implementation research to redesign state systems for child and family behavioral health: the...
TRANSCRIPT
Implementation Research to Redesign
State Systems for Child and Family Behavioral Health:
The Business Case for Clinical and Preventive Care
Or Getting the Right Sight Picture
Kimberly Eaton Hoagwood, PhDAmerican Public Health Association
November 2, 2015
Presenter Disclosure
The following personal financial relationships with commercial interests relevant to this
presentation existed during the past 12 months:
Kimberly Hoagwood, PhD
No relationships to disclose
Key Points
Continued increase in prevalence of mental health problems among children
Service use increasing, but quality of services still poor
Evidence base on effective clinical, preventive, and service interventions for children/families is strong
Healthcare policies offer new structures and reimbursement options
Implementation research misaligned for informing state healthcare policy or improving children’s mental health
Get the right sight picture by looking at the horizon line: 5 dimensions
The National Context: Healthcare Quality and
Accountability Important Federal Initiatives
2008: Mental Health Parity and Addiction Equity Act
2010: The Patient Protection and Affordability Care Act (ACA)
Expansion of Medicaid coverage
New Incentives for care coordination, electronic data systems, pay for performance
Impact on States1. Medicaid Managed Care
2. Shift from separate MH authority to combined health, MH, SA, welfare etc.
3. Concern with costly services, high end users, access
4. Growing involvement of consumers
5. Workforce shortages and task shifting
6. Health homes and care coordination
7. Data monitoring, EHRs
8. Focus on quality measures, accountability, and outcomes
State Context: Fiscal Realities for State Mental Health Systems1
Budget cuts (mainly State General Funds and Medicaid): FY09-FY12 totaling $4.35 billion
76% of 47 state mental health agencies reported budget cuts in 2011
73% of 47 state mental health agencies reported budget cuts in 2012
88% of states in 2013 using managed care to provide behavioral health services
State mental health agencies’ response to budget cuts in 2011-12: 24% reduced community mental health services 27% reduced the number of clients served in the community 39% reduced funds to community providers 52% cut staff 64% had hiring freezes 82% reduced administrative expenses
1NASMHPD Research Institute (2012). The impact of the state fiscal crisis on state mental health systems: Winter 2011-2012 update. http://media.wix.com/ugd/186708_c2fd199b2a9f4d04818b889b93c3a884.pdf.
Implications for States Numbers of children with ND/MH disabilities are rising
States facing major cost constraints
State workforce shortages
State systems under new management (Managed Care)
States supporting EBTs but to a limited extent
Research needs to address the business case: What is the added value of implementing evidence-based services? Addressing workforce issues: New staff models and trainings Developing quality metrics Aligning effective clinical and preventive services with the
business model
Children & Adolescents at Risk (Halfon 2015)
4-8%Significant Disabilities
14-18%Special Health
Care Needs
30-40%Behavioral,
Mental Health Learning Problems
50-60% Good Enough
What % are thriving ?
30% ?
40% ?
50% ?
