EvidenceEvidence--Based Practices in Based Practices in Mental Health:Mental Health:

Ready or Not, Here They ComeReady or Not, Here They Come

Michael FlaumMichael Flaum

Iowa Psychiatric Society Annual MeetingIowa Psychiatric Society Annual Meeting

October 10, 2003October 10, 2003

Cautionary noteCautionary note

“As is true with any newly popularized “As is true with any newly popularized term, the term ‘evidenceterm, the term ‘evidence--based’based’ has an has an almost intuitive ring of credibility to it… almost intuitive ring of credibility to it…

…But this…But this ring may be hollow”.ring may be hollow”.

Hoagwood K et al: EvidenceHoagwood K et al: Evidence--Based Practice in Child and Adolescent Based Practice in Child and Adolescent Mental Health Services.Mental Health Services. Psychiatr Serv 52:1179Psychiatr Serv 52:1179--1189, 20011189, 2001

Medline Search ResultsMedline Search Results

12,29812,29891391319961996--03039595141419931993--9595220019891989--9292000019661966--8888

EBMEBMEBPEBPYearsYears

EBPEBP = “Evidence= “Evidence--Based Practice(s)”Based Practice(s)”EBM = “EvidenceEBM = “Evidence--Based Medicine”Based Medicine”

Task 1: Clarification of Terms and Task 1: Clarification of Terms and ConceptsConcepts

“Best practice”?“Best practice”?

“Promising practice”?“Promising practice”?

“Evidence“Evidence--based practice”?based practice”?

“Evidence“Evidence--based medicine”?based medicine”?

How do we evaluate levels of evidence?How do we evaluate levels of evidence?

Best Practice: Generic DefinitionsBest Practice: Generic Definitions

…… policies, principles, standards, guidelines, policies, principles, standards, guidelines, and procedures that contribute to the highest, and procedures that contribute to the highest, most resourcemost resource-- effective performance of a effective performance of a discipline.discipline.

…a technique or methodology that, through …a technique or methodology that, through experience and research, has proven to experience and research, has proven to reliably lead to a desired result.reliably lead to a desired result.

Best Practices Best Practices –– Business Business definitiondefinition

A group of tasks that optimizes the efficiency A group of tasks that optimizes the efficiency (cost/risk) or effectiveness (service level) of (cost/risk) or effectiveness (service level) of the business discipline or process to which it the business discipline or process to which it contributes. contributes.

It is a standard benchmark for worldIt is a standard benchmark for world--class class operations that is replicable, transferable and operations that is replicable, transferable and adaptable across industriesadaptable across industries

What are EvidenceWhat are Evidence--Based Based Practices?Practices?

Interventions for which there is Interventions for which there is consistent scientific evidence showing consistent scientific evidence showing that they improve client outcomes.that they improve client outcomes.

Source: Drake RE et al, Psychiatric Services, 52:179Source: Drake RE et al, Psychiatric Services, 52:179--82, 200182, 2001

What is an evidenceWhat is an evidence--based based practice?practice?

Intervention with a body of evidence:Intervention with a body of evidence:-- rigorous research studies rigorous research studies -- specified target population specified target population -- specified client outcomesspecified client outcomes

Specific implementation criteria (e.g., Specific implementation criteria (e.g., treatment manual)treatment manual)

A track record showing that the practice can A track record showing that the practice can be implemented in different settingsbe implemented in different settings

Source: Bond et alSource: Bond et al

What is evidenceWhat is evidence--based medicine?based medicine?

A set of strategies derived from developments A set of strategies derived from developments in information technology and clinical in information technology and clinical epidemiology designed to assist the clinician in epidemiology designed to assist the clinician in keeping up to date with the best available keeping up to date with the best available evidence. evidence.

EvidenceEvidence--based medicine is a mixture of clinical based medicine is a mixture of clinical research, expert consensus and practitioner research, expert consensus and practitioner experience.experience.

Source: Geddes, 2000Source: Geddes, 2000

Source: MedMAP toolkitSource: MedMAP toolkit

What is EvidenceWhat is Evidence--Based Medicine?Based Medicine?

