatment as usual (n = 59). This study highlighted the feasibility of implementing MBC, which comprised using rating scales in conjunction with sequential treatment algorithms, into practice (Guo et al., 2015).
An initial overview of the literature revealed an extensive range of topics relating to MBC and psychiatric disorders. The articles detailed a variety of MBC methods, implementation strategies, and outcomes of use within diverse populations and clinical settings.
Articles were identified through PubMed, CINAHL, and PsycINFO. Given the variety of terms used to describe MBC, the keywords in this search were limited to “measurement-based care,” “outcome management,” “mental health,” and “psychiatry.” The reference lists of relevant articles were reviewed for additional retrieval of studies. Initial results using paired keywords and reference reviews resulted in >300 articles.
Inclusion and Exclusion Criteria
Due to the broad nature of the subject, articles were filtered according to specific criteria. Articles retained for the current review included those published within the past 5 years and in English. Articles were further limited to exclude studies examining the use of MBC in participants younger than 18. This limitation was used to improve the consistency of outcomes reported across study populations. After limiting by year of publication and participant age, the resulting number of articles was 77. Titles and abstracts were reviewed for a primary focus on MBC in the out-patient mental health setting. Sixty-one articles were excluded because they did not focus on research within the mental health setting, but instead concentrated on the use of MBC and mental health in other fields, such as primary care, HIV, and oncology. The remaining 16 articles were examined for their application to the subject of MBC methods, clinical use, and implementation strategies.
After a thorough review of the remaining articles, 10 were selected for inclusion based on their relevance to the purpose of the current article. The literature review was organized according to three prevailing themes: (a) to provide an overview of MBC and relevant screening tools; (b) to describe the clinical use of MBC, including empirical evidence and relevance to evidence-based clinical guidelines; and (c) to illustrate the benefits and challenges of MBC implementation.
Measurement-Based Care Methods
Although most articles delivered a brief definition of MBC, two provided an overview of MBC, including relevant screening tools (Morris & Trivedi, 2011; Zimmerman et al., 2012). The studies reviewed used a variety of screening tools to monitor patient outcomes, with the most common tool being the PHQ-9. The PHQ-9 was used in three studies describing MBC outcomes and implementation strategies (Katzelnick et al., 2011; Lewis et al., 2015; Steinfeld et al., 2016). The Hamilton Depression Rating Scale (i.e., a 21-item, clinician-administered questionnaire) and the Quick Inventory of Depressive Symptomatology-Self Report (16 items completed by the patient) were discussed in one study monitoring the outcomes of patients with depression (Guo et al., 2015). Another study used a brief two-item questionnaire for depression and anxiety to highlight the importance of MBC (Zimmerman et al., 2012).
Clinical Use of Measurement-Based Care
The concept of clinical use refers to the ability of a screening test to prevent or improve adverse health outcomes through the adoption of effective treatments based on test results. In general, screening tests improve patient outcomes by providing data that can be used to identify patients who will benefit from helpful management actions (e.g., effective treatment in individuals with positive test results and no treatment for those with negative results). For the purposes of the current review, the screening tests are measures of depression. Approximately all articles offered theoretical support for the clinical use of MBC; however, three studies provided empirical evidence. Of these, one was a randomized controlled trial comparing MBC to standard care for the treatment of major depression in outpatients ages 18 to 65 (N = 120) at a university-affiliated teaching hospital in China (Guo et al., 2015). A second study provided longitudinal observational data on patients (N = 960) older than 18 being treated for depression in 17 participating outpatient psychiatric clinics across the United States (Katzelnick et al., 2011). The third study outlined empirical evidence and implementation strategies of MBC within the Behavioral Health Service Department at Group Health Cooperative, a consumer-governed, not-for-profit health care system providing mental health services to >17,000 individuals per year (Steinfeld et al., 2016).
