Science into Practice: How Do We Make It Matter?
Evidence-Based Practices in Rural Environments
John A. Morris, MSWDirector, 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 innovationSO 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 practice—and there are very few simultaneous translation services (where’s 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?At what cost?
• With what rewardsWith what rewards??
Defined by whom:
• Simplest answer: by consumers of services—the 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 doesn’t 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 DISCUSSIONFRAMEWORKS FOR DISCUSSION
THREE MOVEMENTS
(1) The Nike Imperative
(2) The Kudzu Phenomenon
(3) The Search for the Holy Grail
THE TRENDS -1THE TRENDS -1
THE NIKE IMPERATIVE:
JUST DO IT!!
THE NIKE IMPERATIVETHE 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 - 2The 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 - 3The 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 ~ 2The Trends ~ 2
The
Kudzu
Phenomenon
The Kudzu PhenomenonThe Kudzu Phenomenon
KUDZU?
What IS kudzu?
Kudzu: The facts...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 PHENOMENONTHE 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- 2THE 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 TRENDS ~ 3: THE SEARCH FOR THE HOLY GRAILTHE 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??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 doesn’t work.
• perpetuate sub-optimal care.
Practical implications Practical implications
• Whatever your role on a provider team, you can’t escape this movement:
No outcomes = No incomes
SUMMARYSUMMARY
• It isn’t 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 CAVEATSTHREE BIG CAVEATS
CAVEAT ONE:
“Today’s 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 CAVEATSTHREE 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 CAVEATSTHREE BIG CAVEATS
CAVEAT THREE:
Don’t let the PERFECT
be the enemy of the GOOD.
2. Evidence-Based Practices
Promises and pitfalls…
EBPs: Promises and Pitfalls
• Starting at the beginning:– Isn’t this just the New-New Thing?– Can’t we just wait this out for the next trend?– What does this say about what we’re already
doing?– Isn’t 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, it’s not just the New-New Thing.• It is probably a movement that is here to stay.• What you’re doing now may be fine—but wouldn’t
you like to be sure?• So far, there aren’t 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 insurancePolicy makers: SAMHSA, state MH AuthoritiesScientists: medical researchers and academics
Foundations: MacArthur, RWJAccrediting 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, it’s 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, real-world, 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 consumers—likely 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 evidence-based practices (or best practices, or promising practices, or emerging practices):
EBPs: Promises and Pitfalls
• Be sensitive to practice-based evidence. If it doesn’t work, stop it; but if it just doesn’t 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
• Don’t over-promise! We are at the early stages, so be humble about what will result.
• Accept the evidence about diffusion of innovation: it doesn’t 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 data…It’s hard, but it’s 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 they’re not evil.
EBPs are tools, not ultimate answers—use 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:Speaker Contact Information:
John A. Morris, MSWDirector, 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
