Michael Genovese, MD, JD, and Navdeep Kang, PsyD, chief medical officer and chief quality officer of Franklin, Tenn.-based Acadia Healthcare, respectively, one of the largest behavioral healthcare providers in the U.S., joined Becker's to discuss the importance of measurement-based treatment in behavioral health and how the health system is pioneering it at its facilities.
Editor's note: Responses have been lightly edited for length and clarity. If you would like to contribute to our next question, please email Paige Haeffele at phaeffele@beckershealthcare.com.
Question: What is measurement-based care, in terms of behavioral health?
Dr. Michael Genovese: Psychiatry has become much more important to the functioning of the overall healthcare system. If you look at other areas of medicine, they have metrics by which they can measure their patients' progress. Cardiologists can check patients’ blood pressure, their lipid profile and perform EKGs. Endocrinologists can follow someone's blood glucose or hemoglobin A1C. For a long time, psychiatry has lacked any objective measurements to be able to say, "This is how much our patients are improving" or "This is where we need further improvement." What we have been doing at Acadia is using objective measurements by assigning scores to particular symptoms to assess our patients’ treatment progress.
Dr. Navdeep Kang: This is something that we should pursue as a specialty, and we can’t underestimate the challenge of engaging clinicians in a unique way on this topic. It’s often the norm, even within the field, despite thousands of different psychometrically validated questionnaires or instruments available, to gauge symptom patterns or severity based on the clinician's expertise and by solely relying on clinical interview data. Clinicians oftentimes will think, "I completed years of intensive training on these subjects, I myself am the instrument measuring the patient's status, and my clinical intuition is going to guide my diagnostic impression and how well I think the patient is doing."
I think the important thing to recognize is that it's not an "either or" concept. It's both because that baseline education and training are necessary to get valid, reliable, clinical data from the patient. But we also can benefit from having access to a statistically valid set of objective data which points us in the right direction with treatment planning and other relevant content that the patient doesn't tell us, can't tell us, or we as human interviews don't otherwise pick up on. I think it is an important thing for us, as industry leaders, to effectively make it a norm to use psychometric instruments to gauge our patients' symptom presentation. These measurements can be used to gauge the therapeutic alliance, the connection between the clinician and the patient. They can also guide the structure of therapy programs at all levels of care and for all patient populations. These questions can assess how anxious a patient is or how many symptoms of trauma they have. They can also help us determine how severe the symptoms are and the impact they are having on the patient's functioning. There are also other things that are not necessarily symptom-related but that are relevant to how the patient is doing in terms of engagement and treatment.
We can and should measure all these things, and we should expect to be trained on how to do so. We should then use all of that data as feedback that we can tie into the treatment planning and care delivery processes. I think it is still unfortunately not the typical way to practice, so patients certainly don't expect it. To make it the standard of care is still something that requires an intentional effort. That's part of what we're trying to do.
The questions you ask or the questionnaires you use should vary by patient population based on their condition and their presenting symptoms. Some things might be applicable to all or most patients, similar to when taking a person's vitals, but other things are much more disease-specific. Like every other specialty, every other area of healthcare, and every other disease, we should expect measurement-based care to be a standard part of treatment, and that is what we're trying to push forward for all our teams across the country. It's an exciting thing to be able to set that norm.
Q: Why do you think that psychiatry as a whole has not adapted measurement-based treatment earlier?
MG: That's just not the way psychiatry started. It's not the way that people were trained, and when you diverge from the way one is trained, it takes a long time to turn a big ship. And when you're trained in a specific way, you tend to practice that way. When something comes in that's new, even if it's better, it takes a lot of convincing and introspection to adopt a new technique and change the way one practices.
NK: To add on to that, I think for therapists and clinical psychologists, we're certainly trained in using psychometric tools in the care of our patients. What's interesting, though, is that it's oftentimes used to help with diagnosis or treatment planning to jump-start treatment. But then measurement isn't used later in the progress, to assess progress or lack thereof. And too often, the data isn't shared with the patient in a transparent way. Similar to if you were to do lab work that was ordered by your family physician and you would be able to see the results in your chart, we would take certain results and share them with the patient. It could be something as simple as saying, "According to this, it seems like you've been feeling a little bit more blue lately. Tell me more about that." The idea of feeding it back into treatment in a transparent sense with the patient is also something that's not typically done in training. There are institutes, workshops, seminars and continuing education that actually adhere toward this entire topic, but for it to be the norm as part of foundational training in graduate school and how to conduct psychotherapy or treatment is still too far from being the norm.
Q: How is Acadia incorporating this into your treatment model, and what have you seen resultswise?
NK: We've made it a strategic imperative to add an electronic medical record across our organization across all levels of care. We've found that with EMRs, it's easier to execute on, it's easier to be transparent with the patient and it's easier to feed information back to them. What's also really cool is that you can then take a step back and zoom out at one level and say, "OK, at this facility, in this treatment program, we're really good at treating this, and we're less effective at treating that. So if we want to get better at treating this thing, then here's training that we can do with our staff, or maybe we should add an additional clinician with a specific certification or expertise. This feeds into a culture of continuous quality improvement, which sometimes can sound like a euphemism, but you can actually use population-level clinical data then for program evaluation and improvement. If we're less effective at treating a specific condition for a specific patient population, for example adolescents, then here are some interventions that we can put into place to do more for those individuals. I think this more macro view is something people aren't thinking of for program improvement. But probably the number one vehicle that helps grease the wheels is the EMR itself because these measurements can be built into people's routine workflows and make it part of everything else they normally do with the patient. You combine the EMR with the training and socialization that we're talking about, and it has started to really gain some traction.
MG: In addition to that, I think about the continuum of care of the patient and the chronic diseases we treat, like depression, anxiety, and posttraumatic stress. It's very different than, say, orthopedics, where your arm is broken and then your arm is healed. What we can do is administer testing upon admission in one of our facilities, and then we can administer testing upon discharge and see what has and has not improved. Now as continuum of care methods and behavioral health have evolved to a greater degree, patients can take a look back at the results because this is now part of their medical record. They can see what still needs to be worked on throughout different levels of treatment, which is important given the longitudinal nature of the treatment of psychiatric conditions.
Q: For providers interested in adapting measurement-based treatment, what steps would you recommend doing to ease the implementation process?
NK: You should know your organization and know your patient population. It’s a different thing for an individual clinician in private practice to take on something like this versus a larger organization with multiple sites of care that are geographically spread out. But some of the underlying tactics that make it easier are having tools like electronic medical records. Many providers in behavioral healthcare don't have such a thing. They can start with freely available measures, add them in as part of the intake process, and then use the instruments to guide how periodically they readminister them. As for patients, we can ask what they are accustomed to and what they are willing to tolerate. The idea of sharing information back to the patient in a transparent manner requires a little bit more skill. That would maybe be the point where I would recommend somebody try continuing education to boost some of their knowledge base about the best ways to incorporate clinical data back into treatment in a way that the patient can understand it and make use of it.
MG: I agree. And by building a knowledge point, I think that once you come to the conclusion yourself that you agree that this should be the standard of care in a system setting, it's like many things in life: Once you commit to doing measurement-based care, everything else follows because you're in it, and you're going to do the best you can.
Think about how you're going to talk to your patients about it. Think about how you're going to talk to your staff. Think about how you're going to use the results. And start getting some reps under your belt.