An Illustration of the PracticeWise Model and Tools
Transcript of An Illustration of the PracticeWise Model and Tools
An Illustration of the PracticeWise Model and Tools
Bruce F. Chorpita, Ph.D.University of California, Los AngelesPracticeWise, LLC
Eric L. DaleidenMichael A. Southam-Gerow John R. WeiszChild STEPs Research NetworkDavid H. BarlowRon DrabmanAnne Marie AlbanoRick Barth
Hawaii Departments of Health and EducationMinnesota Department of Human Services John D. & Catherine T. MacArthur
FoundationAnnie E. Casey FoundationCalifornia Alliance of Child and Family
ServicesUS Army CAF Behavioral Health ProponencyLA County Department of Mental HealthLos Angeles Unified School DistrictPasadena Unified School DistrictCalifornia Institute of Mental Health
How can we get more from the evidence we already have?
Isn’t it all really about knowledge management?
Evidence Consolidation Coordination Implementation Practice
Children and Families
Raw RCTs…
EBT “Lists”
Coaching, Feedback, Org/admin supports
Quality services, supervision
1st generation
2nd
generation
3rd
generation
Knowledge Inquiry
“the unmanageable multitude of primary studies or information of variable quality that is out there and that may or may not be easily accessed” (Graham et al., 2006, p. 18)
Knowledge Synthesis
“the application of explicit and reproducible methods to the identification, appraisal, and synthesis of studies or information relevant to specific questions. It is done to make sense of all the relevant knowledge. This knowledge often takes the form of systematic reviews, including meta-analysis and meta-synthesis” (p. 19)
Knowledge Tools
“…provide explicit recommendations with the intent of influencing what stakeholders do.” (p. 19)
• e.g., a Care Pathway is a knowledge tool• What PracticeWise calls “knowledge
appliances”
ACMEEvidence-Based Treatment Manual
ACME
Evidence-
Based
Treatment
Manual
ACME
Evidence-
Based
Treatm
ent
Manual
“How can I learn enough EBTs? “How do they fit with what I was doing
before?” “How will what I learn stay current?” “Are there EBTs for all the different kinds
of kids I see?” “What do I do if there are not?” “What do I do if a child does not respond
to an EBT?” “Aren’t there other forms of evidence?”
In addition to installing new programs in a system…
Develop a knowledge delivery architecture to improve the practices that are already there
See the evidence base as knowledge and not simply products…
TherapeuticPractices
ServiceSetting
ClientProgress
TreatmentIntegrity
Tx ProgramSelection
TherapeuticPractices
ServiceSetting
ClientProgress
TreatmentIntegrity
Tx ProgramSelection
TherapeuticPractices
ServiceSetting
ClientProgress
TreatmentIntegrity
School
Cognitive, Problem Solving…
Competency Checklist for Therapists
RADS, CDI
CBT (adapted CWD)
PhD, MSW
PhD Supervisor
From Kahn et al., 1990
Tx ProgramSelection
TherapeuticPractices
ServiceSetting
ClientProgress
TreatmentIntegrity
GeneralServicesResearch
Tx ProgramSelection
TherapeuticPractices
ServiceSetting
ClientProgress
TreatmentIntegrity
Evidence-Based Services Model
Case-SpecificHistorical
Information
CausalMechanismResearch
Tx ProgramSelection
TherapeuticPractices
ServiceSetting
ClientProgress
TreatmentIntegrity
Individualized Case Conceptualization Model
LocalAggregateEvidence
Case-SpecificHistorical
Information
Tx ProgramSelection
TherapeuticPractices
ServiceSetting
ClientProgress
TreatmentIntegrity
Practice-Based Evidence Model
GeneralServicesResearch
LocalAggregateEvidence
Case-SpecificHistorical
Information
CausalMechanismResearch
Tx ProgramSelection
TherapeuticPractices
ServiceSetting
ClientProgress
TreatmentIntegrity
Ongoing Review of Children’s Treatment Research 464 research papers 44 years 1,205 study groups 864 treatment protocols 46,171 youth participants
GeneralServicesResearch
LocalAggregateEvidence
Case-SpecificHistorical
Information
CausalMechanismResearch
“Good to see you, Sally. As soon as I finish reading these research studies, we can start our session today.”
ProblemAgeGenderEthnicitySettingStrength of Evidence
67 protocols,
19 treatment families
DEPRESSION
Results: Depression
Cognitive Behavior Therapy (19)
Cognitive Behavior Therapy with Parents (4)
Cognitive Behavior Therapy and Medication (3)
Family Therapy (2)
Interpersonal Therapy (3) Expressive
Writing/Journaling (2) Client Centered Therapy
(2) Relaxation (2)
Best Support Good Support
CWD-A PASCETBeck’s
CBT
CBT
Cognitive CognitiveCognitive
Relaxation
ProblemSolving
Relaxation
These are the practice elements.