"Evidence"Evidence--based medicine involves based medicine involves evaluating rigorously the effectiveness of evaluating rigorously the effectiveness of healthcare interventions, disseminating the healthcare interventions, disseminating the results of evaluation and using those findings results of evaluation and using those findings to influence clinical practice.to influence clinical practice.

It can be a complex task, in which the It can be a complex task, in which the production of evidence, its dissemination to production of evidence, its dissemination to the right audiences, and the implementation the right audiences, and the implementation of change can all present problems". of change can all present problems".

Source: Appleby J, Walshe K and Ham C (1995).Source: Appleby J, Walshe K and Ham C (1995). Acting on Acting on the Evidence (NAHAT Research Paper No. 17). Birminghamthe Evidence (NAHAT Research Paper No. 17). Birmingham

EvidenceEvidence--Based MedicineBased Medicine

It recognizes that health care is individualized It recognizes that health care is individualized and ever changing and involves uncertainties and ever changing and involves uncertainties and probabilities.and probabilities.

Ultimately EBP is the formalization of the care Ultimately EBP is the formalization of the care process that the best clinicians have process that the best clinicians have practiced for generations".practiced for generations".

Source: McKibbon KA (1998). Evidence based Source: McKibbon KA (1998). Evidence based practice. Bulletin of the Medical Library Association practice. Bulletin of the Medical Library Association

86 (3): 39686 (3): 396--401.401.

The Evidence PyramidThe Evidence Pyramid

Levels of Evidence: Levels of Evidence: Example Example -- PORT CriteriaPORT Criteria

Level A: Good researchLevel A: Good research--based evidence, with based evidence, with some expert opinion to support some expert opinion to support recommendationrecommendation

Level B: Fair researchLevel B: Fair research--based evidence, with based evidence, with substantial expert opinion to support substantial expert opinion to support recommendationrecommendation

Level C: Minimal researchLevel C: Minimal research--based evidence, based evidence, primarily based on expert opinion and primarily based on expert opinion and significant clinical experience to support significant clinical experience to support recommendationrecommendation

Adapted from AHCPR Depression GuidelinesAdapted from AHCPR Depression Guidelines

Levels of EvidenceLevels of EvidenceExample: CSAP Typology Example: CSAP Typology

Types 1 Types 1 –– 2: “Promising Practices”2: “Promising Practices”

Types 3 Types 3 –– 5: “Best Practices”5: “Best Practices”

Type 1: The program/principle has been Type 1: The program/principle has been identified or recognized publicly, and has identified or recognized publicly, and has received awards, honors, or mentions. received awards, honors, or mentions.

Type 2: The program/principle has appeared Type 2: The program/principle has appeared in a nonin a non--refereed professional publication or refereed professional publication or journal. journal.

Levels of EvidenceLevels of EvidenceExample CSAP Typology (cont.)Example CSAP Typology (cont.)

Type 3: The program’s source documents Type 3: The program’s source documents have undergone thorough scrutiny in a have undergone thorough scrutiny in a expert/peer consensus process for the quality expert/peer consensus process for the quality of implementation and evaluation methods, or of implementation and evaluation methods, or a paper has appear in a peera paper has appear in a peer--reviewed journal. reviewed journal.

Type 4: The programs/principles have Type 4: The programs/principles have undergone either a quantitative metaundergone either a quantitative meta--analysis analysis or an expert/peer consensus process in the or an expert/peer consensus process in the form of a qualitative metaform of a qualitative meta--analysis. analysis.

Type 5: Replications of program/principle Type 5: Replications of program/principle have appeared in several refereedhave appeared in several refereedprofessional journals.professional journals.