Four articles addressed the benefits and challenges of implementing MBC into clinical practice. One article (Lewis et al., 2015) described an ongoing dynamic cluster randomized trial that, once completed, will offer outcome data on standardized versus tailored MBC implementation at the largest outpatient mental health center in the United States. Although the study is still underway, it provides a good overview of implementation strategies. Another study described the implementation of MBC in a California Veterans Affairs Medical Center and included a description of the software program (i.e., COMMEND) that was developed to interact with electronic medical records (Landes et al., 2015). Two studies provided a review of MBC with a primary focus on implementation strategies (Harding et al., 2011; Scott & Lewis, 2015). Lastly, a narrative review of the literature that detailed theoretical and empirical support for MBC provided information that was relevant to all three identified themes (Fortney et al., 2016).
There is strong consensus regarding use of MBC. Several national organizations—namely the APA and SAMHSA—recommend the use of MBC to longitudinally monitor patient progress, symptom severity, treatment tolerability, and safety (APA, 2016; The Kennedy Forum, 2015). Professional psychiatric nursing organizations would do well to incorporate MBC training at their conferences as well as in their professional journals.
MBC is meant for use with clinical practice guidelines. Although MBC has proven benefits, it is not meant to substitute for clinical judgment (Harding et al., 2011). MBC, when used in conjunction with clinical practice guidelines, provides a standardized mechanism for evaluating patient progress and response to treatment and guides a more precise plan of care (Fortney et al., 2016). Katzelnick et al. (2011) examined factors leading to response and remission rates, as defined by the PHQ-9 score, of outpatients with depression (N = 960). They concluded that severity of initial PHQ-9 score, amount of time to first follow up, and documented self-management were predictors of response and remission rates. They also hypothesized that the lack of treatment algorithms to enhance clinical decision making may have delayed response and remission rates. The study demonstrated that symptom screening alone is not significant enough to improve outcomes. Administration of symptom severity rating scales in conjunction with evidence-based clinical guidelines, such as medication algorithms, led to significant improvements in patient outcomes (Fortney et al., 2016). However, despite availability of symptom rating scales and evidence-based clinical guidelines, their use is not standard in clinical practice.
Psychiatric Care's Unfamiliarity Regarding the Importance of Measurement-Based Care
Mental health treatment is largely inconsistent due to lack of standardized psychiatric measures and clinical practice guidelines. Many valid psychiatric measures are available for use; however, agreement on a set of standardized measures is missing in psychiatry (Harding et al., 2011). Psychiatric outcome measures are usually not correlated to specific clinical practice guidelines, thus providing little support to influence treatment decisions. Most available research on MBC and treatment outcomes is restricted to the treatment of depressive disorders, with minimal available research on the use of MBC in other common psychiatric disorders, such as anxiety and post-traumatic stress disorder. To effectively implement MBC in mental health care, more research is needed regarding use of MBC in other psychiatric conditions. In addition, significant variability exists in the use of MBC across practice locations. Most describing MBC outcomes and implementation strategies are specific to a particular practice setting. Greater research is needed to determine the most effective methods for using MBC in the practice setting.
Psychiatric Nursing Implications
Advanced practice psychiatric nurses use MBC with each patient encounter. Symptom rating scales should be completed during the interview or directly prior to the interview to adjust treatment decisions in a timely manner. By doing so regularly, patients come to expect a systematic assessment of their symptoms at each visit and learn to better recognize their symptoms and report them at subsequent visits, building rapport.
Many benefits of MBC exist and affect the patient, provider, and organization. MBC encourages patients to become active members of the treatment process and increases patient knowledge and awareness of symptoms (The Kennedy Forum, 2015). In addition, MBC enhances the therapeutic relationship through joint decision making (The Kennedy Forum, 2015), and promotes collaboration and coordination among providers, enriching patient outcomes (Scott & Lewis, 2015). Through the objective and streamlined assessment of patient symptoms, clinicians evaluated the effectiveness of their treatments and incorporated outcomes to improve practice. Furthermore, patient rating scales increased the likelihood that clinicians identified patients who are nonresponsive to treatment and subsequently adjusted the plan of care (The Kennedy Forum, 2015). Large-scale implementation of MBC demonstrated patient and provider satisfaction with routine use of symptom monitoring scales to track patient progress over time (Steinfeld et al., 2016). In addition to the benefits received by patients and providers, health care organizations profited from the ability to objectively measure organizational performance, evaluate quality improvement efforts, and demonstrate the value of their services (Scott & Lewis, 2015). For advanced practice psychiatric nurses, MBC helps demonstrate their value as providers, substantiating a quicker, less costly remission of symptoms while also reducing suffering.
