Transcript Adding Technology to the Use of Evidence-Based

MARRCH 2007 Annual Conference
October 30, 2007
Adding Technology to
the Use of EvidenceBased Practices
Deni Carise, Ph.D.
Treatment Research Institute
University of Pennsylvania
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Technology and EBP’s
1. Barriers to implementing EBP’s
2. NREPP
3. DENS
4. CASPAR
5. NIDA/ATTC Blending Teams
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The Research-Practice Gap
Medications, behavioral
therapies, and clinical
interventions:
tested & shown effective in
clinical trials
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The Research-Practice Gap
But, very low rates of adoption
of these EBP’s. Possible factors
contributing to this
–Finance, complexity,
organizational structure, policy
issues
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The Research-Practice Gap
Counselors report Finance,
Training & Supervision
barriers are the greatest
contributors to the researchpractice gap
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The Research-Practice Gap
New therapies won’t be adopted
if:
– they cannot be supported by
managers and funding agencies.
– the training and supervision
burden is overwhelming
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Training Barrier
Of 400 national substance abuse treatment
centers, 20% had no staff training budget.
Decreased funding
+
Increased licensing,
accrediting, and
funding compliance
requirements

Decreased clinical
training
and
Increased attention to
administrative issues
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National Registry of Evidence-based
Programs and Practices (NREPP)
NREPP is a service of Substance Abuse
and Mental Health Services
Administration (SAMHSA)
• Began in 1997
• A searchable database of
interventions for the prevention and
treatment of mental and substance
abuse disorders
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NREPP Programs
• To date 150 programs in the
database
• NREPP recently changed the
criteria and previously approved
programs are listed under Legacy
Programs on the website
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Legacy Programs…
• Reviewed between 1997-2004
• Part of CSAP’s Model Programs Initiative
• Model Programs - science-based, effective
& readily available for dissemination
• Effective Programs - science-based,
consistently achieved positive outcomes
• Promising Programs - science-based, show
at least some positive outcomes
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Criteria for Submission to NREPP
• Quality of research
• Readiness for
Dissemination
• Descriptive Information
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Quality of Research
•
•
•
•
•
•
Reliability of outcome measures
Validity of outcome measures
Intervention fidelity
Missing data and attrition
Potential confounding variables
Appropriateness of analysis
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Readiness for Dissemination
• Availability of materials
• Availability of training and
support resources
• Availability of quality assurance
procedures
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For more info
See NREPP’s website:
www.nrepp.samhsa.gov
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Moving to Evidenced-Based
Practices…
An example with the
DENS ASI Software Program
from Evergreen Treatment
Services
Seattle, Washington
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Identify the Problem
• Track systematically the nature of
patients and their presenting problems
• Match treatment services to unmet
patient needs
• Track patient outcomes for program
evaluation and for funding and political
purposes
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Identify Outcomes
Conduct all intakes using the
Addiction Severity Index (ASI)
Have ASI intake data stored in agency
database
Use ASI information as initial
treatment planning guide
Use ASI data for program evaluation
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Assess the Organization
All intake workers will need training in
ASI administration and then on-going
Q.A. for reliability
All intake workers will need training on
computerized ASI
Treatment supervisors and counselors
will need training in how to interpret ASI
assessment
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Assess the Organization (cont’d)
Need supervision to insure
patient’s needs, identified at
intake, are being addressed in
treatment planning and delivery
I.T. Coordinator will need to
maintain database
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Assess the Audience
Regulatory agencies
Funding sources
Political entities
Board of Directors
Staff
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Identify the Approach
Training
• Intake staff
• Counselors & supervisors
• IT Coordinator
Acquire resources
• ASI Software
• Desktop computers
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Implement the Plans
Training – don’t underestimate time
necessary for this component; skill
building can’t be rushed
Resource acquisition – make sure
you forecast all of the necessary
expenses
Pay attention to staff concerns and
morale
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The Move to EBPs
How can
technology help?
