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Integration of behavioral health outcomes into electric health records to improve patient care
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Integration of behavioral health outcomes into electric health records to improve patient care
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Running Head: BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 1
Integration of Behavioral Health outcomes into Electric Health Records to Improve Patient Care
Golnaz Agahi, LCSW, MPH
University of Southern California
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 2
EXECUTIVE SUMMARY
Mental and substance use disorders are public health burdens, that will surpass all
physical diseases as a major cause of disability worldwide by 2020 (SAMHSAb, 2016). In the
Unites States it is estimated that one in four people are affected by mental health or substance
use disorders. Therefore, prevention and treatment of these disorders are critical (SAMHSAa,
2016).
Behavioral health providers play an important role in reducing these public health
burdens. To improve mental and substance use disorders, it is important that a provider solicit
feedback from every patient to monitor outcomes and thereby improve overall patient well-being
(McHugh & Barlow, 2012). Research has shown providers who obtain formal outcome
measures via patient self-report can significantly improve patient care (Anker & et al, 2009;
Lambert & Shimokawa, 2011; Youn & et al. 2012). To improve the delivery of behavioral health
services, there is a need to integrate Behavioral Health Intervention Technologies (BITs) into
existing behavioral health programs (Mohr et al., 2013). When behavioral health outcome
measures are integrated into electronic health records, it allows for better screening, intervention,
monitoring, documentation, referral and integration of care to improve patient outcomes.
(Harding et al, 2011; Young-Wolff & et. al., 2016). Therefore, the Grand Challenge addressed
via this capstone project is ‘Harness technology for social good’ (American Academy of Social
Work and Social Welfare, 2017).
This capstone project used technology to develop behavioral health outcomes measure
and integrate them into electronic health records (EHR) across all Southern California
Permanente Medical Group (SCPMG) and Kaiser Permanente (KP) behavioral health
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 3
departments. The incorporation of behavioral health outcome measures into EHR, where the
providers can monitor patient symptoms and provide informed care is essential to providing
good patient care and possibly reduce burn out.
The proposed solutions will improve the grand challenge by: 1) providing targeted care via
review of outcome measures with patients at each visit to improve patient reported symptoms, 2)
reducing documentation error through the use of automatically populating EHR treatment plans
that utilize patient self-reported outcomes measures,3) providing a more accurate diagnosis for
patients, 4) providing more client centered treatment and engagement 5) providing professional
development opportunities for providers and 6) provide a large data set over an extended
timeframe to improve quality of care provided in behavioral health system.
The two-evidence based frameworks used to implement and evaluate the effectiveness of this
capstone project were Quality Implementation Framework (QIF) and Reach, Effectiveness,
Adoption, Implementation, and Maintenance (RE-AIM). The four phases of the QIF framework
incorporated in this project included: 1) Host Setting Consideration (needs assessment, possible
adaptation, capacity building), 2) Implementation Structure (team and plan), 3) Support
Strategies (supervision, process evaluation), and 4) Improving Application (Meyers, et al., 2012).
Per Gagilo (2013), “RE-AIM is a planning and evaluation model that can help address the
complex and challenging health care issues we face today,” (p.8). This paper provides a
detailed outline how these two frameworks were utilized together.
A common theme in the literature on sustainable scaling strategies identifies networking,
open access, dissemination and funding/profitability of the capstone as good practice (Lyon and
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 4
Fernandez, 2012; Jenner, 2016). The diffusion aspect of promoting a social innovation is further
elaborated by Bloom and colleagues (2009), which identified seven essential factors for success.
These include: staffing, communicating, alliance-building, lobbying, earnings-generation,
replication, and stimulation of market forces. Both scaling and diffusion are social processes
influenced by the nature of relationships one forms. The interaction of individuals with
organizations are an important factor and an advantage (Davies, A. and Simon, J. 2013). This
project offers such an opportunity to have a rich catalogue of data to support improvement of
care for patients and payer; thereby enhancing value-based care. KP is a stakeholder and part of
the national dialogue with SAMHSA, and other governmental entities, in order to support the
development of similar projects on a national level.
This capstone project can make a public health change through implementation of outcome
measures in large health managed care (HMO) systems. This project can determine how
behavioral health services and providers’ professional development can be improved within
SCPMG Behavioral Health clinics. The hope is that a blue-print can be created from this work
for other HMOs and large government organizations.
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 5
Conceptual Framework
Grand Challenge selected and short description. The Grand Challenge addressed via this
capstone project is ‘Harness technology for social good’. This is defined as strategic use of
technology to develop more effective services and to support the public (American Academy of
Social Work and Social Welfare, 2017). Behavioral Health Intervention Technologies (BITs) is
the use of technology systems to improve patient’s behavioral health care (Mohr et al., 2013). To
improve the delivery of behavioral health services, there is a need to integrate BITs into existing
behavioral health programs. The incorporation of behavioral health outcome measures into
electronic health records (EHR), where the providers can monitor patient symptoms and provide
informed care is essential to providing good patient care and improving the wellbeing of the
patient.
Social norms underlying the Grand Challenge. Providers find documentation to be taxing,
redundant and their least favorite part of the job (Sheehan & Lewicki, 2013). Requiring the
addition of behavioral health outcome measures to the patient documentation process is often
perceived as simply more work. Outcome measures are defined as structured instruments that
can measure patient symptoms. Examples are the Patient Health Questionnaire (PHQ) and
Generalized Anxiety Disorder (GAD), Alcohol Use Disorders Identification Test (AUDIT) and
Columbia Suicide Severity Rating Scale. Consistent with the literature regarding documentation
norms (Sheehan & Lewicki, 2013; Ozair, et al. 2015), providers at Kaiser Permanente (KP)
Behavioral Health Departments have shared how they perceive documentation as a burden and
that they rely on “cut and paste” and other short cuts that can cause additional error in
documentation. They report lack of time as a reason not to administer outcome measures because
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 6
the time in session needs to be strictly therapeutic and not spent reviewing data. Additionally,
providers have reported that collection and review of outcome measures are not relevant to their
work and is time consuming. Consistently, providers shared the above concerns with this writer
regarding the use of outcome measures. The two anonymous quotes here summarize providers’
perceptions regarding the use of outcome measures to assess patient’s care at KP: “I know better
what my patient needs than some dataset,” and “outcome measures do not give us a good
assessment because patients lie on these questions,” (Anonymous, 2017).
