Integrating the Recovery Paradigm into the Evidence-Based Practice Movement

1. Integrating the Recovery Paradigm into the Evidence-Based Practice Movement The National Association of Mental Health Planning and Advisory Councils

2. EBP’s and Recovery: Friends or Foes? • Are the values of recovery and current evidence-based practices fundamentally antagonistic? • What are evidence-based practices? • What is all the fuss? • What is recovery? • Can we really infuse recovery-based principles into current EBPs?

3. EBP’s 101: A Quick Overview…

4. Evidence-Based Practices • Why should this be important to Planning Councils? • Surgeon General’s Report: Gap between knowledge of effective mental health services and practice • President’s New Freedom Commission – Integral part of Transformation • The future is now! EBPs are here to stay and PACs need to be educated on the process, benefits and controversy • National Outcomes Measures

5. The importance of EBPs… • Client: • EBPs, when used and implemented appropriately, improve outcome • Every individual has the right to the most effective practices • Mental Health System • EBPs inculcate an outcomes-oriented, quality improvement framework • EBPs help identify and address administrative barriers • General Public • Best use of available dollars • Credibility of interventions

6. Sounds like a good idea, right? • One mechanism to achieve quality and accountability • The Big Plus: Effectiveness is proven and inherent in evidence-based practices • The Big Gap: Surgeon General’s Report finding of the gap between knowledge and practice • The Big Opportunity: Opportunities for system reform embedded in implementation of evidence-based practices

7. Wait! We must answer a few questions first.

8. What IS an Evidence-Based Practice?Some Definitions • An evidence-based practice is considered to be any practice that has been established as effective through scientific research according to a set of explicit criteria (Drake et al, 2001). • Evidence-based treatment is the use of treatments for which there is sufficiently persuasive evidence to support their effectiveness in attaining desired outcomes (Rosen and Proctor, 2002). • Evidence-based practice is the integration of best research evidence with clinical expertise and patient values (Institute of Medicine, 2001).

9. Levels of Research/Evidence Level I -- Randomized Controlled Trials Level II – 1 Well designed trials without randomization 2 Cohort or case control, preferably multi-site 3 Multiple time series – with or without intervention Level III -- Opinions of respected authorities, based on clinical experience; descriptive studies; case reports From Yannacci, Jacqueline, Evidence-Based Practices: Definitions, Models and Issues, presentation at the NAMHPAC winter meeting, January 2005.

10. What is evidence? SAMHSA’s National Registry of Evidence-Based Programs and Practices (NREPP) • Utilize 16 rating criteria (e.g. reliabilty, validity, comparison group) • Criteria rated 1-4, average of 16 criteria scores • Five possible categories • 4 = Effective Program or Practice • 3 = Conditionally Effective Program or Practice • 2 = Emerging Program or Practice • 1 = Program or Practice of Interest • 0 = Insufficient Current Support

11. Who establishes EBPs? • SAMHSA – NREPP • NIMH • Cochrane Collaboration • Center for Mental Health Quality and Accountability To name a few…

12. Wading through the jargon… • Best Practices: Typically have a strong research backing and have been replicated in a variety of settings (also called “Exemplary Practices”) • Promising Practices: Practices for which there is considerable evidence or expert consensus but are not yet supported by “rigorous” scientific evidence. • Emerging Practices: Often used interchangeably with promising practices

13. EBPs: So what is the controversy? • Legislating Evidence-Based Practices • Using EBPs as a cost containment strategy • Using EBPs in exclusion of other treatments • What is evidence? Defining “beneficial outcomes” – who decides? • Recovery Paradigm

14. CULTURAL COMPETENCY • Cultural competence is about adopting mental health care to the needs of consumers from diverse cultures • Culture influences numerous aspects of care (help seeking behavior, preferred settings, language, coping) • May need to tailor EBPs themselves or the context in which they are offered • SAMHSA Toolkits provide a number of recommendations for making EBPs culturally competent • Must collect and analyze data to examine disparities in service • Conduct regular organizational self-assessment of cultural competence

15. Now that we understand EBPs and the potential pitfalls… How do we implement them in our state?

16. Evidence-based Practices Project • EBP Implementation Resource Kits (“toolkits”) (Dartmouth-led consortium) • National Demonstration Project (IN, KS, MD, NH, NY, OH, OR, VT)

17. Evidence-Based Practices for Adults with Serious Mental Illness Toolkit Project • Six evidence-based services in project • Medications • Illness self-management • Assertive community treatment • Family psychoeducation • Supported employment • Integrated substance abuse/mental illness services

