Science into Practice: How Do We Make It Matter? Evidence-Based Practices in Rural Environments

1. Science into Practice: How Do We Make It Matter?Evidence-Based Practices in Rural Environments John A. Morris, MSW Director, Human Services Practice Technical Assistance Collaborative, Inc. Professor and Director of Health Policy Studies, University of South Carolina School of Medicine

2. The Uptake Challenge • Can we deconstruct the core issues in implementing EBPs? • Four interacting elements: • Realities of the practice environment • Realities of the economic environment • Realities of the political environment • Realities of the scientific environment

3. The Uptake Challenge • There is good science on recovery • There is good science on effective interventions for mental and substance use conditions • There is good science on dissemination of innovation SO WHY IS IT TAKING US SO LONG TO MAKE CHANGE HAPPEN??

4. The Uptake Challenge • There is no direct pipeline from the research world to the practice world • The language of science is often not the language of practice—and there are very few simultaneous translation services (where’s the UN when you need them…? • As knowledge accelerates, the gap may widen. • Problems of scale and cost impact local providers especially.

5. The Uptake Challenge • Is there a way to understand these interactions and build better interventions? • A modest suggestion follows…..

7. Making the Transition • So, we have to look at interventions that address all of the variables. • And we need to look at those variables as they apply to small, community based organizations which may have limited infrastructure. • All made more complex in rural/frontier environments

8. First, do no harm… • Interventions need to be tested to ensure that there are not unintended consequences • Does practice change but result in adverse events or trends? • Do the outcomes reflect consumer level outcomes that are consistent with goals of RECOVERY and RESILIENCE?

9. Some national trends: THE BIG TWO Outcomes and Performance Measurement Evidence Based Practices

10. 1. Outcomes and Performance Measurement A question of quality

11. What are some of the dimensions of quality that we need to consider? • As defined by whom? • As measured by what? • At what cost? • With what rewards?

12. Defined by whom: • Simplest answer: by consumers of services—the children and families served by rural providers • Reality more complex: • Purchasers/insurers/sponsors/funders • Accrediting bodies • Professional associations • Management • State and federal policy makers

13. Measured by: • Consumer perception of care • Outcomes research and evaluation • Formal, standardized instruments • Clinical acumen, practice wisdom and word-of-mouth • A suite of indicators

14. At what cost? • Very complex area, subject to very local conditions • Bottom line: there ARE costs: • Staff time and energy • Infrastructure (IT, etc.) • Consumer/family patience • Direct costs of instruments, evaluators, etc. • The dangers of a zero sum game: What doesn’t get done in order to do this?

15. With what rewards? • Intrinsic value of demonstration of competency and effectiveness • Strengthening of client:clinician partnership • Increased credibility with external community • Competitive advantage in tough fiscal environment. • Clinician benchmarking of success and achievement

16. FIELD OVERVIEW • First, some contextual issues and a look at performance measurement/outcomes research • Second, the most promising direction for the field currently, the movement toward evidence based practices

17. FRAMEWORKS FOR DISCUSSION THREE MOVEMENTS (1) The Nike Imperative (2) The Kudzu Phenomenon (3) The Search for the Holy Grail

18. THE TRENDS -1 THE NIKE IMPERATIVE: JUST DO IT!!

19. THE NIKE IMPERATIVE “Purchasers are requiring more data from health plans…” “Consumers are seeking more information to drive their selection of plans…” “Accrediting agencies are developing report cards and other mechanisms to compare quality…” --Dr .Terry Kramer Outcomes and guidelines agenda moves forward, 1998 Behavioral Outcomes and Guidelines Sourcebook

20. The Nike Imperative - 2 • Public purchasers are under special pressure to measure and report because of: • taxpayer/voter accountability • vulnerability of populations served • historic (though often inaccurate) perception of second-tier quality of public services • cultural diversity of populations served

21. The Nike Imperative - 3 • Private providers are equally under pressure to address the concerns of purchasers and insurors • All of healthcare is faced with the imperative of the Institute of Medicine to “bridge the quality chasm”.

22. The Trends ~ 2 The Kudzu Phenomenon

23. The Kudzu Phenomenon KUDZU? What IS kudzu?

24. Kudzu: The facts... • Pueraria thumbergiana • perennial member of the bean family • propagates at the rate of a foot a day • 2 million acres in the South

26. THE KUDZU PHENOMENON Proliferation of measurementsets, report cards, indicator sets-- public & private proprietary & free individual-based & population-based scientifically validated & face valid purchaser-, consumer-, and provider- oriented

27. THE KUDZU PHENOMENON- 2 Remember: KUDZU was introduced to benefit farmers--and sometimes it does--but this quote from the Kudzu Homepage is instructive: “Propagating at the rate of a foot (or more) a day, KUDZU IS AN AWESOME BEAST.” The same may be said for performance and outcome measurement...

28. TRENDS ~ 3: THE SEARCH FOR THE HOLY GRAIL A central question of the current environment: Are we willing to pay the price for making outcomes research a part of normal operations? If so, HOW? If not, WHY NOT?

