Transcript Variably Effective (Provider & Organization

New Wine in Old Bottles?
Challenges in Implementing
New Practices in Old Systems
Peter S. Jensen, MD
Ruane Professor of Child Psychiatry,
Center for the Advancement of Children’s Mental Health
Columbia University College of Physicians and Surgeons
New York State Psychiatric Institute
The Problem: The Gaps Between
What We Know vs. What we Do for
Children’s Mental Health





Unmet need as high now as 20 years ago
Unmet need highest among minority youth
System fragmentation major barrier to access (still)
Only 1/3 to 1/5 of children with most severe needs get
MH services
Knowledge about child mental health has greatly
increased over the past decade—esp. in
neurogenesis, behavioral science, prevention, clinical
treatments and services
National Averages of MH Need
10.00%
9.00%
National Average MH
Need for Children at
6-17: 7.09%
8.00%
7.00%
6.00%
5.00%
4.00%
3.00%
2.00%
1.00%
MH service need
as
hi
ng
to
n
W
isc
on
sin
xa
s
W
Te
Yo
rk
w
y
Ne
Je
rs
e
Ne
w
sip
pi
iss
is
M
M
in
ne
so
ta
ich
ig
an
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tts
hu
se
a
ac
Fl
or
id
as
s
Data Source: NSAF wave 1 and 2
M
Al
ab
am
a
Ca
lif
or
ni
a
Co
lo
ra
do
0.00%
Geographic Variations in Unmet Need
Unmet MH Need Among
Children 6-17: 64.7%
Al
ab
am
C
a
al
ifo
rn
ia
C
ol
or
ad
o
Fl
M
o
as
sa rida
ch
us
et
ts
M
ic
hi
ga
M
n
in
ne
so
M
ta
is
sis
si
N
ew ppi
Je
rs
e
N
ew y
Yo
rk
Te
xa
W
as
s
hi
ng
to
W
n
is
co
ns
in
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Proportion of children with measured need who did not receive
any MH care
Most children with need do not receive any
MH services
65.6
65.2
% No care
65.2
64.8
64.7
64.3
64.4
64
63.6
6 to 17
6 to 11
Age groups
Data from NSAF
12 to 17
Unmet need highest among Hispanic
children
% No care
Qualitative insights from comparisons remain
valid even if absolute numbers are biased
90
80
70
60
50
40
30
20
10
0
77
69
67
59
White
AfricanAmerican
Hispanic
Data from NSAF
Other race
% No care
Non-traditional family structure not associated
with more unmet need
80
70
60
50
40
30
20
10
0
64
65
Single parent
Blended
Family
70
45
No parents
Data from NSAF
Two
biological
parents
Extent of Mental Disorders In
U.S. Children and Adolescents
10
7.8%
8.0%
# of Children
5
(Millions)
5.6%
5.0%
1.0%
0.5%
0
Depression
Anxiety
DBD
ADHD
Sz
Autism/PDD
Source: Office of the Surgeon General, and
National Institute of Mental Health, 1999
The path to long-term negative outcomes for at-risk children
and youth
Risks of not meeting children’s
mental health needs
If children’s mental health needs go untreated,
the risks are great:








Suicide
School failure and dropout
Injuries, hospitalization
Chronic mental illness
Drug and alcohol use
Violence
Divorce, family break-up
Lifelong dependence on welfare
Challenge: Psychotherapies as
Provided in Routine Clinic Settings
Have Little to No Effect
Adults
Children & Adolescents
Mean Effect Sizes
University
1
0.9
0.8
0.7
0.6
0.5
0.4
Clinic settings
0.3
0.2
0.1
0
Smith &
Glass,
1977
Weisz et
al., 1987
Weisz et
al., 1995
Weisz et
al, 1995
Weisz et al., 1995
So what do we know about:




…the obstacles to dissemination of proven
approaches, and where are these obstacles located
across the various levels of “the system?”
…what works, in terms of
 effective assessment and treatment interventions
 effective (vs. ineffective) service models (as well as
ineffective models)
 effective organizational strategies
 effective policies
…how to bring about change in parents, “providers,”
policy-makers, organizations
…specific strategies and potential next steps that we
can start to do now
Barriers vs. “Enhancers” to Delivery
of Effective MH Services
Three Levels:
Child & Family Factors:
e.g., Access & Acceptance
Efficacious
Treatments
“Provider” (school, MH) Factors:
“Effective”
e.g., Skills, Use of EB, Attitudes
Services
Systemic and Societal Factors:
e.g., Organizations, Funding
Policies
PARENT Example (MTA):
Would You Recommend this
Treatment to Another Parent?
Not recommend
Medmgt Comb
9%
3%
Beh
5%
Neutral
9%
1%
2%
Slightly Recommend 4%
2%
2%
Recommend
35%
15%
24%
Strongly recommend 43%
79%
67%
PROVIDER Example:
Treatment Effects on Inattention (teacher)
(Community Controls Separated By Med Use)
2.5
Initial Titration
Dose
Dose Frequency
Average Score
Key Differences,
MedMgt vs. CC:
2
CC-NO
MEDS
CC-MEDS
1.5
BEH
MED
1
#Visits/year
Length of Visits
COMB
0.5
0
Contact w/schools
100
200
300
400
Assessment Point (Days)
ORGANIZATIONAL Example: Glisson &
Himmelgarn (1998) Parameter Estimates for
Hypothesized Six-Variable Model
Organizational
Climate
Service
Outcomes
(problem levels)
-.13*
.12*
-.24*
County
Demographics
-.03
-.20*
.02
Interorganizatnl
Services
Coordination
-.05
Service
Quality
-.36*
.06
.01
Interorganizational
Relationships
* p < .05
Organizational Impact on
Children’s Mental Health




The strongest predictor of child improvement was
organizational climate (Glisson & Himmelgarn, 1998)
But organizational culture, not climate, explained
variations in service quality (Glisson & James, 2002)
Relationship between organizational characteristics
and effective implementation of new technologies
can be identified, but rarely incorporated into
studies of EBPs and their translation into practice
15,000 Hours: Rutter et al., impact of school
environments on children’s outcomes
How Has Change Been Attempted?
The Bad, the Good, and the Ugly

Parent/Family Approaches
 Bad: Finger-wagging, blame, transfer, attrition
 Good: Engagement, empowerment
 Ugly: Current situation mostly reflects bad strategies

Provider (mental health, schools/clinics)
 Bad: CME, CEU, journals
 Good: Academic detailing, hands on, MC/II
 Ugly: Drug companies only using effective methods

System
 Bad: System of Care as the sole answer
 Good: MST, Wraparound, Co-location
 Ugly: Current fragmentation
The Ugly

40-60% families may drop out of services
before their formal completion (Kazdin et al.,
1997)

Children from vulnerable populations are less
likely to stay in treatment past the 1st session
(Kazdin, 1993)

Factors related to drop-out: Stressors
associated with treatment, treatment
irrelevance, poor relationship with therapist
(Kazdin et al., 1997)
Barriers to Participation




Triple threat: poverty, single parent status
and stress
Concrete obstacles: time, transportation,
child care, competing priorities
Attitudes about mental health, stigma
Previous negative experiences with
mental health or institutions
M. McKay, 1999
How Has Change Been Attempted?
The Bad:

Parent/Family Approaches
 Bad:




Finger-wagging: “you should…”
Blame: “The family is non-compliant and
dysfunctional” or “You need to do this, or else I
can’t help you.”
Loss by transfer, attrition (“…maybe the family
will move away or just stop coming…”)
Ugly: the current situation
The Good:
Engagement Interventions


Focused telephone procedures associated
with increased initial show rates
Structural family therapy telephone
engagement intervention associated with
50% decrease in initial no-show rates and
a 24% decrease in premature terminations
(Szapocznik, 1988; 1997)
M. McKay, 1999
The Good:
Family Engagement Study
120
100
80
% for first interview
(n=33)
% for comparison
(n=74)
60
40
20
0
Accepted
1st appt
2nd appt
3rd appt
M. McKay, 1999
Other Examples of “the
Good” – the “5 Es”

Engage, Evaluate: Elicit concerns, Respond to emotions,
Build rapport, Keep questions open-ended, Do not interrupt.