“Best” and “Promising” vs. “Best” and “Promising” vs. “Evidence“Evidence--based” Practicebased” Practice

EvidenceEvidence--based based –– practices that have been practices that have been shown in multiple well controlled studies to shown in multiple well controlled studies to have fidelity to the original model, and to have fidelity to the original model, and to improve the stated outcomes in the target improve the stated outcomes in the target populationpopulation

Best practices Best practices –– treatment models for which treatment models for which there is some scientific evidence that it there is some scientific evidence that it enhances outcomes, but for which the evidence enhances outcomes, but for which the evidence base has not yet been adequately establishedbase has not yet been adequately established

Promising practices Promising practices –– innovative practices with innovative practices with good anecdotal reports, but not yet subjected to good anecdotal reports, but not yet subjected to systematic studysystematic study

Candidates for rigorous effectiveness studies Candidates for rigorous effectiveness studies

FidelityFidelity

The degree to which the implementation of a The degree to which the implementation of a practice is consistent with the intent of the practice is consistent with the intent of the modelmodel

“changing the sign on the door”“changing the sign on the door”

Research on ACT shows that degree of Research on ACT shows that degree of fidelity is highly correlated with outcomesfidelity is highly correlated with outcomes

Much effort now in developing and evaluating Much effort now in developing and evaluating methods to assess fidelitymethods to assess fidelity

Clarity of ConstructClarity of Construct

Is there a model that can be:Is there a model that can be:Taught?Taught?Reliably administered?Reliably administered?Evaluated for fidelity?Evaluated for fidelity?

Manualized?Manualized?

Consistency across providers / sitesConsistency across providers / sites

2001 2001 –– year long seriesyear long series

Presented rationale for emphasis on EBP’sPresented rationale for emphasis on EBP’s

Formal literature reviews on evidenceFormal literature reviews on evidence--based based practices in mental healthpractices in mental health

Introduced “National EBP project” Introduced “National EBP project” 6 “blessed” practices6 “blessed” practices

Why EBP’s? Surgeon General’s Why EBP’s? Surgeon General’s Report on Mental Health (1999)Report on Mental Health (1999)

Many advances in understanding and treating Many advances in understanding and treating mental illnesses over past few decadesmental illnesses over past few decades

Limited evidence of improved outcomesLimited evidence of improved outcomes

“Science to service” gap“Science to service” gap

Why EBP’s? Surgeon General’s Why EBP’s? Surgeon General’s Report on Mental Health (1999)Report on Mental Health (1999)

“A wide variety of effective, community“A wide variety of effective, community--based based services, carefully refined through years of services, carefully refined through years of research, exist for even the most severe research, exist for even the most severe mental illnesses yet are not being translated mental illnesses yet are not being translated into community settings.”into community settings.”

“Numerous explanations for the gap between “Numerous explanations for the gap between what is known from research and what is what is known from research and what is practiced beg for innovative strategies to practiced beg for innovative strategies to bridge it.”bridge it.”

From Ch 8: A vision for the futureFrom Ch 8: A vision for the future

EBP's: Why? Many practices commonly used EBP's: Why? Many practices commonly used for which there is evidence of Ineffectivenessfor which there is evidence of Ineffectiveness

Many of the services provided toMany of the services provided to delinquent delinquent juveniles have little or no evidence base.juveniles have little or no evidence base.

Including institutional care (RCF’s, group Including institutional care (RCF’s, group homes) homes)

Benefits achieved are not maintained in communityBenefits achieved are not maintained in community

Youth Violence:Youth Violence: A Report of the SurgeonA Report of the Surgeon General General

Washington, DC, USWashington, DC, US Public Health Service, 2001 Public Health Service, 2001

EBP's: Why? EBP's: Why?

Despite extensive evidence and agreement on Despite extensive evidence and agreement on effective mental health practices for persons effective mental health practices for persons with SMI, research shows that routine mental with SMI, research shows that routine mental health programs do not provide EBP’s to the health programs do not provide EBP’s to the great majority of clients with these illnessesgreat majority of clients with these illnesses

This finding was a major conclusion of the This finding was a major conclusion of the surgeon general’s reportsurgeon general’s report

PORT study PORT study –– the most extensive the most extensive demonstration of the problem. demonstration of the problem.

Source: Drake RE et al, Psychiatric Services, 52:179Source: Drake RE et al, Psychiatric Services, 52:179--82, 200182, 2001

Schizophrenia PORT StudySchizophrenia PORT Study

PORT PORT –– Patient Outcomes Research TeamPatient Outcomes Research Team

Sponsors: NIMH and AHCPR (Agency for Sponsors: NIMH and AHCPR (Agency for Health Care Policy and Research) 1992Health Care Policy and Research) 1992

Joint effort: Hopkins, University of MarylandJoint effort: Hopkins, University of Maryland

Goal 1: to develop recommendations for the Goal 1: to develop recommendations for the treatment of persons with schizophrenia, treatment of persons with schizophrenia, based on a synthesis of the best scientific based on a synthesis of the best scientific evidence. evidence.