The DENS System
The CASPAR Projects
THE ATTC Blending Teams
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The Drug Evaluation Network
System DENS
8 A national system collecting standardized,
automated information (using ASI)
8 that is clinically important and policy
relevant
8 on people entering addiction treatment
and their treatment programs
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The Addiction Severity Index
• Developed by Tom McLellan &
colleagues at University of
Pennsylvania
• Standardized, semi-structured,
multi-focused screening and
assessment tool
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A. Thomas McLellan
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7 Sections of the ASI
1.
2.
3.
4.
5.
6.
7.
Medical
Employment/Support
Drug
Alcohol
Legal
Family/Social
Psychiatric
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DENS System
• Benefits to the Counselor
• Benefits for Program: Aggregate
Reporting
• Leads to benefits for Clients
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DENS Software
Automates collection of the ASI data
Provides:
Automated error-checks
Comprehensive intake assessment
Room for additional comments
Automated narrative summary
Comprehensive treatment plan
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DENS ASI Software
• Software designed with input from
clinicians
• Assumed most users have little/no
computer experience
• Can enter comments for every ASI
item
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It Writes a Narrative
Summary?
Software: Hints & Comments
How Do You Tailor Treatment
to:
Groups of clients who
you know have different
drug problems?
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An Example with Gender Differences
It is widely believed that
males and females have
very different drug/alcohol
use patterns, histories and
problems
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Gender Differences?
Percent Using in the Past 30 Days
Males
50
48
Females
36
40
34 29
30
20
N=60,952
18 21
10
3
4
0
Heroin
Cocaine
Heavy Alcohol Amphetamines
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Gender Differences
Lifetime - Psychiatric Problems
56
60
40
20
42
40
32
23
10
Percent
Females
0
Suicide
Attempt
Percent
Males
Depression
Anxiety
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Gender Differences
Lifetime - Abuse History
80
63
60
40
Percent
Males
52
41
36
20
20
Percent
Females
8
0
Emotional
Physical
Sexual
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Gender Differences
Recent Abuse
25
19
20
Percent
Males
15
10
8
6
5
2
0
Emotional
Physical
0.3
2.3
Percent
Females
Sexual
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Summary
Among substance
abusers entering
treatment, divided
by gender,
differences in
substance use
variables are the
least impressive
More impressive are
differences in
Lifetime and Past 30
days data - personal
health and social
functioning
variables
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CASPAR
Computer Assisted System
for Patient Assessment and
Referrals
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Background
“Wrap-around” services have been
shown to improve treatment outcomes
But…
…few services available in
contemporary treatment programs
…finding “wrap-around” services can
be difficult
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Problem-Services Linkage
•Alcohol
•Drugs
(e.g. Employ - related services
GED training
•Medical
•Employment
•Psychiatric
Resume Development
Job Finding
Mentoring Sessions
Training Loans
Treatment Research Institute
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Assessment to Treatment Planning
1. Conduct assessment (ASI)
2. Identify problems
3. Prioritize problems
4. Develop goals to address problems (TP)
5. Write Treatment Plan including
referrals not available at your site
(CASPAR)
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What about this “Resource Guide”?
• Electronic source of local, free and low
cost programs and agencies
• Contains a wide range of services
including:
– Mental health
– Job training
– Financial support
– Emergency services (food, clothing,
housing, shelters)
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Why Was the RG Developed?
• The ASI obtains information on many
areas of the client’s life, identifying
problems that may require treatment
and/or assistance
– Often there are more problem areas that need
to be addressed than can be accomplished by
any one counselor or agency alone
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Why Was the RG Developed?
The Resource Guide makes it
easier for counselors to
address client needs that
cannot be met at their agency
by providing referrals
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Resource Guide
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A Software Screen Example
Highlight a
keyword here.
Click here for all
services matching
the keyword.
Click here to enter
patient’s zip code.
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A Software Screen Example
Click
here to
print this
page.
Click here to
view other
programs
provided by
this agency.
