Transcript Implementation of Evidence-based Practices in the New York

Implementation of Evidencebased Practices in the New York
State Office of Mental Health
Molly Finnerty, MD
Director, Adult Services Research &
Evidence-based Medicine
New York State Office of Mental Health
Defining EBPs
• Evidence-based practices (EBPs) are interventions
for which there is consistent, scientific evidence
showing that they improve consumer
outcomes.
– Those practices supported by randomized controlled
trials from two or more independent investigators
– Practices with any evidence base, where the level of
evidence is graded (randomized controlled trials to
expert opinion)
Approach to EBPS:
US vs. England
• In US:
– Development of guidelines and core sets of EBPs
– Top down approach
• In Canada and England:
– Initiated grading of evidence
– See EBPs as a process an individual clinician goes
through in delivering clinical care
– Assessment> formulate clinical question> review
literature > apply treatment > assess result
Clinical Practice Guidelines (CPG)
for Schizophrenia: Expert
Consensus Guideline
• 1996 – 1st CPG for schizophrenia
• Strengths:
– Oriented around clinical questions
– Tries to fill in the gaps where there is no evidence
• Limitations:
– Based on expert opinion – “grade C” level of evidence
– Funded by industry – perception of bias
• Uses:
– Basis for Texas Medication Algorithm Project (TMAP)
– Methodology has been used for other CPG initiatives – TMAP,
TRAAY
CPG in Schizophrenia: TMAP
• 1997-2004
• Strengths:
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–
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–
Developed by Texas to implement
Comes with a manual
Engaged stakeholders
Federal funding available to support implementation in
states
• Limitations
– Expert opinion based
– Implementation challenge- Proscriptive, requires medical
record change, difficult to assess conformance
– Industry funded – perception of bias
• Uses:
– Most widely implemented CPG among states
CPGs for Schizophrenia:
American Psychiatric Association
• 1997, 2004
• Strengths
– Comprehensive review of literature, with graded
evidence
– Endorsement of APA - high credibility
• Limitations
– Implementation challenges: More review than
recommendation, long
• Use:
– Endorsed by many managed care companies (HMOs
accredited by NCQA are required to use CPGs)
CPGs for Schizophrenia: PORT
• 1998 – Patient Outcomes Research Team (PORT)
• Strengths
– 30 concise recommendations, with supporting literature and
graded evidence
– Adherence to recommendations easy to measure
– Federal funding, AHRQ
• Limitations
– ?
• Uses:
– The guideline most frequently used in adherence studies
Conformance to Schizophrenia CPGs
• Studies:
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Lehman, et al 1998 (PORT)
Young, et al 1998 (PORT)
Hudson et al 1999 (PORT & APA)
Owen, et al 2000 (PORT & APA)
Chen, et al 2000 (PORT)
Leslie, et al 2001 (PORT)
• Modest levels of conformance across settings and
methods of evaluation
– Better for pharmacotherapy than psychosocial
• Future issues
– Reasons for non-conformance?
– Ideal levels of conformance?
PORT: Conformance Study
• 2 states, urban/rural, outpt/inpt, n=440 (Lehman 1998)
• Dose:
– 22.5% (inpt) – 32% (outpt) high
– Minorities/urban more likely to receive higher doses
• Side-effect management:
– 46% of those with EPS receive treatment
• Management of Co-morbid Conditions:
– Depression: 48-43% prevalence, 34-46% treated, lower
conformance for minorities
– Anxiety: 18-23% prevalence, 33-47% treated, lower
conformance for women inpts (6% vs. 48%), and men outpt (31
vs. 57%)
• Persistent Symptoms:
– 23-14% receive recommended adjunctive tx
National EBP Toolkit Project
• Robert Wood Johnson work group identifies 6
EBPs for SMI
• RWJ and SAMHSA fund development of a toolkit
for each (phase I)
• SAMHSA funds pilot testing of toolkits (phase II)
– 8 states, each doing 2 EBPs
• SAMHSA funds state planning grants
• SAMHSA funds implementation grants (phase III)
SAMHSA: 6 EBPs for Schizophrenia
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•
Medications
Assertive Community Treatment
Supported Employment
Illness Self Management
Integrated Dual Disorders Treatment
Family Psychoeducation
Implementation of the EBP Toolkits
• Pilot Testing in 8 states
– 50 mental health sites in 8 states
– Kansas, Indiana, Maryland, New Hampshire, NYS, Ohio,
Oregon, and Vermont
• Implementation 8 states:
– California, Hawaii, Illinois, Vermont (Co-Occurring
Disorders), Kentucky (Medication Management), Indiana
(IMR), Maryland (Assertive Community Treatment), and
Ohio (Supported Employment).
