Our Clinical Outcomes Platform
What Does Premier Mental Health Treatment Mean?
We Provide Data-Informed, Outcomes Driven Treatment
Embark has invested in collecting data across more than 13 domains of client and family health, up to two years post-treatment. It is our purpose to Create Joy and Heal Generations; this requires lasting change.
Our clinicians, teachers, medical personal, front-line support staff, etc., have access to cutting-edge client diagnostics in real-time. Care providers can utilize "in the moment" data to create interventions and treatments customized to the client and family. Through the use of outcomes, we meet clients and families with a servant's heart, support the development of relationships, and ultimately, facilitate growth.
Below we show you how clinicians use outcomes to support families, and how program leadership is highly informed when making programmatic decision
Outcomes are one part of a broad framework of treatment that focuses on Neurodevelopment, Family Systems, and Experiential interventions.
We employ outcomes to measure client progress to track how the client and family is improving.
We employ outcomes to measure how the program is improving
We employ outcomes for the purpose of research to inform both client and program improvement.
Data Helps Us Make Informed, Clinically Indicated, Treatment Decisions in Real-Time
In providing care for clients and families at Embark, we are using outcomes to assess:
Client Progress & Mental Health
Client Family Health
The Embark outcomes platform allows us to look at client outcomes as a function of the therapist, house, clinic, or campus. Patterns may emerge in clients assigned to specific therapists, or different programs. The ability to evaluate client data, then look at groups of clients helps our programming improve.
This widespread research helps us to learn about the efficacy of outpatient and out-of-home treatment. It informs both client and program improvement plans. This research is also vital in demonstrating to insurance companies, school districts, governing bodies, etc., that the work we do is important and is helping families.
What Outcomes Are Not
The goal of therapy at Embark is not symptom reduction. Healthy outcomes are often correlated with health and healing, that is the goal. Co-regulation is the goal. Outcomes are tools that help us reach the goal. Outcomes data allows us to ask the right questions. The more we know, the more curious we become, and the more questions we may have.
For example, a therapist is surprised to see a client scoring as less depressed than he was previously. The therapist might wonder why the client is feeling better, but they are not noticing that in session. When they take a deeper look, the outcomes might suggest the client feels more connected with peers, which can lead to more questions; How is the client feeling with adults? Staff? Teachers? Therapists? Parents? That therapist can then dive further into the data to answer each of these questions. The therapist can develop a data-driven theory that can inform treatment.
The data is only useful when it is used to create a qualitative explanation or assessment, as part of a larger picture of what is happening.
We Use a Cutting Edge Data Visualizer to Make Real-Time Adjustments to Treatment Plans
Embark uses a platform for the collection and visualization of outcomes data that allows us to use data in real time. Specific outcomes measures differ by program, population, and level of care. But in general, each program collects data measuring overall functioning (OQ/YOQ), depression (PHQ-9) and family functioning (either FICS, FHA, or FAD).
The OQ (for adults) and YOQ are both measures of behavioral functioning and distress. The higher the score, the more distress. You will see a light horizontal line across the graph which indicates the clinical cutoff. Clients with scores below the cutoff are considered in the “healthy” range. On the bottom left, you will see a chart of colored circles. This represents the scores in each subscale. On the bottom right, you will see the client’s scores on specific items.
Using the OQ/YOQ
The OQ/YOQ graph can show us more than just the client’s data over time. We can also overlay the scores of the caregivers completing the YOQ as well (only for adolescent clients). Parents complete YOQs on their child, so we can compare the child’s and each caregiver’s score to track how the family is seeing distress and functioning. As you can see below, the client’s scores are the solid blue line, the mother a light pink line, and the father is the brown line. We can also add lines to represent all program clients and all program relatives (parents).