Relaxation
Among all the evidence-based treatments for a given problem, which elements are the most common?
0% 25% 50% 75% 100%
Cognitive
Psychoeducational‐Child
Activity Scheduling
Maintenance/Relapse Prevention
Problem Solving
Self‐Monitoring
Communication Skills
Social Skills Training
Goal Setting
Psychoeducational‐Parent
Self‐Reward/Self‐Praise
Behavioral Contracting
Relaxation
Guided Imagery
Talent or Skill Building
Modeling
Stimulus Control or Antecedent …
Therapist Praise/Rewards
Relationship/Rapport Building
Parent Coping
Assertiveness Training
Crisis Management
Insight Building
Tangible Rewards
Family Therapy
Motivational Interviewing
Peer Pairing
Supportive Listening
Frequency of Practice Element
Not just ingredients…
Focus
Connect ConsolidateCultivate
Interference
Focus
Connect
EngagementPsychoeducation
Consolidate
MaintenanceBooster
Cultivate
Pleasant ActivitiesCognitiveProblem Solving…
Interference
Low Motivation: RewardsComplaining and Irritability: Active Ignoring
Tantrums: Time Out…
What if we could enroll every registered youth in a given service system into every randomized clinical trial that was ever published, and see who qualifies for which effective treatments?
Well, we can…
Can map entire service population• How many youth are “coverable” by anything
in the evidence base?• What is the minimum number of practices or
programs my staff need to learn to serve all “coverable” youth?
Example from Hawaii CAMHD Service System 2008
We still have to know the basic steps…right?
Objectives: to increase the amount of positive attention provided to the child, even if the child has misbehaved
at other times during the day
to teach the caregiver to attend to positive behaviors
to promote the child’s sense of self-worth Steps:
Provide rationale Emphasize the importance of providing positive attention to the child. Elicit the caregiver’s opinion about how attention affects behavior and
people’s motivation to do a good job. Have the caregiver describe his or her best and worst “managers”
and the caregiver’s motivation to work for each. Lead the caregiver to recognize that how he or she was treated
affected the caregiver’s desire to work. Discuss how the child’s behavior may be affected by the caregiver’s
behavior towards the child and how the child’s desire to behave can be increased by improving the caregiver-child relationship.
Set aside one-on-one time for caregiver and child
Encourage the caregiver to set aside a block of time (e.g., 10 minutes) each day devoted to joining the child in an activity the child has chosen.
Teach caregiver to provide positive and descriptive commentary
Show the caregiver how to demonstrate sincere interest in the child’s activities while they are playing.
Instruct the caregiver to provide enthusiastic descriptive (e.g., “You are drawing a tree”) and/or positive (e.g., “I like the way you stacked the blocks”) commentary and praise regarding the child’s behavior.
Encourage caregiver to engage in child’s activity
Suggest that the caregiver become actively involved in the play activity by imitating the child’s behavior in order to demonstrate approval.
Restrict criticism, questions, and commands
It is important that the child lead the activity; that is, the caregiver should refrain from making suggestions, asking questions, and criticizing the child.
Allow the child to use his or her imagination (e.g., coloring the green or making up new rules to a game) without caregiver input about the “correct” way to do things.
Anticipate difficulties When the procedure is initially implemented, the child may engage in negative behavior that characterizes the usual caregiver-child interaction. When this occurs, the caregiver should:
consistently ignore negative behavior by looking away; refrain from scolding the child so as to avoid providing negative
attention for misbehavior; end one-to-one time if disruptive behavior continues or is
dangerous. Over time, however, it is expected that consistent positive attending will result in decreased negative behavior and increased positive caregiver-child interactions.
Attending
Use This When:
To improve the quality of the caregiver-child relationship.
Practitioner Guide
For CaretakerFor Caretaker
One 2-sided page per practice
Coordinated library of evidence based procedures Available online and trained online to therapists
How do I know if it is working?
What do I do if it is not?
