1. Evidence-Based Practice John G. Orme & Terri Combs-Orme
Pearson Education
Outcome-Informed
Evidence-Based Practice
John G. Orme & Terri Combs-Orme

2. Measuring and Monitoring Client Progress
“However beautiful the strategy, you should occasionally look at the results.”
Sir Winston Churchill

3. Contemporary Conceptual Definition of EBP
“…a process for making practice decisions in which practitioners integrate the best research evidence available with their practice expertise and with client attributes, values, preferences, and circumstances”
Rubin, 2008, p. 7

4. Steps in the EBP Process
Develop an answerable question
Locate relevant evidence
Critically analyze the evidence
Combine evidence with client attributes, values, preferences, and circumstances and with your practice expertise
Apply to practice
Measure and monitor client outcomes, and adjust intervention as needed

5. Limitations of EBP What you might know
How intervention works when implemented under ideal conditions (i.e., efficacy)
How intervention works when implemented under routine practice conditions (i.e., effectiveness)
What you don’t know
How intervention works when you implement it with your particular client in your practice setting

6. Outcome-Informed Practice (OIP)
Practice in which you:
Measure your client’s outcomes at regular, frequent, pre-designated intervals, in a way that is sensitive to & respectful of client
Monitor these outcomes at regular, frequent, pre-designated intervals to determine if client is making satisfactory progress
Modify your intervention plan as needed along the way by using this practice-based evidence, in concert with evidence-based practice, to improve your client’s outcomes

7. Single-Case Designs Family of designs characterized by:
Systematic repeated measurement of a client’s outcome(s) at regular, frequent, pre-designated intervals under different conditions (baseline and intervention)
Evaluation of outcomes over time & under different conditions in order to monitor client progress, identify intervention effects &, more generally, learn when, why, how, & extent to which client change occurs

8. Intervention Research vs. OIP
Usually initiated to inform practice by developing generalized causal knowledge about interventions
Benefits to participants of secondary importance
Not tailored to individual participants
Specific informed consent requirements
OIP
Primary purpose to improve well-being of particular client
Tailored to emerging problems, goals, needs, characteristics, & circumstances of each particular client without generalization to other clients

9. Why Outcome-Informed Practice?
The Top Ten Reasons

10. 1:To Obtain the Best Client Outcomes
Even empirically supported intervention may not work with a particular client
Many factors other than your intervention have effect on client outcomes
Ongoing, relatively objective feedback to the practitioner reduces deterioration & treatment dropout, improves overall outcome, & leads to fewer treatment sessions

11. Why may ESIs not work for this client?
ESIs beneficial for average research subject; some unchanged & some worse
Research participants
often not representative
of your clients (e.g., race,
ethnicity, sexual
orientation)
ESIs may be difficult to
transport to your practice
setting

12. Why may ESIs not work for this client?
Specific elements of ESIs only one ingredient in recipe that contributes to client success
Quality of therapeutic alliance influences client’s outcome whatever intervention you use
ESIs are templates that need to be customized to individual clients
Tailored to personal, contextual & changing situations causing & maintaining problems faced by a particular client

13. 2: To Avoid Natural Biases
Practitioners tend to overestimate improvement & underestimate deterioration, in relation to client self-reports
Practitioners have much more confidence in their abilities to judge clients’ progress than is warranted by the data

14. Bias
Tendency to see and interpret information consistently with an emotional preference or preconceived expectation

15. Confirmation & Falsification
We seek information to confirm our biases.
We should seek information to falsify our conclusions

16. 3: To Improve Decision-Making
You’ll have more & better information with which to make practice decisions
How else would you know if what you’re doing is working?

17. 4: To Prevent Client Deterioration
5 to 10% of adult & 14 to 24% of child clients deteriorate while receiving services
Practitioners find it
especially difficult to detect
client deterioration
Measuring & monitoring
client outcomes can reduce
rates of deterioration,
partly by reducing rates of
dropout from treatment

18. 5: To Bridge the Gaps in EBP
Evidence-based practice is place to start, but not sufficient:
RCTs tell us whether interventions work with the average client, not a particular client
Clients have individual characteristics & circumstances
Methodologies underlying EBP by no means perfect
Empirically-supported interventions not available for every client problem

19. 6: To Improve Your Relationships with Your Clients
Demonstrates your respect for your client by giving your client an important voice
Demonstrates conscientiousness on your part & may enhance client’s confidence in you

20. 7: To Enhance Your Development as a Practitioner
Huge differences in client outcomes among therapists, even using same intervention methods
Clinical practice without
ongoing feedback is like
learning archery while
wearing a blindfold; your
skills are unlikely to
improve if you cannot see
where the arrow is landing

21. 8: To Be Accountable
Monitoring client outcomes constantly & modifying intervention as needed provides important tool for achieving clients’ goals in as short a time as possible & conserving limited resources
Some argue that, at least for psychotherapy services, outcome-based accountability is coming—soon

22. 9: To Meet Your Ethical Obligations
For example…
NASW Code of Ethics, 5.02 Evaluation and Research
(a) Social workers should monitor and evaluate policies, the implementation of programs, and practice interventions.

