Update on Evidence Based PracticeMarch 13th, 2009

Lacey, WA

Sponsored by:

University of WashingtonDivision of Public Behavioral Health and Justice Policy

Evidence Based Practice Institute (EBPI)and

Washington State Department of Social and Health Services (DSHS)

Establishing a Context

-12%

-13%

-31%

-14%

-4%

-8%

10%

-5%

-2%

-1%

-31%

-25%

-18%

-37%

-27%

-5%

0%

-4%

-14%

13%

-17%

-15%

-12%

10%

-80% -60% -40% -20% 0% 20% 40%

Early Childhood Education for Disadvantaged Youth (N = 6)

Seattle Social Development Project (N = 1)

Quantum Opportunities Program (N = 1)

Children At Risk Program (N = 1)

Mentoring (N = 2)

National Job Corps (N = 1)

Job Training Partnership Act (N = 1)

Diversion with Services (vs. Regular Court) (N = 13)

Diversion-Release, no Services (vs. Regular Court) (N = 7)

Diversion with Services (vs. Release without Services) (N = 9)

Multi-Systemic Therapy (N = 3)

Functional Family Therapy (N = 7)

Aggression Replacement Training (N = 4)

Multidimensional Treatment Foster Care (N = 2)

Adolescent Diversion Project (N = 5)

Juvenile Intensive Probation (N = 7)

Intensive Probation (as alternative to incarceration) (N = 6)

Juvenile Intensive Parole Supervision (N = 7)

Coordinated Services (N = 4)

Scared Straight Type Programs (N = 8)

Other Family-Based Therapy Approaches (N = 6)

Structured Restitution for Juvenile Offenders (N = 6)

Juvenile Sex Offender Treatment (N = 5)

Juvenile Boot Camps (N = 10)

Lower Recidivism Higher Recidivism

The number in each bar is the "effect size" for each program, which approximates a percentage change in recidivism rates.

The length of each bar are 95% confidence intervals.

Type of Program, and the Number (N) of studies in the Summary

Source: Meta-analysis conducted by the Washington State Institute for Public Policy

The Estimated Effect on Criminal Recidivism for Different Types of Programs for Youth and Juvenile Offenders

Economic Estimates From National ResearchFor Adult & Juvenile Justice and Prevention Programs

Pre

ven

tio

n

Pro

gra

ms

Juve

nil

e O

ffe

nd

erP

rog

ram

s

-$20,000 $0 $20,000 $40,000 $60,000 $80,000 $100,000

Net Gain Per Person in ProgramBreak-EvenPoint

Net Loss

Drug CourtsTher. Commun. w/AftercareIn-Prison Non Res.Drug TX

Sex Off. Prog, Cog. Beh..Intensive Super, no TX

Int Super, w/TXAdult Basic Ed.Vocational Ed.

Intensive Super. ProbationFunctional Family

TherapyMultiSystemic TherapyAggression Replacemnt Trng

Coordinated ServicesScared Straight Programs

Intensive Super. ParoleTreatment Foster Care

Boot Camps

Nurse Home VisitationEarly Childhood EducationSeattle Soc. Devlp. Project

Quantum OpportunitiesJob Training Part. Act

Mentoring

Ad

ult

Off

end

erP

rog

ram

s

0

10

20

30

40

50

60

70

80

90

% of Caseload Qualifying as "SED"*

Prevalence of Serious Emotional Disturbance (SED) in Washington State

* Percent of Cases "Not different from" the profile of an SED child, based upon f ive clinical and environmental indices; α = .01

Evidence-Based Treatment

What is Evidence-Based Treatment?

Interventions for which there is consistent scientific evidence indicating that they improve clinical outcomes.