Source: Lehman et al: Schizophrenia Bulletin, Source: Lehman et al: Schizophrenia Bulletin, 24:1124:11--20, 199820, 1998

PORT 1 Results: 30 Treatment PORT 1 Results: 30 Treatment RecommendationsRecommendations

Somatic Treatments: 21Somatic Treatments: 21Pharmacotherapy: 18Pharmacotherapy: 18ECT: 3ECT: 3

Psychological Treatment: 2Psychological Treatment: 2

Family Treatment: 3Family Treatment: 3

Vocational Rehabilitation: 2Vocational Rehabilitation: 2

Service Systems: (ACT) 2Service Systems: (ACT) 2

PORT 2: Conformance StudyPORT 2: Conformance Study

Survey of a stratified random sample of 719 Survey of a stratified random sample of 719 pts with schizophrenia in 2 statespts with schizophrenia in 2 states

Public, private, VAPublic, private, VAInpatient, outpatientInpatient, outpatientDrawn from multiple communitiesDrawn from multiple communities

Looked at concurrence of practice with 12 Looked at concurrence of practice with 12 PORT treatment recommendationsPORT treatment recommendations

Dichotomous ratings (conform vs. not)Dichotomous ratings (conform vs. not)

Source: Lehman et al: Schizophrenia Bulletin, Source: Lehman et al: Schizophrenia Bulletin, 24:1124:11--20, 199820, 1998

PORT Conformance Study: Findings PORT Conformance Study: Findings re: Acute Rx of Schizophreniare: Acute Rx of Schizophrenia

62.4 % receiving appropriate doses of 62.4 % receiving appropriate doses of antipsychotics (300antipsychotics (300--1000 CPZ equiv.) during 1000 CPZ equiv.) during acute phase; acute phase;

15 % on a lower dose15 % on a lower dose22.5 % on a higher dose22.5 % on a higher dose

Minority patients more likely to be on high Minority patients more likely to be on high dosesdoses

PORT Conformance Study: PORT Conformance Study: Findings re: Maintenance RxFindings re: Maintenance Rx

29.1 % receiving appropriate doses of 29.1 % receiving appropriate doses of antipsychotics (300antipsychotics (300--600 CPZ equiv.) during 600 CPZ equiv.) during maintenance phase maintenance phase

39.1 % on a lower dose39.1 % on a lower dose31.9 % on a higher dose31.9 % on a higher dose

Urban patients more likely than rural to be out Urban patients more likely than rural to be out of range and to be on high dosesof range and to be on high doses

Use of Adjunctive Medications Use of Adjunctive Medications (among those who need* them)(among those who need* them)

22.8 / 41.322.8 / 41.317.8 / 33.317.8 / 33.3Adjunctive Anxiety MedsAdjunctive Anxiety Meds

42.8 / 45.742.8 / 45.748.3 / 33.848.3 / 33.8Adjunctive Depression MedsAdjunctive Depression Meds

25 / 14.425 / 14.425 / 22.925 / 22.9Adjunctive Psychosis MedsAdjunctive Psychosis Meds

Outpt. Outpt. Need / gotNeed / got

Inpt. Need / Inpt. Need / gotgot

InterventionIntervention

*Need for antipsychotics – those in upper quartile on SCL psychosis subscale; need for antidepressants and anti-anxiety meds informed through a combination of ratings

Use of other interventions (among Use of other interventions (among those who should benefit)those who should benefit)

10.110.18.68.6Assertive Case Management Assertive Case Management or Assertive Community or Assertive Community TreatmentTreatment

22.522.530.430.4Vocational RehabilitationVocational Rehabilitation

9.69.631.631.6Family Therapy / PsychoFamily Therapy / Psycho--ed.ed.

