winds of change

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Published on September 28, 2007

Author: Gallard

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Slide1:  Creating an Environment of Quality Through Evidence-based Practice Creating an Environment of Quality New York State Office of Mental Health’s v 2.0 2003 New York State Office of Mental Health. All rights reserved. Slide2:  Ruth McDowell's painting, Stormy Landscape, from the book, Sunshine from Darkness - The Other Side of Outsider Art, compilation copyright 1997 NARSAD Artworks, is featured as the background in this presentation with permission from Ms. McDowell and NARSAD Artworks. A special thanks goes out to Ms. McDowell and to NARSAD Artworks. National Alliance for Research on Schizophrenia and Depression Winds of Change:  An educational and awareness-building campaign to introduce evidence-based practice into routine mental health settings Winds of Change What will be learned …:  What will be learned … What is evidence-based practice in mental health How it relates to recovery How it relates to quality in health care New York State plans for the future The Elements for Success:  The Elements for Success Quality as a Priority Recovery as a Reality Evidence-based practices through positive change Slide6:  One Mission… One Vision… Slide7:  Our Strategic Priorities Accountability Best Practices Coordination Slide8:  Mental Health: A Report of the Surgeon General 4 of the10 leading causes of disability for persons age 5 and older are mental disorders Major depression is the leading cause of disability Mental disorders also are tragic contributors to mortality Continued … Slide9:  Of this group about 15% experience a co-occurring substance use disorder 21% of children ages 9 to 17 receive mental health services in a year Yearly, 1 in 5 Americans experiences a mental disorder Mental Health: A Report of the Surgeon General Slide10:  In New York … George Pataki has been coined, “The Mental Health Governor”. Appropriations for mental health services have grown by $380 million including Medicaid funding since 1995. Slide11:  Evidence- Based Practices… for adults and children What is an evidence-based practice ?:  What is an evidence-based practice ? Evidence-based practices (EBPs) are interventions for which there is consistent, scientific evidence showing that they improve consumer outcomes. What is the significance of adopting evidence-based practices in routine health care?:  What is the significance of adopting evidence-based practices in routine health care? The lives of many people with mental illness will be dramatically improved … recovery becomes a reality What does the evidence tell us?:  What does the evidence tell us? For adults with severe mental illness There is a core set of services that consistently promote wellness and community integration The effectiveness of these core services is enhanced when they are used in combination Self-help and peer support services promote recovery and can enhance the effectiveness of other services References:  References Lehman, A.F. and Steinwachs, D.M. (1998). Survey Co-Investigators of the PORT Project: Translating research into practice: The schizophrenia patient outcomes research team (PORT) treatment recommendations. Schizophrenia Bulletin, 24:1-10. Falloon, IRH, Held, T, Coverdale, JH, Roncone, R, Laidlaw, TM. (1999) Psychosocial Interventions for Schizophrenia: A review of long term benefits of international studies. Psychiatric Rehabilitation Skills, 3, 268-290 Felton, C. Center for Performance Evaluation and Outcome Measurement. (2001). Progress report on New York State's public mental health system. Albany, NY: New York State Office of Mental Health. Carpinello, S. E., et al, (2000) The Development of the Mental Health Confidence Scale: A Measure of Self-Efficacy in Individuals Diagnosed With Mental Disorders. Psychiatric Rehabilitation Journal, 23, 236-243. Friedman, M. (2000). Post-Traumatic Stress Disorder: The Latest Assessment in Treatment Strategies. Compact Clinical Publishing. OMH’s Priority Set of Evidence-based Practices for Adults:  OMH’s Priority Set of Evidence-based Practices for Adults Care coordination: Assertive Community Treatment (ACT), Intensive Case Management Supported Employment Wellness Self-management Family Psychoeducation Integrated Treatment for Co-occurring Substance Abuse and Mental Health Disorders Medication (and guidelines for practitioners to promote optimal prescribing practices) Self-help and Peer Support Services Post-Traumatic Stress Disorder (PTSD) Treatment What does the evidence tell us?:  What does