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Scott Webb (Host): Measurement based care is a much needed paradigm shift in the behavioral health field that involves the systematic collection of data to monitor treatment progress, assess outcomes, and guide treatment decisions from initial screening to completion of care. And it's my pleasure to be joined today by Dr. Antoinette Giedzinska. She's the Director of Applied Neuroscience and Outcomes at Sierra Tucson.   This is Let's Talk Mind, Body, Spirit by Sierra Tucson. Sierra Tucson ranked the number one best addiction treatment centers 2020 in Arizona by Newsweek. I'm Scott Webb. Doctor, it's so nice to have you on today. Why is it important to measure treatment fidelity?

Antoinette Giedzinska, PhD (Guest): Well, there's many good reasons to measure treatment fidelity or measurement based care in behavioral health care. The best way I can explain it is thinking about God forbid, you broke a bone and you go see your doctor. Now they're going to do some evaluations. They're going to take some x-rays to assess the degree of damage to the bone, put you on a course of treatment and then do a few more x-rays correct, as you go through treatment to make sure the bone is healing. So, we take that for granted in medicine all the time. We even do it in education to make sure children are progressing the way we expect them to with assessment as well. And what's really interesting is in the field of behavioral health care or mental health care, you know, oftentimes we've been gauging progress based on patient report and clinician observation, which is very critical to the alliance that takes place between a client, and a therapist or a doctor. But the reality is it's extremely subjective and oftentimes it's almost like where we have a testimony of improvement over time, or a decrease over time based on how the patient is reporting their symptoms or the clinician is observing them.

So, the notion of integrating psychometric testing as part of the clinical process in behavioral health care, really helps to serve to substantiate the quality expression or presentation of symptom change. So, we can actually quantify that. Does that make sense?

It almost the x-ray. Yeah, so the patient says, hey I feel good. My arm is healing. I'm not in so much pain. We look at the x-ray, we say, oh yeah you're on point. Everything's great. We can start to titrate this pain medicine or whatever it is as part of the course of treatment. So, measurement based care serves the same purpose. It doesn't supplant the therapeutic alliance between the clinician and the patient. It just adds to bolster it and then it keeping us on track. So, we actually know that we are making progress in treatment.

Host: Yeah, and that's such a great analogy and it really does make sense. And I guess I'm wondering is MBC really required now for behavioral health care practices? Is that standard practice?

Dr. Giedzinska: Yeah it's becoming standard practice. There's some growing pains associated with that as well. So, CARF International is an accrediting body for behavioral health care. And they've been requiring that their institutions be implementing some form of measurement based care since the late nineties. JCAHO started making changes to their measured care outcomes procedures in 2018. What both of the institutions are looking for is not that you are accounting for patients' mental health status, but you're using that information to help formulate what the treatment plan should be, more specific to the patient need. So, it's very much a patient-centered approach or personalized medicine that we know so well. And when we are implementing those same measures throughout the course of treatment, it gives the clinic or the doctor an opportunity to make sure that the treatment plan is absolutely meeting the needs of the patient as we are observing change over time. So, it really becomes part of the clinical tool.

It's not just an assessment process itself alone. And so yes, the answer is it will become standard of care, especially if folks are looking to get accreditation from CARF or JACHO, and also with managed care reimbursement, a lot of these payers are expecting to see substantiation in treatment progress.

Host: Yeah, and you can kind of see why they would. And when we think of this as a clinical tool, really what should be assessed and what are the ways the data can be used?

Dr. Giedzinska: I love that question. So, one of the things I talk about when I lecture on this topic is really understanding your own vision and mission as a practitioner. So, if you're in private practice, you know, your specialty. Is your specialty addiction? Is your specialty depression? Are you an eclectic approach therapist? Right? There's things that people have to dig down a little bit and think about how they go about treating people in mental health. Institutions like ours here at Sierra Tucson, we have programs designed to address specific issues, trauma, pain, addiction, co-morbidity, co-occurring disorders. So, before you even begin to give assessments, you really need to know what your vision is. What are you trying to do as a therapist or practitioner to help someone recover? So, once you've got that identified, whether it's depression or co-morbidity, or you specializing in trauma, then you know what to be asking for in terms of the assessment. So, there's not one golden assessment out there to look at all mental health issues.

That would be way too big of a project to do. Right? But if we're focusing on treating depression, then we want to use a depression scale. We want to use those that are valid. They've been proven to be reliable. So many of these psychometrics are out there in the public domain, so you don't have to pay for them, but you do have to do a little leg work to make sure that the measurement itself has been well validated and reliable through a psychometric process. So, that's where we would go to the professional literature, the peer reviewed literature to make sure that the tool you're using actually measures what it's intended to measure. And so, those are the tools that we want to use and look for based on what we're trying to help the patient recover from. So, it can be very specific to each individual, or if you have a program per se, if you're running a trauma program, then you can have a nice little collection of measures, looking at trauma and anxiety and maybe stress perception and resiliency, sort of like an aggregate bundle of questionnaires, then you have every single patient complete as part of that program.

And the nice thing about that is not only is it helping the individual patient with their progress in treatment, but when you step back and patients have gone through your program, you can begin to aggregate the data, combining it together, so to speak and looking at how well your program as a whole is producing change. And that's the fidelity, that's really important to make sure that we're measuring along the way, is our program really delivering the outcomes that we say we're delivering. Right. And so not only is the individual data helping the individual patient over time, but when we group it together, we can then assess how good is our program as a whole. Does that make sense?