Survey History- Subscales
On the bottom left, there are rows and columns of colors. The rows represent the OQ/YOQ subscales, with the top row being the overall, composite score. You will see a key that shows what the colors mean. The colors are a gradient from green to red, with green being non-clinical, and dark red being the most clinical. The columns represent test instances, or each time the client completed the instrument. In the top right of the Survey History box, we can see the actual raw scores.
The heatmap above lets us see the scores over time by subscale. From this screen it is easy to tell what areas of distress the client is likely experiencing. Intrapersonal Distress is regularly more clinical, while the critical item subscale is regularly not clinical. Using the “Show Complex” button lets us see specific dates and how scores change withing the same color.
This screen also allows us to select specific scores of subscales. As we select a score of a subscale the graph above will adjust to show only the subscale. This makes it easy to track a specific subscale over time.
We can also see all the specific items (questions) and the client’s response to them. By default, they are sorted with the most severe items at the top. As we select different colors on the heatmap, the items will adjust. If we select a score in the “Somatic” subscale, the items will shift to only show the items within that subscale. This enables the provider to track specific responses to items over time.
Using Other Instruments
We can review the list of all the different survey’s the client has completed.
The chart above shows the PHQ-9 of a client. The PHQ-9 is a measure of depression, with the lower score indicating less depression.
The Parent (PESQ) and the Client (CESQ) are engagement questionnaires, measuring parent and client satisfaction with the program. These instruments are psychometrically helpful, and in addition, also collect qualitative data in the form of comments from parents and clients. In the items section, in the bottom right, we can access the direct comments.
Outcomes are Used in Treatment Team Meetings
There are several items that correlated together we often use to assess safety risk.
- YOQ- Critical Item subscale
- OQ- symptom distress subscale (question 8)
- PHQ – question 9
- Columbia Suicide Severity Rating Scale
These instruments are used to consider the safety and risk of a client before the following events:
- Ending a safety intervention
- Different privileges
- Home Visit
- Specific programming
- Program trips or travel
These items are useful in assessing safety, however, are not exhaustive safety assessments themselves. It is important to understand these scores in the context of the client’s progress and history. A client can be at risk even when scores are not in the clinical range.
The Flow of the Treatment Team
The outcomes data are used to create a holistic narrative of the client’s progress.
The primary therapist is the owner of the utilization of the outcomes for their caseload. The therapist’s job is to distill all assessments and recommend interventions. Prior to the Treatment Team meeting, the therapist will conduct an outcomes review. The following workflow is typical along with generic curiosities we may have:
View the YOQ SR (self report)/OQ for the client
- How is client trending?
- What subscales are moving up or down independently of overall score?
- Does subscale scores match qualitative data (day to day presentation)?
View relatives YOQ (YOQ 2.01)
- How are parents reporting?
- How is their report compared to clients?
- How is their report to each other?
- How are subscales trending?
View Client PHQ-9
- See safety item #9
- How is depression trending?
- How is depression manifesting on symptoms listed on YOQ/OQ (relationships, somatic, Critical Items scale, etc..)
View FICS Self(S)/FHA/FAD completed by client
- How is the family currently functioning per the client report?
- How are YOQ/OQ symptoms, depression showing up in family functioning?
- How is the family functioning overtime per the client report?
- FICS- notice client’s rating of own progress on MTP goals
View FICS Parent (P)
- How do parents view functioning?
- Compare and contrast trends with client
- How does each caregiver compare and contrast with other caregivers?
- Notice specific items. Where are alliances, hierarchies, or family roles (compare with FICS S)
- How do parents rate progress on MTP goals
Client & Parent Engagement Score Questionnaire
- How do the client and family experience treatment?
- What areas of the program are they satisfied with, and what areas might they not be?
- Look at specific comments they may have left
The therapist looks at each of these instruments and takes note of anything that may be helpful to the team in creating an overarching narrative of the current state of treatment. The primary therapist keeps a regular pulse on the outcomes data and highlights what may be helpful to the team.
