Translating Evidence Based Research into Quality Services: Hawaii ’ s Experience

1. Translating Evidence Based Research into Quality Services: Hawaii’s Experience Christina M. Donkervoet, M.S.N., APRN Chief, Child & Adolescent Mental Health Division Department of Health

2. Hawaii System of Care - 1999 • Solid statewide foundation & framework • Broad access & availability • Strong team-based decision making value

3. 1999: ….A Not so Good Time • Dramatic cost increase • Results inadequate to poor • Substandard system performance

4. The 1998 AHA Experience • Framework of system of care • Solid values, good intentions & willingness to collaborate are a beginning. Good will ≢ Meaningful Results for Children, Youth, Families, Systems

5. Taking a Step Toward EBS • Desire to learn what services resulted in meaningful life changes for youth • Presenting Problem Areas • Age • Gender • Culture & Ethnicity • Develop mechanism for implementing these types of services across communities and islands

6. Initial Charge • Focus on the Research Data • INITIAL TARGET: CONDUCT DISORDER • high cost, • low satisfaction, • low effectiveness

7. Critical Factors of the EBS Committee • Broad Membership • Cross disciplinary • Family membership • Cross agency – • Public & Private • Community & State • Child serving agencies & Higher education • Unifying Lead • Defined Framework of Evaluating • Design Linkage to Practice Development Activities & Performance Management

8. Hawaii “Blue Menu” of Evidence-Based Services(abbreviated) Problem Level 1 best support Level 2 good support Level 3 moderate support Level 4 Minimal support Level 5 known risks Anxious or Avoidant Behaviors CBT; Exposure; Modeling CBT+ parents; Ed support None EMDR; Play Tx; GIST None Behavior Therapy None None Biofeedback; Play Tx; GIST None Attention/ Hyperactive Behaviors Bipolar Disorder None Interpersonal and social rhythm therapy *Family Psycho education All other psychosocial therapies None Delinquency Willful Misconduct None MST; FFT MTFC; Wrap around Foster care Juvenile Justice; Individual Tx Group Therapy Depressive or Withdrawn Behaviors CBT CBT + parents; IPT; Relaxation None Behavioral problem solving Fam. Tx; Ind. Tx None Disruptive & Oppositional Behaviors Parent& Teacher Training; PCIT Anger Coping; Assertiveness; PSST Social relations training; Project Achieve Client-centered; comm. Skills; HR therapy Group Therapy Substance Use CBT Behavior Tx; Purdue Brief Family Tx None Ind.tx; family drug educ; conjoint fam. tx Group Therapy

9. Overall Summary for Individual Youth CR Number: Example 1 Date of Birth: Initial gistration Date: Report Date: 5/10/2004 ASEBA Total Problems T-Score ASEBA Total Competence T-Score CBCL YSR TRF CBCL YSR TRF 100 100 90 90 80 80 70 70 60 60 50 50 40 40 30 30 20 20 Sep-03 Nov-03 Dec-03 Feb-04 Mar-04 May-04 Sep-03 Nov-03 Dec-03 Jan-04 Feb-04 Mar-04 Apr-04 Jun-04 Oct-03 Jan-04 Apr-04 Jun-04 Oct-03 May-04 CAFAS Role Performance CAFAS 8-Scale Total Score Home School/Work Community 240 210 30 180 150 20 120 90 10 60 30 0 0 Sep-03 Nov-03 Dec-03 Jan-04 Feb-04 Mar-04 Apr-04 May-04 Jun-04 Oct-03 Jan-04 Apr-04 Oct-03 Jun-04 Mar-04 Nov-03 Feb-04 Sep-03 Dec-03 May-04 CALOCUS Total Score CALOCUS Level of Care 35 6 30 5 25 4 20 3 15 10 2 5 1 0 Sep-03 Nov-03 Dec-03 Feb-04 Mar-04 May-04 Oct-03 Jan-04 Apr-04 Jun-04 0 Sep-03 Oct-03 Nov-03 Dec-03 Jan-04 Feb-04 Mar-04 Apr-04 Jun-04 May-04 Attention Adjustment OOS Anxiety HBR Mood CHR Disruptive CBR Substance TGH PDD TFH MR RH Misc. IDS Deferred PH None DT MST IIH FLX RSP Agency Involvement LI CS DHS Court NONE DC Incarcerated ADAD N/A Adult MH Dev. Dis. Early Int. DOH Other Sep-03 Oct-03 Nov-03 Dec-03 Feb-04 Mar-04 Apr-04 Jan-04 Level of Care Diagnostic History Accepted Authorized Services Sep-03 Oct-03 Nov-03 Dec-03 Feb-04 Mar-04 Apr-04 May-04 Jan-04 Jun-04 May-04 Sep-03 Feb-04 Mar-04 Oct-03 Nov-03 Dec-03 Apr-04 Jan-04 Jun-04 May-04 Jun-04

10. EBS Tips of the Week • Week of 10-10-05 Two types of foster care have evidence for their efficacy in treating adolescents with conduct problems: Multidimensional Treatment Foster Care and Wrap-Around Foster Care (source: EBS Biennial Report 2004). [18] • Week of 07-04-05Relaxation alone has been shown to be as effective as many more complicated treatments for child depression. Two well-designed studies support its effects (source: EBS Biennial Report 2004). [4]

11. Monitoring Outcomes • Quality Case Based Reviews • Quantitative Outcomes • Role of Families • Publicly Shared Quarterly Reports

12. Introduction Of EBS System Performance since EBS Quality Dimension Examples: Functional Assessment Service Coordination & Transition Long-term view Caregiver Supports Service Plan & Implementation Effective Results Service Array & Integration Monitoring & Modification

14. Mid-Course Evaluation EBS Task Force Began Avoid Use of Hospital Residential Services for Conduct Disorders

15. Challenges in Sustaining Focus • System Constraints • Clinician Constraints • Rural Communities

16. Satisfying Legislative Mandates • Need for “levels” or “degrees” of evidence • Increase the awareness of the value and limitations of the evidenced based services (the other 35-40%) • Balancing the value of choice and options with effectiveness and cost

17. WHAT IT IS A component of the system of care A means to strengthen the quality of services A strategy to increase positive outcomes For youth & families For stakeholders For clinicians, agencies, administrators WHAT IT’S NOT A way to force change A way to limit services A way to reduce options Hawaii’sEvidence Based Services