Evidence Based Behavioral Health Practices for Older Adults

A Guide to Implementation - 1st Edition

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Contents

Contributors ix

Foreword xi
Patrick J. Kennedy

Acknowledgments xiii

Introduction xv
Sue E. Levkoff, Hongtu Chen, and Maria D. Llorente

CHAPTER 1 Selecting an Evidence-Based Practice 1

Patricia A. Areán and Amber Gum
Step 1: Identifying the Target Population 3
Step 2: Researching EBPs 3
Step 3: Deciding on the EBP 9
Step 4: Determining What to Do if No EBP Exists 13

CHAPTER 2 Assessing Feasibility 17

Jane E. Fisher, Claudia Drossel,
Michael A. Cucciare, and Craig Yury
Assessing Readiness 17
Measuring Organizational Readiness: 18
A Review of the Literature
Assessing Organizational Climate for EBPs 21
Assessing Costs as the Bottom Line 22
Modifying and Implementing an Identified EBP 27
Maintaining Awareness of New EBPs 32

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vi Contents

CHAPTER 3 Quality Management in Evidence-Based 37

Service Programs
Hongtu Chen, Rodolfo Vega, JoAnn E. Kirchner,
James Maxwell, and Sue E. Levkoff
Administrative Strategies for Quality Management 38
Evaluation Strategies for Quality Management 56
Discussion 63

CHAPTER 4 Culturally Grounding Evidence-Based Practice 67

Ramón Valle, Elizabeth Stadick, Jane Latané, Virginia
Cappeller, Monica de La Cerda, and Gregory Archer
The Conceptual Base 67
Program Experiences and Outcomes: 75
Applying the CG EBP Framework
Implementation, Documentation, Measurement, 84
and Outcome Issues
Lessons Learned and the Distance Yet to Go 91

CHAPTER 5 Evidence-Based Practices for the Assessment and 99

Treatment of Depression, Anxiety, and Substance
Use Disorders
Jane E. Fisher, Michael A. Cucciare, Claudia Droßel, and
Craig Yury
Depression in Older Adults 99
Anxiety in Older Adults 108
Substance Use Disorders in Older Adults 118

CHAPTER 6 Evidence-Based Practices for Dementia and 135

Schizophrenia
Jane E. Fisher, Kyle E. Ferguson, and Claudia Droßel
Dementia 135
Schizophrenia in Late Life 146

CHAPTER 7 Evidence-Based Practices by Service Delivery 159

Process
Jeffrey A. Buchanan and Tiffany Berg
Screening and Assessment 160
Treatment 164
Prevention and Outreach 172
Discussion and Conclusions 174
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CHAPTER 8 Evidence-Based Practices Within Special Settings 179

John M. Worrall, Stacey Cherup, Ruth A. Gentry,
Jane E. Fisher, and Hillary LeRoux
Faith-Based Organizations 179
Primary Care 181
Extended Care Settings 192
Services to Older Adults in Rural Communities 197

CHAPTER 9 Moving Toward Sustainable Services 209

Dean D. Krahn and Sue E. Levkoff
Should a Program Be Sustained? 209
What Makes Change More Likely to 210
Be Sustained?
Defining Sustainability 211
Implications of the Literature 213
From Implementing to Sustaining a Program 215
Efforts to Sustain the Kajsiab House Project 217
Tips for Creating a Program That Is Sustainable 221
One Last View of Sustainability 223
Epilogue 224

