MARRCH 2007 Annual Conference October 30 2007 Adding

MARRCH 2007 Annual Conference October 30, 2007 Adding Technology to the Use of Evidence. Based Practices Deni Carise, Ph. D. Treatment Research Institute University of Pennsylvania TRI science addiction

Technology and EBP’s 1. Barriers to implementing EBP’s 2. NREPP 3. DENS 4. CASPAR 5. NIDA/ATTC Blending Teams TRI science addiction

The Research-Practice Gap Medications, behavioral therapies, and clinical interventions: tested & shown effective in clinical trials TRI science addiction

The Research-Practice Gap But, very low rates of adoption of these EBP’s. Possible factors contributing to this –Finance, complexity, organizational structure, policy issues TRI science addiction

The Research-Practice Gap Counselors report Finance, Training & Supervision barriers are the greatest contributors to the researchpractice gap TRI science addiction

The Research-Practice Gap New therapies won’t be adopted if: – they cannot be supported by managers and funding agencies. – the training and supervision burden is overwhelming TRI science addiction

Training Barrier Of 400 national substance abuse treatment centers, 20% had no staff training budget. Decreased funding + Increased licensing, accrediting, and funding compliance requirements Decreased clinical training and Increased attention to administrative issues TRI science addiction

National Registry of Evidence-based Programs and Practices (NREPP) NREPP is a service of Substance Abuse and Mental Health Services Administration (SAMHSA) • Began in 1997 • A searchable database of interventions for the prevention and treatment of mental and substance abuse disorders TRI science addiction

NREPP Programs • To date 150 programs in the database • NREPP recently changed the criteria and previously approved programs are listed under Legacy Programs on the website TRI science addiction

Legacy Programs… • Reviewed between 1997 -2004 • Part of CSAP’s Model Programs Initiative • Model Programs - science-based, effective & readily available for dissemination • Effective Programs - science-based, consistently achieved positive outcomes • Promising Programs - science-based, show at least some positive outcomes TRI science addiction

Criteria for Submission to NREPP • Quality of research • Readiness for Dissemination • Descriptive Information TRI science addiction

Quality of Research • • • Reliability of outcome measures Validity of outcome measures Intervention fidelity Missing data and attrition Potential confounding variables Appropriateness of analysis TRI science addiction

Readiness for Dissemination • Availability of materials • Availability of training and support resources • Availability of quality assurance procedures TRI science addiction

For more info See NREPP’s website: www. nrepp. samhsa. gov TRI science addiction

Moving to Evidenced-Based Practices… An example with the DENS ASI Software Program from Evergreen Treatment Services Seattle, Washington TRI science addiction

Identify the Problem • Track systematically the nature of patients and their presenting problems • Match treatment services to unmet patient needs • Track patient outcomes for program evaluation and for funding and political purposes TRI science addiction

Identify Outcomes üConduct all intakes using the Addiction Severity Index (ASI) üHave ASI intake data stored in agency database üUse ASI information as initial treatment planning guide üUse ASI data for program evaluation TRI science addiction

Assess the Organization üAll intake workers will need training in ASI administration and then on-going Q. A. for reliability üAll intake workers will need training on computerized ASI üTreatment supervisors and counselors will need training in how to interpret ASI assessment TRI science addiction

Assess the Organization (cont’d) üNeed supervision to insure patient’s needs, identified at intake, are being addressed in treatment planning and delivery üI. T. Coordinator will need to maintain database TRI science addiction

Assess the Audience üRegulatory agencies üFunding sources üPolitical entities üBoard of Directors üStaff TRI science addiction

Identify the Approach üTraining • Intake staff • Counselors & supervisors • IT Coordinator üAcquire resources • ASI Software • Desktop computers TRI science addiction

Implement the Plans üTraining – don’t underestimate time necessary for this component; skill building can’t be rushed üResource acquisition – make sure you forecast all of the necessary expenses üPay attention to staff concerns and morale TRI science addiction

The Move to EBPs How can technology help? The DENS System The CASPAR Projects THE ATTC Blending Teams TRI science addiction

The Drug Evaluation Network System DENS 8 A national system collecting standardized, automated information (using ASI) 8 that is clinically important and policy relevant 8 on people entering addiction treatment and their treatment programs TRI science addiction

The Addiction Severity Index • Developed by Tom Mc. Lellan & colleagues at University of Pennsylvania • Standardized, semi-structured, multi-focused screening and assessment tool TRI science addiction

A. Thomas Mc. Lellan TRI science addiction

7 Sections of the ASI 1. 2. 3. 4. 5. 6. 7. Medical Employment/Support Drug Alcohol Legal Family/Social Psychiatric TRI science addiction

DENS System • Benefits to the Counselor • Benefits for Program: Aggregate Reporting • Leads to benefits for Clients TRI science addiction

DENS Software Automates collection of the ASI data Provides: Automated error-checks Comprehensive intake assessment Room for additional comments Automated narrative summary Comprehensive treatment plan TRI science addiction

DENS ASI Software • Software designed with input from clinicians • Assumed most users have little/no computer experience • Can enter comments for every ASI item TRI science addiction

It Writes a Narrative Summary?

