Evidence Based Practices in Oregon: An Overview

1. Evidence Based Practices in Oregon: An Overview Oregon Department of Human Services Addictions and Mental Health Services (AMH) February, 2009

2. ORS 182.515–525 Compliance • The five state agencies must demonstrate that program resources support EBPs in progressively increasing amounts: • Five Agencies include: Department of Corrections, Oregon Youth Authority, Commission on Children and Families, Criminal Justice Commission and Addiction and Mental Health. 25% by 2007 50% by 2009 75% by 2011and thereafter

3. ORS 182.515-525 Applies to Specific Programs/Services • Programs designed to reduce the propensity of a person to commit crimes • Improve the mental health of a person with the result of reducing the likelihood that the person will commit a crime or need emergency mental health services • Reduce the propensity of a person who is less than 18 years of age to engage in antisocial behavior with the result of reducing the likelihood that the person will become a juvenile offender

4. What it does not include: Examples • Medications on an individual basis • Exercise • Nutrition • Safety • Sleep • Security • Medical care of a non-clinical nature, i.e. cuts, heart disease, flu etc. • An educational program or service that is required by state law. • A program that provides basic medical services.

5. It Creates an Opportunity for System Transformation • AMH strategy is to use legislation to transform the service system • Increase the use of EBPs and improve outcomes • AMH definition includes the entire service system, including prevention

6. How Do We Define EBPs? • A continuum of practices, based on level of research confidence • Oregon’s nine Tribes are defining EBPs for use in those nations • Ongoing discussions with stakeholders will continue to redefine EBPs

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

8. 2005 Survey Results • Results indicate • > 25% fund utilization • 56% of substance use treatment and prevention dollars • 33% mental health treatment dollars • Providers spent most implementing the following EBPs: • Mental Health: Assertive Community Treatment (ACT) • Substance Use: Motivational Interviewing, American Society of Addiction Medicine (ASAM), Cognitive Behavioral Therapy (CBT)

9. 2008 Survey Results • Results indicate 54% fund utilization. • Most commonly implemented practices are the following: • Mental Health: Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy (DBT), Solution-Focused Brief Therapy • Substance Use: Cognitive Behavioral Therapy (CBT), Motivational Interviewing and Motivational Enhancement Therapy, American Society of Addiction Medicine (ASAM) • Substance Use Prevention: Strengthening Families Program 10-14, Communities that Care, Project Alert

10. #4 - CBT-Cognitive Behavioral Therapy #2 - ASAM #1 - Motivational Interviewing #5 - Solution-Focused Brief Therapy #3 - Co-Occurring Disorder: IDDT Top Five Evidence Based Practices in Oregon Clatsop (2) Columbia Wallowa Umatilla (3) Multnomah (3) Morrow Hood River (16) (13) (11) (12) (6) Gilliam Washington Tillamook (2) (2) Sherman (3) Wasco Union Yamhill Clackamas (2) (2) Marion (2) Polk (5) Wheeler (2) Baker (3) (4) (7) (5) (5) Lincoln (5) Grant Jefferson (2) (5) Linn Benton Crook Deschutes Lane (2) (7) (2) (5) (2) (6) Malheur Harney (8) Coos Douglas Lake Klamath (2) Jackson Curry Josephine (4) (4) (5) (3) (3) (4)

11. Nine Evidence Based Practices of Interest Assertive Community Treatment (ACT) DBT-Dialectical Behavioral Therapy Outpatient Tx w/ Synthetic Opioid (Methadone) Brief Strategic Family Therapy (BSFT) Functional Family Therapy Parent-Child Interaction Therapy Collaborative Problem Solving Matrix Model Relapse Prevention Columbia Clatsop Umatilla Wallowa Multnomah (2) (2) (6) (6) Morrow Hood River Washington Tillamook Gilliam Union Sherman (9) (5) Yamhill Clackamas Wasco Marion Polk Lincoln Wheeler Grant (2) (2) Baker (4) Jefferson (4) (2) (2) Benton Linn (3) Crook Lane (4) Deschutes Malheur (2) Harney (4) Douglas Lake Coos Klamath (2) (2) Curry Josephine (2) (2) (2) Jackson