The therapist will use the data, combining it with day-to-day information, to create a case conceptualization. Afterward, the team can target patterns, roles, norms, etc., that can promote dysfunction.
- Low YOQ/OQ and Low CESQ- This means the client sees herself as healthy and the program as less helpful. This is a warning predictor of an early discharge, resulting in a Non-Completion.
- Low PESQ and high FICS-P MTP problem areas- This suggests parents are not finding value in treatment, but they see their child as having made all necessary progress, predictive of a Non-Completion.
- High YOQ Intrapersonal Distress and Low PHQ9 – This suggests possible anxiety. The YOQ ID scale is distress within oneself, typically anxiety and depression. If it is high, but PHQ9 suggests low depression, there is a higher likelihood client is experiencing anxiety.
- YOQ/OQ lots of peaks and valleys combined with Critical Items- when there are big changes from instance to instance, the client may experience very intense emotions, being swayed by the moment. This client is at a higher risk for impulsive safety behaviors.
- Low YOQ/OQ and low rating of therapy on CESQ- The client is improving but as they improve connecting with the therapist less. May suggest a therapist change is needed.
- YOQ/OQ and PHQ-9 consistently High- Client is not reporting any progress. Correlate with qualitative data, phases advancements, grades, privileges, etc. The client may be feeling hopeless.
- A previous suicide attempt is the greatest predictor of future attempts, not recency of attempts.
Note that Sudden changes in a trend on any instrument are interpreted cautiously.
Outcomes use in Programming
Rather than looking at individual clients, we look at a population of clients. Looking at a group of clients together can provide treatment teams with data about how clients are interacting, and what type of programming adjustments may be in order.
We can see the average score for all clients that have completed an OQ/YOQ that instance (day in treatment). This graph helps us understand how distressed clients are at admission, during treatment, and discharge. We can view both the client and the parent YOQ scores.
We can see the entire population of clients, and know what percent of clients are healthy, who is critical, and how is the program trending from the month before. This analysis helps us understand where we need extra intervention.
The Pie Charts below give a breakdown of where clients stand. According to the image below, 36.4% of the clients at this program are falling in the healthy range, and 5.5% are in the second to most severe category. Below the pie chart is a list of the clients in the population.
The default view is to show the clients with the most regression from the prior testing at the top. Next to each client, is a color-coded box. Each box represents the severity of the score, and how many times that client has completed the instrument. It shows how each client’s scores have progressed throughout their stay.
Clicking on a section of the pie chart shows the list of clients in that category.
The pie chart on the top right shows the changes from the previous instance. Above, you can see that 20.5% of clients have an improved OQ/YOQ score, 29.5% have regressed, and 50% are unchanged. On the far left is a list of program providers, or therapists.
Program leaders can see what clients are improving or regressing easily when the data is organized this way. This also allows us to see how burdened specific therapists or teams may be when there is an increase in behavioral dysfunction.
The YOQ has 6 domains of functioning or subscales. Each subscale is added up cumulatively to provide an overall composite score. The overall composite score provides the most holistic and accurate data on current functioning, however, subscales can be very useful in understanding growth throughout treatment. With all subscales, the higher the score, the more distress exists. The subscales are:
- Intrapersonal Distress (ID)- Measure of emotional distress within the child/adolescent. This can include issues of anxiety, depression, fearfulness, hopelessness, and self-harm.
- Somatic (S)- Measure of somatic distress. Soma refers to the body. Items address typical symptoms such as headaches, dizziness, stomachaches, nausea, bowel issues, and pain or weakness in joints.
- Interpersonal Relations (IR)- The purpose of this scale is to assess issues relevant to the adolescent’s relationship with parents, other adults, and peers. This scale captures the adolescent’s attitude toward others, communication, and interaction with friends, cooperativeness, aggressiveness, arguing, and defiance.
