Q&A from ‘Advancing Substance Use Disorder Treatment Through Measurement-Based Care’

Implementation: Making It Work in Practice

In a specialized MHSU tertiary care setting, how do we refine the choice of instruments? Should there be program-level measures or more individualized measures? And how much measuring is too much?

This is one of the most thoughtful implementation questions that came up, and the panelists addressed it directly during the session.

Dr. Resnick shared that even when organizations have large libraries of available measures, clinicians tend to gravitate toward a small handful of them. You don’t need an overwhelming number of choices; a curated menu of five to ten measures that cover the key domains relevant to your population is usually enough to support both standardization and personalization.

On the question of program-level versus individualized measures: the panelists recommend a hybrid approach. A small core set of measures, administered consistently across all clients in a program, supports aggregate reporting, quality improvement, and organizational learning. From there, clinicians and clients can add supplementary measures tailored to individual goals, concerns, or presenting issues.

As for “how much is too much”: when MBC is truly embedded into care rather than layered on top of it, it rarely feels excessive. Dr. Barber shared an example of a client who, when offered the option to stop using measures showing stable scores, actually asked to keep them, because the consistency was reassuring and the measures had become a meaningful part of their care experience. The key is integrating MBC into workflows from the start, rather than treating it as a separate administrative task.

How do we reduce administrative burden and ensure MBC feels clinically relevant rather than just additional documentation?

Co-design is the answer Dr. Scott returned to repeatedly in her implementation work at the Healing Measurement Center. Rather than rolling out a standardized MBC system from the top down, the most effective implementations involve clinical leaders, frontline counselors, and clients in designing workflows together.

Specific strategies include: fitting MBC into existing clinical touchpoints rather than creating parallel processes; using technology or EHR integration to surface measure results in real time without requiring manual data entry; and reviewing what existing documentation is actually required versus what has accumulated over time through inertia. Dr. Scott described doing formal de-implementation reviews with sites to identify and remove outdated or redundant paperwork, which creates the space and time for MBC to fit without expanding overall burden.

Is there an efficient way to prevent staff from treating MBC as a checklist rather than a clinical tool? What CQI approaches help?

This challenge (i.e. measures being completed without being meaningfully discussed) is one of the most common barriers to realizing MBC’s clinical value. A few strategies that tend to help:

(1) First, training needs to go beyond the mechanics of completing measures and address the “how” of using data in session. The Collect, Share, Act model is specifically designed to support this. It provides a practical framework for reviewing scores collaboratively with clients, exploring what the data means, and deciding together what to do next. The Yale MBCC Hub includes videos and resources on exactly this, including how to introduce MBC to clients and facilitate these conversations effectively.

(2) Second, embedding MBC review into supervision and team meetings reinforces that data is for clinical use, not just compliance. When supervisors regularly ask how measures are informing treatment decisions, clinicians internalize the difference between checkbox completion and genuine clinical practice.

(3) Third, telling stories matters. Dr. Barber emphasized throughout the webinar that hearing peers share “magic moments” when a measure opened an unexpected conversation or revealed something clinically important, is one of the most powerful ways to shift the culture around MBC. Organizations that create space for these stories, whether in supervision, team huddles, or written case examples, tend to see more sustained and meaningful adoption.

What is the most accessible way to train a large, diverse integrated workforce (nurses, social workers, counselors) to use MBC data more effectively?

Training a broad, multi-disciplinary workforce is one of the most common implementation challenges, and it’s worth addressing in layers.

At the foundational level, all staff who interact with clients and measures need to understand why MBC matters and what it looks like in practice, not just how to administer a screener. Short, role-specific training that grounds MBC in clinical examples from SUD care tends to land better than generic instruction.

At the skill-building level, the Collect, Share, Act model provides a concrete and teachable structure for using measures in session. The Yale MBCC has produced practical training resources that can be used in team training or embedded in onboarding. These are accessible through the Yale MBCC Hub.

At the ongoing support level, identifying clinical champions who have adopted MBC well and empowering them to mentor colleagues is consistently one of the most effective levers. Champions can answer practical questions, share real examples, and make the value of MBC concrete in ways that formal training often can’t.

Working with Specific Populations

How can MBC be helpful in lower-income communities where clients may not have regular access to cell phones or electronics?

Technology access is a real implementation consideration, and the answer is flexibility in how measures are administered. MBC can be delivered through multiple channels — paper forms, clinic kiosks or tablets, staff-assisted completion during session, or remote delivery via SMS or email for clients who do have device access. The clinical process and value of MBC does not require a smartphone.

