Dinosaurs of Delivery- From 'Best Practice' to 'Evidence Based' Treatment Models

Dinosaurs of Delivery- From 'Best Practice' to 'Evidence Based' Treatment Models Elena Cohen, Safe Start Center, Silver Spring, MD James Lewis III, National Center for Children Exposed to Violence, New Haven, CT 10th Annual Symposium on Child Trauma St. Louis, Missouri October 13, 2006

Are you a smart shopper? • How do you buy a car? • What do you do to select a health insurance plan?

Purchasing services • Facts about products are important to make best decision • No different for services: we’d like to receive the best and most cost-effective service.

Best Practices • Have theoretical basis in generally accepted principles • Generally accepted in practice as appropriate for the target population

How do they become ‘best practice’? • Clinicians, academicians, policymakers have hypothesized theories • These became incorporated into treatment, service delivery, organizational or financial approaches

How do they become ‘best practice’? • Theories expanded • But treatment, service, and system approaches often remain • Sometimes they have grown in popularity because they are believed by clinicians and decision-makers to be effective

Best Practices • Anecdotal, clinical literature exists indicate treatment value • No empirical evidence (or theoretical basis) that treatment substantial risk

How do they become ‘best practice’? • They often show promise through individuals or agencies • Incorporated without analysis of results and circumstances under which they are likely to be effective • Primarily based on expertise of practitioner (who have evolved from novices to experts)

Best Practice to Evidence Based • Path from practices based on theory and belief and those that are evidence-based • A way of thinking about the gap between what we know and what we do

Evidence-Based Practices Clinical and administrative practices that have been proven to consistently produce specific, intended results

Evidence Based Practice • Explicit and judicious use of current best evidence in making decisions about the care of individual clients. • Involves integrating individual clinical expertise of front line worker with the best available external evidence from systematic research and individual client preference.

Benefits • Tool to bridge gap between research and practice • Quality and accountability • Cost effectiveness • Tool for eliminating disparities • Tool in professional education—more focused integration of knowledge, education and practice

Concerns • Evidence based practice do not always work on individual clients • Decision makers cannot always agree on merits (vested interests) • Detraction ($ and time) from intervention

Concerns • Not strength-based (based on protocols) • Rigid system—restricts those delivering services • Lack of “context” information

Levels/Types of Evidence • Evidence suggested • Evidence informed • Evidence supported • Evidence based

Evidence Suggested • Consensus driven, based on agreement among experts • Based on framework derived from experience, not strong basis of support in research • Based on qualitative data

Evidence Informed • Evidence inferred based on limited supporting data • Replication/adaptation to meet needs of specific population • Provides a framework for other systems to modify their programs and interventions.

Evidence-Supported • Quasi-experimental studies • Data from administrative databases or quality improvement

Evidence-Based • Based on several randomized controlled studies • Meta analysis shows strong support for the practice • Results have high level of confidence (due to randomization)

Concerns about “evidence” • Developed from homogeneous samples • Evidence is lacking for many of the questions that arise in practice • Care should be taken to include clients in the process

What is “strong evidence” Identifying and Implementing Educational Practices Supported by Rigorous Evaluation: A User Friendly Guide.www.ed.gov/rschstat/research/oubs/rigorousevid/pdf. Criteria used to identify evidence-base programs on the Social Programs that Work website: http://evidencebasedprograms.org Standards of Evidence as outlined by the Society for Prevention Research www.preventionresearch.org/

Barriers • Accessibility of research finding (lag in time) • Practitioners resistance to change • Real gaps in knowledge • Lack of available resources • Organizational supports • Educational system

Interventions supported by rigorous evaluation • Social Programs that Work www.evidencebasedprograms.org/ • Blueprints for Violence Prevention www.colorado.edu/cspv/blueprints/index.html

Helpful Sites The What Works Clearinghouse www.whatworkds.ed.gov International Campbell Collaboration www.campbellcollaboration.org/frontend.asp Turning Knowledge into Practice: A Manual for Behavioral Health Administrators and Practitioners About Understanding and Implementing Evidence-Based Practices. http://www.tacinc.org/index/viewPage47.htm

