AMCHP 2006 ANNUAL CONFERENCE
EARLY CHILDHOOD: BUILDING THE FOUNDATION FOR LIFELONG HEALTH
March 4-8, 2006
ANNE ROSSIER MARKUS: You know? You’re going to leave here so inspired, not only from this workshop, but other workshops. And you’re going to be thinking about, how can I go home? How can I get these things started? So, that’s kind of what I’m going to talk about and I wanted to share something that’s new to me, so I’m still excited about it and I think it’s, it’s really well thought out.
It’s called REAIM and it’s a model for this new buzz word or translational research that I think we used to kind of call dissemination, developed by Russell Glasgow who’s in Colorado and works with Kaiser. And my understanding is that he was working with NIH task force to try and figure out, you know, the push is really, how do we get research results, evidence based research, actually into practice and on a wide enough scale, taking things to scale, that it’s going to really make a difference. And, how do we not just implement things while we’re all enthused about it, but how do we do it in a way that can be sustainable over time. So REAIM stands for Reach Efficacy or Effectiveness, Adoption, Implementation and Maintenance.
And I put the website address down there, which is also, all of these are on a handout. And I would really encourage you to go to that website and look at all of the different things that they have there. Whether you are an evaluator or a researcher whose developing something that you’re hoping will be put into practice by other people, or whether you’re a Program Director, a Program Manager looking for good things to take home and put into practice, I really think this will be helpful for you. They have things like a self-assessment questionnaire. And they have kind of a mathematical model that pulls all of these components together to really give you an idea of what really is going to be a successful program over time. And I’m quickly going to through each one of these things and talk a little bit about how it applies to the LSP and then at the very end, pull it all together, I hope.
The first part of REACH really doesn’t apply as much to an LSP but would be something that would apply more to the NFP, the Nurse Family Partnership. And that’s really a whole program and you want to look at how representative, how broad a program of the target population or the population you’re interested in, is this particular program going to reach. And then, that’s kind of theoretically and then what’s the actual participation rate? We all know that we can offer things but how many people are really actively participating in what we have to offer? Now the reason it doesn’t apply so much to the LSP is because the families are not the one who are deciding whether or not they’re going to have an LSP done on them. That really is a staff decision because they’re, the staff people are the ones, the home visitors that are really rating and scoring the families.
The other thing that you want to start out with if you’re a Program Director is a program that has already some evidence of efficacy or effectiveness. And that’s a good place to start. I think you still need to monitor for your own program. Is it really still working? And if you’re thinking about this for the LSP, I would look at things like, is the use of the LSP really improving the quality of supervision? For example, in healthy families programs, every week the staff person gets an individualized hour and a half of clinical supervision. Is using the LSP improving the quality of the supervision that they are getting at that time? And one way I would look at that would be, is it changing the IFSP, the Individualized Family Support Plan goals that are being written down and negotiated with the family and does using the LSP actually lead to achieving more of the goals that the families are setting for themselves. In addition for a measure such as an LSP or any kind of a scale or tool that you would be using, you also want to look at, is there some evidence of reliability, which Lynda addressed, and is there some evidence of validity for that.
Adoption is the one that I think we often overlook. Sometimes we think, oh, this is a great program. It’s got all of the pieces in place. It’s set to go. But adoption is one of the very first things. Who is going to actually want to take hold of this and implement it in their program? What percent of staff and what percent of sites, in our case, are willing to use the LSP, at least willing to try it out. Does it have enough appeal and it is designed in a way that is going to make it relatively easy for people to use? Can you fit it into your existing practice? What are the training and technical assistance that’s available in order to make it easy for people to use and easy for them to say, yes, you know, I think I can make that work in my own site. If you can’t get beyond that point, it’s unlikely that you’re going to get much, much further down the road. And this, at this level, I think in my experience, you need to get buy in at the top level. And I usually go for, there are some sites and some Program Managers that seem to be able to make anything work and make their staff want to do it. So I would start with those people.