For populations with limited technology access, building assessment completion into the care encounter as a natural part of intake, check-in, or session start, is often the most reliable approach. When clients complete measures with staff present, it also creates an immediate opportunity to discuss responses and begin the “share” step of Collect, Share, Act, rather than waiting for scores to arrive asynchronously.

Greenspace supports all of these delivery methods, allowing organizations to configure assessment workflows that match their clinical setting and client population.

For adolescents, we work with families and caregivers as part of treatment. If we add caregiver measures, does this make things too complicated?

It doesn’t have to, but it does require thoughtful planning. A few considerations:

1. Start simple. Before adding caregiver measures to every case, consider piloting with a subset of families and learning what works in your setting. A brief, validated caregiver report measure that covers the same or complementary domains as the youth’s self-report can add meaningful information without dramatically increasing burden.
2. Be explicit about how data will be used and shared. Adolescents and caregivers both need to understand what will be done with their responses, and there are important confidentiality considerations, particularly around substance use disclosure, that need to be addressed in your protocols before introducing caregiver measures.
3. Use discrepancies clinically. When youth and caregiver reports diverge, that’s not a problem; it’s clinically useful information. A structured conversation about different perspectives can strengthen the therapeutic relationship and help align everyone on treatment goals. The Collect, Share, Act model applies equally well to multi-informant data.

Client Resistance and Engagement

Some clients resist MBC, similar to how they resist treatment plans. How do you respond to those clients?

Resistance to MBC is often resistance to feeling evaluated or surveilled, which is a particularly understandable response in SUD care, where clients may have histories of stigma, shame, or coercive treatment experiences. A few approaches that help:

1. Reframe the purpose explicitly. MBC is not about judgment or compliance, it’s a tool for the client to communicate how they are doing, to see their own progress, and to guide what happens in treatment. When clients understand that measures exist to serve them, not to report on them to funders or administrators, resistance often softens.
2. Involve clients in choosing measures. When clients have some say in which domains are tracked, what matters to them, and what they want to pay attention to, they tend to experience MBC as more relevant and less imposed.
3. Start with quality of life or recovery-oriented measures rather than symptom or use-focused ones. For clients who are already sensitive about their substance use, beginning with measures that surface strengths, values, and wellbeing can be a lower-stakes entry point that builds engagement before introducing more clinical metrics.
4. Use measures in session, visibly and collaboratively. Clients who see their scores reviewed and discussed in real time and who experience MBC as a genuine conversation rather than data collection, are much more likely to find it meaningful. Dr. Barber described a client who, after consistently seeing a happiness item on their measure, began noticing small moments of joy in their daily life between sessions, a spontaneous and therapeutic effect of the measurement process itself.

Is there value in more frequent, shorter interactions that use targeted questions to help clients track their progress and see how treatment is improving their life?

Yes, and this reflects exactly the intent of MBC as a clinical practice. The goal is not simply to accumulate data points, but to create regular, structured opportunities for clients to pause, reflect, and recognize their own progress or identify what’s not working. Research consistently shows that this kind of feedback-informed care improves outcomes and reduces dropout.

Frequent, brief check-ins can be particularly valuable in SUD care, where week-to-week fluctuation is common and small positive changes (i.e. improved sleep, stronger social connection, reduced cravings) may not register as meaningful to a client unless they are made visible. Tracking these shifts over time and showing clients their trajectory can build the sense of agency and momentum that supports continued engagement and recovery.

The key is that data collected must be discussed. Completing measures without reviewing them together removes the clinical value entirely.

Data, Outcomes, and Making the Business Case

As a clinical leader trying to build a business case for MBC in a SUD organization, what quality and ROI arguments are most compelling?

Dr. Scott addressed this directly, and her answer mirrors what Greenspace hears consistently from partners across the sector.

The strongest quality arguments center on: (1) improved treatment alliance and engagement; (2) earlier identification of non-response, allowing timely treatment adjustments; (3) better retention in care, which is a chronic challenge in SUD services; and (4) more consistent clinical formulation and documentation across large, complex caseloads.

From an ROI perspective, organizations that implement MBC with fidelity, meaning they actually discuss and act on data, not just collect it, see measurable improvements in client outcomes that support contract renewals, value-based care arrangements, grant reporting, and accreditation requirements.

Dr. Resnick added a point about sequencing: before aggregated data becomes meaningful for program-level reporting, you need high enough adoption at the clinician and client level. The business case for MBC starts with the clinical case, where organizations use success stories, improved outcomes, and clinician testimonials to build internal momentum. Aggregate reporting value follows as uptake increases.

For organizations still building that internal case, Greenspace’s ROI Calculator can help quantify the potential impact of MBC implementation on outcomes and costs.