Difficulties in the use of outcome measures is further exacerbated by patients who may feel
responding to the outcome measurement is cumbersome. Research on patients who declined to
complete health surveys have identified the following factors: education level, age, counselling
experiences, negative feelings about the therapeutic encounter, and misunderstandings about the
purpose of the data collection, (Williams B, et. al., 2007; Pettersson C et.al., 2009; Barnes M
et.al.;2012). In interviewing KP patients, some have reported the following, “I am here for talk
therapy and these questions are not relevant,” or “I don’t trust where this data goes,” or “my
provider told me I don’t have to do this questionnaire,” (Anonymous, 2017). These norms may
undermine the culture shift to in use of technology to improve patient care.
Literature review. Behavioral health disorders that encompass substance use disorders and/or
mental health disorders are a public health burden (World Health Organization, 2013; Reeves et
al. 2011, Murray & Lopez 2013). Substance Abuse and Mental Health Services Administration
(SAMHSA) defines the two components of behavioral health as follows: mental health disorders
affect the thought process, behavior and/or mood of an individual, while substance use disorders
are the on-going use of alcohol and/or other licit or illicit substances that have clinical
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 7
impairment (SAMHSAa, 2016). The Institute of Medicine (2015a) released a report stating,
“mental health and substance use disorders are a serious problem, affecting approximately 20
percent of Americans” (p.1). It is estimated that one of four people are affected by mental health
or substance use disorders, and they have a significant impact on the health care costs,
accounting for a large proportion of disabilities (25%-27%) in the United States. Disabilities and
mortalities associated with behavioral health disorders include: premature death, 40% to 60%
more than the general population, and health problems such as cancer, diabetes, HIV and suicide
(World Health Organization, 2013; Center for Behavioral Health Statistics and Quality, 2015).
“By 2020, mental and substance use disorders will surpass all physical diseases as a major cause
of disability worldwide.” (SAMHSAb, 2016).
Behavioral health providers play an important role in reducing this public health burden. The
increase in behavioral health disorders has led to shortage of behavioral health providers on a
national level and this shortage is projected to grow over the next decade. According to a recent
analysis by the U.S. Health Resources & Services Administration the nation needs to add 10,000
providers to each of seven separate mental healthcare professions by 2025 to meet the expected
growth in demand (Johnson S, 2016). Therefore, the existing pool of providers often feel
overwhelmed and may not believe they can keep up with the demand to provide comprehensive
patient care.
This challenge to provide comprehensive care is further impacted by providers who need to
use Electronic health records (EHR) for documentation of patient care. EHR documentation
often includes templates and drop-down options with smart-phrases that providers cut and paste
into the templates. As Sheehan and Lewicki (2013) report, though this process may help
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 8
expedite the documentation process, it “undermines the person-centered care ideals” (p. 307).
The literature on EHR indicates that because providers rely on drop down diagnosis options,
treatment goals and assessment plans, the EHR doesn’t include patient specific outcomes and
may significantly reduce patient engagement and it may limit eye contact with patients when
providers are too involved in EHR documentation, instead of listening and engaging patients
(Steinfeld & Keyes, 2011; Sheehan & Lewicki, 2016; Hoagwood, Olin, & Cleek, 2013).
Furthermore, research has noted that other unintentional negative consequences of EHR are the
lack of patient engagement in their individualized treatment plan, and reduced effectiveness of
assessments of patient’s individual symptoms and the follow-up care needed (Mitchell, 2007;
Steinfeld & Keyes, 2011; Sheehan & Lewicki, 2013).
In addition to the problems noted above, patient care in behavioral health services is
further exacerbated by the limited and/or lack of technology use in EHR to standardize use of
outcome measurements as part of routine follow-up utilized to improve care for patients
receiving services for behavioral health disorders (IOMa, 2015; Kennedy Forum, 2015;
Parameswaran et al., 2015). Kennedy Forum (2015) reports, “without the use of symptom
rating scales, behavioral health providers are not detecting many of their patients who are not
responding to treatment, leading to clinical inertia and poor patient outcomes” (p. 13).
One study found that providers detect only 19% of patients whose conditions continue to
be negatively impacted due to their behavioral disorder without the use of validated outcome
measures. (Hatfield et al. 2010). In a study by Bradshaw and colleagues (2014), it was noted that
documentation error and lack of outcome measures in documentation not only impacts service
implementation, but also lead to significant trauma and fatalities among patients. The same
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 9
study found 44% of providers missed the opportunity to report suspected child abuse due lack of
outcome measures (Bradshaw, et al. 2014). A more recent study at the Veterans Affairs, found
that more than 30% of the 9896 male veterans reported positive on their alcohol screening,
however this information was not documented in their medical health record (Lapham, et al.,
2015).
If providers continue to use EHR to “copy and paste” notes versus integrating the use
outcome measures into EHR to assess patient’s mental health status, it will lead to deleterious
circumstances for patients and have significant negative implications for patient care. It can lead
to more missed opportunities to identify high risk behaviors such as partner violence, homicide
or suicide ideations, which can lead to more patients being put on mental health disability, or
even death (Lapham, et al., 2015; Bradshaw, et.al., 2014).
Assessment of practice and innovation in topical area. The purpose of this capstone is to
improve the delivery of behavioral health services via the integration of Behavioral Health
outcomes into EHR to improve patient care. The field of behavioral health outcome
measurements integration into EHR is relatively young in its development and there is a need for
better coordination and standardization in the field to support this work (Torda & Tinoco, 2013;
Mohr et al., 2013).