Children/Adolescents: Mental Health Need and Use of
Services 22.8 % of adolescents have a mental disorder with
impairments (Merikangas et al JAACAP 2010)
Prevalence of all mental disorders in children enrolled in Medicaid rose 40% to 8.2 M from 2001 to 2010 (National Academies of Medicine, Engineering, and Science, 2015)
Inpatient mental health and substance abuse admissions increased 24% between 2007-2010 (Olson et al JAMA Psych 2014)
Rate of outpatient visits resulting in mental health diagnosis among children increased from 7.8% to 15.3% between 1995 and 2010. (Olson et al JAMA Psych 2014)
Impairments due to Mental Health/Neurodevelopmental
Conditions for U.S. Children, 1960-2008: 4 fold increase
Source: Halfon & Houtrow, 2014; IOM Presentation, Disability in Childhood: Trends and Lifecourse Complications
Quality of Services: Penetration rates of evidence-based treatments by state
MH authorities are small
65-80% of states use selected adult EBTs Median clients served in these states 400-700 Penetration rates = 1.5% - 3.0% of estimated adults
with SMI
25%-50% of states use selected child EBTs Median clients served in these states 250-400 Penetration rates = 0.75% - 2.5% of all youths with SED
Several EBTs showed increases in early 2000s followed by decreases or flattening from 2007-2012
Source: Bruns et al., 2015
Evidence-Based Practice Registries*
APA, Div 53, Evidence-based Mental Health Treatment for Children & Adolescents
National Child Traumatic Stress Network National Guideline Clearinghouse, Agency for Healthcare Research and Quality The National Implementation Research Network New Zealand Guidelines Group National Registry of Evidence-based Programs and Practices (NREPP) Oregon Addiction and Mental Health Services (AMH) Promising Practices network (PPN) What Works, Wisconsin Evidence-based Parenting Program Directory Office of Juvenile Justice and Delinquency Prevention (OJJDP) The Campbell Collaboration Child Trends “What Works” The Cochrane Collaboration OTseeker, The University of Queensland Social Care Institute for Excellence (SCIE) Social Programs That Work, Coalition for Evidence-Based Policy Suicide Prevention Resource Center (SPRC) PracticeWise (Managing and Adapting Practice) California Evidence-Based Clearinghouse National Alliance on Mental Illness Model Programs Guide at the Office of Juvenile Justice and Delinquency
Prevention
*Not an inclusive list; only a sampling of registries.
Washington State Institute for Public Policy (WSIPP) Best Bets in Children’s Mental Health
Top 5 Programs, Greatest Chances of Benefits > Costs
Program Name
Review Date
Total Benefits
Taxpayer Benefits
Non-taxpayer Benefits
Costs Benefits-Costs NPV
Benefit to Cost Ratio
Chances Benefits > Costs
Triple P Positive Parenting (Lvl 4, Grp)
4/2012 $1,015 $203 $811 $550 $1,565 n/a 100%
Remote CBT for anxious children
4/2012 $22,720 $6,746 $15,974 $777 $23,497 n/a 99%
Group CBT for anxious children
4/2012 $7,380 $2,167 $5,213 $411 $7,792 n/a 99%
Parent CBT for anxious children
4/2012 $1,845 $461 $1,384 $637 $2,483 n/a 99%
CBT Models for Child Trauma
4/2012 $6,169 $1,837 $4,333 $332 $6,501 n/a 98%
Source: www.wsipp.wa.gov/benefitCost/Program
Why the Lack of Progress?
Prevalence is rising, need/use gap remains, and quality is low. Why? • Tired academic models plus 17-year gap
• Impractical interventions
• Lack of attention to the business case
• Too focused on barriers and program implementation; too little attention to implementation of social policies
• 99% of program announcements from NIH focused on barriers; ½ of funded R01s were atheoretical (Tinkle et al., 2013)
The 17-Year Odyssey
Source: Green L, Ottoson J, García C, Hiatt R. Diffusion theory and knowledge dissemination, utilization, and integration in public health. Annu Rev Public Health 2009;30:151–74; in Altman D, Goodman S. Transfer of technology from statistical journals to the biomedical literature: past trends and future predictions. JAMA 1994;272:129–32
Kimberly Eaton Hoagwood, PhD,Director
Funded by NIMH P30MH090322www.ideas4kidsmentalhealth.org
Community Technical Assistance Center (CTAC)
Community TA Center (CTAC)
McKay & Hoagwood (Co-Directors) Provide training and quality improvement strategies to all NYSOMH licensed clinics (N=346) serving children and families. Address both clinical and business needs.
