What is Measurement-Informed Care?
Measurement-informed care (MIC), also known as measurement-based care, involves “regularly and systematically using patient data to inform clinical decisions and improve quality of care.” Patient data enables providers to develop tailored treatment plans that are responsive to patients’ symptoms and goals. In physical health care, MIC is deeply embedded in clinical practice. Examples include checking blood pressure or using lab tests to check kidney function or cholesterol levels. These objective measures guide diagnosis, treatment planning, and ongoing management.
In contrast, mental health and substance use treatment lacks a similar systematic standard of care. While mental health providers often collect patient-reported outcomes using validated tools to assess symptoms and track progress, providers do not consistently use this data to inform care decisions. Despite growing evidence that MIC improves outcomes in mental health and substance use treatment, its use remains limited. Fewer than 20% of mental health providers report regularly using MIC, and only about 5% implement it at every session, as recommended by evidence-based guidelines [2]. The underuse of MIC in mental health care reflects a broader absence of infrastructure, training, and expectations compared to physical health care where such practices are standard.
Identifying MIC Bright Spots Through Expert Engagement
In February 2025, the Meadows Mental Health Policy Institute and the West Health Policy Center convened a roundtable in Washington, D.C., bringing together distinguished and interdisciplinary leaders representing insurance plans, clinical providers, mental health technology innovators, and policy experts to discuss barriers and opportunities to increase the adoption of MIC in mental health care. This high-level dialogue focused on identifying systemic barriers and key enablers to advancing the adoption and integration of MIC in various settings and highlighted “bright spots,” which are organizations and initiatives effectively utilizing MIC to treat mental health conditions.
The bright spots that roundtable experts identified provide an opportunity to understand how leaders in health care are tackling challenges in implementing MIC and how they are employing measurements to drive high-quality mental health care. To capture these lessons learned in greater detail, seven of the roundtable attendees completed interviews following the in-person roundtable. Through semi-structured, half-hour interviews, attendees provided important information about different bright spots, including the stakeholders engaged in each initiative, the challenges faced in the adoption and implementation of MIC, and paths forward to address these challenges. Together, the roundtable and interviews offer a valuable snapshot of how innovative leaders across health systems are working to embed MIC into routine care. This white paper builds on previous reports on MIC in mental health care by grounding hurdles and opportunities for MIC implementation in real-world examples.
This work is grounded in a broader national context. With one in five Americans experiencing mental health challenges, efforts to integrate mental health into primary care have become increasingly urgent [3]. In one such example, the Meadows Mental Health Policy Institute, the West Health Institute, and Northwestern Medicine recently launched the Northwestern Medicine West Health Accelerator to expand access to mental health care in primary care settings using the evidence-based Collaborative Care Model. While this initiative is not the focus of this paper, it reflects a broader trend explored here: the emergence of “bright spots” that demonstrate MIC implementation to improve mental health outcomes, streamline care delivery, and strengthen the mental health workforce.
Key Findings
Several overarching themes emerged across the “bright spots,” pointing to both critical barriers to implementing MIC, as well as cross-cutting factors that appear key to its successful implementation. In addition to these findings, each “bright spot” highlights innovative approaches to MIC, shaped by factors such as clinical context, population served, organizational infrastructure, and funding models. These variations surface throughout the report and offer important nuances surrounding the implementation of MIC in real-world settings. In each case, we highlight “hurdles,” the challenges that organizations have faced and their approach to overcoming them, as well as the “opportunities” that facilitated the successful delivery of MIC.
Hurdles to Implementing MIC
Measures
Lack of standardization in what should be measured and how data should be reported.
Health systems often struggle to leverage health information technology to support provider adoption of MIC. Many mental health providers lack electronic health records, which are essential to implementing MIC, due to exclusion from federal incentives (e.g., the HITECH Act). Those with electronic health records often face poor interoperability and limited access to validated assessment tools. Many organizations also lack the ability to aggregate and report data in ways that support both clinical decision-making and system-wide quality improvement.
