Implementing EBPs in Mental Health Systems

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Implementing EBPsin Mental Health Systems

• David Lynde, MSW
• Co-Director Dartmouth EBP Center
• Dartmouth Psychiatric Research Center

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Presentation Overview

• EBP Perspective
• Some Lessons We Are Learning Statewide
  Implementation
• Stages of Dissemination of EBPs in Systems

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EBPs in Perspective

• Six currently identified SAMHSA EBPs for adults
  with SMI that have implementation resource kits
• Do not cover all service needs
• Continuing process of evolution
• Identify well researched practices

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Core Values in EBPs

• Recovery
• Comprehensive Assessments
• Individualized Services
• Recovery-oriented practitioner skills
• Informed, shared decision making

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Lessons from the Field
What You Learn When You Step in It
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State/Public Mental Health AuthorityEvidence
Based Practices Dissemination Stages of Change
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System Stages of ChangePrecontemplation
Questions

• What are EBPs?
• What is the difference between EBPs and what we
  are doing right now?
• Why is this a good time for us to tackle this?

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System Stages of ChangePrecontemplation
Questions

• Why should this be one of our system priorities?
• What are the benefits of changing the status quo?

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System Stages of ChangePrecontemplation Actions

• Provide information and forums for meaningful
  discussions for all stakeholders
• Engage providers in discussions at all levels

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System Stages of ChangeContemplation Questions

• How committed is our leadership to disseminating
  EBPs in our system?
• What are the unmet needs in our system for EBPs?
• What EBPs are priorities for our system?

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System Stages of ChangeContemplation Questions

• What other EBPs already exist in our system?
• What lessons can be learned from our previous
  experiences with systems change?

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System Stages of ChangeContemplation Actions

• System leadership honest discussions
• Assessing priority needs areas for the system
  from multiple stakeholder perspectives
• Assessing current outcomes for priority needs
  areas
• Assessing current EBPs in system
• Reviewing system change history

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Lessons Learned Stakeholders

• Consumers, family members and providers play a
  crucial role
• Engage in discussions and discourse with
  stakeholders not just information sharing
• Stress philosophy, values and goals of EBPs
• There is no one single consumer, family or
  provider perspective
• Honor ambivalence

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Lessons Learned Stakeholders

• Involvement Support

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Lessons Learned Stakeholders

• Building consensus is nearly impossible
• Building Informed Support is an alternative
  view
• The Status Quo is powerful
• Finances often drive resistance
• Define significant and meaningful roles for
  stakeholder involvement

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System Stages of ChangePreparation Questions

• Who will lead the EBP dissemination when the
  resistance to this change surfaces?
• Who are the stakeholders that need to be
  involved?
• Are we willing to set up a Statewide EBP Team?

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System Stages of ChangePreparation Questions

• How do EBPs fit with our mission statement?
• What is our system willing to change to support
  EBPs?
• What is our system not willing to change?

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System Stages of ChangePreparation Actions

• Designation of EBP leadership structures
• Commitment to EBP leadership
• Engagement of broad spectrum of stakeholders
• Statewide EBP leadership team
• Understanding EBPs in relationship to system
  mission

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Lessons Learned Leadership

• Why do we want to change the status quo? After
  all, that is what got us where we are today?

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Lessons Learned Leadership

• State Mental Health Authority (SMHA) Leaders have
  used
• Public Forums
• Websites
• Written Statements
• State System Plans and Priorities

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Lessons Learned Leadership

• SMHA Leaders have used
• Commitment of Resources
• System Mission Statements
• Internal and External Forces
• Grant Funding
• Commitment of Personnel

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Lessons Learned Leadership

• Statewide EBP Teams
• Multiple stakeholders
• System feedback regarding
• Implementing
• Sustaining
• Improving
• Coordinated by State EBP Leader

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Lessons Learned Leadership Teams
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System Stages of ChangeAction Questions

• What can we do to keep the sources of support for
  EBPS active and public?
• How will we constantly communicate where we are
  and where we are going with EBPs?
• How will our system support the time for staff to
  be trained in EBPs?

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System Stages of ChangeAction Questions

• How will we utilize and develop training and
  consultation resources for EBPs?
• Will we set up a technical assistance center in
  our system for EBPs?
• How will early sites be selected and what will be
  the expectations?
• What will our system do with fidelity and outcome
  assessments?

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System Stages of ChangeAction Actions

• Plans for constant communication and feedback
• Plans for training and consultation processes
• Development of early site selection protocol
• Description of how fidelity and outcome
  assessments will be used

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Lessons Learned State EBP Plan

• Fit with mission statement
• Methods for describing State responses to EBPs
• EBP implementation process
• Outreach and involvement for stakeholders

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Lessons Learned State EBP Plan

• Funding delivery of EBPs
• Training resources
• Involvement of other State agencies

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Lessons Learned State EBP Plan

• Policies and Funding
• are the fuel of
• Evidence Based Practices

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Lessons Learned Policies Regulations

• Current State System Policies
• Often cited as barrier
• Rarely support EBPs as they exist
• Sometimes punish providers for doing the practice

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Lessons Learned Policies Regulations

• System Policies are Crucial
• Rarely designed for structured practices that
  include
• Preparation Time
• Supervision Time
• Team Meetings
• Outreach Services

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Lessons Learned Policies Regulations

• Every system is perfectly designed to achieve
  the results it is achieving
• --Paul Batalden

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Lessons Learned Policies Regulations

• Non-SMHA are often important Players in this
  Process
• Vocational Rehabilitation in SE
• Substance Abuse, Law Enforcement, Judicial and
  Corrections in IDDT
• Peer Support Agencies in IMR
• Medicaid Authorities in all EBPs

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Lessons Learned Training

• The goal of most mental health training as usual
  is not implementation
• Implement
• to give practical effect to and ensure of actual
  fulfillment by concrete measures
• to put a plan or system into operation

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Lessons Learned Training
We now have thousands of experiments across the
country which have proven that in mental health,
training by itself, is not enough to create
change. --Bob Drake
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Lessons Learned Training

• Effective implementation requires much more than
  just didactic training
• Many agencies and systems benefit from university
  collaborations
• Agencies benefit from consultation
• Skills training is a later stage in the
  organizational change process, not an earlier
  stage

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Lessons Learned Change Takes Time
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Lessons Learned Training

• Agencies benefit from high quality training
  consultation
• Trainers assist agency leadership in the
  organizational change process
• Trainers engage with agencies over a sustained
  period of time
• Trainers have access to their own peer
  supervision collaboration

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Lessons Learned Fidelity Outcomes

• Clear expectations for fidelity and outcomes
  monitoring and use
• Quality improvement/assurance process
• Self-assessment is not a reliable science
• Clear, consistent outcomes definitions and
  reporting

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System Stages of ChangeMaintenance Questions

• What are the current fidelity assessments
  outcomes?
• What are the high fidelity sites are doing that
  they can share with other sites?
• What other EBPs are we going to disseminate?
• How do we extend EBPs to other populations?
• What are the benefits to our system to combine
  EBPs?

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Lessons Learned

• The State Mental Health Authority plays a crucial
  role in the implementation of EBPs
• There are many actions at the State Mental Health
  Authority level that may facilitate the
  dissemination and implementation of EBPs

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Summary

• State system and Mission Achievements
• Education re EBPs
• Stakeholder Involvement
• Costs/Benefits of Doing or Not Doing EBPs
• Leadership
• Policies
• Training and Consultation

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Recovery Hope

• If people are treated as capable, they often
  surprise everyone and live up to expectations.
• Ken Steele The Day the Voices Stopped.