Implementation of Measurement-Based Care in Mental Health Service Settings for Youth: A Systematic Review

Despite the known efficacy of MBC and the push to implement it in a manner that allows for consistent and sustainable use, there remain several barriers to effective implementation. Broadly, multilevel barriers to implementation of MBC in youth and adult behavioral healthcare have been well-documented (Lewis et al., 2020). Specifically, prior research has demonstrated that lack of training in the use of MBC (Levine et al., 2017) is a significant barrier. Thus, clinicians do not regularly or systematically engage in use of MBC when it is available (Jensen-Doss et al., 2020; Hall et al., 2014a, 2014b) and overly rely on their own clinical judgment (Walfish et al., 2012). Clinicians also worry about the impact of MBC on the therapeutic alliance (Norman et al., 2014). Additionally, some clinicians feel nervous about the potential use of unfavorable client feedback data (i.e., lack of client symptom improvement) for performance evaluation and find it challenging to make the time to administer or organize measures (Boswell et al., 2015; Jensen-Doss & Hawley, 2010; Wolpert et al., 2014). Finally, integration of the use of technology to deliver MBC in mental health service settings, such as via MFSs, presents specific challenges, such as the need for additional resources to cover the costs of clinician training, usage, and support (Bickman et al., 2000).

Specific challenges to implementation of MBC in youth mental health service also exist. For example, caregivers might feel that use of MBC adds to the burden of completing forms in service settings which can lead to the inconsistent use (Hall et al., 2013 & 2014b). Yet, integration of caregiver report of mental health symptoms is an important consideration when selecting measures to incorporate into MBC across settings that serve youth. A recent national study suggests that up to 77% of 1,500 mental health service providers exclusively use assessments of youth functioning that are not empirically validated or administered in a standardized manner (Cook et al., 2017) and lack caregiver reports. Despite these existent issues, it is worth noting that there is very limited research in this area given that few studies are published on experiences of use of both youth and caregiver support with MBC use. While there is some evidence that clinicians worry about the potential negative impact of collecting additional measures (e.g., caregiver report) on rapport building with clients, they do not always find this to be the case in actual clinical practice (Connors et al., 2021; Cuperfain et al., 2021). Alternatively and importantly, individualized measures developed by clinicians for their clients are a clinically valid approach to using MBC in addition to use of standardized measures (Jensen-Doss & Hawley, 2010).

Moreover, developmental considerations of measures, such as caregiver reporting and developmental needs in assessment, may affect the implementation models and strategies selected to guide implementation efforts in youth settings, that is, when the models and strategies are used. Despite their utility, implementation models and strategies are rarely used consistently in MBC implementation work either (Lewis et al., 2020), particularly in youth service settings (Bruns et al., 2008). Results from a national survey of youth-serving outpatient mental health clinics demonstrated that less than a third of these facilities implement MBC at all (Cook et al., 2017). Thus, there is much work to be done in this area.

Previous systematic reviews and meta-analyses conducted on MBC across service settings have primarily focused on exploring client symptom improvement (Elmquist et al., 2010; Gondek et al., 2016; Krägeloh et al., 2015; Lambert et al., 2003; Shimokawa et al., 2010; Tam & Ronan, 2017; Waldrop et al., 2017; Williams et al., 2016; Zimmerman & McGlinchey, 2008), with 24% of clients in community mental health settings demonstrating a significant increase in symptoms over the course of treatment, as opposed to 14% of clients in the managed care setting (Warren et al., 2018). However, little attention is given to implementation processes associated with effective and sustained use of MBC. To our knowledge, a review focused on the implementation of MBC in youth mental health service settings has not been published. The inconsistencies in studies focused on use of MBC in youth service settings as well as the low uptake of MBC in these settings could be due to the differences in implementation processes of MBC and nuances between studies (e.g., implementation strategies used, informants utilizing MBC). Thus, the objectives of this systematic review are to (1) review models and strategies used to implement MBC in youth-serving settings; (2) summarize the barriers and use of facilitators to implementation of MBC in these settings; and (3) offer recommendations for future work in this area. This review includes an examination of the primary settings where youth receive mental health care and where the majority of findings related to MBC use have been reported in the literature, including community-based outpatient mental health centers (CMHCs), medical centers/hospital-based pediatric clinics/units, schools, and clinical psychology training clinics.

A systematic review of the literature was conducted in a manner consistent with the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) statement (Moher et al., 2009) to identify peer-reviewed studies on the implementation of MBC in youth service settings, by two independent reviewers. Searches of electronic databases (PsychInfo, Medline, Google Scholar) were conducted using specific keywords (measurement-based care or measurement feedback system or routine outcome monitoring or MBC, mental health, and children or adolescents or youth or child or teenager), for articles published between 1995 and May 2024. Search strategies were the same across databases.