The use of outcome measures in clinical setting has been established as an evidence-based
framework that is effective and can improve care (Lewis et al. 2015). The outcome measures
can be used in a systematic approach to incorporate in treatment plans and intervention and
identify patients whose reports symptoms are not improving (Lambert et al, 2005, Trivedi and
Daly, 2007). This concept received much needed attention and support in 2010, due to Patient
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 10
Protection and Affordable Care Act (ACA), which required the U.S. Health and Human Services
(HHS) to prioritize treatment components at the payer, provider and patient level via
development of the National Behavioral Health Quality Framework (NBHQF) to improve care
(SAMHSA, 2014). However, the adoption of this technology has been slow and challenged. Per
SAMHSA (2017) due to technology challenges many health IT systems cannot communicate
with each other and have conflicting federal policies such as the manner in which the
Confidentiality of Alcohol and Drug Abuse Patient Records, 42 Code of Federal Regulations
(CFR) 2, informs patient consent, and financial incentives program to motivate behavioral health
provider to use EHR.
Furthermore, technology adaptation to incorporate outcome measures is significantly
influenced by providers’ use perception of outcome measures. In the United States., it is
estimated that routine administration of outcome measures to monitor patient’s treatment
response is conducted by only 18% of psychiatrist and 11% of psychologist (Kennedy Forum,
2015). Brodey and colleagues (2005) study on use of outcome measures by providers showed
that only 47% of the providers felt that the outcomes measures administered by the managed care
organization helped monitor patient’s response to treatment. This study also found that many
who have a negative perception about outcome measures are often concerned with the burden of
additional documentation and felt that the managed care organization was intruding in the
provider’s treatment care (Brodey, et. al, 2005).
Capstone Project Logic Model. The logic model developed for this capstone is outlined in
attachment 1. Below is a brief description of the logic model. The inputs column includes
resources placed into the project such as providers, patients and electronic technology such as
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 11
iPad and electronic health records. The activities column which will further be discussed under
methodology section of this paper includes components such as the development of the outcome
measurement, administration of the outcome measurements via iPad by patients, review of the
outcome measurement report by provider and patient, and training for providers. The outcome
column of the logic model is further discussed under assessment section of this paper. It includes
measures used to identify short and long-term goals for this project such as patient’s reductions
in mental health symptoms and increase use of outcome measures by providers to develop better
treatment plans and improvement in delivery of behavioral health services.
Theoretical structure (i.e.: guiding theories or models for Capstone Project). Factors that
contribute to improving patient care are 86% client/life factors, and the other 14% is treatment
effect (Duncan, 2014). The client/life factor defined by Duncan (2014) include circumstances
that improve patients care regardless of therapy. Examples include crisis which have subsided,
new job, support systems, faith, divorce, etc. Duncan further elaborates that of the 14% treatment
effect, about 21-42% is the feedback provided to patient through outcome measures which can
help modify delivery of treatment to improve patient’s care. Therefore, it is important a provider
solicits feedback from every patient to monitor outcomes to improve overall patient well-being
(McHugh & Barlow, 2012).
Research has shown formal feedback collection improves outcomes, identifies patients at risk
for treatment dropout, and it can improve therapeutic alliances (Anker & et al, 2009; Lambert &
Shimokawa, 2011; Youn & et al. 2012). A meta-analysis on the effects of patient feedback
systems, found that when patients are given feedback, reliable positive patient change is
improved, and patients experiencing deterioration are lessened (Lambert & Shumokawa, 2011).
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 12
Another study by Ressee (2014), found that after implementing feedback informed care, the
outcomes achieved to reduce depression were comparable to randomized clinical trials.
In addition, the Kennedy Forum (2015), an advocacy forum that advances behavioral health
policies and programs that are known to be effective, recommends the following steps on
behavioral health outcomes measures within EHR:
• Use self-reported symptom rating scales that have been validated with
respect to reliability, sensitivity to change, and interpretability;
• Administer symptom rating scales frequently and immediately prior to the
clinical encounter to ensure that the information is clinically actionable; and
• Incorporate symptom rating scale scores into the clinical encounter in a
structured manner to support the treatment-to-target principle (p.25).
This capstone incorporated the guiding theories listed above in the development and
administration of the self-reported outcomes measures questionnaire (attachment 2).
Solution
Description of innovation / Capstone Project. The target population for this project is
Southern California Permanente Medical Group (SCPMG) providers, who work in the
Behavioral Health Departments (Psychiatry and/or Addiction Medicine Departments), from Kern
County to San Diego County. The providers may include psychiatrists, licensed, and non-
licensed therapists (psychologists, marriage family therapists, social workers). In addition to the
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 13
providers, the other group targeted by this capstone include all KP members who receive
individual sessions with a KP Behavioral health provider.
Upon a patient’s arrival for her/his individual appointment at KP behavioral health
department, a clerical staff provides the patient with an iPad to complete a behavioral health
outcome questionnaire. The questionnaire includes outcome measure tools that have been
evaluated in the behavioral health field for validity and reliability, such as GAD, PHQ, AUDIT
and, Columbia Suicide Rating Scale. A report is generated that provides the scores for these
outcome measures reported by patient (attachment 3). This report is integrated into KP EHR
within seconds of patient completion of the questionnaire on the iPad. Thereby allowing the
provider to offer informed treatment care to patients by discussing the report with the patient and
allow the development of a mutual treatment plan based on the report. In addition, the provider
has better tools to generate an informed mental health diagnosis and personalize patient’s EHR
documentation via incorporation of the self-reported outcome measures into patient’s chart.
Direct description and explanation of proposed solution. As noted earlier the goal of this
capstone project was to improve the delivery of behavioral health services, via the development
and integration of BITs into existing behavioral health programs. The incorporation of
behavioral health outcome measures into EHR, where the providers can monitor patient
symptoms and provide informed care is essential to providing good patient care and possibly
reduce burn out. A national survey of providers on the use of EHR to provide better care found
88% reported EHR produces clinical benefits for the practice and 75% indicated that EHR helps
them deliver better patient care (Jamoom, 2012). Further details on the proposed solution will be
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 14
described under the methodology section, with attachment four providing a time-line activity
table for the proposed solution.
