Practical Challenges Integrating EBP into Addiction Treatment Programs

Dan Kivlahan, Ph.D.

VA Puget Sound & University of Washington

APA, San Francisco

August 17, 2007

Promoting Action on Research Implementation in Health Services (PARIHS)

The Six Aims of High-Quality Health Care

Safe

Effective

Patient-centered

Timely

Efficient

Equitable

The Six Aims of High-Quality Health Care

Safe Avoiding injuries to patients from care that is intended to help them.

Effective Providing services based on scientific knowledge to all who could benefit

… avoiding underuse and overuse, Patient-centered

Providing care that is respectful and responsive to individual patient preferences, needs, and values…

Crossing the Quality Chasm © 2001 by the National Academy of Sciences, courtesy of the National Academies Press, Washington, DC, Table 1, pp. 5–6.

The Six Aims of High-Quality Health Care

Timely Reducing waits and sometimes harmful delays...

Efficient Avoiding waste, including waste of equipment, supplies, ideas, and energy.

Equitable Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

Crossing the Quality Chasm © 2001 by the National Academy of Sciences, courtesy of the National Academies Press, Washington, DC, Table 1, pp. 5–6.

Promoting Action on Research Implementation in Health Services (PARIHS)

Evidence Challenges

Magnitude of effects How much change in outcome is worth

adopting EBP? Identifying “essential components”

Mechanisms of behavior change Rethinking the paradigm

Morgenstern & McKay, Addiction, 2007 Technology model? Adaptive treatment Monitoring early response

National Voluntary Consensus Standards on EBP to Treat Substance Use Conditions

identification of substance use conditions screening and case finding diagnosis and assessment

initiation and engagement in treatment brief interventions promoting engagement in treatment withdrawal management

therapeutic interventions psychosocial interventions pharmacotherapy

continuing care management management of coexisting conditions and

monitoring of treatment response

http://www.qualityforum.org/projects/ongoing/sud.asp

Ineffective Practices to “De-Implement”

Promoting Action on Research Implementation in Health Services (PARIHS)

Context Challenges

“Buy in” or organizational readiness Often challenging to assess

Staff and leadership turnover Information infrastructure Sustainability

Workload limits – panel size

Promoting Action on Research Implementation in Health Services (PARIHS)

2 “Simple” Principles of Facilitation

(1) Feedback on local performance• carefully defined• accurately measured• ongoing

(2) Accessible supervision or “coaching” from someone with more expertise about improvement

Miller, Sorensen, Selzer, Brigham. JSAT, 2006;21:25-39

Facilitation Challenges

Measurement Feasible, simple, local consensus &

investment NIATx

Wait times Admissions No shows Retention

Incentives Paying for supervision/coaching Motivational incentives for patients

What to ask about EBP findings at APA?

How is the evidence likely to be valued? By consumers, providers, managers, payers Across all 6 domains of quality

How does the EBP address your context of implementation?

What are the implications for facilitation in clinical practice?

References

Greenhalgh, T., et al., (2004). Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 82(4):581-629

Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence based practice: a conceptual framework. Qual Health Care 1998;7:149–58

Miller WR, Sorensen JL, Selzer JA, Brigham GS. Disseminating evidence-based practices in substance abuse treatment: a review with suggestions. J. Subst Abuse Treat. 2006 31, 25-39.

Morgenstern, J., McKay, J.R. (2007). Rethinking the paradigms that inform behavioral treatment research for substance use disorders. Addiction, 102, 1377–1389

National Quality Forum (2007). National Voluntary Consensus Standards on Evidence-Based Practices to Treat Substance Use Conditions http://www.qualityforum.org/projects/ongoing/sud.asp

Pincus, H., et al. (2007). Can psychiatry cross the quality chasm? Improving the quality of health care for mental and substance use conditions. Am J Psychiatry,164(5):712-9.

VA Quality Enhancement Research Initiative (QUERI)

http://www.hsrd.research.va.gov/queri