Use of Measurement-Based 

Care for Behavioral Health 

Care in Community Settings 

A BRIEF REPORT 

The Interdepartmental 

Serious Mental Illness 

Coordinating Committee 

Data and Evaluation 

Working Group 
AUTHORS 

Jessica Barber (VA) 

Kate Bistline (SAMHSA) 

Joel Dubenitz (ASPE) 

Anita Everett (SAMHSA) 

Jennifer Humensky (NIH) 

Ira Katz (VA) 

Edward Liebmann (VA) 

Peggy O’Brien (SAMHSA) 

Kirstin Painter (NIDILRR/ACL) 

Sandra Resnick (VA) 

Michael Schoenbaum (NIH) 

Nima Sheth (SAMHSA) 

Meena Vythilingam (OASH) 

ACKNOWLEDGEMENTS 

Yasmine Brown (Hope Restored Suicide Prevention Project, LLC) 

Jennifer Higgins (CommonWealth GrantWorks) 

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Introduction 

In 2016, the 114th United States Congress passed, and former President Barack Obama signed into law, 

the 21st Century Cures Act (Public Law 114-255) (Cures Act). The Cures Act established the 

Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC or Committee) to enhance 

coordination across federal agencies and improve access to quality, affordable mental health care for 

people experiencing serious mental illness (SMI) or serious emotional disturbance (SED). The ISMICC 

brings together members of 10 federal agencies and 14 non-federal members to coordinate, support, 

and address the needs of people with SMI and SED. The Committee includes national experts on health 

care research, mental health providers, advocates, people living with mental health conditions, and their 

families and caregivers (ISMICC, 2022). The ISMICC also is charged with reporting on advances in 

research on SMI and SED, evaluating the effect of federal programs on mental health supports and 

services, and making recommendations for actions that federal agencies can take to improve the 

coordination and administration of mental health services. One such recommendation by the Data and 

Evaluation Working Group is the promotion of measurement-based care (MBC) in community behavioral 

health treatment (ISMICC, 2022).

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1 This Brief Report uses “behavioral health” as an umbrella term for mental health and substance use disorder 

services combined. 

Objective 

This Brief Report provides a common starting point for the promotion of MBC as a clinical intervention 

in behavioral health care in community settings. We first provide the Data and Evaluation Working 

Group’s operational definition of MBC and a concise and noncomprehensive summary of existing 

research. We identify important considerations for MBC implementation in community-based 

behavioral health settings and suggest areas for further study. This shared understanding will allow our 

Working Group and others to move forward in the promotion of MBC use in community behavioral 

health treatment delivery. 

Measurement Based Care in Community Settings2 

2 For purposes of this Brief Report, we adopt the Substance Abuse and Mental Health Services Administration 

(SAMHSA) definition of community-based provider as being “an agency or individual that delivers services in a 

community setting versus an institution, such as a hospital, jail, or prison” (SAMHSA, 2019). Although MBC may be 

useful in institutional settings, that is beyond the scope of this Brief Report. 

Although there is a lack of consensus regarding the definition of MBC in community behavioral health 

service delivery, we define MBC as 

a clinical process that uses standardized, valid, repeated measurements to track a client’s 

progress over time and to inform treatment, utilizing a shared patient-provider treatmentplanning and treatment decision-making process. 

When a collaborative decision-making model of MBC is followed, MBC is person-centered and recovery 

oriented and has been found to enhance client experience and engagement in care (de Jong et al., 2021; 

Scott et al., 2015), which is central to treatment outcomes. The clinician and an individual client, group, 

or couple/family review and discuss the results of the measure(s) at each administration to ensure 

shared understanding and guide collaborative treatment planning. Although the term MBC is 

sometimes used interchangeably with population screening, quality measurement, program monitoring, 

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or program evaluation, MBC is not 

synonymous with these concepts. The data 

that are gathered for MBC, however, are 

sometimes used secondarily for these 

additional distinct purposes. 

Examples of Measurement Based Care in Use in 

Outpatient Behavioral Health Treatment a

a The form, extent, and purpose of MBC varies across these 

examples. 

,b 

b See, e.g., Alter et al., 2021; Fortney et al., 2017. 

• Veterans Administration (VA) Collect. Share. Act. 