Spreading Evidence Based Practices • Developed by innovators • Early adopters • Implemented by a number of others (late majority) • Becomes commonplace • Traditionalists (long after it is commonplace)

Path From Generation of Evidence to Clinical Practice Haynes, B. et al. BMJ 1998

Environment/Community Level • Funding-reimbursement issues • Lack of incentives or link to rewards to outcomes

Organization level Barriers • No tradition as learning organization • Lack of awareness • Entrenched status • Lack of role models • Training supervision • Disincentive for shorter-term interventions

Microsystem Level (Departments within organizations, multi service agencies, etc) • Belief that the population is “different” • Resentment from other practitioners/colleagues

Individual Practitioner/Client • Misperception about manualized treatment (art versus science) • Perception of lack of “relationship” satisfaction

Strategies for Accelerating Diffusion • Build awareness/belief in efficacy • Support decision to change • Training, coaching, mentoring for skills/knowledge acquisition • Practice/support efficacy

Strategies Environment/Community • Funding (i.e. differential payment for adoption of best practices) • Professional education/marketing (including professional schools, professional societies) • Recruit leaders in the community

Strategies Organization Level • Organizational leadership (agency and program directors) • Learning organizations—continuous flow of information regarding practices and outcomes • Action-oriented implementation plan • Reach out to isolated cultural communities • Give back feedback!

Microsystems level • Clinical supervision/consultation • Change hiring/performance evaluation practices • In-depth training • Peer support networks • Track fidelity—in addition to outcomes • Give feedback!

Practitioner/Client Level • Parental engagement strategies—develop an active engagement plan • Educate clients about the process • Develop protocols and other tools to assess, track progress and outcomes, identify barriers • Overcoming practitioner “resistances” • Give feedback!

Safe Start Initiative Goal • To prevent and reduce the impact of family and community violence on children and their families.

Safe Start Vision • To create a comprehensive service delivery system that improves the access to, delivery of and quality of services for young children at high risk or have exposed to violence.

Guiding Principles • Develop/use an evidence-basein designing services and systems (balancing innovation of practice with efficacy) • Increaseawarenessand identification of children exposed to violence

Guiding Principles • Provide specialized, developmentally appropriate prevention, early identification and intervention • Provide support/ensure safety of BOTH the adult victim and the child at any point of entry • Use ecologicalapproach

Multiple components Practice Innovation • Demonstration sites www.nccev.org • Promising Approaches sites www.safestartcenter.org

Multiple components Research/evaluation • National Quasi-Experimental Evaluation by RAND Corporation www.rand.org • National Incidence and Prevalence Study on Children Exposed to Violence, David Finkelhor and Associates, University of New Hampshire

Safe Start Initiative Training and technical assistance Development/dissemination • Public awareness • Academic journals • Knowledge into practice materials • Educational and other guidelines for different systems

Demonstration Sites • Increased identification of children exposed to violence and capacity to document these children to get real estimates on the prevalence—dispatch and police reports, 211, and hotlines • Ambassador Kits (volunteers trained to deliver key messages), “briefcases” “Flip” Book

Demonstration Sites • Increased awareness of both professionals and public—two nationally award-winning PSA’s • Increased service pathways and collaboration • Created multiple point of entry

Demonstration Sites • Modified local infrastructure by creating centralized access and by developing partnerships that expedited linkages • Changes in policy and procedures—MOUs, Protocols for CPS/DV • Improved mental health services by funding specialized training

Promising Approaches Sites • Parent Child Interactive Therapy (PCIT) • Parent Child Psychotherapy (CPP) • Trauma Focused-Cognitive Behavioral Therapy • Medical Home Model • Child Advocacy Centers • Home Visitation

Promising Approaches Sites • DV Shelter-based Services • Motivational Interviewing • CPS-DV integrated support services • Kinship Care-Therapeutic Services for Kinship-Child Dyad

Promising Approaches Sites • In-Home Family Support Services • Integrated Case Management • Specialized Head Start Services

Dinosaurs of Delivery- From 'Best Practice' to 'Evidence Based' Treatment Models