—by Paul M. Kubek
Cleveland & Columbus, OH—Staff turnover in behavioral healthcare organizations has always been a challenge for sustaining service innovations that improve quality of life and other outcomes for people diagnosed with severe mental illness and addiction to alcohol, tobacco, opioids, and other drugs. Train a team of providers at an agency how to implement an evidence-based practice in year one and by year three—with an annual staff attrition rate of 30 percent—almost no one from that original team remains. The results? Loss of knowledge and skills within organizations; a potentially stalled initiative; unmet objectives; interruptions in safe and trusting relationships between service providers and clients that are essential for maximizing recovery.
One solution for ensuring service continuity in community agencies that has withstood the test of time is the Center for Evidence-Based Practices at Case Western Reserve University, which is celebrating its 20-year anniversary. The Center is a technical-assistance organization that provides consulting, training, and evaluation services to help behavioral healthcare organizations implement and sustain evidence-based practices, best practices, and other services innovations that improve outcomes for people with co-occurring mental illness and substance abuse challenges. The Center is an ongoing partnership between the Jack, Joseph and Morton Mandel School of Applied Social Sciences at Case Western Reserve University and the Department of Psychiatry at the Case Western Reserve School of Medicine.
As a technical-assistance organization based at a university, the Center understands the world of practice, policy, and research. It keeps that knowledge-base intact and makes it available to organizations that work to manage day-to-day challenges of service delivery, such as changes in federal, state, and local policies that govern practice; fluctuations in funding and reimbursements from government and private insurance; crises in the lives of clients because of symptoms of mental illness and addiction; and, of course, a break in service continuity caused by staff turnover.
36 states, 5 countries, veterans affairs & Samhsa
Since the Center’s inception in 1999, policymakers and leaders of state and regional behavioral healthcare authorities, service agencies, courts and criminal justice organizations, hospitals, and health clinics from 36 states and 5 countries—as well as Veterans Affairs (VA) medical centers in Ohio, Indiana, and Michigan—have sought technical assistance from the Center, which has also received requests for help from the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA). The Center is currently active in Ohio, California, Georgia, Iowa, Louisiana, Maryland, Michigan, New Hampshire, North Carolina, North Dakota, Pennsylvania, South Carolina, Tennessee, Texas, and Virginia.
Ohio Department of Medicaid
In its home state of Ohio, the Center has worked with over 60 organizations in a variety of communities throughout the state’s 41,000 square miles, including urban centers in Toledo, Cleveland, Youngstown, Columbus, Cincinnati, and Dayton, as well as numerous suburban and rural communities in between. The Center is currently Ohio’s center of excellence for several best practices, including Assertive Community Treatment (ACT), an evidence-based practice that improves outcomes for people with severe mental illness who are most at-risk of homelessness, psychiatric crisis and hospitalization, and involvement in the criminal justice system. The Ohio Department of Medicaid (ODM) provides support to the Center for its consulting, training, and evaluation services for ACT as part of Ohio’s Behavioral Healthcare Redesign initiative. The Center also disseminates other evidence-based practices and best practices, including the following:
- Assertive Community Treatment (ACT)
- Motivational Interviewing (MI)
- Strategies for Substance Abuse and Mental Illness (SAMI)
- Integrated Dual Disorder Treatment (IDDT)
- Dual Diagnosis Capability in Addiction Treatment (DDCAT)
- Dual Diagnosis Capability in Mental Health Treatment (DDCMHT)
- Supported Employment / Individual Placement and Support (SE/IPS)
- Benefits Advocacy and Planning (BAP)
- Promoting Housing Stability (PHS)
- Integrated Primary and Behavioral Healthcare (IPBH)
- Tobacco: Recovery Across the Continuum (TRAC)
Technology transfer
According to Co-Director Lenore A. Kola, PhD, associate professor emerita of social work at the Mandel School, and Co-Director Robert J. Ronis, MD, MPH, the Douglas Danford Bond Professor and Chairman of the Department of Psychiatry, the Center has gained a national reputation for technology transfer—the translation of research into practice—because of its systematic method of providing consultation, training, and evaluation services. The success, they add, is also built upon the quality of its multidisciplinary staff, which includes consultant-trainers, evaluators, and researchers from the fields of social work, psychiatry, community mental health, chemical-dependency treatment, and vocational rehabilitation. Staff members have many years of experience as direct-service providers, team leaders, program managers, and administrators.