How do you summarize the impact of a program when using multiple measures? Which do you select for pre-post evaluation when you have many measurements?

This is both a methodological and a communication question, and the answer depends on your audience.

For internal quality improvement, trend data on a core set of measures, ideally the same small set administered consistently across your client population, gives you the most actionable picture. Measures with reliable change benchmarks (such as the PHQ-9 or GAD-7, which have published minimal clinically important difference thresholds) allow you to report on the percentage of clients who achieved reliable improvement, not just average score changes.

For external reporting to funders, payers, or accreditation bodies, select measures that align with the outcomes those stakeholders care about and that are recognized in the field. For SUD, this often includes substance use frequency or severity, quality of life, and functional status. HEDIS measures (see the question below) may also shape what you report to behavioral health managed care organizations.

When communicating impact broadly, pair quantitative outcome data with qualitative case examples. Numbers alone rarely move people; a concrete story of how a client’s trajectory changed because of an MBC-informed treatment adjustment makes the value of the data legible to non-clinical audiences.

How does MBC tie into HEDIS and the SUD measurements HEDIS is looking to enforce?

HEDIS (Healthcare Effectiveness Data and Information Set) includes several SUD-related measures that behavioral health and integrated care organizations increasingly need to report on, including measures related to initiation and engagement in SUD treatment (IET), follow-up after emergency department visits for alcohol and drug use (FUA/FUD), and more recently, outcome-focused measures for alcohol and drug use disorders.

MBC directly supports performance on these measures by creating consistent, documented evidence of clinical engagement, treatment monitoring, and response to deterioration. Organizations that implement MBC well are typically in a stronger position on HEDIS SUD metrics because they have systematized the clinical processes those metrics are designed to incentivize.

That said, MBC should not be designed around HEDIS. The clinical value comes first, and the compliance benefits follow from genuine implementation. If you’re designing your MBC program primarily to check HEDIS boxes, you’re likely to end up with a measure-collection process that doesn’t improve care, which ultimately won’t serve either goal.

Measuring Harm, Risk, and Level of Care

ASAM Level of Care criteria focuses on the likelihood of harm occurring as a key indicator. What standardized measurement exists for the concept of “harm”?

The panelists were direct about this: there is no widely used, validated measure in the MBC literature that is specifically designed to assess “harm” as ASAM defines it for level of care determination. That is an important gap.

What MBC can do in this context is support the broader clinical judgment process around level of care. By tracking symptom severity, functional status, and risk indicators over time, MBC data provides a structured evidence base for decisions about whether a client needs a higher or lower level of care. It ultimately helps flag when someone isn’t responding to the current level of treatment, when withdrawal symptoms or cravings are worsening, or when social and environmental risk factors are intensifying.

Dr. Resnick also noted an important distinction: not all clinical assessment is MBC. Standardized assessments used for level of care determination, harm assessment, or diagnostic purposes are distinct from the routine outcome monitoring that defines MBC. The ASAM criteria process involves clinician-administered structured assessment tools that are different in purpose and design from the patient-reported outcome measures used in ongoing MBC practice. Both have a role and serve complementary functions in a well-structured SUD program.

For harm-reduction-oriented organizations specifically, some are using measures of overdose risk (e.g., questions about recent overdose or near-miss, current fentanyl exposure, naloxone access) as supplementary items within their MBC approach, even if these aren’t packaged as formal validated scales. Working collaboratively with clients on these questions within a Collect, Share, Act framework can itself be a form of harm reduction, creating structured opportunities for honest conversation about risk.

Can MBC help identify when a client needs a different level of care?

Yes, and this is one of its most practical clinical uses in SUD settings. As Dr. Scott described, when you are tracking client status over time through MBC, deteriorating scores or persistent non-response to treatment become visible in a way that is harder to see without structured measurement. That data can support a clinical judgment to step up care intensity, refer to a higher level of service, or revisit the treatment plan.

This is particularly important in outpatient SUD settings, where clients may underreport difficulty or deterioration in conversation but communicate it more honestly when completing a self-report measure. MBC creates an additional communication channel — one that is structured and consistent enough to support meaningful level-of-care monitoring over time.

Still have questions?

If you’re interested in learning more about implementing MBC in your SUD program, we’d love to connect. Book a call with a Greenspace implementation specialist, or explore our resources below:

• Yale MBCC Hub — practical guides, videos, and implementation resources from the Yale Measurement-Based Care Collaborative
• Assessments Hub — detailed guidance on over 40 commonly used measures, including SUD-relevant tools
• What is Measurement-Based Care? — an overview of the MBC model and the evidence behind it