Outcome-Informed Evidence-Based Practice John G. Orme & Terri Combs-Orme

1. http://ormebook.com/ Pearson Education Outcome-Informed Evidence-Based Practice John G. Orme & Terri Combs-Orme

2. Measuring and Monitoring Client Progress “However beautiful the strategy, you should occasionally look at the results.” Sir Winston Churchill

3. Contemporary Conceptual Definition of EBP “…a process for making practice decisions in which practitioners integrate the best research evidence available with their practice expertise and with client attributes, values, preferences, and circumstances” Rubin, 2008, p. 7

4. Steps in the EBP Process • Develop an answerable question • Locate relevant evidence • Critically analyze the evidence • Combine evidence with client attributes, values, preferences, and circumstances and with your practice expertise • Apply to practice • Measure and monitor client outcomes, and adjust intervention as needed

5. Limitations of EBP What you don’t know How intervention works when you implement it with your particular client in your practice setting What you might know • How intervention works when implemented under ideal conditions (i.e., efficacy) • How intervention works when implemented under routine practice conditions (i.e., effectiveness)

6. Outcome-Informed Practice (OIP) • Practice in which you: • Measure your client’s outcomes at regular, frequent, pre-designated intervals, in a way that is sensitive to & respectful of client • Monitor these outcomes at regular, frequent, pre-designated intervals to determine if client is making satisfactory progress • Modify your intervention plan as needed along the way by using this practice-based evidence, in concert with evidence-based practice, to improve your client’s outcomes

7. Single-Case Designs • Family of designs characterized by: • Systematic repeated measurement of a client’s outcome(s) at regular, frequent, pre-designated intervals under different conditions (baseline and intervention) • Evaluation of outcomes over time & under different conditions in order to monitor client progress, identify intervention effects &, more generally, learn when, why, how, & extent to which client change occurs

8. Intervention Research vs. OIP OIP Primary purpose to improve well-being of particular client Tailored to emerging problems, goals, needs, characteristics, & circumstances of each particular client without generalization to other clients Intervention Research • Usually initiated to inform practice by developing generalized causal knowledge about interventions • Benefits to participants of secondary importance • Not tailored to individual participants • Specific informed consent requirements

9. Why Outcome-Informed Practice? The Top Ten Reasons

10. 1:To Obtain the Best Client Outcomes • Even empirically supported intervention may not work with a particular client • Many factors other than your intervention have effect on client outcomes • Ongoing, relatively objective feedback to the practitioner reduces deterioration & treatment dropout, improves overall outcome, & leads to fewer treatment sessions

11. Why may ESIs not work for this client? • ESIs beneficial for average research subject; some unchanged & some worse • Research participants often not representative of your clients (e.g., race, ethnicity, sexual orientation) • ESIs may be difficult to transport to your practice setting

12. Why may ESIs not work for this client? • Specific elements of ESIs only one ingredient in recipe that contributes to client success • Quality of therapeutic alliance influences client’s outcome whatever intervention you use • ESIs are templates that need to be customized to individual clients • Tailored to personal, contextual & changing situations causing & maintaining problems faced by a particular client

13. 2: To Avoid Natural Biases • Practitioners tend to overestimate improvement & underestimate deterioration, in relation to client self-reports • Practitioners have much more confidence in their abilities to judge clients’ progress than is warranted by the data

14. Bias Tendency to see and interpret information consistently with an emotional preference or preconceived expectation

15. Confirmation & Falsification • We seek information to confirm our biases. • We should seek information to falsifyour conclusions

16. 3: To Improve Decision-Making • You’ll have more & better information with which to make practice decisions • How else would you know if what you’re doing is working?

