Priority
Populations for Adults and Children
Adult priority populations
- The highest need adults with serious mental illness
- Adults who are victims of trauma
Children's priority populations
- Children with severe emotional disturbance who are currently or may be at
risk for out-of-home treatment
- Children who are victims of trauma
Element 1
Quality, One Priority Sweeping Across The Nation
Notes:
"Confident that we can have a mental health care system that is of high quality
- can't be achieved by continually relying on old systems of care and practices
- nor can be improve quality alone by brow-beating our workforce by asking them
to work harder and do better." We have to have a fundamental paradigm shift
to close the quality chasm.
Berwick, D,: Dirty Words and Magic Spells. Institute for Healthcare Improvement's
National Forum on Quality Improvement in Health Care, December 2000.
Crossing The Quality Chasm:
A New Health System for the 21st Century.
This provocative report by the Institute for Healthcare Improvement challenges
all healthcare providers to shift towards a major rethinking of US and international
healthcare to improve:
- Safety
- Effectiveness
- Consumer-centeredness
- Timeliness
- Efficiency
- Equity
Notes:
Definitional: Safety - avoid injury
Effectiveness - EBPs to those who will benefit
Consumer-centeredness - ISP, value-oriented
Efficiency - avoid waste
Equity - gender, ethnicity, geographic location, socio-economic status
Assumption: Health care today harms too frequently and routinely fails to deliver
its potential benefits.
In a recent evaluation of the fidelity of ACT - in New York State, of 27 current
teams, only 11% had high over-all fidelity. Today, fidelity standards are being
reviewed (e.g., quality improvement effort) to reach and maintain fidelity.
Crossing The Quality Chasm:
A New Health System for the 21st Century.
The vision of a new health care system would be:
- Knowledge-based
- Consumer-centered
- System-minded
The report challenges all of us to look at our system's current array of services
for:
Committee on Quality of Health Care in America, Institute of Medicine: Crossing
the Quality Chasm: A New Health System for the 21st Century. Washington, DC,
National Academy Press, 2001.
Raising The Floor On Clinical Quality.
Notes:
Having success in rolling out multi-year accountability agenda . but discourse
on accountability now needs to move focus from arena of access to arena of access
to arenas of clinical quality and outcomes.
The Current Environment
Notes:
It is acknowledged that while emergency and inpatient treatments are necessary
and very effective for many individuals, these services are sometimes overused
and/or misused. For example, this is a Amish story .
An Amish man, who became acutely psychotic up in Pennsylvania and stole a car,
which was already a highly deviant act for an Amish man to do that. He then
got on Route 95 going south and got to Baltimore and there is a tunnel under
the Chesapeake Bay in Baltimore and there is a dollar toll. His fellow got to
the toll booth and didn't have a dollar. So he panicked, he ran the toll booth,
there was a police chase and a minor accident afterwards. Three years later
this man was still in the forensic hospital in Maryland. Now he was essentially
incarcerated for much longer than any of us would have been. I know if I have
run the toll both and didn't have a dollar, I don't think I would spend three
years in jail.
This is an important point about PACT. PACT is not for everybody. One of the
downfalls of promoting PACT is if it works for some people we think it must
work for everybody. In fact, PACT is targeted to the highest risk patients who
are at risk for not being in treatment or high rates of emergency service use.
In the original PACT study Burt Weisbrod was an economist, looked at a cost
effectiveness or a cost benefit analysis of different diagnostic groups. More
of these folks are able to get back to work in the long term and so on, so the
cost benefit there is quite good, It was also positive for people with schizopherenia,
where it was a negative with patients with personality disorders, mainly cluster
"B" type patients. Where you can just imagine I think some of the bad rap of
assertive community treatment gets. You imagine with someone with a way a borderline
personality disorder or antisocial personality disorder, the kinds of boundary
issues that comes up there from a clinical context you could see where assertive
community treatment if it is not modified. It might actually increase the use
of services with no additional benefit where is exactly what they found in the
Madison Study. So it is important to target this.
Focusing on Quality Outcomes.
Defining Major Performance Areas
- Access to Services
- Support for Recovery
- Impact of Services
Therefore focusing on both .
Efficacy:
An intervention has the capacity to produce a "positive result" or be "effective".
and
Effectiveness:
An intervention that produces "intended" or "expected" results.
