MARRCH 2007 Annual ConferenceOctober 30, 2007

Adding Technology to the Use of Evidence-

Based Practices

Deni Carise, Ph.D.Treatment Research InstituteUniversity of Pennsylvania

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1. Barriers to implementing EBP’s

2. NREPP

3. DENS

4. CASPAR

5. NIDA/ATTC Blending Teams

Technology and EBP’s

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Medications, behavioral therapies, and clinical interventions:

tested & shown effective in clinical trials

The Research-Practice Gap

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But, very low rates of adoption of these EBP’s. Possible factors contributing to this

–Finance, complexity, organizational structure, policy issues

The Research-Practice Gap

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Counselors report Finance, Training & Supervision barriers are the greatest

contributors to the research-practice gap

The Research-Practice Gap

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New therapies won’t be adopted if:

– they cannot be supported by managers and funding agencies.

– the training and supervision burden is overwhelming

The Research-Practice Gap

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Training BarrierOf 400 national substance abuse treatment centers, 20% had no staff training budget.

Decreased funding

++ Increased licensing,

accrediting, and funding compliance

requirements

Decreased clinical training

andIncreased attention to administrative issues

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NREPP is a service of Substance Abuse and Mental Health Services Administration (SAMHSA)

• Began in 1997• A searchable database of

interventions for the prevention and treatment of mental and substance abuse disorders

National Registry of Evidence-based Programs and Practices

(NREPP)

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NREPP Programs• To date 150 programs in the

database• NREPP recently changed the criteria

and previously approved programs are listed under Legacy Programs on the website

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• Reviewed between 1997-2004 • Part of CSAP’s Model Programs Initiative• Model Programs - science-based, effective

& readily available for dissemination• Effective Programs - science-based,

consistently achieved positive outcomes• Promising Programs - science-based, show

at least some positive outcomes

Legacy Programs…

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Criteria for Submission to NREPP

•Quality of research

•Readiness for Dissemination

•Descriptive Information

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Quality of Research• Reliability of outcome measures

• Validity of outcome measures

• Intervention fidelity

• Missing data and attrition

• Potential confounding variables

• Appropriateness of analysis

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Readiness for Dissemination

• Availability of materials

• Availability of training and support resources

• Availability of quality assurance procedures

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For more info

See NREPP’s website:

www.nrepp.samhsa.gov

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An example with the

DENS ASI Software Program

from Evergreen Treatment Services

Seattle, Washington

Moving to Evidenced-Based Practices…

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Identify the Problem• Track systematically the nature of

patients and their presenting problems

• Match treatment services to unmet patient needs

• Track patient outcomes for program evaluation and for funding and political purposes

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Identify OutcomesConduct all intakes using the

Addiction Severity Index (ASI)

Have ASI intake data stored in agency database

Use ASI information as initial treatment planning guide

Use ASI data for program evaluation

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Assess the OrganizationAll intake workers will need training in ASI administration and then on-going Q.A. for reliability

All intake workers will need training on computerized ASI

Treatment supervisors and counselors will need training in how to interpret ASI assessmentTRI

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Assess the Organization (cont’d)

Need supervision to insure patient’s needs, identified at intake, are being addressed in treatment planning and delivery

I.T. Coordinator will need to maintain database

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Assess the AudienceRegulatory agencies

Funding sources

Political entities

Board of Directors

StaffTRI

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Identify the ApproachTraining

• Intake staff

• Counselors & supervisors

• IT CoordinatorAcquire resources

• ASI Software

• Desktop computersTRI

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Implement the PlansTraining – don’t underestimate

time necessary for this component; skill building can’t be rushed

Resource acquisition – make sure you forecast all of the necessary expenses

Pay attention to staff concerns and morale

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The Move to EBPs

How can technology help?

