Supporting Evidence-Based Practice in a Large Public System

Okay, good morning.  I’m Baptist, so you have to speak back to me.  Good morning. [audience response: Good morning.]

Thank you, thank you, okay, good.  What I want to do – so, I’m going to get all of my disclaimers out of the way up front.  So, some of the things I’m going to talk about today are lessons learned but not necessarily things that we’ve done.  So, I want to be clear about that.  And that what I want to do today is spend about 15 minutes talking about both, I think, a framework that might be helpful, but also solutions and strategies.

And before I start, I do want to thank Abe for inviting me.  I think that it is – I’m just thrilled to be here amongst folks that are thinking about these issues and working on it and people whose work I’ve read.  So, I’m very honored to be here.

So, let me start with just acknowledging lots of people who have been involved in the work in Philadelphia, including my staff, my colleagues at Penn, providers, and our partners.

So, I’m a psychologist.  And one of the things I know is that I’ve got about five minutes of your time before you start thinking about lunch, or what are you going to do at the end of the day.  So, I want to get my take-home messages up front.

So, here’s the perspective that I bring.  And I was asked to talk about the life cycle of TA and training and so forth in terms of implementation.  So, I’m going to suggest that taking a systems perspective that attends to multiple levels of analysis is really important in implementation and to successful implementation, and I’ll talk more about that. But very specifically, that as we think about the life cycle of an implementation, it is very useful to think about the practitioner level, the organizational level, and the systems level.  And in my view, the focus of EBP implementation should be on outcomes.

So, those are my take-home messages.  Let me just give you a little background on Philadelphia.  A very, very poor city.  In fact, if you looked at the top ten cities in the country, Philadelphia is the poorest of those.  Probably about 40 percent of the population is below the poverty line.  So, very big challenging issues.  And one of the things I feel extremely proud of is that we’re able to bring state-of-the-art treatments to people who are – who otherwise might not receive those kinds of care – that kind of care.

So, in terms of background of my system, it is a single-payer system.  Pennsylvania’s organized around county government.  Philadelphia’s both a county and a city.  And so, all of the public sector behavioral health care dollars that come into the city come through my department.

We – the city has a contract with the state of Pennsylvania to manage the Medicaid population.  That’s about 460,000 people.  We’re capitated.  We’ve created a managed care company.  I’m the president of the board, and those staff report in to me.  So, we manage the Medicaid dollars as well as the state, federal, local grant dollars for both substance abuse, mental health, children, and adults.

So, it’s kind of a comprehensive system.  It’s about a $1 billion – actually, $1.2 billion service system.  We serve about 120,000 to 130,000 people each year in the system.  A very broad range of providers, from university hospital systems – like University of Pennsylvania or Temple University – to individual practitioners and small mom-and-pop shops, that’s what I would call them, that are in the community.  So, a wide variety in terms of both scope, size, sophistication in the service system.  And again, lots of people that we’re serving.

And very important, as was mentioned in my introduction, that we are very aggressively trying to transform our system around the idea of recovery and resilience.  And it turns out that is a really important point, as I will discuss a little later.

So, the way I look at this, as a payer, we have a billion dollars of taxpayer money.  I want to make sure that that money is spent in the most effective and most efficient way.  So, I come at this from a very, very practical standpoint.  And the way I view EBPs is this: EBPs are simply a way to increase the probability that we’re going to get the outcomes that we’re searching for.  Period.  End of discussion.  That’s the reason that I think about EBPs, very practical.

Over the last six, seven years, we’ve done a variety of implementations.  And essentially the way that we’ve done this is that we’ve partnered with the purveyor of the EBP, and we’ve paid for those, for that implementation, and we’ve worked collaboratively with the providers and the purveyors of the EBPs.

We first started with cognitive therapy.  Aaron Beck is in Philadelphia, and a few years ago he came – about six years ago he came to me and said, “We know that cognitive therapy works.  Lots of studies have shown that.  It’s just not practiced in the field.”  And I asked if we could partner to try to figure out how we, on a large scale, infuse that practice throughout our services.

