Implementation of EvidenceBased Models: Improving Processes

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Implementation of Evidence-Based Models
Improving Processes

• Jeanne L. Obert, MFT, MSM
• Executive Director, Matrix Institute
• UCLA Integrated Substance Abuse Programs

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History of Matrix Model Clinical Services

• 1984 Adult Intensive Outpatient Treatment
  Program began in Los Angeles The Matrix Model
• 1986 - San Bernardino County program begins with
  60 of clients abusing methamphetamine
• 1990 Became affliated with UCLA
• 1994 - First Adolescent Treatment Program
  started at YMCA in Ontario, CA
• 1998 - Rick Rawson left CSAT MTP began
• 2000 Officially became totally nonprofit
• 2005 5 Clinical Sites in the Greater Los
  Angeles Area

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Treatments Available Medical Behavioral

• Drug
• Classes
• Sedatives
• Stimulants
• Opioids
• Alcohol

• Medical Treatments
• Sedatives
• Opioids
• Alcohol

• Behavioral Treatments
• Sedatives
• Stimulants
• Opioids
• Alcohol

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MATRIX MODEL

• AN ORGANIZED
• COLLECTION
• OF SELECT
• EVIDENCE-
• BASED
• INTERVENTIONS

• Cognitive-Behavioral
• Motivational Interviewing
• Contingency Management
• Family Therapies

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Defining Features of Matrix Model Treatments

• Comprehensive, manual-driven, one year program
  with simple, well-organized instructions.
• Developed from grassroots, clinical program with
  empirically-based interventions added where they
  seem to work.
• Patient handouts accompany each session and
  patient workbook contains written and illustrated
  concepts.

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Matrix ModelEvidence-Based Treatments delivered
within

• Individual Sessions
• Early Recovery Groups
• Relapse Prevention Groups
• Family Education Group
• 12-Step Meetings
• Social Support Groups
• Relapse Analysis
• Urine Testing

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3 Large Scale Dissemination Efforts
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The CSAT Methamphetamine Treatment Project
A Multi-site Trial of a Manualized Psychosocial
Protocol for the Treatment of Methamphetamine
Dependence

• Richard Rawson Ph.D.
• U.C.L.A. Integrated Substance Abuse Programs
  (I.S.A.P.)
• Funded by the Center for Substance Abuse
  Treatment

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Goals of the Methamphetamine Treatment Project

• To study the clinical effectiveness of the Matrix
  Model
• To compare the effectiveness of the Matrix model
  to other locally available outpatient treatments
• To establish the cost and cost effectiveness of
  the Matrix model compared to other outpatient
  treatments
• To explore the replicability of the Matrix Model
  and challenges involved in technology transfer

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Motivational Enhancement Therapy (MET) for
Outpatient Retention and Substance Use

• Protocol 005
• Kathleen M. Carroll, Ph.D.
• (Lead Investigator)
• Samuel A. Ball, Ph.D.
• Yale University School of Medicine

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Primary Aims

• To evaluate the effectiveness of MET in
• Retaining diverse clients in outpatient treatment
  
• and reducing their substance use
• when delivered by diverse community clinicians
  in the first month of treatment in different
  practice settings relative to counseling-as-usual
  (CAU)

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Secondary Aims

• Evaluate whether programs treating predominantly
  alcohol vs. drug abusers have better outcomes
• Evaluate the discriminability of MET from
  Counseling-as-Usual (CAU)
• Evaluate client gender and race differences in
  response to MET vs. CAU

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Matrix goes to Thailand

• The Ultimate Train-the-Trainer Project
• Walter Ling, MD
• 12 well-trained sites in Thailand
• resulted in
• 4,000 Matrix Centers in less than 2 years

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Issues in Disseminating Evidence-based Models

• Dealing with modifying human interactions with
  peer-oriented staff, research-oriented trainers,
  and business-oriented administrators
• Suspicion of research
• Conflicting priorities
• Process of creating change (mandated?)
• Accepting manualized treatments
• Modifying protocols adaptation vs. fidelity

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Law Enforcement Officials in 500 US Counties
askedWhat is your primary drug problem?
National Association of Counties - 2005
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The DilemmaHow to Disseminate the Information ?
Effectiveness
Speed
Continuum
Train-the-Trainer(s) Model
Highly-Selective Highly-Intensive Training Model
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Stages of Adaptation

• Step I - Exposure (to new ideas)
• Step 2 - Adoption (formal decision to try
  change)
• Step 3 - Implementation (provider tests
  use of innovation)
• Step 4 - Practice (incorporation of innovation
  into regular use)
• D. Simpson, 2002

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Implementation Research A Synthesis of the
Literature 2005
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Matrix Model Key Supervisor

• Strong champion who can serve as a change
  agent/purveyor in the adoption process
• Serves as a liaison between Matrix and adopting
  program
• Helps educate staff and administrators about new
  program
• Clinical leader who knows the Model well and can
  help others learn

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Step 1 Exposure(to new ideas)

• MATRIX COMMUNITY
• TECHNOLOGY TRANSFER
• One 2.5 day core workshop limited to 30
  participants with a Matrix-experienced trainer
• Key Supervisors identified and scheduled for
  further training
• Manuals available with recommendation for
  training

• CSAT STUDY
• TECHNOLOGY TRANSFER
• 3-day trainings with all sites together
  bi-annually
• On-site visits and consultations at start-up

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Step 2 Adoption(formal decision to try change)

• CSAT STUDY
• TECHNOLOGY TRANSFER
• Site adoption occurred through RFP process
• Individual therapist chosen at site was voluntary
• (Post study recommendation Hold retreat with all
  participants held at start-up to establish good
  working relationships)

• MATRIX COMMUNITY
• TECHNOLOGY TRANSFER
• Returning workshop participants will recommend
  (or not) adoption
• Selection of Key Supervisor will help actualize
  organizational commitment
• (Future? Meet with key program administrators and
  leaders prior to commitment)

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Characteristics of Ideal Key Supervisor

• Respected clinical leader who is both credible to
  clinicians and savvy about organizational
  dynamics
• Possess excellent communication and clinical
  skills
• Committed to actively working to implement the
  Matrix Model with fidelity and good effect

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Policy Recommendations

• ( University of South Florida, Implementation
  Research A Synthesis of the Literature)
• Encourage program-centered service delivery
  rather than practitioner-centered. (Use of
  manuals aids this process.)

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Policy Recommendations

• Invest in development and use of implementation
  strategies and methods that are grounded in
  research and elaborated through accumulated
  experience.
• (Similar to recent investments made in
  information systems.)

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Policy Recommendations

• Develop funding strategies to support
  implementation of evidence-based programs
• Start up costs
• Purveyor support (Change agents and/or
  organizations)
• Adequate funding for services
• Ongoing support of infrastructure for
  sustainability