MACMHB Boardworks 2.0 May 20, 2014 Dave Schneider, CEO

Northern Michigan Regional Entity

What are Evidence Based Practices Background – How Did We Get Here Where, Exactly, Is “Here” Sustainability Questions

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

Specific implementation criteria A track record showing that the practice can be

implemented in different settings Role for Emerging Promising Practices Evidence-based practices are practices that

integrate best research evidence with clinical expertise and patient values (Institute of Medicine, 2001)

Evidence-based behavioral practice (EBBP) "entails making decisions about how to promote health or provide care by integrating the best available evidence with practitioner expertise and other resources, and with the characteristics, state, needs, values and preferences of those who will be affected

Source: Wikipedia - The Free Encyclopedia

Overall this shift toward the use and development of EBPs in behavioral health services is moving in a positive direction. However, many of these EBPs are tested in urban areas, and are not easily adapted to rural areas without losing key components of the tested practice.

Due to the difficulty of developing and evaluating EBPs, the term, “promising practice,” has been used to refer to behavioral health practices that do not yet have the evidence-base to be considered EBPs, but which appear to be effective based on a less stringent definition of research evidence or preliminary and/or simple data evaluation.

The term, “best practice,” is used to refer to a practice which is generally thought to be effective based upon anecdotal evidence, but for which objective data is lacking.

Rural Behavioral Health Programs and Promising Practices, June 2011, DHHS, HRSA

Practices for which scientific evidence is building

Ongoing research to validate their effectiveness

Address a widely held client need or gap in

service system

Practices for which the research base is currently limited or inconclusive with regard to effectiveness

Approaches that consumers and families

request and find helpful

Common concerns regarding EBP and why they should not be concerns: ◦ EBP is not “person-centered” ◦ Focus should be on outcomes, without defining

how to achieve the outcomes ◦ Innovation is stifled ◦ EBP is not recovery-oriented and may in fact

conflict with a recovery orientation

Links research findings to patient care Links consensus treatment guidelines to

patient care Emphasizes measurable outcomes Encourages the use of science to refine and

advance clinical treatment Sets the stage for a process of continually

and systematically evaluating effectiveness.

Blind application of treatment recommended by researchers

“Cook book care” Ivory tower care Just another name for what clinicians have

been doing all along

Provides a solid foundation from which to help a consumer

More likely to get the results you want Provides evidence of effectiveness Tying treatment to outcome assessment

allows for more informed clinical judgment and clinical decision-making

Much more rewarding experience for both consumer and clinician

Evidence-Based Practice (EBP)

Consumer’s Goals and Strengths

Evidence-Based Practice

Community Resources

Clinical Circumstances

Effective EBP

The new challenge now is to broaden our perspective.

Not just talking about evidence-based behavioral practices – we are moving to integrated care.

Additional new challenges for direct care staff, clinical managers, executive directors and Board members.

EBP Steering Committee Initial Meeting July 21, 2004 Response to Governor’s Cabinet Priority

Initiative Short 2-3 month timeline to document

movement Evolved into ongoing groups Nearly 10 years later….. ◦ Has this lost steam… ◦ Latest draft policy….Trauma Informed Care Policy

Initial Approach Appeared to Be Creation of EBP Institute

Through Dialogue New Approach of Shared Leadership between MDCH, CMHSPs/PIHPs and Universities

Rationale ◦ Cost Savings ◦ Commitment - People Support What They Help to

Create ◦ Expertise Exists Within the State ◦ Need for MACMHB/PIHPs/CMH to take lead

Extensive Discussion of the “levels of EBP” Presentations on unique “EBPs” Extensive discussion on “thwarting

innovation” ◦ Innovation and local adaptation is possible with

expert consensus

Settled on nationally accepted EBPs that met the earlier definition AS THE STARTING POINT

Linkages within state with existing national

experts with the SAMHSA Tool Kits and Parent Management Training Oregon Model

Encourage innovation and development of

other EBP’s

Assertive Community Treatment (ACT) Integrated Dual Disorder Treatment (IDDT) Illness Management and Recovery (IMR) Supported Employment Family Psychoeducation (FPE) (Medication Management Approaches)