the evidence tell us? For children and their families A consistent evidence base currently exists in some but not all areas of children’s services. The research evidence linking services to positive outcomes is strongest in several areas: home-based services, therapeutic foster care, case management, and pharmacotherapy for some disorders. Evidence is accumulating documenting the efficacy of specific family educational interventions. Burns, B.J., Hoagwood, K., Mrazek P.J. (1999). Effective Treatment for Mental Disorders in Children and Adolescents. Clinical Child and Family Psychology Review, Vol. 2, No.4 Slide19:  Burns, B.J., Hoagwood, K., Mrazek P.J. (1999). Effective Treatment for Mental Disorders in Children and Adolescents. Clinical Child and Family Psychology Review, Vol. 2, No.4 OMH’s Priority Set of Evidence-Based Practices for Children: Functional Family Therapy (FFT) School-based Mental Health Services Home-based Crisis Intervention (HCBI) Evidence-based Prescribing Practices Home & Community-Based Services (HCBS) Waiver Intensive Case Management (ICM) Family Education and Support Services Post Traumatic Stress Disorder (PTSD) Treatment Priority Populations for Adults and Children:  Priority Populations for Adults and Children Adult priority populations The highest need adults with serious mental illness Adults who are victims of trauma Children’s priority populations Children with severe emotional disturbance who are currently or may be at risk for out-of-home treatment Children who are victims of trauma Slide21:  Quality, One Priority Sweeping Across The Nation Element 1 Slide22:  Crossing The Quality Chasm: A New Health System for the 21st Century… This provocative report by the Institute for Healthcare Improvement challenges all healthcare providers to shift towards a major rethinking of US and international healthcare to improve: Safety Effectiveness Consumer-centeredness Timeliness Efficiency Equity Slide23:  Crossing The Quality Chasm: A New Health System for the 21st Century… The vision of a new health care system would be: Knowledge-based Consumer-centered System-minded The report challenges all of us to look at our system’s current array of services for: Overuse Underuse Misuse Committee on Quality of Health Care in America, Institute of Medicine: Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC, National Academy Press, 2001. Raising The Floor On Clinical Quality…:  Raising The Floor On Clinical Quality… Slide25:  The Current Environment Slide26:  Defining Major Performance Areas Access to Services Support for Recovery Impact of Services Focusing on Quality Outcomes… Slide27:  Therefore focusing on both … Efficacy: An intervention has the capacity to produce a “positive result” or be “effective”.  and Effectiveness: An intervention that produces “intended” or “expected” results. Slide28:  Making Recovery a Reality Element 2 Slide29:  About Recovery… “Recovery is the process of gaining control over one’s life in the context of personal, social and economic losses…” Excerpt from NYS OMH Blueprint, 2001 Slide30:  Evidence-Based Practices Support Recovery ….. by providing practitioners with tools which can help consumers maintain important recovery components such as employment, housing, relationships and relief from symptoms Slide31:  Wellness Physical Health Status Self-esteem Level of symptom management Level of behavior management Level of discomfort from medication side effects Quality of life Using Recovery-Oriented Performance Outcomes for Adults and Children continued … Slide32:  Community Integration Ability in school Housing Status Employment Status Social Role Status Educational Status Parent/caregiver ability Using Recovery-Oriented Performance Outcomes for Adults and Children Slide33:  Evidence-Based Practice through positive change Element 3 Slide34:  Creating a Demand for Evidence-Based Practices: The consumer perspective NYS study of consumer goals identified: Progress Report of New York State’s public mental health system. January 2001. Slide35:  Creating a demand for Evidence- Based Practices: The family perspective Slide36:  Creating a demand for Evidence-Based Practices: The practitioner perspective . Slide37:  Evidence-Based Practices: For Adults Assertive Community Treatment (ACT):  Assertive Community Treatment (ACT) Consumers with long and frequent hospitalizations Repeated users of ER services Homeless consumers Consumers with co-occurring addictive disorder Consumers involved with the criminal justice system Small caseload - 1:10 Interdisciplinary teams Services in client’s natural setting 24 hour coverage Shared caseloads