Evidence Based Evidence Based Practices in Oregon: Practices in Oregon:

An OverviewAn OverviewOregon Department of Human Services Oregon Department of Human Services Addictions and Mental Health Services Addictions and Mental Health Services

(AMH)(AMH)February, 2009February, 2009

ORS 182.515–525 ComplianceORS 182.515–525 Compliance The five state agencies must demonstrate that The five state agencies must demonstrate that

program resources support EBPs in progressively program resources support EBPs in progressively increasing amounts:increasing amounts:

Five Agencies include:Five Agencies include: Department of Corrections, Oregon Youth Department of Corrections, Oregon Youth Authority, Commission on Children and Families, Criminal Justice Authority, Commission on Children and Families, Criminal Justice Commission and Addiction and Mental Health.Commission and Addiction and Mental Health.

25% by 200725% by 2007

50% by 200950% by 2009

75% by 2011and thereafter 75% by 2011and thereafter

ORS 182.515-525 Applies to Specific ORS 182.515-525 Applies to Specific Programs/ServicesPrograms/Services

Programs designed to reduce the propensity of a Programs designed to reduce the propensity of a person to commit crimesperson to commit crimes

Improve the mental health of a person with the Improve the mental health of a person with the result of reducing the likelihood that the person will result of reducing the likelihood that the person will commit a crime or need emergency mental health commit a crime or need emergency mental health servicesservices

Reduce the propensity of a person who is less than Reduce the propensity of a person who is less than 18 years of age to engage in antisocial behavior 18 years of age to engage in antisocial behavior with the result of reducing the likelihood that the with the result of reducing the likelihood that the person will become a juvenile offenderperson will become a juvenile offender

What it does What it does not include:not include:

An educational program An educational program or service that is or service that is required by state law.required by state law.

A program that provides A program that provides basic medical services.basic medical services.

Examples Examples

Medications on an individual Medications on an individual basis basis

ExerciseExercise NutritionNutrition Safety Safety Sleep Sleep Security Security Medical care of a non-clinical Medical care of a non-clinical

nature, i.e. cuts, heart nature, i.e. cuts, heart disease, flu etc. disease, flu etc.

It Creates an Opportunity for It Creates an Opportunity for System TransformationSystem Transformation

AMH strategy is to use legislation to AMH strategy is to use legislation to transform the service system transform the service system

Increase the use of EBPs and improve Increase the use of EBPs and improve outcomesoutcomes

AMH definition includes the entire AMH definition includes the entire service system, including preventionservice system, including prevention

How Do We Define EBPs?How Do We Define EBPs?

A continuum of practices, based on level of A continuum of practices, based on level of research confidenceresearch confidence

Oregon’s nine Tribes are defining EBPs for Oregon’s nine Tribes are defining EBPs for use in those nations use in those nations

Ongoing discussions with stakeholders will Ongoing discussions with stakeholders will continue to redefine EBPscontinue to redefine EBPs

Update of the DefinitionUpdate of the Definition

In September, 2007, AMH updated the In September, 2007, AMH updated the EBP definition to 2 published peer EBP definition to 2 published peer reviewed journal articles instead of reviewed journal articles instead of three and included a better definition for three and included a better definition for prevention programs prevention programs

2005 Survey Results2005 Survey Results

Results indicate Results indicate > 25% fund utilization> 25% fund utilization 56% of substance use treatment and prevention 56% of substance use treatment and prevention

dollarsdollars 33% mental health treatment dollars 33% mental health treatment dollars Providers spent most implementing the following Providers spent most implementing the following

EBPs:EBPs: Mental Health: Assertive Community Treatment Mental Health: Assertive Community Treatment

(ACT)(ACT) Substance Use: Motivational Interviewing, Substance Use: Motivational Interviewing,

American Society of Addiction Medicine (ASAM), American Society of Addiction Medicine (ASAM), Cognitive Behavioral Therapy (CBT)Cognitive Behavioral Therapy (CBT)

2008 Survey Results2008 Survey Results

Results indicate 54% fund utilization.Results indicate 54% fund utilization. Most commonly implemented practices are the Most commonly implemented practices are the

following: following: Mental Health: Cognitive Behavioral Therapy Mental Health: Cognitive Behavioral Therapy

(CBT), Dialectical Behavioral Therapy (DBT), (CBT), Dialectical Behavioral Therapy (DBT), Solution-Focused Brief Therapy Solution-Focused Brief Therapy

Substance Use: Cognitive Behavioral Therapy Substance Use: Cognitive Behavioral Therapy (CBT), Motivational Interviewing and Motivational (CBT), Motivational Interviewing and Motivational Enhancement Therapy, American Society of Enhancement Therapy, American Society of Addiction Medicine (ASAM)Addiction Medicine (ASAM)

Substance Use Prevention: Substance Use Prevention: Strengthening Strengthening Families Program 10-14, Communities that Care, Families Program 10-14, Communities that Care, Project AlertProject Alert