Clear connection to how this project will contribute to improvements in one or more of the
Grand Challenge of Social Work Areas. When BITs are integrated into EHR, it allows for
better screening, intervention, monitoring, documentation, referral and integration of care to
improve patient care (Harding et al, 2011; Young-Wolff & et. al., 2016). Also, the large data set
collected within EHR, allows improvement of intervention qualities and professional
development (Harding et al., 2011; Mohr et al. 2013; Torda et al, 2013). Hence, the proposed
solutions will improve the grand challenge by: 1) providing targeted care to patient via review of
outcome measures with patients at each visit to improve their reporting of symptoms, 2) reducing
treatment error by automatically populating the EHR treatment plan with patient self-reported
outcomes 3) assisting in providing more accurate diagnosis for patients, 4) providing a more
client centered treatment 5) allowing for additional professional development opportunities for
providers, and 6) providing a large data set over an extended timeframe to improve behavioral
health care quality.
Multi-disciplinary stakeholder perspectives. One of the major driving forces which led
KP to make BITs a business priority is the National Committee for Quality Assurance (NCQA).
The NCQA’s primary goal is to improve health care quality (NCQA, 2017). As noted on the
NCQA website (2017), “Since its founding in 1990, NCQA has been … helping to elevate the
issue of health care quality to the top of the national agenda,” (para 1). This partnership, though
it doesn’t result in direct revenue to KP, can indirectly increase or decrease membership revenue
for KP as large purchasers often review NCQA ratings prior to purchasing group health
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 15
coverage. Another major stakeholder is Medicare, which is a large purchaser of Kaiser services.
Medicare is an insurance program for individuals older than 65, and those younger than 65 with
certain disabilities. Medicare is offered by the federal government (Medicare, 2017). There are
also other large purchaser groups who are considered external stakeholders who want to know
what is being purchased and what types of care the service deliveries include.
A strong internal stakeholder advocate is the SCPMG leadership, who is committed to
continued use of BITs to improve patient care. In an interview with Scott Sangsland, a member
of the SCPMG Behavioral Health Leadership team, he stated the following about this project, “it
is a business imperative, it is a key part of clinical operation and we will continue to train staff on
informed feedback care. There is an expectation that clinical progress is incorporated in all notes
for physicians and therapists” (personal communication, February 14, 2017). In addition to
SCPMG leadership, other internal stakeholders are the providers who work at each of the
SCPMG behavioral health offices.
A sub-group of providers, who are part of the National Union of Health Care Workers
(NUHW) labor group, initially opposed this project. They found the proposal cumbersome, felt
it was not relevant to their work, and time consuming to engage patient to review their outcome
measures. In one SCPMG service area, the provider’s union filed a grievance, (which was later
dropped) indicating it was a change in working condition requiring providers to review outcome
measures. The union representing the SCPMG therapists was also concerned that if a patient
doesn’t show improvement, it can be used against the provider in their annual performance
review. In response to the union concerns, the union stewards across SCPMG attended several
meetings during the implementation phase of this project. During these meetings the union and
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 16
management reviewed the process together, providing the ability to roll out of this project as a
collaboration.
Other strategic partners include Tridium, that has developed the software to gather the patient
self-reported data and generates the actual report (attachment 3) that is integrated into KP EHR.
The other partner is EPIC software, which operates KP’s EHR. These two strategic partners are
paid by KP to maintain the existing system and support the incorporation of BITs into EHR.
Comparative Market Analysis of the solution/innovation. There is a national movement to
incorporate outcome measures into EHR to improve patient care. (Torda et al., 2013; Mohr et al.,
2013, SAMHSA 2016c), Unfortunately, the adoption of this technology has been slow and
challenged due to lack of standard workflow and documentation within organizations; especially
those with advance functions designed to integrate data, cost, implementation and account for
federal policies (Kruse et al., 2016, Tordo et al., 2013, SAMHSA, 2017). In a recent report to
Congress from the Office of the National Coordinator for Health Information Technology
(2016), it was noted that 78% of ambulatory providers have reported the use of EHR. The report
however doesn’t indicate how many providers use quality measurements to improve patient’s
care due to limitations noted earlier. Per an interview with Scott Sangland (2017), he indicated
that the KP business office has conducted a market assessment of the BITs project and has
determined the project is feasible and within KP’s budget to implement and sustain.
Opportunities for innovation. As noted above there are opportunities to expand in this field
and develop a blueprint for other larger health care organization to consider. This is discussed
further in the next sections of the paper.
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 17
Theory of change. To change providers’ perceptions around collection and documentation
of patient outcome measures to improve patient care, it required various levels of disrupting the
norm. Both patients and providers must move through the stages of changes from
precontemplation, contemplation, preparation, activity and maintenance on a macro level, which
begins with communication and engagement with the stakeholder (Archer, et al. 2018). In this
project, the process included the marketing of the project by SCPMG leadership to all providers
via email communication, trainings and meetings. The positive implication of implementing this
project within KP was the marketing focus with providers . On a micro level, increase of patient
engagement and feedback to improve session quality was promoted. While on a macro level,
creation of actionable measures to improve programs and services for patients was promoted to
the directors/managers and supervisors. Furthermore, as discussed previously on a macro level
the use of BITs can lead to increased provider transparency and accountability to the payer,
resulting in improved payer reimbursement (Kennedy Forum, 2015). This in turn was motivation
for change on a leadership level.
Herzberg’s (1987) model for motivating employees was used to move stakeholders through
the stages of change via the following steps: 1) making providers accountable for gathering the
outcome measures from each patient, 2) ensuring each provider review the BITs data with the
patient during each session, 3) making BITs available to providers for review with patients in
real time via EPIC EHR, 4) support providers by incorporating additional outcome measures and
providing feedback on the data, and 5) identifying champions in each SCPMG BH service area
who can be trained to develop expertise in BITs and can support this work locally.
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 18
Also, as recommend by in the article by Buckingham (2005), this writer will continue to
evaluate the progress of the providers to: 1) identify provider’s strengths in relation to BITs and
ask them to provide in-service for team members 2) ensure providers use of BITs to
communicate and improve patient’s care with other providers, and 3) continue to identify and
recognize champion providers who integrate BITs in their documentation, diagnosis and in
sessions with patient.