Clinical Dashboard
Progress
Practices
Individual Case Supervision Form Case Number: 6
Age: 12 Diagnosis: Generalized Anxiety Disorder Gender: M
Child Mother Father Other
Progress Measure:Fear rating
RewardsCommands
Time OutPraise
Problem SolvingParent Monitoring
Response Cost Ignoring/DRO
Stimulus Control/AntecedentsAttending/Directed Play
ModelingCognitive
Parent PsychoeducationSelf-Monitoring
RelaxationExposure
MaintenancePsychoeducation
Activity SchedulingSkill BuildingSocial Skills
Self MonitoringOtherOtherOtherOtherOtherOtherOtherOther
Days Since First Event
0 10 20 30 40 50 60 70 80 90 100
0
1
2
3
4
5
6
7
8
0 10 20 30 40 50 60 70 80 90 100
GeneralServicesResearch
LocalAggregateEvidence
Case-SpecificHistorical
Information
CausalMechanismResearch
Wisdom is knowing when to apply our knowledge and when not to (Speigler, 2000).• So….how do we know which of these tools to use
when?
ClinicalProgress?
Clinical Dashboard:Progress Pane
Continue plan until goals met
NotEngaged?
Crisis?
Poor Attendance,Complaints, etc.
Pursue engagement;Take appropriate action
yes
no
no
yes
no
yes
no
yes
Clinical Dashboard:Practice Pane, PW DB
Prob. w/ TxSelection?
TreatmentIntegrity?
Practitioner Guide,Clinical and
Quality ReviewConsider adding consultation or
training supports
Identify barriers and revise plan
Options1. Increase supports
2. Change Intervention3. Further Consultation
4. Add intervention
PW DB, Local Best Practices, Tx Team
New Case?
no
yes Select Evidence-Based Service (EBS)
PWDatabaseStart
The MAP
ClinicalProgress?
Clinical Dashboard:Progress Pane
Continue plan until goals met
NotEngaged?
Crisis?
Poor Attendance,Complaints, etc.
Pursue engagement;Take appropriate action
yes
no
no
yes
no
yes
no
yes
Clinical Dashboard:Practice Pane, PW DB
Prob. w/ TxSelection?
TreatmentIntegrity?
Practitioner Guide,Clinical and
Quality ReviewConsider adding consultation or
training supports
Identify barriers and revise plan
Options1. Increase supports
2. Change Intervention3. Further Consultation
4. Add intervention
PW DB, Local Best Practices, Tx Team
New Case?
no
yes Select Evidence-Based Service (EBS)
PWDatabaseStart
The MAP: Decisions
ClinicalProgress?
Clinical Dashboard:Progress Pane
Continue plan until goals met
NotEngaged?
Crisis?
Poor Attendance,Complaints, etc.
Pursue engagement;Take appropriate action
yes
no
no
yes
no
yes
no
yes
Clinical Dashboard:Practice Pane, PW DB
Prob. w/ TxSelection?
TreatmentIntegrity?
Practitioner Guide,Clinical and
Quality ReviewConsider adding consultation or
training supports
Identify barriers and revise plan
Options1. Increase supports
2. Change Intervention3. Further Consultation
4. Add intervention
PW DB, Local Best Practices, Tx Team
New Case?
no
yes Select Evidence-Based Service (EBS)
PWDatabaseStart
The MAP: Actions
ClinicalProgress?
Clinical Dashboard:Progress Pane
Continue plan until goals met
NotEngaged?
Crisis?
Poor Attendance,Complaints, etc.
Pursue engagement;Take appropriate action
yes
no
no
yes
no
yes
no
yes
Clinical Dashboard:Practice Pane, PW DB
Prob. w/ TxSelection?
TreatmentIntegrity?
Practitioner Guide,Clinical and
Quality ReviewConsider adding consultation or
training supports
Identify barriers and revise plan
Options1. Increase supports
2. Change Intervention3. Further Consultation
4. Add intervention
PW DB, Local Best Practices, Tx Team
New Case?
no
yes Select Evidence-Based Service (EBS)
PWDatabaseStart
The MAP: Guiding Information
ClinicalProgress?
Clinical Dashboard:Progress Pane
Continue plan until goals met
NotEngaged?
Crisis?
Poor Attendance,Complaints, etc.
Pursue engagement;Take appropriate action
yes
no
no
yes
no
yes
no
yes
Clinical Dashboard:Practice Pane, PW DB
Prob. w/ TxSelection?
TreatmentIntegrity?
Practitioner Guide,Clinical and
Quality ReviewConsider adding consultation or
training supports
Identify barriers and revise plan
Options1. Increase supports
2. Change Intervention3. Further Consultation
4. Add intervention
PW DB, Local Best Practices, Tx Team
New Case?
no
yes Select Evidence-Based Service (EBS)
PWDatabaseStart
The MAP: Selecting a Treatment Approach
This tells you the treatment types that work for this problem.