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Study Design
Group 1 - SA
5 Programs
Standard
Group 2 - EA
5 Programs
Enhanced
15
Counselors
18
Counselors
57
Patients
74
Patients
10 Programs
33
Counselors
131
Subjects
Procedures
• Counselors provided their ASI and TP for 5
patients
• TRI staff interviewed patients 2 and 4
weeks post-admission to see how many and
what types of services they received
• Matches between the (1) ASI and TP and (2)
the ASI and Services Received were
evaluated
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Results
Results from the first CASPAR
study on increasing servicespatient match and the number
of services received with ASI
Treatment Care Planning
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Findings
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Hypothesis 1
Patients whose counselors
receive the EA Training
will receive Treatment
Plans that better match
their problems identified
at admission
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% Matched: ASI to TCP
100
80
93
91
73
Enhanced
Assessment
Group
72
57
60
47
57
45
40
16
Standard
Assessment
Group
Emp Family Psych
All p<.05
20
20
5
8
0
Drug
Alc
Med
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Hypothesis 2
Patients whose counselors
receive the EA Training
will receive more
services
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Number of Services Received
Enhanced Assessment Group
Standard Assessment Group
30
20
10
25
19
15
5
3
D/A
Med
5
1
0
Emp
1 0
3 2
Legal
Family
D/A, Med, Emp, Psych all p<.05
3
Psych
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Hypothesis 3
Patients whose counselors
receive the EA Training
will receive Treatment
Services that better
match their problems
identified at admission
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% Matched: ASI to Services Received
Enhanced Group
100
100
93
Standard Group
100
96
92
80
80
53
60
79
78
81
75
61
40
20
0
Drug
Alc
D/A, Med & Emp all *p<.05
Med
Emp Family Psych
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Hypothesis 4
Patients whose counselors
receive the EA Training
will remain in treatment longer
and be more likely to complete
treatment
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Percent Retained at 45 Days
Enhanced
80
Standard
68%
60
40
39%
20
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Percent Retained at 90 Days
Enhanced
Standard
70
49%
50
30
12%
10
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Unexpected Finding
Counselors who
received the EA
Training remained on
the job longer
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Percent Who Quit by 6 Months
Enhanced
70
Standard
60%
50
30
20%
10
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Limitations
• This study evaluated the type and
number of services but not the
quality of services received
• No pre-study measures
• Study was limited to Philadelphia
area treatment programs
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Conclusion
• Counselors are willing to be trained & use
an electronic resource guide
• Resource guide fosters better treatment
planning and more appropriate service
utilization
• NOT YET CLEAR IF THIS WILL LEAD
TO BETTER PATIENT OUTCOMES
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NIDA CASPAR 2
The CASPAR 2 NIDA grant
will be conducted in 3
counties outside of
Philadelphia, and will use
a pre-post design
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CASPAR 2
The CASPAR 2 grant
will collect data from
20 treatment programs
and 400 patients
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Creating an Electronic
Resource Guide:
Linking Services to Client
Needs
NIDA Grant # RO1 DA015125
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Purpose and Background
Provide guidelines and instructions
for community-based SA treatment
programs to develop a customized
resource guide for use by
counselors to increase services
received by clients
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Purpose and Background
Suggestions and time estimates are based
on having developed resource guides for
3 studies in the following areas:
• Philadelphia County
• Bucks, Montgomery, and Delaware
Counties in PA
• Southern New Jersey
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Why Create an Electronic RG?
• Services for many problem areas
identified during assessment are not
available within traditional
community-based treatment
programs
• Counselors have difficulty finding
resources for these services
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Why Create an Electronic RG?
• Paper resource guides are available
but there is a need for materials that
are
1. More user-friendly
2. More easily-updated
3. Useful for counselors
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Things to Consider…
Software Program:
• Data structure & storage
Microsoft Access or Web-based
• Data entry fields
- address, hours, fees, web address,
etc.
• Standardized data dictionary
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Things to Consider…
Functionality & Layout:
• Screen layout
• Search functions
- basic and advanced
• Print functions
• Help function
• Mapquest function or public
transportation services
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Estimated time required = 10 hours
Step 1 – Identifying Services
Identify types of services to be included:
• Free / low-cost services
• Location
• Hotlines
• Medical / Psychiatric services
• Legal services / Drivers license
• Women’s services
• Employment / Vocational services
• Recovery houses
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Step 2 – Identifying Agencies
Locate available lists of resources / agencies
Suggested sources:
• Paper resource guides
• Internet sources
• Counselor resources/smaller guides
• CJS Resource list
• United Way
Our search resulted in 23 sources for the
greater Philadelphia area
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Statistics on 3 Counties in PA
Population
(Source: U.S.
