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

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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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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

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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??

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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 practiceand there are very few simultaneous
  translation services (wheres the UN when you
  need them?
• As knowledge accelerates, the gap may widen.
• Problems of scale and cost impact local providers
  especially.

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The Uptake Challenge

• Is there a way to understand these interactions
  and build better interventions?
• A modest suggestion follows..

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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

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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?

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Some national trends THE BIG TWO

• Outcomes and Performance Measurement
• Evidence Based Practices

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1. Outcomes and Performance Measurement

• A question of quality

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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?

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Defined by whom

• Simplest answer by consumers of servicesthe
  children and families served by rural providers
• Reality more complex
• Purchasers/insurers/sponsors/funders
• Accrediting bodies
• Professional associations
• Management
• State and federal policy makers

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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

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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 doesnt get
  done in order to do this?

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With what rewards?

• Intrinsic value of demonstration of competency
  and effectiveness
• Strengthening of clientclinician partnership
• Increased credibility with external community
• Competitive advantage in tough fiscal
  environment.
• Clinician benchmarking of success and achievement

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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

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FRAMEWORKS FOR DISCUSSION
THREE MOVEMENTS (1) The Nike Imperative (2)
The Kudzu Phenomenon (3) The Search for the Holy
Grail
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THE TRENDS -1
THE NIKE IMPERATIVE JUST DO IT!!
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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
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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

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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.

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The Trends 2
The Kudzu Phenomenon
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The Kudzu Phenomenon
KUDZU? What IS kudzu?
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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

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THE KUDZU PHENOMENON
Proliferation of measurement sets, report cards,
indicator sets-- public private proprietary
free individual-based population-based scientifi
cally validated face valid purchaser-,
consumer-, and provider- oriented
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THE KUDZU PHENOMENON- 2
Remember KUDZU was introduced to benefit
farmers--and sometimes it does--but this quote
from the Kudzu Homepage is instructive Propagat
ing 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...
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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?
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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 doesnt work.
• perpetuate sub-optimal care.

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Practical implications

• Whatever your role on a provider team, you cant
  escape this movement
• No outcomes No incomes

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SUMMARY

• It isnt 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.

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THREE BIG CAVEATS
CAVEAT ONE Todays 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
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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
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THREE BIG CAVEATS
CAVEAT THREE Dont let the PERFECT be the enemy
of the GOOD.
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2. Evidence-Based Practices

• Promises and pitfalls

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EBPs Promises and Pitfalls

• Starting at the beginning
• Isnt this just the New-New Thing?
• Cant we just wait this out for the next trend?
• What does this say about what were already
  doing?
• Isnt this just cook-book medicine or therapy?
• Whose evidence anyway?

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EBPs Promises and Pitfalls

• To the skeptics Your concerns are
  understandable, and will be addressed, but
• No, its not just the New-New Thing.
• It is probably a movement that is here to stay.
• What youre doing now may be finebut wouldnt
  you like to be sure?
• So far, there arent many cookbooks!
• Whose evidence is a great question, and we
  will cover several answers to that one.

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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.

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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.

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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

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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

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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
  19993191618

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EBPs Promises and Pitfalls

• In reality
• Quality reasons
• Administrative reasons
• Financial reasons
• Political reasons
• Yes, its policy pinball

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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

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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

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EBPs Promises and Pitfalls

• Some definitions (from Hyde, Falls, Morris and
  Schoenwald, 2003)
• Promising practice some evidence or strong
  consensus among experts or consumerslikely to
  become an EBP given time and resources
• Emerging practice anecdotal or practice
  evidence broad acceptance

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EBPs Promises and Pitfalls

• Some things to think about while implementing
  evidence-based practices (or best practices, or
  promising practices, or emerging practices)

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EBPs Promises and Pitfalls

• Be sensitive to practice-based evidence. If it
  doesnt work, stop it but if it just doesnt
  have a robust evidence-base, treat it gingerly.
• Cultivate evidence-based thinking. Actively LOOK
  for outcome data--listen to consumers and
  families--be honest.

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EBPs Promises and Pitfalls

• Dont over-promise! We are at the early stages,
  so be humble about what will result.
• Accept the evidence about diffusion of
  innovation it doesnt happen automatically,
  smoothly, or cheerfully.

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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.

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EBPs Promises and Pitfalls

• Learn to love dataIts hard, but its got to
  happen.
• Even better, learn to talk about outcomes and
  performance and quality openly with colleagues,
  but especially with consumers and families

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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.

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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

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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

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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.

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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.

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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

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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 theyre not evil.
• EBPs are tools, not ultimate answersuse them
  wisely in service to people.

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EBPs Promises and Pitfalls

• And finally

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

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

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Implications

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

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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.

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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.

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

• Thanks for having me.

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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_at_tacinc.org