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 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 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 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. The Uptake Challenge Is there a way to understand these interactions and build better interventions? A modest suggestion follows..
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 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 Outcomes and Performance Measurement Evidence Based Practices 1. Outcomes and Performance
Measurement A question of quality 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: 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
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? 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? 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 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
FRAMEWORKS FOR DISCUSSION THREE MOVEMENTS (1) The Nike Imperative (2) The Kudzu Phenomenon (3) The Search for the Holy Grail THE TRENDS -1
THE NIKE IMPERATIVE: JUST DO IT!! 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 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 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
Kudzu Phenomenon The Kudzu Phenomenon KUDZU? What IS kudzu? 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 PHENOMENON Proliferation of measurement sets, 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 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
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??
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. Practical implications
Whatever your role on a provider team, you cant escape this movement: No outcomes = No incomes 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. 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 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 CAVEATS CAVEAT THREE: Dont let the PERFECT be the enemy of the GOOD. 2. Evidence-Based Practices
Promises and pitfalls 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? 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. 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 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 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 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 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 Pitfalls In reality:
Quality reasons Administrative reasons Financial reasons Political reasons Yes, its policy pinball
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 Pitfalls Some definitions (from Hyde, Falls, Morris and Schoenwald): Evidence-Based Practice: gold standard: randomized, controlled, double blind, realworld, experimentally validates Best practice: closest fit between best
available science (EBP) and best available resources 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; EBPs: Promises and Pitfalls Some things to think about while implementing evidencebased practices (or best practices, or promising practices, or emerging
practices): 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. 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. 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 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 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 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 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 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 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 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 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. EBPs: Promises and Pitfalls And finally EBPs: Promises and Pitfalls The movement is in its earliest
stages, and there is still time to be at the forefront. Implications The two national trends of performance measurement and evidence-based practices fit together and support each other.
Implications Providers who are well prepared in these areas are best armed for survival in the increasingly competitive behavioral healthcare marketplace. 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 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. Thanks for having me. 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 [email protected]
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