— Behavioral health settings across the VHA 

• Department of Defense — Patients in specialty 

care, outpatient settings across DoD facilities 

• National Institute of Mental Health Early 

Psychosis Intervention Network (EPINET) — 

National learning health care system for early 

psychosis 

• Federally qualified health centers — Washington 

State 

• Kaiser Permanente — Patients with depression, 

nationwide 

• Psychotherapy in school-based and other settings 

for children and adolescents 

• Reimbursement requirement in psychiatric 

Collaborative Care Model — Primary care 

settings for patients with any behavioral health 

condition 

• The Joint Commission — Required under 

Behavioral Health accreditation standards 

• URAC (formerly known as Utilization Review 

Accreditation Commission) — Voluntary for 

accreditation of health plans and providers 

MBC has many benefits. MBC has been 

shown to enhance treatment decisionmaking, detect changes in illness symptoms 

and severity, result in faster symptom 

reduction, reduce drop out, and improve the 

outcomes of care, treatment, or services 

(Boswell et al., 2015; de Jong et al., 2021; 

Fortney et al., 2017; Gondek et al., 2016; 

Goodman et al., 2013; Resnick et al., 2020; 

Scott et al., 2015; Tarescavage et al., 2014). 

Based on the preponderance of evidence on 

the effectiveness of MBC in improving the 

quality of care and improving treatment 

outcomes, several national efforts are 

underway to increase its use in behavioral 

health treatment. For instance, in 2018, the 

Joint Commission revised its Behavioral 

Health Care Accreditation Program to require 

services accredited under its Behavioral 

Health standards to utilize MBC. In 2016, the 

Department of Veterans Affairs (VA) Office of 

Mental Health and Suicide Prevention 

launched a national initiative, the 

Measurement Based Care (MBC) in Mental 

Health Initiative to establish MBC as the 

standard of care across all VA behavioral 

health programs (Resnick & Hoff, 2020). 

Methods 

At the April 13, 2022, full ISMICC meeting, the Data and Evaluation Working Group presented as a goal, 

and was approved to explore, a collaborative partnership among colleagues from the Department of 

Veterans Affairs (VA), Health and Human Services (HHS), and other potential interested parties to make 

recommendations for the implementation of MBC in community-based settings, with a longer-term goal 

of supporting the integration of MBC into behavioral health treatment and recovery support services. 

From May through October 2022, members of the Working Group were joined by colleagues from the 

VA in bi-weekly meetings. The Working Group heard presentations from federal staff participants and 

others, including the National Institute of Mental Health (NIMH) and the VA and reviewed relevant 

literature. These activities focused on exploring the working definitions of MBC, ways MBC is utilized 

across a diversity of community-based settings for behavioral health care, and lessons on challenges and 

successes of MBC implementation. 

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An overview of the implementation of MBC throughout VA behavioral health, preliminary findings from 

the Working Group, a working definition for MBC in behavioral health community-based settings, and an 

outline of this Brief Report, were presented and accepted at the October 28, 2022 full ISMICC meeting. 

Findings and Considerations for Use 

In preparing this Brief Report, the Working Group highlights the need for flexibility in implementing 

MBC. The Working Group is very conscious of the different settings, populations, and purposes for which 

MBC may be adopted. We encourage future efforts to create consensus definitions of terms, as well as 

to identify critical ingredients of MBC and related clinical processes. 

Factors to Consider in Adoption, Implementation, and Use of MBCs 

Purposes of MBC implementation. MBC is a clinical intervention designed to improve clinical care, and 

thus has a primary benefit to those receiving treatment. There are instances, however, where data from 

MBC may be used by programs or initiatives for secondary purposes, such as program evaluation, or 

with primary benefits to others, such as providers or payers, including reimbursement and value-based 

payment. Our focus in this Brief Report is on MBC as a clinical model of person-centered care. 

Populations served and settings for implementation. MBC is a transtheoretical and transdiagnostic 

evidence-based practice, and therefore appropriate in settings and situations when clinically indicated 

and when adequate measures are available. MBC is appropriate for both adult and child and adolescent 

populations, although the evidence-base is more limited for non-adults (Parikh et al., 2020). Across 

child-adolescent and adult populations, MBC can facilitate patient engagement, treatment planning, and 

problem identification. The incorporation of informants (e.g., parent, caregiver) into MBC may be 

particularly desirable when working with younger populations (Jensen-Doss et al., 2020). 