Clinical Decision Making
Uncertainty around how to use measurement to inform clinical decisions
Mental health providers span a wide range of disciplines—including licensed clinical social workers, licensed marriage and family therapists, licensed professional clinical counselors, psychologists, psychiatrists, and psychiatric nurse practitioners—and their training around the use of measurement in clinical practice varies significantly. Unlike specialists who treat chronic physical health conditions (e.g., cardiologists or endocrinologists), who typically complete fellowships with standardized training that emphasizes the use of measurement in clinical decision-making, mental health providers receive less uniform guidance. While there are clear protocols for using measurement to manage conditions like hypertension or diabetes, similar guidelines are often lacking in mental health care. This challenge is further complicated for mental health providers working with pediatric or geriatric populations, as they have even less direction on best practices for augmenting treatment plans based on measurement tools.
Opportunities for Implementing MIC
Stakeholders
Buy-in from organizational leadership and front-line providers.
Since MIC is not currently the standard of practice in mental health care, changing practice so that it is informed by measurement will require changes to organizational culture and the daily workflow of care teams. These types of large-scale changes are most successful when buy-in has been secured at all levels of an organization. Leadership endorsement is also likely necessary to authorize investment in MIC training and health information technology and to orient organizational culture toward MIC. Organizations also need provider champions who can motivate and inspire their peers to drive changes in organizational culture.
Successful Models
Using evidence-based health care delivery models that integrate MIC.
Many of the bright spots highlighted below have found success using evidence-based health care delivery models that integrate MIC, such as the Collaborative Care Model or the Certified Community Behavioral Health Clinic Model. Although these models have different goals and use cases, they both leverage the principles of MIC to support the delivery of quality mental health care (e.g., required quality reporting measures for Certified Community Behavioral Health Clinics).
Digging Deeper: Select Bright Spots
Certified Community Behavioral Health Clinic
A Certified Community Behavioral Health Clinic is a specially-designated nonprofit organization or unit of a local government mental health authority that provides a comprehensive range of mental health and substance use treatment services. Certified Community Behavioral Health Clinics receive an enhanced Medicaid reimbursement rate based on their anticipated costs of expanding access to care. Federal law requires Certified Community Behavioral Health Clinics to provide nine types of services—either directly or through formal partnerships—including screening, diagnosis, and risk assessment.
Certified Community Behavioral Health Clinic:
Eliot Community Health Services
Program Features
Eliot Community Health Services, a nonprofit health system serving more than 60,000 Massachusetts patients each year, operates a Certified Community Behavioral Health Clinic that has utilized Mirah, an MIC technology solution, to build measurement into clinical encounters from the moment a patient arrives. Core measures, such as those that measure anxiety or depression symptoms, are used in conjunction with tailored assessments chosen based on a patient’s goals and treatment plan. The team at Eliot Community Health Services works to ensure that the data collected is both useful to the provider and patient-centered (easy to use, clear guidance on completion of assessments, and available in multiple forms and languages).
Hurdles
Health Information Technology
Health information technology is essential for Certified Community Behavioral Health Clinics to deliver MIC and meet required standards for quality improvement and reporting. However, these systems can be expensive for organizations to adopt. The funding associated with the Certified Community Behavioral Health Clinic’s program has allowed Eliot Community Health Services to invest in the technology needed to ensure that MIC can be integrated into the workflow.
Measuring "What Matters Most"
Many of the most common measures used in MIC focus on monitoring symptoms. But patients often define their mental health in broader, more holistic ways. To ensure that the health system was aligning treatment decisions to the patients’ goals, it began incorporating patient-centered measures, like quality of life and sense of purpose. These solutions were identified through a collaborative, participative process between leadership, providers, patients, and clinical implementation consultants. This unique approach ensured that the measurement strategy balanced both standardization and customization. This data helped providers highlight trade-offs or competing priorities. For example, a medication may reduce the symptoms of depression but negatively impact energy or sexual functioning. Bringing those issues into focus allows patients and providers to co-create treatment plans that reflect patient preferences.
Opportunities
Benefit of Certified Community Behavioral Health Clinic Model
Since the Certified Community Behavioral Health Clinic Model and its screening requirement were new to the organization, those changes provided the opportunity to onboard frontline staff who understood the program’s expectations and were excited about MIC from the beginning. Workflows and processes for the program were also built “from the ground up,” offering a unique opportunity to center patient perspectives and clinical outcomes.
