2019 HSR&D/QUERI National Conference

1111 — Discussing Mental Health Outcomes in Measurement Based Care: A Qualitative Study of Clinician-Veteran Dyads

Lead/Presenter: Craig Rosen,  COIN - Palo Alto
All Authors: Holliday SB (RAND Corporation), Hepner K (RAND Corporation), Farmer C (RAND Corporation) Mahmud A (RAND Corporation) Kimerling R (National Center for PTSD Dissemination & Training Division, Palo Alto) Smith BN (National Center for PTSD Dissemination & Training Division, Palo Alto) Rosen CS (National Center for PTSD Dissemination & Training Division, Palo Alto)

Since 2016, VHA has been working to implement measurement-based care (MBC) in mental health. This initiative promotes three integrated strategies to improve effectiveness of behavioral health care: 1) routine monitoring of outcomes with validated patient-report measures; 2) regularly sharing outcomes data with patients; and 3) using these data to inform treatment decisions. To help guide implementation, we sought to identify specific behaviors in discussing and using MBC data which were associated with MBC being valued by clinicians and patients.

Twenty six clinician-Veteran dyads were recruited from four VA medical centers that participated in the first (FY 2016) phase of MBC implementation. Clinicians and Veterans participated in separate semi-structured interviews and provided a treatment session recording in which MBC data were discussed. Coding guides for the clinician interviews, patient interviews, and recordings were designed to assess parallel themes, facilitating integration of data across sources.

Qualitative data analyses revealed four subtypes of dyads: 1) clinician and Veteran both valued MBC; 2) clinician valued MBC and Veteran passively participated in MBC; 3) clinician valued MBC and Veteran had mixed perceptions of MBC; 4) both clinician and Veteran reported moderate or low value for MBC. In dyads for whom both the clinician and patient valued MBC, the clinician provided clear and repeated rationale for MBC, discussed MBC data with patients at every administration, and connected observed scores to specific patient skills or strategies. In successful dyads, discussion of MBC data often led to improved case formulations and potential solutions to observed problems.

Emerging best practices for discussing MBC include providing a clear rationale, discussing MBC data frequently, actively engaging patients in these discussions, and using graphs to visualize progress. This largely validates the recommendations in current MBC training. Yet use of these practices is uneven, suggesting a need for coaching and support to improve fidelity.

Using best practices for reviewing outcomes data with patients can potentially improve patient engagement and shared decision-making.