Another level of motivation to move providers through the stages of change included
financial incentives consistent with research which has shown to be an effective approach to
changing employee behavior (Gupta & Shaw, 2014). Here, KP leadership negotiated with
providers a monitory incentive comprised of an annual bonus given to providers in KP clinics
who meet the minimum goal of collecting 70% of outcome measures for their patients. Other
strategies used to change target group level of change are discussed in detail under the
methodology section below.
Methodology
Methods of project implementation. Research has shown that quality implementation is
critical to improved outcomes (Casillas et al. 2016; Durlak 2013; Durlak, Weissberg, et al. 2011;
Aarons et al. 2009). A recent systematic review of 25 implementation frameworks by Meyers
and colleagues (2012) recommended a Quality Implementation Framework (QIF) that includes
four phases: 1) Host Setting Consideration (needs assessment, possible adaptation, capacity
building), 2) Implementation Structure (team and plan), 3) Support Strategies (supervision,
process evaluation), and 4) Improving Application. The authors further note these phases are not
linear in nature but overlap and may be cyclical. Further, the steps provided in this framework
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 19
can be used as guide for future practice and research in the field of implementation (Meyers et
al., 2012). In planning this capstone project, a systematic method to outline the implementation
phases as noted above was used, however there were opportunities for using alternative steps to
further improve the capstone project. In collaboration with the implementation team, this writer
continues to adjust the present project as described below.
Phase One-Host Setting: (3/2017-6/2017): The first phase of the capstone was the planning
and testing phase. Collaboration is noted as essential to the sustainability and fidelity of a
program (Durlak & Dupree, 2008), hence during this phase, it was essential to identify the
stakeholders and partners in implementation of the program. The initial partners included:
Triduum, a Kaiser Permanente (KP) contractor that assists in gathering outcome health measures
for KP Behavioral Health Department, EPIC software, which operates KP’s electronic health
record (EHR) and KP Behavioral Health (BH) Leadership. These initial groups met extensively
to determine where, within KP EHR, the behavioral health outcome measures could be captured.
As the Regional Lead (RL) for the capstone project, this writer developed PowerPoints and
training materials for providers across KP Behavioral Health (BH) to explain the following: the
reason for the capstone project, how collecting BH outcome measures help to improve patient
care, and outline the benefit of the project to patients, providers and to the organization. The RL
provided technical assistance via on-line and in-person training to prepare KP BH to go live with
this capstone project. Initially the training was conducted for all the managers and directors who
assisted in disseminating the program information to each clinic and its’ therapists. Both
strategies noted above (training and technical support), included examples of empirical evidence
demonstrating how management is critical to the steps for a successful implementation
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 20
(Wandersman et al. 2012). In addition, all KP BH providers received a one-day training to better
understand how BH outcome measures can support their clinical work and thus improve
informed care to patients. The trainings addressed how providers can use the data to engage
patients in their therapeutic treatment, and addressed the clinically appropriate way to terminate
care.
Phase Two-Implementation Structure: (7/2017-12/2017): This phase included identification
of an implementation team. The team consisted of at least one champion per clinic, who was a
voluntary provider (therapists and/or physicians). This was modeled after the train-the-trainer
strategy. This model has shown to be effective in public health and mental health services, where
one central trainer trains other individuals in the field to provide an intervention to a targeted
group (Madah-Amiri et al, 2016, Yarber et al., 2015; Williams et al., 2014; Limm et al., 2015).
These champions were trained by RL regarding informed care and use of BH outcome measures
to improve patient care. The champions worked closely with the RL to roll out the program
during the implementation phase and gathered feedback at each specific site.
In addition, the team developed and distributed flyer to patients titled, “Emotional Vital
Signs.” The one-page flyer educates patients on the importance of outcome measures to support
their care. The ultimate purpose of the flyer is help reduce patient reluctance by offering
information and a point of discussion for them to share with their providers at every visit. This
practice is aligned with a systematic review of similar interventions that offered information to
patients and found there was a small but significant reduction in risk behavior (Sheridan, et al.,
2010).
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 21
Another tool utilized by KP to help providers engage patients in their treatment through use
of outcome measures, was a one-day mandatory training for all providers which reviewed
informed care and reiterated how the outcome report can be used to improve patient’s care.
Phase Three- Monitoring Phase (9/2017-present): Programs implemented must be monitored
and adjusted to provide high quality implementation (Durlak, 2013). A good monitoring system
is essential because it can help identify problems during the process to address and improve the
implementation process (Durlak 2013, DuFrene et al., 2005; Greenwood et al.,2003). The RL
continues to work with IT and Triduum to generate monthly and quarterly reports on the BH
outcomes measures collected by each clinic.
In the most recent report generated by KP information technology department for this
project, the data collected showed that patients had BH outcome measures that improved
significantly. Since the implementation of the Capstone project, the rate of collection was
between 10% and 20%. Presently the collection rate ranges between 69%-90% across all the
clinics in KP BH. The increase in data collection is most likely due to multiple strategies used in
implementing this capstone project. Not only are clerical staff distributing the iPad more
frequently, but there has been a change in the patient culture where patients now expect their
providers to review their outcome measures with them. The data collection rate is now shared
quarterly with all the providers to review the prevalence of BH outcomes measures collected by
each clinic.
The RL will also conduct random chart audits in Orange County BH clinics to determine if
the use of outcome measures provide more consistency with the documentation of treatment
goals and DSM 5 diagnosis of patients. The RL and the champions will continue to round with
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 22
providers to determine how the project can be improved to meet the needs of the providers and
the patients.
In addition, patients and providers will be solicited to provide feedback on their experience
with their providers’ use of outcome measures by asking both groups, “was the BH outcomes
measure reviewed during session?” The solicitation will be gathered by each clinic manager via
a purposive sample of patients who have completed BH outcome measure questionnaires on an
iPad, and met with their provider in the past 30 days. The data collection and the feedback from
patients and providers will be shared with the union and the champions on a quarterly basis,
along with the opportunity to propose improvements to the project.
