Now that the Joint Commission has mandated that all accredited behavioral healthcare programs start using patient-reported outcome measures to inform clinical care by January 1, 2018, leaders need to think about how best to accomplish this goal. The Joint Commission is requiring that centers systematically collect information directly from their patients on how they are feeling, use it to inform clinical care, and aggregate the data to measure treatment effectiveness.
In our experience, there are two crucial factors programs starting to monitor outcome measures need to get right. First, you need to design a system that collects useful data with a minimum of staff effort. Second, the system needs to help your clinicians and management quickly and easily apply the data to inform clinical care.
Designing a system that works
There are four key elements to creating a program that will work well for your treatment center.
- Measure the right things
The specific symptom rating scales you choose should vary depending upon your patient population. We’ve found that monitoring substance use disorder patients for depression, anxiety, trauma, eating disorders, suicidal ideation, self-harm, cravings, and satisfaction with treatment provides a wealth of useful information. A behavioral healthcare program might choose to also monitor their patients for mania, psychosis, daily functioning and medication adherence. A therapist providing relationship or general counseling may find that measuring the strength of the therapeutic alliance is sufficient.
Regardless of which conditions you choose to monitor, it is important that the instruments you use are academically validated, designed for self-report, and sensitive to change.
Start by asking a series of screening questions that indicate whether a patient is likely to be suffering from a specific condition, and only require those answering a screening question positively to complete the associated symptom rating scale. In addition to reducing the amount of time it takes patients to complete the surveys, this process has two other advantages. First, it eliminates the need for clinical staff to try to decide upfront which instruments are likely to be relevant for each patient. Second, it will frequently unearth unexpected issues.
For example, one of our clients was surprised to discover that a large number of their SUD patients were dealing with fairly severe eating disorders. After they brought in an eating disorder specialist who could separately bill Medicaid, the entire attitude in the center towards eating disorders started to change. By openly acknowledging and treating the problem, the center saw a dramatic reduction in the compensatory eating behaviors of many of their patients during treatment.
- Systematize data collection
It is certainly possible for smaller programs to use paper surveys to collect patient data. However, if minimizing staff time is important, you’ll want to automate data collection and reporting as much as possible. Build or license software that allows patients to complete surveys online using a laptop, tablet or smart phone and summarizes the data in real time for your clinicians.
Regardless of the system you use, you will likely find that the biggest challenge is getting patients enrolled quickly and then reporting their feelings on a regular basis. While it may seem to make sense to make clinicians responsible for data collection, we highly recommend resisting this urge.
If you ask the clinicians to have their patients fill in the surveys, they will likely do so at the end of their counseling sessions. Not only is this a tremendous waste of precious therapy time, but the data will likely to be a week old by the time the clinician sees the patient next! Our clients have had far better results when they’ve given one of their non-clinical staff responsibility for data collection.
Finally, to further reduce staff time, treatment programs that allow patients access to smart phones or the internet should use a system that can automatically text or email clients on a regular basis to request they take their next survey.
- Make it easy for your clinicians to access and understand the results
We recommend choosing instruments that your clinicians are already familiar with, such as the PHQ-9 for depression and the GAD-7 for anxiety. Then graph the data for each condition that a patient is being monitored for over time so that trends are immediately obvious.
If at all possible, provide your clinicians with the ability to access the graphs immediately after new surveys are submitted. If you’re collecting the surveys manually, make sure that staff sets aside time daily to summarize the results. Information more than a few days old is not likely to be very useful.
Finally, alert the clinicians when new results become available. Clinicians should be immediately notified by text or email if any of their patients are reporting dangerous thoughts or behavior.
- Track your implementation statistics
Change is hard, and many treatment programs will run into a few challenges getting a new patient monitoring system universally used. Periodically reviewing statistics such as the number of patients who have not yet begun to be monitored and how frequently each clinician is logging in to see patient data will help your staff quickly address any issues.
Applying the data to improve treatment results
Outcome measures monitoring will only make a difference, of course, if the data is used effectively to help patients.
Research has shown that clinicians often won’t notice if one of their patients makes a modest improvement and then plateaus. By providing clinicians with graphical evidence that a patient is not improving, patient monitoring can make the biggest difference with your hard-to-treat patients.
Clinicians should be strongly encouraged to review each patients’ report prior to each counseling session so they can structure their sessions appropriately. If a patient is not showing the expected improvement in their depression or anxiety scores, for example, it may be appropriate to adjust medication or modify the treatment plan. If the patient continues to exhibit high levels of PTSD symptoms, a trauma-informed care discussion may be in order. And if the strength and frequency of cravings increases while satisfaction with treatment plummets, it may be time to discuss relapse prevention strategies.
Summary reports that show the most recent data for a group of patients as a function of how long they’ve been in treatment can be particularly helpful in identifying patients who aren’t progressing as well as expected.
A final thing to keep in mind as you design your outcome measures monitoring system is that the Joint Commission will be asking for proof that your clinicians are using the results to improve clinical care and that you are analyzing your aggregated results periodically so your program can become more effective over time.
While it is often challenging to get clinicians and staff in the habit of using a new technology, we’ve found that most will be won over by the additional insights outcome measures monitoring gives them into how their patients are feeling. And one year from now, you may find it hard to believe that you ever provided treatment without the benefit of patient monitoring data.
Joanna L. Conti is Founder and CEO of Vista Research Group, Inc., which provides patient monitoring during treatment and post-treatment outcomes research to addiction and behavioral healthcare treatment programs.