Clatsop Colum

bia

Tillamook

Multnomah

Lincoln

Yamhill

Washingto

n

Hood River

Clackamas

Wasco

Jefferson

CrookDeschutes

Lane

PolkMarion

Linn

Bento

n

Sherm

an Morrow

Gilliam

WheelerGrant

Umatilla

Union

Wallowa

Baker

Lake

HarneyMalheur

JosephineJackson

Klamath

DouglasCoos

Curry

#5 - Solution-Focused Brief Therapy

#4 - CBT-Cognitive Behavioral Therapy

#3 - Co-Occurring Disorder: IDDT#1 - Motivational Interviewing

#2 - ASAM

Top Five Evidence Based Practices in Oregon

(5)

(2)

(4)

(5)

(5)

(13)

(2)

(2)

(5)

(2)

(3)

(11)

(2)

(2)(2)

(5)

(2)

(2)

(4)

(7)

(7)

(16)

(2)

(3)(3)

(4)

(4)(3)

(8)

(5)

(2)

(3)

(6)

(2)

(5)

(3)

(6)

(12)

ClatsopColumbi

a

Tillamoo

k

Multnomah

Linco

ln

Yamhill

Washingto

n

Hood River

Clackamas

Wasco

Jefferson

Crook

Deschutes

Lane

PolkMarion

LinnBenton

Sherm

an

MorrowGilliam

Wheeler Grant

Umatilla

Union

Wallowa

Baker

Lake

Harney

Malheur

Josephine

Jackson

Klamath

DouglasCoos

Curry

Nine Evidence Based Practices of Interest

Assertive Community Treatment (ACT)Brief Strategic Family Therapy (BSFT)

Collaborative Problem Solving

DBT-Dialectical Behavioral Therapy

Functional Family Therapy

Matrix Model

Outpatient Tx w/ Synthetic Opioid (Methadone)

Parent-Child Interaction Therapy

Relapse Prevention

(2)(2)

(2)

(2)

(2)(2)(2)

(2)

(2)(2)

(4)

(4)

(4)

(4)

(2) (2)(6)(6)

(9)(5)

(3)

Clatsop

Columbia

Till

am

oo k

Multnomah

Linco

ln

Yamhill

Washington

Hood River

Clackamas Wasco

Jefferson

Crook

Deschutes

Lane

Polk Marion

Linn

Bento

n

Sherm

an

MorrowGilliam

Wheeler

Grant

Umatilla

Union

Wallowa

Baker

Lake

HarneyMalheur

Josephine

Jackson

Klamath

DouglasCoos

Curry

The Top Three Prevention Evidence Based Practices Implemented in Oregon

(where three of them are tied for third place)

Strengthening Families Program (27 counties)

Communities That Care (9 counties)

Life Skills (Botvin) (6 counties)

Project ALERT (6 counties)

Project Northland (6 counties)

S. F. Tribal Program (2 counties)

Provider Strategies to Meet Provider Strategies to Meet FidelityFidelity

Adherence to the Model (Fidelity)

9988

7367

52 49 46

16

0

20

40

60

80

100

120

o Clinicalsupervision

o Qualityassuranceactivities

o Generalorganization

review

o Individualclinician

proficiencyreviews

o Practicecomponent

reviews

o Consultation

with thedeveloper

o Regularlyoccurring

fidelityreviews

o Corrections

ProgramChecklist

Implementation Phase- EarlyImplementation Phase- Early

Identified the practiceIdentified the practice Outlined the implementation processOutlined the implementation process Established a plan for improvement and Established a plan for improvement and

sustainabilitysustainability

Implementation Phase- MiddleImplementation Phase- Middle

Trained staff in the practiceTrained staff in the practice Delivered the practiceDelivered the practice Completed an internal review and made Completed an internal review and made

revisionsrevisions Had an external review completed and Had an external review completed and

made revisionsmade revisions

Implementation Phase- LateImplementation Phase- Late

Have regular external reviews and made Have regular external reviews and made ongoing revisionsongoing revisions

Revised sustainability planRevised sustainability plan Provided technical assistance to othersProvided technical assistance to others Are identified as a model program for that Are identified as a model program for that

practicepractice

Outcome Results of 2008 EBP Survey

System Improvements****

P erception of care

Housing Stability

Decrease Criminal Involvement

Outcome data not availableat this time

Reduced AcuteCare Use***

Social Connectedness**

Employment/School

Improved Client Outcomes*

*Improved Client Outcomes includes: abstinence/sobriety, completion/compliance, retention/engagement, symptom improvements

**Social Connectedness includes: increase partnerships, alternative activities, parenting

***Reduced Acute Care Use includes: hospitalization, restraints, crisis driven services

****System Improvements includes: increase staff training and EBP use, cost effectiveness, decrease paperwork

Native American TribesNative American Tribes

Tribal Position Paper on Native American Evidence-Tribal Position Paper on Native American Evidence-Based Practices accepted by AMHBased Practices accepted by AMH

On May 14On May 14thth the Oregon Tribes held their 2 the Oregon Tribes held their 2ndnd Gathering Gathering of Tribal Researchers and Evaluators to define criteria of Tribal Researchers and Evaluators to define criteria

The Tribes continue to work to establish proceduresThe Tribes continue to work to establish procedures

Does All of This Matter?Does All of This Matter? Does implementing EBPs produce better system Does implementing EBPs produce better system

outcomes?outcomes?

