—by Paul M. Kubek
The culture of health and human services in the United States has multiple layers. First, there is the culture of the system in which policymakers in state and county government create and enforce the rules that govern the activities of service organizations and the funding or payment of services. Then there is the culture of the organization, which holds together relationships among community stakeholders, administrators, managers, and team leaders of programs that make treatment available. At the core, there is the clinical culture, which supports the relationships between those who provide help and those who receive it.
Understanding the complexities of culture in healthcare and behavioral healthcare is important. When researchers discover new knowledge that can improve practices, clinical outcomes, and costs of services, the knowledge must penetrate—and be absorbed by—at least three layers of culture before it can inspire and create change. That’s why a technical-assistance organization like the Center for Evidence-Based Practices (CEBP) at Case Western Reserve University—a partnership between the Mandel School of Applied Social Sciences and the Department of Psychiatry at the Case School of Medicine—is so important.
As a university-based purveyor of change, the Center understands the world of research and the world of policy and practice. Since its inception in 1999, it has been helping state and county health authorities, community mental-health and addiction service agencies, and hospitals and health clinics to implement and integrate evidence-based practices and other emerging best practices. This improves the quality of life and other outcomes for people with mental illness or co-occurring mental illness and substance use disorders (called dual disorders or co-occurring disorders).
TECHNOLOGY TRANSFER | A STEP-BY-STEP GUIDE
According to Co-Director Lenore A. Kola, PhD, associate professor 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.
"Our staff understands from first-hand experience many of the facilitators and barriers to systems change, organizational structure, and clinical behavior change," Ronis says. "They know how to navigate relationships, to elicit from others their motivation to change, and to make recommendations in a manner that is assertive yet sensitive to people's uncertainties about transforming old routines into new ones."
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 in organizational change and behavior change: pre-contemplation, contemplation, preparation, action, and maintenance. Each stage in the Center's method contains eight to 10 practical 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 its manual, titled "Implementing IDDT: A Step-by-Step Guide to Stages of Organizational Change," which is available as a free PDF on its website ( get resource ).
READINESS TO CHANGE
"So much of the success of technology transfer boils down to readiness to change," Kola says. "Are 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 staffs may learn the new knowledge and integrate it into practice?"
According to Ric Kruszynski, MSSA ('94), LISW, LICDC, director of consulting and training for substance abuse and mental illness (SAMI) initiatives, although the Center's method is systematic, it is also flexible enough to respond to unique circumstances, such as the culture of organizations and communities. Consultants and trainers are skilled at assessing readiness to change continuously and skilled at adjusting to fluctuations in motivation to change. Numerous tools that the consultants use to assist in this process include the following:
- Organizational needs assessments
- Fidelity scales
- Fidelity reviews
- Action plans that are developed in collaboration with the organizations
- Technology-transfer manuals that prime and remind people about core concepts of the practices they are learning
- Onsite training and consulting with administrators, program managers, team leaders, and direct-service providers; and steering committees comprised of community stakeholders
COLLABORATION & INTEGRATION | OHIO, 23 OTHER STATES & 4 COUNTRIES
Over the past 11 years, the Center has been using its methods with success in a variety of communities throughout Ohio's 41,000 square miles, including urban centers in Toledo, Cleveland, Youngstown, Columbus, Cincinnati, and Dayton, as well as numerous rural communities in between. The Center has also received requests for help from the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) and from policymakers and service organizations in 23 other states and four other countries—including Australia, Canada, England, and the Netherlands—and is currently active in Colorado, Maryland, Michigan, New Mexico, North Dakota, Pennsylvania, and South Dakota, among others.
This past year, the Center continued to build upon its past successes. It received grants from the Ohio Department of Mental Health and the Ohio Department of Alcohol and Drug Addiction Services to continue the operation of two State of Ohio Coordinating Center of Excellence (CCOE) initiatives—the Ohio Substance Abuse and Mental Illness CCOE and the Ohio Supported Employment CCOE. (There are a total of six CCOEs in Ohio.) The state support comes from Block Grants awarded to Ohio by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA).
Through its CCOE initiatives, the Center continues to provide consulting, training, and evaluation for Integrated Dual Disorder Treatment (IDDT), the SAMHSA-recognized evidence-based practice, to all six of Ohio’s regional psychiatric hospitals and over 60 community mental health organizations. It also provides technical assistance for Supported Employment (SE), another SAMHSA-recognized evidence-based practice, to 23 organizations in Ohio and works with staff from six of Ohio’s Consumer-Operated Services to encourage employment among their participants. The Center also continues to work with hospitals, health networks, and community health clinics to integrate core components of evidence-based practices and emerging best practices into primary healthcare with Motivational Interviewing (MI) and "Tobacco: Recovery Across the Continuum” (TRAC), a motivational model for tobacco cessation that was developed by the Center specifically for people with severe mental illness.
COST SAVINGS IN STATE OF OHIO
Kola and Ronis explain that the Center’s technical assistance is producing important results. This past year, researchers from the Center conducted an analysis of claims data for behavioral-health services among 1,122 people in the State of Ohio who were receiving Integrated Dual Disorder Treatment (IDDT) and found that the treatment helped save the state approximately $1.4 million in service costs for a subgroup of 160 people: these individuals were among the highest users of services, especially high-cost services like inpatient psychiatric hospitalization. The reduction in service utilization and, thus, reduction in cost took place only one year after these individuals started to receive IDDT services.
According to Patrick E. Boyle, MSSA (’89), LISW-S, LICDC, director of implementation services at the Center, and Debra Hrouda, MSSA (‘94), LISW-S, director of quality improvement at the Center and lead researcher, this is one of the first studies of its kind in the country to use state-level data. The result of this analysis is compelling, because it shows that integrated treatment can make an impact upon costs in a short amount of time ( get full story ).
"IDDT is a paradigm shift that produces results,” Boyle says. "With integrated treatment, consumers get help for both disorders at the same time from staff at one agency. In the past, they would have been required to get help for each problem from different agencies.”
Boyle explains that the results in Ohio have caught the attention of SAMHSA, which invited the Center to participate in three important symposia this past spring and summer. The events were attended by representatives from over 20 states throughout the country. Boyle chaired two sessions and made presentations in collaboration with Hrouda about the cost-analysis study and the Center’s technical-assistance methods. They also presented information about implementing IDDT, as well as emerging results from the Center’s ongoing evaluation of a SAMHSA-funded project at Shawnee Mental Health Center in Portsmouth, Ohio. The project integrates primary-health assessments and services within Shawnee’s mental-health services.
This past year, the Center also began to provide training to the treatment team of "Project RESTORE," an intervention in the Cuyahoga County Jail (click here for story).
WORKFORCE DEVELOPMENT
According to Boyle, Kola, and Ronis, the Center has been fulfilling an important role in workforce development in Ohio, where the staff turnover rate in state psychiatric hospitals and community mental-health organizations is approximately 30 percent annually in some facilities. Policymakers at the Ohio Departments of Mental Health and Alcohol and Drug Addiction Services have recognized the need for a source of constancy in its systems to support the implementation of evidence-based practices, so they have invested in technical-assistance organizations like the Center—and its Coordinating Center of Excellence initiatives—to provide ongoing consulting, training, evaluation, and education, not only among new hires but also among seasoned veterans who are seeking opportunities to improve their knowledge, skills, and clinical relationships.
Paul M. Kubek, MA, is director of communications at the Center for Evidence-Based Practices at Case Western Reserve University, a partnership between the Mandel School of Applied Social Sciences and Department of Psychiatry at the Case School of Medicine.