Promising Practices ◦ Self Determination

Creation of the Developmental Disabilities

Practice Improvement Team, or DD PIT ◦ Evaluating various practices ◦ Seeking improvements ◦ Group addressing services to persons with a dual

diagnosis of DD and MI – has made recommendations ◦ Autism Benefit – ABA

Cognitive Behavioral Therapy PMTO – Parent Management Training –

Oregon Model Promising Practices ◦ Multi-family Groups for Prevention of Schizophrenia

Institute for Research Education and Training in Addictions (IRETA) – Recovery Model

Stages of Change (Prochaska & DiClemente) Motivational Interviewing (Rollnick & Miller)

Currently lists following practices: ◦ Assertive Community Treatment ◦ Case Management ◦ Clubhouse – Psychosocial Rehabilitation ◦ Co-occurring Disorder Treatment Integrated Dual Disorders Treatment

◦ Cognitive Behavioral Therapy Dialectic Behavioral Therapy

◦ Family Psychoeducation ◦ Motivational Enhancement/Motivational Interviewing ◦ Supported Employment ◦ Supported Housing ◦ Trauma-Informed Services ◦ Trauma-Specific Treatment Trauma Recovery and Empowerment Model (TREM) and M-TREM Seeking Safety

What Did We Do, and What Are We Doing?

MDCH ◦ Provide Vision and Leadership ◦ Resource Development and Support

Universities ◦ Evaluation and Fidelity Leadership ◦ Consultation to Local Implementation Teams

PIHPs/CMHSPs ◦ Internal System Champions ◦ Supervision and Consultation to Local

MACMHB ◦ Oversee and Provide Ongoing Training and Support

National Experts ◦ In-State Consultation and Training ◦ Assist with Local Modifications

Integrated Healthcare – Learning Collaborative ◦ MDCH providing funding and leadership ◦ Universities providing evaluation ◦ PIHPs/CMHSPs committing staff time to learning

process ◦ MACMHB managing the learning collaborative

activities Potential – Excellent learning opportunity for

staff throughout the system

Learning Collaborative is ongoing, but also…. Data Analytics ◦ Individual care management ◦ Population level analysis ◦ Identification of health disparities

Health Home Pilot Various Integration Projects Statewide

Integration of physical and behavioral health care can be viewed along a continuum: ◦ Universal Screening Screening for other conditions (PH9, Weight/BP/BMI) ◦ Navigators Beyond referral, assist in accessing, moving through

healthcare system ◦ Co-location Capture both in one location ◦ Health Homes ACA offers 90% federal match ◦ System-Level Integration of Care Most advanced level of integration

Need Charge, Sample Work plan and Diagram Follow up Training, Support ◦ Ongoing Learning Communities

Board Support Executive Director Support Local Champions And…..new tools ◦ Data Analytics, Care Management, HIE, etc.

The promise of EBPS is that they pay for themselves via consumer improvement and reduced costs elsewhere

Current funds and staffing are shifted External supports are included – NAMI, family

members, etc. Staff retention is higher Positive consumer outcomes are nearly guaranteed

if practice guidelines are followed Is this what we are seeing?

Assertive Community Treatment (ACT) ◦ We have been doing this for years in Michigan

Multi-Family Psychoeducation (FPE) Integrated Dual Disorders Treatment (IDDT) Parent Management Training, Oregon (PMTO) ◦ Not required, but competitive grant funded

Supported Employment for Adults with SMI Illness Management and Recovery (IMR) Autism Benefit with ABA Health Home pilot sites learning about various EBP and

Promising Practices for integrated care Various Others Around the State

Fidelity Measurement: the extent to which a particular treatment or program is consistent with the model ◦ Can be assessed in various ways; e.g., carefully

developed scales, expert consensus ◦ Effectiveness and fidelity are directly related ◦ Insures that whatever is being measured is related

to the EBP, rather than billing or productivity

Outcome Measurement: allows for a determination of effectiveness ◦ Important to know whether or not a treatment

works This is not without its challenges – ◦ Better outcomes than what? ◦ Generally not delivered in isolation. ◦ Common measures across the state.

Review existing programs for Evidence Base ◦ Is your organization using EBPs? ◦ What are the outcomes for consumers in your

area? ◦ How and when does the Board review them? ◦ In what timeframe are outcomes achieved?

Review all new suggested programs for relationship to Evidence-Based Practice

Create data to generate new EBP

What matters more: Process Fidelity

or Service Outcomes?