Toolkits: Content
• Information for stakeholders: Public mental
health authority, provider agencies,
clinicians, families, consumers
• Literature- key articles
• Implementation Tips
• Cultural Competence
• Workbook or clinicians
• Outcome measures
• Fidelity instruments
• Video Tapes: Introduction, Training
Toolkit: Implementation Model
• Engage
– Building readiness
– Plan
– Build consensus among stakeholders
• Implementation
– 1 year of training & consultation
– Consultants monitoring fidelity to model
• Sustaining
– Program takes over supervision role
– Program monitors itself
Assertive Community Treatment (ACT)
Rationale
High
rehospitalization
rates for most
impaired
consumers
Description
• Small caseload - 1:10
• Interdisciplinary teams
• Services in client’s
natural setting
• 24 hour coverage
• Shared caseloads
among clinicians
• Direct, not brokered
services
Who Benefits?
• Consumers with long and
frequent hospitalizations
• Repeated users of ER
services
• Homeless consumers
• Consumers with cooccurring addictive disorder
• Consumers involved with
the criminal justice system
The Evidence-Based Challenge…
ACT as a service delivery platform
May not be “implementable” in rural areas
ACT is most effective for individuals with serious barriers to
engagement; their level of service intensity need is so great
that a targeted implementation of ACT Teams will be essential
Can components of ACT
(mobility, multi-disciplinary focus)
can be adopted within the broader
range of case management and
outpatient services?
Supported Employment
Rationale
Description
Who Benefits?
Rates of
• Rapid job search
• Consumers interested
competitive
and placement
in competitive work
work are low
• De-emphasis on preand most
vocational training
consumers
and assessment
want
competitive
• Attention to
work
consumer
preferences
• Follow-along
support provided
The Evidence-Based Challenge…
Supported Employment
•State resources usually support non-competitive employment,
despite solid research showing that integrated, competitive
employment produces better outcomes
•Few individuals utilizing outpatient systems have access to
employment services
•Community/economic factors
•Access to services
Wellness Self-Management
Education
Rationale
Description
Non-adherence • Psychoeducation
to a treatment • Counseling and coaching
plan is
on early warning signs,
avoidance of stressors,
extremely
and minimization of
common and
relapses
closely
associated with • Enhancements of
medication adherence
relapse
through behavioral
tailoring, motivational
interviewing and skills
training for consumerdoctor interactions
Who Benefits?
• Consumers with
cognitive
impairments
• Consumers with a
diagnosed
psychiatric illness.
• Consumers with
psychotic
symptoms
Wellness Self-Management Education
Skills Training
Rationale
Impaired
social
functioning
predicts the
worst
outcomes
Description
Who Benefits?
• Multiple weekly
• Consumers with
training sessions
cognitive
over time (between
impairments
3 months and 1
• Consumers with a
year)
diagnosed
• Individual and
psychiatric illness
group formats
• Consumers with
• ‘In vivo’ training to psychotic
facilitate
symptoms
generalization of
skills
Wellness Self-Management Education
CBT For Psychosis
Rationale
Persistent
psychotic
symptoms are
present in 25-40%
of consumers with
schizophrenia and
persistent
psychotic
symptoms predict
relapse and
rehospitalization
Description
• Collaborative
partnership with
consumer
Who Benefits?
• Consumers with
cognitive
impairments
• Education about • Consumers with a
stress-vulnerability diagnosed
psychiatric illness.
• Behavioral tests
• Consumers with
psychotic
symptoms
The Evidence-Based Challenge…
Wellness Self Management Education
•Existing funding streams make personalized in
vivo instruction difficult to support
•Effective practice requires continual coaching and
reinforcement across all interrelated sectors based
on a coordinated plan of care
•Clinicians not trained in CBT
Family Psychoeducation
Rationale
Description
Who Benefits?
Many consumers • Provided by
• Consumers who are
live at home or
professionals
in regular contact
have contact
with their relatives
• Long-term
with relatives,
and families
(over 6 months)
and education
and support for • Focuses on
families reduces
education, stress
the stress
reduction,
increases risk of
coping skills
relapse
and other
supports
The Evidence-Based Challenge…
Family Psychoeducation
•Effective practice requires time and commitment
from family members who are often strained in
providing basic support to the individual
•Providers need access to a funding mechanism to
organize and maintain groups and classes
•Of all the EBPs providers consider most difficult
to implement
Integrated Treatment for CoOccurring Disorders
Rationale
Description
Substance
abuse worsens • Assertive
outcomes and
outreach
up to 50% of
consumers
• Stage-wise
have cotreatment
occurring
substance
abuse disorders • Harm-
reduction
approach
Who Benefits?
• Consumers
with cooccurring
substance
abuse
disorders
The Evidence-Based Challenge…
Integrated Treatment for Co-occurring Substance
Abuse Disorders
•Services are provided by two different state agencies and
need to be incorporated into a coordinated plan of care
•Effective practice requires a level of service intensity not
currently supported by existing funding and regulatory
structures
•Clinicians not training in Motivational Interviewing
Medication
(Anti-psychotic Medication Algorithm)
Rationale
Description
Who Benefits?