among clinicians Direct, not brokered services High rehospitalization rates for most impaired consumers Who Benefits? Description Rationale Slide39:  The Evidence-Based Challenge… ACT as a service delivery platform May not be “implementable” in rural areas ACT is most effective for individuals with serious barriers to engagement; their level of service intensity need is so great that a targeted implementation of ACT Teams will be essential However, the components of ACT (mobility, multi-disciplinary focus) can be adopted within the broader range of case management and outpatient services. Supported Employment:  Supported Employment Consumers interested in competitive work Rapid job search and placement De-emphasis on pre-vocational training and assessment Attention to consumer preferences Follow-along support provided Rates of competitive work are low and most consumers want competitive work Who Benefits? Description Rationale Slide41:  The Evidence-Based Challenge… Supported Employment State resources usually support non-competitive employment, despite solid research showing that integrated, competitive employment produces better outcomes Few individuals utilizing outpatient systems have access to employment services Community/economic factors Access to services Wellness Self-Management Education :  Wellness Self-Management Education Consumers with cognitive impairments Consumers with a diagnosed psychiatric illness. Consumers with psychotic symptoms Psychoeducation Counseling and coaching on early warning signs, avoidance of stressors, and minimization of relapses Enhancements of medication adherence through behavioral tailoring, motivational interviewing and skills training for consumer-doctor interactions Non-adherence to a treatment plan is extremely common and closely associated with relapse Who Benefits? Description Rationale Cognitive Behavioral Therapy for Psychosis & Skills Training are included in this EBP. Slide43:  Consumers with cognitive impairments Consumers with a diagnosed psychiatric illness Consumers with psychotic symptoms Multiple weekly training sessions over time (between 3 months and 1 year) Individual and group formats ‘In vivo’ training to facilitate generalization of skills Impaired social functioning predicts the worst outcomes Who Benefits? Description Rationale Wellness Self-Management Education Skills Training Wellness Self-Management Education Cognitive Behavioral Therapy For Psychosis :  Wellness Self-Management Education Cognitive Behavioral Therapy For Psychosis Consumers with cognitive impairments Consumers with a diagnosed psychiatric illness. Consumers with psychotic symptoms Collaborative partnership with consumer Education about stress-vulnerability Behavioral tests Persistent psychotic symptoms are present in 25-40% of consumers with schizophrenia and persistent psychotic symptoms predict relapse and rehospitalization Who Benefits? Description Rationale Slide45:  The Evidence-Based Challenge… Wellness Self Management Education Existing funding streams make personalized in vivo instruction difficult to support Effective practice requires continual coaching and reinforcement across all interrelated sectors based on a coordinated plan of care Family Psychoeducation:  Family Psychoeducation Consumers who are in regular contact with their relatives and families Provided by professionals Long-term (over 6 months) Focuses on education, stress reduction, coping skills and other supports Many consumers live at home or have contact with relatives, and education and support for families reduces the stress increases risk of relapse Who Benefits? Description Rationale Slide47:  The Evidence-Based Challenge… Family Psychoeducation Effective practice requires time and commitment From family members who are often strained in providing basic support to the individual Providers need access to a funding mechanism to organize and maintain groups and classes Integrated Treatment for Co-Occurring Disorders:  Integrated Treatment for Co-Occurring Disorders Consumers with co-occurring substance abuse disorders Assertive outreach Stage-wise treatment Harm-reduction approach Substance abuse worsens outcomes and up to 50% of consumers have co-occurring substance abuse disorders Who Benefits? Description Rationale Slide49:  The Evidence-Based Challenge… Integrated Treatment for Co-occurring Substance Abuse Disorders Services are provided by two different state agencies and need to be incorporated into a coordinated plan of care Effective practice requires a level of service intensity not currently supported by existing funding and regulatory structures Medication:  