System-Wide Implementation of Routine Outcome Monitoring and Measurement Feedback System in a National Network of Operational Stress Injury Clinics

Provider Use of, Attitudes Towards, and Self-efficacy with Key Measurement-based Care Practices in Youth Mental Health Treatment: A Multi-site Examination

Measurement-based care (MBC) is an underutilized evidence-based practice, and current implementation efforts demonstrate limited success in increasing MBC use. A better understanding of MBC implementation determinants is needed to improve these efforts, particularly from studies examining the full range of MBC practices and that span multiple samples of diverse providers using different MBC systems. This study addressed these limitations by conducting a multi-site survey examining MBC predictors and use in youth treatment. Participants were 159 clinicians and care coordinators working in youth mental health care settings across the United States. Participants were drawn from three program evaluations of MBC implementation. Providers completed measures assessing use of five MBC practices (administering measures, viewing feedback, reviewing feedback in supervision, sharing feedback with clients in session, and using feedback to plan treatment), MBC self-efficacy, and MBC attitudes. Despite expectations that MBC should be standard care for all clients, providers reported only administering measures to 40-60% of clients on average, with practices related to the use of feedback falling in the 1-39% range. Higher MBC self-efficacy and more positive views of MBC practicality predicted higher MBC use, although other attitude measures were not significant predictors. Effects of predictors were not moderated by site, suggesting consistent predictors across implementation settings. Implications of study findings for future research and for the implementation of MBC are discussed.

The results of clinician-focused implementation strategies on uptake and outcomes of Measurement-Based Care (MBC) in general mental health care

BACKGROUND

Measurement-Based Care (MBC) is the routine administration of measures, clinicians' review of the feedback and discussion of the feedback with their clients, and collaborative evaluation of the treatment plan. Although MBC is a promising way to improve outcomes in clinical practice, the implementation of MBC faces many barriers, and its uptake by clinicians is low. The purpose of this study was to investigate whether implementation strategies that were developed with clinicians and aimed at clinicians had an effect on (a) clinicians' uptake of MBC and (b) clients' outcomes of MBC.

METHODS

We used an effectiveness-implementation hybrid design based on Grol and Wensing's implementation framework to assess the impact of clinician-focused implementation strategies on both clinicians' uptake of MBC and outcomes obtained with MBC for clients in general mental health care. We hereby focused on the first and second parts of MBC, i.e., the administration of measures and use of feedback. Primary outcome measures were questionnaire completion rate and discussion of the feedback with clients. Secondary outcomes were treatment outcome, treatment length, and satisfaction with treatment.

RESULTS

There was a significant effect of the MBC implementation strategies on questionnaire completion rate (one part of clinicians' uptake), but no significant effect on the amount of discussion of the feedback (the other part of clinicians' uptake). Neither was there a significant effect on clients' outcomes (treatment outcome, treatment length, and satisfaction with treatment). Due to various study limitations, the results should be viewed as exploratory.

CONCLUSIONS

Establishing and sustaining MBC in real-world general mental health care is complex. This study helps to disentangle the effects of MBC implementation strategies on differential clinician uptake, but the effects of MBC implementation strategies on client outcomes need further examination.

Measurement feedback system implementation in public youth mental health treatment services: a mixed methods analysis

BACKGROUND

Prior studies indicate the effectiveness of measurement-based care (MBC), an evidence-based practice, in improving and accelerating positive outcomes for youth receiving behavioral health services. MBC is the routine collection and use of client-reported progress measures to inform shared decision-making and collaborative treatment adjustments and is a relatively feasible and scalable clinical practice, particularly well-suited for under-resourced community mental health settings. However, uptake of MBC remains low, so information on determinants related to MBC practice patterns is needed.

METHODS

Quantitative and qualitative data from N = 80 clinicians who implemented MBC using a measurement feedback system (MFS) were merged to understand and describe determinants of practice over three study phases. Quantitative, latent class analysis identified clinician groups based on participants' ratings of MFS acceptability, appropriateness, and feasibility and describes similarities/differences between classes in clinician-level characteristics (e.g., age; perceptions of implementation climate; reported MFS use; phase I). Qualitative analyses of clinicians' responses to open-ended questions about their MFS use and feedback about the MFS and implementation supports were conducted separately to understand multi-level barriers and facilitators to MFS implementation (phase II). Mixing occurred during interpretation, examining clinician experiences and opinions across groups to understand the needs of different classes of clinicians, describe class differences, and inform selection of implementation strategies in future research (phase III).