The antipsychotic
• The antipsychotic
Consumers taking
medication algorithm
medication
medications for
will ensure that
algorithm is an
psychiatric illness
symptoms are
outline of a rational
minimized, side
sequence of
effects are minimal,
and that there is
medications to try in
consumer choice and
the pharmacological
education.
management of
schizophrenia in
order to maximize
medication efficacy
and minimize side
effects.
NYSOMH
Recommendations
for
Pharmacological
Management of
Schizophrenia
The Evidence-Based Challenge…
Medication and medication adherence
•Poly pharmacy
•Medication adherence requires routine monitoring of
blood levels which is not currently done in many
programs and service sectors
•Requires system support of prescribing
•Physicians & other clinicians not trained in effective
strategies for promoting adherence
Combination is the key…
Effect Of Adding Strategies To Medication &
Case Management
Percent
100
90
80
70
60
50
40
30
20
10
0
Percentage of cases
having episodes of
florid psychopathology
or other evidence of
lack of efficacy of
treatment after 12
months of continued
care.
54%
27%
23%
14%
Case
Management
+ Family
Education
+ Problem
Solving
+ Social Skills
Training
Falloon, IRH, Held, T, Coverdale, JH, Roncone, R, Laidlaw, TM. (1999)
Psychosocial Interventions for Schizophrenia: A review of long term
benefits of international studies. Psychiatric Rehabilitation Skills, 3, 268290
Implementing EBPs
• What does IOM say?
• What can states/ counties do?
• What can programs do?
Crossing the Quality Chasm –
Institute of Medicine 2001
• “Between the health care we have and the health
care we could have lies not just a gap but a
chasm.”
• Aims for the 21st Century Health Care System:
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Safe
Efficient
Patient-centered
Timely
Equitable
Effective
IOM: Challenges in Delivering
Effective Care
• Science and technology advance at a rapid pace
• Approximately 10,000 RCTs yearly
• Average of 17 year time lag between RCTs
documenting effectiveness and use in practice
• Care can be exemplary, but often is not: best care
is not applied systematically
• Insufficient tools and incentives to support rapid
adoption of best practices
• “Trying harder will not work;” change will require
system redesign
 Institute of Medicine. Crossing the Quality Chasm, 2001
IOM: Applying Evidence
to Health Care Delivery
• Ongoing synthesis of medical literature and
development of practice guidelines
• Identify best practices in processes of care
• Dissemination to general public and professionals
• Decision support tools for clinicians and patients
• Goals for processes and outcomes
• Quality measures
 Institute of Medicine. Crossing the Quality Chasm, 2001
State: EBP Plan
• The SMHA has an EBP plan that includes the following
components:
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Mechanism for reviewing and prioritizing among EBPs
Scope of initial and future implementation efforts,
Outreach, education, and consensus building among stakeholders
Identify partners and community champions,
Funding sources,
Training resources,
Policy and regulatory levers to support EBP,
Role of other state agencies in supporting the EBP,
Defines how EBP interfaces with other SMHA priorities and
supports SMHA mission
State: Financing
• Financing delivery of EBPS
– Covers all costs or payments for covered costs
compensates for costs not covered
– Incentives for switch
• Financing Start-up and conversions costs
– Lost productivity for staff training,
– hiring staff before clients enrolled (e.g. ACT),
– any costs associated with agency planning and
meetings,
– changing medical records if necessary,
– computer hardware and/or software if necessary,
State: Training
• Ongoing training & technical support
– Observation/ modeling of practice in work setting
– Feedback for clinicans
– 12 months
• Quality
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credible and expert trainer
active learning strategies (e.g. role play, group work, feedback)
good quality manual, e.g. SAMHSA Toolkit
comprehensively addresses all elements of the EBP
modeling of practice for trainees
opportunities to shadow/observe high fidelity clinical work
delivered
– high quality teaching aides/materials including
workbooks/work sheets, slides, videos, handouts
State: Training (cont)
• Infrastructure/ Sustainability
– Mechanism for continuation and expansion of
training activities
– Center of Excellence
– Relationship to university
– Establishing a learning network or learning
collaborative
• Penetration of training
– Access to training state-wide
State: Leadership
• Commissioner
– Commitment
– Planning
– Delegation
• Designated EBP leader
– Authoority
– Time
– Skills
State: Policies & Regulations
• Non-State Mental Health Authority (MCD, Voc, Substance
Abuse)
– Mitigate any policies that present barriers to implementation
– Introduce policies to support EBP
• State Mental Health Authority (SMHA)
– Mitigate any policies that present barriers to implementation
– Introduce policies to support EBP
• SMHA: EBP Standards
– Define standards
– Monitor standards
– Consequences in contracts/ licesning
State: Quality
• Fidelity Assessment
– Monitor fidelity
– Feedback & clear expectations for fidleity
• Client Outcomes
– Monitor outcomes – reporting vs. database
– Feedback & clear expectations
States: Stakeholders
• Stakeholders
– Consumers
– Families
– Providers
• Engaged
– Role in supporting EBPs
– More in favor than against
Programs
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Program Philosphy – commitment to EBPs
Screen and track for eligibility for EBPs
Penetration of EBP – consumer access
Comrehensive evaluation
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Diagnoses & stage
Vocational
Support network
Bio-psychosocial risk factors
• Treatmetn plan related to EBP
• Individualized treatmetn related to the EBP
Programs
• Clinicans trained in EBP
• Clinicans supervised in EBP
• Quality Improvement:
– Quaility Assurance Committee – review EBP q6mo
– Fidleity assessment every 6 monhts
– Client Outcome monitoring every 3 months
• Client choice
EBPs in NYSOMH
• 1996: First clinical practice guideline for
schizophrenia is published the Expert
Consensus Guidelines group
– The Deputy Medical Director supports ECG
adoption
– The Commissioner endorses ECG
– 1996-1998: Psychopharmacology CME and
conferences on the guidelines arranged by
Deputy Medical Director for psychiatrists
EBPs in NYSOMH
• 1998: PORT guidelines and guideline conformance
study published.
