1. Practical Challenges Integrating EBP into Addiction Treatment Programs Dan Kivlahan, Ph.D. VA Puget Sound & University of Washington APA, San Francisco August 17, 2007

3. Promoting Action on Research Implementation in Health Services (PARIHS)

4. The Six Aims of High-Quality Health Care Safe Effective Patient-centered Timely Efficient Equitable

5. The Six Aims of High-Quality Health Care Safe Avoiding injuries to patients from care that is intended to help them. EffectiveProviding services based on scientific knowledge to all who could benefit … avoiding underuse and overuse, Patient-centered Providing care that is respectful and responsive to individual patient preferences, needs, and values… Crossing the Quality Chasm © 2001 by the National Academy of Sciences, courtesy of the National Academies Press, Washington, DC, Table 1, pp. 5–6.

6. The Six Aims of High-Quality Health Care Timely Reducing waits and sometimes harmful delays... Efficient Avoiding waste, including waste of equipment, supplies, ideas, and energy. EquitableProviding care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. Crossing the Quality Chasm © 2001 by the National Academy of Sciences, courtesy of the National Academies Press, Washington, DC, Table 1, pp. 5–6.

7. Promoting Action on Research Implementation in Health Services (PARIHS)

8. Evidence Challenges  Magnitude of effects  How much change in outcome is worth adopting EBP?  Identifying “essential components”  Mechanisms of behavior change  Rethinking the paradigm  Morgenstern & McKay, Addiction, 2007  Technology model?  Adaptive treatment  Monitoring early response

9. National Voluntary Consensus Standards on EBP to Treat Substance Use Conditions  identification of substance use conditions  screening and case finding  diagnosis and assessment  initiation and engagement in treatment  brief interventions  promoting engagement in treatment  withdrawal management  therapeutic interventions  psychosocial interventions  pharmacotherapy  continuing care management  management of coexisting conditions and monitoring of treatment response http://www.qualityforum.org/projects/ongoing/sud.asp

10. Ineffective Practices to “De-Implement”

11. Promoting Action on Research Implementation in Health Services (PARIHS)

12. Context Challenges  “Buy in” or organizational readiness  Often challenging to assess  Staff and leadership turnover  Information infrastructure  Sustainability  Workload limits – panel size

13. Promoting Action on Research Implementation in Health Services (PARIHS)

14. 2 “Simple” Principles of Facilitation (1)Feedback on local performance carefully defined accurately measured ongoing (2)Accessible supervision or “coaching” from someone with more expertise about improvement Miller, Sorensen, Selzer, Brigham. JSAT, 2006;21:25-39

15. Facilitation Challenges  Measurement  Feasible, simple, local consensus & investment  NIATx  Wait times  Admissions  No shows  Retention  Incentives  Paying for supervision/coaching  Motivational incentives for patients

17. What to ask about EBP findings at APA?  How is the evidence likely to be valued?  By consumers, providers, managers, payers  Across all 6 domains of quality  How does the EBP address your context of implementation?  What are the implications for facilitation in clinical practice?

18. References Greenhalgh, T., et al., (2004). Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 82(4):581-629 Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence based practice: a conceptual framework. Qual Health Care 1998;7:149–58 Miller WR, Sorensen JL, Selzer JA, Brigham GS. Disseminating evidence-based practices in substance abuse treatment: a review with suggestions. J. Subst Abuse Treat. 2006 31, 25-39.. Morgenstern, J., McKay, J.R. (2007). Rethinking the paradigms that inform behavioral treatment research for substance use disorders. Addiction, 102, 1377–1389 National Quality Forum (2007). National Voluntary Consensus Standards on Evidence- Based Practices to Treat Substance Use Conditions http://www.qualityforum.org/projects/ongoing/sud.asp Pincus, H., et al. (2007). Can psychiatry cross the quality chasm? Improving the quality of health care for mental and substance use conditions. Am J Psychiatry,164(5):712-9. VA Quality Enhancement Research Initiative (QUERI) http://www.hsrd.research.va.gov/queri