So, we started with the Beck Group, and over the last six years, we’ve done implementations in a wide variety of areas, from children, adult services, inpatient, residential, outpatient, substance abuse, mental health, and schools.  We’ve even begun to train homeless outreach workers who have a bachelor’s level – not even a bachelor’s level – high school level education in cognitive therapy principles.  So, we’ve moved from very specific treatment to trying to understand those principles and how those principles can help people in a wide variety of settings.

We worked with Marshall Linehan on dialectical behavior therapy; Edna Foa, prolonged exposure; Judy Cohen, trauma-focused CBT; sanctuary model with Sandra Bloom.  So, we’ve done a lot of different implementations.  And we also paid for other things, like MST, FFT, within our system.

I mentioned that we are moving to a recovery orientation.  So, here’s the 30-second description of what that is.  And I’m going to do a quick story.  When I was in Connecticut, I was the Deputy Commissioner for several years in Connecticut.

A woman came to me and said, “My son is 25-26, schizophrenia, released from a state hospital.  He lives in my basement.  He smokes cigarettes.  He watches TV all day.  That’s his life.”  In a traditional system, he would be a success.  Know why?

He’s not in the hospital; he’s not in jail; he’s not bothering anyone.  Because the systems have been focused traditionally on maintenance, treating symptoms, and maintaining people.

Recovery orientation would say that our goal with that individual is to help him get out of the basement; get a job if he can have a job; or go to school, if he can go to school; to have relationships; but to really be a part of the community.  For him to achieve his highest level of potential.

That’s a simple idea, but really, really complex, to re-engineer systems that are based on the previous paradigm to a recovery paradigm.  And so, that’s what we’re doing.  That’s what, for those of you who don’t work in behavioral health, public sector systems across the country are trying to make that shift.  And so, we see EBPs as a strategy to help us achieve those outcomes.  And that’s the context that we are implementing.

So let me move then to how we are beginning to think about a framework that helps us to figure out, how do you take this large system – very complicated, with people that have lots of challenges – and implement successfully these EBPs and then scale them up so that they have a systemic impact?

And so, the perspective that I’m going to offer is this idea of really thinking systemically, that these practices are not independent of some system and understanding how they fit within that system, in my view, is very important.

I’ve talked about the practitioner organizational and systems level.  And I want to sort of introduce this idea that I think we’re starting to learn – at least I’m starting to learn – is that it’s important to think about issues that are within particular implementations, but also across implementations.  So, we’ve been doing this for six years, and we’re a much different system.  Our providers, who’ve been participating are different than they were several years ago.  And so, that has some implications then for how we think about implementing practices as we do it.

So, here’s the basic framework.  So, going across – and I just sort of took some sort of arbitrary timelines in terms of thinking about what happens before an implementation, during an implementation, and then post implementation and how we sustain, and then looking across practitioner, organizational, and systems levels.

So, because of time, I’m not going to give you an example for each one of these cells, but I want to give a few examples just to show you how I think our thinking has evolved.

Let’s look at the organizational level.  One of the things we figured out very quickly is that initially we were very focused on how do we get practitioners to practice differently?  Our thinking now is, how do we get organizations to provide a service differently?  That is a very important shift, because what happened was, is we train providers.  One of the things that happens is that those clinicians now become quite valuable and marketable, and they leave.

And so, in a sector where you already have very high turnover, we saw our investments walking out the door.  And so, now when we engage providers, the question isn’t a commitment to train a provider to their clinicians, the commitment that they have to make is that they are going to build organizational capacity, that we’re purchasing organizational capacity.  If people leave, they’re going to replace those individuals.  They’re making a commitment to change their systems to incorporate that practice, and they are making commitments to do ongoing supervision and training.  So, that’s what we’re purchasing, not the training of providers.  So, that’s an example of looking at pre- implementation – pre-implementation organizational types of issues.

Let me take a systems one.  I mentioned that we are doing prolonged exposure.  So, prolonged exposure is an evidence-based practice for the treatment of trauma.  Have lots of research, very strong evidence, very effective.  It’s, in fact, what the VA uses for the treatment of combat veterans who have experienced trauma.