Medication Consumers taking medications for psychiatric illness The antipsychotic medication algorithm is an outline of a rational sequence of medica-tions to try in the pharmacological management of schizophrenia in order to maximize medication efficacy and minimize side effects. Who Benefits? Description Rationale (Anti-psychotic Medication Algorithm) The antipsychotic medication algorithm will ensure that symptoms are minimized, side effects are minimal, and that there is consumer choice and education. Medications…:  Medications… this is an example of a sequence of medication trial Slide52:  The Evidence-Based Challenge… Medication and medication adherence Competing algorithms and guidelines (need for consensus on which to use across state and local sectors) Medication adherence requires routine monitoring of blood levels which is not currently done in many programs and service sectors Self Help & Peer Support Education:  Self Help & Peer Support Education People with limited social networks or with few social relationships which share a common bond People who are interested in developing a ‘helper’ role People who wish to share and learn about personal coping strategies People who desire to participate in self-generated, structured activities which are personally meaningful Educate consumers about self help Encourage referral and attendance Support participation in mutual aid fellow- ships including starting and running autonomous groups Self help as a complement to treatment and as a life-long support has proven to be beneficial to sustained management of many health conditions. For people with mental illness, the benefits of this form of mutual aid are empowerment, an increased sense of self identity and self-esteem. Who Benefits? Description Rationale Slide54:  The Evidence-Based Challenge… Self-help and Peer-run Service Education Few individuals who use the state’s existing inpatient and outpatient services have an opportunity to be educated on the value of these services There are few opportunities to co-locate or create joint ventures between licensed providers and recipient-run programs in existing funding/regulatory structures Post-Traumatic Stress Disorder Treatment:  Post-Traumatic Stress Disorder Treatment People exposed to catastrophic event People with past exposure to trauma People with comorbid disorders Trauma victim, family, friends and society Treatment aimed at both current trauma and past Treatment of comorbid disorders targets symptoms of each disorder simultaneously Combined treatment (e.g., individual therapy and medications Global therapy Individual therapy Family education and therapy Group therapy Social rehab. therapy People exposed to same catastrophic event react differently. Some will develop severe psychological distress while others will not. People treated with PTSD can make a full recovery Who Benefits? Description Rationale (PTSD) Slide56:  The Evidence-Based Challenge… Post-Traumatic Stress Disorder Treatment Evidence-based selection Serving people not traditionally served in public mental health system Educating professionals to provide capacity Professional expertise Effect Of Adding Strategies To Medication & Case Management:  Effect Of Adding Strategies To Medication & Case Management Case Management + Family Education + Problem Solving + Social Skills Training 54% 27% 23% 14% Percent Percentage of cases having episodes of florid psychopathology or other evidence of lack of efficacy of treatment after 12 months of continued care. Combination is the key… Falloon, IRH, Held, T, Coverdale, JH, Roncone, R, Laidlaw, TM. (1999) Psychosocial Interventions for Schizophrenia: A review of long term benefits of international studies. Psychiatric Rehabilitation Skills, 3, 268-290 Slide58:  Turning Over A New Leaf: Moving Forward With EBPs Lessons Learned…:  Lessons Learned… In August 2001, a series of four focus groups were held to introduce the concept of evidence- based practice to local government leaders, service providers, advocates, and recipients of service. Based on these sessions, two different implementations themes emerged: Cultural Change Structural Change Lessons Learned…:  Lessons Learned… Cultural change is needed for: Creating an organization dedicated to continuous learning and quality improvement Creating widespread belief in the possibility for recovery Understanding and valuing shifts to science-based practice Slide61:  Lessons Learned… Structural change is needed for: Licensing Contracting and regulations Workforce supports for education and supervision Uniform standards and procedures for assessment, service