Develop Processes for Tracking Patients, Monitoring Outcomes, and Maintaining Engagement

Track Patients and Monitor Their Outcomes

Treating common mental health conditions is similar to treating chronic medical conditions. After treatment begins, patients should be reassessed periodically. If patients are not reaching treatment goals, treatment should be modified—this is often referred to as “treatment to target.” This measurement-based care approach is just as important for common mental health conditions (e.g., depression or anxiety) as it is for chronic medical conditions such as hypertension or diabetes.

Practices need a system to track and monitor patients through treatment so patients who are not reaching treatment goals or who do not follow through with needed care can be identified. This tracking and monitoring system enables providers to adjust patients’ care plans when needed and maintain patient engagement.

North Star

The setting has a system to track all patients receiving integrated ambulatory care services that allows providers to collaboratively monitor treatment, adjust care plans, and keep patients engaged through treatment.

What is the North Star?

The North Star

The North Star reflects ideal practices of an integrated behavioral health and ambulatory care setting. The North Star can act as a goal or guide toward your desired state of integration.

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How Do You Do It?

A registry or similar tracking tool can help your practice obtain the information necessary to monitor and adjust patients’ treatment. It should be part of a staff member’s job to regularly review the registry or tracking tool. By actively reviewing the registry or tracking tool, the team can be alerted when services are needed or care plans need adjusting. The registry or tracking tool is a key element in the Collaborative Care approach to integrating behavioral health care into the practice.

In Collect and Use Data for Quality Improvement, the Playbook provides tools for monitoring patients. These tools may be used independently or in conjunction with your electronic health record system.

For some conditions, instruments can be used to track progress toward treatment goals. For example, PHQ-9 (Patient Health Questionnaire-9) can track progress for patients with depression and GAD-7 (Generalized Anxiety Disorder Scale-7) can track progress for patients with anxiety. Although scores on these scales need to be correlated with clinical observations to confirm depression or anxiety, they can help capture improvements during ongoing treatment.

For some patients, you may want to use a more general measure to assess whether progress is being made or treatment needs adjustments. These measures could include assessments of general function or the number of days with fair or poor mental health.

Through regular monitoring of treatment response, side effects, and how treatments are fitting the patient’s life, goals, and priorities, the care team can identify:

  • Patients who are improving;
  • Patients who may benefit from adjustments to their care plan; and
  • Patients who are not following up.

A monitoring system allows your practice to reassess the resources and providers needed to manage the patient population and measure population-level processes and outcomes. Your practice might choose to participate in a program evaluation or research project. These opportunities may provide your practice with additional information about “what works” in your setting and facilitate identification of treatments that improve outcomes.

How Others Are Doing It

  • Community Health Plan of Washington uses a Care Management Tracking System as a registry tool to make appointments and track referrals. Read more at Community Health Plan of Washington.

  • MaineHealth uses Integrative Medical Records to assist in referrals, appointment scheduling, and followup. Read more at MaineHealth.

Useful Resource(s) for Monitoring Patients

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By identifying patients who are improving, the care team can start educating patients on self-management and relapse prevention plans. You can find more information about relapse prevention and self-management in Build Patient Understanding of Setbacks and How to Deal With Them.

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If a patient is not responding to treatment, consider the following possible causes:

  • The patient’s treatment needs adjustment.
  • The patient is not following some or all of the treatment plan.
  • The diagnosis is incorrect.

The care team should investigate the possible reasons why a patient may not be responding and promptly adjust the care plan.

A stepped-care approach in which simpler, less intensive interventions are tried first can be helpful for patients who could benefit from a change in their care (treatment) plan. A treatment algorithm or similar tool could also be used for guidance.

How Others Are Doing It

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Patients may not follow up or follow their care plan for reasons beyond the patient’s control (i.e., related to their social, cultural, or otherwise “external” environment). Be sure that the plan “fits” and is accessible for each patient.