Index 225
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Contributors

Gregory Archer, PsyD, Program Evaluator, Tiempo de Oro Program, Valle del Sol
Inc., Phoenix, AZ.
Patricia A. Areán, PhD, Associate Professor, Department of Psychiatry, University
of California-San Francisco, CA.
Tiffany Berg, BS, Department of Psychology, Minnesota State University, Mankato,
MN.
Jeffrey A. Buchanan, PhD, Assistant Professor of Psychology, Center on Aging,
Minnesota State University, Mankato, MN.
Virginia Cappeller, PhD, Clinical Director, Health Improvement Program, Jewish
Family and Children’s Services, Tucson, AZ.
Monica de La Cerda, MEd, Principal Investigator, Tiempo de Oro Program, Valle
del Sol Inc., Phoenix, AZ.
Stacey Cherup, BA, Department of Psychology, University of Nevada, Reno, NV.
Michael A. Cucciare, MA, Department of Psychology, University of Nevada, Reno,
NV.
Claudia Droßel, PhD, Department of Psychology, University of Nevada, Reno, NV.
Kyle E. Ferguson, MA, Department of Psychology, University of Nevada, Reno, NV.
Ruth A. Gentry, MA, Department of Psychology, University of Nevada, Reno, NV.
Amber Gum, PhD, Florida Institute of Mental Health, University of South Florida,
Tampa, FL.
JoAnn E. Kirchner, MD, Associate Director for Clinical Care, VA South Central,
Mental Illness Research, Education, and Clinical Center (MIRECC); Associate
Professor of Psychiatry, University of Arkansas for Medical Sciences, Little
Rock, AR.
Dean D. Krahn, MD, MS, Clinical Associate Professor of Psychiatry, University of
Wisconsin Medical School; Chief, Mental Health Service, William S. Middle-
ton Memorial Veterans Hospital, Madison, WI.
Jane Latané, MEd, Program Coordinator, Health Improvement Program, Jewish
Family and Children’s Services Inc., Tucson, AZ.
Hillary LeRoux, BA, Department of Psychology, University of Nevada, Reno, NV.

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x Contributors

Maria D. Llorente, MD, Director, Geriatric Psychiatry, Veterans Administration

Medical Center; Associate Professor of Psychiatry, University of Miami School
of Medicine, Miami, FL.
James Maxwell, PhD, Director of Health Policy and Management Research, John
Snow Research & Training Institute, Inc., Boston, MA.
Elizabeth Stadick, BA, Coordinator, Tiempo de Oro Program, Valle del Sol, Inc.,
Phoenix, AZ.
Ramón Valle, PhD, Professor Emeritus, San Diego State University; Director,
Alzheimer’s Cross Cultural Research and Development (ACCORD), San Diego,
CA.
Rodolfo Vega, PhD, Senior Consultant, Program Evaluation Specialist, John Snow
Research & Training Institute, Inc., Boston, MA.
John M. Worrall, MBA, Department of Psychology, University of Nevada, Reno, NV.
Craig Yury, MA, Department of Psychology, University of Nevada, Reno, NV.
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Foreword

One thing is sure. We have to do something. We have to do the best we

know how at the moment . . . ; If it doesn’t turn out right, we can modify
it as we go along.
—Franklin D. Roosevelt

The pursuit of happiness is enshrined in the Declaration of Independence

as one of our inalienable rights, but for too many older Americans the prom-
ise of the golden years is replaced by the reality of blue years. Positive aging
in older Americans relies heavily on access to and receipt of quality and ef-
fective mental health services. Frequently, however, the mental health needs
of our older neighbors, family members, and friends go unmet. As high-
lighted in the Positive Aging Act, first introduced in Congress on July 9,
2002, we must “adopt and implement evidence-based protocols, to the ex-
tent available, for prevalent mental health disorders” among seniors in our
communities.
The good news is that in the past decade if we are to close this care gap,
the research community has made tremendous progress in consolidating
scientific evidence and expert consensus on processes for managing care for
older adults with mental illnesses. The overall message is hopeful: (a) sys-
tematic screening can help successfully identify prevalent mental health
problems in older persons and (b) there are scientifically proven ways to al-
leviate mental health problems such as depression and anxiety in older
adults. These problems do not have to be part of the normal aging process.
Our challenge is to translate this knowledge into practice, into everyday ser-
vice delivery to older people and their families.
Most of the successful mental health service programs for older adults
require integration and collaboration between mental health services and

