Measuring outcomes in behavioral health has become a quagmire of misinformation and marketing buzzwords. Given that the three main accrediting bodies (i.e., the Joint Commission, Council on Accreditation, and the Commission on Accreditation of Rehabilitation Facilities) now require the use of standardized mental health outcomes assessment tools, the sheer number of measures and systems has reached atmospheric heights. How do you save yourself from drowning in options? With help from this quick reference guide to understanding the different types of outcome measures.
Mental Health Outcomes and Assessment Tools
Standardized vs. Evidence-Based Measures
The Joint Commission, Council on Accreditation (COA), and the Commission on Accreditation of Rehabilitation Facilities (CARF) all call for “standardized” measures to inform treatment decisions. This is, of course, a good thing because in times past agencies often made up their own measures of outcome that were not “standardized.” This meant that the measures contained minimal to zero reliability or validity and couldn’t be used to truly evaluate effectiveness nor compare one program to another.
Because a measure is standardized, however, does not mean it is evidence based. Standardized mental health outcomes assessment tools use measures that have been psychometrically validated in studies demonstrating reliability and validity, and have established norms for distinguishing clinical vs. nonclinical populations.
“Evidence based” has an entirely different meaning and is a much higher standard to achieve. It is the language of science, not marketing. It means that these types of outcome measures have been demonstrated to improve outcomes in at least two controlled, or randomized clinical, trials and published in peer-reviewed journals — not in reports published online in PDF files that look quite official (but nevertheless are never published in peer-reviewed journals, usually for good reason).
DLA-20 and the Evidence
For example, consider the Daily Living Activities Scale (DLA-20) recommended by the National Council for Behavioral Health. While it has demonstrated reliability and validity, and it claims to improve effectiveness and efficiency, it has zero randomized clinical trials to support such claims. Slide presentations and PDF reports make the case, not science.
The eight randomized clinical trials of the Partners for Change Outcome Management System (PCOMS) span across various cross-cultural sites (including the U.S., Europe, and China), client populations (including the impoverished and disenfranchised), therapeutic models, and modalities of service, making a strong case for the routine use of PCOMS in everyday practice.
Bottom Line: The DLA-20 and many others like it are reliable and valid types of outcome measures but have not demonstrated improved outcomes and are not “evidence based.” The OQ system and PCOMS are the only measurement-based care solutions that are truly evidence based.
Client vs. Provider-Generated Measures
Accreditation standards lean toward outcome measures that are client generated. For example, the Joint Commission states: “Ideally, the tool or instrument monitors progress from the individual’s perspective.” Of course, from our perspective, it makes best sense to privilege consumer perceptions of benefit given it is improvement in their quality of life that we are targeting — clients are the best judge of how well, or not, they are doing.
DLA-20 and Collaboration
Once again, this is not the case with many types of outcome measures. For example, consider the following instruction for the DLA-20: “The patient’s primary clinician or case manager typically has the most information about daily functioning at home or in the community and is best prepared to complete the DLA-20.”
While lip service is given regarding “collaboration” with consumers to fill out the measure, the reality is that these measures wind up being clinician judgement alone, often for the sake of expediency. Given the time required to complete the measures “collaboratively,” they wind up being done at convenient intervals for the clinician rather than timely evaluations of how the client perceives life is going. An important question emerges about the data: Whose data is it and what does it really mean for treatment planning?
Bottom Line: PCOMS is the only evidence-based clinical process that includes clients as full partners, involving them in all decisions affecting their care. The collaboration is not about filling out the measure but rather what should be done in treatment based on the client’s perspective of benefit.
Don’t select a mental health outcomes assessment tool just to meet the accreditation requirements. Select a systematic solution – one proven in eight randomized clinical trials to significantly improve effectiveness in real clinical settings as well as substantially reduce costs related to length of treatment and provider productivity.