Transcript Evidence Based Practices Recovery

Integrating the Recovery
Paradigm into the
Evidence-Based Practice
Movement
The National Association of Mental Health
Planning and Advisory Councils
EBP’s and Recovery:
Friends or Foes?
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Are the values of recovery and current
evidence-based practices
fundamentally antagonistic?
What are evidence-based practices?
What is all the fuss?
What is recovery?
Can we really infuse recovery-based
principles into current EBPs?
EBP’s 101:
A Quick Overview…
Evidence-Based Practices
– Why should this be important to Planning
Councils?
Surgeon General’s Report: Gap between
knowledge of effective mental health services
and practice
 President’s New Freedom Commission – Integral
part of Transformation
 The future is now! EBPs are here to stay and
PACs need to be educated on the process,
benefits and controversy
 National Outcomes Measures
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The importance of EBPs…
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Client:
– EBPs, when used and implemented appropriately,
improve outcome
– Every individual has the right to the most effective
practices
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Mental Health System
– EBPs inculcate an outcomes-oriented, quality
improvement framework
– EBPs help identify and address administrative barriers
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General Public
– Best use of available dollars
– Credibility of interventions
Sounds like a good idea,
right?
 One mechanism to achieve quality and
accountability
 The Big Plus: Effectiveness is proven and
inherent in evidence-based practices
 The Big Gap: Surgeon General’s Report
finding of the gap between knowledge
and practice
 The Big Opportunity: Opportunities for
system reform embedded in
implementation of evidence-based
practices
Wait! We must answer a
few questions first.
What IS an Evidence-Based Practice?
Some Definitions
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An evidence-based practice is considered to be
any practice that has been established as effective
through scientific research according to a set of
explicit criteria (Drake et al, 2001).
Evidence-based treatment is the use of treatments
for which there is sufficiently persuasive evidence
to support their effectiveness in attaining desired
outcomes (Rosen and Proctor, 2002).
Evidence-based practice is the integration of best
research evidence with clinical expertise and
patient values (Institute of Medicine, 2001).
Levels of
Research/Evidence
Level I -- Randomized Controlled Trials
Level II – 1 Well designed trials without
randomization
2 Cohort or case control, preferably
multi-site
3 Multiple time series – with or without
intervention
Level III -- Opinions of respected authorities, based
on clinical experience; descriptive studies; case
reports
From Yannacci, Jacqueline, Evidence-Based Practices: Definitions, Models and Issues,
presentation at the NAMHPAC winter meeting, January 2005.
What is evidence?
SAMHSA’s National Registry of Evidence-Based
Programs and Practices (NREPP)
 Utilize 16 rating criteria (e.g. reliabilty, validity,
comparison group)
 Criteria rated 1-4, average of 16 criteria scores
 Five possible categories
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4 = Effective Program or Practice
3 = Conditionally Effective Program or Practice
2 = Emerging Program or Practice
1 = Program or Practice of Interest
0 = Insufficient Current Support
Who establishes
EBPs?
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SAMHSA – NREPP
NIMH
Cochrane Collaboration
Center for Mental Health Quality and
Accountability
To name a few…
Wading through the
jargon…
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Best Practices: Typically have a strong
research backing and have been replicated
in a variety of settings (also called
“Exemplary Practices”)
Promising Practices: Practices for which
there is considerable evidence or expert
consensus but are not yet supported by
“rigorous” scientific evidence.
Emerging Practices: Often used
interchangeably with promising practices
EBPs: So what is the
controversy?
– Legislating Evidence-Based Practices
– Using EBPs as a cost containment
strategy
– Using EBPs in exclusion of other
treatments
– What is evidence? Defining “beneficial
outcomes” – who decides?
– Recovery Paradigm
CULTURAL COMPETENCY
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Cultural competence is about adopting mental
health care to the needs of consumers from diverse
cultures
– Culture influences numerous aspects of care (help seeking
behavior, preferred settings, language, coping)
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May need to tailor EBPs themselves or the context
in which they are offered
SAMHSA Toolkits provide a number of
recommendations for making EBPs culturally
competent
– Must collect and analyze data to examine disparities in
service
– Conduct regular organizational self-assessment of cultural
competence
Now that we understand
EBPs and the potential
pitfalls…
How do we implement them in
our state?
Evidence-based Practices
Project
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EBP Implementation
Resource Kits (“toolkits”)
(Dartmouth-led
consortium)
National Demonstration
Project (IN, KS, MD, NH,
NY, OH, OR, VT)
Evidence-Based Practices for
Adults with Serious Mental Illness
Toolkit Project
Six evidence-based services in project
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Medications
Illness self-management
Assertive community treatment
Family psychoeducation
Supported employment
Integrated substance abuse/mental illness
services
Different Toolkits for
Different Audiences
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For each evidence-based practice,
there are toolkits for different
audiences
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State Mental Health Authority
Provider organization
Clinician/provider
Consumer
Family member
Child & Adolescent
Evidence-Based Practices
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Multi-systemic Therapy (MST)
Therapeutic Foster Care
Positive Behavioral Interventions and
Supports (PBIS)
rapidly
www.nri-inc.org/CMHQA/CMHQA.cfm
A word on FIDELITY…
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What is fidelity?
