Implementation of Evidence- based Practices in the New York State Office of Mental Health Molly...

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Implementation of Evidence-based Practices in the New York

State Office of Mental Health

Molly Finnerty, MD

Director, Adult Services Research & Evidence-based Medicine

New York State Office of Mental Health

Defining EBPs

• Evidence-based practices (EBPs) are interventions for which there is consistent, scientific evidence showing that they improve consumer outcomes.– Those practices supported by randomized controlled

trials from two or more independent investigators

– Practices with any evidence base, where the level of evidence is graded (randomized controlled trials to expert opinion)

Approach to EBPS: US vs. England

• In US:– Development of guidelines and core sets of EBPs

– Top down approach

• In Canada and England:– Initiated grading of evidence

– See EBPs as a process an individual clinician goes through in delivering clinical care

– Assessment> formulate clinical question> review literature > apply treatment > assess result

Clinical Practice Guidelines (CPG) for Schizophrenia: Expert

Consensus Guideline• 1996 – 1st CPG for schizophrenia• Strengths:

– Oriented around clinical questions – Tries to fill in the gaps where there is no evidence

• Limitations: – Based on expert opinion – “grade C” level of evidence – Funded by industry – perception of bias

• Uses: – Basis for Texas Medication Algorithm Project (TMAP)– Methodology has been used for other CPG initiatives – TMAP,

CPG in Schizophrenia: TMAP• 1997-2004• Strengths:

– Developed by Texas to implement – Comes with a manual– Engaged stakeholders– Federal funding available to support implementation in states

• Limitations– Expert opinion based– Implementation challenge- Proscriptive, requires medical record change,

difficult to assess conformance– Industry funded – perception of bias

• Uses:– Most widely implemented CPG among states

CPGs for Schizophrenia: American Psychiatric Association

• 1997, 2004• Strengths

– Comprehensive review of literature, with graded evidence– Endorsement of APA - high credibility

• Limitations– Implementation challenges: More review than

recommendation, long

• Use:– Endorsed by many managed care companies (HMOs

accredited by NCQA are required to use CPGs)

CPGs for Schizophrenia: PORT

• 1998 – Patient Outcomes Research Team (PORT) • Strengths

– 30 concise recommendations, with supporting literature and graded evidence

– Adherence to recommendations easy to measure – Federal funding, AHRQ

• Limitations– ?

• Uses:– The guideline most frequently used in adherence studies

Conformance to Schizophrenia CPGs• Studies:

– Lehman, et al 1998 (PORT)– Young, et al 1998 (PORT)– Hudson et al 1999 (PORT & APA)– Owen, et al 2000 (PORT & APA) – Chen, et al 2000 (PORT)– Leslie, et al 2001 (PORT)

• Modest levels of conformance across settings and methods of evaluation– Better for pharmacotherapy than psychosocial

• Future issues– Reasons for non-conformance?– Ideal levels of conformance?

PORT: Conformance Study• 2 states, urban/rural, outpt/inpt, n=440 (Lehman 1998)• Dose:

– 22.5% (inpt) – 32% (outpt) high– Minorities/urban more likely to receive higher doses

• Side-effect management:– 46% of those with EPS receive treatment

• Management of Co-morbid Conditions:– Depression: 48-43% prevalence, 34-46% treated, lower conformance for minorities– Anxiety: 18-23% prevalence, 33-47% treated, lower conformance for women inpts

(6% vs. 48%), and men outpt (31 vs. 57%)

• Persistent Symptoms: – 23-14% receive recommended adjunctive tx

National EBP Toolkit Project

• Robert Wood Johnson work group identifies 6 EBPs for SMI

• RWJ and SAMHSA fund development of a toolkit for each (phase I)

• SAMHSA funds pilot testing of toolkits (phase II)– 8 states, each doing 2 EBPs

• SAMHSA funds state planning grants• SAMHSA funds implementation grants (phase III)

SAMHSA: 6 EBPs for Schizophrenia

• Medications

• Assertive Community Treatment

• Supported Employment

• Illness Self Management

• Integrated Dual Disorders Treatment

• Family Psychoeducation

Implementation of the EBP Toolkits

• Pilot Testing in 8 states– 50 mental health sites in 8 states – Kansas, Indiana, Maryland, New Hampshire,

NYS, Ohio, Oregon, and Vermont

• Implementation 8 states:– California, Hawaii, Illinois, Vermont (Co-

Occurring Disorders), Kentucky (Medication Management), Indiana (IMR), Maryland (Assertive Community Treatment), and Ohio (Supported Employment).

