Using Patient Measurements to Drive Care
The Collaborative Care Model (CoCM) is built upon the foundation of data-driven decision-making – in behavioral health, this is often referred to as Measurement-Based Care or MBC. Much in the same way that blood test results or blood pressure readings drive your day-to-day clinical care for your patients, results from CoCM measurements can provide useful information to support your clinical interventions.
Mirah’s CoCM platform was built to support this, making it easy to administer, score, and interpret a wide range of behavioral health measurements. This can give you real-time access to understand who is doing well and who may need a change in their care plan.
Here are a few ways you can integrate MBC into your workflow:
Determine which set of symptoms (depression, anxiety, or ADHD) most closely fit for each patient you see in the CoCM program to monitor throughout enrollment. Be sure to select the correct measurement bundle based on the patient’s age.
You can also assign supplemental measures to assist with differential diagnoses and/or monitor those symptoms over the course of treatment. These may be helpful with the patient has very specific symptoms (eg: eating concerns), or the psychiatric consultant or behavioral health clinician may suggest specific measures for certain patients.
Review your patient's progress on CoCM measures. You can review assessment results directly in Mirah’s CoCM platform, document your own observations, and communicate with PCP colleagues on where to get updates on patient progress.
Share measurement results: Patients can benefit from seeing and understanding their measurement results and progress over time. Sharing a summary of scores or even showing patients charts of their progress on the Mirah platform can be a great way to help them monitor their own progress.
If you aren’t sure how to discuss the results of measurements with your client, here are a few conversation starters to try:
When I was reviewing the questions you answered this week, I noticed…
What do you notice about your results/answers?
Can you tell me more about this answer/result/question?
Was there anything in the questions this week that you wanted to discuss with me today?
Is there anything missing from these results that you think it’s important for me to know?
CoCM works (at least in part) because it allows quick identification of patients who are not making the expected progress in treatment. Measurement-based care is the foundation to this.
Most patients will require at least one change in their care plan in CoCM. Changes in a patient’s care plan are not signs of failure – they are a sign that the program is working as intended.
Next steps to consider based on measurement results:
Risk/safety concerns?
Patients with risk or safety concerns may require more immediate crisis or emergency evaluation. Interventions such as Safety planning and counseling on access to lethal means are effective interventions for individuals at risk of self-harm or suicide.
On track?
Patients who are making progress towards their goals are probably on the right track. Continue to implement the care plan and monitor progress over time. Don’t forget to celebrate the small successes with patients to keep their motivation up!
Already made progress? Achieved goals?
Once patients have met their goal(s) or shown significant progress, they may be nearing readiness for discharge. Alternatively, work with the patient to set new goals and adjust the care plan to work towards those goals.
Not making progress?
If a patient is not making progress in CoCM, you may need to change the intervention or modality. Care managers should also be attentive to what is happening for the patient in treatment. Sometimes lack of progress can be caused by a strain or conflict in the relationship with the care team or when a patient disagrees with their care plan. Patients who are not improving after 2-3 months in COCM should be discussed in the team’s weekly psychiatric case consultation meeting.
Unexpected results?
Sometimes a patient’s needs or symptoms can change unexpectedly or even rapidly. When this happens, it might be necessary to update the patient’s treatment goals or care plan.
Unsure of progress? Unclear results? Other concerns?
Any time you are not sure about measurement results or a patient’s care plan, you can seek input by speaking to a supervisor, discussing with your team’s behavioral health clinician or bringing the case to the weekly psychiatric case consultation meeting.