– 1998-2000: Several Commissioner level staff initiate
independent projects within their divisions, designed to
improve quality of care in response to the PORT findings
– Division of Planning: pilot implementation of clinical practice
guidelines.
– Operations: Licensing pilot in NYC. Identify failure to deliver
EBPs, many barriers to delivery including attitudes, lack of
understanding.
– IT: attempts to embed prompts, and standardize clinical and
process outcome assessment in the automated medical record.
EBPs in NYSOMH
• 1999 – 2000: Kendra Webdale case
– Executive Retreat develops “A, B, Cs” (Accountability, Best
Practices, Coordination). For the first time EBPs have agency
wide support, and are identified as a top priority.
– Governor approves OMH plan, large influx of funding to
support EBP implementation.
• 2000: National Toolkit Project
– NYSOMH chooses a core set of EBPs matching the toolkit set
– NYS becomes on of the sites for field testing toolkits
• 2000 – 2001: Develop PR campaign
– “Winds of Change” presentations and dialogues
– June 2001: Best Practices Conference
• 2001-present: Develop and implement plan for each EBP
ACT as a Platform for EBPs:
Expansion Model
• 28 exiting programs
• No MCD funding
• Programs not licensed
• 70 programs
• MCD funded
• Licensing and certification of
ACT teams according to fidelity
to models for all EBPs
• No state-wide standards for: • State-wide uniform standards for:
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Admission
Processes of care
Assessment
Outcomes
• Current DACT fidelity
X=3.91 of 5 max score
11% high fidelity
– Admission
– Process of care assuring delivery of
all EBPs
– Assessments
– Reporting on recovery outcomes
– QI
• Goal DACT fidelity
X=4.5 of 5 max score
ACT (cont)
• 5 sites participated in National Toolkit Project
– Within 6 months fidelity most sites surpassed
previous state average
• Technical Assistance Center with CUNY
Family Psychoeducation
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Family Dialogues
Engage NAMI-NYS in evaluation of need
Technical assistance center: University of Rochester
RFP: sites to receive training and consultation
Sites selected:
– 17 sites around the state to receive initial training and
monthly consultation
– Western Care Coordination: 21 programs – collaborative
learning
– 9 sites invited to receive initial training alone; 5 accepted
• FPE grant focusing on ethnically diverse settings
• Will incorporate into PROS
Medications
• Development of PSYCKES, a software designed to
support clinical decision making
– Summarizes all medication data in easy to use formats at
patient, clinician, facility and state level
• Pilot test at Creedmoor with 5 physicians
– All target guideline recommendations endorsed, but to
varying degrees
– Recommendations with higher endorsement were more likely
to change (dose, antipsychotic monotherapy)
– 58% reduction in patients receiving dose higher than
recommended range
• Expansion to 8 inpatient OMH facilities
• Explore MCD data interface with PSYCKES
Wellness Self Management
• 4 sites participating in toolkit project
implementation of Illness Management and
Recovery
• Will incorporate into PROS
Supported Employment
• Milestones project established programs
around the state
• Technical assistance center – Coalition for
Voluntary Mental Health Agencies
• Will incorporate into PROS
Integrated Dual Disorder Treatment
• Developing an RFP for a collaborative
learning model
• Will offer to PROS programs
Self-Help
• Peer-to-peer education to increase
awareness of EBPs
• Development of Self-Help Toolkit
• Will incorporate into PROS