And then the other thing that’s important is to continue supporting them during that really early phase. And if they start to do something, they may say yes initially, they try it, and it doesn’t really work, you really need to listen to, why did that not work for you? What other modifications might we be able to make in order for you to be able to really implement this? And even the people, and I know you probably have some people in your state as well. I can’t be the only state, where no matter what is presented, their first response is no. To really listen to why are they saying no, it may be poor timing. We may have tried to get them to do three other new things and they are just on overload. So I think some of it is trying to really know the people, know the sites, know the timing, and be patient but persistent, which if you’re Public Health people, you know how to do that, I know.
The implementation is really looking at the extent to which the LSP in this case or anything is being used as designed. Is it being used routinely by all staff with all families? How exactly is it being used in supervision? If you’re looking at staff at a site or sites in a state, who is completing the LSP? How often are they doing it? Is it really being used the way it was intended to be used? And the other piece that Russell Glasgow add into the implementation is really looking at, at kind of a cost analysis, not just the dollar amount, which Lynda fortunately set it up in the way where you could print off as many copies of the LSP and all of the forms that you want. You don’t have to order them from some central site and pay an arm and a leg for it. But, you know, what are the costs of implementation in terms of how much time does it really take people to complete it. Maybe initially it might take a little bit longer but as they become more familiar and more used to it, it really doesn’t take much time. Is there time that needs to be spent on data entry? Does it increase the amount of time and supervision? If, for example, in Healthy Families we didn’t already have supervision built into the program, and we’re asking people to say, well, in order to use this you also need to be adding another hour of supervision time per week. That might be a hurdle that’s a little bigger for them to do. And if you’re going to incorporate it into an existing management information system, what are some of the costs of entering it into the computer and is it worth that kind of cost?
The other, last of REAIM, the M stands for the maintenance. And this would be, you know, you may get something adopted. You may get it implemented initially, but you need to go back and say, is it continuing to be used over time? How are things going in the first six months, the next 12 months? Does it get tossed out as management changes? Is it really being instituted and not just the initial buy in, but is this really part of the program? And some of the ways that you can do that is to make it required, link to reimbursement for services, which we do with Healthy Families. It’s unit rate reimbursement. You have to do certain things in order to be able to build for it. Is it linked to credentialing standards, national standards, state level standards? And within our own site, is it linked to the performance measures, which go for promotion, for just merit pay or the incremental increases? One of the strongest things, I think, is using it to evaluate a program site and a statewide program. And people tend to want to do things if they think that the information is going to be used. And in this case, with the LSP, it’s used at the individual clinical level. It’s also used at the program level. And when people can see the results of the data that they’ve been entering and the progress that they’re making with families, that, to me, is a powerful incentive to continue to do it. Most people don’t like to keep filling out paperwork if they think nobody looks at it and it’s not particularly useful to them to begin with.
And then one thing I forgot to add, but it’s important, is are you able to use the information, not just to do a one shot evaluation of your program, but can you use it continuously to improve the quality, so that you might find that at a particular site, many staff people are having difficulty even scoring somebody on the continuum, because they don’t really know what’s going on in that area. For example, substance abuse or domestic violence or something like that. Well that’s a supervisory issue because, you know, if you’re doing a comprehensive program, you really would want to know about all of those kinds of things. So I think there’s ways that you can use continuous quality improvement at the individual supervisory level. If it’s widespread, it becomes a training and a technical assistance issue that would be dealt with more on a system wide basis.
So what are we doing with the LSP and Healthy Families Indiana? We started out by having Lynda come and do an initial training, it’s something that we do twice a year, which is a, we call it The Institute and it has about five or 700 people attending. And that was the, an opportunity, I felt good about it, because Lynda and I used to work together. And so, you know, we’re kind of on the same page. But I really needed to get other people’s opinions. And so I invited Lynda to come out and present at an institute and train some people not only from Indiana but some key leaders within Healthy Families that were invited. Their response was just as positive as mine. And so one of the things that we do, we have a fairly large state program of 56 sites serving about 18,000 families a year in 92 counties. So we have over 850 home visitors. So I keep thinking, okay. How are we going to really make this work? Well, I like Lynda a lot but I just simply can’t afford to fly her out from California all the time. So we had to build in from the very beginning, a train the trainer component to build our own in state capacity to do that training and to do it on an ongoing basis. And so we picked some people who are good trainers, they train in other parts of our program. They run very effective sites, and/or they are part of our technical assistance team. So I kind of creamed off and hand picked our best people to become trainers in the LSP and then we tested that out and had them do kind of their evaluation training, co-training with Linda, evaluation training with Lynda, at the sites that we were going to introduce this as kind of a pilot project. And so now we have that in state training team that’s able to continue doing the trainings at the twice a year institutes so that we can broaden it.