23. Can I practice without measuring and monitoring client outcomes?No
All practitioners measure and monitor client outcomes—the question is how best to do it

24. Instructor’s Manual Free download from Pearson website Sample syllabus
For each chapter:
Suggested discussion prompts
Suggested chapter activities and assignments;
Essay questions;
Additional resources (i.e., books, journal articles, websites)

25. Companion Website Ormebook.com For each chapter:
PowerPoint presentation.
List of recent relevant published articles and books for additional reading
Internet resources
Chapter tables and figures in Microsoft Word

26. Companion Website (cont’d)
Chapter 2
Bibliography of evidence-based practice texts
Online resources for evidence-based practices
Single-case design bibliography
Chapter 5
Microsoft Word 2007 templates for constructing single-case design graphs and instructions for using these templates (illustrated below)

27. Companion Website (cont’d)
Chapter 9
Excel program for scoring CES-D
Excel program for scoring Hudson’s scales
Excel program for calculating reliable change
Word document describing how to determine a clinical cutoff
Word document describing how to determine clinically significant change for Hudson’s scales

28. Companion Website (cont’d)
Coming soon…
Crossword puzzles
Flashcards
Additional in-class and out-of-class exercises
Send us your ideas
Contribute to the web page

29. Textbook For each chapter:
Critical thinking questions and practice tests integrated with 2008 CSWE EPAS to assess student application of the core competencies
Complex, realistic case with session-by-session descriptions, monitoring data & graphs made with the Excel template

30. An Example Case

31. Eve 32-year-old HIV-positive client, hospital outpatient clinic
Referred to social worker for non-adherence to retroviral medication regimen
Lives with partner of 7 years & young daughter: not HIV-positive.
BFA in music & works occasionally playing piano in restaurants or bars
Client reports high stress & drug side-effects as problems with parenting & working

32. Searching the evidence
Social worker finds few evidence-based interventions for HIV+ women
Best option (with men) seems to be individually tailored intervention that focuses on eliminating client’s individual barriers to adherence (Martin et al., 2010)
Eve’s barriers: high levels of stress, forgets medications (does understand regimen)
Many evidence-based interventions for reducing stress
Most common barrier is lack of understanding of the complex regimen for anti-retroviral medication/
If not adhered to 100% may actually increase viral load
Evidence-backed stress reduction interventions are plentiful.

33. Constructing the Baseline
Before intervention can be selected must check the level of adherence.
Eve says she “almost always” takes her meds right, though her viral load suggests not.
Also want to see if Eve’s explanation that stress makes her forget is accurate.

34. Eve is shocked at her overall compliance of 76% as she thought she was doing well
Data seem to confirm relationship between stress & compliance
Time is of the essence, so they decide on a simple intervention with quick implementation. SW teaches her deep breathing techniques and also gives her some internet links to read about DB and see it demonstrated

35. Course of the Intervention
Eve practices deep breathing & reports feeling better
Makes gradual progress in adherence, but not to 100% quickly enough
SW suggests several other evidence-based interventions to reduce stress, such as meditation, & involving partner, but Eve refuses
Finally turn to technology
No time for gradual progress.
Perhaps stress isn’t the only contributor to her non-adherence, but there is no time for exploring other options.

36. The Pill Phone Provides visual/audible prompts to take medication
 Tracks/stores pill-taking records
 Shows what most pills look like
 Confirms dose was
taken
Displays potential side
effects
Now an iPhone app
Eve forgot meds when under stress. Rather than try to reduce stress—and even though there is solid evidence behind several interventions to do that—we individualize for Eve and go straight to remembering.

37. The Course of Intervention

38. The Course of Intervention

39. The Course of Intervention

40. The Course of Intervention

41. The Course of Intervention

42. In this case…
Monitoring permitted early identification of serious problem & quick implementation of intervention
Graphing illustrated early that pace of change was insufficient
Graphs provided clear understanding of problem & motivation to client
Note focus on the client, not the intervention

43. Thank you