Organizational Buy-In
The organization’s leadership was enthusiastic about the Certified Community Behavioral Health Clinic’s program and the integration of MIC and intentional about embedding MIC within the organization’s existing quality improvement processes. As other programs across the organization saw how impactful MIC was in supporting the Certified Community Behavioral Health Clinic to deliver quality care, an “organic” excitement about measurement spread across the organization. The organization has since adopted MIC across its programming, from traditional outpatient services to specialized in-home pediatric care and outreach programs for unhoused people and individuals with severe mental illness.
Adult Primary Care:
Northwestern Medicine West Health Accelerator
Program Features
The Northwestern Medicine West Health Accelerator is a multi-year initiative advancing measurement-informed, integrated mental health care at scale. In partnership with West Health, Northwestern Medicine, and the Meadows Mental Health Policy Institute, the Accelerator expands access to mental health services by embedding the Collaborative Care Model across 75 primary care clinics, reaching over 500,000 patients in the Chicagoland region.
As part of the broader Collaborative Behavioral Health Program, patients are screened for mental health needs during routine primary care visits. Those who screen positive are connected to a dedicated care team—including Behavioral Care Coordinators and consulting psychiatrists—who use validated clinical tools and data dashboards to inform ongoing care decisions. MIC is foundational to the model.
MIC enables longitudinal tracking of clinical progress, stratification of risk, and targeted interventions that improve outcomes while reducing care variation across sites.
Hurdles
Rapid Expansion and Consistency
As the Collaborative Care Model expands across dozens of primary care sites, ensuring consistency in clinical fidelity, data usage, and training across care teams posed a challenge. Each clinic varies in resources, workflows, and readiness to adopt population health models for psychiatric referrals.
The Accelerator has addressed this by developing standardized onboarding protocols, training modules, and feedback loops. However, scaling such a complex, data-driven model at pace requires continuous investment in training, tech enablement, and operational alignment.
Opportunities
Technology-Driven Decision Support
The Accelerator is leveraging real-time dashboards to bring MIC directly into the hands of front-line clinicians and mental health teams. These dashboards provide clinic- and patient-level insights on access, engagement, symptom trends, and clinical outcomes—enabling proactive decision-making and personalized care adjustments.
Cross-Disciplinary Collaboration
The model fosters collaboration across primary care, psychiatry, and mental health teams. Behavioral Care Coordinators are empowered to track progress through structured assessments and escalate care when data suggests deterioration. This integration enhances accountability and enables early intervention.
National Leadership in MIC
The Accelerator is positioned as a national leader in measurement-informed mental health integration. Its scale, data infrastructure, and partnership with national organizations like the Meadows Mental Health Policy Institute serve as a model for how MIC can drive both quality and equity in mental health care delivery.
Adult Primary Care:
Penn Integrated Care
Program Features
Penn Integrated Care, part of the University of Pennsylvania Health System, uses the Collaborative Care Model to integrate mental health services into more than 50 primary care practices in Southeastern Pennsylvania and New Jersey. Patients in the primary care setting are referred to, and screened by, a centralized referral management center. Patients are then stratified according to their risk level and, using a decision-support algorithm, referred to the appropriate level of care. [4]
Hurdles
Getting Payors On-Board
The organization’s ability to use MIC to report on quality measures excited payors, but payors were less familiar with specific billing codes to support the work. The organization had to invest time in educating payors about the Collaborative Care Model-specific billing codes that make it possible to reimburse for MIC, helping to bridge the gap between clinical innovation and payment policy.
Opportunities
Organizational Buy-In
To gain buy-in for the initiative, the Penn Integrated Care team worked with primary care providers to develop a Collaborative Care Model workflow that providers could easily adopt. In addition, the Penn Integrated Care team motivated primary care providers to adopt initiatives that facilitated high-quality patient care. After deploying the Collaborative Care Model, primary care providers could readily access data that showed their patients’ improvements, helping secure their support for the initiative.
The Power of Collaborative Care Models
At the start of the initiative, some primary care providers were unfamiliar with the idea of leveraging MIC for mental health. Since these primary care providers were already bought in on Collaborative Care Models as a way to deliver financially sustainable evidence-based care, the Collaborative Care Model team simply explained that MIC is at the foundation of the model. The act of screening and delivering routine assessments to patients to monitor their progress and updating their treatment plan accordingly is an example of MIC.
