Implementing EBPs in Mental Health Systems David Lynde, MSW Co-Director Dartmouth EBP Center Dartmouth Psychiatric Research Center

Presentation Overview  EBP Perspective  Some Lessons We Are Learning: Statewide Implementation  Stages of Dissemination of EBPs in Systems

EBPs in Perspective  Six currently identified SAMHSA EBPs for adults with SMI that have implementation resource kits  Do not cover all service needs  Continuing process of evolution  Identify well researched practices

Core Values in EBPs  Recovery  Comprehensive Assessments  Individualized Services  Recovery-oriented practitioner skills  Informed, shared decision making

Lessons from the Field

“What You Learn When You Step in It”

State/Public Mental Health Authority Evidence Based Practices Dissemination Stages of Change

System Stages of Change:

Precontemplation

Questions  What are EBPs?

 What is the difference between EBPs and what we are doing right now?

 Why is this a good time for us to tackle this?

System Stages of Change:

Precontemplation

Questions  Why should this be one of our system priorities?

 What are the benefits of changing the status quo?

System Stages of Change:

Precontemplation

Actions  Provide information and forums for meaningful discussions for all stakeholders  Engage providers in discussions at all levels

System Stages of Change:

Contemplation

Questions  How committed is our leadership to disseminating EBPs in our system?

 What are the unmet needs in our system for EBPs?

 What EBPs are priorities for our system?

System Stages of Change:

Contemplation

Questions  What other EBPs already exist in our system?  What lessons can be learned from our previous experiences with systems change?

System Stages of Change:

Contemplation

Actions  System leadership honest discussions  Assessing priority needs areas for the system from multiple stakeholder perspectives  Assessing current outcomes for priority needs areas  Assessing current EBPs in system  Reviewing system change history

Lessons Learned: Stakeholders  Consumers, family members and providers play a crucial role – Engage in discussions and discourse with stakeholders not just information sharing – Stress philosophy, values and goals of EBPs – There is no one single consumer, family or provider perspective – Honor ambivalence

Lessons Learned: Stakeholders

Involvement

=

Support

Lessons Learned: Stakeholders  Building “consensus” is nearly impossible – Building “Informed Support” is an alternative view – The Status Quo is powerful – Finances often “drive” resistance – Define significant and meaningful roles for stakeholder involvement

System Stages of Change:

Preparation

Questions  Who will lead the EBP dissemination when the resistance to this change surfaces?

 Who are the stakeholders that need to be involved?

 Are we willing to set up a Statewide EBP Team?

System Stages of Change:

Preparation

Questions  How do EBPs fit with our mission statement?

 What is our system willing to change to support EBPs?

 What is our system not willing to change?

System Stages of Change:

Preparation

Actions  Designation of EBP leadership structures  Commitment to EBP leadership  Engagement of broad spectrum of stakeholders  Statewide EBP leadership team  Understanding EBPs in relationship to system mission

Lessons Learned: Leadership “Why do we want to change the status quo? After all, that is what got us where we are today?”

Lessons Learned: Leadership  State Mental Health Authority (SMHA) Leaders have used – Public Forums – Websites – Written Statements – State System Plans and Priorities

Lessons Learned: Leadership  SMHA Leaders have used – Commitment of Resources – System Mission Statements – Internal and External Forces – Grant Funding – Commitment of Personnel

Lessons Learned: Leadership  Statewide EBP Teams – Multiple stakeholders – System feedback regarding • Implementing • Sustaining • Improving – Coordinated by State EBP Leader

Lessons Learned: Leadership Teams

System Stages of Change: Action Questions  What can we do to keep the sources of support for EBPS active and public?  How will we constantly communicate where we are and where we are going with EBPs?

 How will our system support the time for staff to be trained in EBPs?

System Stages of Change: Action Questions  How will we utilize and develop training and consultation resources for EBPs?

 Will we set up a technical assistance center in our system for EBPs?  How will early sites be selected and what will be the expectations?

 What will our system do with fidelity and outcome assessments?

System Stages of Change:

Action

Actions  Plans for constant communication and feedback  Plans for training and consultation processes  Development of early site selection protocol  Description of how fidelity and outcome assessments will be used

Lessons Learned: State EBP Plan  Fit with mission statement  Methods for describing State responses to EBPs  EBP implementation process  Outreach and involvement for stakeholders

Lessons Learned: State EBP Plan  Funding delivery of EBPs  Training resources  Involvement of other State agencies

Lessons Learned: State EBP Plan “ Policies and Funding are the fuel of Evidence Based Practices ”

Lessons Learned: Policies & Regulations  Current State System Policies – Often cited as barrier – Rarely support EBPs as they exist – Sometimes punish providers for doing the practice

Lessons Learned: Policies & Regulations  System Policies are Crucial – Rarely designed for “structured practices” that include • Preparation Time • Supervision Time • Team Meetings • Outreach Services

Lessons Learned: Policies & Regulations “Every system is perfectly designed to achieve the results it is achieving” --Paul Batalden

Lessons Learned: Policies & Regulations  Non SMHA are often important “Players in this Process” – Vocational Rehabilitation in SE – Substance Abuse, Law Enforcement, Judicial and Corrections in IDDT – Peer Support Agencies in IMR – Medicaid Authorities in all EBPs

Lessons Learned: Training  The goal of most mental health training as usual is

not

“ implementation ”  Implement – to give practical effect to and ensure of actual fulfillment by concrete measures – to put a plan or system into operation

Lessons Learned: Training “We now have thousands of experiments across the country which have proven that in mental health, training by itself, is not enough to create change.” --Bob Drake

Lessons Learned: Training  Effective implementation requires much more than just didactic “training” – Many agencies and systems benefit from university collaborations – Agencies benefit from consultation – “Skills training” is a later stage in the organizational change process, not an earlier stage

Lessons Learned: Change Takes Time

Lessons Learned: Training  Agencies benefit from high quality training & consultation – Trainers assist agency leadership in the organizational change process – Trainers engage with agencies over a sustained period of time – Trainers have access to their own peer supervision & collaboration

Lessons Learned: Fidelity & Outcomes  Clear expectations for fidelity and outcomes monitoring and use  Quality improvement/assurance process  Self-assessment is not a reliable science  Clear, consistent outcomes definitions and reporting

System Stages of Change: Maintenance Questions  What are the current fidelity assessments & outcomes?

 What are the high fidelity sites are doing that they can share with other sites?

 What other EBPs are we going to disseminate?

 How do we extend EBPs to other populations?

 What are the benefits to our system to combine EBPs?

Lessons Learned  The State Mental Health Authority plays a crucial role in the implementation of EBPs  There are many actions at the State Mental Health Authority level that may facilitate the dissemination and implementation of EBPs

Summary  State system and Mission Achievements  Education re: EBPs  Stakeholder Involvement  Costs/Benefits of Doing or Not Doing EBPs  Leadership  Policies  Training and Consultation

Recovery & Hope “If people are treated as capable, they often surprise everyone and live up to expectations.” • Ken Steele “The Day the Voices Stopped.”