Business improvement practices (Lloyd, 2012) Open access Centralized scheduling Concurrent documentation Volume and productivity
Evidence-informed clinical practices Engagement training (McKay et al., 2012) addressing no show rates Multi-family Groups for Disruptive Behavior Disorders (Chacko et al., 2014) Managing and Adapting Practice (MAP) training (Chorpita & Daleiden)
through the Evidence-based Treatment Dissemination Center in NY. N=150 therapists per year. Common factors
Webinar (1 hour) In-person training (full-day) Learning Collaboratives (6 months to one year)
CTAC Business Consultation• Help clinics develop strong business and financial
models to ensure sustainability• BEAM: Business Effectiveness Assessment Module
Practice Improvement Network (assess viability)• BEEP: Business Efficiencies and Effectiveness
Project Learning Collaborative (redesign financial and practice process flows)
• CARE: The Change Action & Resource Exchange Network (builds on BEAM)
• Just-in-Time Scheduling Initiative • Increase access, decrease no-show
• Business Tools (e.g. benchmarking, productivity)• Revenue cycles
Source: Community Technical Assistance Center, Business Trainings, 2015.
Two Examples
Participation in state-sponsored trainings: Adoption Studies
Parent partners and workforce development: Multi-family group therapy for disruptive behaviors
Study #1: Adoption Study
To characterize adoption/uptake of CTAC offerings in New York State
To identify factors that facilitate or challenge adoption at multiple levels
To design interventions to improve state roll-outs
Why: to help state policy-makers decide how to efficiently roll-out new programs or services. Costs of prior roll-outs range from $2M to $60M
Characterizing Adoption Patterns Aim: Develop operational definitions for adoption
Approach: Based on CTAC attendance data of the 346 clinics, adoption defined 4 ways:1. By number of trainings adopted2. By intensity of trainings adopted3. By type of trainings adopted4. By classifying clinics into distinct adopter groups:
Low: Webinar = Highest intensity adopted Medium: In-person training = highest intensity adopted High: 1 LC = highest intensity adopted Super: Both LCs = highest intensity adopted
Source: Chor KH, Olin SS, Weaver J, Cleek AF, McKay MM, Hoagwood KE & Horwitz SM (2014). Adoption of Clinical and Business Trainings by Child Mental Health Clinics in New York State. Psychiatric Services, 65(12), 1439-1444.
Number, intensity and type
Number of trainings adopted: 248 of 346 clinics adopted at least 1 training Mean = 4.8 trainings; median = 3 trainings
Intensity of training 94.4% webinair 49.6% in person 19.0% learning collaborative
Type of training 186 (75.0%) adopted ≥1 business training. – among 26 LC adopters, 76.9%
sampled business webinars first before signing on 187 (75.4%) adopted ≥1 clinical training 120 (48.4%) adopted ≥1 hybrid training
Source: Chor KH, Olin SS, Weaver J, Cleek AF, McKay MM, Hoagwood KE & Horwitz SM (2014). Adoption of Clinical and Business Trainings by Child Mental Health Clinics in New York State. Psychiatric Services, 65(12), 1439-1444.
Adopter Groups
Non Low Med Hi Super0
50
100
150
200
250
44.8%
36.3%
15.7%
3.2%
28.3%
Source: Chor KH, Olin SS, Weaver J, Cleek AF, McKay MM, Hoagwood KE & Horwitz SM (2014). Adoption of Clinical and Business Trainings by Child Mental Health Clinics in New York State. Psychiatric Services, 65(12), 1439-1444.
Predictors of Adoption
Aim: Predicting clinic responses to trainings Business practices vs. clinical trainings examined
separately
Approach: Based on clinic attendance data between September 2011 and August 2013, adopter groups were created Adopter of any training (yes/no) Intensity of training participation among adopters (low/high)
Multiple logistic regression (adjusted odds ratios) were used to assess the independent effects of predictor variables on clinic training participation.
Source: Olin SS, Chor KH, Weaver J, Duan N, Kerker B, Clark L, Cleek AF, Hoagwood KE, Horwitz SM (2015). Multilevel Predictors of Clinic Adoption of State-Supported Trainings in Children's Services. Psychiatric Services.