Notes:
Efficacy: generally shown through clinical trials
Evidence that a treatment has beneficial effects when delivered under carefully
controlled conditions designed for experimentation; in efficacy studies, the
investigator exerts considerable control over sample selection, delivery of
the intervention, and the settings in which the intervention takes place.
Effectiveness:
Evidence that a treatment has beneficial effects when delivered to heterogeneous
samples of clinically referred individuals treated in clinical settings by clinicians
rather than researchers.
Element 2
Making Recovery a Reality
About Recovery.
"Recovery is the process of gaining control over one's life in the
context of personal, social and economic losses."
Excerpt from NYS OMH Blueprint, 2001
Evidence-Based Practices Support Recovery
... by providing practitioners with tools which can help consumers maintain
important recovery components such as employment, housing, relationships and
relief from symptoms
Using Recovery-Oriented Performance Outcomes for Adults and Children
Wellness
- Physical Health Status
- Self-esteem
- Level of symptom management
- Level of behavior management
- Level of discomfort from medication side effects Quality of life
Notes:
Emphasize self-esteem is not just about symptoms
Community Integration
- Ability in school
- Housing Status
- Employment Status
- Social Role Status
- Educational Status
- Parent/caregiver ability
Element 3
Evidence-Based Practice through positive change
Creating a Demand for Evidence-Based Practices: The consumer perspective
NYS study of consumer goals identified:
Adults with severe mental illness say their most important goals have to do
with work, housing, interpersonal relationships and education
| Vocational |
48% |
| Housing |
39% |
| Interpersonal |
28% |
| Educational |
27% |
Progress Report of New York State's public mental health system. January 2001.
Notes:
Consumer demand
Work: is highest goal priority
Winds of Change: targeted to consumer - currently engaged with advocate/consumer
groups
Consumer demand will arise if "best scientific information is used by consumer
Creating a demand for Evidence-Based
Practices:
The family perspective
Creating a demand for Evidence-Based
Practices:
The practitioner perspective
Notes:
Begins in classroom
Education of mental health professions
Emphasize quaity improvement - using research evidence.
Evidence-Based Practices: For Adults
Assertive Community Treatment (ACT)
Rationale
|
Description
|
Who
Benefits?
|
| High rehospitalization
rates for most impaired consumers |
- Small caseload - 1:10
- Interdisciplinary teams
- Services in client's natural setting
- 24 hour coverage
- Shared caseloads among clinicians
- Direct, not brokered services
|
- 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
|
Notes:
Definitional
- Advantage over case management is case management is not a single
model.
- The distinction is blurred with ICM, but the team missing.
- ACT has been around for upwards of 20 years; origin in Madison, Wisconsin
- The fidelity of ACT model is critical to the outcome of the decrease in hospitalizaitons.
Research demonstrates a significant association between total fidelity index
scores and two fidelity subscales on staffing and orgranization.
Act as a platform for service delivery: - Idea of combination of
services. for strong evidences around employment attainments where ACT team
member has vocational skillls . Mr. MdFarland ACT/VOC/PsychoEd
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
However, the components of ACT(mobility, multi-disciplinary focus) can be adopted
within the broader range of case management and outpatient services.
Notes:
Bullet 2: Raises questions about "level of service intensity" over time. Is
there a minimum dose of ACT were consumer could "step-down?" We think so.
After Bullet 3: "becomes fuzzy with ICM."
Build into Medicaid rates
Supported Employment
Rationale
|
Description
|
Who
Benefits?
|
| Rates of competitive
work are low and most consumers want competitive work |
- Rapid job search and placement
- De-emphasis on pre-vocational training and assessment
- Attention to consumer preferences
- Follow-along support provided
|
- Consumers interested in competitive work
|
Notes:
Definitional - Direct placement in competitive employment with on-going supports.
(Not transitional employment which is a step toward competitive employment.
- Outcomes improved when compared to lengthy pre-employment assessment, training,
Stepside Systems, etc.
- Gary Bond, '98
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
Notes:
Bullet 1:
Also, allocated smaller in this area.
Must have job placement.
Problems with insurance; fear of moving on.
Success improved with follow-along supports from an integrated MH team - NOT
UNIVERSALLY PRACTICED
Wake Up Call
VESID issues - always raised; underperformance of their system
Wellness Self-Management Education
Rationale
|
Description
|
Who
Benefits?
|
| Non-adherence
to a treatment plan is extremely common and closely associated with relapse
|
- 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
|
- Consumers with cognitive impairments
- Consumers with a diagnosed psychiatric illness.