This tells you the practice elements associated with those treatment types.
ClinicalProgress?
Clinical Dashboard:Progress Pane
Continue plan until goals met
NotEngaged?
Crisis?
Poor Attendance,Complaints, etc.
Pursue engagement;Take appropriate action
yes
no
no
yes
no
yes
no
yes
Clinical Dashboard:Practice Pane, PW DB
Prob. w/ TxSelection?
TreatmentIntegrity?
Practitioner Guide,Clinical and
Quality ReviewConsider adding consultation or
training supports
Identify barriers and revise plan
Options1. Increase supports
2. Change Intervention3. Further Consultation
4. Add intervention
PW DB, Local Best Practices, Tx Team
New Case?
no
yes Select Evidence-Based Service (EBS)
PWDatabaseStart
The MAP: Getting on Track
ClinicalProgress?
Clinical Dashboard:Progress Pane
Continue plan until goals met
NotEngaged?
Crisis?
Poor Attendance,Complaints, etc.
Pursue engagement;Take appropriate action
yes
no
no
yes
no
yes
no
yes
Clinical Dashboard:Practice Pane, PW DB
Prob. w/ TxSelection?
TreatmentIntegrity?
Practitioner Guide,Clinical and
Quality ReviewConsider adding consultation or
training supports
Identify barriers and revise plan
Options1. Increase supports
2. Change Intervention3. Further Consultation
4. Add intervention
PW DB, Local Best Practices, Tx Team
New Case?
no
yes Select Evidence-Based Service (EBS)
PWDatabaseStart
The MAP: Treatment Going Along Well
Individual Case Supervision Form Case Number: 6
Age: 12 Diagnosis: Generalized Anxiety Disorder Gender: M
Child Mother Father Other
Progress Measure:Fear rating
RewardsCommands
Time OutPraise
Problem SolvingParent Monitoring
Response Cost Ignoring/DRO
Stimulus Control/AntecedentsAttending/Directed Play
ModelingCognitive
Parent PsychoeducationSelf-Monitoring
RelaxationExposure
MaintenancePsychoeducation
Activity SchedulingSkill BuildingSocial Skills
Self MonitoringOtherOtherOtherOtherOtherOtherOtherOther
Days Since First Event
0 10 20 30 40 50 60 70 80 90 100
0
1
2
3
4
5
6
7
8
0 10 20 30 40 50 60 70 80 90 100
Individual Case Supervision Form Case Number: 6
Age: 12 Diagnosis: Generalized Anxiety Disorder Gender: M
Child Mother Father Other
Progress Measure:Fear rating
RewardsCommands
Time OutPraise
Problem SolvingParent Monitoring
Response Cost Ignoring/DRO
Stimulus Control/AntecedentsAttending/Directed Play
ModelingCognitive
Parent PsychoeducationSelf-Monitoring
RelaxationExposure
MaintenancePsychoeducation
Activity SchedulingSkill BuildingSocial Skills
Self MonitoringOtherOtherOtherOtherOtherOtherOtherOther
Days Since First Event
0 10 20 30 40 50 60 70 80 90 100
0
1
2
3
4
5
6
7
8
0 10 20 30 40 50 60 70 80 90 100
ClinicalProgress?
Clinical Dashboard:Progress Pane
Continue plan until goals met
NotEngaged?
Crisis?
Poor Attendance,Complaints, etc.
Pursue engagement;Take appropriate action
yes
no
no
yes
no
yes
yes
Clinical Dashboard:Practice Pane, PW DB
Prob. w/ TxSelection?
TreatmentIntegrity?
Practitioner Guide,Clinical and
Quality ReviewConsider adding consultation or
training supports
Identify barriers and revise plan
Options1. Increase supports
2. Change Intervention3. Further Consultation
4. Add intervention
PW DB, Local Best Practices, Tx Team
New Case?