17. 4: To Prevent Client Deterioration • 5 to 10% of adult & 14 to 24% of child clients deteriorate while receiving services • Practitioners find it especially difficult to detect client deterioration • Measuring & monitoring client outcomes can reduce rates of deterioration, partly by reducing rates of dropout from treatment

18. 5: To Bridge the Gaps in EBP • Evidence-based practice is place to start, but not sufficient: • RCTs tell us whether interventions work with the average client, not a particular client • Clients have individual characteristics & circumstances • Methodologies underlying EBP by no means perfect • Empirically-supported interventions not available for every client problem

19. 6: To Improve Your Relationships with Your Clients • Demonstrates your respect for your client by giving your client an important voice • Demonstrates conscientiousness on your part & may enhance client’s confidence in you

20. 7: To Enhance Your Development as a Practitioner • Huge differences in client outcomes among therapists, even using same intervention methods • Clinical practice without ongoing feedback is like learning archery while wearing a blindfold; your skills are unlikely to improve if you cannot see where the arrow is landing

21. 8: To Be Accountable • Monitoring client outcomes constantly & modifying intervention as needed provides important tool for achieving clients’ goals in as short a time as possible & conserving limited resources • Some argue that, at least for psychotherapy services, outcome-based accountability is coming—soon

22. 9: To Meet Your Ethical Obligations For example… • NASW Code of Ethics, 5.02 Evaluation and Research • (a) Social workers should monitor and evaluate policies, the implementation of programs, and practice interventions.

23. Can I practice without measuring and monitoring client outcomes? • No • All practitioners measure and monitor client outcomes—the question is how best to do it

24. Instructor’s Manual • Free download from Pearson website • Sample syllabus • For each chapter: • Suggested discussion prompts • Suggested chapter activities and assignments; • Essay questions; • Additional resources (i.e., books, journal articles, websites)

25. Companion Website • Ormebook.com • For each chapter: • PowerPoint presentation. • List of recent relevant published articles and books for additional reading • Internet resources • Chapter tables and figures in Microsoft Word

26. Companion Website (cont’d) • Chapter 2 • Bibliography of evidence-based practice texts • Online resources for evidence-based practices • Single-case design bibliography • Chapter 5 • Microsoft Word 2007 templates for constructing single-case design graphs and instructions for using these templates (illustrated below)

27. Companion Website (cont’d) • Chapter 9 • Excel program for scoring CES-D • Excel program for scoring Hudson’s scales • Excel program for calculating reliable change • Word document describing how to determine a clinical cutoff • Word document describing how to determine clinically significant change for Hudson’s scales

28. Companion Website (cont’d) • Coming soon… • Crossword puzzles • Flashcards • Additional in-class and out-of-class exercises • Send us your ideas • Contribute to the web page

29. Textbook • For each chapter: • Critical thinking questions and practice tests integrated with 2008 CSWE EPAS to assess student application of the core competencies • Complex, realistic case with session-by-session descriptions, monitoring data & graphs made with the Excel template

30. An Example Case

31. Eve • 32-year-old HIV-positive client, hospital outpatient clinic • Referred to social worker for non-adherence to retroviral medication regimen • Lives with partner of 7 years & young daughter: not HIV-positive. • BFA in music & works occasionally playing piano in restaurants or bars • Client reports high stress& drug side-effects as problems with parenting & working

32. Searching the evidence • Social worker finds few evidence-based interventions for HIV+ women • Best option (with men) seems to be individually tailored intervention that focuses on eliminating client’s individual barriers to adherence (Martin et al., 2010) • Eve’s barriers: high levels of stress, forgets medications (does understand regimen) • Many evidence-based interventions for reducing stress

33. Constructing the Baseline

35. Course of the Intervention • Eve practices deep breathing & reports feeling better • Makes gradual progress in adherence, but not to 100% quickly enough • SW suggests several other evidence-based interventions to reduce stress, such as meditation, & involving partner, but Eve refuses • Finally turn to technology

36. The Pill Phone • Provides visual/audible prompts to take medication •  Tracks/stores pill-taking records •  Shows what most pills look like • Confirms dose was • taken • Displays potential side • effects • Now an iPhone app

37. The Course of Intervention

38. The Course of Intervention

39. The Course of Intervention

40. The Course of Intervention

41. The Course of Intervention

42. In this case… • Monitoring permitted early identification of serious problem & quick implementation of intervention • Graphing illustrated early that pace of change was insufficient • Graphs provided clear understanding of problem & motivation to client • Note focus on the client, not the intervention

43. Thank you