Adult Primary Care:
Washington State Mental Health Integration Program
Program Features
Managed by the State of Washington, the Washington State Mental Health Integration Program deployed Collaborative Care Models across more than 100 clinics for individuals with short-term disability benefits. The program resulted in meaningful impacts to patients’ health, such as shortened time to depression improvement.
Hurdles
Training Investment
The state made a significant training investment to help providers learn how to implement MIC as part of their clinical decision making.
Health Information Technology
To help address the sizable health information technology barriers associated with MIC, the state partnered with the University of Washington to build out a patient registry that would allow providers to see a panel of patients enrolled in Collaborative Care Models and to track the change in the outcome measure scores over time. In addition, the Collaborative Care Model team’s primary care provider, psychiatric consultant, and behavioral health care manager used the registry to track the last and next primary care appointments, last and next behavioral health care manager touchpoints, and flag patients they thought needed additional attention.
Opportunities
Funding Flexibility
In rolling out this program, the payor, Community Health Plan of Washington, provided participating clinics with a block grant and gave each clinic flexibility in how they used the associated funding. This flexibility helped individual clinics spend money on what they needed to implement Collaborative Care Models and MIC to fidelity, such as paying for the behavioral health care manager.
Stepped Rollout
The program’s reporting requirements were rolled out gradually, starting with collecting and reporting process measures, then outcome measures. Eventually, a portion of the block grant funds was contingent on the clinic’s associated quality indicators. MIC helped clinics improve individual patient care, which, when aggregated across the clinic, was reflected in clinic-wide quality reporting measures [5].
Adult Primary Care:
Veterans Health Administration (VHA)
Program Features
The U.S. Department of Veterans Affairs (VA) is recognized as a national leader in implementing MIC. A core infrastructure for this success is the Behavioral Health Laboratory, which provides specialized software to record and track patient-reported outcomes in a standardized manner. As of 2022, approximately 75% of VA facilities use the Behavioral Health Laboratory platform to guide mental health treatment decisions for Veterans [6]. The Behavioral Health Laboratory system operationalizes MIC by collecting measures, integrating them into clinical workflows, and presenting them in accessible formats for use in shared decision-making between clinicians and Veterans.
Hurdles
Partial Implementation and Workflow Challenges
While the Behavioral Health Laboratory and MIC have been broadly adopted, implementation is inconsistent across disciplines and settings. In some VA Primary Care settings, measures are still collected using pen and paper, limiting their utility [7]. Survey data from 230 VA providers across 47 medical centers showed variation in MIC uptake: while 58% of providers reported using MIC for at least half their patients, use was highest among psychologists and lowest among psychiatrists. This suggests that cultural and training-related differences influence adoption across professional roles [8].
Opportunities
Standardized Clinical Decision-Making
MIC provides a structured approach to treatment by enabling the “collect, share, act” model: patients complete validated measures like the PHQ-9, GAD-7, BAM, and PCL-5 regularly; clinicians and Veterans review the data together; and care plans are adjusted accordingly. This supports treatment personalization and can signal early when a treatment plan isn’t effective [6]. The Behavioral Health Laboratory also facilitates documentation that is accessible in the Mental Health Assistant file, making data usable for team-based care and clinical monitoring [8].
Team Function and Communication
In integrated care settings, MIC has the potential to significantly enhance interdisciplinary communication. A 2018 VA implementation study emphasized that full integration of patient-reported outcome measures into team-based workflows improves the function of primary care teams by enabling realtime, data-driven collaboration between primary care and mental health clinicians [7].
Adult Primary Care:
Intermountain Health
Program Features
Intermountain Health is one of the nation’s largest integrated health organizations, operating more than 400 clinics and 33 hospitals across six different states [9]. Although the organization has a culture of integrating mental health in primary care services, implementing symptom screening measures and other MIC tools was difficult to perform at scale due to the staff resources and time required for in-person data collection. In 2024, Intermountain Health partnered with NeuroFlow, a third-party digital health platform, to better capture and analyze patient data.