Outpt. Outpt. Inpt. Inpt. InterventionIntervention

PORT PORT -- ConclusionsConclusions

Real world practice is inconsistent with Real world practice is inconsistent with practice as recommended by academicspractice as recommended by academics

“Best practices” are markedly underutilized“Best practices” are markedly underutilized

Other strategies necessary to enhance Other strategies necessary to enhance implementationimplementation

Which mental health practices Which mental health practices have a solid evidence base?have a solid evidence base?

National EvidenceNational Evidence--Based Practices Based Practices Project: SponsorsProject: Sponsors

SAMHSA SAMHSA –– Center for Mental Health ServicesCenter for Mental Health Services

Robert Wood Johnson FoundationRobert Wood Johnson Foundation

National Alliance for the Mentally IllNational Alliance for the Mentally Ill

Several state and local mental health Several state and local mental health agenciesagencies

New HampshireNew HampshireMarylandMarylandOhioOhioTexasTexasNorth CarolinaNorth Carolina

National EvidenceNational Evidence--Based Practices Based Practices Project: PhasesProject: Phases

Identification of EBP’s (~ ‘98)Identification of EBP’s (~ ‘98)

Development of initial training and evaluation Development of initial training and evaluation materials (‘98 materials (‘98 –– 99’)99’)

Piloting of EBP’s in 7 states (‘99 Piloting of EBP’s in 7 states (‘99 –– 02’)02’)

Full development of implementation “toolkits” Full development of implementation “toolkits” (‘01 (‘01 –– 02’)02’)

Broader implementation in an additional 7 Broader implementation in an additional 7 states with toolkits (‘03 states with toolkits (‘03 –– 06’)06’)

National EBP Project:National EBP Project:6 Selected Practices6 Selected Practices

Assertive Community TreatmentAssertive Community Treatment

CoCo--occurring Disorders: Integrated occurring Disorders: Integrated TreatmentTreatment

Family PsychoFamily Psycho--educationeducation

Illness Management and Recovery Illness Management and Recovery

Medication Management Approaches in Medication Management Approaches in PsychiatryPsychiatry (MedMAP) (MedMAP)

Supported EmploymentSupported Employment

National EBP project: Current National EBP project: Current GoalsGoals

Develop standardized guidelines and training Develop standardized guidelines and training materials in the form of toolkits (near materials in the form of toolkits (near completion)completion)

Demonstrate that toolkits can be used to Demonstrate that toolkits can be used to facilitate the faithful implementation of EBP’s facilitate the faithful implementation of EBP’s

Demonstrate that this results in improved Demonstrate that this results in improved outcomes in routine mental health service outcomes in routine mental health service settingssettings

Implementation Resource KitsImplementation Resource Kits

http://www.mentalhealthpractices.org/http://www.mentalhealthpractices.org/

Target PopulationTarget Population

Most well studied EBP’s in mental health are Most well studied EBP’s in mental health are targeted to adults with serious mental targeted to adults with serious mental illnessesillnesses

Generalizability to other populations and Generalizability to other populations and needs remains largely untestedneeds remains largely untested

ACT for other populations/needs, e.g. reACT for other populations/needs, e.g. re--entry from entry from prison for SMI offendersprison for SMI offendersLimited data for children’s MH issuesLimited data for children’s MH issuesLimited data for elderly MH issuesLimited data for elderly MH issues

EvidenceEvidence--Based PracticeBased Practicess vs. vs. EvidenceEvidence--Based PracticeBased Practice

Concerns about a topConcerns about a top--down modeldown model

“Blessed” practices vs. a commitment “Blessed” practices vs. a commitment to continually use outcome data to to continually use outcome data to drive resource allocation, training, etc. drive resource allocation, training, etc.

Other potential EBP’s for kidsOther potential EBP’s for kids

MultiMulti--Systemic TherapySystemic Therapy

Therapeutic Foster CareTherapeutic Foster Care

State Implementation ProgressState Implementation Progress

10 12 214 8 6

1624

19

26 125

11 2

32

3

44 1

8

46

21 6 4 621 27

01020304050

Family Psychoeduc...

ACT

Supported Employ...

Integrated MH/SA

Illness Self-Manag...

