I am attending the NRI's State Mental Health Agency Services Research, Program Evaluation and Policy in DC listening to the presentation, The Use Of Learning Collaboratives To Promote Implementation Of Evidence-Based Practices In New York State, by Edith Kealey, Anthony Salerno, Paul Margolies, Molly Finnerty, Andrew Cleek.
They have developed two Learning Collaboratives (LCs) for Wellness self management and Family consultation thought the focus of this is on the process of developing LCs.
Train individual clinicians - The addition of evidence based practices (EBP) is extremely resource intensive. It is difficult to find out if they are really following the model (fidelity). While adapting the practices where we add components shows positive outcomes, removing components seems to have a negative impact. Staff turn over is also a big problem with learning the models and having the core competencies to actually carry out these models.
Develop systems level changes - How to engage and support the systems to make these changes. The key principals are transparency and a learning orientation. Us a grass roots process.
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Identify a felt need
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Recruit experts to help with clinical, technical and social support. (The latter because it is hard to change and folks need support to make these changes.)
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Enroll providers
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Alternate fate-to-face learning with action periods.
Develop local QI process with clinical supervision, administrator (who can get things done) and a QI/data staff. Also bring in folks as needed with additional skills. These teams also need an outside resource panel of experts. (These individuals help the agencies understand what they have, what they need, and what they can do.)
Advantages
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Align with IOM vision of "learning organizations,
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emphasis on rapid sustainable changes,
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build on the power of the collaborative,
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use of data to inform the decision making.
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Agencies really like these approaches because they can learn from each other.
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Opportunity to step back from the day-to-day activities to look at the system.
Wellness Self-Management. NY has developed a structure written Wellness Self-Management curriculum is a group based intervention based on the individualized Illness Management and Recovery program (a nationally recognized evidence based practice (link). As part of this process the learning sessions were structured to cover:
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Presentation of aggregate date
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Agency data
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Discussion what is the story
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spread the information
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Agency agreements to change
The results of these groups were generally positive (e.g., 76% retention with positive and negative reasons for those who discontinue). Groups went though the workbook at their own pace. 4 of the 8 agencies were extending this process to others.
They had trouble getting data on psychiatric hospitalizations. What they decided was that the data was not sensitive to change and the the providers "did not find it useful." It was not an actionable data element.
Family Oriented Services. Most Mental Health systems are not designed to involve family members. concern with how to bill. This was permissible as collateral services but folks needed TA to figure out how to structure and document these to facilitate billing.
Developed multiple family groups (MFG) to support this. This was to expensive and difficult to maintain. Worked toward "family consultation" to help families work with the practical problems (e.g.,"what does the Dr mean my bipolar", "my son locks himself in his room. What should I do?").
Problems with one measure of success (# consumers approached about family consultation / # in program). This was a snapshot view looking at an engagement process. With turnover you will have an increase in the denominator but because it is a process these new folks may not be there yet.
Counting the number of consultations themselves was a better measure. It was responsive to change and easy to collect and report. Interestingly when aggregated it hid very significant regional differences. However, this suggests that it may be more useful for the individual agencies to compare their performance with others.
The project provides funding for the materials but not for staff and agency time. They acknowledged that this was a problem suggested that agencies with more slack resources (that is larger agencies) can do this much more easily than smaller ones.
NY developed a DVD based training system to build up internal capacity. So there was an initial face-to-face training but for new staff they learn via the DVD.
They have found it difficult for agencies to take "ownership" of their data. They still see that the data is being colleted for the state rather than for themselves. The participating agencies have not taken this model to heart and using it in different places nor are they feeling "ownership" of the data that they are collecting. Perhaps the difficulty is that whenever it is being directed by a higher group. What would happen if the state would simply mandate that these CQI groups be setup and run. The difficult would be that they would not necessarily follow the EBP.
In Missouri these descriptions tie into the work with the RWJ funded Advancing Recovery project. This 2 year effort is using a continuous quality improvement process to implement evidence based practices into the treatment of persons with alcohol and other drug abuse. The interesting thing is that New York use "quarterly learning sessions, monthly phone calls, and technical assistance" to support these relationships. They had a web site to offer additional support but did not share any information about its utilization. They saw this as an "auxiliary approach" and not a primary purpose. This differs from the Missouri effort that has tried to build a web resource for all participating agencies.