A Roadmap to Transformation: Innovations, Perspectives, and Partners for Action

1. A Roadmap to Transformation: Innovations, Perspectives, and Partners for Action Evidence-Based Practices for Children, Adolescents & their Families

2. GOALS OF SESSION • National Overview of Evidence Based Practices • Implementation of MST and FFT • Importance of Family Voice • Questions & Answers

3. “Above All, Do No Harm…” Hippocrates

4. “…Evidence-Based Practices (EBPs) are interventions for which there is consistent, scientific evidence showing that they improve consumer outcomes…” (NYS OMH, 2005) "Evidence-based practices are interventions for which there is consistent scientific evidence showing that they improve client outcomes." (Drake et al., 2001) (http://nri-inc.org/CMHQA.cfm)

5. “Evidence-based practices are skills, techniques, and strategies that can be used by a practitioner. Such practices describe core intervention components that have been shown to reliably produce desirable effects and can be used individually or in combination to form more complex procedures or programs (Embry, 2004).” (NIRN, FMHI, USF, 2005)

6. "Evidence-based practice is the integration of best research evidence with clinical expertise and patient values......Patient values refers to the unique preferences, concerns, and expectations that each patient brings to a clinical encounter“(Crossing the Quality Chasm, Institute of Medicine, 2001, p. 147) (http://nri-inc.org/CMHQA.cfm)

7. Common Elements of Evidence Based Programs • Clear philosophy, beliefs, and values • Specific treatment components (treatment technologies) • Treatment decision making (within the program framework) • Structured service delivery components. • Continuous improvement components (NIRN, FMHI, USF, 2005)

8. CRITERIA (http://nri-inc.org/CMHQA.cfm) • SAMHSA’s NREP: Promising; Effective; Model • The American Psychological Association • Cochrane Collaboration • Campbell Collaboration • The Society for Prevention Research • Center for the Study and Prevention of Violence • The Hawaii Department of Health - Child and Adolescent Mental Health Division • Oregon EBP Model

9. STRONGESTPOSITIVE OUTCOMES FOR CHILDREN WITH SED & FAMILIES • Home-based services, including Multi-systemic Treatment • Therapeutic foster care, including Multidimension Treatment Foster Care • Case management • Cognitive-behavioral therapies for some disorders • Pharmacotherapy for some disorders • Specific family educational or supportive interventions, including Functional Family Therapy (NYS OMH, 2005)

10. States required to report to NRI on implementation of the following three EBPs • Multi-systemic Treatment • Functional Family Therapy • Therapeutic Foster Care (i.e.Multidimension Treatment Foster Care)

11. SEVERAL STATES WITH SPECIAL EBP FOCUS • Ohio: Research on Agency Readiness RothD@mh.state.oh.us • New Mexico: Medicaid for MST kens.warner@state.nm.us • Oregon & Hawaii: Approval Process for EBPs http://egov.oregon.gov/DHS/mentalhealth/ebp/ebp-list & cmdonker@camhmis.health.state.hi.us • California: County based penny.knapp@dmh.ca.gov • Minnesota & Delaware: Medicaid Mental Health Transformation Grants for EBPs peggy.clark@cms.hhs.gov

12. HELP & SUPPORT W/ EBP • National Research Institute: www.nri-inc.org • Chart of EBP Implementation by State • Implementation Tool Kit (in development) • Resource Guide for Children & Families (in development) • Center for Advancement of Children’s Mental Health: www.kidsmentalhealth.org • Training Institute for Evidence-based (NYC 10/05) • National Implementation Research Network: www.nirn.fmhi.usf.edu • Implementation Support

14. TRANSFORMATION

15. Blueprint for New Treatment Development Clinic/Community Intervention Development Model: 8 steps ranging from theoretical and clinically informed construct to initial efficacy trial under controlled conditions to single case application in practice setting to full test and test of different variations and assessment and dissemination (Burns, 2003)

