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December 19, 2018

Implementing Measurement-Based Care in Behavioral Health: A Review

Author Affiliations
  • 1Kaiser Permanente Washington Health Research Institute, Seattle
  • 2Department of Psychology, UCLA (University of California, Los Angeles)
  • 3Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
  • 4Department of Psychological and Brain Sciences, Indiana University, Bloomington
  • 5Department of Psychology, Ohio University, Athens
  • 6Department of Psychology, West Virginia University, Morgantown
  • 7School of Public Health, Brown University, Providence, Rhode Island
  • 8Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
  • 9Department of Leadership, Policy and Organizations, Peabody College, Vanderbilt University, Nashville, Tennessee
  • 10Regenstrief Institute, Indianapolis, Indiana
JAMA Psychiatry. 2019;76(3):324-335. doi:10.1001/jamapsychiatry.2018.3329

Importance  Measurement-based care (MBC) is the systematic evaluation of patient symptoms before or during an encounter to inform behavioral health treatment. Despite MBC’s demonstrated ability to enhance usual care by expediting improvements and rapidly detecting patients whose health would otherwise deteriorate, it is underused, with typically less than 20% of behavioral health practitioners integrating it into their practice. This narrative review addresses definitional issues, offers a concrete and evaluable operationalization of MBC fidelity, and summarizes the evidence base and utility of MBC. It also synthesizes the extant literature’s characterization of barriers to and strategies for supporting MBC implementation, sustainment, and scale-up.

Observations  Barriers to implementing MBC occur at multiple levels: patient (eg, concerns about confidentiality breach), practitioner (eg, beliefs that measures are no better than clinical judgment), organization (eg, no resources for training), and system (eg, competing requirements). Implementation science—the study of methods to integrate evidence-based practices such as MBC into routine care—offers strategies to address barriers. These strategies include using measurement feedback systems, leveraging local champions, forming learning collaboratives, training leadership, improving expert consultation with clinical staff, and generating incentives.

Conclusions and Relevance  This narrative review, informed by implementation science, offers a 10-point research agenda to improve the integration of MBC into clinical practice: (1) harmonize terminology and specify MBC’s core components; (2) develop criterion standard methods for monitoring fidelity and reporting quality of implementation; (3) develop algorithms for MBC to guide psychotherapy; (4) test putative mechanisms of change, particularly for psychotherapy; (5) develop brief and psychometrically strong measures for use in combination; (6) assess the critical timing of administration needed to optimize patient outcomes; (7) streamline measurement feedback systems to include only key ingredients and enhance electronic health record interoperability; (8) identify discrete strategies to support implementation; (9) make evidence-based policy decisions; and (10) align reimbursement structures.

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