Outcomes Measurement in the Human Services

by Tom Pyle

Magnabosco, J.L. and R.W. Manderscheid, (eds.), Outcomes measurement in the human services (2nd edition): Cross-cutting issues and methods in the era of health reform . 2011, Washington, DC: National Association of Social Workers.

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As the family member navigating the maelstrom of a loved one’s serious mental illness, I have become highly attuned to the deficiencies of the public mental health system. As an older executive from banking, business, and nonprofit management now back in graduate school studying the business, management, and economics of mental health services delivery, I am searching for answers to the groaning social question of our time: how can we improve mental health services delivery?

I have learned of the great strides in elevating some mental health service modalities (e.g., Assertive Community Treatment (ACT), Supported Employment, Integrated Dual Disorder Treatment) to “evidence-based” status [1]. Achievement in mental health services is increasingly measured. In the ACT modality alone, there are 24 specific measures in the SAMHSA-sanctioned evidenced-based fidelity scale [2]. As even the public sector is coming to understand, what is measured can be managed–and improved.

But I have also learned of the blizzard out there of different and often disparate measurement approaches, systems, methods, and means. So many measures! (And, dare I add, so little professional consensus about even their terms and definitions!) To what end? As a graduate student I am heartened that the science of mental health services has become more technically robust. As a taxpayer and family member at this precarious moment in economic history, however, I am anxiously wondering how we can get better “value” from our mental health care system. What is the true cost of a particular outcome over a correct care continuum period, and is that outcome worth that cost, especially from the consumer’s point of view?

Value is something more than outcomes. Value ascribes a worth to outcomes. A ratio, value includes outcomes as its numerator [3]. But it also includes a cost-accounting calculation (called Time Driven Activity Based Costing, or TDABC) as its denominator [4]. This concept of value is being increasingly examined in the broader health care sector. Major strategic thinkers like Michael Porter of Harvard Business School are proposing the value concept as the rational, workable, and inclusive means by which to achieve the ultimate objective for health care reform: better total care for patients over a continuum of care [5].

In my search for the value concept dialogue in mental health, I came across a collection of essays under the promising title, Outcomes Measurement in the Human Services: Cross-Cutting Issues and Methods in the Era of Health Reform (“Outcomes”) [6]. Edited by Jennifer Magnabosco and Ronald Manderscheid, two giants in the human services field, Outcomes first catalogues “overarching issues and methods”. Outcomes treks across the Government Performance and Results Act, the Performance Assessment Rating Tool, OMB performance data reporting, foundation reporting requirements, community-level indicators, and evidence-based practices. Outcomes then drills down into particular outcomes measures in subfields like mental health and children and family services. We read of qualitative measures which resist standardization (“…and the myth that everything that matters can be quantified and scaled”.) We even learn of difficulties with quantitative measures which abide standardization (“…particular perspectives usually promote their own [quantitative] measures and too often ignore others.”). Outcomes then describes the organizational and leadership challenge (“a wicked problem”) posed by the implementation of outcomes measurement at even this late date.

In its section on mental and behavioral health outcome measurement, two particular chapters stand out. Psychologist Timothy Kelly helpfully explains the differing views of providers, insurers, consumers, and governments regarding EBPs and outcomes measurement [7]. Kelly concludes with a bold call for America to “do what it takes” to engage outcomes measurement. James Siemianowski and Thomas Kirk usefully detail Connecticut’s reasonably successful experience in integrating performance measurement [8]. By and large, however, the contributors to the mental health chapter stayed within the academic confines of outcomes, avoiding the question of value. Otherwise, only one contributor, Rebecca Kilburn in her “Costs and Outcomes Analysis of Child Well-Being” chapter, gets close to the value concept when she burrows into cost matters [9]. But, cost-minimization and value-maximization are different and often antithetical.

In their conclusion, editors Magnabosco and Manderscheid most correctly state: “National health reform cannot succeed without using outcomes and performance measures…” And yet, as they also depressingly admit, “To date, no strong, overarching, integrated approach to outcomes has been established within health services.” Perhaps the fog of such elementary deficiency obscures the wider view. There is clearly a need, as the editors recommend, for “a multidisciplinary consortium of stakeholders to develop a common human services outcomes measurement culture.” For that recommended measurement culture to be complete, however, such a commission–indeed all human services leaders–must also include among their measuring tools the concept of value.

References

1. Drake, R.E., M.R. Merrens, and D.W. Lynde, Evidence-based mental health practice. 2005, New York: W. W. Norton & Co.

2. SAMHSA, Assertive community treatment: An evidence-based practice, 2008, Substance Abuse and Mental Health Services Administration: Washington, DC.

3. Kaplan, R.S. and M.E. Porter, How to solve the cost crisis in health care. Harvard Business Review, 2011. 89(9): p. 46-64.

4. Kaplan, R.S. and S. Anderson, Time-driven activity based costing [Working Paper], 2004, Harvard Business School: Boston, MA. p. 1-20.

5. Porter, M.E., What is value in health care? New England Journal of Medicine, 2010. 363(26): p. 2477-2481.

6. Magnabosco, J.L. and R.W. Manderscheid, (eds.), Outcomes measurement in the human services (2nd edition). 2011, Washington, DC: National Association of Social Workers. 406.

7. Kelly, T.A., New directions for outcome-oriented mental health system transformation, in Outcomes measurement in the human services (2nd edition), J.L. Magnabosco and R.W. Manderscheid, Editors. 2011, National Association of Social Workers: Washington, DC. p. 191-205.

8. Siemianowski, J. and T.A. Kirk, Toward integrated outcome measurement for mental health and substance use services and systems, in Outcome measurement in the human services (2nd edition), J.L. Magnabosco and R.W. Manderscheid, Editors. 2011, National Association of Social Workers: Washington, DC. p. 207-222.

9. Kilburn, M.R., Cost and outcomes analysis of child well-being, in Outcomes Measurement in the Human Services, J.L. Magnabosco and R.W. Manderscheid, Editors. 2011, National Association of Social Workers: Washington, DC. p. 283-295.

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