Selection and use of measures. Measures (also often referred to as instruments or tools) selected for use 

in MBC should align with the clinical services provided and the populations served, and they should be 

actionable by the provider(s) using them, either directly or by referral. Symptom measures are most 

frequently used for MBC, but monitoring other outcomes can provide significant clinical utility in an 

episode of care including measures of general distress, quality of life, functioning, employment, and 

recovery. Measures may be focused on a population (e.g., children) or a diagnostic category (e.g., 

depression), or a specific problem (e.g., pain, social functioning), or on factors such as the therapeutic 

alliance. Multiple instruments can be selected that are relevant to different populations served, settings, 

services, and needs. Measures should be psychometrically valid and, because the measure should target 

what is expected to change in treatment, it must have demonstrated sensitivity to change. Efforts also 

should be made to ensure the cultural sensitivity and relevance of a measure and its availability in 

multiple languages if needed. Measures should be brief to minimize burden across repeated 

administrations. 

Patient-reported outcome measures (PROMs) are encouraged for use in MBC. PROMs support client 

engagement and minimize provider bias but, depending on the population served and the treatment 

target, outcomes may be assessed from a caregiver or family member. In certain clinical situations or for 

certain populations, administrative (e.g., treatment attendance) or biomedical indicators—whether 

specific to a behavioral health diagnosis (e.g., urine drug screens) or relevant to physical health concerns 

(e.g., blood pressure, A1c)--may be used. Situations warranting the use of administrative or biological 

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measures for MBC may also benefit from the addition of PROMs, as the process of completing them 

affords critical opportunity for self-reflection and the promotion of treatment engagement. 

The selection of which PROM(s) to use is ideally a collaborative and engaging process, and patients 

and/or care partners should be included as much as possible in identifying which PROM is most relevant 

for them and how they should be completed. Thus, while beginning MBC at the initiation of a treatment 

episode is ideal, it may take multiple visits to identify which PROM(s) best align with the client’s goals 

and the treatment being delivered (Barber & Resnick, 2022). Proprietary measurement-feedback 

systems have been developed to facilitate MBC, however there are many PROMs that are free and 

available in the public domain for use (Beidas et al, 2015). 

Completion of measures ideally takes place immediately before a clinical interaction, which reveals how 

the individual was doing in the days before the interaction, and provides relevant clinical information to 

be used as part of treatment. Generic recommendations for the frequency of PROM administration are 

difficult to make because many factors may influence ideal frequency, including: patient preference, the 

treatment or service being delivered, the measure selected, how often a patient is seen, and local 

workflow considerations in a clinic. However, given that MBC is predicated on regular and repeated 

assessment, measures should be administered frequently enough to identify non-response or worsening 

and guide changes in treatment. 

Implementation of MBC into practice. Implementation strategies are the methods or practices that a 

health care setting and/or policymakers use to integrate a new practice into a standard of care (Proctor 

et al., 2013). Tailoring MBC practice to existing workflows, workforce capacity, the immediate needs of 

local clinical populations, and existing health care information technology (HIT) is imperative for 

successful MBC implementation. Many options for implementation strategies may be useful in 

integrating MBC in a way that is feasible and acceptable for particular providers and clients (Dollar et al., 

2019; Powell et al., 2013). Meaningful implementation targets can be developed with the aid of an 

implementation planning guide such as the MBC-specific guide developed by Dollar and colleagues 

(2019). Implementation plans are useful tools for thinking through implementation facilitators and 

challenges and provide a tailored framework based on the specific needs of the setting. An 

implementation plan allows teams to map out their goals and processes then revisit the plan over time 

to adjust the plan as needed. 

The champion model 

for implementation of 

changes in health care 

settings is a process 

that develops localized 

staff who are accessible 

and who can both 

support the change as 

well as troubleshoot 

problems and questions 

about implementation 

(e.g., Flanagan et al., 

2018). 