29. THE HOLY GRAIL: SEARCH?? • First, “If not” is not a viable question for the field. Continued inaction will: • fail purchasers and consumers; • waste resources that are already too scarce to meet the needs of consumers and families by continuing to do stuff that doesn’t work. • perpetuate sub-optimal care.

30. Practical implications • Whatever your role on a provider team, you can’t escape this movement: • No outcomes = No incomes

31. SUMMARY • It isn’t easy. • There are no silver bullets, no magic solutions, maybe not even a Holy Grail. • It IS worth it. • Bad data begets better data. • Be humble but determined.

32. THREE BIG CAVEATS CAVEAT ONE: “Today’s measures tend to be blunt, expensive, incomplete and distorting. And they can easily be inaccurate and misleading.” David M. Eddy, MD Performance Measurement: Problems and Solutions. Health Affairs, July/August 1998

33. THREE BIG CAVEATS CAVEAT TWO: “In the field of performance measurement, there has been a great deal of flapping, but very little flight.” Vijay Ganju, PhD

34. THREE BIG CAVEATS CAVEAT THREE: Don’t let the PERFECT be the enemy of the GOOD.

35. 2. Evidence-Based Practices Promises and pitfalls…

36. EBPs: Promises and Pitfalls • Starting at the beginning: • Isn’t this just the New-New Thing? • Can’t we just wait this out for the next trend? • What does this say about what we’re already doing? • Isn’t this just cook-book medicine or therapy? • Whose “evidence” anyway?

37. EBPs: Promises and Pitfalls • To the skeptics: Your concerns are understandable, and will be addressed, but: • No, it’s not just the New-New Thing. • It is probably a movement that is here to stay. • What you’re doing now may be fine—but wouldn’t you like to be sure? • So far, there aren’t many cookbooks! • “Whose evidence” is a great question, and we will cover several answers to that one.

38. EBPs: Promises and Pitfalls Why evidence-based practices, and why now? Evidence based medicine, and demand for increased quality and accountability. Purchasers of healthcare no longer accept any variant of “Just trust me” as sufficient.

39. EBPs: Promises and Pitfalls Bottom line: Behavioral health went down a path of what some have called the “secular priesthood”, with the notion of the skills being resident in the appointed healer. Now there is an emerging science base that we cannot ignore.

40. EBPs: Promises and Pitfalls Who are the key drivers? Purchasers: Medicaid, private insurance Policy makers: SAMHSA, state MH Authorities Scientists: medical researchers and academics Foundations: MacArthur, RWJ Accrediting organizations: JCAHO,CoA, carf, etc. To a lesser extent, but growing: families and consumers

41. EBPs: Promises and Pitfalls What are the alternatives to evidence-based practice? According to Isaacs and Fitzgerald, there are seven alternatives to evidence-based medicine:

42. EBPs: Promises and Pitfalls • Eminence based medicine • Vehemence based medicine • Eloquence based medicine • Providence based medicine • Diffidence based medicine • Nervousness based medicine • Confidence based medicine • Isaacs & Fitzgerald, British Medical Journal 1999;319:1618

43. EBPs: Promises and Pitfalls • In reality: • Quality reasons • Administrative reasons • Financial reasons • Political reasons Yes, it’s policy pinball…

44. EBPs: Promises and Pitfalls • The National Perspective • SAMHSA and the Toolkits • Illness self-management/recovery; medication management; ACT; supported employment; family education; integrated dual disorders • Blueprint programs for youth • Annie E. Casey “Blue Sky” • Multi-Systemic Therapy (MST), Functional Family Therapy; Treatment Foster Care

45. EBPs: Promises and Pitfalls • Some definitions (from Hyde, Falls, Morris and Schoenwald): • Evidence-Based Practice: gold standard: randomized, controlled, double blind, real-world, experimentally validates • Best practice: closest fit between best available science (EBP) and best available resources

46. EBPs: Promises and Pitfalls • Some definitions (from Hyde, Falls, Morris and Schoenwald, 2003): • Promising practice: some evidence or strong consensus among experts or consumers—likely to become an EBP given time and resources • Emerging practice: anecdotal or practice evidence; broad acceptance;

47. EBPs: Promises and Pitfalls • Some things to think about while implementing evidence-based practices (or best practices, or promising practices, or emerging practices):

48. EBPs: Promises and Pitfalls • Be sensitive to practice-based evidence. If it doesn’t work, stop it; but if it just doesn’t have a robust evidence-base, treat it gingerly. • Cultivate evidence-based thinking. Actively LOOK for outcome data--listen to consumers and families--be honest.

49. EBPs: Promises and Pitfalls • Don’t over-promise! We are at the early stages, so be humble about what will result. • Accept the evidence about diffusion of innovation: it doesn’t happen automatically, smoothly, or cheerfully.

50. EBPs: Promises and Pitfalls • Be respectful of skeptics (be skeptical yourselves), but demand evidence in opposition to EBPs as well as providing evidence in support of EBPs. • Pay attention to system issues, and avoid the temptation to see implementation problems as “resistance” from clinicians or consumers.