The CANS and Evidence Based Practice Implementation: Hanging Together or Just Left Hanging?

Abram Rosenblatt, Ph.D.EMQ FamiliesFirst

Presentation OverviewContextEBP’sMeasurementGapsExampleConclusions

Service Systems Are ComplexPracticeProgramSystem

Impact is ComplexEffectivenessEfficiencyEquity

Setting the Stage: A FrameworkSystem Goals

Practice Level Program Level System Level

Effectiveness The effect of a clinical intervention on outcomes

The effect of program philosophy/culture on outcomes

The effect of standards of care, service provision, and/or funding on outcomes

Efficiency The effect of provider productivity on costs

The effects of staffing choices, provider mix, and/or work hours on costs

The effect of fiscal incentives, service system integration, and/or service mix on costs

Equity The effect of provider choice and decision making on disparities

The effect of program location and accessibility on disparities

The effect of program mix and/or fiscal incentives on disparities

Purposes of Collecting Data and Perceived Value

Setting the Stage: TrendsSystems of Care

System Focus? Efficiency and Equity Impacts Effectiveness unclear

Wraparound Mostly Program, also practice and system Fidelity Effectiveness…maybe

Evidence Based Practice Practice, also program Effectiveness

The Current Star: EBP’sMore Effective than Usual Care

Don’t know a lot about “usual care”Arbitrary Metrics ProblemReplication ConcernsTransportability and Drift

Equity?Iatrogenic potential at system level

Efficiency?Cost Effectiveness usually unknown

EBP Alphabet SoupMandate for EBP’s and Motivation to select most

effective services creates challengesEMQ FF EBP Implementation (Partial List)

PCITIncredible YearsTriple PTF-CBTACRABSFTACTFFT

Where to Go?Outcomes Management

TCOMMeasurement Feedback SystemsResults Based AccountabilityClinical Dashboards

Common Elements Approaches MAP/Child STEPS

Quality of Care

Turbulence AheadCounty or project specific Outcome

RequirementsEBP Measurement RequirementsOver 30 Different Measures used at EMQ FF,

most of which can not be changed or consolidated

Multiple Measures and PerspectivesThe Importance of ValuesRapidly changing economic and funding

landscapeHealth Care Reform

What to do? An Example from One AgencyStrong History of WraparoundIntensive EBP implementationStrong Commitment to Outcomes and

EvaluationMultiple Counties and RegionsStrong ValuesFoster Care and Mental Health

Addressing GapsAssessmentOutcomes Management/Measurement

FeedbackStrategic Use of Evidence Based PracticeOverall Clinical Competencies and SkillsOutcome data collection across all programs

Evolution Values

Assessment and Outcomes: Child and Adolescent Needs and Strengths (CANS)Clinician Based Rating ScaleParent and Child Perspectives?Mental Health Assessment

SymptomsDiagnosis

Real World ReferentsIn HomeIn SchoolOut of Trouble

Clinical Skills: Development Needs“Usual Care” not as effective and beneficial

as Evidence Based PracticesMany EBPs already in place at EMQ FF and

no strategic plan for EBP implementationEBPs do not exist for all clinical situationsEMQ FF serves youth who do not match

existing EBPs EBPs costly and labor intensiveSome clinical staff at EMQ FF are not

qualified for some EBP trainings

Use EBPs Efficiently and Effectively: Relevance Mapping

Can create a guideline for EBP implementation at EMQ FF based on existing data

Includes: Presenting problem or diagnosis Age Gender Ethnicity Setting

Allow for a more rational approach to determining EBP implementation at EMQ FF and more efficient resource allocation given high cost of most EBP’s.

Examples from Relevance MappingSeventy six percent (71%) of youth are covered by at least ‐

one evidence based treatment that applies to their primary ‐problem, age group, and gender.

About half of youth with attention/hyperactivity problems are above the tested age range for evidence based treatments.‐

Aside from treatments developed for disruptive behavior, many evidence based treatments are less often tested in ‐settings typical of the service model.

Cognitive Behavior Therapy alone applies to 61% of all youth—almost all of the youth coverable by any evidence based ‐practice.

Core Clinical Skills: Managing and Adapting Practice (MAP)Common Elements Approach: Effective

services from high quality partsMatch practice elements to specific clinical

scenariosPractice elements based on extensive review of

existing literature (“Evidence Based” practice elements)

Practice Wise Data BaseHelps select practice elementsHelps select EBP’s if appropriate

Clinical DashboardFeedback on selected outcomes

Creating an Integrated Clinical ModelStandard Assessment with the CANSEfficient and Effective planning for EBP

implementation with relevance mappingCore clinical skill development with the Common

Elements ApproachUse of the CANS to enhance selection of

appropriate common elements or EBPs at the clinical level

Clinical Quality Improvement with the Clinical Dashboard using the CANS as core measure

Development and refinement of current practices at EMQ FF

Integrated Model: CANS and Relevance MappingCANS for Assessment and Outcomes Tracking

Assists in EBP implementationAssists in “common elements” selectionCore component of Clinical Dashboard trackingAssists in level of care determinations

EBP Relevance mapping Empirically map potential EBP’s to young people

servedAppropriate use of EBP’sShows where common elements approach is most

neededDemonstrates where novel program development is

most needed

Integrated Model: Baseline Clinical Skills and Clinical CQIMAP model

Assures baseline clinical competenciesApplies to young people and families for whom

EBPs are not relevantApplies to young people and families for whom

EBPs can not be provided Helps guide EBP selection by clinical staffHelps provide continuous quality improvement

at the clinical levelIntegrate with CANS

AdvantagesStandardization of assessmentStandardization of core clinical competenciesApplicable to most or all young people and

families served at EMQ FFCompatible with existing servicesDoes NOT replace existing clinical skill sets and

judgmentEfficient and effective use of costly service

optionsEnhances clinical workforce developmentEmpirically based and “state of the art”

Conclusion: Moving the CANS to Center StageAssessment

Replace EBP measures?Outcomes

Usual Care?EBP Relative Effectiveness

Measurement FeedbackEBP planningCommon Elements SelectionQuality of Care