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xii Foreword

other medical and social services. The implementation of these evidence-

based practices is challenging because it requires changes at many levels, in-
cluding various service providers’ behavior, organizational arrangements,
and, most of all, the way we think about the problems and develop solutions.
As with all worthy causes, making a change in the real world and turning a
good idea into a good program take two sets of qualities and resources
working in tandem. First, they take leadership, championing of changes, in-
dividual initiative, visionary thinking, determination, and a deep sense of
social responsibility to start something worthwhile and overcoming inertia
and the barriers that will inevitably arise. Second, they require cooperation,
collaboration, peer support, teamwork, generosity, and collective wisdom
and knowledge to get something completed.
With this observation in mind, I applaud Evidence-Based Behavioral
Health Practices for Older Adults: A Guide to Implementation, as it will help
people nurture and develop the skills necessary to try something new and
innovative and to deliver better and more effective care to those in need.
This book comes from a group of thoughtful people who have helped, ob-
served, and researched the difficult and complicated process of implement-
ing evidence-based mental health services for older Americans. I hope this
book will bring about more learning and action among all of us involved in
the cause of helping millions of older Americans live a positive and better
life, the life they deserve.

Congressman Patrick J. Kennedy

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Acknowledgments

We wish to express our gratitude to the many people who have directly
or indirectly helped us in the production of this book. Most of all, we want
to thank those frontline service leaders and developers of the Targeted Ca-
pacity Expansion (TCE) Programs designed to improve behavioral health
programs for older adults. The thoughtfulness, diligence, and creativity of
these program implementers are the inspiration for this book. It is their ex-
perience with the difficulties and their courage to overcome the barriers con-
fronting them that made us realize the need for such a book. If those who
are funded and supported need such a book, then many others who want to
develop similar service programs for older adults will likely benefit from it
as well. Since each TCE program involves many people, some of whom have
already left their organizations, we want to acknowledge their contribution
by mentioning the names of the participating organizations: La Clinica Del
Pueblo in Washington, DC; COTTAGE Expanded Elder Services in Tucson,
Arizona; ElderLynk Expansion Program in Kirksville, Missouri; Health Im-
provement in Tucson, Arizona; Kajsiab House in Madison, Wisconsin; Pro-
ject FOCUS in El Paso, Texas; Senior Behavioral Health Service Program in
San Francisco, California; Senior Outreach Program in Rochester, New York;
and Tiempo de Oro Program in Phoenix, Arizona. A description of these
programs can be found at www.positiveaging.org.
Our funding agency, the Center for Mental Health Services of the Sub-
stance Abuse and Mental Health Services Administration (SAMHSA), de-
serves our salute. Its original vision and continuous support along the way
were critical to the success of the TCE Project. Our special thanks go to
Betsy McDonel Herr, PhD, the project officer of the TCE program, and Neal
Brown, MPA, chief of the Community Support Program at SAMHSA’s Cen-
ter for Mental Health Services, for their support, advice, and many technical
contributions to the project.

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xiv Acknowledgments

We would also like to thank all of the older adults and their families
participating in the services programs. Their presence, feedback, and guid-
ance significantly enhanced and directed our efforts to improve care. They are
the sustaining power and the ultimate justification for the meaning and value
of our work.
We thank the many consultants for their thoughtful support for the ser-
vice program developed at each site, and for those who participated in the
initial teleconference meetings to help conceptualize this book.
We are grateful to Milly Krakow who provided important editorial sup-
port with her extraordinarily perceptive and helpful comments.
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Introduction

Sue E. Levkoff, Hongtu Chen, and Maria D. Llorente

American health-care delivery systems are working to improve health ser-

vices through research on and implementation of evidence-based practices
(EBPs). Research on EBP has gained momentum since its inception almost
a decade ago, but the service delivery field is increasingly challenged by the
lack of guidance on processes for successfully implementing EBPs. This book
provides critically needed guidance for behavioral health-care providers re-
garding the implementation of evidence-based practices to improve service
delivery.
This book supports the nationwide effort to improve services for older
Americans in response to the expansion of the aging population and the in-
creasing demand for cost-effective mental health care of older persons. To
improve the capacity and quality of mental health care for older adults, the
nation must gather the available resources and equip its frontline service
leaders and providers with adequate knowledge, training, and instruments
for them to make urgently needed changes. Through our work with the Sub-
stance Abuse and Mental Health Services Administration (SAMHSA), a fed-
eral agency devoted to the improvement of mental health-care quality, we,
as a group affiliated with the Positive Aging Resource Center (PARC) and
its partner service sites, have learned many lessons about how to successfully
implement evidence-based programs and principles in real-world clinical
service settings. This book provides information on these lessons and on re-
sources for frontline service providers.