One lesson already learned in this phase is that not all providers or clerical staff review their
emails thoroughly, nor do the quarterly communication with champions always trickle down to
front line staff on a consistent basis. Therefore, an adjustment was made to communication so
that all managers have a standing agenda item during their weekly or bimonthly team meeting to
briefly review the data and gather information from all stakeholders about the implementation
process. This is a new change that must be further evaluated to determine its effectiveness.
Phase Four- Improving Application: One impediment to full implementation was a lower
than expected number of iPad questionnaires filled out. Based on personal observation and
interviews conducted with the clerical team early in the implementation phase, the RL was able
to identify one of the barriers to the collection of data was that the clerical staff was not
distributing the iPads to patients on a consistent basis. The reasons given by the clerical staff
included: they forgot, didn’t understand the reason patients must take it at every visit, they were
distracted with other duties while checking in patients, and patients declined. In reflecting on this
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 23
phase, it was determined that the clerical team responsible for distributing the Questionnaire
iPads did not receive sufficient training.
Presently the RL is working on this portion of the implementation phase. Based on some
initial feedback from both patients and providers regarding the questionnaire, a team of providers
and researchers are being recruited to review the tools. The RL has also asked to schedule a
meeting by end of December 2018 with Triduum, KP research department and KP BH leadership
to review the implementation process and identify the lessons learned from this first year of the
implementation process.
Financial plans, including line item project budget and three-year projection. The
funding for the first year was approved via the reserved funds at SCPMG regional finance
department. The largest expense for the first year was hiring the consultants (Triduum and Epic)
to help create the integration system.
At this time, SCPMG leadership is committed to the on-going funding of this project
beyond the first-year pilot. This includes the on-going funding of the following components of
the project 1) update iPads to collect data, 2) upgrade EHR system as needed it to integrate
outcome measures, and 3) review and update the questionnaire as better outcome measures are
identified. On a macro level, the availability of BITs to insurance purchasers may generate more
revenue by attracting those customers who want to know up front what type of quantifiable
results they are purchasing for their constituents. On a micro level, revenue will be generated by
reducing diagnostic errors using BITs.
Detailed methods of assessment. The framework model used to measure effectiveness of this
project is Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM). Per
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 24
Gagilo (2013), “RE-AIM is a planning and evaluation model that can help address the complex
and challenging health care issues we face today,” (p.8).
In this project the five domains are listed below, each outlining briefly how its domain will
be used to evaluate the various components of this project. The Reach domain is to have 70% of
patients complete the questions and all providers to incorporate the information into EHR
treatment notes. The effective domain will be measured by the reduction in reported symptoms
by patients during consecutive visits. The adoption domain will be the number of staff training
and delivery of information on a quarterly basis to providers through all SCPMG KP BH
settings. The Implementation domain are all the interventions components to support fidelity of
the project. This is outlined below noting both qualitative, quantitative and process measures to
support a sustainable implementation of this project. Maintenance domain is also essential to
measure post implementation the effectiveness of the project. This will also be incorporated in
the evaluation by having on-going report on collection of the outcome measures by patients and
focus groups one year after implementation (details outlined below).
To measure fidelity of this capstone project, quantitative measures collected will include: 1)
incorporation of patient completed outcome measures within provider’s EHR treatment notes; 2)
diagnosis given to patients based on available outcome measures; 3) assess provider’s progress
over time with patients using the outcome measures; 4) number of high Behavioral Health Index
(BHI) patients. BHI is cumulative score from all the questions answered by patient and provides
a prediction if patient is high risk for possible suicide, homicide, neglect and possible
decompensation. If a patient has a score of 70% or more on the BHI, it indicates that patient is
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 25
considered high risk with severe mental health and/or substance use disorders that are impacting
their social functioning. This score can be monitored over time to identify if patient is improving.
The above measurements will be evaluated as follows: a random 100 EHR charts will be
selected from each of the SCPMG KP BH clinics. This will provide over 10,000-data sets for
review and analysis to measure the percentage of outcome measure data that has been
incorporated into provider’s EHR notes. Also, the charts will be reviewed to determine whether
a provider’s diagnosis is aligned with patient reporting symptoms on PHQ and GAD and other
outcome measures incorporated in the questionnaire. The parameter to measure the provider’s
progress will be determined based on patients who completed at least 4 individual visits over a
one-year period with a single provider where outcome measures were collected and incorporated
into the EHR documentation. The BHI data on patients can help us review if there are certain
clinics that have higher rates of BHI patients over time and determine if specific interventions
are needs to better train providers.
To measure the implementation process within the first year, the following process
measurements will be monitored: 1) number of Informed Care/Use of Outcome Measure
trainings offered to SCPMG providers; 2) number of quarterly meetings with union and
champions to support the planning and implementation phase of the program
As for qualitative measurement, a focus group will be conducted with randomly selected
clinicians and managers from various sites one year after the implementation phase. The focus
group will assist with identifying initial barriers, how the use of outcome measures has changed
their clinical work/administrative decisions, and how the use of outcomes measures can be
sustained. As outlined in Lewis et al. study (2015), this writer will model the focus group “to
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 26
evaluate norms and attitudes, structure and process, policies and incentives, resources, networks
and linkages, and media and change agents,” (p.10).
This writer will also schedule a meeting with the KP Research Department in Winter of 2018
to determine the best statistical analysis used to measure the variables outlined above in both the
qualitative and quantitative section.
Communication products and marketing possibilities. The communication product was
addressed in earlier section under Methodology and the marketing possibilities will be further
discussed in detail in the Conclusion.