- Consumers with psychotic symptoms
|
Cognitive Behavioral Therapy for Psychosis & Skills Training are included
in this EBP.
Notes:
Theory of self-efficacy
Coping Skills
Wellness Self-Management Education
Skills Training
Rationale
|
Description
|
Who
Benefits?
|
| Impaired social
functioning predicts the worst outcomes |
- Multiple weekly training sessions over time (between 3 months and
1 year)
- Individual and group formats
- 'In vivo' training to facilitate generalization of skills
|
- Consumers with cognitive impairments
- Consumers with a diagnosed psychiatric illness
- Consumers with psychotic symptoms
|
Wellness Self-Management Education
Cognitive Behavioral Therapy For Psychosis
Rationale
|
Description
|
Who
Benefits?
|
| Persistent
psychotic symptoms are present in 25-40% of consumers with schizophrenia
and persistent psychotic symptoms predict relapse and rehospitalization
|
- Collaborative partnership with consumer
- Education about stress-vulnerability
- Behavioral tests
|
- Consumers with cognitive impairments
- Consumers with a diagnosed psychiatric illness.
- Consumers with psychotic symptoms
|
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
Family Psychoeducation
Rationale
|
Description
|
Who
Benefits?
|
| Many
consumers live at home or have contact with relatives, and education and
support for families reduces the stress increases risk of relapse |
- Provided by professionals
- Long-term (over 6 months)
- Focuses on education, stress reduction, coping skills and other supports
|
- Consumers who are in regular contact with their relatives and families
|
Notes:
Single, individual, or group multi-family
Not a prescribed model like ACT but based on same 15 principles
Consumer participation not a prerequisite.
The Evidence-Based Challenge.
Family Psychoeducation
- 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
Notes:
Bullet 2: scheduling/work/conflicts
Stigma, multi-family
Fear of "Blame the Family"
Reimbursement issues if consumer doesn't sanction/participate in process
Integrated Treatment for Co-Occurring Disorders
Rationale
|
Description
|
Who
Benefits?
|
| Substance
abuse worsens outcomes and up to 50% of consumers have co-occurring substance
abuse disorders |
- Assertive outreach
- Stage-wise treatment
- Harm-reduction approach
|
- Consumers with co-occurring substance abuse disorders
|
Notes:
Not a standalone. needs to be integrated with case management, medications,
housing, vocational rehab, etc. "Seamlessness"
Definitional
Integration - e.g.,in mental health, focus on social skills and develop
relationships, but need to avoid social situations which precipitate substance
abuse
Assertive outreach - housing, case management, etc.
Harm-reduction approach - strengthen environment to reduce harm
Stage-wise treatment - trust, motivational skills, etc.
Co-occurring disorders - mental health and substance abuse
The Evidence-Based Challenge.
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
Notes:
Focus on abstinence in most programs - "no flexibility"
Cultural sensitivity and competence critical. Need to tailor, especially with
African Americans, Hispanics, homeless
Clear service models not strong
Medication
(Anti-psychotic Medication Algorithm)
Rationale
|
Description
|
Who
Benefits?
|
| The
antipsychotic medication algorithm will ensure that symptoms are minimized,
side effects are minimal, and that there is consumer choice and education.
|
- The antipsychotic medication algorithm is an outline of a rational
sequence of medica-tions to try in the pharmacological management of
schizophrenia in order to maximize medication efficacy and minimize
side effects.
|
- Consumers taking medications for psychiatric illness
|
Medications.
this is
an example of a sequence of medication trial
The Evidence-Based Challenge.
Medication and medication adherence
- Competing algorithms and guidelines (need for consensus on which to
use across state and local sectors)
- Medication adherence requires routine monitoring of blood levels which
is not currently done in many programs and service sectors
|
|
Notes:
MDs egos and practices routines: inability to let go of personal standards of
care
Self Help & Peer Support Education
Rationale
|
Description
|
Who
Benefits?
|
Self
help as a complement to treatment and as a life-long support has proven
to be beneficial to sustained management of many health conditions.