Are we hitting the intended targets of the legislature Are we hitting the intended targets of the legislature under ORS 182.535?under ORS 182.535?

- Reduces propensity of a person to commit crimes- Reduces propensity of a person to commit crimes- Improves mental health of a person with the result of - Improves mental health of a person with the result of reducing the likelihood that the person will need reducing the likelihood that the person will need emergency mental health servicesemergency mental health services- Reduces antisocial behavior and juvenile crime- Reduces antisocial behavior and juvenile crime

What does this amount to in financial terms?What does this amount to in financial terms?

Example from PreventionExample from PreventionStrengthening Families Program Strengthening Families Program

10-1410-14 Savings Savings to society in criminal justice costs related to society in criminal justice costs related

to substance abuse are estimated to be to substance abuse are estimated to be $5805$5805 for for each youtheach youth who participates in the Strengthening who participates in the Strengthening Families Program (Washington State Institute for Families Program (Washington State Institute for Public Policy, 2003) Public Policy, 2003)

To date, investing in the Strengthening Families To date, investing in the Strengthening Families Program has yielded a Program has yielded a net benefitnet benefit to Oregon of to Oregon of over a million dollars: over a million dollars:

OREGON’S COST SAVINGS:OREGON’S COST SAVINGS: $1,184,220$1,184,220

ConsiderConsider Limiting the scope of programsLimiting the scope of programs

Using the Correctional Program Checklist (CPC) as a standard for Using the Correctional Program Checklist (CPC) as a standard for serving criminal justice clients serving criminal justice clients

Identifying core components and protocols as EBPsIdentifying core components and protocols as EBPs

Individualizing definitions, criteria and procedures for populationsIndividualizing definitions, criteria and procedures for populations

Systems organization, supervision and review processes as EBPsSystems organization, supervision and review processes as EBPs

Performance measures and outcomes Performance measures and outcomes

Investing in a data system Investing in a data system

EBP Haiku

from evidence based caterpillar to larvae practiced butterfly

ResourcesResources

Turning Knowledge Into Practice: Turning Knowledge Into Practice: http://tacinc.org/cms/admin/cms/_uploads/docs/EBPhttp://tacinc.org/cms/admin/cms/_uploads/docs/EBPmanual.pdfmanual.pdf

AMH EBP Website: AMH EBP Website: http://www.oregon.gov/DHS/mentalhealth/ebp/main.shttp://www.oregon.gov/DHS/mentalhealth/ebp/main.shtmlhtml

12 Steps of EBPs 12 Steps of EBPs by Bonnie Malekby Bonnie Malek

1.1. We admitted we were powerless over SB267 and that our IT needs had We admitted we were powerless over SB267 and that our IT needs had become unmanageable.become unmanageable.

2.2. Came to believe that the right set of manuals could restore us to pre-Came to believe that the right set of manuals could restore us to pre-morbid functioning.morbid functioning.

3.3. Made a decision to turn our program development and training resources Made a decision to turn our program development and training resources over to SAMHSA before we understood why.over to SAMHSA before we understood why.

4.4. Took inventories of everyone that voted for this bill (and in some cases Took inventories of everyone that voted for this bill (and in some cases their mothers and their dogs).their mothers and their dogs).

5.5. Admitted to AMH and the Oregon Legislature that for the past 70 years, Admitted to AMH and the Oregon Legislature that for the past 70 years, we’ve been running on sweat equity, imagination and rubber bands.we’ve been running on sweat equity, imagination and rubber bands.

6.6. Grudgingly agreed to do some reading and to keep an open mind.Grudgingly agreed to do some reading and to keep an open mind.

7.7. Swore all the way to the dumpster with our favorite videos and handouts.Swore all the way to the dumpster with our favorite videos and handouts.

12 Steps of EBPs12 Steps of EBPs8.8. Made a list of all the practices that made sense to us and became Made a list of all the practices that made sense to us and became

willing to check at least some of them out.willing to check at least some of them out.9.9. Agreed to learn at least one new thing as long as it didn’t substantially Agreed to learn at least one new thing as long as it didn’t substantially

add to our caseloads or paperwork.add to our caseloads or paperwork.10.10. Continued to work on doing the impossible with no new resources Continued to work on doing the impossible with no new resources

and dreamed of deleting databases when no one was looking.and dreamed of deleting databases when no one was looking.11.11. Sought through outcomes data and SSRIs to improve our conscious Sought through outcomes data and SSRIs to improve our conscious

contact with the legislature, praying only to prove that treatment works contact with the legislature, praying only to prove that treatment works and we’re truly not sleeping at our desks.and we’re truly not sleeping at our desks.

12.12. Having had a rude awakening as the result of these steps, we vowed Having had a rude awakening as the result of these steps, we vowed to share our retention data with programs that were still pre-to share our retention data with programs that were still pre-contemplative and to practice fidelity in all of our affairs.contemplative and to practice fidelity in all of our affairs.