Psychiatric Measurement-Based Care (MBC) in Safety Net Clinical Settings: Implications for Health Equity 

Summary

Measurement-Based Care (MBC) is a way of measuring mental health symptoms, quality of life, and functioning to help patients and providers plan treatment.^1,2 The adoption of MBC in mental health care has been slow, despite growing evidence of its effectiveness and the increasing demand from health care payers for its inclusion in mental health treatment.^3,4 Although much of the existing research demonstrates that MBC is effective and improves treatment outcomes, prior work has predominantly focused on single, lower-acuity conditions (e.g., depression and anxiety) and involved measurement during a mental health appointment in the presence of a mental health provider. MBC is increasingly being used for patients with multiple overlapping or higher acuity mental health conditions who have more social and economic barriers to health care. Additionally, advances in technology-assisted or remote data collection are changing the way MBC can be utilized.^5,6 However, there are emerging disparities evident in MBC implementation, including lower uptake by some patient populations.⁷ Safety net health systems, which provide health care regardless of insurance status, face complex feasibility and equity challenges when implementing MBC for their diverse patient populations, particularly given the resource constraints at both the system and patient levels.

The need for MBC adaptations in diverse populations has been recognized, yet safety net health systems embarking on behavioral health MBC implementations largely lack the data they need to address this system-level challenge. To address this challenge, since 2020, our team has studied the implementation of MBC at (a) three outpatient adult psychiatric clinics and (b) an adolescent inpatient (hospitalization) unit, both part of a larger safety net health system in Cambridge, MA. The system implemented a computer-adaptive suite of measures for multiple mental health conditions in adolescents and adults through self-report via smartphone, tablet, and/or computer (in English or Spanish). The adult mental health symptom measure was completed remotely before an outpatient mental health visit, while the adolescent mental health measure was completed at the outset of a psychiatric inpatient hospitalization. In both cases, the MBC workflow was designed so that provider teams and patients would have patient-reported outcome results available during the mental health visit (or stay, in the case of hospitalization) to assist with treatment planning and shared decision-making. Our pragmatic work includes targeted observational studies at multiple stages, including the pre-implementation, early implementation (0-6 months after roll-out), and 1-year post-roll-out of MBC.

Significance

Our work found that for adult outpatient MBC, providers, patients, and clinical administrators who weighed in on barriers and facilitators pre-implementation envisioned different optimal MBC workflows that coincided with where they saw the most potential/immediate benefit. Specifically, providers and patients saw the most potential benefit to improve individual patient care, whereas administrators were also interested in prioritizing system-level use of MBC data – suggesting more systematized data collection and application. During pre-implementation, all stakeholders shared concerns about whether it would be feasible for symptom measures to be collected remotely in a way that was equally accessible for racially, ethnically, and linguistically diverse patients across the system. During early implementation in adult outpatient settings, over 1000 eligible patients across the three clinics demonstrated variable uptake based on the clinic, patient race/ethnicity, and language in which the measure was administered – demonstrating that some early concerns about equity were warranted. One year after the MBC roll-out in adult settings, a mixed methods analysis showed provider attitudes toward the success of MBC implementation and its current utility still varied substantially, that providers shared persistent concerns that MBC was not benefitting all patients equally, and providers agreed that some early implementation barriers (such as sufficient time before, after, and during visits to review and discuss scores) remained unaddressed. More details from some of this work are available via publications in Learning Health Systems in 2022 and 2024.^8,9

Many of these same themes also emerged in our mixed methods pre-implementation study which used key informant interviews and surveys to gather and analyze data on barriers and facilitators to MBC implementation in the adolescent inpatient unit. Among the top anticipated barriers in the adolescent inpatient setting were measure compatibility within the inpatient context and workflow, uncertainty about whether measure data collection would provide immediate benefit to inpatient care teams and patients, and equity concerns given that some patient-caregiver dyads may be unable to complete the measure (e.g., due to acute psychiatric symptoms or the MBC tool being unavailable in their primary language of care).

In theory, implementing MBC in safety net community settings may enhance patient care and improve health equity. The use of MBC is also increasingly being considered as a marker of high-quality mental health care as indicated by the quality measures and value-based payment contracts into which safety net systems are entering.^10,11 Yet, safety net settings face greater challenges to MBC implementation because they serve higher-need and more diverse patient populations while operating under significant time and resource constraints. The findings of our work suggest that without robust targeted implementation strategies to address anticipated and emerging health equity concerns, MBC implementation may fail to mitigate and may even exacerbate health disparities in safety net systems.

