Implementing Evidence-Based Practice Implementing Evidence-Based Practice (EBPs) in Mental Health(EBPs) in Mental Health

Richard H. BeineckeRichard H. BeineckeSuffolk University Department of Public ManagementSuffolk University Department of Public Management

8 Ashburton Place, Boston, MA 021088 Ashburton Place, Boston, MA 02108617-573-8062, rickdeb61@aol.com617-573-8062, rickdeb61@aol.com

American Public Health AssociationAmerican Public Health AssociationDecember 12, 2005December 12, 2005

SourcesSources

Ongoing literature review.Ongoing literature review. Study of mental health EBPs in England Study of mental health EBPs in England

during sabbatical, spring 2004.during sabbatical, spring 2004. Brandeis/Suffolk forum, “Implementing Brandeis/Suffolk forum, “Implementing

Evidence-Based Practices and Evidence-Based Practices and Performance Measures for Performance Measures for Massachusetts Mental Health Massachusetts Mental Health Services”, co-sponsored with Mass Services”, co-sponsored with Mass DMH and DPH and funded by CMHS, DMH and DPH and funded by CMHS, September 28, 2005.September 28, 2005.

Evidence-Based PracticesEvidence-Based Practices

“ “ A quality improvement process that provides A quality improvement process that provides accountability through the monitoring of the accountability through the monitoring of the practices to models that have been practices to models that have been demonstrated by research to be effective.” demonstrated by research to be effective.” (Goldman et al, 2001)(Goldman et al, 2001)

““The purchase of treatments and services that The purchase of treatments and services that have been scientifically confirmed to improve have been scientifically confirmed to improve outcomes.” (Lehman et al, 2004)outcomes.” (Lehman et al, 2004)

Status of EBPsStatus of EBPs

Mental health (and health) systems are in shambles. Much Mental health (and health) systems are in shambles. Much improvement in care is needed (e.g., effective care for improvement in care is needed (e.g., effective care for depression only 57% of the time; for alcohol dependence only depression only 57% of the time; for alcohol dependence only 10% of the time). Need to change yourself, your program, and 10% of the time). Need to change yourself, your program, and your environment.your environment.

Many EBPs are now known but are not being implemented, e.g.Many EBPs are now known but are not being implemented, e.g. Supportive Employment ProgramsSupportive Employment Programs Assertive Community TreatmentAssertive Community Treatment Integrated treatment for mental health and substance use Integrated treatment for mental health and substance use

disordersdisorders Family PsychoEducationFamily PsychoEducation

Calls for Implementing EBPsCalls for Implementing EBPs

Crossing the Quality Chasm (IOM 2001)Crossing the Quality Chasm (IOM 2001)Four areas for redesigning health systems: “Applying Four areas for redesigning health systems: “Applying evidence to the delivery of health services.”evidence to the delivery of health services.”

President’s New Freedom Commission (2003)President’s New Freedom Commission (2003)““Goal: Advancing evidence-based practices.”Goal: Advancing evidence-based practices.”

Committee on Crossing the Quality Chasm Committee on Crossing the Quality Chasm Adaptation to Mental Health and Addictive Services Adaptation to Mental Health and Addictive Services (IOM, 2005)(IOM, 2005)Call for “Better dissemination and adoption of Call for “Better dissemination and adoption of evidence through the use of evidence-based evidence through the use of evidence-based approaches to knowledge dissemination and uptake.”approaches to knowledge dissemination and uptake.”

Factors for Successful ImplementationFactors for Successful Implementation

Implementation: “Implementation: “A specified set of activities A specified set of activities designed to put into practice an activity or program of designed to put into practice an activity or program of known dimensions. (Fixsen et al, 2005)known dimensions. (Fixsen et al, 2005)

Success depends uponSuccess depends upon Scientific study of what works or is not effective. Scientific study of what works or is not effective.

Effectiveness of the intervention practices or policies. Effectiveness of the intervention practices or policies. Compilation, distribution, and use in practice of this Compilation, distribution, and use in practice of this

information. Effectiveness of the implementation information. Effectiveness of the implementation practices. practices.

Elements Important to Organizational Elements Important to Organizational Change (Redesign Process) (Fixsen et al, Change (Redesign Process) (Fixsen et al,

2005)2005) Commitment of leadership to the implementation Commitment of leadership to the implementation

process.process. Involvement of stakeholders.Involvement of stakeholders. Creation of an implementation task force with Creation of an implementation task force with

stakeholders.stakeholders. Suggestions for “unfreezing” current organizational Suggestions for “unfreezing” current organizational

practices.practices. Resources for extra costs, effort, materials, recruiting, Resources for extra costs, effort, materials, recruiting,

access to expertise, retraining.access to expertise, retraining. Alignment of organizational structures to integrate Alignment of organizational structures to integrate

staff selection, training, performance evaluation. staff selection, training, performance evaluation.

Core Implementation Components Core Implementation Components (Fixsen et al, 2005)(Fixsen et al, 2005)

Communication and feedback from the source of the innovation to those who Communication and feedback from the source of the innovation to those who will implement it.will implement it.