Status of Mental Health System and Evidence-Based Treatments

• President’s Commission reports public mental health system is “in a shamble” (President’s new Freedom Commission Report, 2004)

• 90% of public mental health services do not deliver treatments programs or services that have empirical support

(Elliot, 1999; Henggeler et al., 2003)

Use of EBTs: Strength of the Evidence• More than 1500 published clinical trials on outcomes of psychotherapies for

youth

• 6 meta-analyses of their effects

• More than 300 published clinical trials on efficacy of psychotropic medications

• Approximately 50 field trials of community-based services

• Dozens of preventive intervention trials (34 effective interventions cited by Greenberg et al, 1999)

Characteristics of EBTs used with Children & Families

• Focus on the development of skills, not on catharsis or insight

• Active engagement and empowerment of family or caregiver in a culturally competent manner

• Utilization of manuals emphasizing adherence and fidelity

Characteristics of EBTs used with Children & Families

• Consistent supervision of clinicians

• Homework or out-of-session work

• Focus on problems and solutions, rather than changing personality

Use of EBTs: Disconnect between “Science” and “Service”

• 80% of programs reviewed for inclusion in the Blueprints for Violence Prevention programs had no evaluation (Elliot, 1999)

• 95% of school-based mental health programs reviewed had no evaluation (Rones & Hoagwood, 2000)

• The most popular and widely-implemented programs have no evidence behind them, and some do harm (Elliot, 1999; Weisz, et al., 1995; 2001)

Implementation Challenges: Clinical

• Clinicians must change familiar practices– Traditional mental health settings place a high value on

clinician creativity and intuition.– Clinicians often spend much time in therapy “putting out

fires”: not much time for a systematic approach

• Tension around manualized treatment– Manualized interventions may be viewed as overly

simplified, “cookie-cutter”

• Intensive feedback, quality improvement loop

• Rigorous supervision; ongoing training– Often challenging to provide adequate support

Implementation Challenges: Systemic

• Inter-system ‘ownership’ of program/service

• Identifying and selecting EBTs within a context of a community planning process

• Changing administrative processes

• Shift to outcomes-based system of care

• Developing data base & evaluation capacity

• Students not being trained in EBTs

• Provider salaries do not support staff retention

Implementation Challenges: Financial

• Often takes new ‘bridge’ funding up front to finance start up

• Very difficult to alter funding patterns that are long established

• Mechanics of reimbursement and limitations of fee for service

• EBP implementation may be in conflict with traditional productivity approaches

Why is Evidence Based Treatment often not implemented or implemented inadequately?

Barriers to the Implementation of EBT

• Clinical trials are often not generalize-able to the “real world”– Participants in research trials are often carefully selected,

and are often screened out if they have multiple problems– Research Clinicians work exclusively with one population

and one intervention– Treatment is typically manualized and closely supervised– All materials that are needed for an intervention are not

always available

Barriers to the Implementation of EBT

• Clinicians often work with individuals who vary widely in age, ethnicity, culture, acuity, and presenting problem(s)

– Can not be experts on best practice for all diagnoses, all ages

• Clinicians working with children must address the treatment needs of the parents and other family members, as well as the children.

Barriers to Implementation of EBT

• High cost of initial training, too few resources, too little supervision

• Clinicians often spend much time in therapy “putting out fires”—not much time for a systematic approach to intervention

• Poor dissemination—clinicians may not have access to research literature or time to review it.

Barriers to Implementation of EBT

• Traditional mental health settings place a high value on clinician creativity and intuition.

• Manualized interventions may be viewed as overly simplified, “cookie-cutter” approaches that are dehumanizing to the client and stifling to the therapist.

Given these barriers, how can evidence-based treatments be implemented in “real world” settings?

Percent of All Children Served Receiving Mental Health Services in FY04

Compiled from Department of Social and Health Services’ data by Mental Health Division, Children’s Administration, Juvenile Rehabilitation Administration, and Research and Data Analysis Division staff.

Total Served Within Program

# Receiving MH Service

Within Program

% Receiving MH Service

Within Program

% Receiving MH Service from

Other DSHS Program

Children’s Administration 96,301a 10,121 11% 23%Juvenile Rehabilitation

Administration 4,189b 2,046c 49% 34%

HRSA-Mental Health Division 41,801 41,801 100% 45%

HRSA-Medical Assistance 669,545d 59,696e 9% 6%

NOTES

a Includes all persons served by the Children’s Administration in FY 2004 who were age 0 to 18 as of January 1 2004.

b Includes all persons served by the Juvenile Rehabilitation Administration in FY 2004 (not restricted to age 0-18).

c Includes all persons served by JRA in FY 2004 with a JRA-identified mental health need (not restricted to age 0-18).

d Includes all persons served by HRSA Medical Assistance in FY 2004 who were age 0 to 18 as of January 1 2004.

e Includes mental health medications and outpatient services provided through Healthy Options and fee-for-service coverage.