Several barriers have been identified regarding MBC implementation—most notably time and resources (Landes et al., 2015; Scott & Lewis, 2015). Concern that MBC may prove burdensome to clinicians by increasing interview time has deterred its implementation (Scott & Lewis, 2015). In addition, financial restraints and limited technological resources were a concern for many providers and organizations (Scott & Lewis, 2015). Qualitative data from a large-scale implementation study of MBC revealed that patients were concerned about their privacy when completing rating scales in the waiting room (Steinfeld et al., 2015). The current authors' practice chose to administer surveys in a private office, resulting in freedom for patients to ask questions or make comments. With patient encounters often abbreviated to 30-minute sessions, MBC allows for an efficient assessment.
Several large-scale programs demonstrated the feasibility of implementing MBC into routine clinical practice. Steinfeld et al. (2015) reported that the application of MBC at a large health care system improved patient and clinician satisfaction and provided a process for the objective collection of quality outcome measures. They advised that creating a process that was simple and easy (e.g., administering the same measure at every visit) was essential to successful implementation (Steinfeld et al., 2015). Development of a software program at a Veterans Affairs Medical Center demonstrated the importance of tailoring implementation strategies to address the needs of a particular organization or practice site to increase the likelihood of successful adaptation (Landes et al., 2015).
Reimbursement for mental health services is shifting in the direction of payment incentives for providing quality care (The Kennedy Forum, 2015). MBC allows organizations to monitor the effectiveness of quality improvement efforts and communicate overall performance, which can influence accreditation and funding (Scott & Lewis, 2015). Payer and accreditation organizations, such as the National Committee for Quality Assurance and the Centers for Medicare & Medicaid Services, are moving toward value-based incentive programs that encourage use of MBC (Fortney et al., 2016). In addition, MBC aligns with the Patient Protection and Affordable Care Act by providing systematic evaluation of services and meeting requirements for meaningful use (Fortney et al., 2016).
When used with clinical practice guidelines, MBC is a systematic method for psychiatric nurses to improve patient outcomes via a consistent method of tracking patient progress over time. It is a framework with implications for promoting evidence-based care across patient populations and treatment settings (Lewis et al., 2015). MBC involves the use of patient-reported symptom rating scales, in conjunction with clinical practice guidelines, to objectively monitor patient response to treatment and drive psychiatric symptoms into remission. MBC, with clearly defined outcomes and measures, has the potential to reduce variability in mental health care and improve patient outcomes (Harding et al., 2011). It is likely to be used more widely in the future.
MBC enhances the acumen of psychiatric nurses by systematically evaluating the effectiveness of their treatments. Through the routine collection of outcome measures, organizations may monitor the effectiveness of quality improvement projects and demonstrate the value of their services. If MBC is not currently in use within a clinical setting, psychiatric nurses can begin the dialogue of how it might be incorporated into treatment, citing its efficacy and ability to decrease the length of time required for remission of symptoms. All patients deserve this scientifically proven approach. Accreditation organizations and payers will incentivize the use of MBC for performance improvement and reimbursement to meet accreditation standards within the next few years (Fortney et al., 2016). Psychiatric nurses can advocate for this quality improvement approach.
Moreover, psychiatric nurses embrace the idea that nothing can replace good clinical reasoning and patient-centered care. Patients cannot be defined by symptoms alo ne; therefore, it is important to be mindful of individual recovery goals. Psychiatric nurses should discuss patients' goals of treatment along with the results of symptom rating scales at every clinical encounter to inform treatment decisions (Fortney et al., 2016).
As mental health care moves in the direction of value-driven incentives, it will be important for providers and organizations to consider MBC as an evidence-based framework to reduce variability in psychiatric treatment and improve patient outcomes. Through the standardization of care, MBC increases the likelihood that patients with mental illness will experience less suffering and enter recovery sooner.
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