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

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


1
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

2
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

3
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??

4
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.

5
The Uptake Challenge
  • Is there a way to understand these interactions
    and build better interventions?
  • A modest suggestion follows..

6
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7
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

8
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?

9
Some national trends THE BIG TWO
  • Outcomes and Performance Measurement
  • Evidence Based Practices

10
1. Outcomes and Performance Measurement
  • A question of quality

11
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?

12
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

13
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

14
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?

15
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

16
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

17
FRAMEWORKS FOR DISCUSSION
THREE MOVEMENTS (1) The Nike Imperative (2)
The Kudzu Phenomenon (3) The Search for the Holy
Grail
18
THE TRENDS -1
THE NIKE IMPERATIVE JUST DO IT!!
19
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
20
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

21
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.

22
The Trends 2
The Kudzu Phenomenon
23
The Kudzu Phenomenon
KUDZU? What IS kudzu?
24
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

25
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26
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
27
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...
28
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?
29
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.

30
Practical implications
  • Whatever your role on a provider team, you cant
    escape this movement
  • No outcomes No incomes

31
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.

32
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
33
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
34
THREE BIG CAVEATS
CAVEAT THREE Dont let the PERFECT be the enemy
of the GOOD.
35
2. Evidence-Based Practices
  • Promises and pitfalls

36
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?

37
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.

38
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.

39
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.

40
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

41
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

42
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

43
EBPs Promises and Pitfalls
  • In reality
  • Quality reasons
  • Administrative reasons
  • Financial reasons
  • Political reasons
  • Yes, its policy pinball

44
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

45
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

46
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

47
EBPs Promises and Pitfalls
  • Some things to think about while implementing
    evidence-based practices (or best practices, or
    promising practices, or emerging practices)

48
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.

49
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.

50
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.

51
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

52
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.

53
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

54
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

55
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.

56
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.

57
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

58
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.

59
EBPs Promises and Pitfalls
  • And finally

60
EBPs Promises and Pitfalls
The movement is in its earliest stages, and there
is still time to be at the forefront.
61
Implications
  • The two national trends of performance
    measurement and evidence-based practices fit
    together and support each other.

62
Implications
  • Providers who are well prepared in these areas
    are best armed for survival in the increasingly
    competitive behavioral healthcare marketplace.

63
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.

64
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.

65
Good luck to each of you as you lead your
organization toward ever higher standards of
quality.
  • Thanks for having me.

66
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
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