18. Different Toolkits for Different Audiences • For each evidence-based practice, there are toolkits for different audiences • State Mental Health Authority • Provider organization • Clinician/provider • Consumer • Family member

19. Child & Adolescent Evidence-Based Practices • Multi-systemic Therapy (MST) • Therapeutic Foster Care • Positive Behavioral Interventions and Supports (PBIS)

20. rapidly www.nri-inc.org/CMHQA/CMHQA.cfm

21. A word on FIDELITY… • What is fidelity? • Adherence to program standards and principles • Why is fidelity important? • The more similar the implemented practice is to the model, the better outcomes obtained • Diagnose program weakness/Clarify strengths • How do we monitor fidelity? • SAMHSA Toolkits • Fidelity scales must adequately sample all the critical ingredients • Must be sensitive enough to detect change as the program develops SAMHSA Fidelity Scales: http://ebp.networkofcare.net/uploads/fidelityscales_6513943.htm

22. Fidelity in Rural, Ethnically Diverse and Non-traditional settings… • Each Evidence-Based Practice developed in certain location/population • Goodness of fit problem • In rural, ethnically diverse, non-traditional settings may not be possible to have full fidelity to the model • However, the more we modify and deviate from the original model, need increased attention to measuring fidelity and outcomes. • Why? Need to measure the effects of changes in practice in communities with differing cultures and values.

23. Review of ACT Teams Using Dartmouth Fidelity Scale (2004) - Alabama • Along with consumers, families, and Mental Health Association representatives, met with providers to discuss their assessments and to review data • Reviews were conducted in July and August • There are three domains assessed: Human Resources: structure and composition Organizational Boundaries Nature of Services From Carlson, Greg, The Role of Planning Councils in Advocating and Implementing Evidence Based Practices. Presentation at the NAMHPAC winter meeting, January 2005.

24. Implementation of ACT with High and Low Fidelity Source: Rosenheck, et al. 1995

25. Implementation of ACT with High and Low Fidelity Source: Rosenheck, et al. 1995

26. Infusing the Recovery Paradigm

27. Recovery Model: It’s all about the outcomes… • Recovery should be the “common, recognized outcome of mental health services” – President’s New Freedom Commission • Draft Consensus Statement: “A journey of healing & transformation for a person with a mental health disability to be able to live a meaningful life in communities of his or her choice while striving to achieve full human potential or ‘personhood’.”

28. New York State Office of Mental Health: A more productive stance … • “… a movement toward infusing our (consumers’) definition of quality into evidence-based practices or any other initiative within the mental health service delivery system.” Infusing recovery-based principles into mental health services: A white paper by people who are New York state consumers, survivors, patients and ex-patients. September, 2004. New York State Office of Mental Health.

29. Integrating Ten Rules for Quality Mental Health Services • Informed Choice • Recovery Focus • Person Centered • Do No Harm • Free Access To Records • A System Based on Trust • A Focus On Cultural Values • Knowledge-Based • Partnership Between Consumer & Provider • Access to Services Regardless Of Ability To Pay

30. Another model of integration: • A time and place for everything: • More controversial • For persons who are so seriously impaired they are unable to discern best interests, a paternalistic, externally reasoned treatment approach is appropriate (traditional EBPs) • As person benefits from externally initiated interventions, control should shift to person who is recovering – given greater choice about evidence-based interventions and other available services (more recovery oriented) • Advanced Directives means of finding a middle ground to this stance

31. Factors Affecting State-Wide Recovery-Oriented EBP Implementation • Workforce Development & Training • Financial Resources & Medicaid Reimbursement • Consensus Building among all stakeholders • Policies/procedures • Integration with performance/quality improvement

32. Latest News on the EBP Front:Federal Action Agenda • Expand NREPP to include best evidence-based interventions • Develop procedure through which consensus can be developed across key mental health groups, consumer and family members regarding implementation of EBPs • Develop new toolkits: children’s services, older adults, supportive housing, trauma and violence, models in primary care, consumer-operated services and supported education

33. Some Tangible Examples for PAC Action: • Host a planning meeting and invite stakeholders and national experts with expertise on different evidence-based services to address the group. • Ask state mental health planning staff to discuss any plans the state is working on for implementing evidence-based programs and different efforts to measure quality and outcomes of these programs. • Establish a sub-committee or task force to focus on the issue of evidence-based mental health services and further explore the needs of consumers and families in the state and how new programs can meet those needs. • Participate in consensus buildingby initiating statewide training/education familiarizing key stakeholders with the evidence-based practice(s) the state would like to implement • Block Grant: • Review allocation of the Block Grant funds in the state and determine the extent to which funds are being used to support implementation and delivery of EBPs. If dollars are not being used to support EBPs, councils can issue recommendations encouraging at least a portion of funds be used to support recovery-oriented initiatives, consumer-operated services and/or implementation of EBPs.