Med Algorithms

Not ImplmentingPlanningPilotingParts of stateStatewide

Source: NASMHPD Research Institute, 2001

ACT nationallyACT nationally

EBP’s in IowaEBP’s in Iowa

Several MH practices have a solid evidence Several MH practices have a solid evidence basebase

Most are targeted towards severely mentally Most are targeted towards severely mentally ill adultsill adults

These EBPThese EBP’’s are being unders are being under--utilized in Iowa. utilized in Iowa.

There are innovative practices going on There are innovative practices going on throughout the state, which should be further throughout the state, which should be further studied re their evidence basestudied re their evidence base

Dissemination and consensus building is Dissemination and consensus building is necessarynecessary

EBP’s in IowaEBP’s in IowaModel Evidence-

Based Use in

US Use in Iowa Barriers in Iowa

Assertive Community Treatment

+ + + + + + + + Shortage and misdistribution of MH professionals, funding, training of staff, awareness, rurality

Supported Employment

+ + + + + + + + Funding, oversight, family and patient concerns about loss of benefits

Family Psychoeducation + + + + ++ +

Labor intensive, attitudinal, reimbursement

Medication Treatment Algorithms

+ + + ++ + Lack of centralized mental health authority, education, enforcement, funding

Integrated substance abuse & MH services

+ + + + + + + Reimbursement, credentialing

“Promising Practices” in Iowa“Promising Practices” in Iowa

Model Evidence-Based

Use in US

Use in Iowa Barriers in Iowa

School-based Clinical MH services

+ + + + + + + Funding, decentralized distributed governance, community buy-in

Elder Outreach Programs + + + + + +

Funding, training issues, shortage and maldistribution of professionals

Early childhood Interventions

+ + + Reimbursement, parental attitudes

Mental Health Courts + + +

Judicial resistance to specialty courts, lack of large population centers within jursidictions

Factors that can enhance Factors that can enhance implementation of EBP’simplementation of EBP’s

Creating financial incentives and penaltiesCreating financial incentives and penalties

Using administrative rules and regulationsUsing administrative rules and regulations

Providing clinicians with ongoing supervision Providing clinicians with ongoing supervision and feedback and feedback

Increasing consumer demand for serviceIncreasing consumer demand for service

Factors that promote change in the Factors that promote change in the behavior of health care providersbehavior of health care providers

Disseminating strategiesDisseminating strategiesEducational events, written materialsEducational events, written materials

Enabling methodsEnabling methodsPractice guidelines, decision supportPractice guidelines, decision support

Reinforcing strategiesReinforcing strategiesPractice feedback mechanismsPractice feedback mechanisms

The steps toward full The steps toward full implementationimplementation

Consensus BuildingConsensus Building

Development of implementation planDevelopment of implementation plan

Enacting the implementationEnacting the implementation

Monitoring and evaluationMonitoring and evaluation

Consensus buildingConsensus building

Build support for changeBuild support for changeIdentify key stakeholdersIdentify key stakeholdersProvide information to all stakeholdersProvide information to all stakeholdersDevelop consensus regarding a vision for the Develop consensus regarding a vision for the practice at your agencypractice at your agencyConvey a vision and commitment to stakeholdersConvey a vision and commitment to stakeholders

Material in Resource Kits Material in Resource Kits Developed for StakeholdersDeveloped for Stakeholders

Consumers of mental health servicesConsumers of mental health services

Family members and other supportersFamily members and other supporters

Practitioners and clinical supervisorsPractitioners and clinical supervisors

Program leaders of mental health programsProgram leaders of mental health programs

Public mental health authoritiesPublic mental health authorities

Dangers of EBP’sDangers of EBP’s

Dogma Dogma –– top down approachtop down approach

“Cookbook” approach“Cookbook” approach

OverOver--reliance on diagnostic categoriesreliance on diagnostic categories

www.www.MentalHealthCommissionMentalHealthCommission.gov.gov

The Commission shall…The Commission shall…“…review the quality and effectiveness of … services “…review the quality and effectiveness of … services to individuals with SMI/SED and identify unmet needs to individuals with SMI/SED and identify unmet needs and barriers”and barriers”“…Identify innovative treatments, services and “…Identify innovative treatments, services and technologies that are demonstrably effective and can technologies that are demonstrably effective and can be widely replicated in different settings”be widely replicated in different settings”“…Formulate policy options that could be “…Formulate policy options that could be implemented to integrate effective treatments, improve implemented to integrate effective treatments, improve coordination and improve community integration”coordination and improve community integration”