Possible ethical concerns and how to address them. While there is a legal and ethical
obligation for providers to document a patient visit, the extent of information included in the
documentation varies by provider. Providers who already feel time constrained for
documentation are prone to finding that incorporating patient outcome measures into their
documentation notes is not necessary and may lead to the practice of chart “cut and paste” that
can increase the liability for the provider and the organization (Sheehan, et al., 2016; Gelzer, et
al., 2009; Ozair, et al., 2015). Therefore, smart templates will be created for providers within the
KP HER system, which will directly draw the results of the outcome measures into the
documentation to deter providers from the “cut and paste” approach and avoid documentation
error. Another ethical concern is when patient’s data is shared without their knowledge.(Ozair, et
al., 2015). To protect the privacy of patient’s outcome health measures and provider’s
documentation, the behavioral health data of patients within KP EHR is encrypted and only
authorized providers who work within Behavioral Health will have access to a patient’s
information collected via this capstone project.
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 27
Implication to Practice
Potential impact to progress in the identified Grand Challenge(s) of Social Work. As noted
earlier, there is more receptiveness on a national level for most providers to use EHR to improve
care (Jamoom, 2012). This fact supports the progress of this capstone. SAMHSA (2014) has
indicated on its’ National Behavioral Health Quality Framework (NBHQF) website that, over
time, the goal is to have a large data set of behavioral health outcomes and measures that can
endorse appropriate level of care and by the payer. Due to the national level of interest, progress
is being made in the behavioral health field to establish outcome behavioral health measures to
improve patient care via use of EHR. This capstone project can make a major change through the
implementation of outcome measures in large health managed care (HMO) systems. The hope is
that a blue-print can be created from this work for other HMOs and large government
organizations.
Significance to the field of Social Work and beyond. Presently the integration of BITS is in
“varying stages of evaluation and maturity, requiring research that ranges from basic
development and evaluation to implementation studies,” (Mohr et al., p.337). This project offers
such opportunity to have a rich catalogue of data to support improvement of care for patients and
payer; thereby enhancing value-based care. As more health care organizations consider their
options to improve patient care through the development of behavioral health outcome measures,
the promotion of this capstone for consideration becomes more essential. KP is a stakeholder and
part of the national dialogue with SAMHSA, and other governmental entities, to influence and
improve future iterations of the NBHQF. Therefore, this project can be discussed and reviewed
and presented by KP National representatives, who have on-going dialogue with various national
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 28
governmental entities. In addition, BITs can contribute to the larger data set collected on patients
to improve the overall well-being of the nation.
Influence or meaning to relevant practitioners, stakeholders, and populations. To
accomplish this Grand Challenge (GC), this writer must draw on her leadership skills to
strategically engage internal and external stakeholders. There is a need to motivate and inspire
the team to see the importance of this work and how it can improve patient care and the
relationship between provider and patient. The strategies were discussed in prior sections of this
paper noting education, training, and solicitation of feedback from providers and patients as a
few examples to engage stakeholders. The positive implication of this project within a managed
health care organization is twofold: on a micro level it can improve patient engagement and
feedback, thus improving session quality and leading to more effective treatment. On a macro
level, the program will create actionable measures to improve programs and services for patients
and will also lead to increased provider transparency and accountability to the payer, resulting in
improved payer reimbursement (Kennedy Forum, 2015). Other strategies with stakeholders will
be discussed in the next section to support the sustainability and diffusion of this project through
KP and other similar organizations.
Limitations and challenges of the project and how to address them. In addition to
challenges and solutions discussed in prior sections, there are additional constraints related to
existing norms which continue to support the problem. Informal limits cited in literature around
use of EHR and documentation include: the amount of time allocated for documentation and
patient interaction, implementation time of a new initiative, and computer challenges due to
provider errors (Cellucci L., et. al.,2015). These issues are also common at KP. One of the most
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 29
common formal limits is a patient’s late arrival to his/her appointment. This may lead to provider
running late for to his/her next patient, and often results in elimination of time devoted to
outcome measures. Another formal limit is the time allocated for each patient to be seen by a
provider. This can vary from 30 minutes to 50 minutes and providers may feel the focus of their
session should not be patient outcome measures but what is on patient’s mind. Both issues are
being addressed through a cultural shift in how outcome measures are viewed at KP, where
review of the outcome measures is seen as part of the therapy session.
On a national level, there are concerns that the dismantling of Affordable Care Act under the
Trump administration will have significant impact on health care delivery and services available
to patients. However, in an interview with Modern Health Magazine, Bernard Tyson, KP CEO
emphasized KP’s commitment to patient care.
He stated, “as people become more informed about expectations of the care delivery system,
they are asking very different questions...I think that will continue under the next
administration,” (Livingston, 2017). Per the articles, many health analysts agree with Mr.
Tyson’s statement.
Conclusion
Concrete plans for advancing next steps of capstone project. With the successful launch of
this capstone project within KP SCPMG, the goal has shifted to emulating this project in other
KP systems outside of Southern California, and even to other behavioral health organizations.
The literature on scaling and diffusion of social innovation has grown exponentially in the past
decade and there is a wide range of blogs, articles, and research articles addressing this topic
(Davis, 2010; Major, 2011, Koh, Karamchandani & Katz, 2012; Kochi, 2013).
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 30
A common theme in the literature on sustainable scaling strategies identifies networking,
open access, dissemination and funding/profitability of the capstone as good practice (Lyon and
Fernandez, 2012; Jenner, 2016). The diffusion aspect of promoting a social innovation is further
elaborated by Bloom and colleagues (2009) who identified seven essential factors to success;
these include staffing, communicating, alliance-building, lobbying, earnings-generation,
replication, and stimulation of market forces. Both scaling and diffusion are social processes that
are influenced by the nature of relationships one forms. The interaction of individuals with
organization are an important factor and an advantage (Davies, A. and Simon, J. 2013).
As recommended in the literature noted above, networking, communication and
dissemination through presentations at national and international conferences as a platform will
promote this capstone for diffusion. Open access to the materials is another important factor in
supporting replication of any social innovation. Hence, the educational materials, PowerPoints,
and scientific papers developed as part of this social innovation will be free to the community via
the KP website.
