Meeting the Evidence-Based Standard

1. One Sky Center R. Dale Walker, MD, Director Michelle Singer, Communications Coordinator, ICMI Project Director Doug Bigelow, PhD, Deputy Director Meeting the Evidence-Based Standard

2. “The Learning HealthCare System”

3. Evidence-Based vs Culture-Based Dilemma • What is “Evidence”? • Multiple Streams of Evidence • The Learning Healthcare System • Description: A Scientific Framework • Some Culture-Based Interventions Outline

4. Epistemological gulf • Western • Traditional AI/AN • Epistemological debate • Validity of traditional world view • Freedom to live by a traditional world view • Practical debate • Controlling by purse strings EBI – CBI Dilemma

5. Bridging • Evidence is? • Status of evidence for EBI • How to meet reasonable standards of evidence • Practice Improvement • Multiple Streams of Evidence • Learning Healthcare System Bridging EBI – CBI http://coce.samhsa.gov/cod_resources/PDF/OP5-Practices-8-13-07.pdf http://www.iom.edu/CMS/28312/RT-EBM/41894.aspx

6. Intervention/program research • Randomized Controlled Trials (RCT) • Nonrandomized, uncontrolled • Evaluation • Adaptation of Proven Intervention • Like a Proven Intervention • Basis in Proven Theory, Principles, Facts Sources of Evidence

7. Criteria: • Fidelity • Internal Validity (vs confounding variables) • External validity • Reliability—repeatability. • Process: • Scientific experts • Independent judging and rating • Compilation and Summary Evidence-based InterventionsProcess and Criteria

8. Therapeutic power of Choice • Self-healing guided by expert healers • Uniqueness of interpersonal relationships • Complexity of factors Nature of Behavioral Intervention

9. Individual studies Reviewed collections Lists of model, best, promising, alternative Survivors of meta-analyses Status of “Evidence” in EBI

10. Meta-analysis “Best Practice” Review Research Description Practice Culture The Buffalo jump for Ebi

11. “Best Practices” = highest scientific standards • Balance point • Reasonable standards are: • Repeatability • Achievable within resources and constraints • Allow conclusions without intolerable doubt • Low risk of harm, if conclusions are wrong Reasonable standards of evidencefor improved practices

12. Adoption requires buy-in • Acceptance • Implementation Adaptation-Adoption

13. Adaptation to unique local culture and context • Players • Rules, expectations, traditions • Resources/collaborations • Opportunity to contribute to strategic plan Adaptation-Adoption

14. MI, CBT, SFP, Project Venture, Canoe Journey implementations • are unique in every setting • Every replication is an Adaptation Adaptation-Adoption

15. The EBI idea is changing • SAMHSA: “multiple streams of evidence” • IOM: “Learning Healthcare System” EBI out of the box

16. Intervention/program RTC; Evaluation • Adaptation of Proven Intervention • Analogous to a Proven Intervention • Basis in Proven Theory, Principles, Facts Other Sources of Evidence

17. Description

18. “Operationalization” a way of knowing/believing • From black box to detail • Consistency with body of knowledge • Who, what, when, where, how, decisions • Repeatability Importance of Program Manuals

19. Proven Theory, Principles & Facts • Social ecology (influences) • Prevention • Universal/ selected/ indicated • Risk and Resilience • Readiness to Change • Risk taking/seeking • Stress vulnerability • Modeling (observational learning) • Instrumental learning • Group dynamics • Conformity, altruism • Listening and support • Catharsis • Psychopharmacology

20. Kinds of Intervention Strategy • Screening • Gatekeeping • Diagnosis • Treatment • Traditional healing • Traditional ritual/ceremony • Postvention • Parent/family training • Group work • School/institution-based • Education/skills • Experiential • Socialization/acculturation • Public Health (risk/resilience) • Services develop/coord • L E/justice/corrections • Community competency • Community change • Culture

21. AI/AN Prevention, Tx, Rehab Interventions • Story telling • Talking circles • Sweat Lodge • Ceremonies and Ritual • Purification • Passages • Naming • Grieving • Drumming, singing, dancing Vision Quest Flute playing/meditation Reconciliation Mentoring Service learning GONA

22. Cultural Enhancement Through Story Telling (Tohono O’odham Res) • AI Strengthening Families Program (U UT) • Across Ages (Mentoring) (Temple U) • Creating Lasting Family Connections • Dare to Be You (Ute Res) • With Eagles Wings (N. Arapaho Nat) • Families That Care—Guiding Good Choices “Best Practices”

23. Families and Schools Together (Rural Wisconsin Res) • Parenting Wisely • Preparing for Drug Free Years • Project Alert • Project Venture (NIYLP) • Promoting Alternative Thinking Strategies • Zuni Life Skills (Zuni Pueblo) “Best Practices” http://www.spokane.wsu.edu/ResearchOutreach/wimhrt/research2.asp

24. Deal with Epistemological Gulf • Know limitations of Evidence in EBI • Agree upon “Practice Improvement” Goal • Make credibility gains with “Scientific Framework” for Description • Use existing practices and knowledge as evidence for similar CBI Bottom Line

25. Feel Free To Contact Us At: One Sky Center (o) 503-494-3703 onesky@ohsu.edu www.oneskycenter.org