Pre-service training.Pre-service training. Staff and program evaluation.Staff and program evaluation. Consultation and coaching.Consultation and coaching.

Also organizational components, e.g.:Also organizational components, e.g.: Administrative supportsAdministrative supports Information technologies.Information technologies. Financing.Financing. Organizational Culture and climateOrganizational Culture and climate

External Influences: Social, economic, and political.External Influences: Social, economic, and political.

Strong leadership and powerful champions.Strong leadership and powerful champions.

Seven Task Clusters to Promote State Seven Task Clusters to Promote State EBPs ((Rapp et al, 2005)EBPs ((Rapp et al, 2005)

Strategic planning.Strategic planning. Involve stakeholders.Involve stakeholders. Focus on outcomes that clients value.Focus on outcomes that clients value. Have design and task specifications in the Have design and task specifications in the

regulatory standards.regulatory standards. Create incentives and disincentives.Create incentives and disincentives. Maximize funding.Maximize funding. Provide workforce developmentProvide workforce development

Stages of the Implementation Process Stages of the Implementation Process (Catalytic Leadership) (Luke, 1998)(Catalytic Leadership) (Luke, 1998)

1.1. Focus attention by elevating the issue.Focus attention by elevating the issue.2.2. Engage people in the effort.Engage people in the effort.3.3. Stimulate multiple strategies and options for Stimulate multiple strategies and options for

action.action.4.4. Sustain action and maintain momentum.Sustain action and maintain momentum.

Stages of Change (Lynde, 2005)Stages of Change (Lynde, 2005)

1.1. Pre-contemplation (information sharing)Pre-contemplation (information sharing)2.2. Contemplation (needs assessment)Contemplation (needs assessment)3.3. Preparation (leadership and stakeholder Preparation (leadership and stakeholder

engagement)engagement)4.4. Action (planning, training, consultation, Action (planning, training, consultation,

communication and feedback, policies and communication and feedback, policies and regulations, funding)regulations, funding)

5.5. Maintenance.Maintenance.

Must fully involve consumers, family members, Must fully involve consumers, family members, providers).providers).

Degrees of Implementation (Fixsen, Degrees of Implementation (Fixsen, 2005)2005)

Paper Implementation: Put into place new Paper Implementation: Put into place new policies and procedures.policies and procedures.

Process Implementation: Putting new Process Implementation: Putting new procedures into place to conduct training, procedures into place to conduct training, supervision, change reporting forms, etc.supervision, change reporting forms, etc.

Performance Implementation: Procedures Performance Implementation: Procedures and processes of change are used to good and processes of change are used to good effect for consumers (outcomes, real effect for consumers (outcomes, real performance measurement).performance measurement).

State Initiatives to Promote EBPs State Initiatives to Promote EBPs (Ganju, 2005)(Ganju, 2005)

All states offering at least one EBP and 23 offering at least six. But All states offering at least one EBP and 23 offering at least six. But few states are implementing EBPs in a comprehensive way.few states are implementing EBPs in a comprehensive way.

State Approaches:State Approaches: Awareness/training/support for clinicians; Centers of Excellence.Awareness/training/support for clinicians; Centers of Excellence. Building consensus.Building consensus. Incorporating EBPs into contracts.Incorporating EBPs into contracts. Fidelity monitoring.Fidelity monitoring. Modifications to information systems.Modifications to information systems. EBP budget requests and financial incentivesEBP budget requests and financial incentives..

Future of Behavioral Health EBPs (Leff, Future of Behavioral Health EBPs (Leff, 2005)2005)

EBPs identified by national registries (e.g. NREPP) EBPs identified by national registries (e.g. NREPP) and venues for meta-analyses (e.g. Cochrane and venues for meta-analyses (e.g. Cochrane Collaboration).Collaboration).

Explicit criteria for recognizing practices.Explicit criteria for recognizing practices. Convergence of Federal, state, and private payer Convergence of Federal, state, and private payer

listings.listings. Listings as “Arbiters of Value.”Listings as “Arbiters of Value.” This will alter the nature of mental health services, This will alter the nature of mental health services,

favor some practices and not others, and make favor some practices and not others, and make favored practices more consistent and expensive.favored practices more consistent and expensive.

Status in MassachusettsStatus in Massachusetts

Some EBPs being supported by the state.Some EBPs being supported by the state. ““Expanding and sharing evidence-based Expanding and sharing evidence-based

and best practices and convening and best practices and convening evidence-based practice training for evidence-based practice training for providers is one of the goals in the state providers is one of the goals in the state Department of Mental Health plan.Department of Mental Health plan.

Introductory forum September 2005.Introductory forum September 2005. Committee of stakeholders being formed. Committee of stakeholders being formed. Delays now due to possible restructuring Delays now due to possible restructuring

of the Medicaid Behavioral Health Plan.of the Medicaid Behavioral Health Plan.

DiscussionDiscussion

Lessons and application to other public sector Lessons and application to other public sector change initiatives and business innovationchange initiatives and business innovation