The DENS System The CASPAR Projects

THE ATTC Blending Teams

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8A national system collecting standardized, automated information (using ASI)

8 that is clinically important and policy relevant

8on people entering addiction treatment and their treatment programs

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The Drug Evaluation Network System DENS

The Addiction Severity Index

• Developed by Tom McLellan & colleagues at University of Pennsylvania

• Standardized, semi-structured, multi-focused screening and assessment tool

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A. Thomas McLellan

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7 Sections of the ASI1. Medical

2. Employment/Support

3. Drug

4. Alcohol

5. Legal

6. Family/Social

7. Psychiatric

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• Benefits to the Counselor

• Benefits for Program: Aggregate Reporting

• Leads to benefits for Clients

DENS System

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DENS SoftwareAutomates collection of the ASI data Provides:

Automated error-checksComprehensive intake assessmentRoom for additional commentsAutomated narrative summary Comprehensive treatment plan

• Software designed with input from clinicians

• Assumed most users have little/no computer experience

• Can enter comments for every ASI item

DENS ASI Software

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It Writes a Narrative Summary?

Software: Hints & Comments

How Do You Tailor Treatment to:

Groups of clients who you know have different

drug problems?

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It is widely believed that males and females have

very different drug/alcohol use patterns, histories and

problems

An Example with Gender Differences

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Gender Differences?Percent Using in the Past 30 Days

18

48

29

3634

3

21

40

10

20

30

40

50

Heroin Cocaine Heavy Alcohol Amphetamines

Males Females

N=60,952

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Lifetime - Psychiatric Problems

4032

10

23

42

56

0

20

40

60

SuicideAttempt

Depression Anxiety

PercentMales

PercentFemales

Gender Differences

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Lifetime - Abuse History

20

8

36

63

41

52

0

20

40

60

80

Emotional Physical Sexual

PercentMales

PercentFemales

Gender Differences

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Recent Abuse

20.3

8

19

2.3

6

0

5

10

15

20

25

Emotional Physical Sexual

PercentMales

PercentFemales

Gender Differences

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Among substance abusers entering treatment, divided by gender, differences in substance use variables are the least impressive

Summary

More impressive are differences in Lifetime and Past 30 days data - personal health and social functioning variables

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CASPAR

Computer Assisted System for Patient Assessment and

Referrals

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Background “Wrap-around” services have been

shown to improve treatment outcomesBut……few services available in

contemporary treatment programs …finding “wrap-around” services can

be difficultTRI

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Problem-Services Linkage

Treatment Research Institute

•Alcohol

•Drugs

•Medical

•Employment

•Psychiatric

GED training

Resume Development

Job Finding

Mentoring Sessions

Training Loans

(e.g. Employ - related services

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1. Conduct assessment (ASI)2. Identify problems 3. Prioritize problems 4. Develop goals to address problems (TP)5. Write Treatment Plan including

referrals not available at your site (CASPAR)

Assessment to Treatment Planning

Therapeutic Thread

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What about this “Resource Guide”?• Electronic source of local, free and low cost

programs and agencies• Contains a wide range of services including:

– Mental health– Job training– Financial support– Emergency services (food, clothing,

housing, shelters)

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Why Was the RG Developed?

• The ASI obtains information on many areas of the client’s life, identifying problems that may require treatment and/or assistance– Often there are more problem areas that need to

be addressed than can be accomplished by any one counselor or agency alone

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Why Was the RG Developed?

The Resource Guide makes it easier for counselors to address client needs that

cannot be met at their agency by providing referrals

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Resource Guide

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A Software Screen Example

Click here to enter patient’s zip code.

Click here for all services matching the keyword.

Highlight a keyword here.

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A Software Screen Example

Click here to print this page.

Click here to view other programs provided by this agency.