There is also opportunity beyond KP to emulate the project as outlined in this paper. As
noted earlier, since there is interest in the field, and a national commitment to establish outcome
behavioral health measures to improve patient care, the goal is for a blue-print to be created from
this work for other large behavioral health care and government organizations. This is a realistic
possibility since presently there is a commitment from SAMHSA and other federal agencies in
addition to HHS and private behavioral health organizations (such as Kaiser Permanente) to
measuring and implementing quality behavioral health care outcome measures. Therefore, as
SAMHSA has outlined on its National Behavioral Health Quality Framework (NBHQF) website,
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 31
“it is expected that SAMHSA and stakeholders will work together to incorporate these
improvements in subsequent iterations of the NBHQF,” (para 9). Since KP is a national partner
in this process, KP leadership will contribute to the subsequent modifications as outlined by
NBHQF to make a system change in how we provide behavioral health services.
Discussion of future decision and actions instigated by capstone project. D'Amore and
colleagues (2018) summarize the next steps best by stating, “improving clinical data will not
only improve clinical quality measurement but will also improve care transitions” (p. 8). Hence
the next phase of the capstone project is the review of the outcome measurement used during the
pilot phase and determine if any of the outcomes measures need to be amended to improve not
only documentation but quality of care. Also, in the coming year, the goal is to review the
aggregated data collected by this project and determine how behavioral health services and
providers professional development can be improved within SCPMG Behavioral Health clinics.
Also, as noted earlier, since there is interest in the field to establish outcome behavioral
health measures to improve patient care, the hope is that a blue-print can be created from this
work for other large health care organizations and large government organizations.
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 32
Attachment 1: Logic Model (uploaded as a separate document)
Attachment 2: Intake Questionnaire (uploaded as a separate document)
Attachment 3: Sample Report Generated in the EHR
-Intake:
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 33
-Monitor (follow-up) Report:
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 34
Attachment 4: Capstone Project Time Line
Activity Stakeholders Timeline
Work with EPIC to incorporate BITs into EHR
• Monthly meeting
• Use training field to test input of BITs into
HER
• Develop a roll out training for providers
• Develop smart templates to incorporate BITs
into provider’s note
SCPMG
Leadership, IT,
EPIC Vendor
September 2016-
March 2017
Work with SCPMG local service area leadership
• Obtain buy in from local leadership to roll out
BITs
• Reach out to each individual director and
discuss the project
• Provide a presentation at the regional Director’s
meeting
• Have directors identify champions at each
service area
Local SCPMG
Directors for BH
September 2016-
May 2017
Work with providers in OC
• Present the BITs GC to OC BH department
• Identify 2-3 champions per service area who
will assist in rolling BITs in OC
• Train of Champions in Informed Care and
Outcome
OC Providers May 2017
Measurements
• Quarterly meetings with SCPMG champions
• Quarterly meetings with SCPMG union
stewards
SCPMG providers
On-going
Go Live with BITs in HC in all BH clinics in KP
SCPMG
• Data Collection begins
All SCPMG
Provider
July-Sept 2017
Training of all providers (therapist and MD)
• One day training for all users to better
understand how the data can help improve care.
All SCPMG
Provider
August-October
2017
Monitor the use of BITs in documentation and
diagnosis in EHR
• Request IT to run report
• Random audits of charts
SCPMG
Champions, IT
April 2017-
December 2017
Unit of Service to be analyzed:
• Unit of Service:
SCPMG
Leadership,
Research Dept, IT,
January 2018-
April 2018
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 35
o Number of BITs trainings offered to
SCPMG providers
o Number of quarterly meetings with
union and champions to support the
planning and implementation phase of
the program
o Number of collected BITs by each clinic
post implementation
o Number of surveys (a minimum of 50)
collected on patient’s experience with
program
o Number of high Behavioral Health
Index (BHI) patients
▪ BHI is one of the indicators that
is presently collected on each
member via the BITs. A score of
70% or more on the BHI
indicates that patient is
considered high risk with severe
mental health and/or substance
use disorders.
• Assess provider’s progress over time with
patients using the BITs measures
o The parameter to measure progress will
be determined based on patients who
completed at least 4 individual visits
over a one-year period with a provider,
where BITs were collected and
incorporated into the EHR
documentation.
• Compare BITs measures across all SCPMG
Orange County BH clinics over a two-year
period to better identify high risk clinic for
future evidence-based program interventions.
SCPMG Local
Directors, SCPMG
providers
Write up findings, recommendations
• Communicate with various service areas within
SCPMG
• Present to Orange County Providers
SCPMG
Leadership,
SCPMG Local
Directors, SCPMG
providers, SCPMG
Champions
May 2018-
August 2018
BEHAVIORAL HEALTH OUTCOMES TO IMPROVE PATIENT CARE 36
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Abstract (if available)
Abstract
This study describes the use of innovative technology to develop behavioral health outcome measures and integrate them into electronic health records (EHR) across a large healthcare organization (HMO) Behavioral Health departments in Southern California. An evidence-based implementation model, the Quality Implementation Framework consisting of four phases (i.e., the host setting consideration, implementation structure, support strategies and improving application) are used along with the Reach, Effectiveness, Adoption, Implementation, and Maintenance approach as a means of implementation of the innovation. The study demonstrates how a behavioral health organization can promote capacity to implement a new innovation while accelerating impact in the provision of behavioral health services. As more health care organizations consider their options in improving patient care through the development of technological behavioral health outcome measures, the promotion of this project can serve as a blue-print for other large health and human service organizations to accelerate impact in client/patient outcomes while harnessing the power of innovation.
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Asset Metadata
Creator
Agahi, Golnaz
(author)
Core Title
Integration of behavioral health outcomes into electric health records to improve patient care
School
Suzanne Dworak-Peck School of Social Work
Degree
Doctor of Social Work
Degree Program
Social Work
Publication Date
02/27/2019
Defense Date
08/01/2019
Publisher
University of Southern California
(original),
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Tag
behavioral health,electronic health record,feedback informed care,OAI-PMH Harvest,outcome measures,program implementation models
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(imt)
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English
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Enrile, Annalisa (
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fishiez@hotmail.com,golnaz@socialwiseconsulting.com
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Tags
behavioral health
electronic health record
feedback informed care
outcome measures
program implementation models