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xvi Introduction

COMPLEXITY OF EBP IMPLEMENTATION

Evidence-based practice is a conscious effort to use the best available evi-

dence to guide decision making in the delivery of health services. It incor-
porates research findings and professional judgment and knowledge with
individual patient characteristics and preferences in formulating clinical
decisions (Dubouloz et al., 1999; Gerrish & Clayton, 2004; Goldman, The-
lander, & Cleas-Goran, 2000). When implementing any EBP, one typically
would consider following basic strategies:

• Integrating research with practice: use of current best evidence from

relevant, valid research about the effects of different forms of health care
(O’Rourke, 1997); systematically find, appraise, and use research find-
ings as a basis for clinical decisions (Lockett, 1997).
• Including evaluation in practice: systematic application of rigorous sci-
entific methods to the evaluation of the effectiveness of health-care in-
terventions; an approach that promotes the collection, interpretation,
and integration of valid, important and applicable patient-reported,
clinician-observed, and research-derived evidence (McKibbon, 1998).
• Incorporating clinical expertise: integration of individual clinical exper-
tise with the best available external clinical evidence from systematic
research (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996; Bar-
tels et al., 2002).
• Assessing patient characteristics: consideration of patient circumstances
and preferences when assessing the interaction between the clinician
and the client in order to improve the quality of clinical judgments
(McKibbon, 1998).

Moving an EBP discussion from an academic setting to a clinical health-

care setting is challenging and complex for several reasons. First, different
organizations developing an EBP have different starting points, particularly
with regard to cultural background, familiarity with types of evidence, ability
to manage information and conduct evaluations, attitudes toward change
and improving quality of services, and the ongoing daily functioning of the
current program. Second, program planners may have different aims in mind:
Some want to develop a program focusing only on outreach, prevention,
screening, or treatment; others want to provide care for a population and
community with a unique cultural profile.
Contextual variation may influence EBP implementers to take different
routes in developing an evidence-based method or approach. Some may try
to improve practice based on the best scientific evidence available, using their
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Introduction xvii

access to well-established EBP guidelines or protocols to fit to the site’s ser-

vice situation. Others may aim to improve practice by making conscious de-
cisions based on best available evidence, especially in those circumstances
where (a) it is difficult to find an established EBP guideline appropriate for
a specific situation, or (b) there is a need to undertake a more innovative and
groundbreaking experience-based approach in order to develop the service.
Regardless of the approach, EBP implementation becomes part of a contin-
uous quality improvement process, with an emphasis on translating, adapt-
ing, and integrating different levels of evidence and knowledge obtained
from both scientific research and practice experience.
While handling the day-to-day tasks of developing a behavioral health
clinical program, the EBP program administrators often need to address
complicated issues related to resources development and constraints. To in-
troduce changes necessary for an EBP implementation, the implementation
leaders need to gain support from senior managers, form a coalition with
service providers, and ask for extra effort from staff members. Developing
an evidence-based behavioral health program for older adults often requires
collaboration with other health or social service organizations, or at least
integration of services among different departments within the same organi-
zations. In addition, a community-based organization often has to seek ex-
ternal technical support and resources to help identify EBP guidelines, design
program evaluation plans, and collect and analyze data or evidence to in-
form and justify major implementation decisions. Those who begin a pro-
gram or intervention using the best scientific evidence available will have to
incorporate new knowledge gained from local practice in particular settings.
Similarly, those who begin with evidence derived from local practice and
consensus based on expert opinion often need to develop more generalizable
knowledge through efforts such as advanced program evaluation.