Software: Hints & Comments

How Do You Tailor Treatment to: Groups of clients who you know have different drug problems? TRI science addiction

An Example with Gender Differences It is widely believed that males and females have very different drug/alcohol use patterns, histories and problems TRI science addiction

Gender Differences? N=60, 952 TRI science addiction

Gender Differences TRI science addiction

Summary Among substance abusers entering treatment, divided by gender, differences in substance use variables are the least impressive More impressive are differences in Lifetime and Past 30 days data - personal health and social functioning variables TRI science addiction

CASPAR Computer Assisted System for Patient Assessment and Referrals TRI science addiction

Background “Wrap-around” services have been shown to improve treatment outcomes But… …few services available in contemporary treatment programs …finding “wrap-around” services can be difficult TRI science addiction

Problem-Services Linkage • Alcohol • Drugs (e. g. Employ - related services GED training • Medical • Employment • Psychiatric Resume Development Job Finding Mentoring Sessions Training Loans Treatment Research Institute TRI science addiction

Assessment to Treatment Planning 1. Conduct assessment (ASI) 2. Identify problems Therapeu tic Threa d 3. Prioritize problems 4. Develop goals to address problems (TP) 5. Write Treatment Plan including referrals not available at your site (CASPAR) TRI science addiction

What about this “Resource Guide”? • Electronic source of local, free and low cost programs and agencies • Contains a wide range of services including: – Mental health – Job training – Financial support – Emergency services (food, clothing, housing, shelters) TRI science addiction

Why Was the RG Developed? • The ASI obtains information on many areas of the client’s life, identifying problems that may require treatment and/or assistance – Often there are more problem areas that need to be addressed than can be accomplished by any one counselor or agency alone TRI science addiction

Why Was the RG Developed? The Resource Guide makes it easier for counselors to address client needs that cannot be met at their agency by providing referrals TRI science addiction

Resource Guide TRI science addiction

A Software Screen Example Highlight a keyword here. Click here for all services matching the keyword. Click here to enter patient’s zip code. TRI science addiction

A Software Screen Example Click here to print this page. Click here to view other programs provided by this agency. TRI science addiction

Study Design Group 1 - SA 5 Programs Standard Group 2 - EA 5 Programs Enhanced 15 Counselors 18 Counselors 57 Patients 74 Patients 10 Programs 33 Counselors 131 Subjects

Procedures • Counselors provided their ASI and TP for 5 patients • TRI staff interviewed patients 2 and 4 weeks post-admission to see how many and what types of services they received • Matches between the (1) ASI and TP and (2) the ASI and Services Received were evaluated TRI science addiction

Results from the first CASPAR study on increasing servicespatient match and the number of services received with ASI Treatment Care Planning TRI science addiction

Findings TRI science addiction

Hypothesis 1 Patients whose counselors receive the EA Training will receive Treatment Plans that better match their problems identified at admission TRI science addiction

% Matched: ASI to TCP All p<. 05 TRI science addiction

Hypothesis 2 Patients whose counselors receive the EA Training will receive more services TRI science addiction

Number of Services Received D/A, Med, Emp, Psych all p<. 05 TRI science addiction

Hypothesis 3 Patients whose counselors receive the EA Training will receive Treatment Services that better match their problems identified at admission TRI science addiction

% Matched: ASI to Services Received D/A, Med & Emp all *p<. 05 TRI science addiction

Hypothesis 4 Patients whose counselors receive the EA Training will remain in treatment longer and be more likely to complete treatment TRI science addiction

Percent Retained at 45 Days TRI science addiction

Percent Retained at 90 Days TRI science addiction

Unexpected Finding Counselors who received the EA Training remained on the job longer TRI science addiction

Percent Who Quit by 6 Months TRI science addiction

Limitations • This study evaluated the type and number of services but not the quality of services received • No pre-study measures • Study was limited to Philadelphia area treatment programs TRI science addiction

Conclusion • Counselors are willing to be trained & use an electronic resource guide • Resource guide fosters better treatment planning and more appropriate service utilization • NOT YET CLEAR IF THIS WILL LEAD TO BETTER PATIENT OUTCOMES TRI science addiction

NIDA CASPAR 2 The CASPAR 2 NIDA grant will be conducted in 3 counties outside of Philadelphia, and will use a pre-post design TRI science addiction

CASPAR 2 The CASPAR 2 grant will collect data from 20 treatment programs and 400 patients TRI science addiction

Creating an Electronic Resource Guide: Linking Services to Client Needs NIDA Grant # RO 1 DA 015125 TRI science addiction

Purpose and Background Provide guidelines and instructions for community-based SA treatment programs to develop a customized resource guide for use by counselors to increase services received by clients TRI science addiction

Purpose and Background Suggestions and time estimates are based on having developed resource guides for 3 studies in the following areas: • Philadelphia County • Bucks, Montgomery, and Delaware Counties in PA • Southern New Jersey TRI science addiction

Why Create an Electronic RG? • Services for many problem areas identified during assessment are not available within traditional community-based treatment programs • Counselors have difficulty finding resources for these services TRI science addiction

