Screeners, Evaluations, Questionnaires, Measures, and Surveys – Oh My! The differences between these five behavioral health assessment tools and when to use them for value-based care
This article provides definitions, features, methods for use, and examples of five types of behavioral health assessment tools and instruments. We discuss how these can be used to support initiatives, including value-based care, continuous quality improvement, social determinants of health (SDoH), person-centered care, and whole person care.
As care for mental health disorders and substance use disorders are integrated into primary care, there is more emphasis on brief, strategic, targeted and goal-oriented care which is supported by measures. At the same time, health care is beginning to focus on social determinants of health (SDoH) and reducing health disparities. As health care moves into integrated, coordinated care that contextualizes need into person-centered treatment, questions arise about how we will change our process to capture patient information. Where, how and when can screeners, evaluations, questionnaires, and surveys play a role to provide enough information and structure without becoming a burden and getting in the way of the work?
What is the difference between behavioral health data tools?
First, let’s cover the different purposes of different tools. All of these tools create structured data through sets of questions that either the patient answers or the clinician answers on behalf of the patient.
1. What is a behavioral health screener?
A health screener is a preliminary question set to determine the possibility of presence of diseases or other conditions. However, confirmation of that condition would require further assessment and evaluation. The screener is designed to contain the least number of questions possible to rule in or out the need for further evaluation. It helps determine if the patient has any symptoms or conditions that may require more in-depth medical examination and/or treatment. A health screener can also help to identify patients who are at risk of developing certain diseases or conditions.
How is a screener performed?
A screener is usually performed on or around the time of a first care appointment regardless of reason for the appointment, and patients are often re-screened after certain intervals of time, such as annually. Screeners are sometimes completed as questionnaires handed to the patient in the waiting room, but some clinicians are finding more efficiency with high rates of response through emailed or texted screeners (https://www.opeeka.com/solutions/).
Five features of a screener.
- Short, often focused on symptoms and needs.
- Targeted to a certain condition.
- Identifies risk for conditions and need for further evaluation.
- Often performed on first appointment and at regular intervals.
- Supports HEDIS measures; not confirmatory of a diagnosis.
Examples of screener tools.
- Patient Health Questionnaire (PHQ-9).
- General Anxiety Disorder (GAD-7).
What is an example of use of a screener in behavioral health care?
“I will look at the score maybe before I go in, or if it’s on the EHR I will see the list of scores over time. That is just one little piece of information that I will put in the back of my head, but when I sit in front of the patient, I am not going to start off with the score, I am going to start off with some important piece of their context that I think might be a relevant place to start the contextual interview and get to know the person and figure out where we can help best move that person forward with regard to their goals and values and how to live life more meaningfully.” -Neftali Serrano, PsyD, Chief Executive Officer, Collaborative Family Healthcare Association (CFHA)
2. What is a behavioral health evaluation?
A behavioral health evaluation is aimed at confirming the presence of a condition or disorder with the goal of ruling in or ruling out a diagnosis. It is usually performed after a screener indicates the possibility of the presence of a condition. A behavioral health evaluation usually includes a combination of evaluation tools, including a physical examination, clinical interview, tests, and written questionnaires. An evaluation may require more than one appointment to complete and may take several weeks or months to complete.
Five features of a behavioral health evaluation.
- Comprehensive, contextualized information about needs, strengths, and supports.
- Usually contains several modalities of evaluation (interviews, lab work, tests, examination, questionnaires).
- Identifies need for treatment.
- May occur over an extended period of time and updated often.
- Confirmatory of a diagnosis.
Examples of evaluate tools.
- Biopsychosocial Assessment.
- DSM5 PROMIS Emotional Distress Depression.
- DSM5 Altman Self-Rating Mania Scale (ASRM).
- Contextual Interview.
What is an example of use of evaluations in behavioral health care?
“Biopsychosocial formulation is something that we do when we are really trying to understand who a patient is and why the look the way they look in front of us on a given day. It is kind of a living entity. It is something that changes over time depending on what is going on in their life, but it is something that we use when we communicate with each other, and also when we think to ourselves as clinicians about what has brought this person to where they are….when you do this you are drawing on the areas of biology, and psychology, and sociology and also culture. You are building on these areas and you are trying to build something. What you are trying to build is an understanding.” -Dr. Erin Carter, St. Joseph’s Healthcare Centre in Toronto, Canada
3. What is a behavioral health questionnaire?
A behavioral health questionnaire is a document that collects information about context and history that is not captured through the standard behavioral health evaluation, in consideration of the whole person. It typically consists of questions on topics such as social determinants of health (SDoH), cultural beliefs, preferences, lifestyle, resilient factors, and stigma. SDoH questions ask about things such as a person’s financial security, housing stability, proximity to healthy food options, neighborhood safety, and access to transportation. A behavioral health questionnaire can also include questions about a patient’s perceived safety and well-being in areas of their life. It can also ask about their spiritual beliefs, tribal association, cultural belief system and other preferences that influence the type of care that is best for the patient. The purpose of a behavioral health questionnaire is to supplement what is gathered through other sources in order to personalize treatment for the patient in support of person-centered care and whole person care.
Five features of a behavioral health questionnaire.
- Broad collection of an array of contextual information.
- Usually asks about many different areas of a patient’s life.
- Identifies patient preferences to individualize treatment.
- Often collected at first appointment and updated only every several years.
- Supports person-centered care and whole person care.
Examples of questionnaire tools.
- Social Needs Screening Tool (American Academy of Family Physicians).
- Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE).
- Internalized Stigma of Mental Illness Scale-9 (ISMI-9).
- Resilience Scale for Adults (RSA).
What is an example of use of questionnaires in behavioral health care?