no
yes Select Evidence-Based Service (EBS)
PWDatabaseStart
The MAP: Treatment Not Going So Well
no
Individual Case Supervision Form Case Number: 6
Age: 12 Diagnosis: Generalized Anxiety Disorder Gender: M
Child Mother Father Other
Progress Measure:Fear rating
RewardsCommands
Time OutPraise
Problem SolvingParent Monitoring
Response Cost Ignoring/DRO
Stimulus Control/AntecedentsAttending/Directed Play
ModelingCognitive
Parent PsychoeducationSelf-Monitoring
RelaxationExposure
MaintenancePsychoeducation
Activity SchedulingSkill BuildingSocial Skills
Self MonitoringOtherOtherOtherOtherOtherOtherOtherOther
Days Since First Event
0 10 20 30 40 50 60 70 80 90 100
0
1
2
3
4
5
6
7
8
0 10 20 30 40 50 60 70 80 90 100
Do the practices fit the problem?Individual Case Supervision Form Case Number: 6
Age: 12 Diagnosis: Generalized Anxiety Disorder Gender: M
Child Mother Father Other
Progress Measure:Fear rating
RewardsCommands
Time OutPraise
Problem SolvingParent Monitoring
Response Cost Ignoring/DRO
Stimulus Control/AntecedentsAttending/Directed Play
ModelingCognitive
Parent PsychoeducationSelf-Monitoring
RelaxationExposure
MaintenancePsychoeducation
Activity SchedulingSkill BuildingSocial Skills
Self MonitoringOtherOtherOtherOtherOtherOtherOtherOther
Days Since First Event
0 10 20 30 40 50 60 70 80 90 100
0
1
2
3
4
5
6
7
8
0 10 20 30 40 50 60 70 80 90 100
ClinicalProgress?
Clinical Dashboard:Progress Pane
Continue plan until goals met
NotEngaged?
Crisis?
Poor Attendance,Complaints, etc.
Pursue engagement;Take appropriate action
yes
no
no
yes
no
yes
no
yes
Clinical Dashboard:Practice Pane, PW DB
Prob. w/ TxSelection?
TreatmentIntegrity?
Practitioner Guide,Clinical and
Quality ReviewConsider adding consultation or
training supports
Identify barriers and revise plan
Options1. Increase supports
2. Change Intervention3. Further Consultation
4. Add intervention
PW DB, Local Best Practices, Tx Team
New Case?
no
yes Select Evidence-Based Service (EBS)
PWDatabaseStart
The MAP: Service Quality and Treatment Integrity
ClinicalProgress?
Clinical Dashboard:Progress Pane
Continue plan until goals met
NotEngaged?
Crisis?
Poor Attendance,Complaints, etc.
Pursue engagement;Take appropriate action
yes
no
no
yes
no
yes
no
yes
Clinical Dashboard:Practice Pane, PW DB
Prob. w/ TxSelection?
TreatmentIntegrity?
Practitioner Guide,Clinical and
Quality ReviewConsider adding consultation or
training supports
Identify barriers and revise plan
Options1. Increase supports
2. Change Intervention3. Further Consultation
4. Add intervention
PW DB, Local Best Practices, Tx Team
New Case?
no
yes Select Evidence-Based Service (EBS)
PWDatabaseStart
The MAP: Getting Unstuck…
Youth Network on Child Mental Health (Weisz, PI)
5-Year, multisite randomized trial• Boston, Honolulu
Anxiety, Depression, Conduct ProblemsCommunity therapistsStandard Manuals, MATCH, Usual CareN = 174 children ages 7-13Funded by John D. and Catherine T.
MacArthur Foundation
If therapists like it better, they will be more engaged
Attitudes Towards Evidence-Based Practices
p < .05
Borntrager, C. F., Chorpita, B. F., Higa‐McMillan, C. K., & Weisz, J. R. (2009). Provider attitudes towards evidence‐based practices: Are the concerns with the evidence or with the manuals? Mental Health Services Research, 60, 677‐681.
If therapists like it better, they will use it when the study is over
Therapist Satisfaction with Treatment (rated after each case)
p < .05 p < .05
CAFAS 8-Scale Total
-1.1
-1.5-1.3 -1.3 -1.4
-1.7 -1.8 -1.8
-2.3 -2.3-2.6 -2.6
-3.0
-2.5
-2.0
-1.5
-1.0
-0.5
0.0
2002.12002.2 2002.3 2002.4 2003.12003.2 2003.3 2003.4 2004.12004.2 2004.3 2004.4
Fiscal Quarter
Cha
nge
per M
onth
(M +
/- SE
)
Final Effect Size for Change = .07/mo, .84/yrDaleiden, Chorpita, Donkervoet, Arensdorf, & Brogan (2006).
$4,640$3,535
$2,087$1,080 $654 $564
$12,477
$9,325
$6,828
$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
$14,00020
02
2003
2004
2002
2003
2004
2002
2003
2004
Expe
nditu
res
(US$
)
CALOCUSLevel of Care
(0 - 5)
ASEBAParent CBCL
T-Score
CAFAS8-Scale Total
(0 - 240)
Service Expenditures per Unit of Improvement(Annual Cost per Youth / Average Annual Rate of Improvement)
There are many answers already in the evidence base
Knowing is not enoughWe need to develop and implement the
tools that will help guide system performance