12. The Top Three Prevention Evidence Based Practices Implemented in Oregon (where three of them are tied for third place) Clatsop Columbia Umatilla Washington Hood River Wallowa Multnomah Sherman Tillamook Morrow Union Gilliam Yamhill Clackamas Wasco Polk Marion Lincoln Baker Wheeler Jefferson Linn Benton Grant Crook Deschutes Lane Malheur Douglas Harney Coos Lake Klamath Curry Jackson Josephine Strengthening Families Program (27 counties) Life Skills (Botvin) (6 counties) Project Northland (6 counties) Communities That Care (9 counties) Project ALERT (6 counties) S. F. Tribal Program (2 counties)

13. Provider Strategies to Meet Fidelity

14. Implementation Phase- Early • Identified the practice • Outlined the implementation process • Established a plan for improvement and sustainability

15. Implementation Phase- Middle • Trained staff in the practice • Delivered the practice • Completed an internal review and made revisions • Had an external review completed and made revisions

16. Implementation Phase- Late • Have regular external reviews and made ongoing revisions • Revised sustainability plan • Provided technical assistance to others • Are identified as a model program for that practice

18. *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

19. Native American Tribes • Tribal Position Paper on Native American Evidence-Based Practices accepted by AMH • On May 14th the Oregon Tribes held their 2nd Gathering of Tribal Researchers and Evaluators to define criteria • The Tribes continue to work to establish procedures

20. Does All of This Matter? • Does implementing EBPs produce better system outcomes? • Are we hitting the intended targets of the legislature under ORS 182.535?- Reduces propensity of a person to commit crimes- Improves mental health of a person with the result of reducing the likelihood that the person will need emergency mental health services- Reduces antisocial behavior and juvenile crime • What does this amount to in financial terms?

21. Example from PreventionStrengthening Families Program 10-14 • Savings to society in criminal justice costs related to substance abuse are estimated to be $5805for each youth who participates in the Strengthening Families Program (Washington State Institute for Public Policy, 2003) • To date, investing in the Strengthening Families Program has yielded a net benefit to Oregon of over a million dollars: • OREGON’S COST SAVINGS: • $1,184,220

22. Consider • Limiting the scope of programs • Using the Correctional Program Checklist (CPC) as a standard for serving criminal justice clients • Identifying core components and protocols as EBPs • Individualizing definitions, criteria and procedures for populations • Systems organization, supervision and review processes as EBPs • Performance measures and outcomes • Investing in a data system

23. EBP Haiku from evidence based caterpillar to larvae practiced butterfly

24. Resources • Turning Knowledge Into Practice: http://tacinc.org/cms/admin/cms/_uploads/docs/EBPmanual.pdf • AMH EBP Website: http://www.oregon.gov/DHS/mentalhealth/ebp/main.shtml

25. 12 Steps of EBPs by Bonnie Malek • We admitted we were powerless over SB267 and that our IT needs had become unmanageable. • Came to believe that the right set of manuals could restore us to pre-morbid functioning. • Made a decision to turn our program development and training resources over to SAMHSA before we understood why. • Took inventories of everyone that voted for this bill (and in some cases their mothers and their dogs). • Admitted to AMH and the Oregon Legislature that for the past 70 years, we’ve been running on sweat equity, imagination and rubber bands. • Grudgingly agreed to do some reading and to keep an open mind. • Swore all the way to the dumpster with our favorite videos and handouts.

26. 12 Steps of EBPs • Made a list of all the practices that made sense to us and became willing to check at least some of them out. • Agreed to learn at least one new thing as long as it didn’t substantially add to our caseloads or paperwork. • Continued to work on doing the impossible with no new resources and dreamed of deleting databases when no one was looking. • Sought through outcomes data and SSRIs to improve our conscious contact with the legislature, praying only to prove that treatment works and we’re truly not sleeping at our desks. • Having had a rude awakening as the result of these steps, we vowed to share our retention data with programs that were still pre-contemplative and to practice fidelity in all of our affairs.