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Evidence-Based Guidelines, Evidence-Based Practices, and Evidence-Based Decision Making

Evidence-Based Guidelines, Evidence-Based Practices, and Evidence-Based Decision Making. The Intersection of Research and CQI in the Quest to Change Offender Behavior Kimberly Sperber, PhD Talbert House. Evolution of Evidence-Based Decision Making. Medicine

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Evidence-Based Guidelines, Evidence-Based Practices, and Evidence-Based Decision Making

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  1. Evidence-Based Guidelines, Evidence-Based Practices, and Evidence-Based Decision Making The Intersection of Research and CQI in the Quest to Change Offender Behavior Kimberly Sperber, PhD Talbert House

  2. Evolution of Evidence-Based Decision Making • Medicine • Physician as expert with little reliance on research • 1970s document wide variation in physician practices • 1980s document that number of physician practices are inappropriate • Increasing reliance on research led to development of evidence-based guidelines • Research starts to inform coverage, payment, performance measures • Corrections • Practitioner as expert with little reliance on research • 1970s document many programs ineffective and that “nothing works” • 1980s find that punishing smarter programs also not effective • Increasing reliance on research led to development of evidence-based guidelines • Research starts to inform contracts, regulatory standards, performance measures

  3. Corrections at a Crossroads • Evidence-Based Guidelines • RNR • Evidence-Based Practices • ORAS, LSI-R • CBT • Role-Play • Dosage • Evidence-Based Decision Making • Applying available evidence to specific client’s situation to make best possible choice for the client

  4. Moving from Evidence-Based Guidelines to Evidence-Based Decision Making • Evidence-Based Guidelines • Impact on care is indirect • Impetus for providing certain types of care to certain groups of people • Do not directly determine the care provided to a particular client. • Evidence-Based Decision Making • Explicit and intentional use of current best evidence to make decisions about the care of individual clients. • Done by individual staff • Relies on EBG but also accommodates client issues not currently addressed by EBG

  5. Example 1:Triaging Dosage by Risk • Sperber, Latessa, & Makarios (2013): • 100-bed CBCF for adult male felons • Sample size = 689 clients • Clients successfully discharged between 8/30/06 and 8/30/09 • Excluded sex offenders • Dosage defined as number of group hours per client • Recidivism defined as return to prison • All offenders out of program minimum of 12 months

  6. Summary of Findings • Overall, increased dosage reduces recidivism • But not equally for all categories or risk levels • Low / Moderate and Moderate • Curvilinear relationship • Matters at the low ends of dosage, but effects taper off and eventually reverse as dosage increases • High / Moderate • Increases in dosage consistently result in decreases in recidivism, but • Saturation effect at high dosage levels

  7. Current Implications • Optimal range for Low/Moderate risk = 100-149 hours • Optimal range for Moderate risk = 150-199 hours • Optimal range for High/Moderate risk = 250-299 • Findings are specific to men

  8. Unanswered Questions • Laying out a comprehensive dosage research agenda: • Defining dosage • What counts as dosage? • Prioritization of criminogenic needs • Counting dosage outside of treatment environments

  9. Unanswered Questions • Sequence of dosage • Cumulative impact of dosage • Impact of program setting • Low risk but high risk for specific criminogenic need

  10. Unanswered Questions • Nature of dosage for special populations • Impact of skill acquisition • Identifying moderators of risk-dosage relationship • Conditions under which dosage produces minimal or no impact

  11. Practice and Policy Implications • Research clearly demonstrates need to vary services by risk • Currently have general evidence-based guidelines • Should not misinterpret to imply that 200 hours is required to have any impact on high risk offenders • Not likely that there is a one-size-fits-all protocol for administering dosage • Many questions still remain • Need for evidence-based decision making

  12. Requirements of Effective Execution • Process for assessing risk for all clients • Modified policies and curricula that allow for variation in dosage by risk • Definitions of what counts as dosage and mechanism to measure and track dosage • Formal CQI mechanism to: • monitor whether clients get appropriate dosage by risk • Monitor outcomes of clients receiving dosage outside of EBG