– Adherence to program standards and principles
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Why is fidelity important?
– The more similar the implemented practice is to the model, the
better outcomes obtained
– Diagnose program weakness/Clarify strengths
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How do we monitor fidelity?
– SAMHSA Toolkits
– Fidelity scales must adequately sample all the critical ingredients
– Must be sensitive enough to detect change as the program
develops
SAMHSA Fidelity Scales:
http://ebp.networkofcare.net/uploads/fidelityscales_6513943.htm
Fidelity in Rural, Ethnically
Diverse and Non-traditional
settings…
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Each Evidence-Based Practice developed in
certain location/population
Goodness of fit problem
– In rural, ethnically diverse, non-traditional
settings may not be possible to have full fidelity
to the model
– However, the more we modify and deviate from
the original model, need increased attention to
measuring fidelity and outcomes.
– Why? Need to measure the effects of changes in
practice in communities with differing cultures
and values.
Review of ACT Teams Using Dartmouth
Fidelity Scale (2004) - Alabama
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Along with consumers, families, and Mental Health
Association representatives, met with providers to
discuss their assessments and to review data
Reviews were conducted in July and August
There are three domains assessed:
Human Resources: structure and composition
Organizational Boundaries
Nature of Services
From Carlson, Greg, The Role of Planning Councils in Advocating
and Implementing Evidence Based Practices. Presentation at the
NAMHPAC winter meeting, January 2005.
Implementation of ACT with
High and Low Fidelity
$20,000
$15,000
$10,000
$5,000
$0
-$5,000
-$10,000
-$15,000
-$20,000
High Fidelity
Low Fidelity
Changes in Costs (2-year mean)
Source: Rosenheck, et al. 1995
Implementation of ACT with
High and Low Fidelity
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20
0
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High Fidelity
Low Fidelity
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-60
-80
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Changes in Inpatient Days (2-year
mean)
Source: Rosenheck, et al. 1995
Infusing the Recovery
Paradigm
Recovery Model: It’s all
about the outcomes…
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Recovery should be the “common,
recognized outcome of mental health
services” – President’s New Freedom
Commission
Draft Consensus Statement: “A journey of
healing & transformation for a person with a
mental health disability to be able to live a
meaningful life in communities of his or her
choice while striving to achieve full human
potential or ‘personhood’.”
New York State Office of
Mental Health: A more
productive stance …
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“… a movement toward infusing our
(consumers’) definition of quality into
evidence-based practices or any other
initiative within the mental health
service delivery system.”
Infusing recovery-based principles into mental health services: A white paper by
people who are New York state consumers, survivors, patients and expatients. September, 2004. New York State Office of Mental Health.
Integrating Ten Rules for
Quality Mental Health Services
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Informed Choice
Recovery Focus
Person Centered
Do No Harm
Free Access To Records
A System Based on Trust
A Focus On Cultural Values
Knowledge-Based
Partnership Between Consumer & Provider
Access to Services Regardless Of Ability To Pay
Another model of
integration:
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A time and place for everything:
– More controversial
– For persons who are so seriously impaired they
are unable to discern best interests, a
paternalistic, externally reasoned treatment
approach is appropriate (traditional EBPs)
– As person benefits from externally initiated
interventions, control should shift to person who
is recovering – given greater choice about
evidence-based interventions and other available
services (more recovery oriented)
– Advanced Directives means of finding a middle
ground to this stance
Factors Affecting State-Wide
Recovery-Oriented EBP
Implementation
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Workforce Development & Training
Financial Resources & Medicaid
Reimbursement
Consensus Building among all
stakeholders
Policies/procedures
Integration with performance/quality
improvement
Latest News on the EBP Front:
Federal Action Agenda
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Expand NREPP to include best evidencebased interventions
Develop procedure through which
consensus can be developed across key
mental health groups, consumer and family
members regarding implementation of EBPs
Develop new toolkits: children’s services,
older adults, supportive housing, trauma
and violence, models in primary care,
consumer-operated services and supported
education
Some Tangible Examples for
PAC Action:
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Host a planning meeting and invite stakeholders and national experts with
expertise on different evidence-based services to address the group.
Ask state mental health planning staff to discuss any plans the state is working
on for implementing evidence-based programs and different efforts to
measure quality and outcomes of these programs.