Elicit: How does patient explain illness?
Educate: Tell, Ask: “I think you have…”, “What do you know
about...?”, “Let me tell you more about…”, “Can you repeat what I
said…?”

Enlist/Negotiate/Review: “Would you be willing to…?”
Negotiate: “Why don’t we agree on…?”
Implications re: Parents/families


Participation rates can be increased by
intensive engagement interventions that
are tailored to specific populations
Collaboration, engagement, family input
and choice, active problem solving are key
M. McKay, 1999
THE UGLY: Model vs. Typical Treatments for
ADHD
2.5
Initial Titration
Dose
Dose Frequency
Average Score
Key Differences,
MedMgt vs. CC:
2
CC-No
Meds
CC-Meds
1.5
Beh
Med
1
#Visits/year
Comb
Length of Visits
0.5
0
Contact w/schools
100
200
300
400
Assessment Point (Days)
The Good and the Bad: Effectiveness of
Interventions by Intervention Type
Positive
Negative
35
30
No. of Interventions
demonstrating positive 25
or negative/inconclusive 20
15
change
10
5
0
ta
De
ia
t er
Ma
ls
erv
Int
lt.
Mu
erv
Int
le
ub
Do
ers
nd
mi
Re
bk
/Fd
di t
Au
ed
iat
ed
t. M
rs
Pa
Ld
on
ini
g
Op
ilin
ad
Ac
E
CM
uc
Ed
Davis, 2000
Implications re: Changing Provider
Behaviors
• Summary: Changing professional performance is
•
•
•
•
complex - internal, external, and enabling factors
• No “magic bullets” to change practice in all
circumstances and settings (Oxman, 1995)
• Multifaceted interventions targeting different barriers
more likely effective than single interventions (Davis,
1999)
Adult learning methods: learner-centered, active,
relevant to needs, learn-work-learn
“readiness to change,” Prochaska & DiClemente, 1983
Little to no theory-based studies, yet are desperately
needed due to excessive costs, lack of progress in field
Consensus guideline approach necessary, but not
sufficient. Lack of fit w/physicians’ mental models
The Good and the Bad:
Systems of Care




Ideological commitment to integration of
services, family involvement, cultural
competence
CASSP--state mh child/adolescent
services
Fort Bragg Demonstration Project
Stark County Project
System of Care Studies:
(Bickman et al.)






Comprehensive and coordinated range of
services
Fort Bragg = $94 million, 5 year
Demonstration funded by the Army
Quasi-experimental - Demonstration and
control sites
Longitudinal - 7 waves of data collection
Sample 1 = 984 families= “outcome
sample”
Sample 2 = 8,813 families= “ service use
pop”
The Good: Demonstration of
Increased Access
10
% Served
8
6
4
2
Start of Demonstration June 1, 1990
0
FY88
FY89
Pre-Demonstration
FY90
FY91
Demonstration
FY92
FY93
Comparison
The Good: Fewer drop-outs

More than 3 times as many outpatient clients had
only one visit at the comparison (24%) than at the
demonstration (7%)
The Good: Better continuity of
care (fewer breaks in care)
% in Continuous Care
At 6 months
50
40
30
20
10
0
Demonstration
Comparison
The Good: Parent satisfaction
greater



Most aspects of intake and assessment
services
Most aspects of outpatient services
Transition and discharge issues in inpatient
and outpatient services
The Good: Demonstration Sites
were rated as having:




Fewer reported system-level problems
Greater quality of mental health services
available
Better service system performance
Better adherence to the goals of an ideal service
system
The Good? Service System
Coordination greater
High
5
4
3
2
Low
1
Coordination Overall
Ft. Bragg
Coordination for Military
Dependents
Ft. Campbell
Ft. Stewart
The Bad: Outcomes






Child Behavior Checklist (CBCL & YABL)
Youth Self Report (YSR & YASR)
Vanderbilt Functioning Index (VFI) -parent
and youth versions
Caregiver Strain Index (CSI)
Family Assessment Device (FAD)
Individualized Measures - most severe
subscale, presenting problem - parent and
youth
The Bad: YSR No differences
65
Comparison
60
Demonstration
55
50
45
0
1
2
3
Years from Intake
4
5
The Bad: Vanderbilt Functioning
Index Shows No Differences
25
VFI Score
20
Demo-O
Comp-O
Demo-M
Comp-M
15
10
5
0
0
1
2
3
Time in Years
4
5
More of the The Bad: Average Cost Per
Treated Child Higher in Demonstration
Average Cost in $100 Dollars
N = 8,813 Children
$10
$8
$6
$4
$2
$0
FY 93
Demonstration
Demonstration Period
(over 3 years)
Comparison
Implications re: Systems Change

Demonstration increased access

Demonstration used less restrictive settings

Greater client satisfaction at Demonstration

But, no differences in clinical outcomes

Clients got better at both sites equally

Relapse was significant and unexplained

Costs significantly higher at Demonstration
K. Hoagwood, 2003
The Good: Strength of the Evidence
on Prevention, Treatment, & Services






Two major reviews of preventive intervention trials in
past 3 years; 34 effective interventions cited by
Greenberg et al, 1999, focused largely on parenting
and school-delivered interventions
Reviews of school-based services (Rones &
Hoagwood, 2000) identified 2 dozen effective
programs targeting risk reduction and treatments
More than 1500 published clinical trials on outcomes
of psychotherapies for youth
6 meta-analyses of their effects
More than 300 published clinical trials on
safety/efficacy of psychotropic medications
Approx 50 field trials of community-based services
K. Hoagwood, 2003
The Good: Available Summaries of
Evidence-based Interventions
Surgeon General’s Mental Health Report, 1999
Surgeon General’s Youth Violence Report, 2001
Surgeon General’s Report on Culture, Race & Ethnicity,
2002
Weisz & Jensen (1999) Mental Health Services Research
Burns, Hoagwood, Mrazek (2000) Child Clinical and Family
Psychology Review
Burns & Hoagwood (2002) Eds. Evidence-based
treatments for youth. Oxford University Press
Barriers vs. “Enhancers” to Delivery
of Effective MH Services
Three Levels:
Child & Family Factors:
e.g., Access & Acceptance
Efficacious
Treatments
“Provider” (school, MH) Factors:
“Effective”
e.g., Skills, Use of EB, Attitudes
Services
Systemic and Societal Factors:
e.g., Organizations, Funding
Policies
Redesign Attempts to Circumvent Multiple Levels
of Obstacles: Wraparound and MST: Common
Characteristics

Comprehensive community-based interventions
for severe emotional and behavioral disorders

System of care values

Provided at home, in schools, and neighborhoods

Operated within any human service sector

Developed and studied in the ‘real world’