The woman who created it is at Penn, partnered with us, and one of the things that we found was our initial way of approaching this was we identified the providers.  We trained them up – eight providers for adults.  We learned very quickly that because this is a very intense – we kind of thought about a pyramid of people who have experienced trauma.  These are the people that are right at the top of that pyramid for which this intervention is most effective.

So, what we figured out very quickly was that the providers had not been able to identify those individuals within their programs.  Now, I believe, just because I know what happens in Philadelphia, that there are lots of people in Philadelphia who can benefit from this treatment.  But the system had not been set up such that we could readily identify them.

So, people who could benefit from the treatment, who might have been in a different program, might have not been in treatment, were not in the providers where we had trained the folks.  So, we had this very significant investment with no one benefiting from it.  And from those providers not being able to maintain the practice as well as they could because they didn’t have the volume.

So, the lesson learned for us is that we need to think about those kinds of systems issues beforehand, make sure that we attend to those so that as we implement the practice, the practice can actually be sustained.

I want to give you one more example.  I only have one minute, so I don’t know if I can do that; I can’t talk that fast.  Okay, so why don’t I do this.  I won’t give you this example, but one that I’m really excited about is in our work with the Beck Group.  We are using cognitive therapy on inpatient units for people who have psychotic disorders.  And the particular area is an area where we don’t have – where individuals have very long lengths of stay, very complicated clinical presentations.

But in that instance, what we’re doing is not only changing – using a milieu approach, not just training the therapist but training everyone, including the janitors, all the way through.  So, really trying to create a milieu.

We’ve targeted our ACT teams, which is another evidence-based practice, trained them up in CT, cognitive therapy, and we trained the outpatient provider.  So, essentially what we’ve done is create a Continuum of Care, where people will be treated on the inpatient unit, will be followed by an ACT team and receive services in a outpatient provider who also is using the same therapy.

So, people are getting reinforced all the way through.  That is a systemic approach.  And so, again, it’s another example of how sort of thinking systemically, the other point that I was going to make, is that we also are now partnering with our housing agency to have vouchers so that individuals can live in a supported housing environment. So, again, more of a systemic approach, and not just doing that independent acontextual.

So, what I’m going to do is I’m going to jump to – these are just food for thought.  Since part of today is talking about or having discussions with each other, I thought I would put a few provocative statements out there, just to kind of stimulate all this.

So, my first is that the gap is not enough.  When we started our work in Philadelphia, we – our mantra was, “There is a gap between what people do and what the science tells us.”  And we’re trying to close that gap.  That was our focus.  I’ve just given you some examples of why simply arguing that we need to close the gap is really not sufficient.  We really need to think about these broader contextual issues and how the practice is going to fit within that.

Barriers are important, but one of the things I’m starting to do is refrain and stop – not stop--but to begin thinking about, what are the drivers of people’s behavior, not just what are the barriers to implementation.

And what drives people’s behaviors in health care, it is what people get paid for.  And if you understand that, it gives you a lot of insights into what you can do and the levers that you have to try to shape behavior.

In child welfare, I was Commissioner for child welfare for about 18 months, and it is survival.  I mean workers don’t want to be in the newspaper.  And if you understand that, you need to understand that if you’re going to give people an alternative way to work, you got to know that that’s what’s driving their behavior, and you’ve got to show how what you’re offering them is going to do that.  So, understanding drivers of behavior, I think, can be very useful.

I’m going to argue that doing one evidence-based practice implementation is one evidence-based practice implementation.  And I’d love to talk about that because I am very convinced that while there are things that we’ve learned that cut across each implementation is different for a variety of reasons.

I think thinking about a developmental milestone’s way of thinking about where organizations are can be useful.  So, again, moving from thinking about sort of a checklist of things to do at certain points; thinking about, what are the developmental capacities that organizations need to have at various points within a implementation, I think, can be useful.

And also, successful implementation requires multidirectional communication.  So, I think that the typical model that I see and hear is, how do we get these folks to change how they do practice?  What we’re learning, particularly with the Beck Group, is that they’re learning as much from the providers and from us as we are – as the providers are learning from the purveyors.  And that’s really helping us to shape and, I think, come up with more successful implementations.

And my final point is outcomes trump fidelity.  So, I want to end on that point.  I really think that that’s where the focus needs to be.  So, thank you.