- Critical Items- This scale measures specific features that are typically associated with the residential level of care. Such as paranoia, obsessive-compulsive behaviors, hallucination, delusions, suicide, mania, and eating disorders. A high score on any single item should receive serious attention from the provider.
- Social Problems (SP)- This scale measures problematic behaviors that are socially related. Many items describe delinquent or aggressive behavior. Aggressive content found in this scale is of a more serious nature than the aggressiveness found in IR scale. This includes truancy, sexual problems, running away from home, destruction of property, and substance abuse. Items in this subscale are typically slow to change.
- Behavioral Dysfunction (BD)- This subscale assesses the adolescent’s ability to organize tasks, complete assignments, concentrate, handle frustration including times of inattention, hyperactivity, and impulsivity. This is similar to a measure of Executive Functioning.
There are two versions of the YOQ used at Embark. The YOQ-SR (Self Report) is completed regularly by the client in treatment at our program. The YOQ 2.01 is completed by parents/caregivers. It is the same instrument with the same questions but asks caregivers to respond referencing their child. Correlating the client’s and the parent’s responses can provide insight into how each member views the client’s stress and current progress. It provides insight into family alignment (is each member seeing the distress similarly?). It provides insight into programs on how the family system is responding to program interventions.
The Outcome Questionnaire is the adult version of the YOQ. Because it is designed to be used with an adult population, the subscales are different, but work similarly with each subscale added together to create an overall composite score, with the higher the score the more distress. The subscales are:
- Symptom Distress (SD)- This scale measures subjective (symptom) distress, most related to depression and anxiety.
- Interpersonal Distress (ID)- Includes items that measure satisfaction with, and problems with, interpersonal relations. Items in this scale deal with friendships, family, family life, and marriage, and include components of friction, conflict, isolation, inadequacy, and withdrawal in interpersonal relationships.
- Social Role (SR)- This is a measure of the client’s level of dissatisfaction, conflict, distress, and inadequacy in tasks related to their employment, family roles, and leisure life. These variables are highly related to overall life satisfaction but can exist somewhat independently of intrapsychic symptoms and subjective distress.
The Patient Health Questionnaire-9 is a subset of questions from the full Patient Health Questionnaire, using the 9 items that measure depression. The PHQ 9 has 9 items scoring each of the 9 DSM V depression criteria. This instrument is primarily used to monitor the severity of depressive symptoms and their response to treatment. This instrument also contains a direct safety assessment item which can give an immediate indication of some risk for suicide. The higher the score the greater likelihood of depression, and the more severe the depression. This instrument is only administered to the client in treatment.
The Family Interaction and Communication Scale is a proprietary instrument that is designed to measure client interaction patterns and overall communication. The items ask each client, along with caregivers, to rate their relationship and interactions with each other. The utility of the FICS is in comparing the specific items between each member of the family. This instrument can facilitate the assessment of family roles, relationship structures, alliances, and alignment between the families. It is given throughout treatment to track each member of the family’s perception over time. In adolescent programs, this is also where the client and caregivers (parents) rate their progress on Master Treatment Plan goals.
The FICS-S (self) is the client version. The FICS- P (Parent) is you guessed it, the parent version.
The Client/Parent Engagement and Satisfaction Questionnaire is a standardized instrument measuring client and family satisfaction with the program. We believe that seeking parent involvement and agreement with our individual program's approach is highly important for the best outcome for the student. It asks a set of five questions that align with the treatment team plus the Ultimate Question (“Would you recommend this program to a friend”). The five treatment team questions fall into these categories:
- Front-line Staff
Every question is based on a ten-point scale and will be scored according to the NPS scale. With this, we will be able to measure parent satisfaction and engagement as well as better predict client and family alignment with the program.
Embark has a recommended battery of instruments for each program to utilize depending upon their population, level of care, and treatment setting. In addition to this, programs have some discretion to add instruments in accordance with Embark Policy and Procedure. For ease of utility, not all instruments are discussed on this page.