“Health actually begins where we live, learn, work, play, pray. It does not really happen in the acute care facilities where we receive the comprehensive care…but the knowledge of solutions to act in a way that both supports and individual and also drives systemic change has been elusive because it is outside of our core training, it is outside of our areas of areas of influence. It requires for us to reach and work with a vast array of organizations across a community. So in order to make progress, I believe that we need to better quantify and understand comprehensively an individual, whether it is his or her health but also the neighborhood where they spend their time as well as information about their lives and their preferences. So we can appreciate not only the choices that an individual has, but also influences that support the decisions that we are guiding them to make…It is proven through behavioral sciences that engaging an individual in decision making and choices is much more effective than dictating a course of treatment. So we need to empower individuals and base that on context about their ability for self-care, resources, challenges, and preferences that they have.” -Steve Miff, PhD, CEO and President of the Parkland Center for Clinical Innovation
4. What is a behavioral health outcome measure?
Behavioral Health Outcome Measure (BHOM) is a measure of progress, effectiveness and efficiency of interventions to improve health. The BHOM can be targeted to decrease a symptom (e.g., reduce anxiety), increase a resilience factor (e.g., develop coping skills), or meet a general life goal (e.g., enjoy socializing with friends again). BHOM are usually first measured at the beginning of treatment and then tracked as a measure of progress throughout treatment. Unlike diagnostic tools, BHOM are expected to be sensitive to slight improvements or regressions in behavioral health status and condition. These assessment tools identify progress in treatment an incremental scale and can act as an early warning when response to treatment is poor. BHOM indicate the impact of care on patient’s lives and can be utilized in for value-based care, identifying who is served well by a provider.
Five features of a behavioral health outcome measure.
- Incremental measurements expected to improve gradually during care.
- Targeted to level of symptoms, resilience and progress toward goals.
- Identifies effectiveness of care.
- Often collected at first appointment and updated as often as every day for intense care.
- Supports value-based care models.
Examples of behavioral health outcome measures.
- Child and Adolescents Needs and Strengths (CANS).
- Daily Living Activities-20 (DLA-20).
- World Health Organization (WHO) Five Well-being Index (WHO-5).
- Likert scale self-assessment on progress toward personal goal in care.
What is an example of use of outcome measures behavioral health care?
“I am going to figure out where we can help best move that person forward with regard to their goals and values and how to live life more meaningfully…More often than not, I am going to point to a functional metric. This is a question that I use most often. If we start medication today, what would be the difference in your life? What would you see happen? What would we hope to see happen? Because I want the patient to know what better looks like. Because a lot of times when you are in the middle of a behavioral crisis, you don’t know even what better looks like? What does better look like in my life? I can get up and play with my kids, and spend more time with them and pay more attention to them. That is a really great functional metric.” -Neftali Serrano, PsyD, Chief Executive Officer, Collaborative Family Healthcare Association (CFHA).
5. What is a behavioral health survey?
Behavioral health surveys are tools that ask the opinion of patients with regard to quality of care, satisfaction of care, and their perception of the treatment which might relate to adherence to program fidelity. Patient surveys often have the lowest response rates of all assessment tools because they provide information back to the health care provider from an anonymous sample where there is no opportunity to address patient questions or concerns raised. These tools are often administered only at the end of care or just after discharge from a behavioral health program. They collect information from to evaluate the quality of care to support continuous quality improvement, satisfaction of care, or care fidelity to program model, which supports requirements for value-based care models.
Five features of a behavioral health survey.
- Collects patient opinions, often on Likert scale.
- Generally administered to a sample of patients anonymously.
- Usually targets quality, satisfaction, or fidelity.
- Often collected at end of treatment only.
- Supports value-based care models.
Examples of behavioral health surveys.
- Patient Satisfaction Survey.
- Experience of Care & Health Outcomes (ECHO) Survey.
- Revised-Cognitive Therapy for Psychosis Adherence Scale.
What is an example of use of surveys in health care?
Why is measuring the quality of care critical?
“The reason why it’s critical is because when you look at the classic equation of what is the value of healthcare it’s the quality divided by the cost. Quite honestly, we haven’t had very good measures of the quality in terms of individual physician, so then it comes down to cost. That is a very frustrating environment to be in…Let’s make sure that the environment to care for patients is under so much pressure that it is an uncomfortable place to be…If we can manage the quality, we will provide the best care with the best evidence with the best cost. I don’t think you can do that unless you really work on keeping track of what the physicians are doing in terms of quality, having these measurements in place which are beyond the simple broad healthcare spectrum measurements, and then having methods in a quality assessment program to remedy deficiencies or variations in care so that you can get that on the best track for the best quality for the right price.” -Anthony A. Romeo, MD – Chicago Orthopaedic Specialist
What are the Right Assessment Tools to Support Value-Based Care?
The use of the five assessment tools (screeners, evaluations, questionnaires, measures, and surveys) are all imperative to support a value-based care model. It can seem like an overwhelming about of work to implement all five types, but if a process is created that incorporates the right assessment tools to be part of the work at the right time, then tools work together support the goals of the work and become the work. The right process includes emailing and texting patients assessments (https://www.opeeka.com/solutions/) to be completed before or after appointments (see Reasons People Complete Assessments: Tips for High Response Rates for Patient and Client Assessments). It also includes converting the data into meaningful display of information for the clinician and the patient, when appropriate (see The Value of the Right Visual Presentation of Assessment Data at the Point of Care). Finally, includes the right positive workforce culture to value whole person care and well-being for all (www.opeeka.com/workforce). Value-based care for behavioral health starts with identifying those in need of care through screeners. It proceeds with evaluating types of needs, is embedded in context from questionnaires, tracks progress on measures to person-centered goals, and surveys for patient satisfaction through fidelity to process. These tools not only support value-based care, they ensure it.