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Study Design10 ProgramsGroup 1 - SA

5 ProgramsStandard

Group 2 - EA5 ProgramsEnhanced

131 Subjects

57 Patients

74 Patients

33 Counselors

15 Counselors

18 Counselors

Procedures• Counselors provided their ASI and TP for 5

patients

• TRI staff interviewed patients 2 and 4 weeks post-admission to see how many and what types of services they received

• Matches between the (1) ASI and TP and (2) the ASI and Services Received were evaluated

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ResultsResults from the first CASPAR

study on increasing services-patient match and the number of services received with ASI Treatment Care Planning

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Findings

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Hypothesis 1

Patients whose counselorsreceive the EA Training will receive Treatment Plans that better match their problems identified at admission

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47 45

57 57

73 72

5 8

93 91

1620

0

20

40

60

80

100

Drug Alc Med Emp Family Psych

EnhancedAssessmentGroup

StandardAssessmentGroup

% Matched: ASI to TCP

All p<.05

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Hypothesis 2Patients whose counselorsreceive the EA Training will receive more services

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Number of Services Received

19

1 1

25

35

15

5 3 30 2

0

10

20

30

D/A Med Emp Legal Family Psych

Enhanced Assessment Group Standard Assessment Group

D/A, Med, Emp, Psych all p<.05 TRIscience

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Hypothesis 3Patients whose counselorsreceive the EA Training will receive Treatment Services that better match their problems identified at admission

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80 78 79

96100 100

8175

93 92

5361

0

20

40

60

80

100

Drug Alc Med Emp Family Psych

Enhanced Group Standard Group

% Matched: ASI to Services Received

D/A, Med & Emp all *p<.05 TRIscience

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Hypothesis 4

Patients whose counselorsreceive the EA Training will remain in treatment longerand be more likely to completetreatment

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Percent Retained at 45 Days

68%

39%

20

40

60

80

Enhanced Standard

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Percent Retained at 90 Days

49%

12%10

30

50

70

Enhanced Standard

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Unexpected Finding

Counselors who received the EA

Training remained on the job longer

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Percent Who Quit by 6 Months

20%

60%

10

30

50

70Enhanced Standard

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Limitations• This study evaluated the type and

number of services but not the quality of services received

• No pre-study measures

• Study was limited to Philadelphia area treatment programs

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Conclusion• Counselors are willing to be trained & use

an electronic resource guide

• Resource guide fosters better treatment planning and more appropriate service utilization

• NOT YET CLEAR IF THIS WILL LEAD TO BETTER PATIENT OUTCOMES

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NIDA CASPAR 2

The CASPAR 2 NIDA grant will be conducted in 3 counties outside of Philadelphia, and will use a pre-post design

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CASPAR 2

The CASPAR 2 grant will collect data from 20 treatment programs and 400 patients

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Creating an Electronic Resource Guide:

Linking Services to Client Needs

NIDA Grant # RO1 DA015125

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Purpose and Background

Provide guidelines and instructions for community-based SA treatment programs to develop a customized resource guide for use by counselors to increase services received by clients

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Purpose and Background

Suggestions and time estimates are based on having developed resource guides for 3 studies in the following areas:

• Philadelphia County• Bucks, Montgomery, and Delaware

Counties in PA• Southern New Jersey

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Why Create an Electronic RG?

• Services for many problem areas identified during assessment are not available within traditional community-based treatment programs

• Counselors have difficulty finding resources for these services

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Why Create an Electronic RG?

• Paper resource guides are available but there is a need for materials that are

1. More user-friendly 2. More easily-updated3. Useful for counselors

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Things to Consider…Software Program:• Data structure & storage Microsoft Access or Web-based• Data entry fields

- address, hours, fees, web address, etc.

• Standardized data dictionary

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Things to Consider…Functionality & Layout:• Screen layout• Search functions - basic and advanced • Print functions• Help function• Mapquest function or public

transportation services

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Step 1 – Identifying ServicesIdentify types of services to be included:

• Free / low-cost services• Location • Hotlines • Medical / Psychiatric services• Legal services / Drivers license• Women’s services • Employment / Vocational services• Recovery houses

Estimated time required = 10 hours

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Step 2 – Identifying Agencies

Locate available lists of resources / agenciesSuggested sources:

• Paper resource guides• Internet sources• Counselor resources/smaller guides• CJS Resource list• United WayOur search resulted in 23 sources for the greater Philadelphia area