16. PRACTICE BASED EVIDENCE • Research shows the first three client contacts account for a majority of the Outcome • Relationship factors account for 55% of successful outcomes: • Agreed upon Goals • Agreed upon Objectives to meet Goals • Ability to develop an empathetic relationship • Client strengths account for 40% • (Arizona DBHS, SW Behavioral Health Services, 2005)

17. Emerging Positive Practices • Trauma Informed Care (NASMHPD/NTAC, 2005) • Executive Skill Functioning (Greene, 2005) • NETI/NTAC Core Strategies for Reducing Coercive Interventions (NASMHPD/NTAC, 2005) • Focus on Permanency: KevinC@ccsww.org

18. One child program where R/S reduced by 88% over 3 years: • ALOS < by 50% • Hours spent on Treatment > from 76.7% to 95.5% • 52% > in discharges occurring w/ admission treatment goals attained • 92% vs 75% of success at less restrictive level of care at 6 months post discharge • 98% reduction in staff days missed at work • 52% reduction in sick time • 83.3% reduction in staff turnover • 30% reduction in workman's comp claims • 98% reduction in paid compensation & medical costs paid (Lebel, 2005)

19. Kevin Campbell, KevinC@ccsww.org 253-225-0988

20. “You never change things by fighting existing reality. To change something, build a new model that makes the old model obsolete.” - Buckminster Fuller

21. CONTACT INFORMATION Beth Caldwell Caldwell Management Associates 413-644-9319 bethcaldwell@mailcity.com

22. Olmstead ConferenceLessons Learned from Ohio Patrick Kanary Center for Innovative Practices www.cipohio.org

23. Center for Innovative Practices • Created by ODMH as part of its Coordinating Centers of Excellence Initiative—CCOE • CCOEs across the state focusing on several treatment and/or population specific areas: MH/CJ; Illness Recovery and Management; MH/MRDD, SAMI

24. Center for Innovative PracticesObjectives • To identify and promote the use of specific evidence based behavioral interventions (e.g., MST) for youth and their families • To develop partnerships and affiliations with EBP-BP developers and other relevant organizations in order to implement strategies • Increase awareness of and access to EBP • Assist communities in development of EBP • To participate in state and local program and policy discussions & recommendations

25. Transformation Implications Using a “Center of Excellence” Model • An identifiable entity (tool) that is accessible to stakeholders • Use real world experience to prepare ‘the field’ • Identify the active ‘transportability’ elements that best prepare the field, regardless of the specific practice • Gains and shares knowledge both academically and pragmatically • Source of good information, reliable, trustworthy • Understands and spans the boundaries among stakeholders

26. Initiatives • Multisystemic Therapy • Intensive Home and Community Based Services • Wrap Around • Integrated Co-Occurring Treatment • Mental Health Services to Juvenile Offenders • Resilience • Access to Better Care • Technical assistance related to evaluation and research

27. Lessons from MST and other Practices • Implementation of MST has provided us our strongest base of Lessons Learned • CIP is a licensed Network Partner of MSTServices, Inc. • CIP provides all aspects of development and implementation of MST in Ohio • 2 full time MST Consultants • 9 Providers with 12 teams in 13 counties • Presentations and dissemination of information • Support to local communities to develop MST programs

28. MST Theoretical Assumptions Based on Bronfenbrenner, Haley , and Minuchin • Children and adolescents live in “ecologies” or systems that impact their behaviors in direct and indirect ways • These influences act in both each directions (they are reciprocal and bi-directional)

29. Ecological Model Community/Culture Neighborhood School Peers Family Child

30. How does MST “work” Intervention strategies: MST draws from research-based treatment options: • Behavior therapy • Cognitive behavior therapy • Pragmatic family therapies • Structural Family Therapy • Strategic Family Therapy • Pharmacological interventions (e.g., for ADHD)