New Freedom CommissionNew Freedom CommissionSubSub--CommitteesCommittees

Acute CareAcute Care

Children and FamiliesChildren and Families

Consumer Issues Consumer Issues

CoCo--Occurring Occurring Disorders Disorders

Criminal Justice Criminal Justice

Cultural CompetenceCultural Competence

Employment and Employment and IncomeIncome

Evidence Based Evidence Based PracticesPractices

Housing and Housing and Homelessness Homelessness

Interface with General Interface with General MedicineMedicine

Medicaid and MedicareMedicaid and Medicare

MedicationsMedications

Older AdultsOlder Adults

Rights and EngagementRights and Engagement

Rural IssuesRural Issues

Suicide PreventionSuicide Prevention

EBP Subcommittee Report EBP Subcommittee Report (draft 11/02)(draft 11/02)

CMHS (SAMHSA) and NIMH (NIH) should CMHS (SAMHSA) and NIMH (NIH) should strengthen their collaboration in planning, strengthen their collaboration in planning, fielding, and evaluating mental health service fielding, and evaluating mental health service programs in evidenceprograms in evidence--based practices. based practices.

They are encouraged to collaborate with other They are encouraged to collaborate with other federal agencies, state and local federal agencies, state and local govgov’’tsts, as , as well as private organizations.well as private organizations.

The process must involve all stakeholders, The process must involve all stakeholders, including consumers and families, in an effort including consumers and families, in an effort to improve the relevance and generalizability to improve the relevance and generalizability of the research and other efforts to advance of the research and other efforts to advance knowledge.knowledge.

New Freedom CommissionNew Freedom CommissionEBP Subcommittee Report (Draft 11/02)EBP Subcommittee Report (Draft 11/02)

The failure of most mental health service The failure of most mental health service financing mechanisms to pay adequately for financing mechanisms to pay adequately for evidenceevidence--based practices is one of the most based practices is one of the most important reasons for problems with important reasons for problems with implementation. implementation.

It is essential to reduce financial barriers to It is essential to reduce financial barriers to providing evidenceproviding evidence--based practices. based practices.

The subThe sub--committee suggests a range of committee suggests a range of strategies and tactics to assure financing:strategies and tactics to assure financing:

Source: Draft Report of the Subcommittee on EvidenceSource: Draft Report of the Subcommittee on Evidence--Based Practices Based Practices November 26, 2002November 26, 2002

Recommended Strategies to Recommended Strategies to Finance EBP’s in MHFinance EBP’s in MH

Modify Medicaid and MedicareModify Medicaid and MedicareAssure EBP’s are coveredAssure EBP’s are coveredRates should be set to provide incentives to Rates should be set to provide incentives to providersproviders

Using the Mental Health Services Block Grant Using the Mental Health Services Block Grant to Initiate Evidenceto Initiate Evidence--Based PracticesBased Practices

Source: Draft Report of the Subcommittee on EvidenceSource: Draft Report of the Subcommittee on Evidence--Based Practices Based Practices November 26, 2002November 26, 2002

EBP Subcommittee Report*: EBP Subcommittee Report*: Using the Mental Health Block Grant to Using the Mental Health Block Grant to

Support EvidenceSupport Evidence--Based PracticesBased Practices

““Even though it represents a small Even though it represents a small portion of state mental health portion of state mental health resources, the block grant is a flexible resources, the block grant is a flexible source of financing for initiating and source of financing for initiating and supporting evidencesupporting evidence--based practices.based practices.””