Toolkits: Content

• Information for stakeholders: Public mental health authority, provider agencies, clinicians, families, consumers

• Literature- key articles• Implementation Tips• Cultural Competence• Workbook or clinicians• Outcome measures• Fidelity instruments• Video Tapes: Introduction, Training

Toolkit: Implementation Model

• Engage– Building readiness

– Plan

– Build consensus among stakeholders

• Implementation– 1 year of training & consultation

– Consultants monitoring fidelity to model

• Sustaining– Program takes over supervision role

– Program monitors itself

Assertive Community Treatment (ACT)

• Consumers with long and frequent hospitalizations

• Repeated users of ER services

• Homeless consumers

• Consumers with co-occurring addictive disorder

• Consumers involved with the criminal justice system

• Small caseload - 1:10

• Interdisciplinary teams

• Services in client’s natural setting

• 24 hour coverage

• Shared caseloads among clinicians

• Direct, not brokered services

High rehospitalization rates for most impaired consumers

Who Benefits?DescriptionRationale

The Evidence-Based Challenge…ACT as a service delivery platform

May not be “implementable” in rural areas

ACT is most effective for individuals with serious barriers to engagement; their level of service intensity need is so great

that a targeted implementation of ACT Teams will be essential

Can components of ACT (mobility, multi-disciplinary focus) can be adopted within the broader

range of case management and outpatient services?

Supported Employment

• Consumers interested in competitive work

• Rapid job search and placement

• De-emphasis on pre-vocational training and assessment

• Attention to consumer preferences

• Follow-along support provided

Rates of competitive work are low and most consumers want competitive work

The Evidence-Based Challenge…Supported Employment

•State resources usually support non-competitive employment, despite solid research showing that integrated, competitive employment produces better outcomes

•Few individuals utilizing outpatient systems have access to employment services

•Community/economic factors

•Access to services

Wellness Self-Management Education

• Consumers with cognitive impairments

• Consumers with a diagnosed psychiatric illness.

• Consumers with psychotic symptoms

• Psychoeducation

• Counseling and coaching on early warning signs, avoidance of stressors, and minimization of relapses

• Enhancements of medication adherence through behavioral tailoring, motivational interviewing and skills training for consumer-doctor interactions

Non-adherence to a treatment plan is extremely common and closely associated with relapse

• Consumers with a diagnosed psychiatric illness

• Multiple weekly training sessions over time (between 3 months and 1 year)

• Individual and group formats

• ‘In vivo’ training to facilitate generalization of skills

Impaired social functioning predicts the worst outcomes

Who Benefits? DescriptionRationale

Skills Training

CBT For Psychosis

• Consumers with a diagnosed psychiatric illness.

• Collaborative partnership with consumer

• Education about stress-vulnerability

• Behavioral tests

Persistent psychotic symptoms are present in 25-40% of consumers with schizophrenia and persistent psychotic symptoms predict relapse and rehospitalization

Who Benefits?Description Rationale

The Evidence-Based Challenge…

Wellness Self Management Education

•Existing funding streams make personalized in

vivo instruction difficult to support

•Effective practice requires continual coaching and

reinforcement across all interrelated sectors based

on a coordinated plan of care

•Clinicians not trained in CBT

Family Psychoeducation

• Consumers who are in regular contact with their relatives and families

• Provided by professionals

• Long-term (over 6 months)

• Focuses on education, stress reduction, coping skills and other supports

Many consumers live at home or have contact with relatives, and education and support for families reduces the stress increases risk of relapse

•Effective practice requires time and commitment from family members who are often strained in providing basic support to the individual

•Providers need access to a funding mechanism to organize and maintain groups and classes

•Of all the EBPs providers consider most difficult to implement

Integrated Treatment for Co-Occurring Disorders

• Consumers with co-occurring substance abuse disorders

• Assertive outreach

• Stage-wise treatment

• Harm-reduction approach

Substance abuse worsens outcomes and up to 50% of consumers have co-occurring substance abuse disorders

Integrated Treatment for Co-occurring Substance Abuse Disorders

•Services are provided by two different state agencies and need to be incorporated into a coordinated plan of care

•Effective practice requires a level of service intensity not currently supported by existing funding and regulatory structures

•Clinicians not training in Motivational Interviewing

Medication

Consumers taking medications for psychiatric illness

• The antipsychotic medication algorithm is an outline of a rational sequence of medications to try in the pharmacological management of schizophrenia in order to maximize medication efficacy and minimize side effects.