Leadership. Active leadership is one critical input for successful MBC 

implementation, including both formal organizational leadership and 

MBC Implementation Champions, the latter of whom are local 

practitioners who are proponents of MBC. Leaders can define a culture of 

MBC and facilitate the uptake of MBC efforts by making it clear that MBC 

is a priority for the organization and through the provision of necessary 

resources such as administrative time, training on correct use and 

administration of measures, tangible resources (e.g., HIT infrastructure), 

and workflow adjustments that allow for MBC implementation and 

uptake. Designated MBC Implementation Champions can guide this 

process, working with organizational leadership. Champions can be 

leveraged as an ongoing source of organizational knowledge and can 

facilitate the shaping of local practice toward MBC (Lewis et al., 2018). 

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Teamwork and partnership. Designing a successful implementation of MBC often requires a team, 

including clinicians, administrative, and support staff, as well as patients or family caregivers. Although 

level of participation may vary across team members, including all relevant partners in the planning 

phase can optimize engagement and allow broader input around workflow design and problem-solving. 

Teamwork can be enhanced through the process of developing an implementation plan, referenced 

above. When everyone is engaged in the implementation planning process it can facilitate buy-in and 

engagement. 

Performance improvement strategies. In addition to administrative processes and workflows, settings 

should determine how to allow for appropriate clinical training in MBC and how discussions of MBC will 

be integrated into existing supervision and team-based clinical discussions. Providing recognition, such 

as celebrating successes, reinforces the use of MBC and facilitates sustainment and increased uptake of 

MBC over time, as do audit and feedback strategies. MBC also creates opportunities for performance 

improvement across a team or setting. 

Building a culture of safety and growth. It is important that leadership establish a culture of safety in 

which it is clear to all involved how data from MBC will be used at an organizational level. If providers 

perceive MBC as a vehicle for encroachment of management and accountability efforts into routine 

care, or as monitoring efforts for which measures do not align with patient concerns, they may be 

reluctant to engage in its implementation and use (Boswell et al., 2015; Wolpert, 2014). To reduce 

concerns regarding inappropriate and unfair uses of MBC data, organizations should have a clear 

rationale for and policy around the use of any outcome measures derived from MBC data and ongoing 

dialogue between providers and leadership (Lewis et al., 2018). It is not recommended that leadership 

use outcomes from MBC to evaluate the performance of individual providers. However, it may be 

appropriate to evaluate clinicians’ utilization of MBC and offer feedback to support growth in MBC 

implementation and utilization over time. Additionally, data from measures collected as part of MBC can 

be rich information to use as part of clinical supervision and team meetings for troubleshooting 

challenging clinical situations and for general learning. 

Health information technology (HIT). HIT is not required for MBC implementation, but technological 

solutions may facilitate MBC implementation. Personnel demands are most reduced when MBC is 

seamlessly integrated into electronic health record systems (EHRs) (Lewis et al., 2018). A measurementfeedback system (MFS) is software, typically proprietary and distinct from the EHR, that supports the 

regular administration of outcome measures and the sharing of data to facilitate MBC. MFSs vary widely 

in their functionality, the outcome measures they include, and their capacity for integration with 

existing EHRs (Lyon et al., 2016). The increasing availability of mobile and digital platforms for outcome 

measure collection holds promise for further increasing MBC uptake (Hallgren et al., 2017). While 

mobile and digital applications hold promise for expanding MBC, organizations must be cognizant of 

inequities in access to technology and how this may create unintended inequities in access to MBC (Liu 

et al., 2019; Sisodia et al., 2021). The determination of technology needs for MBC and addressing them 

requires that service systems have a clear working model of MBC, knowledge of the requisite measures, 

understanding of clinical workflow, and ongoing assessment of the technological landscape. 

Policy considerations. All of these implementation considerations, while executed largely at the health 

care setting itself, may also be influenced or encouraged by policy. One area of implementation that is 

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more directly aligned with and influenced by policy is reimbursement. Reimbursement, however, is a 

complex subject and beyond the scope of this Brief Report. 

Limitations 

This Brief Report has limitations. Because of resource and time constraints, the Working Group’s scan of 

the literature is not comprehensive and our ability to gather nongovernmental experts to explore and 

discuss current implementation of MBC in a greater array of behavioral health settings has been limited. 