*Source: Draft Report of the Subcommittee on Evidence*Source: Draft Report of the Subcommittee on Evidence--Based Practices Based Practices November 26, 2002November 26, 2002

EBP Subcommittee Report*: Specific EBP Subcommittee Report*: Specific RecommendationsRecommendations

““The subThe sub--committee recommends that committee recommends that state mental health directors be state mental health directors be encouragedencouraged to continue to use these to continue to use these federal resources to implement federal resources to implement evidenceevidence--based practices but that they based practices but that they be be requiredrequired to use the block grant to to use the block grant to create an infrastructure, such as a create an infrastructure, such as a center for implementing evidencecenter for implementing evidence--based practices in each state.based practices in each state.””

*Source: Draft Report of the Subcommittee on Evidence*Source: Draft Report of the Subcommittee on Evidence--Based Practices Based Practices November 26, 2002November 26, 2002

EBP’s in Iowa’s Block GrantEBP’s in Iowa’s Block Grant

The MHA and MHPC recognize that IowaThe MHA and MHPC recognize that Iowa’’s s communitycommunity--based mental health service based mental health service system is fragmented, undersystem is fragmented, under--resourced, and resourced, and not as comprehensive as is necessary if the not as comprehensive as is necessary if the state is to fully achieve the overarching goal state is to fully achieve the overarching goal of reducing institutional bias. of reducing institutional bias.

The MHA and MHPC recognize the limitation The MHA and MHPC recognize the limitation in the capacity to dramatically expand in the capacity to dramatically expand services in light of ongoing budgetary services in light of ongoing budgetary restrictions.restrictions.

Iowa Mental Health Block Grant,2003Iowa Mental Health Block Grant,2003

EBP’s in Iowa’s Block GrantEBP’s in Iowa’s Block Grant

The MHA and the MHPC are committed to The MHA and the MHPC are committed to furthering evidencefurthering evidence--based practices. based practices.

The intent is to use increasing proportions of The intent is to use increasing proportions of block grant funds over the next several years block grant funds over the next several years as incentives for providers to enhance their as incentives for providers to enhance their capacity to provide these services. capacity to provide these services.

This will be a gradual process, involving staff This will be a gradual process, involving staff training and development, methods to training and development, methods to evaluate model fidelity, methods to evaluate evaluate model fidelity, methods to evaluate appropriateness for these services and appropriateness for these services and methods to evaluate outcomes. methods to evaluate outcomes.

Iowa Mental Health Block Grant,2003Iowa Mental Health Block Grant,2003

Technical Assistance Center for Technical Assistance Center for EBP’s in IowaEBP’s in Iowa

Established April ‘03Established April ‘03

Funded (1 year) by MagellanFunded (1 year) by Magellan“Community reinvestment” funds“Community reinvestment” funds

Initial Focus: ACT, RecoveryInitial Focus: ACT, Recovery

TAC Goals TAC Goals -- ACTACT

Establishment of statewide advisory Establishment of statewide advisory committee for ACTcommittee for ACT

Develop Iowa standards for ACT and get them Develop Iowa standards for ACT and get them into state codeinto state code

Common set of outcome measures across Common set of outcome measures across programsprograms

Review and fidelity assessment methodologyReview and fidelity assessment methodology

Identify and support training needsIdentify and support training needs

Expand ACT Expand ACT –– 2 new programs over 1 year, 2 new programs over 1 year, including at least one in a rural siteincluding at least one in a rural site

TAC goals TAC goals -- RecoveryRecovery

Establishment of statewide advisory Establishment of statewide advisory committee for Recoverycommittee for Recovery

Develop standard set of outcome measuresDevelop standard set of outcome measures

Fidelity assessment and review methodologyFidelity assessment and review methodology

Develop training methodologyDevelop training methodology

Train on WRAP in at least 3 CMHC’sTrain on WRAP in at least 3 CMHC’s100 consumers100 consumers

Readiness for EBP’s?Readiness for EBP’s?

ResearchResearchClinicalClinicalServicesServices

Administrative Administrative Data Data infrastructureinfrastructureFinancingFinancingCredentialingCredentialing

ClinicalClinical

EducationalEducationalCME’sCME’s

TraineesTrainees

Training ImplicationsTraining Implications

Tough to teach old dogs new tricksTough to teach old dogs new tricks

Get them while they are puppiesGet them while they are puppies

EBP’s should be prioritized at all levels EBP’s should be prioritized at all levels of trainingof training