PCORI funds implementation projects to promote the use of findings from PCORI-funded studies. This project focuses on implementing findings from the completed PCORI-funded research project: Matching Patients with Therapists to Improve Mental Health Care
1. What were the results from the original PCORI-funded research study?
The project team tested a new system for matching mental health care (MHC) patients to therapists who have strengths in treating patients’ specific presenting concern(s). This work followed prior research demonstrating that most MHC therapists have some strengths and some weaknesses in treating patients with different mental health problems, which suggested that such performance information (i.e., multidimensional effectiveness “report cards”) could be used to improve patients’ therapy outcomes.
Moreover, the project team’s prior research indicated that MHC patients would value being assigned to empirically well-matched therapists, even more so than being matched on other variables, such as gender and race/ethnicity. Addressing this patient value, we compared measurement-based matching to non-measurement-based case assignment as usual (CAU) prior to routine outpatient therapy with adults within an MHC network. Specifically, we assessed each of 48 therapists’ pretrial performance across 15 or more cases based on their patients’ pre-/posttreatment reporting on the 12 problem domains assessed with the routinely administered Treatment Outcome Package (TOP). Based on these outcomes data, each clinician was classified in each TOP domain as effective (their average patient exceeded their expected improvement), neutral (their average patient improved no more or less than the expected degree), or ineffective (their average patient fell short of their expected improvement). With these classifications, each therapist had a report card of strengths and weaknesses to inform the match.
Next, 218 new study patients were randomly assigned to therapists either empirically (match) or pragmatically (CAU). Matching ranged from therapists being effective on the patients’ three most problematic domains and not ineffective on any others (highest level) to neutral on patients’ most elevated domains, but also not ineffective on any domain (lowest level). On average, patients were about 34 years old. About 67 percent identified as female and about 89 percent identified as white. Results indicated that match versus CAU patients showed significantly more improvement in their symptoms/functioning. As a prominent example of clinical meaningfulness, the average match, but not CAU, patient ended treatment with an impairment level that was indistinguishable from a community norm of nondistressed, non-treatment-seeking individuals. Also, the positive effect of matching was especially strong for patients who identified as racial/ethnic minorities. The positive effect was also stronger for patients with more versus less severe mental health concerns.
2. Why is this research finding important?
Research demonstrates significant variability in patients’ MHC outcomes, and too many patients, especially those identifying as racial/ethnic minorities, experience nonresponse or deterioration after engaging in therapy. Such outcome variability is partly a function of therapists possessing measurable strengths and weaknesses in treating different problems. Thus, research underscores that MHC can be improved not just by developing and using evidence-based interventions, but also by harnessing therapist performance information to determine personalized patient-therapist matches.
Despite this promise, routine case assignment in MHC is largely based on convenience and therapist self-identified expertise (which is often overestimated), leaving it to chance whether patients will be assigned to objectively good- versus poor-fitting therapists. Addressing this gap, the project team’s trial showed that once therapists’ effectiveness report cards are established, the information can be used prospectively for patient-tailored matching at the time of intake, which improves patient outcomes. Importantly, MHC patients value and prefer such matching, and the trial demonstrated clear buy-in among patients and frontline leaders in the MHC network in which the system was tested.
3. What is the goal of this project?
With the strong trial results, the project team will implement the match system widely. In phase 1, the team aims to demonstrate that routine TOP assessment, development of therapist report cards, and prospective matching can be integrated into the current operations within a large regional MHC network in the Philadelphia area (Springfield Psychological). In phase 2, the team will rely on the information gathered, materials developed, and lessons learned in phase 1 to rapidly replicate its implementation efforts more widely across the largest national network of MHC centers (Refresh Mental Health).
4. What is the project team doing?
The team’s overarching evidence-based implementation strategy will follow the Framework for Dissemination (FFD), further informed by the Dynamic Sustainability Framework, which approaches implementation with the expectation that some degree of adaptation will be necessary for sustainment. Activities in partner MHC networks will include working with an implementation team to integrate the match system into the existing electronic health record, establish training protocols for future adoptions, assess and refine the match system to meet the network’s needs, and demonstrate fidelity and beneficial patient treatment outcomes that meet or exceed those observed in the trial.
The phase 1 setting is a large regional network of nine MHC sites in the Philadelphia area (Springfield Psychological). Within this network, the match system is estimated to reach a minimum of 140 therapists and 10,000 patients. The phase 2 setting is the country’s largest network of approximately 50 MHC sites in over 30 states (Refresh Mental Health), for which Springfield is the most established and largest network under the Refresh umbrella. With this established connection, Springfield is the ideal phase 1 site to set the standard Refresh’s other affiliated networks in phase 2. Across the broader Refresh network in phase 2, the team estimates the match system will reach a minimum of 700 additional therapists and 50,000 additional patients.
5. How is the team evaluating this project?
There are six contextual domains in the FFD theorized to determine successful implementation: norms and attitudes, structure and process, resources, policies and incentives, networks and linkages, and media and change agents. As such, the framework organizes the evaluation of factors that may promote or hinder the successful implementation and sustainment of the match (marked by patient MHC outcomes, as well as system outcomes like electronic health record integration, seamless use of TOP assessments, and efficient application of the match at intake). This drives a three-phase evaluation process: capacity and needs assessment, implementation/process evaluation, and fidelity and outcome/impact evaluation. The team will use mixed methods for evaluation, including team meetings/consensus building and surveys/interviews with key stakeholders (i.e., therapists, patients, nonclinical staff).
6. How is the team involving patients and others in making sure the findings reach people who can use them?
Key stakeholders include administrators, nonclinical staff, therapists, and patients within adopting MHC clinics. The first three stakeholder categories all have effort included in the Springfield/Refresh subcontractor budget to serve on the implementation team and as local champions, and to coordinate direct implementation efforts. The prime UMass budget also includes consultant fees for additional, nonaffiliated implementation team members, including a patient with lived experience and the Program and Outreach Coordinator at the NAMI Philadelphia Chapter. The team has secured letters of endorsement from several other professional, clinical, and advocacy organizations that have a stake in the even broader application of results based on the present implementation efforts.
7. How will this project help ensure future uptake and use of findings from patient-centered outcomes research?
The potential for future uptake and sustainability is extremely high, as this is a minimalist, readily scalable intervention. Once the team’s processes, outcomes, and training materials are established, refined, and optimized in the present project, the team expects that other MHC systems (such as Albany Medical Center, as indicated in their letter of endorsement) can implement the TOP and its match process for little cost and with few human resources. Moreover, industry partner ORI will offer low-cost options for stakeholders to use their MatchedTherapists.com platform for matching among patients and individual providers for traditional therapy or teletherapy.
Initial PCORI-Funded Research Study
This implementation project focuses on putting findings into practice from this completed PCORI-funded research study: Matching Patients with Therapists to Improve Mental Health Care
*All proposed projects, including requested budgets and project periods, are approved subject to a programmatic and budget review by PCORI staff and the negotiation of a formal award contract.