According to Kola, the Center developed its method of technical assistance from the practice experiences of its consultant-trainers and from research that has identified five stages of organizational and behavior change: pre-contemplation, contemplation, preparation, action, and maintenance. Each stage in the Center’s method contains multiple action steps that help organizations fulfill incremental goals during the implementation process. This stage-wise approach is important, because it sets a realistic, manageable pace for achieving and sustaining high fidelity to best practices and improved outcomes over time. The Center’s method is described in detail in two e-books available as free downloads from its website: “Implementing IDDT: A Step-by-Step Guide to Stages of Organizational Change” and “ACT | Timeline for Implementation.”
“So much of the success of technology transfer boils down to assessing and fostering readiness to change and willingness to invest,” Kola says. “Are agency executives and individual staff members ready to utilize new knowledge to change what they do? Are the people who manage systems and organizations ready to commit the human resources and financial resources and time so their staff members may learn the new knowledge and integrate it into practice?”
Workforce development in Ohio
According to Ronis, the Center has always been an expert in organizational change, best-practice implementation, and workforce development. He recalls that in 1999 the Ohio Department of Mental Health (ODMH) helped create the Center for Evidence-Based Practices as a center of excellence to help organizations enhance services for people with co-occurring substance abuse and mental illness.
At the time, ODMH Director Michael Hogan, PhD, and Medical Director Dale Svendsen, MD, decided to use SAMHSA Block Grant dollars to create the Center and support it over time to provide leadership in EBP implementation and workforce development in Ohio, where the staff turnover rate in state psychiatric hospitals and community mental-health organizations was approximately 30 percent annually in some facilities. Drs. Hogan and Svendsen recognized the need for a source of constancy in the state mental health and addiction-services systems to support the implementation of evidence-based practices. They invested in technical-assistance organizations like the Center to provide ongoing consulting, training, evaluation, and education, not only among new hires but also among seasoned veterans seeking opportunities to improve their knowledge, skills, and clinical relationships.
“It’s an approach that still has traction today,” Ronis says, explaining that the Ohio Department of Medicaid has recognized the value of keeping the implementation knowledge-base available to service providers in the state. “Ohio has been a leader in sustaining EBPs, and other states have taken notice and reached out to make use of our expertise.”
Innovations in Ohio
Ronis and Kola both explain that the initial grants from ODMH in 1999 supported a pilot project of nine Ohio behavioral health organizations—with additional support from the Ohio Department of Alcohol and Drug Addiction Services. Over the course of 20 years, the initiative expanded with support from the Ohio Department of Mental Health and Addiction Services (OhioMHAS) and Ohio Department of Medicaid (ODM) to include over 60 community-based organizations and all state psychiatric hospitals. The Center’s impact upon the service system in Ohio has been made possible by a dedicated staff of licensed social workers, counselors, addictions counselors, and psychiatrists under the leadership of Patrick E. Boyle, PhD, MSSA, LISW-S, who served as director of implementation services for 20 years. Boyle, who now serves as consulting director, plans to retire in December: he is serving as a mentor to new leadership during the transitional period.
“The Center is poised to keep building on its successes,” Boyle says. “We have an incredible staff of dedicated people who are fierce advocates for quality care that promotes and supports recovery among the most vulnerable people in our local communities. The Center is unique in the United States because it offers a full array of technical assistance for several important EBPs.”
Boyle brought to his leadership role at the Center experience in research, more than 20 years of teaching, and 45 years in direct practice, clinical supervision, and administration in the fields of addiction services, mental-health services, and employee-assistance programs. From this diverse professional history, Boyle helped shape the technical-assistance services of the Center to emphasize the importance of organizational consultation that helps service providers become self-sufficient with implementing, evaluating, and sustaining clinical innovations over time. He has also ensured that the Center actively promotes and supports inter-system collaborations among mental health services, addiction services, vocational rehabilitation, health, housing, residential services, consumer advocacy, and criminal justice, among others.
Recovery Relationships
Boyle adds that while the Center has worked primarily with service organizations and service systems, the mission of the Center has always been to promote recovery among people with mental illness, substance use disorders, and co-occurring disorders through the implementation of evidence-based practices and other best practices.
Recovery, he explains, is the belief that people can and do manage symptoms of mental illness and addiction and thrive despite the existence or recurrence of the challenges presented by those symptoms. He adds that recovery occurs within the context of safe, trusting, and consistent relationships among clients of services, service providers, and family and friends of clients.
“What the recovery approach teaches us is that we need each other,” Boyle says. “Plain and simple. Human beings exist within a context of relationships and those relationships can function as a protective factor against symptoms and negative consequences of the symptoms. With the right kind of support from people in service systems willing to do the right thing, people who struggle with mental illness and addiction can live and work in the community and enjoy all the benefits of achieving goals that they identify as important to them.”