Included studies met the following criteria: (1) examined the implementation of MBC in mental health services for youth; (2) focused exclusively on settings that provide mental health services, such as community-based care and pediatric medical centers; and (3) identified strategies or barriers associated with implementation processes in study procedures and findings. The reference lists from included papers and other systematic reviews (Elmquist et al., 2010; Lewis et al., 2020) were also reviewed for papers that matched inclusion criteria. Exclusion criteria included studies that (1) were not in English; (2) not implementation focused; (3) focused on use of MBC for non-mental health-related issues or teaching purposes; (4) did not focus on the use or system of the MBC (e.g., focused on creation of a measure in a MFS that delivers MBC); (5) used the acronym “MBC” to refer to something else; and (6) examined adult-focused settings and did not include youth (ages 0–18). Exclusion criteria for the Medline search also included articles that were duplicates from the PsychInfo search. A search of Google Scholar and review of reference lists in the aforementioned papers produced 8 additional papers that met the inclusion criteria and were not included in the PsychInfo or Medline searches. Coding of the papers was conducted a priori such that each study was examined for descriptive information (e.g., setting, population/age, youth sample size), mode of delivery (e.g., MFS, paper–pencil), measures employed, implementation model/framework and strategies used, and barriers and facilitators to implementation discussed. When multiple articles were drawn from the same study (e.g., Bickman et al., 2016 and Gleacher et al., 2016), they were counted as a single study in our review.

Overall, nine out of the 26 articles included mention of implementation models. Studies included in this review paper mentioned use of the Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2009), Aarons and colleagues (2011) conceptual framework, the Exploration, Preparation, Implementation, Sustainment (EPIS) model (Aarons et al., 2011), and Powell and colleagues (2012) conceptual framework to guide implementation efforts. Additionally, the Reach, Efficacy, Adoption, Implementation and Maintenance framework (RE-AIM) (Glasgow et al., 2001) was used to guide the implementation efforts in a primary care setting study, and the Fixsen, Naoom, Blasé, Friedman, and Wallace (2005) process framework was used in the context of a clinical psychology training clinic.

In contrast to implementation models, multiple implementation strategies were described in the studies reviewed. General strategies common across all service settings included use of training which varied in scope across studies (Bantjes et al., 2018, Batty et al., 2013; Bruns et al., 2008; Childs et al., 2022; Cooper et al., 2019; Gatto et al., 2024; Lavik et al., 2018; Lyon et al., 2015; Norman et al., 2014; Trivedi et al., 2019) and use of technology to collect, analyze, and link patient data through digital systems, also known as Health Information Technology (HIT) strategies (Bantjes et al., 2018; Black et al., 2020; Bruns et al., 2008; Childs et al., 2022; Cooper et al., 2019; Gatto et al., 2024; Gleacher et al., 2016; Lyon et al., 2015; Monga et al., 2023; Moran et al., 2012; Sichel & Connors, 2022; Trivedi et al., 2019; Van Sonsbeek et al., 2021; Waschbusch et al., 2020; Woodard et al., 2023). In many of the studies reviewed, HIT strategies, such as a MFS or EHR, were used to deliver MBC. Of note, studies also used various forms of web-based platforms, paper forms, and electronic routine outcome monitoring systems with results entered into clinical records routinely. Additionally, some systems included integration of not only clinical measures, but also scoring and tracking of these measures in the patient portal (e.g., through MyChart) (e.g., Childs et al., 2022). Another strategy mentioned in literature from CMHCs and clinical psychology training clinics was the involvement of key stakeholders, such as clinicians, caregivers, and/or youth, in implementation planning (Batty et al., 2013; Bruns et al., 2008; Lavik et al., 2018; Monga et al., 2023; Victor et al., 2023). For example, focus groups, semi-structured interviews, or pre-implementation surveys were used to obtain feedback in areas such as measure selection and mode of measure administration as well as general barriers and facilitators to implementation of MBC within a MFS (Bantjes et al., 2018; Cooper et al., 2019; Gleacher et al., 2016; Moran et al., 2012; Waschbusch et al., 2020).

All barriers and facilitators or the individual characteristics and contextual factors that enhanced or impeded implementation processes, including those that are less common across settings, are discussed below. They are subdivided into clinician-, client-, and organizational-level strategies.