TOTAL = 40,526 Children on psychiatric medication

56% received NO outpatient mental health care* 22,498 children

44% received

outpatient mental

health care 18,028 children

Drug classes include:

Antidepressant

Antipsychotic

Antianxiety

Antimania

ADHD

(FY ’04)(FY ’04)

Medication and MH

Developing an Evidence-Based Culture

• Washington State committed to promoting a more wide-spread culture supporting EBT’s

– SB 5763 (2005) requires RSNs to develop criteria for implementing EBTs.– HB 1088 (2007) requires the access-to-care standards and the benefits packages for

children's mental health services be revised, and that the system of care be based on defined elements and evaluated on outcome-based performance measures.

– HB 1373 (2009) will improve mental health outcomes for children and the families who care for them by allowing early access to care before problems become too difficult and expensive to treat.

– SB 5141 (2009) proposes funding of a pilot program to increase parental participation in evidence-based programs by providing incentives for parents already involved in rehabilitation of their children.

– HR 2 State Children’s Health Insurance Program Reauthorization Act of 2009 (SCHIP)– Children’s Mental Health Initiative established a matrix of EBTs for use with youth with

behavioral health disorders.– Braam Oversight Panel recommends implementing best practices for youth in the foster

care system. – 2006 legislative proviso provided support for pilot implementation of EBTs in children’s

mental health and child welfare. – MacArthur Models for Change Program– Reinvesting in Youth– Robert Wood Johnson Reclaiming Futures

House Bill 1088

• A continuum of services from early identification, intervention, and prevention through crisis intervention and inpatient treatment

• Equity in access to services for similarly situated children

• Developmentally appropriate, high quality, and culturally competent services available statewide

• Treatment of each child in the context of his/her family and other person that are a source of support and stability in her/her life

Legislative Goals by 2012 for Children’s Mental Health

Legislative Goals by 2012 for Children’s Mental Health, Cont’d

• A sufficient supply of qualified and culturally competent children’s mental health providers

• Use of developmentally appropriate evidence-based and research-based practices

• Integrated and flexible services to meet the needs of children who are at risk of out-of-home placement or involved with multiple child-serving systems

House Bill 1088

Evidence Based Practice Institute

Expand Healthy Options

Medicaid Eligibility

Convene RSNs, CMHCs

Improve Medication

Management

Revise Benefit Package

Revise Access to Care

Standards

House Bill1088

• Sustained training and consultation

• Implementation of PfS model

• Community empowerment and education

• Monitor outcomes and quality assurance

• State resource through continuous synthesis of vast information-base

Evidence-Based Practice Institute

UW PBHJP, Nursing, Social Work, CHMC

Increasing community capacity

Youth receiving appropriate EBP services

Improving youth outcomes

Sustained training and consultation in MH and Primary Care

Implementation of PfS model

Community empowerment and education

Monitor outcomes and quality assurance

State resource

Building strong collaborations

• Responsibilities and Goals

– Review and summarize current law

– Review current practices that actively engage parents

– Continue successful implementation of PfS

– Develop literature and information sessions for families

– Identify outcome-based performance measures

Evidence-Based Practice Institute

• Responsibilities and Goals, cont’d

– Serve as a statewide resource on children’s mental health practices

– Implement Wraparound Pilot

– Implement Primary Care Pilot

Evidence-Based Practice Institute

Improve Medication Management and care coordination

• Develop and implement policies to improve prescribing practices• Improve quality of children’s mental health therapy• Improve communication and care coordination btw primary care and

mental health providers• Prioritize care in the family home• Identify children with emotional/behavioral disturbances who may be at

high risk due to a variety of reasons• Review and evaluate appropriateness of psychotropic medications given

to children under 5 years of age• Track prescriptive practices with goal of reducing use of psychotropic

medication

Convene a representative group of regional support networks, community mental health centers, and

managed care health systems to: • Establish mechanisms and develop contract language that ensures

increased coordination of and access to Medicaid mental health benefits available to children and families

• Define performance standards that track access to and utilization of services

• Set standards for reducing the number of children prescribed antipsychotic drugs and receive no outpatient mental health services with their medication

• Submit report on progress and findings to legislature by January 1, 2009

Facilitating Medicaid Eligibility

• When youth are released from confinement, their medical assistance coverage will be fully reinstated on the day of their release

