Behavioral health outcome management (BHOM) involves the use of behavioral health outcome measurement data to help guide and inform the treatment of each individual patient. Like blood pressure, cholesterol and other routine lab work that helps to guide and inform general medical practice, the use of routine measurement in behavioral health is proving to be invaluable in assisting therapists to deliver better quality care.
Macro-context In behavioral healthcare (mental health and substance abuse treatment) routine health outcomes measurement has expanded beyond aggregating measurements for quality improvement studies and has placed equal emphasis on the therapeutic gain delivered by real-time patient-level outcome feedback.Pushing the Quality Envelope: A New Outcomes Management System. Brown, G. S., et al. 2001, PSYCHIATRIC SERVICES, Vol. 52(7), pp. 925-934. With the $200 billion behavioral health marketplace in a state of public health crisis as defined by the US Surgeon GeneralUS Surgeon General. Mental Health: A Report of the Surgeon General. US Department of Health and Human Services. Rockville, MD : U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services, National Institutes of Health, National Institute on Mental Health, 1999. with most patients receiving substandard care, outcome management is helping to provide quality controls, data and structure for a large subsection (more than 27%) of the US population.
Almost by definition, psychotherapy is a rather unstructured process, leaving many people who are going through the process of guided self-discovery and behavioral change to wonder whether therapy is helping. Tracking progress with repeated administrations of a self-report questionnaire allows both therapist and client to know what is getting better from the perspective that matters most—the patient's.
Uses of behavioral health outcome management data
The data collected through formal (typically self-report) measurement (like the PHQ-9 for depressionThe PHQ-9: validity of a brief depression severity measure. Kroenke, K., Spitzer, L.R. and Williams, B.J. 2001, Journal of General Internal Medicine, Vol. 16(9), pp. 606-613.) has been used to enhance the accuracy of clinical assessments, provide a basis for treatment planning, deliver an objective methodology for tracking treatment progress, alert therapists with clinically proven guidelines to get refractory cases back on track, help prevent hospitalizations with warning guidance, and provide primary care physicians and other referral sources with outcome-based referrals linking new patients to therapists with a proven track record of delivering exceptional care to patients with similar behavioral health needs. The most powerful use of BHOM has been documented in healthcare's first randomized clinical trial of a referral process using outcome data. Constantino MJ, Boswell JF, Coyne AE, Swales TP, Kraus DR. Effect of Matching Therapists to Patients vs Assignment as Usual on Adult Psychotherapy Outcomes: A Randomized Clinical Trial. JAMA Psychiatry. Published online June 09, 2021. doi:10.1001/jamapsychiatry.2021.1221 Bright Path Behavioral Health, 22 September 2023
More accurate clinical assessments Behavioral healthcare rarely uses genetic markers or blood tests to assist in diagnosing major depression or other behavioral health disorders like schizophrenia and substance abuse. Instead, the field relies on the careful assessment of symptoms, like changes in mood and behavior, to make a formal diagnosis. However, with more than half of behavioral healthcare delivered by primary care physiciansThe de facto US mental and addictive disorders service system: Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Reiger, D., et al. 1993, Archives of General Psychiatry, Vol. 50, pp. 85–94. where there is rarely sufficient time or expertise to conduct a formal interview, a standardized assessment and screening process using formal questionnaires administered in the waiting room or over the internet are invaluable. Even for behavioral health specialists like psychologists, psychiatrists and social workers who are trained to interview and diagnose behavioral health problems, their efforts are hampered by patient's willingness, or lack thereof, to honestly report relevant symptoms. For example, in an initial interview, only half of patients honestly disclose previous suicide attempts,Client Receptiveness to the Routine Assessment of Past Suicide Attempts. Hahn, W. K. and Marks, L. I. 1996, Professional Psychology: Research and Practice., Vol. 27(6), pp. 592-594. greatly hampering therapists' efforts to keep patients safe. By contrast, six controlled studies document that patients not only like completing paper-and-pencil or web-based questionnaires, patients are more accurate when they do so,Response of phobic patients to direct computer assessment. Carr, A.C. and Ghosh, A. 1983, British Journal of Psychiatry, Vol. 142, pp. 60–65.Direct patient computer interviewing. Erdman, H.P., Klein, M. and Greist, J.H. 1985, Journal of Consulting and Clinical Psychology, Vol. 53(6), pp. 760–773.Do substance abuse and mental health clients prefer automated assessments?. Hile, M.G. and Adkins, R.E. 1997, Behavior Res Methods, Instruments, Computers, Vol. 29(2), pp. 146–150.Psychiatrists and a computer as interrogators of patients with alcohol related illnesses: A comparison. Lucas, R.W., et al. 1977, British Journal of Psychiatry, Vol. 131, pp. 160-167.Self-report of drinking using touch-tone telephone: Extending the limits of reliable daily contact. Searles, J.S., et al. 1995, J Studies Alcohol, Vol. 56(4), pp. 375–382.Adolescent sexual behavior, drug use, and violence: Increased reporting with computer survey technology. Turner, C.F., et al. 1998, Science, Vol. 280, pp. 867–873. giving therapists and primary care physicians more accurate assessments of client's symptoms and issues, and a new and potentially different perspective than seen in face-to-face interviews.
