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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.

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science into practice how do we make it matter evidence based practices in rural environments

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

the uptake challenge
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
the uptake challenge1
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??

the uptake challenge2
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.
the uptake challenge3
The Uptake Challenge
  • Is there a way to understand these interactions and build better interventions?
  • A modest suggestion follows…..
making the transition
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
first do no harm
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?
some national trends the big two
Some national trends: THE BIG TWO

Outcomes and Performance Measurement

Evidence Based Practices

what are some of the dimensions of quality that we need to consider
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?
defined by whom
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
measured by
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
at what cost
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?
with what rewards
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
field overview
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
slide17

FRAMEWORKS FOR DISCUSSION

THREE MOVEMENTS

(1) The Nike Imperative

(2) The Kudzu Phenomenon

(3) The Search for the Holy Grail

the trends 1
THE TRENDS -1

THE NIKE IMPERATIVE:

JUST DO IT!!

the nike imperative
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

the nike imperative 2
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
the nike imperative 3
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”.
the trends 2
The Trends ~ 2

The

Kudzu

Phenomenon

the kudzu phenomenon
The Kudzu Phenomenon

KUDZU?

What IS kudzu?

kudzu the facts
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
the kudzu phenomenon1
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

the kudzu phenomenon 2
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...

trends 3 the search for the holy grail
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?

the holy grail search
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.
practical implications
Practical implications
  • Whatever your role on a provider team, you can’t escape this movement:
  • No outcomes = No incomes
summary
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.
three big caveats
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

three big caveats1
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

three big caveats2
THREE BIG CAVEATS

CAVEAT THREE:

Don’t let the PERFECT

be the enemy of the GOOD.

2 evidence based practices

2. Evidence-Based Practices

Promises and pitfalls…

ebps promises and pitfalls
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?
ebps promises and pitfalls1
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.
ebps promises and pitfalls2
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.

ebps promises and pitfalls3
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.

ebps promises and pitfalls4
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

ebps promises and pitfalls5
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:

ebps promises and pitfalls6
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
ebps promises and pitfalls7
EBPs: Promises and Pitfalls
  • In reality:
    • Quality reasons
    • Administrative reasons
    • Financial reasons
    • Political reasons

Yes, it’s policy pinball…

ebps promises and pitfalls8
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
ebps promises and pitfalls9
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

ebps promises and pitfalls10
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;
ebps promises and pitfalls11
EBPs: Promises and Pitfalls
  • Some things to think about while implementing evidence-based practices (or best practices, or promising practices, or emerging practices):
ebps promises and pitfalls12
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.
ebps promises and pitfalls13
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.
ebps promises and pitfalls14
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.
ebps promises and pitfalls15
EBPs: Promises and Pitfalls
  • Learn to love data…It’s hard, but it’s got to happen.
  • Even better, learn to talk about outcomes and performance and quality openly with colleagues, but especially with consumers and families
ebps promises and pitfalls16
EBPs: Promises and Pitfalls
  • Demand:
    • Better pre-professional training of staff for the real world.
    • Better continuing education that is linked to consumer desires and outcomes.
    • Better educational materials for consumers and families about quality of care.
    • More attention to system redesign issues to support quality.
    • An emphasis on team work, involving ALL stakeholders, whatever their role in services.
ebps special rural challenges
EBPs: Special rural challenges
  • For many models, lack of sufficient numbers of appropriate clients in any reasonable geographic area
  • Complications of providing basic linguistic and cultural competence
  • General issues of access to health/behavioral health services
ebps special rural challenges1
EBPs: Special rural challenges
  • Difficulties in achieving fidelity to some models
  • Lack of research focused on rural delivery of current models
  • Need for adaptation without resources to map effectiveness of model changes
  • Workforce, workforce, workforce…
ebps promises and pitfalls17
EBPs: Promises and Pitfalls
  • THE BIGGEST PITFALL:

Ignoring the complexity of the human experience of mental and substance use conditions, especially as they impact people from different cultural, ethnic and linguistic traditions. This is especially true with children and adolescents, and amplified by social determinants like poverty, racism and geographic isolation.

ebps promises and pitfalls18
EBPs: Promises and Pitfalls
  • THE BIGGEST PROMISE:

Improved quality of life for people with mental and substance use conditions, whose recovery journey can be enhanced by science working on their behalf. For children and families, the stakes are huge and the potential benefits multigenerational.

ebps promises and pitfalls19
EBPs: Promises and Pitfalls
  • If you want to know more:
    • www.tacinc.org Turning Knowledge into Practice
    • www.nasmhpd-nri.org
    • www.ahrq.gov
    • www.samhsa.gov
ebps promises and pitfalls20
EBPs: Promises and Pitfalls

Take home messages:

EBPs are here to stay.

EBPs are worth the investment.

EBPs are not the silver bullet or the panacea, but they’re not evil.

EBPs are tools, not ultimate answers—use them wisely in service to people.

ebps promises and pitfalls22
EBPs: Promises and Pitfalls

The movement is in its earliest stages, and there is still time to be at the forefront.

implications
Implications

The two national trends of performance measurement and evidence-based practices fit together and support each other.

implications1
Implications

Providers who are well prepared in these areas are best armed for survival in the increasingly competitive behavioral healthcare marketplace.

implications2
Implications

As an organization devoted to the care of some of our most vulnerable people, embracing these trends helps ensure that we are doing everything we can to positively impact their lives.

the final words
The final words…

Because a commitment to quality is a hallmark of leadership;

Because we want our quality efforts to be demonstrable;

Because we care deeply about what we do, and we want to do it consistently and effectively for each child, adult or family we are privileged to serve.

good luck to each of you as you lead your organization toward ever higher standards of quality

Good luck to each of you as you lead your organization toward ever higher standards of quality.

Thanks for having me.

speaker contact information
Speaker Contact Information:

John A. Morris, MSW

Director, Human Services Practice

Technical Assistance Collaborative, Inc.

&

Professor and Director of Health Policy Studies

Department of Neuropsychiatry and Behavioral Science

University of South Carolina School of Medicine

803.434.4243

Jmorris@tacinc.org