Implementing EBPs in Mental Health Systems David Lynde, MSW Co-Director Dartmouth EBP Center Dartmouth Psychiatric Research Center

Presentation Overview EBP Perspective EBP Perspective Some Lessons We Are Learning: Statewide Implementation Some Lessons We Are Learning: Statewide Implementation Stages of Dissemination of EBPs in Systems Stages of Dissemination of EBPs in Systems

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

Core Values in EBPs Recovery Recovery Comprehensive Assessments Comprehensive Assessments Individualized Services Individualized Services Recovery-oriented practitioner skills Recovery-oriented practitioner skills Informed, shared decision making Informed, shared decision making

Lessons from the Field “What You Learn When You Step in It”

State/Public Mental Health Authority Evidence Based Practices Dissemination Stages of Change

System Stages of Change: Precontemplation Questions What are EBPs? What are EBPs? What is the difference between EBPs and what we are doing right now? What is the difference between EBPs and what we are doing right now? Why is this a good time for us to tackle this? Why is this a good time for us to tackle this?

System Stages of Change: Precontemplation Questions Why should this be one of our system priorities? Why should this be one of our system priorities? What are the benefits of changing the status quo? What are the benefits of changing the status quo?

System Stages of Change: Precontemplation Actions Provide information and forums for meaningful discussions for all stakeholders Provide information and forums for meaningful discussions for all stakeholders Engage providers in discussions at all levels Engage providers in discussions at all levels

System Stages of Change: Contemplation Questions How committed is our leadership to disseminating EBPs in our system? How committed is our leadership to disseminating EBPs in our system? What are the unmet needs in our system for EBPs? What are the unmet needs in our system for EBPs? What EBPs are priorities for our system? What EBPs are priorities for our system?

System Stages of Change: Contemplation Questions What other EBPs already exist in our system? What other EBPs already exist in our system? What lessons can be learned from our previous experiences with systems change? What lessons can be learned from our previous experiences with systems change?

System Stages of Change: Contemplation Actions System leadership honest discussions System leadership honest discussions Assessing priority needs areas for the system from multiple stakeholder perspectives Assessing priority needs areas for the system from multiple stakeholder perspectives Assessing current outcomes for priority needs areas Assessing current outcomes for priority needs areas Assessing current EBPs in system Assessing current EBPs in system Reviewing system change history Reviewing system change history

Lessons Learned: Stakeholders Consumers, family members and providers play a crucial role 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

Lessons Learned: Stakeholders Involvement = Support

Lessons Learned: Stakeholders Building “consensus” is nearly impossible 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

System Stages of Change: Preparation Questions Who will lead the EBP dissemination when the resistance to this change surfaces? Who will lead the EBP dissemination when the resistance to this change surfaces? Who are the stakeholders that need to be involved? Who are the stakeholders that need to be involved? Are we willing to set up a Statewide EBP Team? Are we willing to set up a Statewide EBP Team?

System Stages of Change: Preparation Questions How do EBPs fit with our mission statement? How do EBPs fit with our mission statement? What is our system willing to change to support EBPs? What is our system willing to change to support EBPs? What is our system not willing to change? What is our system not willing to change?

System Stages of Change: Preparation Actions Designation of EBP leadership structures Designation of EBP leadership structures Commitment to EBP leadership Commitment to EBP leadership Engagement of broad spectrum of stakeholders Engagement of broad spectrum of stakeholders Statewide EBP leadership team Statewide EBP leadership team Understanding EBPs in relationship to system mission Understanding EBPs in relationship to system mission

Lessons Learned: Leadership “Why do we want to change the status quo? After all, that is what got us where we are today?”

Lessons Learned: Leadership State Mental Health Authority (SMHA) Leaders have used State Mental Health Authority (SMHA) Leaders have used –Public Forums –Websites –Written Statements –State System Plans and Priorities

Lessons Learned: Leadership SMHA Leaders have used SMHA Leaders have used –Commitment of Resources –System Mission Statements –Internal and External Forces –Grant Funding –Commitment of Personnel

Lessons Learned: Leadership Statewide EBP Teams Statewide EBP Teams –Multiple stakeholders –System feedback regarding ImplementingImplementing SustainingSustaining ImprovingImproving –Coordinated by State EBP Leader

Lessons Learned: Leadership Teams

System Stages of Change: Action Questions What can we do to keep the sources of support for EBPS active and public? 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 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? How will our system support the time for staff to be trained in EBPs?

System Stages of Change: Action Questions How will we utilize and develop training and consultation resources for EBPs? 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? 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? How will early sites be selected and what will be the expectations? What will our system do with fidelity and outcome assessments? What will our system do with fidelity and outcome assessments?

System Stages of Change: Action Actions Plans for constant communication and feedback Plans for constant communication and feedback Plans for training and consultation processes Plans for training and consultation processes Development of early site selection protocol Development of early site selection protocol Description of how fidelity and outcome assessments will be used Description of how fidelity and outcome assessments will be used

Lessons Learned: State EBP Plan Fit with mission statement Fit with mission statement Methods for describing State responses to EBPs Methods for describing State responses to EBPs EBP implementation process EBP implementation process Outreach and involvement for stakeholders Outreach and involvement for stakeholders

Lessons Learned: State EBP Plan Funding delivery of EBPs Funding delivery of EBPs Training resources Training resources Involvement of other State agencies Involvement of other State agencies

Lessons Learned: State EBP Plan “ Policies and Funding are the fuel of Evidence Based Practices ”

Lessons Learned: Policies & Regulations Current State System Policies Current State System Policies –Often cited as barrier –Rarely support EBPs as they exist –Sometimes punish providers for doing the practice

Lessons Learned: Policies & Regulations System Policies are Crucial System Policies are Crucial –Rarely designed for “structured practices” that include Preparation TimePreparation Time Supervision TimeSupervision Time Team MeetingsTeam Meetings Outreach ServicesOutreach Services

Lessons Learned: Policies & Regulations “Every system is perfectly designed to achieve the results it is achieving” --Paul Batalden

Lessons Learned: Policies & Regulations Non-SMHA are often important “Players in this Process” 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

Lessons Learned: Training The goal of most mental health training as usual is not “ implementation ” The goal of most mental health training as usual is not “ implementation ” Implement Implement –to give practical effect to and ensure of actual fulfillment by concrete measures –to put a plan or system into operation

“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 Lessons Learned: Training

Effective implementation requires much more than just didactic “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

Lessons Learned: Change Takes Time

Lessons Learned: Training Agencies benefit from high quality training & consultation 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

Lessons Learned: Fidelity & Outcomes Clear expectations for fidelity and outcomes monitoring and use Clear expectations for fidelity and outcomes monitoring and use Quality improvement/assurance process Quality improvement/assurance process Self-assessment is not a reliable science Self-assessment is not a reliable science Clear, consistent outcomes definitions and reporting Clear, consistent outcomes definitions and reporting

System Stages of Change: Maintenance Questions What are the current fidelity assessments & outcomes? What are the current fidelity assessments & outcomes? What are the high fidelity sites are doing that they can share with other sites? What are the high fidelity sites are doing that they can share with other sites? What other EBPs are we going to disseminate? What other EBPs are we going to disseminate? How do we extend EBPs to other populations? How do we extend EBPs to other populations? What are the benefits to our system to combine EBPs? What are the benefits to our system to combine EBPs?

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

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

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