The feasibility of standardized patient assessments as a best practice in an academic training program

Using a Quality Improvement Approach to Implement Measurement-Based Care (MBC) in Outpatient General Psychiatry

BACKGROUND

Measurement-based care (MBC) is the clinical practice of using patient-reported symptom measurement to inform treatment decisions. MBC has been shown to improve patient outcomes and quality of care in outpatient psychiatry. Despite these benefits, MBC is not routinely used in most psychiatric outpatient settings. This quality improvement (QI) project aimed to achieve 75% completion of symptom scales using an online MBC platform in a general psychiatry clinic in Toronto, Canada, by June 2022.

METHODS

The QI team used the Model for Improvement methodology. The main outcome measure was completion of symptom scales using an online MBC platform. Process measures included counts of invitations to join the MBC platform, counts of online MBC account creation, and counts of symptom scale assignment by clinicians. Balancing measures included administrative task completion and physician workload assessment. Stakeholder interviews explored barriers and facilitators to MBC utilization.

RESULTS

Completion of symptom scales increased from 7/65 (10.8%) preintervention to 40/70 (57.1%) during the 26-week intervention. Clinician reminders and coaching clinicians about how to incorporate MBC into the care process facilitated uptake of MBC. Stakeholders identified several barriers to implementation, particularly physician attitudes toward MBC and perceived administrative burden.

CONCLUSION

Completion of symptom scales increased over the course of this QI initiative. Successful implementation of MBC in general psychiatry outpatient settings requires the availability of a broad range of measurement scales given the diversity of mental health diagnoses. Implementation must also consider health equity, including access to technology and availability of symptom scales in multiple languages.

Educating Mental Health Trainees About Measurement-Based Care: A Scoping Review

OBJECTIVE

Measurement-based care (MBC) refers to the routine use of symptom rating scales to guide treatment decisions. Although effective, it is an underused approach to enhance patient care. A significant barrier to integration of MBC is insubstantial foundational training. This scoping review aims to survey the literature on MBC educational curricula for mental health trainees.

METHODS

Investigators searched Ovid Medline, PsycINFO, Embase, Cochrane Central, and Ebsco CINAHL through June 2021 to select records that described studies of MBC educational programs for undergraduate, graduate, or postgraduate learners in mental healthcare.

RESULTS

From 1270 unique records, 1263 were excluded in abstract/title and full-text screening. This scoping review included seven articles, of which most were empirical or case studies and took place in the USA. These curricula involved many delivery formats, including lectures and in-service training. Measured learner outcomes include those that are learner-focused (i.e. learner reaction, or attitudinal/behavioral change) and organizational-focused (i.e. increased clinical use of MBC). Mechanisms of positive outcomes are posited to include enhanced stakeholder support and continual curriculum improvement.

CONCLUSIONS

MBC curricula can be taught in various formats to diverse learners in mental healthcare. Contextual factors, such as dedicated resources, MBC champions, supervisor training, online measurement feedback systems, simple measures, and gathering and disseminating feedback may facilitate curricular success by fostering stakeholder support and continual program improvement. To address literature gaps, future research in MBC education should involve educational frameworks in designing curriculum and address the use of quality improvement approaches in the implementation of MBC education.

The Brief Adolescent Depression Screen: A Brief Screening Tool for Depression and Suicidal Behavior in Inpatient Adolescents

Background

In clinical settings, there is significant need for brief, easily-administered assessment tools for adolescent depression that can be used by mental health clinicians from a variety of training backgrounds. Existing depression screening tools do not assess for duration and consistency of symptoms, two key indicators of pathological depression.

Objective

The Brief Adolescent Depression Screen (BADS) was developed to screen for major and persistent depressive disorders in adolescents in order to meet the assessment needs in an inpatient setting, and the validity of this tool was tested.

Method

The current study used a sample of 396 inpatient adolescents to assess the screening utility of the BADS for detecting whether the adolescent meets criteria for a depressive diagnosis according to a well-validated semi-structured interview, as well as detecting a positive history of suicidal behavior. Further, the screening utility of this measure was compared to the utility of an established depression rating scale.

Results

Analyses first determined the duration of depressive symptoms on the BADS that optimally screened for the presence of Major Depressive Disorder and Persistent Depressive Disorder. Findings indicated that, using these optimal screening cut-offs, the BADS showed a strong screening utility, resulting in a sensitivity and specificity for identifying full depressive diagnoses and a positive history of suicidal behavior with similar or greater accuracy than an established rating scale.

Conclusions

These findings provide initial evidence to suggest that the BADS may be a helpful screening tool for adolescent depressive disorders in inpatient settings.

Integrating Measurement-Based Care into Trainee Education

Although there is no published literature on the use of rating scales in child and adolescent psychiatry fellowships, there is evidence of use of rating scales in other residency programs including general psychiatry, pediatrics, and family medicine. The authors surveyed the American Association of Directors of Psychiatric Residency Training listserv inquiring how rating scales are used in child and adolescent psychiatry training programs. Results included the use of specific rating scales, if they are optional or required, presence or absence of didactics, perception of rating instruments by fellows and faculty, integration with quality improvement projects, and use in practice after graduation.

Implementing Outcome-based Care in Pediatric Psychiatry: Early Results and Overcoming Barriers

Background:

Poor utilization of standardized outcome measures for monitoring patient care and progress in mental health services is evident. The objective of this work was to implement computerized diagnostic and history assessments for outpatient mental health visits in the ambulatory psychiatric clinic of a large pediatric health system.

Methods:

A computerized assessment system was created for the iPad to administer and score a series of validated diagnostics before new patient and follow-up appointments with a psychiatry provider. Outcome measures were a percentage of completed assessments, provider satisfaction, and patient satisfaction.

Results:

Across all outpatient psychiatry clinics, screener completion rate for new patients increased from 0% to 90% within 1 year of implementation and sustained within 3σ process control limits for 2 years. Return visit assessment completion increased from 0% to 80%. The most substantial completion rate increase was related to scheduling assessment time as part of the visit. Assessment of provider and patient satisfaction through surveys before and after the implementation showed 94% of providers felt that visit efficiency had improved, and overall opinion of the system was highly positive. Patients also reported high satisfaction with the assessment process (4.1 on Likert scale 0–5, 5 = very positive).

Conclusions:

This quality improvement program demonstrates strategies for overcoming barriers to the use of standardized assessments in outpatient psychiatry. We show that a large pediatric mental health system can achieve systematic outcome data collection with minimal disruption to routine clinical care.