Best Clinical Practices: The Integration
of Research, Clinical Experience and
Consumer Perspectives
New York University November 5, 2012
Anthony Salerno Ph.D.
McSilver Institute for Poverty Policy and
Research
• What’s a really good practice?
• Why the gap? No simple answer- The systems
alignment view
• What to do about the gap?
◦ What the implementation science literature tells us
◦ The challenge of practice adaptations and fidelity
• Designing tools that promote uptake and integrate
The Institute of Medicine
(2001) defines evidence-based
medicine as the
“integration
of
best researched evidence
AND
clinical expertise
WITH
patient
values” (p. 147).
Research evidence Consumer perspectives Practitioner experience and expertise
Knowledgeable and
skillful providers,
offering the latest
treatments, are
rendered ineffectual
without the day to
day efforts of actively
involved clients.
There is a big gap….research informed
practices and usual practices
So you want to successfully implement and sustain a
new practice such as Integrated Dual Diagnosis Treatment (IDDT)?
•
*
Fixsen’s answer:
◦ carefully select practitioners…coordinated training…coaching… performance assessments;
◦ infrastructure for timely training, skillful supervision and coaching
◦ regular process and outcome evaluations
◦ communities and consumers fully involved
◦ state and federal funding avenues, policies, and regulations are aligned
*Implementation Research: A Synthesis of the Literature Dean L. Fixsen ,Sandra F. Naoo Karen A. Blasé ,Robert M. Friedman
•
Leadership
•
Staff competency and supervision
•Fiscal alignment
•
Get the right people on
the bus
•
Wrong people off the bus
•Right people in the right
seat
Then….
•
Figure out where you are
going? How to get there?
The right
people
in the right
environment
knowing how to do the right
practice
with the
right
clients.
• Staff turnover
• Workforce competencies
• Lack of easily accessible resources • Lack of practice specific supervision
• Expense of training, consultation and outside
supervision
• Demands on leadership and staff time
• Incongruence with prevailing stakeholder attitudes and
Illness Management and Recovery (Mueser
and Gingerich 2001, 2010)
http://store.samhsa.gov/product/Illness-Management-and-Recovery-Evidence-Based-Practices-EBP-KIT/SMA09-4463
Wellness Self Management (Salerno,
Margolies and Cleek, 2007)
Wellness
Self-Management Plus (Salerno et al 2009)
www.practiceinnovations.org
Wellness Recovery Action Planning ( Mary
Ellen Copeland)
http://www.mentalhealthrecovery.com/ Team Solutions and Solution for Wellness (Lilly)
Diabetes education materials
http://clinicians.org/our-issues/acu-diabetes-patient-education-series/
Tobacco cessation toolkit:
http://www.integration.samhsa.gov/resource/tobac
co
cessation-for-persons-with-mental-illnesses-a-toolkit-for
mental-health-providers
Behavioral Health and Wellness Program:University
of Colorado Denver (Chad Morris)
18
Person and Community Experience of Quality
Access Timeliness Effectiveness Coordination Safety Continuity Equity
Agency/organization level
Leadership Organizational governing body Administration/Management
Microsystems
Treatment Teams Program/ Residential/Support staff Medical team Peers
Environmental Context
Government Fiscal systems UNIVERSITIES Accrediting Bodies Research Regulations Advocacy organizations Licensing/Credentialing
19
Person/Community
Access Timeliness Effectiveness Coordination Safety Continuity Equity
Agency/organization level
Leadership Organizational governing body Administration/Management
Microsystems
Treatment Teams Program/Residential/Support staff Medical team Peers
Environmental Context
Government Fiscal systems UNIVERSITIES Accrediting Bodies Research Regulations Advocacy organizations Licensing/Credentialing Social policy Third party payers
Perspectives shaped by contextual factors: personal
background and cultural/religious values
Engagement is everything! Interpersonal and
system factors facilitate or impede engagement at person and community level
We all need to be really good communicators
View
c
ommunities as partners in health rather than“recipients” of care.
Healthy communities involves illness prevention
and health promotion (link between poverty, trauma and overall health
Workforce competencies are critical
Role of universities, research, policy, reimbursement
methods, in service training and supervision is vital
CSWE project (NYU as a national leader)
Integrated teams focused on coordination, collaboration,
partnership, common and specialized competencies/roles
Role of peers on integrated teams (role of universities) Requires knowledge beyond well defined traditional
professional boundaries
Thinking beyond the boundaries of any specific program Systems-minded approach (increasingly more likely that
health related organizations (BH and Medical) will be part of a multi-service system of care
Knowledge of business practices as well as clinical
practices
Care coordination (navigating the system will
become increasingly important)
Team work
Use of data, focus on achieving measurable
outcomes at individual and population levels
Use of advances in health information technology Integrated assessment (understanding
interdependence)
◦ Mental health
◦ Substance use
◦ Physical health
Knowledge and skills in change management
and practical leadership strategies
Not just for the CEO or executive level
leadership
◦ Middle level administration and project management including managing up
Leaders who view change as routine
How to guide and manage change is critical
Organizational leaders coordinating and
Role of professional education (preparing the micro-system
to meet the demands of a changing healthcare system
Development of intensive- critical competencies focused
education
Role of peer education and professionalizing of peer
specialists
Multi-system collaboration addressing the basic human
needs for jobs, homes, income, education, social networks
Applied research designed to add value to the current and
future system
◦ Alignment with fiscal and organizational realities
◦ Implementation Science in the real world
Outcomes need to include impact on costs Health information technology
List of songs by Eagles
Eagles - After The Thrill Is Gone
Eagles - Do Something
Eagles - Frail Grasp On The Big Picture Eagles - Get Over It
Eagles - How Long
Eagles - I Can't Tell You Why
Eagles - I Don't Want To Hear Anymore Eagles - No More Walks in the Wood Eagles - Take It Easy
Eagles - Take It To The Limit Eagles - Wasted Time
McSilver Institute for Poverty Policy and Research
www.mcsilver.org
Clinic Technical Assistance Center
www.ctacny.org
◦ Business practices and clinical quality
◦ Clinical topics series
◦ Evidence based practices (practical and susatianable implementation
National Council for Community Behavioral
Health
www.nccbh.org
Center for Integrated Health Solutions
http://www.thenationalcouncil.org/cs/center_f
or_integrated_health_solutions
