Evaluating Measurement-Based Care in a Virtual Clinic

Abstract Information: Measurement-based care (MBC) is more than frequent and routine measurement for mental health outcome assessment and quality improvement. MBC involves the administration of recurring measures to enhance client empowerment, collaborative decision-making, therapeutic alliance, and clinical outcomes. Adopting an MBC model of care, Centerstone of Tennessee launched a Virtual Clinic in late 2011 to serve commercial-pay clients seeking telemental health services. Supported by a SAMHSA Community Mental Health Centers grant, the clinic restores access to clients with emerging needs in a post-pandemic world. With these funds, Centerstone’s Research Institute recently launched a pilot to explore insurance reimbursement for psychological assessment, create efficient clinical workflows, monitor fidelity to MBC principles, and examine outcomes. While several brief outcome measures addressing a variety of mental health dimensions are regularly used at the TVC, the most commonly used tools assess for suicidality (Columbia-Suicide Severity Rating Scale; CSSR-S), depression (Patient Health Questionnaire-9; PHQ-9) and anxiety (Generalized Anxiety Disorder-7; GAD-7). Currently, 12 therapists trained in therapeutic MBC provide telemental health services to 260+ clients a week, of which approximately 50% are enrolled in the program evaluation. Since inception of the evaluation in December 2021, more than 1,100 C-SSRSs, >5,200 PHQ-9s, and >3,900 GAD-7s have been administered in session to TVC clients. Data from evaluation participants will be presented, including 286 clients with C-SSRSs, 325 clients with PHQ-9s, and 328 clients with GAD-7s. Data will be separated and analyzed by symptom presentation (suicidality) and diagnosis (depression, anxiety, and mixed depression/anxiety where feasible). Bisby et al. (2022) found that depression and anxiety symptoms improved faster during the first half of internet-based treatment. The current study will report changes from session to session and conduct statistical analyses addressing the hypothesis that all three symptom areas will show improvement over time. We also anticipate that improvement will be faster earlier in treatment, then slow down before discharge. This presentation will highlight the stories of common client trajectories to illustrate the ability of measurement-based care to inform collaborative treatment planning and supervision.

Relevance Statement: When evaluating the effectiveness of mental health services, reliable and valid measurement is critical. In order to monitor progress over time, for clinical, research, and evaluation purposes, repeated administration of standardized clinical measures must be collected. Harvesting information at every therapy session, where feasible, also affords an excellent opportunity to visualize change over time. With an MBC approach to therapy, clinicians gather and share real-time data with clients, reinforcing treatment goals and enhancing therapeutic alliance. Reviews of empirical evidence for the effectiveness of MBC consistently show improved outcomes over non-MBC care (Fortney et al., 2017). As such, the MBC approach to clinical care, coupled with electronic health record systems that facilitate data collection, provides a powerful opportunity for evaluators. Change over time can be modeled from session to session and week to week, whereas typical outcome measurement models rely on data collected at baseline and reassessments, with are typically further apart and fewer in number . Unfortunately, fewer than 20% of mental health practitioners integrate recurring measures into practice (Lewis et al., 2019). Even when clinical measures are used in care, this treasure trove of useful information for clinical feedback, quality improvement, and outcome measurement, tragically goes largely unused. The current evaluation seeks to address this gap.

References: Bisby et al. (2023). The timing and magnitude of symptom improvements during an Internet-delivered transdiagnostic treatment program for anxiety and depression. Journal of Consulting and Clinical Psychology, 91, 95-111. doi: 10.1037/ccp0000761 Lewis, C. E. (2019). Implementing measurement-based care in behavioral health: A review. JAMA Psychiatry, 76, 324-335. doi: 10.1001/jamapsychiatry.2018.3329 Research reported in this presentation is part of the Community Mental Health Centers (CMHC) Grant Program awarded to Centerstone of Tennessee. This grant is supported by the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, of the Department of Health and Human Services under award SM85416.