Reduced Logistic Regression Model with AORs for Clinic Effects on Business Practice (BP) Uptake
N = 287
Any uptake vs. No uptake†
AOR 95% CI p
Extra-Organizational Variable Region-urbanicity
Downstate urban - Upstate urban - Upstate rural - Agency-Level Variables
Affiliation Community affiliated ref.
Hospital affiliated 0.50 0.18-1.36 ns Total expenses, in millions (M±SE) 0.65 0.50-0.84 ** Gain or loss per service unit (M±SE) 0.62 0.41-0.94 * % Clinical staff (M±SE) -
Clinic-Provider Profile Variables Total clinical full-time equivalent (M±SE) 1.33 0.94-1.88 ns % Clinical staff contracted out (M±SE) 0.60 0.46-0.80 *** Clinic-Client Profile Variables % Under age 18 clients (M±SE) -
% Medicaid & MMC visits (M±SE) - % SED clients (M±SE) -
Hospital affiliation X Total clinical FTEs 4.89 1.31-18.28 * pseudo R2=0.1213, LR chi2=44.71, df=6, p<.001; *p<.05, **p<.01, ***p<.001; -Variable was not included in the final model because p≥.05
Reduced Logistic Regression Model with AORs for Clinic Effects on Clinical Trainings (CT) Uptake
N = 294
Any uptake vs. No uptake†
AOR 95% CI p
Extra-organizational Variable Region-urbanicity
Downstate urban
- Upstate urban
-
Upstate rural
- Agency Level Variables
Affiliation Community affiliated
- Hospital affiliated
-
Total expenses, in millions (M±SE)
- Gain or loss per service unit (M±SE)
-
% Clinical staff (M±SE)
- Clinic-Provider Profile Variables
Total clinical FTEs (M±SE)
1.52 1.11-2.08 ** % Clinical staff contracted out (M±SE)
-
Clinic-Client Profile Variables % Under age 18 clients (M±SE)
1.90 1.42-2.55 ***
% Medicaid & MMC visits (M±SE)
- % SED clients (M±SE) -
pseudo R2=0.079, LR chi2=29.74, df=2, p<.001*p<.05, **p<.01, ***p<.001; -Variable was not included in the final model because p≥.05
Lessons Learned
1. Increasing sheer number of trainings unlikely to improve adoption Median = 3 trainings
2. Intensity and accessibility of trainings drive adoption preference Webinar uptake > In-person training uptake > Learning collaborative uptake Trialability: Clinics that adopted an LC were likely to have sampled a webinar first
3. Business and clinical trainings are equally important to clinics’ needs and viability
Business vs. Clinical: Identical rate of uptake (75%) Address climate of accountability and quality Size, affiliation (hospital or community) and clinical outsourcing drive interest in
participating in business practices
4. Adopter groups communicate meaningful adopter profiles From low- to super-adopters, the continuum represents an increase in quantity
and intensity of trainings adopted
5. States can develop different strategies for different roll-outs
Study #2. Parent Partners and Workforce Development: Multi-Family
Groups (McKay, Hoagwood et al)
Parent partner training: 400+ parent partners trained and certified in NYS (Rodriguez et al 2011)
Multiple Family Group (MFG): service delivery strategy to enhance child service use and outcomes for urban, low-income children of color (McKay et al 2011)
NIMH-funded (R01MH072649) randomized effectiveness trial of MFG vs. services as usual in 10 outpatient clinics across NYC; Youth 7 to 11 and their families Met criteria for ODD or CD Majority of families with low household income and of African
American and/or Latino descent
Parent Partners and Workforce Development: Multi-Family
Groups (continued)
MFG content and process designed in collaboration with parents and providers (McKay et al 2011)
Involves 6 to 8 families; At least two generations of a family are present in each session
Knowledge sharing and practice activities foster both within family and between family learning/interaction
Second R01 in the field in 2015 to further replicate MFG model, funded by NIMH (R01MH106771-01)
MFG Evidence-Informed Targets