Host: Yeah, it definitely does. And when we think about the patients, do you discuss the outcomes with them? And how do they typically respond?

Dr. Giedzinska: That's one of my favorite parts of my job, actually. So, what we've done here is we've used the data very creatively in that it's a standard protocol of assessments that we ask our patients. We not only are looking at mood and difficulty in managing stress, let's say, and other issues related to mental health, but we're also looking at quality of life. How are they functioning? Right? Because a lot of people can function in the world with depression. When they end up coming to a place like Sierra Tucson, their lives have become unmanageable and so they need further assistance. And so if we can assess their state of mind, their spirit, their functioning in the world, if we can do that in a holistic approach, we can also measure it that way too. And that's what we've done here. And I'm very proud of this work actually, because it's a very comprehensive snapshot of someone's profile. When a patient completes this comprehensive questionnaire, we give them feedback immediately in terms of graphs and then qualitative descriptions.

And then they can actually see where their weaknesses are, but they can also see where they may be more resilient and they forgot about that. So, the fact that we're very comprehensive and we use standardized data that's from validated measures, patients can gauge themselves against other clinical populations or the normative populations, just so they can see where they're at. They get this profile, it really hones in and validates their suffering. And they really like to see what that looks like. It's a very colorful graphic output. They really do like them. And then we bring them back in about two weeks into treatment, about midway through, and then they get this pre-med comparison.

So, they actually get to see their progress in treatment here and they love it. It helps them understand what's going on with themselves and they get really excited to see that they're making progress. The literature actually supports that even one to two point change improvement can do huge help in someone's belief in the system, belief in the therapy, it gives them a sense of hope and empowerment. So, there's almost a metacognitive process when they review the data with you. So, they know they're making progress, they do the evaluation and then it helps to substantiate and validate their own experience. So, it's actually very powerful to observe alongside that, it's very joyful.

The other thing I want to add in there though, is one of the reasons why measurement based care has really grown traction, just recently, especially with JACHO is because, it is very good at catching patients who may be falling through the cracks. And that's really one of the main reasons why I'm very passionate about this work, because oftentimes when you're working in mental health with patients, they may present a certain way and assure you that they're doing fine. Or they may not be aware that they're not progressing in a certain way. And so much of the healing that takes place between a therapist and their patient is this alliance, this therapeutic alliance between two people. And sometimes as humans, we miss certain criteria that we just don't think to ask or pick up or the patient has the insight to express and measurement based care, the assessment process can pick up little pieces of information where we forget to pick up on it through our therapeutic acumen. And we can capture people who are actually falling through the cracks. Maybe their anxiety is getting greater. Maybe there's a part of their depression that's getting worse. And this allows us to stop and say, hey Joe, you’re doing really good in these domains over here, but I'm noticing, this uptick in social anxiety in this particular measure, let's say. And then the therapist and the patient could sit down and address that and we can make changes to the treatment plan based on that. And so there's this magic piece that the data can provide that really helps to involve that whole process. And that's really one of the reasons why it's so good to be able to review the progress data with patients and that they're an active participant in that.

Host: A lot to unpack there, but back to your analogy at the beginning about x-rays. And of course, when you go for a follow-up x-ray and you see that you're healing, it makes us feel good. And as you say here, that people, patients really like to see their progress that it's actually being measured. Right? And they can see their progress and they respond well to that. So it's really amazing. Doctor, anything else as we wrap up here today, what are the takeaways when it comes to measurement based care?

Dr. Giedzinska: Yeah, thank you for asking me that question. There's a couple of things I think, as we move into this paradigm where it becomes standard of care, especially across the mental health paradigm is that, our therapists and our psychiatrists, shouldn't be afraid of it. I think there's a few biases that still need to be worked out as we push through with this field. Oftentimes, I get teased a lot because I actually like data and statistics. I'm not afraid of these things, but most of my clinical colleagues, I mean, that was the case coursework that they hated the most in grad school. And I don't care if you're a medical doctor, psychologist, or a licensed social worker, they just, there's terror around statistics.

And if I can convey anything to the listeners is don't be afraid of the data. The data are your friend. They're there to help to make sure that you’re on point, that you're delivering the treatment that you intend to deliver, and it's there to support you. It's not there to supplant you or there as a punitive expression that you're not doing your clinical work correctly. If we could step back and say, you know what, the data are here to support me. This is actually saving me time. It's allowing me to get closer with my patients and it's providing me some therapeutic talking points. All of a sudden, it's no longer that big scary statistics 502 class that you had to ace in order to graduate.

Right? And there's no statistics involved unless you want to. But I think that's one of the things is that there's a few biases and a few misconceptions that have to be cleared in order for us to look at it as a tool for the clinical process and not just this separate entity of data collection and research. In fact, measurement based care can be used for outcomes, but the reality at the end of the day, it really should be used on the individual level as a support for the clinical process.

Host: That's well said, and I love the way you put that, you know, data really is our friend. Right? And it doesn't define us. It doesn't define patients, but it is a tool for clinicians, for patients and does help us sort of hone in and get to the heart of things and make sure that we dot all the I's and cross all the T's. And as you say, because clinicians are human and may miss things, the data is there to help as a tool. So, this is really fascinating. Doctor, thanks so much for your time today and you stay well.

Dr. Giedzinska: Thank you, Scott. It was a pleasure to speak with you. Thank you.

Host: For more information, visit Sierratucson.com or call (800) 842-4487. Sierra Tucson, we work with most insurance. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for additional topics of interest. This is Let's Talk Mind, Body, Spirit from Sierra Tucson. I'm Scott Webb. Stay well.