Census Bureau
2006)
# of Programs
included in the
Resource Guide
Bucks
County
Montgomery
County
Delaware
County
623,205
775,688
555,996
607
1275
676
Total # of Programs included for these 3 counties= 2,558
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Step 3 – Verifying Information
Verified information by:
• Internet searches on all agencies
• Verification calls on random 10%
sample
Estimated time required:
Verifying by telephone = 40 hours per 100 agencies
Verifying by internet = 35 hours per 1000 agencies
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Verification Call Results
Bucks, Montgomery, Delaware and surrounding
Pennsylvania Counties
N = 230
11%
Correct
5%
Corrections
12%
No Answer
72%
Closed
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Step 4 – Deleting Agencies
Delete agencies that are:
1. Duplicates
2. No longer deliver services listed
3. Not appropriate
4. Closed, Disconnected / No Answer
Resulted in the deletion of 875 agencies for the
present study
Estimated time required = 15 hours
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Step 5 – Enter Program Info & Categorize
Enter Program Info:
• Standardize data
• Data enter all program information
• Check accuracy
Estimated time required:
Entering program info - 80 hours/1000 agencies
Categorizing - 20 hours/1000 agencies
Est. total time - 280 hours
Step 5 – Enter Program Info & Categorize
Sample of a Program Info Screen
NIDA ATTC Blending Team
Providing training,
dissemination and technology
transfer of EBP.
An example with the Addiction
Severity Index and Treatment
Care Planning
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NIDA Blending Teams
Who?
–NIDA Researchers
–SAMHSA's Addiction Technology
Transfer Centers (ATTCs)
What do they do?
–Work together to develop ‘products’
based on research conducted within
NIDA's Clinical Trials Network (CTN)
and other supported research
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NIDA Blending Teams
Why do they do it?
–To give treatment providers the
necessary tools to adopt science-based
interventions in community-based
programs
–Create necessary tools to allow for the
trouble-free adoption of science-based
interventions in community-based
programs
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NIDA Blending ‘Products’
Products Completed
• Buprenorphine Treatment: Training for
Multidisciplinary Addiction Professionals
• Short-Term Opioid Withdrawal Using
Buprenorphine
• M.A.T.R.S. Treatment Planning: Utilizing
the Addiction Severity Index (ASI)
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NIDA Blending ‘Products’
In Development
• Motivational Interviewing
Assessment: Supervisory Tools for
Enhancing Proficiency (MIA:
STEP)
• Promoting Awareness of
Motivational Incentives (PAMI)
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MATRS Treatment Planning
• NIDA Researchers
– Deni Carise, Ph.D., TRI
– Meghan Love, TRI
– Tom McLellan, Ph.D., TRI
• ATTCs
– Nancy Roget, Mountain West ATTC
– Dick Spence, Gulf Coast ATTC
– Pat Stilen, Mid-America ATTC
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NIDA Approved Products
A
•Trainer script
•PowerPoint slides
•CD-Rom)
•Handouts
•Reference
Lists/Examples
T
6-hour
classroom
training
NIDA Approved Products
4-week online
version
•Designed in Moodle
course management
system (CMS)
(Free, open source
software!)
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MATRS Training Package
• How ASI can be used in
clinical and program
evaluation activities
• Identifies differences
between program-driven and
individualized treatment
planning processes
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MATRS Training Package
• Focus on process of
treatment planning
• Defines guidelines and
legal considerations in
documenting client status
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Adapted Products Mountain West ATTC
Curriculum Infusion
Package
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Mid America ATTC
TX.
Plan
Check
list
http://www.mattc.org/information/smart/ASI-SMART%20BIRP%20CHECKLIST.pdf
Mid America ATTC
Documentation
Checklist
http://www.mattc.org/info
rmation/smart/ASIMART%20BIRP%20CH
ECKLIST.pdf
Mid-America ATTC
On-Line 6-week Course
In Blackboard
• Focus on
skill
development
& application
in
clinical
setting
(12 hours)
MATRS Treatment Planning Software
In
Development!
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Building a Master Problem List
Problem Statements
Building a Specific Problem Plan
Identifying Client Strengths
THANK YOU!!