Center for Integrated Primary Care Blog Posts

Reflections from My Measurement-Based Care Teeter Totter of Ambivalence 

By: Amber Cahill, PsyD

Measurement-Based Care (MBC) is increasingly discussed as a best practice in integrated care, but in the reality of busy primary care settings, it can feel difficult to implement and even harder to sustain. Many of us are rightly concerned about patient-level burden and whether the measures we use are truly meaningful to the patient sitting in front of us, or capable of detecting change across the complex facets of a patient’s day-to-day functioning.

A new Resource Guide on the Implementation of Measurement-Based Care in Integrated Care, developed by the CFHA Measurement-Based Care Workgroup, along with this journal article, was created to offer practical, real-world guidance for clinicians and teams working in fast-paced primary care settings. Rather than treating MBC as mere paperwork, the guide frames it as a flexible clinical process that enhances patient engagement, team-based care, and informed clinical decision-making. Kudos to our CFHA colleagues for creating a valuable and grounded resource for those of us working in integrated primary care.

I often find myself on a teeter-totter of ambivalence when it comes to MBC. There are many reasons I’ve personally struggled to fully adopt standardized MBC in my own clinical practice, compounded by the fact that it is not currently a system-level priority or requirement where I work. This CFHA document helped balance my perspective by highlighting the opportunities that come with MBC implementation.

In my clinical work, I’ve always incorporated what I’d call a more naturalistic or ad hoc form of MBC. My patients know that I structure visits in a predictable way. I begin each session with the same question: What would be the most helpful way we could use our time today? I end most sessions by asking, Is there anything we missed or didn’t get to today that we should start with next time? After about three to five sessions, I pause more intentionally to assess the usefulness of the current episode of care: Is this helping? Are we addressing your original goals of care? Are we missing something? Is this still the right setting for you? Is my approach the right fit? Where should we go next?

I recognize there are limitations to this approach. When delivering trainings on behavioral health screening in primary care, I teach clinicians that not every patient communicates their truth through face-to-face questioning. Some patients feel more comfortable responding to a written questionnaire than answering verbal questions. I also know how difficult it can be for patients to say out loud that something isn’t helping (or that I’m not helping in the way they hoped). I can see how having standardizedMBC systems in place may allow greater clarity and quicker identification when “course correction” is needed.

I work in a primary care practice affiliated with a safety-net hospital and care for many patients facing multiple social and structural adversities. I’m often sensitive to system- or clinic-centered health care (rather than patient-centered), and I carry a concern that measurement-based care, if not implemented thoughtfully and with respect for patient autonomy, can unintentionally drift in that direction. Many of my patients engage with me through telephone visits, are not regularly logging into patient portals, and expend a significant amount of energy just to make it to their appointments. Asking them to complete additional questionnaires, especially ones that may not feel relevant to them, may be perceived as overly burdensome and misaligned with their priorities.

More recently, I’ve been exploring measures that focus less narrowly on symptom reduction and more broadly on functioning, quality of life, self-efficacy, and behavioral goals. These kinds of measures feel more aligned with how many of us actually work in primary care and acknowledge the limitations of an overly symptom-focused approach. In many cases, they feel more patient-centered and less clinical than tools like the PHQ-9 or GAD-7. Ideally, patients would have the ability to choose a selection of measures that align most closely with their goals and values, having a say in what is measured and with what tool. 

Here are some of the more function and quality-of-life-focused measures I have come across that I could imagine myself using more routinely (several highlighted by the CFHA group): 

Overall, I really appreciated this resource from our CFHA colleagues. While I wouldn’t say my ambivalence is entirely resolved, this document did move me closer to seriously considering how a thoughtful, flexible, and patient-centered standardization of MBC could strengthen my clinical work in primary care.