Why Create an Electronic RG? • Paper resource guides are available but there is a need for materials that are 1. More user-friendly 2. More easily-updated 3. Useful for counselors TRI science addiction

Things to Consider… Software Program: • Data structure & storage Microsoft Access or Web-based • Data entry fields - address, hours, fees, web address, etc. • Standardized data dictionary TRI science addiction

Things to Consider… Functionality & Layout: • Screen layout • Search functions - basic and advanced • Print functions • Help function • Mapquest function or public transportation services TRI science addiction

Estimated time required = 10 hours Step 1 – Identifying Services Identify types of services to be included: • Free / low-cost services • Location • Hotlines • Medical / Psychiatric services • Legal services / Drivers license • Women’s services • Employment / Vocational services • Recovery houses TRI science addiction

Estimated time required = 80 hours Step 2 – Identifying Agencies Locate available lists of resources / agencies Suggested sources: • Paper resource guides • Internet sources • Counselor resources/smaller guides • CJS Resource list • United Way Our search resulted in 23 sources for the greater Philadelphia area TRI science addiction

Statistics on 3 Counties in PA Bucks County Population (Source: U. S. Census Bureau 2006) # of Programs included in the Resource Guide Montgomery Delaware County 623, 205 775, 688 555, 996 607 1275 676 Total # of Programs included for these 3 counties= 2, 558 TRI science addiction

Step 3 – Verifying Information Verified information by: • Internet searches on all agencies • Verification calls on random 10% sample Estimated time required: Verifying by telephone = 40 hours per 100 agencies Verifying by internet = 35 hours per 1000 agencies TRI science addiction

Verification Call Results Bucks, Montgomery, Delaware and surrounding Pennsylvania Counties N = 230 TRI science addiction

Step 4 – Deleting Agencies Delete agencies that are: 1. Duplicates 2. No longer deliver services listed 3. Not appropriate 4. Closed, Disconnected / No Answer Resulted in the deletion of 875 agencies for the present study Estimated time required = 15 hours TRI science addiction

Step 5 – Enter Program Info & Categorize Enter Program Info: • Standardize data • Data enter all program information • Check accuracy Estimated time required: Entering program info - 80 hours/1000 agencies Categorizing - 20 hours/1000 agencies Est. total time - 280 hours

Step 5 – Enter Program Info & Categorize

Sample of a Program Info Screen

NIDA ATTC Blending Team Providing training, dissemination and technology transfer of EBP. An example with the Addiction Severity Index and Treatment Care Planning TRI science addiction

NIDA Blending Teams Who? –NIDA Researchers –SAMHSA's Addiction Technology Transfer Centers (ATTCs) What do they do? –Work together to develop ‘products’ based on research conducted within NIDA's Clinical Trials Network (CTN) and other supported research TRI science addiction

NIDA Blending Teams Why do they do it? –To give treatment providers the necessary tools to adopt science-based interventions in community-based programs –Create necessary tools to allow for the trouble-free adoption of science-based interventions in community-based programs TRI science addiction

NIDA Blending ‘Products’ Products Completed • Buprenorphine Treatment: Training for Multidisciplinary Addiction Professionals • Short-Term Opioid Withdrawal Using Buprenorphine • M. A. T. R. S. Treatment Planning: Utilizing the Addiction Severity Index (ASI) TRI science addiction

NIDA Blending ‘Products’ In Development • Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency (MIA: STEP) • Promoting Awareness of Motivational Incentives (PAMI) TRI science addiction

MATRS Treatment Planning • NIDA Researchers – Deni Carise, Ph. D. , TRI – Meghan Love, TRI – Tom Mc. Lellan, Ph. D. , TRI • ATTCs – Nancy Roget, Mountain West ATTC – Dick Spence, Gulf Coast ATTC – Pat Stilen, Mid-America ATTC TRI science addiction

NIDA Approved Products M A • Trainer script • Power. Point slides • CD-Rom) • Handouts • Reference Lists/Examples T 6 -hour classroom training R S!

NIDA Approved Products 4 -week online version • Designed in Moodle course management system (CMS) (Free, open source software!) TRI science addiction

MATRS Training Package • How ASI can be used in clinical and program evaluation activities • Identifies differences between program-driven and individualized treatment planning processes TRI science addiction

MATRS Training Package • Focus on process of treatment planning • Defines guidelines and legal considerations in documenting client status TRI science addiction

Adapted Products Mountain West ATTC Curriculum Infusion Package TRI science addiction

Mid America ATTC TX. Plan Check list http: //www. mattc. org/information/smart/ASI-SMART%20 BIRP%20 CHECKLIST. pdf

Mid America ATTC Documentation Checklist http: //www. mattc. org/info rmation/smart/ASIMART%20 BIRP%20 CH ECKLIST. pdf

Mid-America ATTC On-Line 6 -week Course In Blackboard • Focus on skill development & application in clinical setting (12 hours)

MATRS Treatment Planning Software In Development! TRI science addiction

Building a Master Problem List

Problem Statements

Building a Specific Problem Plan

Identifying Client Strengths

THANK YOU!!