THE SYSTEM APPROACH TO A SUCCESSFUL

EBP IMPLEMENTATION

The system approach is critical to the successful implementation of an EBP

in mental health services (Berwick, 2002; Eddy 2005). This approach em-
phasizes the need to be aware of the service environment including the or-
ganizational and community setting, and the client’s and provider’s cultural
context—before and during implementation of an EBP program. This sys-
tem approach can be summarized into five operational principles that sup-
port the successful implementation of an EBP. These principles are further
elaborated on in Chapters 1 through 4 and 9.
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xviii Introduction

Principle 1—Selecting the best EBP with the best fit for the target population
and service staff. The best EBP is not only based on those with the most
rigorous scientific evidence: it should also be acceptable to and feasible
for the consumer base and staff capability. The authors of Chapter 1
provide a logic model for identifying the most useful and promising
EBP for the community.
Principle 2—Assessing feasibility for implementing an EBP with the whole
journey in mind. Assessing the feasibility of implementing an EBP is
not only about examining the readiness of the parent organization but
also about broader issues. Strategies provided in Chapter 2 encourage
the EBP implementers to augment information on clinical effectiveness
and to look further ahead by assessing resources for training and main-
tenance of the project, barriers to implementation, and the degree to
which the EBP should be modified in order to be applicable to a par-
ticular setting.
Principle 3—Managing quality of EBP implementation through involvement of
people and evaluation of the entire organization. The success of program
development depends on the project team’s ability to utilize both human
and information resources to orchestrate a thoughtful and persistent
process of continuous improvement and assurance of the quality of im-
plementation. Based on fundamental principles developed from the
quality management movement since the 1950s, Chapter 3 provides
recommendations for how to use the quality management process in
developing an EBP program.
Principle 4—Developing EBP in a cultural context. Implementing an EBP re-
quires integration of EBP principles with the cultural characteristics of
both the client population and the service providers. A culturally
grounded model for the application of evidence-based practice in men-
tal and behavioral health is described in Chapter 4.
Principle 5—Sustaining an EBP program through thoughtful planning that
ensures the EBP is embedded organically in its parent organization. To in-
crease the likelihood of sustainability, the authors of Chapter 9 suggest
that future mental health improvement projects must not only improve
people’s lives but must also positively impact the organization and
community in which the project “lives.”

In a review of all major studies of quality improvement work in health

care in the past decades, Shojania and Grimshaw (2005) identified the suc-
cess of any EBP effort as dependent on the implementers being willing to
seek a comprehensive understanding of the problem. In the system approach,
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Introduction xix

understanding the problem is mainly about understanding the specific con-

text of the problem. To facilitate a consideration of the service context,
Chapters 5 to 8 present information on how EBPs are practiced in relation
to specific mental health conditions, service delivery processes, and service
institutions.
The EBP implementation that uses a systems approach should keep the
system, however defined, as an open system, to increase its chances to stay
healthy, self-motivated, and essentially good. It is open to better services that
should eventually benefit all parties involved (it is good); it is open to com-
plexities intrinsically imbedded in the cultural context of service populations,
organizational politics, and provider styles (it is good for whom, by whom);
it is open to changes that should happen in a gradual, coordinated, and
thoughtful manner (how it becomes good); and it is open to the future with
sophisticated and flexible plans for sustainable services (how the good will
last).

HOW TO USE THIS BOOK

We developed Evidence-Based Behavioral Health Practices for Older Adults: A

Guide to Implementation as part of our efforts to improve the quality of men-
tal health services for older adults and their families. This book was mostly
written by faculty and coaches affiliated with the Positive Aging Resource
Center (PARC) and its partner sites across the country. Although the con-
tent of this book is relevant to all people who work with elderly clients with
mental-health needs, the following three groups of readers may find this
how-to book particularly useful: (1) program administrators and clinical
supervisors such as directors of mental-health programs, senior centers,
nursing homes, and senior day-care programs; (2) health-care professionals
in both the fields of mental health services and geriatric services, including
clinical social workers, nurses, psychiatrists, psychologists, occupational
therapists, physical therapists, nutritionists, and recreational therapists; and
(3) teachers and students participating in courses related to service deliv-
ery, service program development, health administration, aging, mental
health, and rehabilitation. The first two groups will find this book useful
and beneficial in helping them move an innovative idea to a real and sus-
tainable improvement in a service program. This book will provide the
third group with an in-depth understanding of one of the critical chal-
lenges in the health-care field: how to improve quality of health care through
evidence-based practice.