The CANS and Evidence Based Practice Implementation: Hanging Together or Just Left Hanging?

1
The CANS and Evidence Based Practice
Implementation Hanging Together or Just Left
Hanging?

• Abram Rosenblatt, Ph.D.
• EMQ FamiliesFirst

2
Presentation Overview

• Context
• EBPs
• Measurement
• Gaps
• Example
• Conclusions

3
Service Systems Are Complex

• Practice
• Program
• System

4
Impact is Complex

• Effectiveness
• Efficiency
• Equity

5
Setting the Stage A Framework
6
Purposes of Collecting Data and Perceived Value
7
Setting the Stage Trends

• Systems of Care
• System Focus?
• Efficiency and Equity Impacts
• Effectiveness unclear
• Wraparound
• Mostly Program, also practice and system
• Fidelity
• Effectivenessmaybe
• Evidence Based Practice
• Practice, also program
• Effectiveness

8
The Current Star EBPs

• More Effective than Usual Care
• Dont know a lot about usual care
• Arbitrary Metrics Problem
• Replication Concerns
• Transportability and Drift
• Equity?
• Iatrogenic potential at system level
• Efficiency?
• Cost Effectiveness usually unknown

9
EBP Alphabet Soup

• Mandate for EBPs and Motivation to select most
  effective services creates challenges
• EMQ FF EBP Implementation (Partial List)
• PCIT
• Incredible Years
• Triple P
• TF-CBT
• ACRA
• BSFT
• ACT
• FFT

10
Where to Go?

• Outcomes Management
• TCOM
• Measurement Feedback Systems
• Results Based Accountability
• Clinical Dashboards
• Common Elements Approaches
• MAP/Child STEPS
• Quality of Care

11
Turbulence Ahead

• County or project specific Outcome Requirements
• EBP Measurement Requirements
• Over 30 Different Measures used at EMQ FF, most
  of which can not be changed or consolidated
• Multiple Measures and Perspectives
• The Importance of Values
• Rapidly changing economic and funding landscape
• Health Care Reform

12
What to do? An Example from One Agency

• Strong History of Wraparound
• Intensive EBP implementation
• Strong Commitment to Outcomes and Evaluation
• Multiple Counties and Regions
• Strong Values
• Foster Care and Mental Health

13
Addressing Gaps

• Assessment
• Outcomes Management/Measurement Feedback
• Strategic Use of Evidence Based Practice
• Overall Clinical Competencies and Skills
• Outcome data collection across all programs
• Evolution
• Values

14
Assessment and Outcomes Child and Adolescent
Needs and Strengths (CANS)

• Clinician Based Rating Scale
• Parent and Child Perspectives?
• Mental Health Assessment
• Symptoms
• Diagnosis
• Real World Referents
• In Home
• In School
• Out of Trouble

15
Clinical Skills Development Needs

• Usual Care not as effective and beneficial as
  Evidence Based Practices
• Many EBPs already in place at EMQ FF and no
  strategic plan for EBP implementation
• EBPs do not exist for all clinical situations
• EMQ FF serves youth who do not match existing
  EBPs
• EBPs costly and labor intensive
• Some clinical staff at EMQ FF are not qualified
  for some EBP trainings

16
Use EBPs Efficiently and Effectively Relevance
Mapping

• Can create a guideline for EBP implementation at
  EMQ FF based on existing data
• Includes
• Presenting problem or diagnosis
• Age
• Gender
• Ethnicity
• Setting
• Allow for a more rational approach to determining
  EBP implementation at EMQ FF and more efficient
  resource allocation given high cost of most EBPs.

17
Examples from Relevance Mapping

• Seventy-six percent (71) of youth are covered by
  at least one evidence-based treatment that
  applies to their primary problem, age group, and
  gender.
• About half of youth with attention/hyperactivity
  problems are above the tested age range for
  evidence-based treatments.
• Aside from treatments developed for disruptive
  behavior, many evidence-based treatments are less
  often tested in settings typical of the service
  model.
• Cognitive Behavior Therapy alone applies to 61
  of all youthalmost all of the youth coverable by
  any evidence-based practice.

18
Core Clinical Skills Managing and Adapting
Practice (MAP)

• Common Elements Approach Effective services from
  high quality parts
• Match practice elements to specific clinical
  scenarios
• Practice elements based on extensive review of
  existing literature (Evidence Based practice
  elements)
• Practice Wise Data Base
• Helps select practice elements
• Helps select EBPs if appropriate
• Clinical Dashboard
• Feedback on selected outcomes

19
Creating an Integrated Clinical Model

• Standard Assessment with the CANS
• Efficient and Effective planning for EBP
  implementation with relevance mapping
• Core clinical skill development with the Common
  Elements Approach
• Use of the CANS to enhance selection of
  appropriate common elements or EBPs at the
  clinical level
• Clinical Quality Improvement with the Clinical
  Dashboard using the CANS as core measure
• Development and refinement of current practices
  at EMQ FF

20
Integrated Model CANS and Relevance Mapping

• CANS for Assessment and Outcomes Tracking
• Assists in EBP implementation
• Assists in common elements selection
• Core component of Clinical Dashboard tracking
• Assists in level of care determinations
• EBP Relevance mapping
• Empirically map potential EBPs to young people
  served
• Appropriate use of EBPs
• Shows where common elements approach is most
  needed
• Demonstrates where novel program development is
  most needed

21
Integrated Model Baseline Clinical Skills and
Clinical CQI

• MAP model
• Assures baseline clinical competencies
• Applies to young people and families for whom
  EBPs are not relevant
• Applies to young people and families for whom
  EBPs can not be provided
• Helps guide EBP selection by clinical staff
• Helps provide continuous quality improvement at
  the clinical level
• Integrate with CANS

22
Advantages

• Standardization of assessment
• Standardization of core clinical competencies
• Applicable to most or all young people and
  families served at EMQ FF
• Compatible with existing services
• Does NOT replace existing clinical skill sets and
  judgment
• Efficient and effective use of costly service
  options
• Enhances clinical workforce development
• Empirically based and state of the art

23
Conclusion Moving the CANS to Center Stage

• Assessment
• Replace EBP measures?
• Outcomes
• Usual Care?
• EBP Relative Effectiveness
• Measurement Feedback
• EBP planning
• Common Elements Selection
• Quality of Care