3 minute read

In spring 2022, CFHA CEO Neftali Serrano approached the Primary Care Behavioral Health Special Interest Group (PCBH SIG) to begin the work of catalyzing standardized outcomes for measuring success in a PCBH environment. This invitation was warmly received as the role of the PCBH SIG is to grow interest and enthusiasm, provide learning experiences, and disseminate actionable resources among CFHA members regarding PCBH Service Model delivery.  

Across a handful of SIG meetings and announcements, a workgroup formed. The workgroup, composed of a mixture of clinicians, consultants, researchers, and informatics professionals, started meeting in summer 2022 and began discussions of how to fill the PCBH measurement gap. Collaboration across SIGs and committees bloomed when a representative from the CFHA Research & Evaluation Committee (REC) joined our team. 

The first task to tackle became distinguishing between screening (including screening instruments) and outcomes in PCBH. At the outset members of the field were able to distinguish the terms. Challenges arose when discussing implementation. We heard use of the terms interchangeably, and trends emerged where front line clinicians and administrators appeared focused on screening and researchers/informatics professionals appeared more interested in outcome measures. 

We needed to clarify if we were talking about simply obtaining completed patient screenings (universal or targeted) to inform today’s care plan or were we using longitudinal data from multiple assessments to inform treatment and interventions for individuals and populations? Without alignment on evidence-based tools for screening in PCBH or the definition of “outcome measures,” confusion reigns strong. CFHA members have routinely asked for a clear set of universal guidelines and instructions on screening administration in primary care behavioral health, including: 

1. Which screening instruments should be used and when,
2. Best practice recommendations for both pediatrics and adults, and 
3. Rescreening protocols (i.e. when should clinicians be readministering screenings, how often, and why?). 

Other arguments in the discussion also emerged: 

1. Opportunities & costs of universal screening versus targeted screening
2. Symptom measures versus functional measures, and 
3. Impact measure of BHC (and IBH program) versus population-based outcomes. 

We’ve also been inspired by the simplicity of the Psychiatric Collaborative Care Model’s (CoCM) use of symptom measures and benchmarks for treatment response. Suddenly, but not surprisingly, this became a big project for a small group of volunteers. 

CFHA members have routinely asked for a clear set of universal guidelines and instructions on screening administration in primary care behavioral health

We decided to start small and issue a survey of CFHA members and conference attendees in Fall 2022 that would gather insights into which screening instruments were being used and how they were being administered. During the 2022 annual Integrated Care Conference in Boise, the workgroup sought to maximize survey engagement through QR code, plenary announcements, and listserv requests on CFHA website . 

The responses came in. A total of 108 (majority from conference attendees) were received, representing less than 15% of CFHA membership. Clearly, we had a small sample size from a biased group of engaged PCBH professionals. 

The responses were not shocking. A very broad range of measurement tools are being used (110 in total) with very little standardization or intentional utilization for measuring patient progress and outcomes. There are very few organizations with protocols to track changes over time and report on them to patients or systems. We also saw that Pediatrics is a major consumer of screening instruments (a topic for another blog post one day). 

What is becoming more clear is that there is work to do to advance standard, measurement-based practices while simultaneously supporting the change management process of incorporating data-driven care to our patients that advances standards of measurement-based practices into PCBH care. To support primary care, the end product of our efforts should be simple and flexible enough to adopt into an array of clinics, and widespread enough to move the field towards consistent screening and outcomes measurement.

To accomplish this work, we need:

1. Free access to a standard set of validated and reliable behavioral health measures appropriate for the context of primary care (brief, language and culturally appropriate, etc.)
2. Algorithm-based screening strategies supported by health information technology for targeted or universal screening
3. Team-based screening protocols that maximize top-of-license practice and target high-need, complex patients
4. Payor support to compensate for the use of screeners as a universal approach to steering patients efficiently into appropriate treatment pathways and enabling proactive team care.

The workgroup continues to meet and welcome input, engagement, and participation from members. On our horizon is constructing infographics depicting the steps from universal screening to outcomes-based measurement for PCBH, creating materials through participatory processes that identify free and accessible measurement tools to use in primary care, and engaging members in learning opportunities to optimize their EHR and prepare their organizations and payers for measuring outcomes. 

If you are interested in reviewing the screener usage survey results and executive summary report, they are located under the “resources” section at the bottom of the CFHA PCBH SIG webpage: https://www.cfha.net/learn-network/special-interest-group/primary-care-behavioral-health-special-interest-group/

Acknowledgements

Blog authors: Amanda Brooks, Kelli Bosak, and Meghan Fondow, with editing/contributions by Bill Sieber and Dave Haddick

PCBH Workgroup: Amanda Brooks, Kelli Bosak, Meghan Fondow, Bill Sieber, Dave Haddick, Stephanie Field, Chris Hunter, Meghan Fondow, Stanley Lieberson