Establish a sub-committee or task force to focus on the issue of evidencebased mental health services and further explore the needs of consumers and
families in the state and how new programs can meet those needs.
Participate in consensus building by initiating statewide training/education
familiarizing key stakeholders with the evidence-based practice(s) the state
would like to implement
Block Grant:
– Review allocation of the Block Grant funds in the state and determine the
extent to which funds are being used to support implementation and
delivery of EBPs. If dollars are not being used to support EBPs, councils
can issue recommendations encouraging at least a portion of funds be
used to support recovery-oriented initiatives, consumer-operated services
and/or implementation of EBPs.
Some Tangible Examples for
PAC Action:
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Advocate for:
– consumer and family member involvement at all stages of the
planning process in development and implementation of EBPs.
– research on promising practices
– policy changes in the way services are funded in order that
flexible funding streams will be available to support evidencebased initiatives
Work with your local university department of psychology, psychiatry
and social work to identify evidence-based practices, gather and
interpret information about specific programs of interest, and
evaluate the effectiveness of exemplary State programs that have not
previously been scientifically tested.
Monitoring:
– Fidelity Assessment
– Quality assurance assessment feedback loop
– Sit on taskforce committees created to develop standards for
EBPs
Placing Consumers in the
Driver’s Seat on the EBP
Highway…
Consumer Recommendations for
Developing and Implementing EBPs
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Consumer participation in the EBP movement is
critical to its success.
The EBP movement and mental health researchers
should seek the participation of people with mental
illness in all levels of EBP development.
The EBP movement must reexamine and reallocate
their research resources that encompass the entire
breadth of program and outcomes.
EBPs must be linked to all aspects of living with a
mental illness.
What Works? What Doesn’t? Consumer perspectives and needs related to evidence-based
practices. Center for Mental Health Quality and Accountability. February, 2005
Promising/Emerging
Practices
Consumer-Operated Services
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Programs that are administratively controlled and
operated by consumers and emphasize self-help
and their operational approach
Multi-site study of 1827 participants who were
randomly assigned to either traditional MH services
or traditional MH services and peer run services
From: The Consumer-Operated Service Program Multisite Research Initiative:
Overview and Preliminary Findings. Presentation made by Jean Campbell at
the Alternatives Conference
COSP Study Results
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“Participants randomly assigned to consumeroperated services programs of the drop-in type in
addition to their traditional MH services showed
greater improvement in well-being over the course
of the study than participants randomly assigned to
only traditional mental health services at those
sites”
From: The Consumer-Operated Service Program Multisite Research Initiative:
Overview and Preliminary Findings. Presentation made by Jean Campbell at
the Alternatives Conference
Fully Integrating Consumers
into the EBP Movement
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Recognizing consumers as allies
– Develop strategies to move peer support from
a promising practice to an EBP
– Obtain pilot funding to show that existing
consumer run, peer support programs are an
EBP/Promising practice
– Expand “SAMSHA Evidence-Based
Implementation Resource Kit Steering
Committee” to include consumer researchers
and community providers
Information From: Evidence-Based Practices: Challenges and Opportunities. Presented at NMHA
2005 Annual Conference by Sara Thompson.
Integration Continued…
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Some tangible examples of steps to
integration of recovery from the consumers’
perspectives into EBPs:
– Disseminate Jean Campbell’s findings on
COSPs – fund data analysis and evaluation
– Increase mental health block grant spending
to funding promising or emerging practices set
aside for COSP
– Develop a “Consumer Information Packet” on
“the possibility of recovery” which would be
included in treatment planning materials for
providers.
Integration Continued…
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Consumers Can Address Workforce
Shortages:
– e.g. Use State Infrastructure Grants to develop a
“recovery mentor program” so a consumer
knows what to expect when s/he goes to the ER
or hospital
– Educate health care professionals, academic
health centers and related institutions on
consumer run EBPs
Integration Continued…
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Making Research More Consumer-Friendly:
– Train consumers to research promising practices to
determine what is effective and to develop implementation
strategies (e.g. a Consumer Research Institute)
– CONTAC and National Empowerment Center to convened
meeting for consumers on research and evaluation in
August, 2005 (info on CONTAC website: www.contac.org)
– Encourage NIMH to disseminate all research to consumers
in layperson language. This could be accomplished by
making it a requirement of NIMH grantees.
Integration Continued…
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Expanding and Accelerating Research Partnerships
with Consumers to Support EBP
– Advocate for NIMH/SAMHSA inclusion of consumers in
the development of RFA process
– Ensure that there are specific requirements that
consumers are consistently part of the team in design,
delivery, implementation and evaluation of SAMHSA
grantees in the development of EBPs
– Develop a systematic process for putting consumers in
touch with established NIMH researchers
EBPs: Under the Umbrella
of Recovery
RECOVERY
EBPs