1. Achieving Our Mission Using Continuous Quality Improvement to Promote and Enhance Community Corrections Kimberly Gentry Sperber, Ph.D.

2. Efforts To Date “What Works” Literature –Principles of Effective Interventions –Growing evidence based on individual program evaluations and meta-analyses Continuing Gap Between Science and Practice –Few programs score as satisfactory on CPAI

3. Why Isn’t “It” Working? Latessa, Cullen, and Gendreau (2002) Article notes 4 common failures of correctional programs: –Failure to use research in designing programs –Failure to follow appropriate assessment and classification practices –Failure to use effective treatment models –Failure to evaluate what we do

4. CPAI Data as Evidence of Fidelity Lowenkamp and Latessa (2005) Examined data from 38 residential correctional programs for adults Looked at relationship between program fidelity and program effectiveness. Program fidelity was assessed using the CPAI. Found significant correlation between fidelity and effectiveness –CPAI scores correlated to reincarceration

5. Lowenkamp and Latessa Findings Continued Differences in recidivism rates based on CPAI scores: –Scores of 0-49% demonstrated 1.7% reduction compared to comparison group. –Scores of 50-59% demonstrated 8.1% reduction. –Scores of 60-69% demonstrated 22% reduction.

6. CPAI Data Continued Holsinger (1999) Examined data from Adolescent Community Correctional Facilities in Ohio Looked at relationship between program fidelity and program effectiveness. Program fidelity was assessed using the CPAI. Outcome measures examined included any court contact, felony or misdemeanor, felony, personal offense, and commitment to a secure facility

7. CPAI Data Continued Total composite score significantly correlated with all outcome measures. Each individual domain of the CPAI also significantly correlated with all of the outcomes –Program Implementation –Client Assessment –Program Characteristics –Staff Quality –Evaluation

8. More Fidelity Research Landenberger and Lipsey (2005) –Brand of CBT didn’t matter but quality of implementation did. –Implementation defined as low dropout rate, close monitoring of quality and fidelity, and adequate training for providers. Schoenwald et al. (2003) –Therapist adherence to the model predicted post-treatment reductions in problem behaviors of the clients. Henggeler et al. (2002) –Supervisors’ expertise in the model predicted therapist adherence to the model. Sexton (2001) –Direct linear relationship between staff competence and recidivism reductions.

9. More Fidelity Research Cont’d. Schoenwald and Chapman (2007) –A 1-unit increase in therapist adherence score predicted 38% lower rate of criminal charges 2 years post-treatment –A 1-unit increase in supervisor adherence score predicted 53% lower rate of criminal charges 2 years post-treatment. Schoenwald et al. (2007) –When therapist adherence was low, criminal outcomes for substance abusing youth were worse relative to the outcomes of the non-substance abusing youth.

10. Washington State Example (Barnowski, 2004) For each program (FFT and ART), an equivalent comparison/control group was created Felony recidivism rates were calculated for each of three groups, for each of the programs Youth who received services from therapists deemed ‘competent’ Youth who received services from therapists deemed ‘not competent’ Youth who did not receive any services (control group)

11. Family Functional Therapy Results: % New Felony Results calculated using multivariate models in order to control for potential differences between groups

12. Project Greenlight Short-term prison-based reentry program in New York –CBT Skills Training –Employment Services –Housing Services –Drug Education and Awareness –Family Counseling –Practical Skills Training –Community-Based Networks –Familiarity With Parole –Individualized Release Plans

13. Project Greenlight Benefits Participants received more service referrals Participants reported more contacts with community services after release Participants demonstrated significantly more familiarity with parole conditions Participants were more positive about parole

14. But Did It Work?

15. What Went Wrong? Violation of the risk principle –Ceased use of risk assessment instrument when staff deemed process too cumbersome Violation of the need principle –All offenders received same services whether needed or not Violation of the fidelity principle –Staff modified delivery of the CBT curriculum (shortened the duration, increased frequency, increased class size) Differential staff competence –Certain case managers produced worse outcomes

16. UC Halfway House/CBCF Study in Ohio: A Look at Fidelity Statewide Average Treatment Effect was 4% reduction in recidivism Lowest was a 41% Increase in recidivism Highest was a 43% reduction in recidivism Programs that had acceptable termination rates, had been in operation for 3 years or more, had a cognitive behavioral program, targeted criminogenic needs, used role playing in almost every session, and varied treatment and length of supervision by risk had a 39% reduction in recidivism

17. What Do We Know About Fidelity? Fidelity is related to successful outcomes (i.e., recidivism reductions). Poor fidelity can lead to null effects or even iatrogenic effects. Fidelity can be measured and monitored. Fidelity cannot be assumed.

18. Monitoring Fidelity Through a CQI Process QA versus CQI CQI – What Is It? Infrastructure Peer Review Indicators Client Satisfaction Action Planning Process Evaluation Outcome Evaluation Benefits

19. QA – The Old Way Retrospective review process Emphasis on regulatory and contract compliance Catching people being bad leads to hide and seek behavior

20. CQI – The New Way CQI is a prospective process Holds quality as a central priority within the organization Focus on customer needs; relies on feedback from internal and external customers Emphasizes systematic use of data Not blame-seeking Trust, respect, and communication Move toward staff responsibility for quality, problem solving and ownership of services

21. Objectives of CQI To facilitate the Agency’s mission To ensure appropriateness of services To improve efficiency of services/processes To improve effectiveness of directing services to client needs To foster a culture of learning To ensure compliance with funding and regulatory standards

22. Building a CQI Process Formal infrastructure Core Elements –Documentation Review –Indicators Process Versus Outcome Performance Goals Action Planning –Customer Satisfaction Clients, Staff, Stakeholders –Program Evaluation

23. Process Evaluation Sample Projects

24. Process Evaluation Are we serving our target population? Are the services being delivered? Did we implement the program as designed (tx fidelity)? Are there areas that need improvement?