Trainers and training materials developed

Outcomes monitored

Less expensive than residential care

Fidelity measures
Multi-systemic Therapy (MST) Model
HOME BASED MODEL (vs. outpatient,
inpatient)
 Low case load (4-6 families/therapist)
 24 hr./7 day availability of clinicians
 Target children at risk of placement
 Services provided to the family (&
individuals)
 Time limited (average 4 months)
Consistent MST clinical outcomes
In Comparison with Control Groups, MST:
 Improved family relations and functioning
 Increased school attendance
 Decreased adolescent psychiatric
symptoms
 Decreased adolescent substance use
 Decreased long-term rates of rearrest 25%
to 70%
Missouri Delinquency Project
Percent of Offenders
Not Re-Arrested
120%
100%
MST
Completers
80%
MST
Dropouts
60%
40%
IT Completers
20%
IT Dropouts
Refusers
0%
0
0.6
1.1
1.7
2.2
2.8
3.3
3.9
Years Past Treatment Termination
4.4
5
The Good with the Bad: Effective
Community-based Services Cost $dollars
Intensive Case Management
(including Wraparound)
Cost: $2,500 - 35,000 per
year
Multisystemic Therapy
Cost: $5,063 per year
5 RCTs and 1 quasiexperimental
• less restrictive placements
• some increased functioning
7 RCTs and 1 quasiexperimental
• fewer arrests
• fewer placements
• decreased aggressive
behavior
Teen Screen Study
REDESIGN: CO-LOCATION EFFECTS ON REFERRAL
FOR TREATMENT IN A SCHOOL-SCREENED
POPULATION
Average vs. Focused
Referral
Co-location
In need but not
yet obtaining Rx
100%
100%
100%
Refuse referral
33%
19%
5%
Fail first visit
22%
25%
4%
First visit only
20%
17%
6%
> One visit
25%
38%
85%
But WHAT ELSE
goes into the service system?
The Good: Evidence-Based Outpatient Treatment
Well-Established
Probably Efficacious
DEPRESSION
None
Self-Control (children)
Coping with Depression (adolescents)
ADHD
Behavioral Parent Training
Behavioral Interventions in the Classroom
Behavioral Management Training
Behavioral Modification in the Classroom
ANXIETY
None
Cognitive-Behavioral
Phobia
Participant Modeling
Reinforced Practice
Imaginal and In Vivo Desensitization
Live and Filmed Modeling
DISRUPTIVE BEHAVIOR
Living with Children
Videotape Modeling
Preschool
Delinquency Prevention Program
Parent-Child Interaction Therapy
Parent Training Program
Time-Out Plus Signal Seat Treatment
School Age
Anger Coping Therapy
Problem Solving Skills Training
Adolescent
Anger Control Training with Stress Inocul.
Assertiveness Training
Multisystemic Therapy
Rational-Emotive Therapy
Source: Journal of Clinical Child Psychology, Volume 27, Number 2, 1998
The Good, the Bad, and the Ugly: Varying
Evidence for Medications in Childhood Disorders
STRONG
ADHD
Stimulants
TCAs
MODERATE
DEPRESSION
SSRIs
AUTISM
Antipsychotics
OCD
SSRIs, TCAs
ODD/CD
Antipsychotics, Mood stabilizers, Stimulants
ANXIETY
SSRIs
WEAK
K. Hoagwood, 2003
BIPOLAR
Lithium
TOURETTE’S
Antipsychotics
The Good: Other Comprehensive Community-Based
Interventions
Treatment Foster Care
4 RCTs
Family Education and Support
1 RCT
• more rapid improvement
• decreased aggression
• better post-discharge outcomes
• increased knowledge and self-efficacy
Mentoring
1 RCT
Respite Services
1 quasi-experimental
• less substance use and aggression;
• better school, peer, and family
functioning
• fewer placements
• reduced family stress
Crisis Services
0 controlled, 1 pre-post
• placement prevented in 60-90% of
cases
The Ugly: Evidence for Institutionally-Based Care
Hospital
3 randomized clinical trials
• findings in favor of community comparison
conditions
Residential
Treatment
Center
2 quasi-experimental study designs
• Project Re-Ed: gains versus untreated
• Gains in residential treatment center were equal
to treatment foster care (TFC @ one-half cost)
Group Home
2 quasi-experimental study designs
• mixed findings -- gains and
deterioration (arrest rates)
Partial
Hospitalization
1 randomized clinical trial
• partial hospital versus wait-list controls
• benefits at 6 months for behavior symptoms,
and family
More Ugly: What doesn’t work
(Elliott, 2000)








