IMPLEMENTING EVIDENCE-BASED PRACTICES 2005 Leadership Symposium on Evidence-Based Practice in Human Services Bill Carter LCSW
CIMH EBP Dissemination • 20 Counties & 10 Private Provider Agencies • 5 New Projects for FY 2005/2006 • Featured Practices: • Incredible Years (IY) • Aggression Replacement Training (ART) • Functional Family Therapy (FFT) • Multidimensional Treatment Foster Care (MTFC) • SAMHSA Toolkits – (Adult MH/AOD) • CalMAP (Medication Algorithm) • IDDT (Integrated Dual Diagnosis Treatment)
IMPLEMENTING EVIDENCE-BASED PRACTICES Section 1: Selecting a Practice Section 2: Stakeholder Concerns Section 3: Implementation & Maintenance Section 4: The Irresistible Urge to Drift
Section 1 Selecting a Practice
Selecting a Practice • Specific to local needs and goals • Consistent with client/family (cultural) beliefs and values • Endorsed, supported or valued by agency staff • Cost to use • Cost to learn • Level of science
Definitions • No Consensus Definition of EBP • Every Practice Wants to be an EBP • Be Skeptical • Become a Knowledgeable Consumer of EBP Information
Levels of Evidence • Effective-achieves child/family outcomes, based on controlled research (random assignment), with independent replication in usual care settings • Efficacious-achieves child/family outcomes, based on controlled research (random assignment), independent replication in controlled settings • Not effective- significant evidence of a null, negative, or harmful effect • Promising-some positive research evidence, quasi-experimental, of success and/or expert consensus • Emerging -recognizable as a distinct practice with “face” validity or common sense test
Finding EBPs • Office of the Surgeon General • http://www.surgeongeneral.gov/index.html • Strengthening America’s Families (OJJDP & CSAT) • http://www.strengtheningfamilies.org • SAMHSA Model Programs • http://www.modelprograms.samhsa.gov
Finding EBPs • Evidence-Based Practices in Mental Health Services for Foster Youth – California Institute for Mental Health • http://www.cimh.org/downloads/Fostercaremanual.pdf • National Clearinghouse on Child Abuse and Neglect Information • http://nccanch.acf.hhs.gov/ • The California Child Welfare Clearinghouse for Evidence-based Practice • http://www.chadwickcenter.org/Clearinghouse.htm
Finding EBPs • SAMHSA’s National Mental Health Information Center (Adult MH Toolkits) • http://www.mentalhealth.org/cmhs/communitysupport/toolkits/ • A Roadmap to Mental Health Services for Transition Age Young Women: A Research Review – California Women’s Mental Health Policy Council • http://www.cimh.org/downloads/TAY_Final_Report_4-21-05.pdf/ • National Institute of Mental Health • http://www.nimh.nih.gov/publicat
Finding EBPs • The Guide to Community Preventive Services: Systematic Reviews and Evidence-Based Recommendations(Public Health Resources) • http://www.the communityguide.org/ • Promising Practices Network on Children, Families and Communities • http://www.promisingpractices.net • CIMH MHSA Matrix – In Hand Outs
Finding Practices • Look past the label or the “pitch” • What is the strength of the research? • Is there a comparison group? • Is there random assignment? • What was the setting? • Usual care setting? Every day clients and practitioners? • Restrictive inclusion criteria and practitioners? • Has it been independently replicated? • Has it been implemented successfully in other places?
Fidelity • Adopting-Implementing with fidelity to the program principles and practices • Most likely to result in outcomes similar to those reported in research • Adapting-Applying the practice with adjustments from the prescribed program • Adopt—Validate—Adapt—Evaluate
Section 2 Stakeholder Concerns Or 101 Reasons to Hate EBPs
Practitioner Challenges to EBP • That may work for them but not us. • How do you know that what we are doing isn’t working? • We already do that. • They are too prescribed, manualized and inflexible • What we do is an ART not a SCIENCE. • It is just a fad.
Top 4 Concerns • Limits Consumer/Practitioner Choice • Devalues Professional Expertise • Inconsistent with Consumer-Driven, Recovery Oriented, Family-Driven, Strengths-based Services • Are Not Culturally Competent
Limits Consumer/Practitioner Choice Devalues Professional Expertise • Do evidence-based practices limit consumer and family choice? • Do evidence-based practices limit practitioner choice? • Do evidence-based practices devalue professional expertise?
Limits Consumer/Practitioner ChoiceDevalues Professional Expertise.Points for Consideration . . . • What is our experience in other health care fields, when evidence-based practices are implemented well?
Defining Evidence Based Practices …the integration of the best research evidence with clinical expertise and patient values (Institute of Medicine)
Inconsistent with Consumer-Driven Services or Recovery? • What if Evidence-based Practices. . . • Shame and Blame? • Separate Families? • Are punitive? • Promote Hopelessness/Helplessness? • Are incompatible with what Consumers and Families want?
