Advancing Measurement-Informed Care in Outpatient Community Behavioral Health

We propose that a measurement-informed care (MIC) approach can advance repeated clinical measurement in community behavioral health care. We assert that MIC is not a new construct but represents an evolution of MBC that is more explicit about the role of patient-related factors (i.e., cultural, psychological, and social) in clinical decision making. Like MBC, MIC involves repeated measurement of a small set of psychometrically sound, low-burden patient-reported outcomes or biometric measures. These measures are meaningful across clinical and organizational purposes and are sustainable because of their low burden and benefits to patients, providers, payers, and regulatory agencies. Consistent with seminal descriptions of MBC (5), MIC positions measurement as necessary for treatment decision making but not sufficient for determining care. We propose that the term informed has valuable cultural currency, calling attention to the limits of basing care on measurement in behavioral health. MIC also explicitly recognizes variability in patient reporting and provider administration of measurement tools, which can be influenced by health literacy (9) and equity considerations, including varied perspectives on the meaning, purpose, and utility of treatments. Although some readers may prefer other terminology, such as MBC or PROMs, for the measurement process, the collective clinical and academic consensus of the behavioral health experts who contributed to this effort supports the MIC terminology (10).

We conducted a literature review summarizing the available quality measures endorsed by U.S. national health care organizations between September 2022 and February 2023 (10). We then reviewed and coded them along MIC-relevant dimensions, including diagnosis or disorder, population, psychometric properties, process versus outcome orientation, and specification of standardized assessment tools. Fewer than 25% of the >200 identified measures were patient-reported outcomes. A panel of 12 experts in addiction, administration, clinical care, integrated care, primary care, psychology, psychiatry, quality measurement, research, and social work, identified through the authors’ professional networks, reviewed the coded measure set.

The primary theme that expert panel members raised was the disconnect between regulators’, payers’, and general medical partners’ measurement expectations and the availability of suitable measures for MIC in behavioral health. Although regulators and payers were expecting behavioral health systems and clinicians to engage in MIC, the experts asserted that no widely accepted and agreed-upon measures were available for use. The experts attributed this gap to differences between the organization-endorsed quality measures that payers and regulators mandate or incentivize (e.g., HEDIS- or NCQA-endorsed measures) and measures that indicate clinical change or are important to people providing or receiving care. For example, the HEDIS measure of posthospitalization follow-up within 30 days is a useful systemic measure of care quality, but it says little about how clinicians should direct care for an individual. Similarly, the PHQ-9 instrument is a useful indicator of clinical progress, but annual PHQ-9 reassessments are too infrequent to direct care. Further, depression response and remission measures are aligned with MIC, but their reporting specifications are burdensome to providers and of variable interest to payers. Alignment of all parties on a small set of measures that can be used for improving both individual outcomes and value-based care is necessary to reduce provider burden, enable benchmarking across populations, and sustain MIC. (The online supplement to the Open Forum lists criteria used by the expert panel to select measures.)

On the basis of the recommendations of our expert panel, we defined MIC as follows: use of reliable and valid service user–reported outcomes or biometric indicators; use of repeated measurements at clinically meaningful, regular intervals; use of measure scores as one among other sources of information (e.g., service user preferences, social driver needs, culture, quality of life, functional needs and goals, family support, health literacy, and others) for making care decisions to support recovery; and use of the same measures to indicate accountability and efficiency of care. Consistent with these recommendations, we propose a two-tiered MIC set of measures for use with adult (ages 18–65 years) outpatient populations who receive community behavioral health services. Additional research is needed to validate the approach with other populations and settings.

MIC has the potential to improve behavioral health measurement uptake, implementation, and sustainability. Clinically, MIC may efficiently inform care and improve outcomes through effective use of data (5, 6). Organizationally, a tightly curated and payer-aligned measure set can reduce burden from competing clinical, quality, accountability, and fiscal reporting practices (1, 2). Aligned and synthesizable data sets can illustrate the impact of behavioral health services nationwide, which can help attract investment in behavioral health care (1, 2).

Our two-tier approach to prioritizing MIC measures serves as a template for immediate actions (tier 1) and future innovations (tier 2). Tier 1 is feasible and meaningful because it makes use of measures that many behavioral health organizations already use, directs quality measurement bodies to modify specifications in order to lower clinician and system burden, and provides a concise set of measures that the field can include when exploring sustainability strategies such as value-based payment. Our approach to tier 2, in which we propose concepts and candidate measures instead of advocating for specific widely used scales, reflects the state of the field, and shows the need for significant field testing before these new or updated measures are endorsed by national organizations that direct how care is measured and reported.

The authors acknowledge Senior Project Manager Tiffany Francis and other NCMW collaborators, including members of the expert panel. The authors also acknowledge session participants of the NatCon23 meeting in Los Angeles on May 3, 2023, and of the Substance Abuse and Mental Health Services Administration lunch-and-learn on May 30, 2023, who provided input on the project.