DARE (5th and 6th grade curriculum)
Gun Buyback programs
Boot Camps
Peer counseling programs
Summer job programs (at risk youth)
Home detention with electronic monitoring
Wilderness / challenge programs
Generic counseling (non-behavioral)
The Good, the Bad, and the Ugly:
Variation in the Evidence Base
STRONG
EVIDENCE
Multisystemic Therapy
Intensive Case
Management
Treatment Foster Care
MODERATE
EVIDENCE
Family Education and
Support
Mentoring
Partial Hospitalization
Respite Care
NEGATIVE, MIXED,
or NO EVIDENCE
Psychiatric Hospital (Inpatien
Residential Treatment Center
Group Home
Crisis Intervention
K. Hoagwood, 2003
Model for Effective Implementation of EBPs
Extra-Organizational Context
(financial policies, methods of reimbursement, state policies)
Organizational
Fit
Clinician
Fidelity
Child & Family
Outcomes
culture, climate, structure
Clinical care processes
training, supervision, alliance
Stakeholder engagement
shared understanding of problems and choice
K. Hoagwood, 2003
Dissemination and Adoption of
New Interventions

Interpersonal contact

Organizational support

Persistent championship of the intervention

Adaptability of the intervention to local situations

Availability of credible evidence of success

Ongoing technical assistance, consultation
Source: Backer, Liberman, & Kuehnel (1986) Dissemination and Adoption of Innovative
Psychosocial Interventions. Journal of Consulting and Clinical Psychology, 54:111-118;
Jensen, Hoagwood, & Trickett (1997) From Ivory Towers to Earthen Trenches. J Appliied
Developmental Psychology
Developing Consensus for Useful (and
Used) Knowledge: A Primer?




“Begin with the end in mind” – who must eventually apply
the knowledge?
Identification of key stakeholders
 enablers/disseminators (policy makers, mavens,
connectors), and those with veto power
Formation of key working group
 Shared view and identification of the problem
 Consensus/agreed-upon knowledge: College of
Cardinals, Rand methodology, variations, etc.
 “Buy-in”, involvement in developing solution
 Identify who else is needed for implementation
Strategic plan (varies by situation)
 Tool development, dissemination
Stakeholders w/Vested Interests in Improving
MH Practices in Schools










School Administrators – Local, State, National
Policy makers (state, national)
Taxpayers
Key Administrators: NASDE, NASMHPD
Technical assistance centers, vendors for services
Federal agencies, (DOE, OSEP)
Educational and MH researchers
Professional groups: NASP, AACAP, APA, NASW,
School counselor associations
Parents, Child Advocacy groups
Teachers (regular and special ed), NEA, AFT
“To tell you the truth, I don’t have much hope for this broad-based coalition”
Special Challenges in Reaching Consensus on
Assessment, Diagnosis, & Interventions







Civil rights of the individual child, of parents
Mental health needs of the individual child
To diagnose or not to diagnose: philosophical
differences, system responsibility differences
Vested interests in current systems and methods
Who is responsible?
How to serve children who are identified?
Ethical issues, confidentiality
Problems Identified by Consensus Group


Mission disparity between schools and school-based mental
health programs
 Schools may not want to talk about mental health issues
(need to fly in under the radar?)
 You have to go into the school and help solve the mission
of the school
 Lack of a clear mandate for schools to deal with mental
health treatment issues directly
Inadequate training in mental health issues for teachers,
administrators and other school professionals
Problems Identified by Consensus Group

Lack of strong advocacy efforts for school-based mental health
 Professional organizations need to unite around this issue
 Mental health is most likely to get into schools through
advocacy at the local
 Lack of a sustaining fiscal base and infrastructure to
support school-based mental health programs


Funding for school-based mental health comes from various
sources, difficult to financially sustain SBMH services
Shared Agenda paper published by NASDMH and state planning
grant program as an example of how to build infrastructure
Problems Identified by Consensus Group