First, we recommend incorporating comprehensive training in use of MBC for clinicians who work with youth and families as well as continuous support, as needed, post-training. Specifically, receiving training prior to using MBC, or a MFS that delivers MBC, can improve clinician usage rates of MBC, attitudes toward MBC (Bruns et al., 2008), and knowledge and skill sets with MBC practices (Peterson & Fagan, 2017; Warren & Park, 2018). Ideally, training in evidence-based practices, such as MBC, should be provided at the “earliest stages of professional training” when clinicians are learning new practices. This helps to ensure that clinicians will implement knowledge correctly and understand how to integrate MBC into their clinic workflow (Bantjes et al., 2018; Peterson & Fagan, 2017; Warren & Park, 2018). Embedding training in MBC in the context of graduate education (i.e., training clinics) has been associated with implementation successes (Cooper et al., 2019) and sets the stage for continuation of this practice in future service settings.

Our review also suggests that there are important topics to integrate into training with clinicians to address potential barriers and enhance facilitators to implementation. First, the training should include information about why MBC is important and how it improves quality of patient care. Time should also be devoted to describing when and how feedback should be delivered to youth and families. This includes a discussion of how regular monitoring of symptoms and feedback can be used to enhance rapport, communication, and collaborative decision-making between families and clinicians. The importance of delivering regular MBC feedback to youth and families (i.e., via graphs, charts) over the course of care for optimal outcomes should also be emphasized. It may also be helpful to convey that the results of assessments are not meant to replace clinical judgment but can be used as another valuable source of information that can be integrated into clinical decision-making. For example, MBC can be used to help guide triage decisions upon entry into care, aid in treatment planning, and inform discharge decisions (Jensen-Doss et al., 2020). In addition, if the data collected will be used for additional purposes (e.g., aggregated for program evaluation and/or to meet accreditation standards), this information should also be conveyed so that clinicians have a full understanding of the use and utility of MBC in their practice setting. Such information may ultimately help improve clinicians’ attitudes toward MBC, which in turn, may enhance implementation outcomes.

Training with clinicians should also incorporate psychoeducation around how to discuss MBC with youth and families. For example, clinicians should learn how to describe the utility of assessment measures to both youth and their families and how MBC can be used to enhance treatment outcomes (e.g., faster reduction in mental health symptoms, shorter time to remission). Information on common barriers to MBC use with families, such as limited time outside of session, lack of understanding of relevance/importance of measures, and poor understanding of technology, as well as how to address these barriers, should also be included in clinician training.

Importantly, training should also provide clinicians with ample time and space to ask questions, offer feedback, discuss concerns, and problem solve through potential obstacles. Needed adjustments should be made to the implementation process based on information obtained. For example, adjustments may need to be made to the clinical workflow or measures added to the MBC system, using feedback from clinicians. Continuous support and consultation should also be provided to clinicians post-training to help sustain and/or enhance use of MBC, and any new feedback gathered during this process may also be used to further improve implementation strategies and efforts.

Second, clinicians play a central role in enhancing youth and parent use of MBC. In particular, it is critical for clinicians to engage clients in use of MBC and address barriers to using MBC with families at the start of care (Chiauzzi, 2020). Encouraging clinicians to address barriers to completing measures with youth and families and problem-solving as needed may enhance “buy-in” for using MBC. Setting goals around MBC use with families may also be helpful in this regard (Bickman et al., 2016; Lamers et al., 2015). Ensuring that families understand the clinical relevance of measures for their children’s treatment and mental health (Lavik et al., 2018) is also important. When possible, selecting measures that are focused on the personal goals and values of the unique youth (Lavik et al., 2018) can enhance engagement in MBC. Providing support for completing measures, especially for families or children with literacy problems, as well as offering assessments in a client’s native language, when at all possible (Moran et al., 2012), will also enhance measure completion. Additionally, some caregivers worry that their family will lose service access if symptom improvement is evidenced via MBC. Families should be assured that they will not lose access to needed services as a function of MBC use (Moran et al., 2012). Given research which suggests that sharing weekly, or regular, assessment results with clients may lead to quicker improvement in youth mental health symptoms (Bickman et al., 2011), feedback should be a continuous process throughout treatment. Feedback that incorporates both quantitative (i.e., symptom inventories) and qualitative (i.e., verbal discussion about results of assessments) assessment in the context of outcome monitoring may be particularly beneficial for clients (Turner, 1998).