For people with mental illness, the benefits of this form of mutual aid
are empowerment, an increased sense of self identity and self-esteem. |
- Educate consumers about self help
- Encourage referral and attendance
- Support participation in mutual aid fellow- ships including starting
and running autonomous groups
|
- People with limited social networks or with few social relationships
which share a common bond
- People who are interested in developing a 'helper' role
- People who wish to share and learn about personal coping strategies
- People who desire to participate in self-generated, structured activities
which are personally meaningful
|
The Evidence-Based Challenge.
Self-help and Peer-run Service Education
- Few individuals who use the state's existing inpatient and outpatient
services have an opportunity to be educated on the value of these services
- There are few opportunities to co-locate or create joint ventures
between licensed providers and recipient-run programs in existing funding/regulatory
structures
|
|
Post-Traumatic Stress Disorder Treatment
Rationale
|
Description
|
Who
Benefits?
|
| People
exposed to same catastrophic event react differently. Some will develop
severe psychological distress while others will not. People treated with
PTSD can make a full recovery |
- Treatment aimed at both current trauma and past
- Treatment of comorbid disorders targets symptoms of each disorder
simultaneously
- Combined treatment (e.g., individual therapy and medications
- Global therapy
- Individual therapy
- Family education and therapy
- Group therapy
- Social rehab. therapy
|
- People exposed to catastrophic event
- People with past exposure to trauma
- People with comorbid disorders
- Trauma victim, family, friends and society
|
Notes
Examples: Bedford Hills trauma/mental health program
OMH/OCHS residential program
OMH workgroups on self-injurious behavior
OMH Best Practices conference
DBT intensive training: 8 teams from state and local programs
The Evidence-Based Challenge.
Post-Traumatic Stress Disorder Treatment
- Evidence-based selection
- Serving people not traditionally served in public mental health system
- Educating professionals to provide capacity
- Professional expertise
|
|
Notes:
Individualized/customizing
Expertise specific to trauma different than professional expertise
Combination is the key.
Effect Of Adding Strategies To Medication & Case Management
Percentage of cases having episodes of florid psychopathology or other evidence
of lack of efficacy of treatment after 12 months of continued care.
| Case Management |
54% |
| + Family Education |
27% |
| + Problem Solving |
23% |
| + Social Skills Training |
14% |
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
Notes:
This shows percent of individuals with episodes of psychopathology after 12
months of care
Turning Over A New Leaf:
Moving Forward With EBPs
Lessons Learned.
In August 2001,
a series of four focus groups were held to introduce the concept of evidence-
based practice to local government leaders, service providers, advocates,
and recipients of service.
Based on these sessions, two different implementations themes emerged:
- Cultural Change
- Structural Change
|
|
Lessons Learned.
Cultural change is needed for:
- Creating an organization dedicated to continuous learning and quality
improvement
- Creating widespread belief in the possibility for recovery
- Understanding and valuing shifts to science-based practice
|
|
Lessons Learned.
Structural change is needed for:
- Licensing
- Contracting and regulations
- Workforce supports for education and supervision
- Uniform standards and procedures for assessment, service planning,
and outcomes management
|
|
Notes:
ALWAYS mention the literature that we already know and the need to disseminate
it widely to "clinician-scientists"
Strategies for Change
Strategies
for Change
| Change Strategies |
Phase I: Consensus Building
|
Phase II: Enacting
|
Phase III: Sustaining |
Awareness:
Encouragement and collaboration with our stakeholders
|
Identify and use a network
of champions from local government, stakeholders, and advising groups
|
Using formal consensus-building
projects to create a set of evidence-based demonstrations throughout the
state
|
Evaluate for widespread
replication
|
Education:
Introduction and development of new quality initiatives
|
Produce introductory
materials, include national EBP toolkits and quality outcome measures
|
Develop several ‘Centers
for Excellence’ for ongoing research and education
|
Secure permanent funding
for ‘Centers for Excellence’
|
Structural &
Clinical Imporvement:
Incorporation of quality measures into both individual practitioner and
provider performance
|
Develop and test quality
outcome measures using network of champions and demonstration sites |
Develop fiscal and regulatory
changes indicated during development and testing
|
Create a local level
evaluative capacity to monitor performance against outcomes
|
Continual Improvement
& Support:
Monitoring of the quality measures and means for continuous upgrading
Ongoing identification of new areas of promise, knowledge gaps and emerging
EBPs |
Use existing progress
report structure to ‘test’ and initial series of performance reviews
in selected EBP areas
|
Use performance data
in selected EBP areas to make regulatory and funding decisions
|
Periodically revisit
consensus building stages to identify and promote innovations
|
Notes:
Model meant to be fluid. Recognizes current environment and progress we've made.