RESULTS

We identified two classes of clinicians: "Higher MFS" and "Lower MFS," and found similarities and differences in MFS use across groups. Compared to Lower MFS participants, clinicians in the Higher MFS group reported facilitators at a higher rate. Four determinants of practice were associated with the uptake of MBC and MFS in youth-serving community mental health settings for all clinicians: clarity, appropriateness, and feasibility of the MFS and its measures; clinician knowledge and skills; client preferences and behaviors; and incentives and resources (e.g., time; continuing educational support). Findings also highlighted the need for individual-level implementation strategies to target clinician needs, skills, and perceptions for future MBC and MFS implementation efforts.

CONCLUSION

This study has implications for the adoption of evidence-based practices, such as MBC, in the context of community-based mental health services for youth.

Factors affecting the implementation of an outcome measurement feedback system in youth mental health settings

Objective: Measurement feedback systems provide clinicians with regular snapshots of a client's mental health status, which can be used in treatment planning and client feedback. There are numerous barriers to clinicians using outcome measures routinely. This study aimed to investigate factors affecting the use of a measurement feedback system across youth mental health settings. Methods: The participants were 210 clinicians from headspace youth mental health services across Australia. They were surveyed on predictors and use of MyLifeTracker, a routine outcome measure. This was explored through three processes: looking at MyLifeTracker before session, using MyLifeTracker in treatment planning, and providing feedback of MyLifeTracker scores to clients. Results: Clinicians were more likely to look at MyLifeTracker before session, less likely to use it in treatment planning, and least likely to provide MyLifeTracker scores to clients. Each measurement feedback system process had a distinct group of predictors. Perceptions of MyLifeTracker's practicality was the only significant predictor of all three processes. Conclusion: Practically, organisations and supervisors can increase the use of measurement feedback systems through targeted supports.

Attitudes Towards the Use of Routine Outcome Monitoring of Psychological Therapies Among Mental Health Providers: The EBPAS-ROM

Implementation of routine outcome monitoring (ROM) in mental health care is progressing slowly. Knowledge about factors influencing ROM implementation, including health providers' attitudes towards ROM, is necessary. Based on a survey of 662 psychologists and nurses, this article describes (1) the development of a short instrument measuring provider attitudes towards ROM, derived from the Evidence-based Practice Attitude Scale (EBPAS), and (2) how attitudinal domains relate to clinicians' current use of standardized instruments for treatment evaluation. The EBPAS-ROM showed concurrent validity in predicting aspects important for the implementation of ROM, including perceived limitations and the value of organizational support.

A qualitative evaluation of Veterans Health Administration's implementation of measurement-based care in behavioral health

Measurement-based care (MBC) in behavioral health involves the repeated collection of patient-reported data that is used to track progress, inform care, and engage patients in shared decision making about their treatment. Research suggests that MBC increases the quality and effectiveness of mental health care. However, there can be challenges to implementing MBC, such as time burden, lack of resources to support MBC, and clinician attitudes. The Veterans Health Administration (VHA) is currently undertaking a multiphase MBC roll-out, the first phase of which included 59 sites across the country. The present study examined implementation of this initiative in an effort to learn more about the process of implementation, including best practices, challenges, and innovations. Semistructured interviews were conducted with 20 MBC site champions and 60 staff members from 25 VHA medical centers across the country. Qualitative data analysis was conducted to identify key themes related to MBC implementation. Results were described for 3 components of MBC implementation: preparing for implementation, administering measures, and using and sharing data. Training and staff buy-in were key to the preparation phase. Staff members reported a variety of methods and frequencies for the collection of MBC data, with many staff members identifying a need to streamline the collection process. Staff members reported using data to track progress and adjust treatment with patients. Efforts to use data on a programmatic level were identified as a next step. Innovative solutions across clinics and sites are described in an effort to inform future MBC implementation, both within and outside of VHA. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Synchronizing Watches: The Challenge of Aligning Implementation Science and Public Systems

This special issue of Administration and Policy in Mental Health explores the complexities of the outer system context in implementation science research. In this commentary, we highlight areas of asynchrony between implementation science research and policy realities of public systems. Timing is a critical factor for many aspects of system-level implementation including when and how evidence-based practice initiatives are launched, short and inconsistent timeframes for funding and support, need for early indicators of success and demonstrating return on investment. Greater consideration for the timing that drives change in public systems will strengthen efforts to implement and sustain EBPs in community settings.