Inconsistent with Consumer-Driven ServicesPoints for Consideration . . . • EBPs for Consumers: • Are Family and Community Based • Identify Engagement as a Critical Phase • Create Hope • Identify Engagement as the responsibility of the Interventionist, not the Consumer • Focus upon Skills Building • Structured Flexibility / Individually Tailored
Are Not Culturally Competent • “Ethnic minority” populations have been abused in scientific experiments • Most research includes the limited cultural, ethnic, gender populations • There is concern that practices researched only with the majority population, will be forced upon diverse communities to their detriment
Are Not Culturally CompetentPoints for Consideration . . . • Advocate for a Culturally Competent research agenda. • Examine research supporting an EBP carefully re: culture/ethnicity/etc. • Evidence-based practices should be available, as an option, for all individuals regardless of ethnicity or culture, unless there is evidence to the contrary. (CIMH Draft Recommendation)
LV HE Level of Scientific Evidence LE Values Driven Evidence-Based Practices high sciencelow value high sciencehigh value Values Driven Evidence-Based Practices low sciencelow value low sciencehigh value LV HV Values
P(low cost) P(low cost) LV HC HE high sciencelow value high sciencehigh value Values Driven Evidence-Based Practices Values Driven Evidence-Based Cost Effectiveness Level of Scientific Evidence (x)(performance) low sciencelow value low sciencehigh value LC P(low cost) LE HC LV HV CIMH Values (y) (Importance) California Institute for Mental HealthValues Driven Evidence-Based MH Practices
Section 3 Implementation and Maintenance
Funding • How will the training be funded? • How will the practice be funded? • Will it be new funding, or re-tooling of existing funding? • Is the funding on-going? • Are there billing or other requirements? • Are the individuals responsible for billing involved in the planning?
Integrating Into the Local Service System • Where will the practice fit into the service system? • Who will be referred? • Who will be responsible for making referrals, and under what circumstances? • Who will provide the service? • Will the service be provided independently of, in addition to, or instead of other services?
Staffing • Who will be the practitioners? • How will they be selected? • Will they have a choice? • Will they have time to learn the practice? • Will they have model adherent workloads?
Learning the Practice • Who will provide the training and consultation? • How much training and consultation is needed? • How will you know if the practice has been learned? • How will the capacity to train to the practice be maintained?
Training & Fidelity • Training alone does not result in high fidelity implementation. • The level of training varies by practice but typically involves: • Intensive training (2-3 days) • Booster trainings • Daily/every contact data & weekly supervision • Evaluation of fidelity • Evaluation of outcomes
Supervision • Who will be responsible for insuring that the referrals are made? • Who will be responsible for insuring that the practices are used? • Who will support practitioners in their early efforts to learn the practice? • How will they be selected? • Will they have a choice? • Will they be involved, given sufficient time, and be supportive of the practice?
Monitoring and Evaluation • How will you know if the practice is being used with fidelity? • How will you know if the practice is working (achieving child and family outcomes)
Administrative Oversight • Who at the administrative level participated in implementation planning? • Who at the administrative level is committed to making sure that everything happens? • Who at the administrative level will review fidelity and outcome reports and oversee any needed corrections? • How will growing demand for the practice be managed? • How will staff attrition be managed?
Section 4 The Irresistible Urge to Drift
Drift • Insufficient training or supervision • Practitioners have multiple or competing duties • Little or no attention to fidelity monitoring • Failure to adhere to practice specific caseload standards
Drift • Insufficient intra- and inter-agency coordination around referrals, funding, and so forth • The mid-managers/supervisors are wary, too busy, or not supportive of the practice • Staff are not interested in/oppose the practice
Drift • Increased scrutiny and accountability (“if it does not work then….”) • Attrition of practice specific practitioners • Delays between training and service provision
Drift • The service system is involved in multiple demanding reform efforts or initiatives • Competing initiatives • Demand to use the practice before it is well-established • Interest in adapting the practice
Considerations • Select a practice that is needed and wanted • Do not over-sell the practice • Align agency support, at all levels, for the practice • Value involvement; involvement leads to ownership
Considerations • Set reasonable time frames for implementation • Designate an administrative lead • Involve administrative lead and managers/supervisors in planning • Select staff with interest, based on an understanding of the practice
Considerations • Focus on fidelity from the outset • Start strategically to build skill, confidence, capacity and success • Be sensitive to the increased scrutiny on involved practitioners • Develop strong training and consultation plans –Plan for funding them
Considerations • Be sensitive to other change initiatives impacting consumers and staff • Document results (positive results are empowering and support system capacity for change) • Evaluate new practices and existing practices, then share and discuss results
Bonus Section Child Welfare Evidence-Based Practices
Child Welfare EBPs • Family connections • Nurse family partnership • Parent-child interaction therapy • The incredible years • Early intervention foster care • Triple P parenting • Project 12 ways • Functional family therapy • Multidimensional treatment foster care
Family Connections • In-home intervention for the prevention of child neglect • www.family.umaryland.edu/community-services/fc.htm • Decrease in caregiver depression • Decrease in caregiver drug use • Increase in appropriate parenting attitudes • Increase in social support • Improved caregiver coping strategies • Promotes spirituality, cultural roots, and economic stability
Nurse Family Partnership • Intensive home visitation to promote health and welfare of parents and children • www.nursefamilypartnership.org • Improved pregnancy outcomes • Improved child health and well being • Increases economic self-sufficiency
Parent-Child Interaction Therapy • Parent-child guided intervention • www.pcit.org • Decrease child behavior problems • Increases parenting competencies
The Incredible Years • Multi-component parenting, child, teacher skills development programs • www.incredibleyears.org • Decreases child behavior problems • Increases parenting competencies • Decreases maternal stress • Strengthens parent-teacher and parent-caregiver relationships
Early Intervention Foster Care • Therapeutic foster care program • Contact: firstname.lastname@example.org • Increases foster parent competencies • Strong support for foster parents • Decrease in child behavior problems • Develops age appropriate child competencies • Improves parenting competencies • Decreases parental stress and depression • Increase in social support • Promotes reunification