Measurement-Based Practices in Integrated Care
Measurement-based care (MBC) is a framework in which validated symptom rating scales and screening tools are routinely used in clinical practice to inform treatment decisions and adjustments. The most widely used tool in MBC is the Patient Health Questionnaire nine-item scale (PHQ-9). The PHQ-9 is a multipurpose tool used for screening, diagnosing, monitoring and measuring the severity of depression. The PHQ-9 has also been modified for use with patients aged 11-17 years. The modified version, the PHQ-Adolescent (PHQ-A), was validated for use in both primary care and school-based healthcare.
The impetus for providers to adopt MBC made a significant step forward with the adoption of measure-based depression care measures by the National Committee for Quality Assurance (NCQA) in their 2016 Healthcare Effectiveness Data Set (HEDIS). Each of the depression measures is described below:
- Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults
This quality measure was first implemented in HEDIS 2016 and reflects the percentage of health plan members 12-years-of-age and older with a diagnosis of major depressive disorder or dysthymia who had a PHQ-9 or PHQ-A tool administered at least once during a four-month period.
NCQA’s phase-in implementation began with this measure to emphasize the importance of routine monitoring and to help providers improve their ability to measure outcomes. The New York State Medicaid Program is considering using this new measure in its contracts with health plans.
- Depression Remission or Response for Adolescents and Adults
The second measure, first implemented in HEDIS 2017, reflects the percentage of health plan members, ages 12 years and older, with a diagnosis of major depressive disorder or dysthymia with an elevated PHQ-9 or PHQ-A score, who had evidence of response or remission within five to seven months of the initial elevated score.
Evidence of remission or response is considered to be a PHQ score less than 5 or a 50% reduction in the score. A score of less than 5 indicates that the patient has minimal symptoms and suggests that depression treatment is no longer needed. For some complex patients, symptoms are greatly reduced and treatment goals may be achieved at 50% reduction in score--even if the score is not less than 5.
Similar depression remission measures and performance expectations are already tied to shared savings for some accountable care organizations (ACOs). Boeing, one of Washington State’s largest employers, includes depression remission metrics in their direct contracts with two ACOs, the Providence-Swedish Health Alliance and the University of Washington Medicine Accountable Care Network.
- Depression Screening and Follow-up for Adolescents and Adults
The third measure is planned for implementation in HEDIS 2018 and is based upon National Quality Forum (NQF) measure # 0418, age appropriate depression screening and follow-up plan, which was first endorsed by NQF in 2008. This third HEDIS measure will reflect the percentage of health plan members 12-years-of-age and older who were screened for clinical depression using an age appropriate tool and, if screened positive for depression, received follow-up care within 30 days or screened negative for depression.
This measure is one of seventeen measures selected by the Oregon Health Authority to evaluate the performance of Oregon’s Coordinated Care Organizations (CCOs). The CCOs have reported on depression screening and follow up care since 2013. In 2014, the Health Resources and Services Administration adopted the depression screening and follow-up measure for all Health Center Program grantees and look-alikes to report yearly as part of the Uniform Data System.
HEDIS Learning Collaborative on Depression Measures
The NCQA led a HEDIS Learning Collaborative in 2016 comprised of thirteen health plans that explored and evaluated methods to collect and report on the new HEDIS depression measures. All of the participating organizations have unique delivery care systems, data challenges, and different perspectives on data collection and reporting.
Recognizing the gaps and challenges in electronic communication and interoperability that make quality measurement difficult in depression care, NCQA's goal was to evaluate innovative uses of electronic clinical data systems (ECDS) in contributing data to report on the new depression measures. Allowable ECDS may also support other care-related activities, such as evidence-based decision support, and must be accessible by the healthcare team at the point of care. Examples of ECDS include electronic care management systems and clinical registries. NCQA has continued to refine and establish requirements for ECDS and will host a virtual event in February 2017 to share the results of the Learning Collaborative.
One participant in the Learning Collaborative, Kaiser Permanente of Northern California, has successfully implemented measurement-based care, which Kaiser calls “feedback-informed care,” in a number of its programs. “We first started using feedback-informed care in our specialty mental health clinics for adult psychiatry,” said John Peters, PhD, Associate Director of Outcomes and Technology for Regional Mental Health & Chemical Dependency at Kaiser Permanente, Northern California. “We have continued to develop innovative ways to regularly monitor progress and use that information in real-time with patients and started to pilot them in other programs.”
Peters notes that even with processes in place, putting a measurement-based care approach into clinical practice is not always straightforward. It takes a committed and collaborative team to establish and maintain reliable screening protocols and make it successful. “It’s vital that senior leadership completely supports the [measurement-based care] effort,” says Peters. “It’s also important that the measures you choose are as effective as possible for front line clinicians and the patients. You need to ensure that the measures are feasible and can be used across diagnoses.”
2/21/17: This story has been updated to reflect the adoption of the HEDIS depression measures.