Who Benefits?DescriptionRationale(Anti-psychotic Medication Algorithm)

The antipsychotic medication algorithm will ensure that symptoms are minimized, side effects are minimal, and that there is consumer choice and education.

NYSOMH Recommendations

for Pharmacological Management of Schizophrenia

Medication and medication adherence

•Poly pharmacy

•Medication adherence requires routine monitoring of blood levels which is not currently done in many programs and service sectors

•Requires system support of prescribing

•Physicians & other clinicians not trained in effective strategies for promoting adherence

Effect Of Adding Strategies To Medication & Case Management

Case Management

+ Family Education

+ Problem Solving

+ Social Skills

Training

27% 23%

Percent

Percentage of cases having episodes of florid psychopathology or other evidence of lack of efficacy of treatment after 12 months of continued care.

Combination is the key…

Falloon, IRH, Held, T, Coverdale, JH, Roncone, R, Laidlaw, TM. (1999) Psychosocial Interventions for Schizophrenia: A review of long term benefits of international studies. Psychiatric Rehabilitation Skills, 3, 268-290

Implementing EBPs

• What does IOM say?

• What can states/ counties do?

• What can programs do?

Crossing the Quality Chasm – Institute of Medicine 2001

• “Between the health care we have and the health care we could have lies not just a gap but a chasm.”

• Aims for the 21st Century Health Care System: – Safe– Efficient – Patient-centered – Timely – Equitable – Effective

IOM: Challenges in Delivering Effective Care

• Science and technology advance at a rapid pace• Approximately 10,000 RCTs yearly

• Average of 17 year time lag between RCTs documenting effectiveness and use in practice

• Care can be exemplary, but often is not: best care is not applied systematically

• Insufficient tools and incentives to support rapid adoption of best practices

• “Trying harder will not work;” change will require system redesign

Institute of Medicine. Crossing the Quality Chasm, 2001

IOM: Applying Evidence to Health Care Delivery

• Ongoing synthesis of medical literature and development of practice guidelines

• Identify best practices in processes of care• Dissemination to general public and professionals• Decision support tools for clinicians and patients• Goals for processes and outcomes• Quality measures

Institute of Medicine. Crossing the Quality Chasm, 2001

State: EBP Plan• The SMHA has an EBP plan that includes the following components:

– Mechanism for reviewing and prioritizing among EBPs– Scope of initial and future implementation efforts, – Outreach, education, and consensus building among stakeholders– Identify partners and community champions, – Funding sources, – Training resources, – Policy and regulatory levers to support EBP, – Role of other state agencies in supporting the EBP, – Defines how EBP interfaces with other SMHA priorities and supports SMHA

mission

State: Financing

• Financing delivery of EBPS– Covers all costs or payments for covered costs

compensates for costs not covered– Incentives for switch

• Financing Start-up and conversions costs– Lost productivity for staff training, – hiring staff before clients enrolled (e.g. ACT), – any costs associated with agency planning and meetings, – changing medical records if necessary, – computer hardware and/or software if necessary,

State: Training• Ongoing training & technical support

– Observation/ modeling of practice in work setting– Feedback for clinicans– 12 months

• Quality– credible and expert trainer– active learning strategies (e.g. role play, group work, feedback)– good quality manual, e.g. SAMHSA Toolkit – comprehensively addresses all elements of the EBP– modeling of practice for trainees– opportunities to shadow/observe high fidelity clinical work delivered– high quality teaching aides/materials including workbooks/work sheets, slides,

videos, handouts

State: Training (cont)

• Infrastructure/ Sustainability– Mechanism for continuation and expansion of

training activities – Center of Excellence– Relationship to university – Establishing a learning network or learning

collaborative

• Penetration of training– Access to training state-wide

State: Leadership

• Commissioner– Commitment– Planning– Delegation

• Designated EBP leader– Authoority– Time– Skills

State: Policies & Regulations

• Non-State Mental Health Authority (MCD, Voc, Substance Abuse)– Mitigate any policies that present barriers to implementation– Introduce policies to support EBP

• State Mental Health Authority (SMHA)– Mitigate any policies that present barriers to implementation– Introduce policies to support EBP

• SMHA: EBP Standards– Define standards– Monitor standards– Consequences in contracts/ licesning

State: Quality

• Fidelity Assessment– Monitor fidelity – Feedback & clear expectations for fidleity