31. How does MST “work”(continued) Context for use of evidence-based intervention strategies • Services are comprehensive, individualized and address all identified drivers of the problem behaviors • MST program philosophy emphasizes that service providers are accountable for outcomes • Families and communities are central and essential partners in MST “treatment”and • Caregivers/parents are key to long-term success • Program structure removes barriers to service access

32. How is MST implemented? • Single Therapist working intensively with 4 to 6 families at a time • 4 months is the typical treatment time • Work is done in the community: home, school neighborhood, etc. • MST staff deliver all treatment • MST staff take a “lead” role in clinical decision making for each case

33. Cost Effectiveness of MST • Washington State Institute of Public Policy (2001) • Research to identify ways to lower crime and lower total costs to taxpayers and crime victims • Detailed evaluations of 14 programs/program types: Program Rank Net taxpayers savings MST 1 $ 31,661 to $131,918/youth Treatment Foster Care 2 $ 21,836 to $ 87,622 Functional Family Ther 3 $ 14,149 to $ 59,067 Scared Straight Programs 14 $ - 6,572 to $-24,531

34. Why Stakeholders Care about Effective Practices • Funders • Consumers and Families • Providers • Policy Makers

35. Funders • Limited resources need to be maximized • Cost effectiveness • Redirecting funds from services that are not effective; refinancing • Outcomes

36. Consumers and Families • Expectation of access to effective services • Focus on ‘real world’ outcomes as measures of success • Family strength approach and engagement • Often intersystem or ecological in operation • Outcomes

37. Providers • Deliver quality services to their consumers • Leading edge of progress in the system • Funding sources are requiring EBP/BP • System moving to outcome based • Opportunity to enhance service array • Outcomes

38. Policy Makers • Consistent with good public health practice • Strategy to link public serving systems together • Meets common goals of multiple systems • Strengthens relationship to research and evaluation activities • Responds to a growing demand and expectation by consumers and families • Outcomes

39. Reality: Considerable Challenges • Financial • Clinical • Systemic

40. Clinical Challenges • Changing practices for both clinicians and organizations • Rigorous supervision/coaching; ongoing training • Focus on Quality Improvement and Assurance • Staffing

41. Systemic Challenges • The allure of ‘the list’ • Identifying and selecting practices within a context of a community planning process • Shift to an outcomes based (qualitative) system of care • Developing local evaluation capacity • Going to scale…making effective practices the rule

42. Financial Challenges • ‘Bridge’ funding to finance start up: Where’s the money? • Anticipating all the costs • Mechanics of reimbursement and limitations of fee for service • Potential ‘conflict’ with productivity approach

43. Factors that Inhibit Development • Perceived ‘over-promise’ of the intervention • Lack of adequate advance strategic planning • High level of resistance to change • Workforce issues • Short term plan for financing

44. Factors that Facilitate Development • EBP within framework of SOC • Parents and youth are partners and represented • Identifiable outcomes for multiple systems • Flexible funding • Risk takers and ‘boundary spanners’, particularly at the local level

45. Elements for Success • Service development based on data driven needs assessment; what can and will the local system support • Investment in ‘Practice Based Evidence’…documenting effectiveness • ‘Real world’ data to capture clinical and cost effectiveness • Diversion from more costly, more restrictive level of care • The more complex and challenging the targeted need area, the higher the need for strong, effective services

46. Location! Location! Location! • “All politics are local.” • “All Evidence Based Practice implementation is local.”

47. Thanks To • Jane Timmons-Mitchell, CIP • Keller Strother, MST Services • Lynne Marsenich, California Institute for MH • Annapolis Coalition material • Karen Blasé of the National Implementation Research Network • Lots of others

48. Contact Info Patrick J. Kanary, Director Center for Innovative Practices patrick@cipohio.org 216-371-0113 WWW.CIPOHIO.ORG

49. Implementing Evidence Based Treatments One State’s Experience with FFT Michael Bigley New York Office of Mental Health

50. What is Functional family Therapy ?- A treatment technique