Treatment planning With formal assessments of patient needs, the clinician can devise an individualized treatment plan that incorporates these needs and evidence-based practices and principals.The outcomes assistant: A kinder philosophy to the management of outcomes. Kraus, D. R., Castonguay, L. G. and Wolf, A. 2006, Psychotherapy Bulletin, Vol. 41(3), pp. 23-31. Some health plans now require the integration of BHOM into routine care and treatment planningStelk, W. Outcomes management 2009. http://www.masspartnership.com/provider/outcomesmanagement/Outcomesfiles/FY09FAQsFinal12909.pdf and a well designed BHOM system provides the clinician feedback and guidance to keep up with these evidence-based principals.Kraus, D.R. and Castonguay, L.G. TOP: Development & Use In Naturalistic Settings. (ed.) M. Barkham, G. Hardy and J. Mellor-Clark. A Core Approach To Delivering Practice-Based Evidence In Counseling And The Psychological Therapies. London : Wiley Press, in press.
Tracking treatment progress Obviously, the most fundamental use of BHOM is to use the data to track treatment progress on a patient-by-patient basis. Especially with session-by-session assessments, real-time scoring and report generation the data provides clinicians and patients with excellent feedback about the course of treatment and whether adjustments need to be made to the treatment plan.Lambert, M. Emerging methods for providing clinicians with timely feedback on treatment effectiveness: An introduction. Journal of Clinical Psychology. 2005, Vol. 61, pp. 141-144. Some of the first and second generation BHOM tools have been hampered by their ability to document reliable patient improvementJacobson, N. S. and Truax, P. Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology. 1991, Vol. 59, pp. 12-19. with only 20-30% of cases showing reliable improvement,Estimating variability in outcomes attributable to therapists: A naturalistic study of outcomes in managed care. Wampold, Bruce E and Brown, George S. 2005, Journal of Consulting and Clinical Psychology, Vol. 73(5), pp. 914-923.From Ordinal Observation to Linear Measurement. Doucette, A. Burr Oak, OH : s.n., 2006. North American Society for Psychotherapy Research annual conference. while some of the more advanced tools can document reliable improvement on more than 50% of cases on a single domain, and more than 90% with multi-dimensional analyses.Validation of a Behavioral Health Treatment Outcome and Assessment Tool Designed for Naturalistic Settings: The Treatment Outcome Package. Kraus, D. R., Seligman, D. and Jordan, J. R. 2005, Journal of Clinical Psychology, Vol. 61(3), pp. 285-314. http://onlinelibrary.wiley.com/doi/10.1002/jclp.20084/abstract If documenting patient improvement to payers and purchasers is important, these statistics may be vitally important to evaluate before building and deploying a BHOM system (see below).
Refractory case alerts Researchers at Brigham Young and other universities have clinically proven that BHOM helps therapists to deliver better care by identifying cases that are not likely to improve with the current treatment plan.Lambert, M. J. Presidential address: What have we learned from a decade of research aiming at improving psychotherapy outcome in routine clinical care. Psychotherapy Research. 2007, Vol. 17, pp. 1-14. These refractory cases, or negative responders, account for approximately 15% of all treatment cases when a BHOM system is not used. A well designed BHOM system can reduce the population of negative responders to less than 5%, increasing the effectiveness of psychotherapy by at least 10%. Since clinicians, on their own, are abysmal at predicating what patients will negatively respond to treatment,Hannan, C., et al. A lab test and algorithms for identifying clients at risk for treatment failure. Journal of Clinical Psychology. 2005, Vol. 61, pp. 155-163. a BHOM system is the only known way to facilitate this level of effectiveness.
Hospitalization and other warnings Other uses of BHOM are also emerging as the systems evolve from simple, single-domain alert systems like the OQ-45Lambert, M. J., Gregersen, A. T. and Burlingame, G. M. The Outcome Questionnaire-45. (book auth.) M. E. Murish. Use of psychological testing for treatment planning and outcome assessment. 3rd. Mahway : Erlbaum, 2004, Vol. 3, pp. 191–234. to more complex, multi-dimensional systems. Single-domain alert systems, while effective at identifying some negative responders with a single, global measure of distress, do not capture the full complexity of issues seen in behavioral healthcare (e.g. depression, psychosis, mania, anxiety, substance abuse, etc.). With more elaborate measurement, BHOMs have been shown to facilitate the identification of high-risk cases (clients that are at high-risk for behavioral health hospitalization due to suicide, violence, etc., and other high-cost/high-risk services) allowing the health plan and clinician to collaborate in flexing treatment benefits to prevent the loss of life and increased healthcare costs.Predictive Modeling: Using TOP Clinical Domain Items to Identify Adult Medicaid Recipients at Risk for High Utilization of Behavioral Health Services in a Managed Care Provider Network. Stelk, W. and Berger, M. Santiago de Chile : s.n., 2009. 40th SPR International Annual Meeting.
Outcome-based referrals