1. Supporting Population‐Based Care (BHI‐I Plan for Measurement)
Learning Session #1:
Supporting Population‐Based Care
(BHI‐I Plan for Measurement)
Marc Avery, MD
Dale Jarvis, CPA
Todd Gilmer, PhD

2. LS#1: Supporting Population‐Based Care
Session Objectives
Understand BHI‐I Plan for Measurement: including options, requirements, timelines, measures and tools
Learn about plans for Population Management Tool
Understand how BHI‐I work will be evaluated and meet the evaluation team.

3. So much data, so little time!!
What are the types of data that you will be using in BHII?

4. BHII Data Categories
Measurement of team integration
and engagement
During PDSA cycles
Clinical Outcomes Measurement
Behavioral
Medical
Clinical registry
Encounter / cost data
Evaluation of the BHII effort itself

5. Why Measure Real-Time Outcomes?
Maintain clinical focus
Keep track of patients
Determine if a change
in care is needed
Patient education,
empowerment, self-management
Because it results in better outcomes!

6. What Can Clinicians Expect?
Screening and tracking tools
Registry
New workflows

7. Clinical Outcomes Tracking
Behavioral
PHQ9 plus optional second measure in 1st year
Second measure must meet T2T criteria
Kids tools need special consideration
Medical
BMI/Weight
Blood pressure
HBA1c (if diabetic or taking atypical antipsychotics).

8. Criteria for the optional Treat to Target tool
Must measure a clinically relevant symptom, function or behavioral domain.
Has a linear scoring scale that supports sequential measurement.
The tool must help the client and clinician determine progress.
The tool must be short and preferably be self-reported.