The same registry or tracking system that is used to monitor response to treatment also can be used to identify patients who are not following up as planned. Patients who do not follow up include the following:

  • Patients who are “no shows” at scheduled appointments;
  • Patients who do not schedule followup appointments; and
  • Patients who do not respond to emails, phone calls, or paper letters after a reasonable period of time.

A patient may not follow up for a variety of reasons, including the following:

  • The patient is not “improving.”
  • The patient feels he or she has “improved.”
  • The patient has encountered setbacks.
  • The patient does not like the provider or the care received.
  • The patient’s contact information is not up to date.
  • The patient is not engaged in his or her own care plan.

Understanding why a patient has not followed up allows for an outreach approach tailored to the specific circumstances.

If assist and support services are available, such as through a care/case management program, assist and support personnel can provide outreach to patients and assess treatment adherence and response.

Specific outreach strategies might include:

  • Onsite clinic/practice assistance;
  • Phone calls;
  • Emails;
  • Patient portal notifications;
  • Postcards; and/or
  • Home visits.

Which outreach method is most appropriate depends on factors specific to your integrated care setting. Any of these methods can be effective if used consistently.

Review your practice’s followup procedures and ensure that there is a systematic followup system in place. Systematic followup may involve a wide range of tools or methods such as appointment reminders, panel reviews using a registry, and many others.

How Others Are Doing It

  • At UPMC Matilda Theiss Health Center, a social worker visited a patient’s home with her diabetes medication after failed contact attempts. The home visit re-engaged the patient, who resumed meeting weekly with her care team. Staff worked with Pittsburgh Regional Health Initiative to create a process of matching patients to care team members using patient outreach and data analysis to prevent missed patient appointments. Read more at http://prhi.org/safety-net-medical-home-initiative-upmc-matilda-theiss.

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What Not to Do

  • Don’t assume that non-adherence is the reason for lack of improvement.
  • Don’t blame the patient for non-adherence.
  • Don’t ignore the patient when developing the maintenance plan. Find out if the plan is feasible for the patient and fits his or her preferences and values, and be aware of potential distractions or roadblocks.

Contribute

The Playbook includes many examples of how sites have implemented specific aspects of integration. If you would like to contribute, please send us your example of how your organization tracks patients and monitors their outcomes.

Send Us Your Example

Resources

Tools: Clinical Outcome Measures

A collection of tools to assess clinical outcomes, such as anxiety, depression, and diabetes.

Source: AHRQ Academy
Stepped Care Model

This resource provides information about the stepped care recovery model.

Source: Cambridge and Peterborough NHS Foundation Trust
Stepped Care for Depression in Primary Care: What Should be Offered and How?

This article provides an overview of a stepped care approach for patients with depression.

Source: The Medical Journal of Australia, Vol. 192, No. 11 (2010)
MI Reminder Card (Am I Doing This Right?)

This reminder card includes 11 questions for providers to consider as they work with patients and encourage behavior change.

Source: Case Western Reserve University – Center for Evidence-Based Practices
Motivational Interviewing: Preparing People to Change Health Behaviors – Tips Sheet

This resource provides tips and strategies for motivational interviewing.

Source: Fort Defiance Indian Hospital Board
Worksheets

Download free worksheets for relapse prevention planning and building discrepancy.

Source: Therapist Aid
Patient Tracking Spreadsheet Example

This patient tracking spreadsheet is an example of how practices can track and monitor patients.

Source: University of Washington – AIMS Center
Exemplars in the Use of Technology for Management of Depression in Primary Care

This article provides an overview of the use of registries for depression care management.

Source: The Wisconsin Medical Journal, Vol. 111, No. 3 (2012)
Minimally Disruptive Medicine: A Pragmatically Comprehensive Model for Delivering Care to Patients with Multiple Chronic Conditions

This article presents the minimally disruptive care model and rationale for applying the approach for the care of patients with chronic conditions.

Source: Healthcare, Vol. 3, No. 1 (2015)
Adverse Drug Reactions: Types and Treatment Options

This article reviews different types of adverse drug reaction, including the evaluation and management of the drug reaction.

Source: American Family Physician, Vol. 68, No. 9 (2003)

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