Third, we recommend using electronic systems to deliver MBC that allow for real-time feedback (i.e., instantaneously score and show assessment results) and offer continuous consultation/technical support for clinicians and families, when possible. The literature suggests that timely and specific feedback through MFSs that deliver MBC is a critical ingredient for improving patient outcomes (Bickman et al., 2011; Mellor-Clark et al., 2016). Clinicians and organizational leaders use feedback from these MFSs in their treatment planning as well as to monitor implementation outcomes in service settings when it is available (Liu et al., 2019). It is recommended that feedback be: (1) readily accessible to clinicians at both the individual level and the team/service level; (2) presented in graphs or short reports that can be shared with families in sessions as part of monitoring treatment progress; and (3) has the ability to be compared across all assessment timepoints over the course of treatment (Batty et al., 2013; Chiauzzi, 2020). Lastly, given that system usability and technological issues can interfere with implementation processes, service settings that employ consultation or technical support for MFSs benefit greatly (Liu et al., 2019). The amount and type of consultation and technical support needed will vary by treatment setting and the complexity of the MBC employed.

In addition to the key takeaways gleaned from understanding the barriers and successful strategies to implementation of MBC for youth across service settings, there are several important considerations for scaling up implementation and improving access to MBC for families. Lewis and colleagues (2020) created a 10-point research agenda to improve the implementation of MBC in clinical practice broadly, and several of the strategies most important for youth service settings are highlighted below.

A significant issue impacting the implementation of MBC is the associated cost. While training and administrative costs were cited as a barrier in the studies reviewed, MBC systems themselves can also be costly (e.g., EHRs/MFSs that deliver MBC, use of copyrighted measures). Lewis and colleagues (2020) pointed to a need to “align reimbursement structures” to help cover this cost, especially as many systems become electronic. Upward of 95% of caregivers prefer to complete measures electronically rather than by paper and pencil when offered a choice (Waschbusch et al., 2020). This is an important consideration given that caregiver burden is a significant barrier to consistent MBC use. Billing concerns for assessment services are not unique to mental health facilities. They also exist in integrated healthcare settings where many families access services and early identification of mental health issues among youth is possible (Patient-Centered Medical Home; Croghan & Brown, 2010), particularly when electronic systems are available. There are Current Procedural Terminology (CPT) codes for mental health evaluations that can be used to bill for initial assessment procedures (e.g., 90,791, 90,792) as well as brief emotional-behavioral assessments using standardized instruments (e.g., 96,127), but they do not fully cover the costs of MBC systems, in particular if there are multiple bills entered per family (e.g., siblings, caregiver reports, and teacher reports). Unlike mental health treatment for adults, mental health treatment with youth often incorporates family work, which necessitates a different billing structure. Decreasing the costs, advocating for insurance coverage, and identifying funding streams for electronic systems so that optimal MBC can be implemented, including in economically disadvantaged areas, will be critical for eliminating barriers related to the complexity of reimbursement for MBC and enhancing uptake of MBC.

Additionally, future research should be conducted to examine and/or develop free, brief, developmentally sensitive, and psychometrically sound measures that can be optimally used in the context of MBC systems (Bickman et al., 2016; Lewis et al., 2020; Liu & Adrian, 2019). These measures should span multiple mental health areas to mimic the comorbidity commonly experienced by youth who seek treatment services and include versions for multiple informants (child, caregiver) for optimal assessment, given that several measures might be given to a family at the onset of treatment. Relatedly, unlike work with adults, which often focuses solely on self-reported assessments, it may also be important to train therapists in the clinical utility of discrepant reports from youth and family, which is often the rule rather than the exception (De Los Reyes et al., 2017). Measures should also be validated in multiple languages and be culturally sound to ensure that diverse youth/caregivers have access to MBC across service settings (Liu et al., 2019). Notably, research on implementation of MBC is being conducted worldwide (e.g., the Netherlands, the UK, the USA, and South Africa) and measures in multiple languages are being developed. For example, the Patient-Reported Outcomes Measurement Information System (PROMIS) Measures promoted through the American Psychological Association, are brief, cover multiple mental health areas, are validated in over 90 languages (select measures), and are free to the general public (https://​www.​healthmeasures.​net/​index.​php?​Itemid=​992). However, there is a fee for their commercial use in electronic MBC systems, which if waived, may help reduce address inequities in access to MBC. Notably, Beidas et al. (2015) and Becker-Haimes et al. (2020) have compiled free and brief standardized instruments for use in youth mental health settings, which could greatly assist with MBC implementation despite noted difficulties with measure access.

In a similar vein, additional research should be conducted on the use of audio computer-assisted self-interviewing and simple response options to decrease barriers to MBC use for those with low literacy and disabilities (visual impairment, reading disabilities, etc.), and for working with youth with developmental delays. Importantly, a model has recently been developed for examining MBC through an equity specific lens (ASPIRE framework-Gaias et al., 2021), as well as a model to improve engagement with racial minoritized youth (STAY- Connors et al., 2022). Using this model to guide future implementation efforts may help address documented inequities in access to and use of MBC so that all youth and families may benefit from this evidence-based practice.