The need to standardize service delivery has become increasingly critical for better consumer experience, for better outcomes, and for consistent pricing and performance in value-based arrangements. This was the focus of my closing keynote, Reinventing Your Organization: Key Management Best Practices For A Value-Based World, at The 2018 OPEN MINDS Management Best Practices Institute.
One key element of service standardization is the routine use of “best practice” service delivery—whether evidence-based practices (EBP) or practice-based evidence. Health and human service organizations should have models that identify the “best services and approaches” for consumers with specific characteristics and needs, increase the likelihood of a good outcome, provide a great consumer experience, and come with a predictable cost.
But in the sectors of the health and human service field, standardized treatment approaches are the exception rather than the rule. First there is the overarching problem of slow adoption of scientifically validated processes. The typical “new development” takes 15 to 20 years to get most consumers. Then there is the lack of consistency in delivery of the current models—or even lack of models. This situation is illustrated by recent research that found that in 2016, of the 10 million adults in the United States who were living with serious mental illness (SMI), only 32% received medication management and only 19% received support for illness self-management. Of the seven million children and youth who experienced a serious emotional disturbance (SED) less than 5% received multi-systemic therapy or therapeutic foster care, and about 7% received functional family therapy (see Why Do Only A Third Of Consumers With SMI Receive Evidence-Based Treatment).
This situation in the complex consumer market and the use of technology to address the current problems of decision support and service delivery consistency was the focus of the remarks of Carol Reynolds, Executive Vice President, Client Experience of Netsmart in her session, Evidence-Based Practice & Practice-Based Evidence: How Technology Should Support The Former & Produce The Latter, at The 2018 OPEN MINDS Management Best Practices Institute.
Her primary message—using and extending the use of your electronic health record (EHR) can provide health and human service organizations with the technology platform to push evidence-based practices by creating a “learning system” that proactively manages the health of populations. Collecting data through an EHR can enable organizations to share data, analyze population health, and implement clinical decision support tools.
But what are the impediments to standardization of service delivery in general—and use of EBPs in particular? The American Nurses Association found that the biggest barriers to EBP implementation included a lack of educational opportunities, knowledgeable mentors, resources, and tools needed (see Barriers To Implementing Evidence-Based Practice Remain High For U.S. Nurses). Additionally, implementing EBPs can demand a large initial investment to design the program, train and hire new staff, and building an operational structure to document and measure the program’s outcomes—which can present big challenges for many organizations. Adding to these challenges, we are seeing systematic stigma from health care professionals and poor reimbursement for all elements of the EBP (see Behavioral Health Evidence-Based Practices As Population Health Management Tools). All of these factors add up to big challenges that have halted the progress of EBP implementation across the complex consumer market.
During the institute session, there was a great exchange with Greg Loop, Chief Executive Officer of Family Services of Northwest Pennsylvania. He pointed out one challenge of EBP adoption—the misinterpretation of EBP as “cookie cutter” and not individualized treatment. This was a perception of both clinical staff and of auditors. After the session, we touched base with Mr. Loop, who further explained:
We come into the field with what are now EBP, where we know assessments and interventions need to be presented in a certain order to be the most effective. Whether that’s multi-systemic therapy, functional family therapy, trauma-focused cognitive behavioral therapy, or any of the therapies that have gone through the rigor to be recognized as truly evidenced based. You really have phases, or prescriptions where you do A first, then B, then C. Then reviewers are coming in and seeing treatment plans that look similar because they are using an evidenced based approach. The individualized aspect of service is truly the assessment and diagnostic phase. The application of the intervention is in fact standardized. This is what makes it effective and an evidenced based approach. Important to note, that the EBPs have risen in use and are touted, because their outcomes are better than typical practice-say 20% or 30% more effective for the population being referred.
From my perspective, those reviewers want to see that the treatment is “highly individualized” and not just appropriately applied because of an individualized assessment. By comparison, if I went to a physician with my daughter and she had a diagnosis of an ear infection, he’d likely be recommending something in the amoxicillin family of antibiotics. And he’d know how many grams how many times a day. The individuation would be based on his assessment and diagnosis. And he would individuate that recommendation based on whether there was an allergy as well. But because amoxicillin is the intervention of choice, he wouldn’t further individuate it, just so it doesn’t look “cookie cutter.”
But that is the paradigm we find ourselves in when reviewers say our treatment plans look similar. We respond that’s because they are both for depression. We are using an appropriate intervention that is structured for depression and for this population. Then yes, they should look similar. I think our reviewers have been focused on making sure that everything must be “individual” but don’t understand the relationship with clinical best practice. Then, our clinicians start to feel pushed not to use the same kind of prescription for similar presenting consumers, for fear they won’t be individualizing the treatment plan.
The reality is, as provider organizations, we must work within our field, with our colleagues across agencies to define successful treatment. We need to find the appropriate entry and exit points for a course of treatment. We must develop a model for what a course of treatment should look like.
I think this issue is just one example of a fundamental confusion about “best practice” treatment models. Providing consumer with “best practice treatment” is the best case of personalized medicine and individualized care. This doesn’t happen without the consumer voice in terms of preferences—but it requires sharing with consumers (in language they understand) that “why” behind those models.
Looking for more? OPEN MINDS (@openmindscircle) will be providing live coverage on social media, and day-to-day updates, of this year’s OPEN MINDS Consumer Engagement Technologies Summit on October 22, and The 2018 OPEN MINDS Technology & Informatics Institute, running October 23-24 at the Loews Philadelphia Hotel, in Philadelphia, Pennsylvania. To join the discussion on Twitter, use this year’s official hashtag: #OMTechnology.