Strengthens parenting skills and family relationship processes Child management skills Family communication Within family support Parent/child interaction
Addresses factors affecting service use and outcomes Parental stress Use of emotional and parenting support Stigma associated with mental health care
In the words of families…
Multiple family groups should focus on: (4Rs) . . . Rules Roles and Responsibilities Respectful communication Relationships
. . . As well as the 2Ss Stress Support
Study Participants and Analyses
(Gopalan et al 2015; Chacko et al 2015) Adult caregivers: 87% female; low income; ½ completed
high school; 45% employed 47% African American; 42% Latino
Families had an average of 3 children living with them
Youth average age = 9.5 years
Random coefficient modeling to examine change over time and differences between MFG and Service as Usual
Time modeled as months from baseline using measurements from 4 time points: Baseline Mid-test (midway through intervention) Post-test (following intervention) 6-month follow-up
Outcome Variable B SE Z p ES
Child Disruptive Behavior -1.2 .51 -2.4 .02 .35
Impairment in peer relationships -.41 .20 -2.1 .04 .28
Impairment in self esteem -.42 .20 2.1 .03 .29
Overall severity/impairment in functioning
-.41 .17 -2.4 .02 .37
Social Skills1 3.5 1.5 2.4 .02 .33
Total parenting stress -6.0 3.2 -2.4 .06 .27
Perceptions of child as difficult -3.0 1.3 -2.4 .02 .35
Child rearing distress -5.0 2.2 -2.3 .02 .33
Adult caregiver depression2 -4.8 1.8 -2.7 .01 .42
Positive parent/child involvement3 7.6 3.7 2.1 .04 .91
Family organization4 3.1 .96 3.2 .01 .28
Primary Outcomes
1 2 3 4 effect for youth/adults with clinical needs at baseline
Implications
Workforce: Paired team model using parent partners improves family/child outcomes
Billable
Improves volume of services
Robust show rates
Individual and group models so adaptable for different settings
Next: 2nd R01 (June 2015) funded by NIMH to Replicate effectiveness findings Study an implementation strategy: Continuous quality
improvement teams added to MFG training to assess fidelity and sustainability
Getting the right sight picture
Deguild
Drive with data
Distill
Democratize
Disentangle social determinants
1. Deguild: Task Shifting and Team-based Services
Engagement strategies to reduce no-shows (McKay et al., 2010)
Workforce development: Parent peer advisors (Kutash et al., 2013; Hogan et al., 2002; Olin et al., 2010)
Key opinion leaders (Atkins et al., 2005; 2015)
Team-based models (Kutash et al., 2013; Epstein et al., 2006)
Family-based services
Psychoeducation (Fristad et al., 2006)
Multi-family groups (McKay et al.)
Family Support (Olin et al., 2010)
2. Distill: Training alone will not suffice
Chorpita et al. (2011) identified 395 evidence-based protocols of over 750 psychosocial treatments tested in controlled clinical trialsEven if a practitioner knew 395 EBTs, it would only
cover 1/3 of the children receiving usual carePractice elements and component-driven EBPs
(Chorpita et al., 2002; Weist et al, 2006)
EBP Training and Overload
Source: Chorpita & Daleiden, 2009
Distill into Common Practice Elements (Chorpita & Daleiden, 2009)
CognitivePsychoeducational-Child
Activity SchedulingMaintenance/Relapse Prevention
Problem SolvingSelf-Monitoring
Goal SettingSocial Skills Training
Communication SkillsSelf-Reward/Self-Praise
RelaxationBehavioral Contracting
Guided ImageryPsychoeducational-Parent
Talent or Skill BuildingTherapist Praise/Rewards
ModelingStimulus Control or Antecedent Management
Assertiveness TrainingRelationship/Rapport Building
Tangible Rewards
0% 25% 50% 75% 100%
Frequency of Practice Element: Depression
3. Drive with Data: Managing and Adapting Practice
(MAP)The MAP system (Chorpita & Daleiden)
Three tools support practice:
PracticeWise Evidence-Based Services (PWEBS) Database. Online database that can make recommendations about formal evidence-based programs OR about specific components of evidence-based treatments (based on client characteristics)
Practitioner Guides. Provides user-friendly measurement tools and clinical protocols
Clinical Dashboard. Tracks outcomes and practices on a graphical clinical dashboard
*Source: PracticeWise website, www.practicewise.com
Sample Clinical DashboardProgress and Practice Monitoring Tool Clear All Data
Age (in years): 13.4 Gender: Male Yes Redact FileNoTo Today
Progress Measures: To Last Event Left Scale
Anxiety SUDS Yes Anxiety SUDS
Yes Depression Suds
Yes Getting to School
Yes Talking to others
Yes Measure 5
Right Scale
Depression Suds
Getting to School
Talking to others
Measure 5
Engagement w ith Child
Engagement w ith Caregiver
Relationship/ Rapport Building
Goal Setting
Monitoring
Self-Monitoring
Caregiver Psychoed: Anxiety
Child Psychoed: Anxiety
Exposure
Cognitive: Anxiety
Modeling
Child Psychoed: Depression
Caregiver Psychoed: Depression
Problem Solving
Activity Selection
Relaxation
Social Skills
Skill Building
Cognitive: Depression
Caregiver Psychoed: Disruptive
Praise
Attending
Rew ards
Response Cost
Commands/ Effective Instruction
Dif. Reinforce./ Active Ignoring
Time Out
Antecedent/ Stimulus Control
Communication Skills: Advanced
Assertiveness Skills
Communication Skills: Early Dev
Maintenance
Other
Other
Other
Days Since First Event
Display Time:
To today
Display Measure:
Primary Diagnosis: Social Anxiety Ethnicity: Caucasian
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4. Democratize Access to Innovations
Where Good Ideas Come From: The Natural
History of Innovation (Steven Johnson, 2010)
Johnson’s seven ideas to promote innovation• Adjacent possible• Liquid networks• Slow hunch: The deep dive• Serendipity or generative chaos• Error: Fail faster• Exaptation• Emergent Platforms
Market/IndividualPrinting Press, Mercator Projection
Pressure Cooker, Manned hot air Balloon, Lithography
Mason Jar, Tesla Coil, Nylon, Gatling Gun, Vulcanized Rubber, Revolver, Programmable Computer, Dynamite, AC
Motor, Air Conditioning, Transistor
N = 2, N = 3, N = 11
Market/NetworkPortable Watches, Double-Entry Bookkeeping, Stocking
Frame
Chronometer, Balance Spring Watches, Steam Engine, Steamboat, Spinning Jenny, Power Loom, Cotton Gin
Airplane, Steel, Induction Motor, Contact Lenses, Moving Assembly Line, Locomotive, Electric Motor, Refrigerator, Telegraph, Sewing Machine, Elevator, Steel, Typewriter,
Plastic, Calculator, Internal Combustion, Engine, Telephone, Bicycle, Personal Computer, VCR, Laser, Tape Recorder, Jet Engine, Photography, Television, Helicopter,
Vacuum Tube, Washing Machine, Vacuum Cleaner, Motion Picture Camera, Welding Machine, Radio, Automobile,
LightbulbN = 3, N = 7, N = 35
Non-Market/IndividualEarth rotates around sun, Flush toilet…
Bifocal Lenses, Plant Respiration, Analytic Geometry…
Spectroscope, Bunsen Burner, Rechargeable Battery, Nitroglycerine, Liquid Engine Rocket, Uncertainty Principle, Electrons in Chemical Bonds, Absolute Zero, Atomic Theory, Stethoscope, Uniformitarianism, Cell Nucleus, Benzene
Structure, Heredity, Natural Selection, X-Rays, Blood Groups, Hormones, E=mc2, Special Relativity, Earth’s Core, Radiometric
Dating, Cosmic Radiation, General Relativity, Universe expanding, Ecosystem, Double Helix, CT Scan, Archaea, World Wide Web, Continental Drift, Superconductors, Neutron, Early
Life Simulated
N = 13, N = 21, N = 34
Non-Market/NetworkPencil, Microscope…
Telescope, Photosynthesis, Smallpox Vaccine, Ocean Tides…Braille, Periodic Table, RNA Splicing, EKG, Aspirin, Cell
Division, Global Warming, MRI, Enzymes, Cell Differentiation, DNA Forensics, Radioactivity, Cosmic Rays,
