Evidence Based and Promising Practices

Most, if not all, of the current evidence-based practices (EBPs) in mental health were developed in urban areas. Implementing these EBPs with full fidelity in rural areas is typically impossible, due to limitations in personnel, vast geographic areas, and other resource shortages. Additionally, states are mandating the use of EBPs, with possible penalties for those counties or areas that do not comply. See Oregon's web site for more information on their state mandates regarding EBP's - (http://www.oregon.gov/DHS/mentalhealth/ebp/main.shtml#overview). This places rural areas in a difficult position given the issues noted. However, there are several approaches that can help rural mental health systems in this regard. These are: 1) developing rural-specific promising and, ultimately, EBPs; 2) applying “core components” of existing EBPs that show the most clinical effectiveness in rural; and 3) developing a continuum of care model that provides reality-based standards for rural areas. Current EBPs include multiple components, including a particular number of staff who provide different types of services in an integrated way to their clients. Undoubtedly, those who developed these EBPs would make the case that only “pure” fidelity to their models can be considered the EBP as it has been defined and researched. While no one would argue that implementing EBPs with full fidelity is the ideal, it obviously will not work in rural (with rare exception). Thus, states mandating EBPs, even in rural areas, need to be aware of the limitations that prevent full fidelity but also be given an alternative that is reasonable.

What we're up to...

Developing Rural Promising Practices into Evidence-Based Practices: WICHE has undertaken a project called The Rural Road from Promising Practice to Evidence-Based Practices, which is a collaborative effort with the Evaluation Center at the Human Services Research Institute (HSRI). The project will accelerate the development of rural-focused EBPs by identifying and documenting promising behavioral health (i.e., mental health and substance abuse) practices in rural communities and facilitating individualized technical assistance and evaluation research. A longer term goal for this project is for each promising practice to be listed on the SAMHSA sponsored National Registry of Evidence-based Programs and Practices (NREPP). NREPP includes the following steps in the ladder to becoming an evidence based program: 1) discovering & describing interesting programs: basic research, clinical judgment; 2) pilot studies: manuals, fidelity & outcome measures; 3) initial evaluation studies; 4) multiple & multi-site replication studies; 5) disseminability studies; 6) post recognition quality monitoring.

To recruit programs for this project, we contacted the Mental Health Directors of the 15 WICHE states requesting nominations of appropriate promising rural programs or practices in their state. Six programs were nominated overall. Once identified, we contacted a key administrator of each organization to explain the genesis of the project and the expectations for participation. We asked the organizations to complete a brief online survey regarding their intervention or program. The survey solicited information on each promising practice as well as the stated organizational needs and their desired forms of technical assistance. We then held a technical assistance meeting in the Spring of 2006. At the end of the meeting, evaluation consultation teams were created to include members of HSRI and WICHE staff. These evaluation teams will work with programs to develop a “Technical Assistance Roadmap” including an assessment of current evaluation efforts and a plan to move up the “evidence ladder.”

WICHE can serve to both educate legislators or others who are mandating EBPs in rural and provide the research and technical assistance to help identify core EBP components that can be implemented in rural. For instance, one of the programs identified as a promising practice actually combined elements of ACT and a mental health court to create a hybrid program that is achieving very positive outcomes for their clients. Choosing these two EBPs to integrate was driven by the reality of the place in which they work, which included relationships among various state agencies, available resources, and the true needs of its clientele.

The WICHE mental health program is also in the process of collaborating with the University of New Mexico Health Sciences Center in writing an R34 grant proposal to evaluate clinical outcomes of a rural Native American promising practice model in South Dakota. Our interest is whether the core elements of this model can be replicated in other treatment settings that serve Native American clients with mental health and substance abuse problems. Ultimately, we hope to establish a research base that demonstrates the program to be a rural-focused evidence-based practice. This would include a logic model for effective program elements and a sophisticated manualized protocol. Fortunately, research has been done with EBPs such as Assertive Community Treatment (ACT) that show how identifying and implementing core components of an EBP in rural areas can result in good clinical outcomes for rural clients.