A couple of months ago, we wrote about the lack of measurement-based care or the use of decision support tools and data to inform how consumers receive care. Measurement-based care is defined as the collection of quantifiable data using validated scales and then incorporating that data into the treatment planning process creating a feedback loop (see Measurement Informed Treatment Resource Assistant For Mental Health ). Currently only 7% of psychiatrists use measurement-based psychiatric scales when consumer treatment planning (see Why So Little Measurement-Based Mental Health Care?), and only 11.1% of psychologists routinely administer symptom rating scales (see A Tipping Point for Measurement-Based Care).
Where does measurement-based care “fit” in the move toward metrics-based performance management and value-based reimbursement (VBR)? Measurement-based care facilitates standardization of service delivery. And, going a step further, measurement-based care allows clinical managers to identify the most effective service models. By measuring care outcomes, managers of provider organizations can see what is and isn’t working, and adjust accordingly in real time (see Practice Performance Management-The Key To Sustainability& Success) these are essential skills in value-based reimbursement environments.
What does measurement-based care look like in practice? I had a chance to see a system in action at The 2019 OPEN MINDS Strategy & Innovation Institute during the session, Grafton’s Journey Into Measurable Patient Success, presented by Scott Zeiter, Executive Vice President/Chief Operating Officer, and Jeremy Ulderich, Director of Educational Consulting at Grafton Integrated Health Network. In the Welligent-sponsored session, Mr. Zeiter and Mr. Ulderich talked about Grafton’s development of measurement-based care and what they learned from that experience.
Grafton’s strategy for investing in measurement-based care began with questions—what do payers want from services for children with complex, co-morbid intellectual/developmental disability (I/DD) and behavioral health conditions? And, how could the Grafton team deliver on that? Answering the first question started with market research on what payers and health plans are looking for. Mr. Zeiter explained that their research found that payers are looking for efficiency, empiricism, evidence of change, and expedited responses to lack of change.
The answer to the second question was to build a measurement-based care system that provided payers with these answers. To build the system, the Grafton team started with a goal mastery model that they had already developed. The model creates quantifiable goals for individuals and then tracked those goals to determine whether they are met. While this existing system identified the “what” of the desired outcomes, it did not recommend an appropriate clinical pathway, or provide decision support. Adding that functionality was key to having a working measurement-based care system.
How Grafton’s Model For Measurement Based Care Works
To implement their model for children with complex behavioral conditions, Grafton’s clinical professionals first select from nine broad categories of actions that result in the children they serve needing supportive services. These categories include physical aggression, self-injurious behavior, elopement, lack of safety awareness, disruption, property destruction, sexual acting out, threats of harm, and psychological impairment (Grafton identified these categories as team). These categories form the basis of Grafton’s analysis. For example, they may find that children with physical aggression and elope have better outcomes when they receive motivational interviewing compared to cognitive behavioral therapy (CBT). Any of the variables in the EHR, from demographics to diagnosis to treatment approach can be compared to seek correlations.
In step two, the clinical professional develops a goal to address each problem area. This is a structured process that must include data points such as how long the goal will take to complete, the current rate of behavior occurrence (baseline), and the target rate. In step three, the clinical professional chooses from a list of empirically-based practices This is a structured process that must include data points such as: how long the goal will take to complete,the current rate of behavior occurrence (baseline), and the target rate, such as antecedent-based interventions, reinforcement, and prompting that will be used to meet the goal. Finally, in step four, the clinical professional selects from a list of “intervention objectives” nested under each empirically-based practice. These intervention objectives are the individualized for each client.
Step five is focused on behavior tracking. The direct support professionals working with the children enter the behaviors into the EHR as the behaviors occur (or shortly thereafter). The frequency of the behavior is then updated in real-time on the graphs that Grafton uses to track changes in behavior. If the behaviors are more than three points off the planned trajectory than staff know that it may be time to intervene to meet the goals. In the future, Grafton is partnering with Welligent to set up alerts for when goals go off track.
The Grafton measurement-based care system is in its initial implementation. Over time, Grafton will be able to use and analysis this data to inform appropriate clinical pathways and decision support. Mr. Zeiter and Mr. Ulderich explained that this obviously isn’t an academically rigorous study, it does tell them what works in the “real world” and will be used to refine their service approaches over time.
Advice To Executives Embarking On The Measurement-Based Care Journey
Mr. Zeiter and Mr. Ulderich had much to share about their evidence-based care journey. Their advice to other executives – know when to compromise, be constantly vigilant about model fidelity, and ensure a consumer-driven care plan.
First, know when to compromise and when to hold your ground. Mr. Zeiter explained that the new system was specifically designed to be user friendly and as simple as possible. As part of this, Grafton leadership decided not to develop a user manual for the new EHR system. However, staff were uncomfortable with this and in the end, they compromised to come up with a series of videos that explain the system. One area where Grafton leadership chose not to compromise was when staff wanted to implement a complicated paper system to enter behaviors in the EHR. For the new system to work and be updated in (near) real-time, data needed to be entered directly into the EHR.
Second, ensuring the fidelity of the model takes vigilance. Initially, Mr. Zeiter was afraid that staff would not accurately track behaviors in the EHR and then the model wouldn’t work due to a lack of data. What they found was that ease of the system means that sometimes staff are over-tracking behaviors, or two staff members will enter the same behavior. Grafton is working to ensure that behaviors are accurately tracked in the system. Additionally, just because a clinical professional chooses a specific intervention for a child, it is difficult to ensure that a child is getting that intervention.
Third, using a measurement-based model means that organizations must be extra careful that they are offering a consumer-driven care plan. With the ability to choose from drop downs and a set number of options, there is the possibility that plans may not be individualized enough for payers. Mr. Zeiter explained that in order to maintain a consumer-driven organization, Grafton must ensure that this is an important part of their culture and that care plans are carefully monitored.
Implementing a measurement-based care model is a heavy lift, but for organizations who have the culture and the will, it is possible. Crucial to developing this model is the use of a technology platform that is easy for staff to use and can capture the needed data and show progress in near real-time.
To learn about using technology to actively manage your organization, join us The 2019 OPEN MINDS Management Best Practices Institute on August 13 in Long Beach for the plenary address Taking Your EHR From Data To Strategic Information: Real-World Cases Of EHRs Supporting Value-Based Care featuring Monica E. Oss, Chief Executive Officer, OPEN MINDS.