Hurdles
Organizational Buy-In
Primary care providers at Intermountain Health were concerned about screening patients for mental health conditions or suicide risk when they had few treatment options to which to refer patients. Through working with experts in MIC, providers came to understand that measurement was one way to stratify patients according to risk, helping them determine which patients had the most critical need for mental health services. As a result, primary care providers could make the most efficient use of the limited mental health resources available.
Opportunities
Automated Patient Engagement
Intermountain automated part of the MIC process using NeuroFlow’s platform. Patients, for example, may receive automated text messages prior to their appointments asking them to complete a mental health questionnaire. This automation and remote collection supported the adoption of MIC in new markets at Intermountain.
Pediatric Primary Care:
Magellan Health Pediatric Collaborative Care Management
Program Features
Magellan Health, a leader in mental health, helps facilitate the delivery of Collaborative Care Model services at a pediatric primary care clinic. To deliver these services, the organization contracts with Magellan Health to provide a psychiatric consultant and behavioral health care manager. In exchange, the organization pays Magellan Health a monthly fixed fee per patient enrolled in the Collaborative Care Model program.
Hurdles
Health Information Technology
Primary care clinic leaders reviewed external measurement technology solutions but elected to utilize features of their existing electronic health record which supports the Collaborative Care Model team to collect, manage, and track pediatric patients’ mental health data.
Opportunities
Organizational Buy-In
Leaders within the clinic decided that the Collaborative Care Model, supported by MIC, could be a useful tool to ensure their patients receive the highest quality mental health care and broaden mental health access for underserved pediatric populations. The support of the clinic’s leadership and the lead provider helped facilitate widespread buy-in among other providers and support staff.
Responsive to Feedback
Providers are routinely prompted to provide specific feedback to ensure the MIC implementation fits seamlessly into their clinical workflow. The Collaborative Care Model team makes iterative changes based on provider feedback, ensuring efficiency and provider satisfaction.
Medicare and Older Adults:
The Villages Health
Program Features
The Villages Health is a Florida-based health system serving more than 55,000 Medicare Advantage patients. The Villages Health utilizes a Collaborative Care Model program called Tandem Care [10] to help identify and treat older adults with mental health conditions. The organization uses NeuroFlow, a thirdparty digital health platform, to engage patients and collect data through remote assessments.
Hurdles
Breaking Stereotypes
Despite a misconception that the Medicare population would not engage with the technology [11] used to roll out remote mental health assessments, engagement with the NeuroFlow tools has been high [10]. The 1,350-person cohort using NeuroFlow logged more than 45,000 mental health activities on the platform during a six-month period.
Opportunities
The Role of Risk
The Villages Health serves more than 5,000 Medicare Advantage patients and operates under a full-risk capitation model, with payments risk-adjusted based on the clinical complexity of the patient. Under this model, the organization assumes financial responsibility for the total cost of care, creating a strong incentive to proactively identify and manage mental health conditions. MIC supports this goal by helping The Villages Health better understand the mental health needs of its population, allowing the health system to mitigate costs through early intervention and prioritize resources for those most in need [10].
Early Detection Between Visits
A retrospective study examining 587 patients who completed both in-clinic and remote digital mental health assessments between November 2021 and April 2024 found that remote assessments successfully identified rising risk in 12.9% of participants [12]. “Rising risk” is defined as patients whose remote assessment scores increased by at least 5 points and showed categorical worsening of symptom severity (e.g., from “mild” to “moderate”) compared to their previous in-clinic assessment [12].
Incentivizing Progress
Organizations that are in full-risk capitated models have more clearly aligned incentives to use MIC to reduce risk and closely manage the cost of delivering care. However, a minority of organizations are in such arrangements. For those not in full-risk capitated arrangements, financially incentivizing the collection and reporting of measures in mental health care could be a first step toward increasing the use of MIC.
Moving MIC Forward: Strategic Recommendations
The bright spots summarized in this document highlight the transformative potential of using MIC to deliver mental health care while offering critical insights into the structural and operational challenges that organizations may encounter during implementation. The innovation and leadership highlighted in the featured bright spots underscore the value of MIC as a cornerstone for advancing equitable, high-quality mental health care. Drawing from these bright spots, several strategic opportunities emerge to accelerate the adoption and sustainability of MIC, including:
Educate primary and specialty care providers, including trainees, on the expert roundtable findings and bright spots.