Electron, Atomic Reactor, Modern Computer, Mitochondria, Nuclear Forces, Artificial Pacemaker, Oral Contraceptive, Radiocarbon Dating, Neurotransmitters, Graphic Interface,
Genes on Chromosomes, Endorphins, Chemical Bonds, Infant Incubator, Radiography, Gamma-Ray Bursts,
Oncogenes, Penicillin, Universe Accelerating, Atoms Form Molecules, Quantum Mechanics, Radar, GPS, Suspension
Bridge, Liquid-Fueled Rocket, Second Law, DNA (as Genetic Material), Internet, Anesthesia, Krebs Cycle, RNA (As
Genetic Material), Germ Theory, Computer, Asteroid K-T Extinction…
N = 4, N= 19, N = 54
Innovation: 1400-1600, 1600-1800, 1800-present
Source: Adapted from Steven Johnson, Where Good Ideas Come From: The Natural History of Innovation, 2010
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Innovation over Time
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ons
Adapted from Steven Johnson, Where Good Ideas Come From: The Natural History of Innovation (2010)
The Proprietary Problem“The best ideas come from networked
associations with others in non proprietary environments” (S. Johnson) or Give the tools of psychology away (G. Miller)
Costs to one agency for training on 6 of the strongest EBTs (for anxiety, depression, trauma, ODD, CD, and ADHD). How much for one agency to train 8 therapists?
Between $160K and $190KProblem of practicality and feasibility. But also
Ethical: Children are suffering Moral: Taxpayers are being stiffed Intellectual: It stifles innovation
Alternative: Incentives to promote EBP implementation and fidelity
Change the incentive system: Instead of government
incentivizing intellectual property, which encourages commercialization of programs, what if:
Developers were paid for their time to train
User agreements were crafted so that agencies could use programs for free if they agreed to share data on implementation.
National funding agencies for services supported open access/data sharing on implementation and maintained an electronic repository, constantly updated, to share data on use, adaptations, outcomes, and costs
5. Disentangle Social Determinants: Policies not
programs Poverty is a risk factor for child disability and child disability is a risk
factor for family poverty: Mental Disorders and Disability among Children: Report from the National Academies of Medicine, Engineering and Science, 2015
Children in poverty more likely than children in general population to have mental disorders and more likely to have severe impairments.
The majority of the SES achievement gap between high and low SES is already present at school entry (Too many children left behind: Bradbury, et al., 2015). 60% of the SES reading gap in 8th grade is attributed to differences in ability present in kindergarten; 40% is a result of children from different SES groups following different trajectories after kindergarten.
Social policies to address the gap Evidence-based parenting programs Universal preschool programs Income support
From: Costello et al. Relationships Between Poverty and Psychopathology: A Natural Experiment
JAMA. 2003;290(15):2023-2029. doi:10.1001/jama.290.15.2023
Conclusion Healthcare redesign requires a focus on practical issues
related to quality of services, costs, and collaborative models. Early intervention services
Team-based and family-centered approaches: Task-shifting. Redefine roles for parent partners as part of the workforce. Deguild.
E-health tools for real-time quality improvement. Drive with data.
Briefer service and training models. Common factors. Distill.
Avoid proprietary nonsense. Focus on ecology not programs (Atkins et al., 2015). Democratize.
Study implementation of social policies not programs. Disentangle social determinants.
The IDEAS Centerhttp://www.ideas4kidsmentalhealth.org
The Community Technical Assistance Center
http://www.ctacny.com