34. Some Tangible Examples for PAC Action: • Advocate for: • consumer and family member involvement at all stages of the planning process in development and implementation of EBPs. • research on promising practices • policy changes in the way services are funded in order that flexible funding streams will be available to support evidence-based initiatives • Work with your local university department of psychology, psychiatry and social work to identify evidence-based practices, gather and interpret information about specific programs of interest, and evaluate the effectiveness of exemplary State programs that have not previously been scientifically tested. • Monitoring: • Fidelity Assessment • Quality assurance assessment feedback loop • Sit on taskforce committees created to develop standards for EBPs

35. Placing Consumers in the Driver’s Seat on the EBP Highway…

36. Consumer Recommendations for Developing and Implementing EBPs • Consumer participation in the EBP movement is critical to its success. • The EBP movement and mental health researchers should seek the participation of people with mental illness in all levels of EBP development. • The EBP movement must reexamine and reallocate their research resources that encompass the entire breadth of program and outcomes. • EBPs must be linked to all aspects of living with a mental illness. What Works? What Doesn’t? Consumer perspectives and needs related to evidence-based practices. Center for Mental Health Quality and Accountability. February, 2005

37. Promising/Emerging Practices Consumer-Operated Services • Programs that are administratively controlled and operated by consumers and emphasize self-help and their operational approach • Multi-site study of 1827 participants who were randomly assigned to either traditional MH services or traditional MH services and peer run services From: The Consumer-Operated Service Program Multisite Research Initiative: Overview and Preliminary Findings. Presentation made by Jean Campbell at the Alternatives Conference

38. COSP Study Results • “Participants randomly assigned to consumer-operated services programs of the drop-in type in addition to their traditional MH services showed greater improvement in well-being over the course of the study than participants randomly assigned to only traditional mental health services at those sites” From: The Consumer-Operated Service Program Multisite Research Initiative: Overview and Preliminary Findings. Presentation made by Jean Campbell at the Alternatives Conference

39. Fully Integrating Consumers into the EBP Movement • Recognizing consumers as allies • Develop strategies to move peer support from a promising practice to an EBP • Obtain pilot funding to show that existing consumer run, peer support programs are an EBP/Promising practice • Expand “SAMSHA Evidence-Based Implementation Resource Kit Steering Committee” to include consumer researchers and community providers Information From: Evidence-Based Practices: Challenges and Opportunities. Presented at NMHA 2005 Annual Conference by Sara Thompson.

40. Integration Continued… • Some tangible examples of steps to integration of recovery from the consumers’ perspectives into EBPs: • Disseminate Jean Campbell’s findings on COSPs – fund data analysis and evaluation • Increase mental health block grant spending to funding promising or emerging practices set aside for COSP • Develop a “Consumer Information Packet” on “the possibility of recovery” which would be included in treatment planning materials for providers.

41. Integration Continued… • Consumers Can Address Workforce Shortages: • e.g. Use State Infrastructure Grants to develop a “recovery mentor program” so a consumer knows what to expect when s/he goes to the ER or hospital • Educate health care professionals, academic health centers and related institutions on consumer run EBPs

42. Integration Continued… • Making Research More Consumer-Friendly: • Train consumers to research promising practices to determine what is effective and to develop implementation strategies (e.g. a Consumer Research Institute) • CONTAC and National Empowerment Center to convened meeting for consumers on research and evaluation in August, 2005 (info on CONTAC website: www.contac.org) • Encourage NIMH to disseminate all research to consumers in layperson language. This could be accomplished by making it a requirement of NIMH grantees.

43. Integration Continued… • Expanding and Accelerating Research Partnerships with Consumers to Support EBP • Advocate for NIMH/SAMHSA inclusion of consumers in the development of RFA process • Ensure that there are specific requirements that consumers are consistently part of the team in design, delivery, implementation and evaluation of SAMHSA grantees in the development of EBPs • Develop a systematic process for putting consumers in touch with established NIMH researchers

44. EBPs: Under the Umbrella of Recovery RECOVERY EBPs