We’re also incorporating the LSP into something that’s called Event Supervisor Training, which a lot of supervisors will come to because they like that training a lot and this is our way of kind of hooking them in. They might not come if we called it LSP training. But if we bring it into something that’s already existing, that already has a good reputation, then they will see it and it will be a painless introduction for them, at least that’s our strategy.
We also had to do something and I’m almost embarrassed to say this because it’s my own site. But the two pilot sites that we picked, one was my own because I could make it happen. The other one was the site that seems to be able to figure anything out, without any great deal of difficulty. I don’t know how she does it, but she’s wonderful and she’s now one of our trainers. And my own particular site has a lot of very bright people that seem to be able to find, if there’s something wrong, they will identify it right off the bat. And in some ways that’s kind of good to know because if we can get my site to do it, almost anybody else, you’re going to be able to get to do it, too. So, but for my site, they decided that they would have to have a waiver request that if they were going to add the LSP because they liked it so much, could they drop the home scale. And so reluctantly I supported that decision and said, okay. We’re not going to do the home scale routinely as every other site in the state does, but you will still know how to do it and you will use it when you need it. And if you’re unable to fill out the appropriate pieces of the LSP, perhaps you ought to do a home scale because you don’t have the information already that you need. So, that was their little thing.
And then we’re going to, we tested the computer program that Lynda mentioned with the two pilot sites and at the back of the handout is one of those printouts that you get from that, that I just took 20 families that we had, two LSP scores that we could enter into and you could see, this is just one of the 43 ones, this is supportive development. And it shows, you know, where everybody scored at the initial and then subsequent LSP’s. And then you can see the ones, the percent that were in the shaded area, which was the target range. And then there’s one that says targets and it gives you, 44 percent were in the target range on this item at intake and then for the LSP’s that were done later, it went to 67 percent, 63 percent, and then we just had one that was later on. But it gives an idea of it. And for our sites, we have a very, pretty sophisticated home visit tracking information system. So, we’re going to do this for now, but we’re already planning on putting it into our HVTIS system because we can do lots of things with it. And that will also help, I think, to implement it statewide, which is my goal. It just, you have to take things a step at a time.
The other things that we’re doing is we have now four pilot sites, who are going to be using a particular curriculum that is a, enhances functional health literacy and uses the LSP as the outcome tool. And that’s, we think it’s going to be funded by NIH. We’ll know in May, and that’s another way to get people to doing things because they like the idea of being part of a really fairly well thought out high level research project. I’m also including the LSP as an outcome measure in a research project that I’m going to do that will, basically we’ve got local foundation funding and we’re going to randomize clinical trial between Healthy Families and Healthy Families enhanced with a Dula component, community based Dula component and use the LSP for that. And then we’re applying for a CDC. We’re submitting a proposal and we’re going to put the LSP in on that. And my, the principal investigator is actually somebody from Michigan and he wrote an email to me and he said, you know? What I’d like would be the home visitors appraisal of how the family is progressing in a lot of these different measures. What do they think is really going on in addition to all these other measures and tools that are already out there. And I said to him, I said. Are you talking about the Life Skills Progression Scale? And he said, no. And I said, well, let me send you the book. You know, you will love that. So, you know, we’re going to put that in and I think we’ll also be able to do some very good validity testing on this scale, because it was so new he hadn’t even heard about it.
And then the last step, I already mentioned the, incorporating it into our HVTIS system. But the last step for really full implementation, how I will see it as, implementation that’s going to stand the test of time, is that it will be required as state level policy across all of our sites. And this is a process that we’ve done with many, many things, where you have to start out and it’s an incremental approach. And you start smaller where you can. You get good results. You build upon those results and eventually it will become common practice in our state through all of our home visiting sites. And I think we’ll be able to make some very good comparisons and improve what we’re doing right now, which we already think is fairly good. So, I just want to thank you for sitting through the last presentation, the last workshop, on the last day of the conference. Thank you so much.