Encourage leading member organizations to establish standards and clinical guidelines for MIC in mental health for primary care and specialty care.
Establish a standardized set of measures that all payors and providers agree to collect and report, enabling consistent implementation of measurement-informed care across settings.
Develop clinical care guidelines that support providers in interpreting measurement scores and determining appropriate next steps, ensuring that data meaningfully informs clinical decisions and improves care quality.
Increase the use of goal attainment scaling and other patient-centered measures that ensure organizations are measuring what matters to patients.
Support policies that enable mental health providers to adopt health information technology.
Work with electronic health record vendors to ensure that MIC workflows for mental health are readily available, affordable, and easy to use.
Incentivize the adoption of mental health care delivery models, such as the Collaborative Care Model, that include MIC as a foundational element.
Inform patients and families of the availability of Collaborative Care Models, an appealing option to those who would like to receive their mental health care from their primary care provider.
Engage stakeholders in efforts to advance the COMPLETE Care Act (S.931/H.R. 2509) in Congress, which would encourage MIC adoption by incentivizing primary care providers to implement Collaborative Care Models.
References
National Council for Mental Wellbeing. Advancing measurement-Informed care In community behavioral health. 2024. https://www.thenationalcouncil.org/news/national-council-introduces-measurement-informed-care/
Lewis, C. C., Boyd, M., Puspitasari, A., Navarro, E., Howard, J., Kassab, H., Hoffman, M., Scott, K., Lyon, A., Douglas, S., Simon, G., & Kroenke, K. Implementing Measurement-Based Care in Behavioral Health: A Review. JAMA Psychiatry. 2018. https://doi.org/10.1001/jamapsychiatry.2018.3329
National Institute of Mental Health. (2024, September). Mental illness. National Institute of Mental Health. https://www.nimh.nih.gov/health/statistics/mental-illness
Wolk CB, Last BS, Livsey C, Oquendo MA, Press MJ, Mandell DS, Ingram E, Futterer AC, Klinker GP, Oslin DW. Addressing Common Challenges In the Implementation of Collaborative Care for Mental Health: The Penn Integrated Care Program. Ann Fam Med. 2021; 19(2):148-156. doi: 10.1370/afm.2651
Unützer J, Chan Y, Hafer E, Knaster J, Shields A, Powers D, Veith RC. Quality Improvement with pay-for-performance Incentives In Integrated behavioral healthcare. Am J Public Health. 2012; 102. https://doi.org/10.2105/AJPH.2011.300555
Oslin, D. W. Department of Veterans Affairs. Measurement-Based Mental Health Care. VA Research Currents. January 27, 2022.
Wray, L. O., Ritchie, M. J., Oslin, D. W., & Beehler, G. P. Enhancing implementation of measurement-based mental health care in Primary care: a mixed-methods randomized effectiveness evaluation of Implementation facilitation. BMC Health Serv Res, 2018; 18(1), 753. https://doi.org/10.1186/s12913-018-3493-z
Oslin, D. W., Hoff, R., Migongo, J., & Resnick, S. G. Provider attitudes and experience with measurement-based mental health care in the VA Implementation project. Psychiatr Serv. 2019; 70(2), 135–138. https://doi.org/10.1176/appi.ps.201800228
Intermountain Health. About us. N.d. Accessed at: https://Intermountainhealthcare.org/about
The Villages Health & NeuroFlow. The Villages Health expands access to behavioral health programs using NeuroFlow. 2024. Accessed at: https://www.neuroflow.com/the-villages-health-amplifies-the-impact-of-its-integrated-care-program-using-neuroflow/amp/
Clarke MA, Fruhling AL, Stolrus M, Windle TA, Bernard TL, Windle JR. Impact of Age on Patients' Communication and Technology Preferences In the Era of Meaningful Use: Mixed Methods Study. J Med Internet Res 2020;22(6):e13470 doi: 10.2196/13470
Holley D, Brooks A, Zaubler T, Thomas S, Reilly R. Remote behavioral health screenings can surface population risk of anxiety and depression: a retrospective database study. Innov Dig Health Diagn Bio. 2024;4:59–61. DOI: 10.36401/IDDB-24-6
