Measurement-Based Treatment to Target

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Five core principles define Collaborative Care and should inform every aspect of an implementation. The principle of Treatment to Target is comprised of two important processes.

Measurement-Based Care

Using clinical outcome measures is a relatively new idea in the world of behavioral health but has been used in other areas of health care for decades. Every time a patient visits a primary care clinic someone takes their blood pressure. Increasingly, primary care practices and some behavioral health organizations are using this same principle to screen for the most common behavioral health conditions, like depression and anxiety.

There are a variety of well validated measures that can help identify behavioral health conditions and some track treatment progress over time. These measures can play an important role in identifying people who may not otherwise be recognized as needing care for a behavioral health condition. However, their most important role is measuring the effect of treatment on symptoms. Once a patient has been identified as having a behavioral health condition and has started treatment for that condition, it’s very important to re-measure the symptoms at each contact so that the treating provider has specific information about whether or not symptoms are improving and which symptoms are or are not improving.

Some people are concerned that the concept of measuring mental health with a validated rating instrument invalidates the patient’s feelings or experience or disregards the complexity of the patient’s story. These measures are an important piece of information about the patient but are not meant to represent the entire clinical picture of the patient, nor are they meant to replace the clinical judgment of the provider. They are an important tool to assist the clinician and the patient with identification of the specific symptoms causing difficulty for the patient and how well those symptoms respond to treatment over time.

The following sites offer a variety of validated screening and treatment monitoring measures:
http://www.integration.samhsa.gov/clinical-practice/screening-tool
http://integrationacademy.ahrq.gov/evaluationtools
http://www.phqscreeners.com/overview.aspx

Treatment to Target

Adjusting the treatment plan based on symptom measures is one of the most important components of Collaborative Care. Clinicians change the treatment until the patient has at least a 50% reduction in measured symptoms.

Frequent measurement of symptoms allows the treating providers and the patient to know whether the patient is having a full response, partial response or no response to treatment. These measures also provide clues about which symptoms are improving and which are not if there is a partial response to treatment. This information is critically important in making decisions about how to adjust treatment.

Collaborative Care requires a change in the treatment plan every 10-12 weeks if the patient has not had at least a 50% improvement in symptoms using a validated measure. This prevents the clinical inertia that is often found in usual care and is likely one of the key factors behind the better treatment outcomes that can be achieved with Collaborative Care. If the treatment plan started with medication therapy as the primary treatment, the adjustment might be a change in dosage and/or the addition of evidence-based psychotherapy. If the treatment plan started with evidence-based psychotherapy, the adjustment might be the addition of medication therapy.