Implementing Evidence-Based Practices in Behavioral Health. Mark P. McGovern, Ph.D. Geisel School of Medicine at Dartmouth

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1 Implementing Evidence-Based Practices in Behavioral Health Mark P. McGovern, Ph.D. Geisel School of Medicine at Dartmouth

2 Implementing Evidence-Based Practices in Behavioral Health Sponsored by the Hazelden Betty Ford Foundation with the Geisel School of Medicine at Dartmouth

3 Implementing Evidence-Based Practices in Behavioral Health Presenter Mark P. McGovern, Ph.D. Department of Psychiatry Department of Community and Family Medicine Geisel School of Medicine at Dartmouth

4 Objectives 1. Define important terminology in implementation science and understand key concepts for implementation of evidencebased practices 2. Learn about the three primary stages of implementation: preparation, implementation and maintenance 3. Recognize the risks involved and factors that could make or break implementation 4. Understand how evidence-based practices can help achieve the desired outcomes with successful implementation

5 The Frustrations of Ignaz Semmelweis

6 An array of evidence-based medications and psychosocial interventions typically used together now allows for successful treatment of most mental disorders. Despite these advances in science, many Americans are not benefitting from these investments. Far too often, treatments and services based on rigorous clinical research languish for years rather than being used effectively at the earliest opportunity. President s New Freedom Commission on Mental Health (2003)

7 Dissemination and Implementation (D&I) 17 years to translate 14% of research to direct patient care benefit (Balas & Boren, 2000) Approximately 1.5% (of $100 b) of U.S. biomedical research funding is D&I research (Woolf, 2008) <1% of NIH funding to D&I (Chambers, 2012) <1% of publications in prominent health scientific journals (Colditz, 2012) What is the real public health return on investment (ROI) from the U.S. research enterprise?

8 Terminology Dissemination: An active approach of spreading evidence-based interventions to the target audience via determined channels using planned strategies. Implementation: The process of putting to use or integrating evidence-based interventions within a setting. (Rabin & Brownson, 2012)

9 POLLING QUESTION #1: What is the evidence-based program you are most interested in implementing in your agency or your practice? A) a medication B) a therapy C) a service D) a standardized protocol E) other

10 Challenges to Implementation Push and pull dynamics of the process Evidence-based treatments developed in austere and controlled circumstances: Too complex to deliver, not a good fit with real world patients Research-based treatments may not be all that much better than existing practice May be more costly and with no economic incentives Shift to research solving real-world problems (local) not simply advancing careers

11 Emerging Science of Implementation Implementation research: Scientific study of processes and factors that are associated with successful integration of evidence-based interventions within a particular setting. or How do you get evidence-based practices into routine practice settings so that more people can receive the best care possible?

12 Everett Rogers (1962) Diffusion of Innovation 5 categories of system member innovativeness Innovators (2.5%) Early adopters (13.5%) Early majority (34%) Late majority (34%) Laggards (16%)

13 Implementation Science 100 terms for Dissemination and Implementation; Tower of Babel (McKibbon et al, 2010) 450+ implementation research measures (Seattle Implementation Research Center, 2013) 68 implementation strategies (Powell et al, 2012) 61 D&I models (Tabak, 2012) Consolidated Framework for Implementation Research (CFIR): Consolidation of 19 models (Damschroder et al, 2009)

14 How to Make Sense of This Emerging Science? Process of scientific development: Concept to measurement to replication to comparison to evidence and predictability Practical guidance or What to do in the meantime? Implementing Evidence-Based Practices in Behavioral Health by Drs. McGovern, McHugo, Drake, Bond, and Merrens. Hazelden, 2013

15 Simplified Flow of the Implementation Process

16 The Six Key Components to Implementation The evidence-based practice to be implemented Contextual barriers and facilitators to the implementation The strategy or intervention being used to implement and sustain the evidence-based practice (i.e. the implementation strategy) Desired outcomes of the implementation The stage of the implementation process The level of the implementation (the target audience)

17 Contextual Barriers and Facilitators From the consolidated framework for implementation research (CFIR) I. Intervention characteristics II. Outer setting (system influences) III. Inner setting (organizational influences) IV. Characteristics of individuals (providers)