planning, and outcomes management Slide62:  Strategies for Change Strategies for Change…:  Strategies for Change… Ongoing identification of new areas of promise, knowledge gaps and emerging EBPs  Change Strategies PHASE I: Consensus Building PHASE II: Enacting PHASE III: Sustaining AWARENESS: Encouragement and collaboration with our stakeholders Identify and use a network of champions from local government, stakeholders, and advising groups Using formal consensus-building projects to create a set of evidence-based demonstrations throughout the state Evaluate for widespread replication EDUCATION: Introduction and development of new quality initiatives Produce introductory materials, include national EBP toolkits and quality outcome measures Develop several ‘Centers for Excellence’ for ongoing research and education Secure permanent funding for ‘Centers for Excellence’ STRUCTURAL & CLINICAL IMPROVEMENT: Incorporation of quality measures into both individual practitioner and provider performance Develop and test quality outcome measures using network of champions and demonstration sites Develop fiscal and regulatory changes indicated during development and testing Create a local level evaluative capacity to monitor performance against outcomes CONTINUAL IMPROVEMENT & SUPPORT: Monitoring of the quality measures and means for continuous upgrading Use existing progress report structure to ‘test’ and initial series of performance reviews in selected EBP areas Use performance data in selected EBP areas to make regulatory and funding decisions Periodically revisit consensus building stages to identify and promote innovations Slide64:  The Four Change Strategies… AWARENESS: Encouragement and collaboration with our stakeholders EDUCATION: Introduction and development of new quality initiatives STRUCTURAL & CLINICAL IMPROVEMENT:   Incorporation of quality measures into both individual practitioner and provider performance CONTINUAL IMPROVEMENT & SUPPORT: Monitoring of the quality measures and means for continuous upgrading Ongoing identification of new areas of promise, knowledge gaps and emerging EBPs  Slide65:  The Three Performance Phases… This will be an opportunity to begin an ongoing dialogue with multiple stakeholders. The intent of this phase is to predispose stakeholders on the issue of restructuring services so that they support recovery. During this phase, consensus will be sought to create the cultural shifts toward OMH operating as a continuous learning organization. PHASE 1: Consensus Building Slide66:  PHASE 2: Enacting During this phase, efforts will be undertaken to build support structures for evidence-based practices. Efforts of the stakeholders will be aligned in key areas such as development of centers for excellence and fiscal reform. The Three Performance Phases Slide67:  The Three Performance Phases… PHASE 3: Sustaining Key steps will be taken during this phase to build ongoing technology transfer capability; to develop a performance indicator structure for management of recovery-oriented outcomes, and define and implement flexible fiscal and regulatory systems capable of providing a resource base necessary for full implementation. Slide68:  Looking Forward: Enacting New Approaches Slide69:  There are significant challenges to implementing evidence-based practices due to issues of … Leadership Education Funding Regulations Workforce retention and Systems integration Summary: The Challenges continued … Slide70:  Appropriate clinical formulation (diagnosis, treatment regimen, individual service plan) Coordinated treatment planning between inpatient and outpatient service Coordinated treatment planning between state and local sectors Slide71:  Mindful of these Challenges… OMH will proceed in partnership with key stakeholders at the national, state and local level to rollout our Winds of Change campaign. Slide72:  Increasing the likelihood … thus the likelihood that individuals receive high quality, proven-to-be-effective services will be guaranteed. Slide73:  OMH’s desired outcomes For children and adolescents with serious emotional disorders, use of evidence-based practices will ensure receipt of state-of-the-art treatment. These interventions can help keep families together and children in school. Slide74:  OMH’s desired outcomes For adults with mental illness, use of evidence-based practices will ensure receipt of state-of-the-art treatment. These interventions will help achieve meaningful personal goals. Slide75:  A Partnership for Change “One voice is a whisper carried by the wind, but many voices are the wind…”

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