Our work advances the field by suggesting key topics for further equity-focused MBC research and identifying priority areas for targeting equity-focused implementation strategies. To the extent that health systems, including safety net systems, are increasingly interested in creating infrastructure to enable a “learning health systems” (LHS) approach using academic and clinical partners, our work provides a possible template for pragmatic embedded implementation infrastructure that produces findings that are immediately useful to clinicians and psychiatric leadership and provides potentially transferable knowledge to other sites that share similar challenges or characteristics.

Benefits

Demonstrated benefits are those that have been observed and are verifiable.

Potential benefits are those logically expected with moderate to high confidence.

Demonstrated both the benefit of MBC for therapeutic alliance for some patients, and also the need to develop strategies for preserving therapeutic alliance when starting MBC with established patients, particularly from diverse backgrounds. demonstrated.

Clinical

Investigative procedures

Demonstrated the challenges of implementing and integrating computer-adaptive tests administered remotely into routine health system infrastructure (e.g., data storage infrastructure in electronic health records). demonstrated.

Clinical

Software technologies

Informs training for mental health clinicians performing MBC, which includes presenting to patients the rationale for using MBC, discussing findings with patients, and discussing the implications for the treatment trajectory with patients to alter treatment plans.¹² potential.

Clinical

Therapeutic procedures

Demonstrated differences in the distribution of health care quality (MBC uptake) by age, race/ethnicity, language, and clinic type in adult settings.⁹ demonstrated.

Community

Health care quality

Informs quality improvement of mental health services (e.g., delivering therapy, prescribing psychiatric medications) in the Learning Health Systems model through the measurement of symptoms at individual and community health level to enhance population health. potential.

Community

Community health services

Informs improved delivery of remote technology-assisted measurement tools to improve digital health equity for similar kinds of tech-enabled data collection. potential.

Community

Consumer software

Informs strategies to ensure policies that incentivize MBC (for example, value-based payment^10,11); account for increased challenges faced by safety net systems and do not disproportionately penalize safety net systems. potential.

Policy

Standards

This research has clinical, community, and policy implications. The framework for these implications was derived from the Translational Science Benefits Model created by the Institute of Clinical & Translational Sciences at Washington University in St. Louis.¹³

Clinical 

Our work has helped alert providers and health systems to key areas where health inequities are likely to emerge in MBC processes in order to mitigate them in pre-implementation planning and continue to monitor them after MBC implementation. Mental health clinicians and administrators  involved in MBC may need to take additional steps to ensure equitable access to MBC benefits by ensuring patients have equitable access to opportunities for MBC measure administration, patient-clinician discussions of findings, and opportunity to alter treatment plans as needed.¹² Our work also demonstrated that while some patient-provider dyads experience a benefit to therapeutic alliance from engaging in MBC, others experience systematized, centralized MBC as a challenge to established therapeutic alliance. Therefore, safety net systems will need to develop strategies for preserving therapeutic alliance when starting MBC with established patients, particularly those from diverse backgrounds.¹⁴ Further, the demonstrated challenges of implementing and integrating computer-adaptive questionnaire responses into routine health system data storage infrastructure raise questions about the trade-offs of using these kinds of questionnaires vs. simpler sets of items.

Community

This work was focused on improving mental health care equity and delivery in safety net (community) mental health clinical settings. The resource constraints and equity concerns raised in this project may be especially relevant for community mental health settings where clinical leaders face numerous challenges related to increasing the volume of patients that can be treated within the health system, under conditions of few resources and provider burnout. Our finding that there were health disparities in uptake of remotely administered symptom measures raises important equity questions about the use of technology to collect patient-reported outcome data in safety net settings on the large scale. This has equity implications for LHS models that seek to build robust data infrastructure to measure disparities in health care access and study treatment outcomes.¹⁵

Policy

In the long-term, our findings may inform policy and guidelines around MBC implementation as well as measurement of mental health quality (e.g., for the purposes of Value Based Payment or pay-for-quality models). This work may inform strategies to ensure policy approaches that incentivize MBC account for increased challenges faced by safety net systems and do not disproportionately penalize safety net systems. They may also inform policy efforts to distribute increased resources to safety net health systems seeking to implement such innovations so that they can adequately tailor and adapt these processes to ensure they can reach the most vulnerable patients. Without sufficient attention to adaptation and penetration of MBC that considers the disparities in MBC uptake, it is possible that in some diverse settings, the benefits of MBC may accrue disproportionately to patients who have more robust access to care.  

Lessons Learned

This project benefited from a strong partnership between clinicians, clinical leaders, and researchers with expertise in implementation science and health equity. The partnership with clinical leadership was key to understanding the challenges facing safety net health systems when it comes to system-level MBC implementation. Implementation science and health equity expertise were essential for operationalizing key study parameters. Moving forward, this project would benefit from a more direct and robust partnership with patients and families in co-designing improvements to MBC processes and decision-making.