  13. Example 2:Women’s Pathways to Serious and Habitual Crime • Brennan, Breitenbach, Dieterich, Salisbury, and Van Voorhis (2012) • Quantitative exploration into identifying trajectories of offending for women • Relied on person-centered approach versus variable-centered approach • Found 8 trajectories

  14. Female Trajectories “Normal Functioning” but Drug-Abusing Women • 2 Paths • More vocational/educational resources, less poverty than other types. • Minimal abuse, few MH problems, minimal homelessness • Both chronic substance abusers with multiple arrests • Path 1 mostly single mothers, above average functioning, younger with more parenting anxiety than Path 2 • Path 2 older, functional in many areas, not currently parenting

  15. Female Trajectories Battered Woman • 2 Paths • Both with lifelong physical and sexual abuse, social marginalization. • Neither reflected MH problems, psychosis or antisocial personality. • Path 3 stressed single mothers with lifelong abuse, depression, AOD, abusive SO relationships. • Path 4 abused older women, conflicted relationships, chronic AOD, unsafe housing, chaotic lives. Most without children under 18.

  16. Female Trajectories Socialized Subcultural with Less Victimization and Few Mental Health Needs • 2 Paths • Serious social marginalization, education/vocation deficits, high crime residences, stronger antisocial significant other influences. • Little evidence of sexual/physical abuse. • Path 5 younger, poor, stressed single mothers with low self-efficacy in conflicted but not violent relationships. All with children under 18. • Path 6 addicted, older, isolated women with extreme marginalization, poverty, low self-efficacy, most without children under 18.

  17. Female Trajectories Aggressive Antisocial Women • 2 Paths • Characterized by most extreme risk and need profiles. • Lifelong sexual and physical abuse, antisocial families, hostile antisocial personality, MH, homelessness, antisocial significant others. • Path 7 abused and aggressive, antisocial with hostility, MH/depression, homelessness, mostly single, most with children. • Path 8 abused and addicted single mothers with serious MH, psychosis, suicide risk, aggressive, violent, and noncompliant.

  18. Variable-Centered Findings on Women Offenders • Evidence-Based Guidelines and Practices reflect generalized understanding of relationships among variables • Therefore, women as a group are described as: • High in abuse and trauma • High in mental illness • High in parenting stress • High in economic marginalization • Low in self-efficacy • Suggests similar approaches for women as a group

  19. Heterogeneity Among Women • 4 subgroups experienced repeated sexual and physical abuse (Pathways 3, 4, 7, 8) • Link between childhood abuse and adult criminal behavior not generalized • 3 subgroups scored high on mental illness (Pathways 3, 7, 8) • 5 subgroups characterized by parental stress (Pathways 1, 3, 5, 7, 8) • 2 subgroups scored low on economic marginalization (Pathways 1 and 2) • One group largely characterized by gender-neutral risk factors rather than gender-responsive risk factors (Pathway 2)

  20. Policy and Practice Implications • Need more than one “gender-responsive” approach to female offenders • Need effective risk assessment and analysis systems to efficiently identify different subgroups • Modified policies and curricula to address the different needs of the various groups • CQI system to track that appropriate services were matched to each subgroup

  21. Moving Forward to Achieve Effective and Efficient EBDM • The Next Evolution of CQI • Data tied to individual clients • Ability to trend in the aggregate as well as at the individual client level • Data mining and data surveillance capabilities • Development of contextualized feedback systems

  22. Contextualized Feedback Systems • Characteristics: • Provides staff with real-time, pertinent, client-specific information • Information has been intelligently filtered • Delivered at the point of care • Offers actionable recommendation • Evidence: • Systems have been shown to change staff behavior (i.e., better adherence to EBP) • One study showed that staff who viewed the information more frequently had clients who demonstrated greater improvements AND clients who demonstrated improvements more quickly

  23. Conclusions • Corrections has benefitted from a number of well-established Evidence-Based Guidelines and Evidence-Based Practices • Next evolution will focus on bringing a more nuanced understanding and application of these EBG’s and EBP’s to the individual client level • Practitioner-driven CQI needs to intersect with research to drive this process so that we continually move the field forward to maximize public safety outcomes

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