Implementation of Evidence-Based Models: Improving Processes

1. Implementation of Evidence-Based Models: Improving Processes Jeanne L. Obert, MFT, MSM Executive Director, Matrix Institute UCLA Integrated Substance Abuse Programs

2. History of Matrix Model Clinical Services • 1984 – Adult Intensive Outpatient Treatment Program began in Los Angeles – The Matrix Model • 1986 - San Bernardino County program begins with 60% of clients abusing methamphetamine • 1990 – Became affliated with UCLA • 1994 - First Adolescent Treatment Program started at YMCA in Ontario, CA • 1998 - Rick Rawson left – CSAT MTP began • 2000 – Officially became totally nonprofit • 2005 – 5 Clinical Sites in the Greater Los Angeles Area

3. Drug Classes Sedatives Stimulants Opioids Alcohol Medical Treatments Sedatives Opioids Alcohol Treatments Available Medical & Behavioral Behavioral Treatments • Sedatives • Stimulants • Opioids • Alcohol

4. AN ORGANIZED COLLECTION OF SELECT EVIDENCE- BASED INTERVENTIONS Cognitive-Behavioral Motivational Interviewing Contingency Management Family Therapies MATRIX MODEL

5. Defining Features of Matrix Model Treatments • Comprehensive, manual-driven, one year program with simple, well-organized instructions. • Developed from grassroots, clinical program with empirically-based interventions added where they seem to work. • Patient handouts accompany each session and patient workbook contains written and illustrated concepts.

6. Matrix ModelEvidence-Based Treatments delivered within Individual Sessions Early Recovery Groups Relapse Prevention Groups Family Education Group 12-Step Meetings Social Support Groups Relapse Analysis Urine Testing

7. 3 Large Scale Dissemination Efforts

8. The CSAT Methamphetamine Treatment Project A Multi-site Trial of a Manualized Psychosocial Protocol for the Treatment of Methamphetamine Dependence Richard Rawson Ph.D. U.C.L.A. Integrated Substance Abuse Programs (I.S.A.P.) Funded by the Center for Substance Abuse Treatment

9. Goals of the Methamphetamine Treatment Project • To study the clinical effectiveness of the Matrix Model • To compare the effectiveness of the Matrix model to other locally available outpatient treatments • To establish the cost and cost effectiveness of the Matrix model compared to other outpatient treatments • To explore the replicability of the Matrix Model and challenges involved in technology transfer

10. Motivational Enhancement Therapy (MET) for Outpatient Retention and Substance Use Protocol 005 Kathleen M. Carroll, Ph.D. (Lead Investigator) Samuel A. Ball, Ph.D. Yale University School of Medicine

11. Primary Aims • To evaluate the effectiveness of MET in: • Retaining diverse clients in outpatient treatment and reducing their substance use … • …when delivered by diverse community clinicians in the first month of treatment in different practice settings relative to counseling-as-usual (CAU)

12. Secondary Aims • Evaluate whether programs treating predominantly alcohol vs. drug abusers have better outcomes • Evaluate the discriminability of MET from Counseling-as-Usual (CAU) • Evaluate client gender and race differences in response to MET vs. CAU

13. Matrix goes to Thailand The Ultimate Train-the-Trainer Project Walter Ling, MD 12 well-trained sites in Thailand resulted in 4,000 Matrix Centers in less than 2 years

14. Issues in Disseminating Evidence-based Models • Dealing with modifying human interactions with peer-oriented staff, research-oriented trainers, and business-oriented administrators • Suspicion of research • Conflicting priorities • Process of creating change (mandated?) • Accepting “manualized” treatments • Modifying protocols – adaptation vs. fidelity

15. Law Enforcement Officials in 500 US Counties asked“What is your primary drug problem? National Association of Counties - 2005

16. The DilemmaHow to Disseminate the Information ? Effectiveness Speed Continuum Train-the-Trainer(s) Model Highly-Selective Highly-Intensive Training Model

17. Stages of Adaptation* • Step I - Exposure (to new ideas) • Step 2 - Adoption (formal decision to try change) • Step 3 - Implementation (provider tests use of innovation) • Step 4 - Practice (incorporation of innovation into regular use) * D. Simpson, 2002

18. Implementation Research: A Synthesis of the Literature 2005

19. Matrix Model Key Supervisor • Strong champion who can serve as a change agent/purveyor in the adoption process • Serves as a liaison between Matrix and adopting program • Helps educate staff and administrators about new program • Clinical leader who knows the Model well and can help others learn

20. CSAT STUDY TECHNOLOGY TRANSFER 3-day trainings with all sites together bi-annually On-site visits and consultations at start-up MATRIX COMMUNITY TECHNOLOGY TRANSFER One 2.5 day core workshop limited to 30 participants with a Matrix-experienced trainer Key Supervisors identified and scheduled for further training Manuals available with recommendation for training Step 1 – Exposure(to new ideas)

21. CSAT STUDY TECHNOLOGY TRANSFER Site adoption occurred through RFP process Individual therapist chosen at site was voluntary (Post study recommendation: Hold retreat with all participants held at start-up to establish good working relationships) MATRIX COMMUNITY TECHNOLOGY TRANSFER Returning workshop participants will recommend (or not) adoption Selection of Key Supervisor will help actualize organizational commitment (Future? Meet with key program administrators and leaders prior to commitment) Step 2 – Adoption(formal decision to try change)

22. Characteristics of Ideal Key Supervisor • Respected clinical leader who is both credible to clinicians and savvy about organizational dynamics • Possess excellent communication and clinical skills • Committed to actively working to implement the Matrix Model with fidelity and good effect

23. Policy Recommendations ( University of South Florida, Implementation Research: A Synthesis of the Literature) • Encourage program-centered service delivery rather than practitioner-centered. (Use of manuals aids this process.)

24. Policy Recommendations • Invest in development and use of implementation strategies and methods that are grounded in research and elaborated through accumulated experience. (Similar to recent investments made in information systems.)

25. Policy Recommendations • Develop funding strategies to support implementation of evidence-based programs • Start up costs • Purveyor support (Change agents and/or organizations) • Adequate funding for services • Ongoing support of infrastructure for sustainability