Estimated time required = 80 hours

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Statistics on 3 Counties in PABucks

County Montgomery

CountyDelaware County

Population

(Source: U.S. Census Bureau

2006)

623,205 775,688 555,996

# of Programs included in the Resource Guide

607 1275 676

Total # of Programs included for these 3 counties= 2,558

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Step 3 – Verifying Information

Verified information by:

• Internet searches on all agencies

• Verification calls on random 10% sample

Estimated time required:Verifying by telephone = 40 hours per 100 agenciesVerifying by internet = 35 hours per 1000 agencies

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Verification Call Results

72%

12%

5%11% Correct

Corrections

No Answer

Closed

Bucks, Montgomery, Delaware and surrounding Pennsylvania Counties

N = 230

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Step 4 – Deleting AgenciesDelete agencies that are:

1. Duplicates2. No longer deliver services listed3. Not appropriate4. Closed, Disconnected / No Answer

Resulted in the deletion of 875 agencies for the present study

Estimated time required = 15 hoursTRI

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Step 5 – Enter Program Info & Categorize

Enter Program Info:• Standardize data• Data enter all program information• Check accuracy

Estimated time required:Entering program info - 80 hours/1000 agenciesCategorizing - 20 hours/1000 agenciesEst. total time - 280 hours

Step 5 – Enter Program Info & Categorize

Sample of a Program Info Screen

NIDA ATTC Blending Team

Providing training, dissemination and technology

transfer of EBP. An example with the Addiction Severity Index and Treatment

Care Planning

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NIDA Blending TeamsWho?

–NIDA Researchers –SAMHSA's Addiction Technology Transfer Centers (ATTCs)

What do they do?–Work together to develop ‘products’ based on research conducted within NIDA's Clinical Trials Network (CTN) and other supported research

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NIDA Blending TeamsWhy do they do it?

–To give treatment providers the necessary tools to adopt science-based interventions in community-based programs

–Create necessary tools to allow for the trouble-free adoption of science-based interventions in community-based programs

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Products Completed

• Buprenorphine Treatment: Training for Multidisciplinary Addiction Professionals

• Short-Term Opioid Withdrawal Using Buprenorphine

• M.A.T.R.S. Treatment Planning: Utilizing the Addiction Severity Index (ASI)

NIDA Blending ‘Products’

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In Development

• Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency (MIA: STEP)

• Promoting Awareness of Motivational Incentives (PAMI)

NIDA Blending ‘Products’

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MATRS Treatment Planning• NIDA Researchers

– Deni Carise, Ph.D., TRI

– Meghan Love, TRI

– Tom McLellan, Ph.D., TRI

• ATTCs – Nancy Roget, Mountain West ATTC

– Dick Spence, Gulf Coast ATTC

– Pat Stilen, Mid-America ATTCTRI

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NIDA Approved Products

6-hour classroom training

•Trainer script•PowerPoint slides•CD-Rom)•Handouts•Reference Lists/Examples

M

TR

S!

A

NIDA Approved Products

4-week online version

•Designed in Moodle course management system (CMS)

(Free, open source software!)

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MATRS Training Package

• How ASI can be used in clinical and program evaluation activities

• Identifies differences between program-driven and individualized treatment planning processes

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MATRS Training Package

• Focus on process of treatment planning

• Defines guidelines and legal considerations in documenting client status

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Adapted Products Mountain West ATTC

Curriculum Infusion Package

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TX. Plan Checklist

http://www.mattc.org/information/smart/ASI-SMART%20BIRP%20CHECKLIST.pdf

Mid America ATTC

http://www.mattc.org/information/smart/ASI-MART%20BIRP%20CHECKLIST.pdf

Mid America ATTC

Documentation Checklist

In Blackboard• Focus on skill development & application in clinical setting (12 hours)

Mid-America ATTC On-Line 6-week Course

MATRS Treatment Planning Software

In Development!

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Building a Master Problem List

Problem Statements

Building a Specific Problem Plan

Identifying Client Strengths

THANK YOU!!