25. Example 1 Review of LSI Scores Reviewed all open cases at Facility A Recorded LSI risk category, UC Risk category, and name of interviewer 77.5% of cases reviewed did not have a match between staff rating and UC rating

26. LSI Scores Post-Training First 2 weeks after training – 0 matches 3-6 weeks after training – 46.2% matched First 2 weeks after training – 50% were off by 2 risk categories 3-6 weeks after the training – 0% were off by 2 risk categories

27. Individual LSI Reviews Schedule of videotaped interviews Submitted for review Use of standardized audit sheet Feedback loop for staff development Aggregate results to inform training efforts

28. Sample LSI Audit Items Explained purpose of interview Adequate use of open-ended questions Avoided double-barreled questions Adequate use of follow-up questions Overcame problems such as silence or excessive talking Used interview guide Scored correctly Tx plan clearly relates to information captured in LSI

29. Example2 CBIT Site Assessments Cognitive Behavioral Implementation Team Site visits for observation and rating Standardized assessment process Standardized reports back to sites Combination of quantitative data and qualitative data

30. Example 3 Focus Review at an Adolescent Residential Program Examined changes in client characteristics over time Examined successful completion over time Identified factors predictive of AWOL’s, incidents, and completion Examined use of role-plays in groups Primary predictors of intermediate outcomes: –Overall Risk (education and peers specifically also important) –Criminal History –Treatment Dosage –Involvement in incidents

31. Example 4 Focus Review at a Male Halfway House - Rural Clients with any/more incidents were less likely to graduate successfully. Clients who lost a job while in the program were significantly less likely to graduate successfully. Clients with higher total LSI-R scores were also less likely to successfully complete the program. Clients with higher total LSI-R scores were more likely to engage in program rule infractions. Clients with higher intake HIT scores were more likely to engage in program rule infractions at TCC. Thus, individuals categorized as having stronger anti-social thinking patterns were more likely to be involved in incidents. Age was also found to be predictive of rule infractions, with younger clients exhibiting greater likelihood of engaging in more incidents than older clients.  Employments status was found to be a significant predictor of program incidents. Specifically, clients who lost a job while in the program were more likely to violate program rules. Dosage levels were found to be predictive of raw HIT score improvement.

32. Example 5 Assessing Best Practices at 17 Sites Use of ICCA Treatment Survey to establish baseline Complete again based on best practice Perform Gap Analysis Action Plan Reassess

33. Outcome Evaluation Sample Projects

34. Outcome Evaluation Are our services effective? Do clients benefit (change) from the services? Intermediate outcomes –Reduction in risk –Reduction in antisocial values Long-term outcomes –Recidivism –Sobriety

35. Example 1 Off-Site Non-Emergency Medical Visits for 6 Months Goals of the project: –Reduce the overall number of off-site visits for non- emergency medical care. –Reduce the number of staff-escorted visits (impacts dollars and coverage) –Reduce the amount of behavioral treatment missed –Increase the number of referrals for primary care upon discharge

36. Example 1 Continued Outcomes Data

37. Sample Cost Comparison ER versus On-Site Care ER VISIT COSTS $ 400 Average Visit $ 34 Average Staff Cost $$$ Hospital Pharmacy TOTAL $ 434 not including pharmacy savings TALBERT HOUSE $ 62.50 Average Visit $ 0 off-site staff cost Medication savings: samples, patient assistance programs TOTAL $62.50 average cost/visit Savings of $371.50/visit

38. Example 2 Relationship Between Intermediate Outcomes and Recidivism Female adolescent program’s intermediate outcome measures: –Antisocial attitudes –Self-esteem –Self-efficacy –Family functioning Determine whether improvement on intermediate measures results in lower recidivism.

39. Example 2 Relationship Between Intermediate Outcomes and Recidivism Preliminary Results –Increased self-esteem = 71% –Increased self-efficacy = 61.3% –Reduced antisocial attitudes = 82.7% All statistically significant –Statistically significant improvement in family functioning: Cohesion Conflict Organization Intellectual-Cultural Orientation Moral-Religious Emphasis

40. Example 3 Outcomes Pre/Post TFM Implementation Passages Program for Girls

41. Example 4 Outcome Evaluation of New Dosage Protocol Practical application of the risk principle Seeking to quantify how much dosage is required to reduce recidivism Will compare clients discharged from the program pre-implementation to clients discharged from the program post- implementation.

42. Benefits of Program Evaluation Proof of effective services Maintain or secure funding Improve staff morale and retention Educate key stakeholders about services Highlights opportunities for improvement Data to inform quality improvement initiatives Establish/enhance best practices Monitor/ensure treatment fidelity

43. The Role of QA/QI in Community Corrections (based on UC Halfway House and CBCF study)

44. NPC Research on Drug Courts

45. Conclusions Many programs are not implementing the principles of effective intervention with strong fidelity. Result is an ongoing gap between science and practice. This gap often results in null or even iatrogenic effects. Correctional organizations have a responsibility to ensure effective services. Monitoring fidelity is key to success. Responsibility for EBP needs to be aligned at all levels – administration, management, line staff. Need to focus on creating formal infrastructure to support and sustain evidence-based practices.