• Client Outcomes– Monitor outcomes – reporting vs. database– Feedback & clear expectations

States: Stakeholders

• Stakeholders– Consumers– Families– Providers

• Engaged– Role in supporting EBPs– More in favor than against

Programs

• Program Philosphy – commitment to EBPs• Screen and track for eligibility for EBPs• Penetration of EBP – consumer access• Comrehensive evaluation

– Diagnoses & stage– Vocational– Support network– Bio-psychosocial risk factors

• Treatmetn plan related to EBP• Individualized treatmetn related to the EBP

Programs

• Clinicans trained in EBP

• Clinicans supervised in EBP

• Quality Improvement: – Quaility Assurance Committee – review EBP q6mo– Fidleity assessment every 6 monhts– Client Outcome monitoring every 3 months

• Client choice

EBPs in NYSOMH

• 1996: First clinical practice guideline for schizophrenia is published the Expert Consensus Guidelines group– The Deputy Medical Director supports ECG

adoption– The Commissioner endorses ECG – 1996-1998: Psychopharmacology CME and

conferences on the guidelines arranged by Deputy Medical Director for psychiatrists

EBPs in NYSOMH• 1998: PORT guidelines and guideline conformance study

published.– 1998-2000: Several Commissioner level staff initiate independent

projects within their divisions, designed to improve quality of care in response to the PORT findings

– Division of Planning: pilot implementation of clinical practice guidelines.

– Operations: Licensing pilot in NYC. Identify failure to deliver EBPs, many barriers to delivery including attitudes, lack of understanding.

– IT: attempts to embed prompts, and standardize clinical and process outcome assessment in the automated medical record.

EBPs in NYSOMH• 1999 – 2000: Kendra Webdale case

– Executive Retreat develops “A, B, Cs” (Accountability, Best Practices, Coordination). For the first time EBPs have agency wide support, and are identified as a top priority.

– Governor approves OMH plan, large influx of funding to support EBP implementation.

• 2000: National Toolkit Project– NYSOMH chooses a core set of EBPs matching the toolkit set– NYS becomes on of the sites for field testing toolkits

• 2000 – 2001: Develop PR campaign– “Winds of Change” presentations and dialogues– June 2001: Best Practices Conference

• 2001-present: Develop and implement plan for each EBP

ACT as a Platform for EBPs:Expansion Model

• 28 exiting programs• No MCD funding• Programs not licensed

• No state-wide standards for: – Admission– Processes of care– Assessment– Outcomes

• Current DACT fidelity X=3.91 of 5 max score 11% high fidelity

• 70 programs • MCD funded• Licensing and certification of ACT

teams according to fidelity to models for all EBPs

• State-wide uniform standards for:– Admission– Process of care assuring delivery of all EBPs– Assessments – Reporting on recovery outcomes– QI

• Goal DACT fidelity X=4.5 of 5 max score

ACT (cont)

• 5 sites participated in National Toolkit Project– Within 6 months fidelity most sites surpassed

previous state average

• Technical Assistance Center with CUNY

• Family Dialogues• Engage NAMI-NYS in evaluation of need• Technical assistance center: University of Rochester• RFP: sites to receive training and consultation• Sites selected:

– 17 sites around the state to receive initial training and monthly consultation

– Western Care Coordination: 21 programs – collaborative learning

– 9 sites invited to receive initial training alone; 5 accepted

• FPE grant focusing on ethnically diverse settings• Will incorporate into PROS

Medications• Development of PSYCKES, a software designed to support

clinical decision making– Summarizes all medication data in easy to use formats at patient,

clinician, facility and state level

• Pilot test at Creedmoor with 5 physicians– All target guideline recommendations endorsed, but to varying degrees– Recommendations with higher endorsement were more likely to

change (dose, antipsychotic monotherapy) – 58% reduction in patients receiving dose higher than recommended

• Expansion to 8 inpatient OMH facilities• Explore MCD data interface with PSYCKES

Wellness Self Management

• 4 sites participating in toolkit project implementation of Illness Management and Recovery

• Will incorporate into PROS

Supported Employment

• Milestones project established programs around the state

• Technical assistance center – Coalition for Voluntary Mental Health Agencies

Integrated Dual Disorder Treatment

• Developing an RFP for a collaborative learning model

• Will offer to PROS programs

Self-Help

• Peer-to-peer education to increase awareness of EBPs

• Development of Self-Help Toolkit

Implementation of Evidence- based Practices in the New York State Office of Mental Health Molly...

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