Also, incorporate the "lessions learned."
Everything begins at a "local level"
GO through the next 4 slides when using this slide
The Four Change Strategies.
AWARENESS:
|
Encouragement and collaboration
with our stakeholders
|
EDUCATION:
|
Introduction and development
of new quality initiatives |
STRUCTURAL
& CLINICAL
IMPROVEMENT: |
Incorporation of quality measures into both individual practitioner and
provider performance |
CONTINUAL
IMPROVEMENT
& SUPPORT: |
Monitoring of the quality measures and means for continuous upgrading
Ongoing identification of new areas of promise, knowledge gaps and emerging
EBPs |
The Three Performance Phases.
PHASE 1: Consensus Building
This will be
an opportunity to begin an ongoing dialogue with multiple stakeholders.
The intent of this phase is to predispose stakeholders on the issue of restructuring
services so that they support recovery.
During this phase, consensus will be sought to create the cultural shifts
toward OMH operating as a continuous learning organization. |
|
Notes:
Emphasis on champions
The Three Performance Phases.
PHASE 2: Enacting
During this phase,
efforts will be undertaken to build support structures for evidence-based
practices.
Efforts of the stakeholders will be aligned in key areas such as development
of centers for excellence and fiscal reform. |
|
Notes:
Still a concept.
Centers for Excellence.
Definition of the desired scope and role
Potential Roles - Serve as a Technical Assistance Center, continuously cultivating
and sharing content expertise for their respective domains.
- Concentrate on a domain(s) to infuse into their undergraduate and graduate
courses of study.
- Function in an education and training role to develop and sustain a "real
world" clinical setting while maintaining high fidelity to the domain model
- Establish/maintain a complementary research/evaluation component.
- Retain/increase capacity to obtain grant funding.
Ideal Characteristics for Centers of Excellence
- Center should have one or more 'Champion', Opinion Leader, Content Expert
- Center components (Clinical Program and Academic Program) may be separate
from each other but geographically proximo.
- It is preferable for the Clinical and/or Academic Program to be an already
existing program that has an exemplary history for the domain or has leadership
representatives comprised of leading clinicians/academics in the domain. However,
other programs may be examined. - Urban and rural-based
Ideal Characteristics of Clinical Component
- Important Domain Focus
- High Fidelity
- Established and High Quality Clinical and Administrative Leadership
- Financial Viability
Ideal Characteristics of Academic Component
- Grant Capacity
- Publications/Research in Domain
- Opportunities for Staffing
- Established courses of study, concentrations, certificate and/or training
programs
- Professional Accreditation, credentialing capacity
- Research and Evaluation capability and capacity
The Three Performance Phases.
PHASE 3: Sustaining
| Key steps will
be taken during this phase to build ongoing technology transfer capability;
to develop a performance indicator structure for management of recovery-oriented
outcomes, and define and implement flexible fiscal and regulatory systems
capable of providing a resource base necessary for full implementation.
|
|
Looking Forward:
Enacting New Approaches
Summary: The Challenges
There are significant
challenges to implementing evidence-based practices due to issues of .
- Leadership
- Education
- Funding
- Regulations
- Workforce retention and
- Systems integration
|
|
- Appropriate clinical formulation (diagnosis, treatment regimen, individual
service plan)
- Coordinated treatment planning between inpatient and outpatient service
- Coordinated treatment planning between state and local sectors
|
|
Mindful of these Challenges.
OMH will proceed in partnership with key stakeholders at the national, state
and local level to rollout our Winds of Change campaign.
Increasing the likelihood
| .
thus the likelihood that individuals receive high quality, proven-to-be-effective
services will be guaranteed. |
|
OMH's desired outcomes
| .
For children and adolescents with serious emotional disorders, use of evidence-based
practices will ensure receipt of state-of-the-art treatment. These interventions
can help keep families together and children in school. |
|
OMH's desired outcomes
| .
For adults with mental illness, use of evidence-based practices will ensure
receipt of state-of-the-art treatment. These interventions will help achieve
meaningful personal goals. |
|
A Partnership for Change
"One voice is a whisper carried by the wind, but many voices are the
wind."