In 2006, NAMI gave the State of Michigan a grade of “C” for our mental health services

In 2009, after a few years of striving to

implement multiple evidence-based practices, the State of Michigan received a “D” for our mental health services

What’s wrong with this picture?

EBP Staffing Levels?

Initial Training?

Ongoing Training?

Fidelity Reviews?

Opportunity Costs?

ACT

FPE

IDDT / COD

SE

SH

IMR

DBT

PMTO

CBT for ___

?

?

As additional evidence-based practices become strongly recommended and/or mandated, but do not come along with additional resources for sustainability, at what point does a limited-resource, public-sector provider reach its limit to implement and sustain multiple EPBs at a high level of model fidelity?

When does the good become the enemy of the

better?

C. 40%

A. 30%

B. 15%

D. 15%

A. Relationship with an agent of change (therapist, doctor, case manager, sponsor, pastor, friend, family member, etc.)

B. Treatment modality (technique, method, model of change)

C. Individual change factors (including willingness and readiness to change)

D. Individual’s belief that change is possible (hope, confidence)

It is a theoretical hypothesis that implementing an evidence-based practice will automatically lead to improved outcomes. There is overwhelming evidence that points to the quality of the treatment relationship being the most significant indicator of beneficial outcomes, twice as significant as the treatment modality being used.

And even if EBPs do result in better outcomes, are

the outcome gains worth the involved costs, as compared/contrasted with other approaches that could be equally or even more efficacious?

The reality is that a number of the EBP models were researched/normed on client populations that are not the same as the SMI consumers that we serve, so high-fidelity implementation may not actually be indicated. Goodness of fit matters, yet local adjustments to EBP models may violate model fidelity and disqualify providers from being considered excellent and effective practitioners.

Additionally the EBP label is gained by demonstrating through duplicated research that the model in question is better than placebo or treatment as usual, NOT that it is better than other alternative models of treatment.

◦ Ex. Is it really surprising that ACT or IDDT shows better results than lower-resourced “treatment as usual” or nothing at all?

There is ongoing interest in the issue of high-fidelity implementation and the outcomes achieved.

This requires the identification of common outcome measures so that changes in fidelity can be evaluated in terms of impact on outcomes.

This effort has been a challenge but is central to the next emerging issue…..

As noted, the MDCH provided grant funding for implementation. But maintaining fidelity is challenging.

How do we ensure sustainability of the evidence based practices that have been implemented?

How do we make additional practice implementation reasonable?

This has been focus of considerable attention from the PISC, with help from Mary Ruffolo, PhD, from U of M

Themes that have emerged from Dr. Ruffolo’s study: ◦ Organizational factors, e.g., turnover, cost, communication ◦ Training, e.g., this takes staff from regular work ◦ Staff involved in multiple EBPs ◦ Consumer knowledge, interest ◦ Environmental issues, such as urban and rural differences ◦ Fidelity – difficult to monitor, what is standard, is this QI or

is this the price to play ◦ Technology – both in terms of EMR and in terms of use of

technology for training ◦ Billing – when can you report EBP, who decides, etc.

Some organizational guidelines for sustainability (Ruffolo) ◦ Initial and permanent funding ◦ Dedicated champions ◦ Training, and technology enhanced training ◦ Continuous internal fidelity monitoring ◦ Ongoing EBP supervision ◦ Leadership support ◦ Low staff turnover ◦ Universities must incorporate into curriculum (at least

common core competencies) ◦ EBPs must be matched to consumers’ needs and desires ◦ Must demonstrate positive recovery outcomes

Dr. Ruffolo addressed training, and the common elements of EBPs. Proposed training modules may include: ◦ Relationship Building and Stages of Change ◦ Cognitive Behavioral Essentials ◦ Behavioral Methods ◦ Acceptance-based Strategies ◦ Motivational Enhancement Skills ◦ Problem Solving ◦ Social Skill and Support Building

Now working to develop modules to then pilot.

As noted previously, the MDCH has created a website for practice improvement.

www.improvingMIpractices.org As healthcare system moves to greater integration

of primary and behavioral healthcare, the public mental health system will need awareness and understanding of a whole new array of EBPs.

Applying experience gained through implementing EBPs to preparing for integrated care.