• The department shall establish procedures for coordination between department field offices, JRA institutions, and county juvenile courts that result in prompt reinstatement of eligibility for youth who are likely to be eligible for medical assistance services upon release

• The department shall adopt standardized statewide screening and application practices and forms designed to facilitate the application of a confined youth who is likely to be eligible for a medical assistance program

Develop revised children’s mental health benefit package

• Strong consideration given to:– Developmentally appropriate evidence-based and research-

based practices– Family-based interventions– The use of natural and peer support– Community support services– Review of other states’ efforts– Recommend revisions to legislature by January 1, 2009

• Expansion from 12 to 20 visits for a child per year for both managed care plans and fee for service plans

• Expansion in providers to licensed mental health professionals

Healthy Options

Performance Measures

Decreased emergency room utilization Decreased psychiatric hospitalization Decreased out-of-home placement Decreased involvement with juvenile

justice system Improved school attendance and

performance Reduced used of medication Reduced symptomatology

Develop recommended revisions to the access to care standards for children.

RECOMMENDATIONS

• #1: Address limits to access to services posed by current Access to Care Standards (ACS)

• #2: Adopt the STI Mental Health Benefits Design report recommendation to shift utilization management from front end restrictions to proactive care management of the most intensive and costly services

• #3: Increase access to services for youth and families not covered by Medicaid or insurance

RECOMMENDATIONS, Cont’d

• #4: Support provider organizations to increase youth and family access to & engagement in services

• #5: Increase access to child psychiatrists by expanding the Partnership Access Line (PAL), a primary care consultation program, statewide

RECOMMENDATIONS, Cont’d

• #6: Implement EBPs that align with stakeholder priorities and systematically engage families in treatment, including:– Intensive models for youth at risk of/transitioning from out-of-

home placement :• Multidimensional Treatment Foster Care (MTFC)• Family Integrated Transitions (FIT)• Functional Family Therapy (FFT)• Multisystemic Therapy (MST)• Project MATCH

RECOMMENDATIONS, Cont’d

• #7: Implement EBPs that align with stakeholder priorities and systematically engage families in treatment, including:

– Evidence based models for youth exposed to past trauma, such as

• Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT)

RECOMMENDATIONS, Cont’d

• #8: Implement EBPs that align with stakeholder priorities and systematically engage families in treatment, including:

– Evidence-based models for youth with co-occurring mental health and substance abuse disorders

• Multisystemic Therapy (MST)

• Family Integrated Transitions (FIT)

• Multidimensional Family Therapy (MDFT)

RECOMMENDATIONS, Cont’d

• #9: Implement evidence based models that target early signs of behavioral problems & assist parents in working with oppositional and defiant behaviors:

– Parent-Child Interaction Therapy (PCIT)

– Positive Parenting Program (Triple-P)

– The Incredible Years

RECOMMENDATIONS, Cont’d

• #10: Implement prevention & early intervention programs with evidence for effectiveness that align with stakeholder priorities, such as:– Nurse-Family Partnership– Positive Parenting Program (Triple-P)– School-based prevention programs with evidence for

effectiveness (e.g., Good Behavior Game, School Development Project)

RECOMMENDATIONS, Cont’d

• #11a: Build infrastructure to support EBP implementation:

– Support community and tribal decision-making & oversight of EBP implementation, using models we know work (Partnerships for Success)

• #11b: Build infrastructure to support EBP implementation:

– Ensure that reimbursement processes align with EBP implementation

Now is the time!

• Expansion of Evidence-Based Practice

• Strong stakeholder commitments

• Cross System Collaboration

Future Directions

Important Websites

• PBHJP: http://depts.washington.edu/pbhjp • EBPI: http://depts.washington.edu/ebpi• PAL: http://palforkids.org• Primary Care Principles for CMH:

http://palforkids.org/docs/Care_Principles_081508.pdf

Eric W. Trupin, Ph.D.Professor & Vice ChairmanUniversity of Washington School of MedicineDepartment of Psychiatry & Behavioral SciencesDirector, Division Public Behavioral Health & Justice Policy2815 Eastlake Avenue East, Suite 200Seattle, WA 98102Ph: 206-685-2085; Fx: 206-685-3430