Translating Evidence Based Research into Quality Services: Hawaii ’ s Experience Christina M. Donkervoet, M.S.N., APRN Chief, Child & Adolescent Mental Health Division Department of Health

Hawaii System of Care Solid statewide foundation & framework Broad access & availability Strong team-based decision making value

1999: ….A Not so Good Time Dramatic cost increase Results inadequate to poor Substandard system performance

The 1998 AHA Experience Framework of system of care Solid values, good intentions & willingness to collaborate are a beginning. Good will ≢ Meaningful Results for Children, Youth, Families, Systems

Taking a Step Toward EBS Desire to learn what services resulted in meaningful life changes for youth –Presenting Problem Areas –Age –Gender –Culture & Ethnicity Develop mechanism for implementing these types of services across communities and islands

Initial Charge Focus on the Research Data INITIAL TARGET: CONDUCT DISORDER –high cost, –low satisfaction, –low effectiveness

Critical Factors of the EBS Committee Broad Membership –Cross disciplinary –Family membership –Cross agency – Public & Private Community & State Child serving agencies & Higher education Unifying Lead Defined Framework of Evaluating Design Linkage to Practice Development Activities & Performance Management

Hawaii “Blue Menu” of Evidence-Based Services (abbreviated) Bipolar Disorder Delinquency Willful Misconduct Depressive or Withdrawn Behaviors Disruptive & Oppositional Behaviors Substance Use None CBT Parent& Teacher Training; PCIT CBT Interpersonal and social rhythm therapy MST; FFT CBT + parents; IPT; Relaxation Anger Coping; Assertiveness; PSST Behavior Tx; Purdue Brief Family Tx *Family Psycho education MTFC; Wrap around Foster care None Social relations training; Project Achieve None All other psychosocial therapies Juvenile Justice; Individual Tx Behavioral problem solving Fam. Tx; Ind. Tx Client-centered; comm. Skills; HR therapy Ind.tx; family drug educ; conjoint fam. tx Attention/ Hyperactive Behaviors Behavior Therapy None Biofeedback; Play Tx; GIST None Group Therapy None Group Therapy Anxious or Avoidant Behaviors CBT; Exposure; Modeling CBT+ parents; Ed support None EMDR; Play Tx; GIST None Problem Level 1 best support Level 2 good support Level 3 moderate support Level 4 Minimal support Level 5 known risks

May-04 Jun-04 Diagnostic History Sep-03 Oct-03 Nov-03Dec-03 Jan-04 Feb-04Mar-04 Apr-04 May-04 Jun-04 Level of Care Sep-03 Oct-03 Nov-03Dec-03 Jan-04 Feb-04Mar-04 Apr-04 May-04 Jun-04 AcceptedAuthorized Services

EBS Tips of the Week Week of Two types of foster care have evidence for their efficacy in treating adolescents with conduct problems: Multidimensional Treatment Foster Care and Wrap- Around Foster Care (source: EBS Biennial Report 2004). [18] Week of Relaxation alone has been shown to be as effective as many more complicated treatments for child depression. Two well-designed studies support its effects (source: EBS Biennial Report 2004). [4]

Monitoring Outcomes Quality Case Based Reviews Quantitative Outcomes Role of Families Publicly Shared Quarterly Reports

System Performance since EBS Quality Dimension Examples: Functional AssessmentService Coordination & Transition Long-term viewCaregiver Supports Service Plan & ImplementationEffective Results Service Array & Integration Monitoring & Modification Introduction Of EBS

Avoid Use of Hospital Residential Services for Conduct Disorders EBS Task Force Began Mid-Course Evaluation

Challenges in Sustaining Focus System Constraints Clinician Constraints Rural Communities

Satisfying Legislative Mandates Need for “levels” or “degrees” of evidence Increase the awareness of the value and limitations of the evidenced based services (the other 35-40%) Balancing the value of choice and options with effectiveness and cost

Hawaii’s Evidence Based Services WHAT IT IS A component of the system of care A means to strengthen the quality of services A strategy to increase positive outcomes –For youth & families –For stakeholders –For clinicians, agencies, administrators WHAT IT’S NOT A way to force change A way to limit services A way to reduce options