Challenges associated with disseminating evidencebased mental health programs in schools
 Need for user friendly materials, infrastructure to
support training, and ongoing training
 Planning and scheduling issues
 Fidelity to program
 Adaptation
Consensus Recommendations: National Level
Identify what is being done to support SBMH in terms of 1) national
and state level SBMH coalitions; 2) services in place within the
portfolios of various federal and state agencies; 3) existing school
reform efforts; and 4) existing materials, toolkits, communication
strategies, training, etc.
Establish clear expectations that all schools and all school-based
personnel will address the social-emotional as well as academic
development of students
Develop policy initiatives to improve communication, collaboration,
cooperation, and coalition-forming among local, state and federal
agencies and advocacy groups that are responsible for supporting
the social-emotional well-being of school students
Fund research investigating the variables related to sustaining
implementation of effective school-based mental health practices
Develop a research recommendation to OSEP and other agencies
regarding funding research that investigates variables related to
sustained implementation of effective practices
Consensus Recommendations: National Level
Promote collaboration in school mental health research between NIH, the
Department of Education, and SAMSA.
Consolidate existing curricula (on social-emotional competencies) for
teaching and models of training
Identify core content for all disciplines that can be infused into the existing
curriculum relating to course work in the areas of teacher, principal, and
school psychologist preparation, etc.
Build consensus among experts re: knowledge and skills educators need in
order to promote S-E competencies in children.
Convene a group to explore potential funding sources for training initiatives
Work through credentialing bodies like NKAPA to promote inclusion of S-E
competencies in standards for teacher and educator training
Develop an infrastructure and 5-year plan to keep summit group working
together. Convene subgroups on key issues such as fiscal resources,
teacher education, and evaluation/assessment
Develop a consensus document and allow other organizations to sign off on it
Consensus Recommendations: State Level
Market the value of school-based mental health and evidence-based
practice to state education departments and other agencies.
Develop a consolidated web clearinghouse and a 800 number that
people can access to get information about evidence-based school
mental health practices
Develop a report card of the 10 key indicators of best practice in the
area of school mental health (support Learning First Alliance
efforts in this area). This report card could be used by states to
assess how well schools are doing in this area
Develop a state-to-state network to promote school-based mental
health
Consensus Recommendations: Local Level
Identify key change agents in local school districts – a
leadership core
Teach and provide ongoing consultation to these change
agents the process (outlined by the group) of
introducing mental health services to a school
Develop a manual/tool kit for how to introduce mental
health service to a school
CACMH Approach: A 4-step
process
Step 1
Determine the Need
• Identify important new advances
• Work w/family partners & professional
• Obtain consensus & commitment on
proven, best practices
Step 2
Share the Solutions
• Through strategic partnerships
- (Parents, providers, policymakers, etc.)
• Traditional media outlets
Step 4
Test, Refine, Disseminate
• Evaluate test sites
• Roll-out nationally
• Spread the word - results fed
back into Step 2
Step 3
Put Science to Work!
• Prepare the tools
• Implement and train at key sites
Education and Mental Health Initiative
• Improvement in MH Assessments/Interventions
• Partnerships for Change with key stakeholders
• Definition of “Best Practices”
• Helping stakeholders to “own” and disseminate their
message and findings
But: 14 years from innovation development to
application!
• Careful site selection; systematic technical assistance vs.
UC
• Feedback into political & professional processes
Knowledge Development & Application:
Strategic Issues
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Leadership, therapeutic alliance factors critical at all levels of “the
system”
All Policy is “personal”
Begin with the end in mind: Don’t set out to build a house no one can
afford or wants to live in.
The enemy of the good is the perfect: raise the floor, not the ceiling
Win-win strategies with other key players who otherwise have veto
power
”Buy-in” -- partnership, not ownership
Co-location and blending of resources
Facilitate increased MH quality based on political action and clinicalethical principles, not only on RCTs, or business models/economic
incentives
Strategic action committees, short- and long-term objectives