18 Contextual Barriers and Facilitators I. Intervention Characteristics A. Intervention source B. Evidence-strength and quality C. Relative advantage D. Adaptability E. Trialability F. Complexity G. Design quality and packaging H. Cost

19 Contextual Barriers and Facilitators II. Outer Setting A. Patient needs and resources B. Cosmopolitanism C. Peer pressure D. External policy and incentives

20 Contextual Barriers and Facilitators III. Inner Setting A. Structural characteristics B. Networks and communications C. Culture

21 Contextual Barriers and Facilitators III. Inner Setting (continued) D. Implementation climate 1) Tension for change 2) Compatibility 3) Relative priority 4) Organizational incentives and rewards 5) Goals and feedback 6) Learning climate

22 Contextual Barriers and Facilitators III. Inner Setting (continued) E. Readiness for implementation 1) Leadership engagement 2) Available resources 3) Access to knowledge and information

23 Contextual Barriers and Facilitators IV. Characteristics of Individuals A. Knowledge and beliefs about the intervention B. Self-efficacy C. Individual stage of change D. Individual identification with organization E. Other personal attributes

24 Implementation Strategies Training/workshop Expert consultant/coach/technical assistance Learning collaborative Clinical supervision Fidelity monitoring Financing/reimbursement/contracting Protocol/policy (including medical records) Multi-faceted (e.g, NIATx) Hodgepodge

25 Implementation Implementation Outcomes Acceptability, Adoption, Appropriateness, Costs, Feasibility, Fidelity, Penetration, Sustainability Services Efficiency, Safety, Effectiveness, Equity, Patientcenteredness, Timeliness Patient/Client/Participant Symptoms, Functioning, Satisfaction (Proctor et al, 2010)

26 Two Basic or Core Implementation Outcomes Quantity Did patients get it? (# receiving the EBP/# eligible) Quality Was the it what it was supposed to be? (Fidelity or adherence measurement)

27 Stages of Implementation Preparation Prioritization, leadership, training Implementation Workforce, workflow, fidelity Maintenance Reinforcement, fidelity, outcomes See also Aarons,et al (2011) Four-Stage Model of Implementation: Exploration, Preparation, Implementation and Sustainment (EPIS)

28 Measuring Core Implementation Outcomes Intervention Type Medication Therapy Service Quantity # prescribed/ # eligible # receiving/ # eligible # receiving/ # eligible Quality Guideline adherence Adherence and competence rating Fidelity rating

29 Levels of Implementation System (Outer Setting) National, state, county, tribe Organization (Inner Setting) Agency, program, clinic Provider Physician, social worker, counselor Consumer Clients, patients, families

30 Polling Question #2: On a five-point scale, how difficult do you believe it would be to assess some implementation outcomes in your agency or practice? 1 - not at all difficult/relatively easy difficult but doable impossible/cannot or do not have capacity to track numbers

31 Practical Checklist Approach to Implementation Atul Gawande Checklist Manifesto (2009) Checklists for implementation 7-items (did it, didn t) By stage: Preparation, Implementation, Maintenance By role and levels: Consumers of services, practitioners, team leader or supervisor, clinical director, CEO, technical assistance center, state or system regulatory agency, federal government

32 Implementing Evidence-Based Practices in Behavioral Health Implementation Manual (170 pages) Stages of Implementation Implementation Measures The Checklist Approach to Implementation: Who Needs to do What When Implementing Multiple Evidence-Based Practices Simultaneously FAQ Interview with an Agency Director

33 Implementing Evidence-Based Practices in Behavioral Health CD-ROM with reproducible materials Agency implementation task list Dual Diagnosis Capability measures Implementation checklists for every level of implementation Fidelity scales for evidence-based programs and practices: Supported Employment, Assertive Community Treatment, Illness Management and Recovery, Integrated Dual Disorders Treatment, Family Psycho-education

34 Mark P. McGovern, Ph.D. Department of Psychiatry Department of Community & Family Medicine Geisel School of Medicine at Dartmouth 85 Mechanic Street, Suite B4-1 Lebanon, NH (603) (603) FAX

35 Discussion For more information call or visit our bookstore: hazelden.org/bookstore Price: $39.95 Includes implementation manual (recommended textbook) with implementation research and references, CD-ROM with reproducible implementation checklists, fidelity measures, and capability assessments.

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