Additionally, by virtue of our mandate from the ISMICC, we restricted this Brief Report to outpatient 

community settings, but recognize that institutional and other noncommunity settings (e.g., hospital, 

residential, criminal justice settings) also may implement forms of MBC. Additionally, many important 

subjects (e.g., reimbursement to incentivize MBC) are beyond the scope of this Brief Report. 

Additional Activities Important to Further Program Development and Implementation 

Although there is strong empirical support for the clinical practice of MBC in some areas, there are also 

many aspects of MBC that would benefit from future study. Some of these include: 

• What treatments? Most of the evidence for MBC is from symptom-focused traditional 

individual outpatient therapies, such as psychotherapy and medication management for 

depression. There is little to no research examining the use of MBC in other treatment 

modalities, such as psychiatric rehabilitation (e.g., Assertive Community Treatment, Supported 

Employment), case management, group therapies, etc. 

• What is the setting? How might MBC be used in acute inpatient mental health, residential 

treatment, correctional facilities, or other non-outpatient care environments for the provision of 

behavioral healthcare treatment? 

• What populations benefit from MBC? There are unique considerations for different populations 

that have not been studied. For example: 

o How should MBC be implemented in geriatric populations, especially when there is 

cognitive impairment? 

o There are currently no validated self-report measures for assessing the symptoms of 

schizophrenia. What should MBC for this population look like generally and at different 

stages of illness? 

o There is some evidence that MBC may not be effective for individuals in treatment for 

personality disorders. What should MBC look like for this population? 

• What measures or types of measures are needed? Many existing PROMs are used in MBC to 

assess symptoms. Fewer measures of functioning, recovery, quality of life, etc. have been 

validated for use in MBC. Additionally, how can measures other than PROMs best be used, such 

as participation in treatment, measures of the experience of care, and biological factors? What 

is the potential value of including measures related to patients’ satisfaction with care and using 

responses to trigger program-focused or clinic-level problem-solving to promote retention in 

treatment? What is the role of clinician-administered measures in MBC? Most MBC research 

uses standardized (nomothetic) measures. How can individualized (idiographic) measures be 

used? Is there a role for Computer Adaptive Testing (CAT) in MBC? 

• How are instruments to be administered? When using PROMs, are there ideal strategies for 

administration? How do we maximize the validity and reliability of these measures in routine 

use? What HIT would be optimal to support measure administration? 

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• Are the measures psychometrically valid and sensitive to change and are they available in 

relevant languages? Many measures have been validated on non-representative samples. How 

can we ensure that measures are culturally responsible and valid for all individuals who might 

use them, including cutoff scores and norms? How do we understand clinically reliable change 

for each measure? 

• What is the ideal frequency of measurement? Does this vary by measure, by treatment, by 

population? How do we maximize treatment outcomes and minimize burden and assessment 

fatigue? 

• What are the ideal strategies for integrating MBC into the clinical workflow to optimize use and 

minimize burden? 

• How do providers maximally use measures? What is the best way to present and discuss 

measure results with patients? What kind of information do providers and patients need to 

make good decisions? How should that information be presented to providers and patients? 

Should patients and providers receive information in different ways? What kinds of decision 

support tools (e.g., alerts, visuals) are most effective? Does MBC with decision support tools 

based on recovery response curves produce better outcomes than those without? 

• What are the most effective strategies to train and supervise staff in MBC? Is there an optimal 

way to communicate the intended purpose of MBC? 

• What implementation strategies work best for implementing MBC? 

• What secondary uses of data obtained as part of the MBC process, aside from person-centered 

treatment and treatment planning, may be intended as part of implementation? If there are 

intentions beyond treatment and treatment planning, such as research, program or quality 

monitoring, or incentive payments, what implications do those uses have for patients, individual 

providers, and the health system or facility? 

Conclusion 

MBC is a collaborative clinical process that uses psychometrically validated, brief measures administered 

systematically throughout care to track a patient’s progress and inform treatment. Though further 

research is needed to clarify key questions related to the implementation and practice of MBC, MBC is a 

clinical intervention that is adaptable to various settings and populations and can enhance behavioral 

health treatment outcomes and improve the quality of patient care in community-based care. 

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