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PCOMS/CDOI Facts

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This handout describes the Partners for Change Outcome Management System (PCOMS) and client directed outcome informed (CDOI) ideas and practices. It presents the advantages of PCOMS and describes the …

This handout describes the Partners for Change Outcome Management System (PCOMS) and client directed outcome informed (CDOI) ideas and practices. It presents the advantages of PCOMS and describes the implementation process of the Heart and Soul of Change Project--one that not only provides organizational consultation but also attention to the front line practitioner.

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  • 1. Dr. Barry L. Duncan, Director_______________________________________________________________________ CDOI Training and Implementation of the Partners for Change Outcome Management System PCOMS and CDOI What Is PCOMS? The Partners for Change Outcome Management System or PCOMS incorporates the most robust predictors of therapeutic success into an outcome management system that partners with clients while honoring the daily pressures of front-line clinicians. Unlike other methods of measuring outcome, this system truly gives clients the voice they deserve and assigns consumers key roles in determining how services are delivered and perhaps funded. PCOMS uses two brief scales, the Outcome Rating Scale (ORS) and the Session Rating Scale (SRS) to measure the clients perspective of benefit and the alliance, respectively. It is the only system that includes a transparent discussion of the results with clients and the only system to include routine measurement of the therapeutic alliance. PCOMS has been shown in 3 randomized clinical trials (RCTs), all conducted by Heart and Soul of Change Project researchers and published in top tier journals, to significantly improve effectiveness in real clinical settings. Because of the 3 RCTs, PCOMS is recognized in SAMHSA’s National Registry of Evidence- based Programs and Practices (NREPP). PCOMS has been implemented by hundreds of organizations, public and private, by thousands of behavioral healthcare professionals in all 50 states and 20 countries serving over 100,000 clients a year. PCOMS is a-theoretical and may be added to or integrated with any model of practice. What Is CDOI? While PCOMS is not based in any model-based assumptions and can be incorporated in any treatment, it does promote a set of service delivery values that we call client-directed and outcome informed or CDOI. Any interaction can be client-directed and outcome-informed when the consumer’s voice is privileged, social justice is embraced, recovery is expected, and helpers purposefully form partnerships to: (1) enhance the common factors across theories that account for success—especially the heart and soul of change (client resources and the therapeutic alliance); (2) use client’s ideas and preferences (theories) to guide choice of technique and model; and (3) inform the work with reliable and valid measures of the consumer’s experience of the alliance and outcome. PCOMS offers a way to operationalize these values. Why Is PCOMS a Good Idea? • There is a growing worldwide movement, both private and governmental, to involve consumers in mental health and substance abuse care and improve the outcome or value of rendered services. Both the Presidents New Freedom Commission and SAMHSA call for consumer centered care with services tailored to the individual’s unique recovery journey. PCOMS proactively partners with consumers to improve the value of the care they receive and is the only system that by design includes clients in all aspects of outcome management. • The use of evidence based treatments (EBT) does not guarantee success. In recognition of the inability of any model to predict success for the individual client, the APA Task Force on evidence based practice (EBP) suggested that “ongoing monitoring of patient progress andPO Box 6157, Jensen Beach., FL 34957; 772.204.2511; 561.239.3640; barrylduncan@comcast.net
  • 2. 2 adjustment of treatment as needed are essential.” PCOMS provides a method to combine EBP with “practice-based evidence” to ensure success at the individual client level. PCOMS is included in SAMHSA’s NREPP. • Although psychosocial intervention is successful for many clients, a portion of clients do not benefit. In addition, public behavioral health drop-out rates average 47%. Making matters worse is the fact that clinicians often fail to identify people at risk for dropping out or unsuccessful outcome. PCOMS rectifies these problems by providing an early warning system to identify failing clients based on the best known predictors of outcome and retention. • Two factors are strongly predictive of retention, progress, and the eventual success of treatment: The consumer’s rating of the alliance with the provider of services and the consumer’s rating of early progress in response to the provider, level, and type of treatment offered. PCOMS monitors these two predictive variables with reliable, valid, and feasible outcome and alliance measures. • Providing clinicians with ongoing consumer feedback regarding the alliance and progress in treatment dramatically increases success rates as well the cost-effectiveness (reduces cancellations, no shows, length of stay, etc) of provided services. • Three randomized clinical trials (RCT) used PCOMS (the ORS and SRS) to investigate the effects of feedback versus treatment as usual (TAU). First, Reese, Norsworthy, & Rowlands (2009; Psychotherapy) found that individuals who attended therapy at a university counseling center and a graduate training clinic demonstrated significant treatment gains for feedback when compared to TAU. Second, our study in Norway (Anker, Duncan, & Sparks, 2009; Journal of Consulting and Clinical Psychology), the largest (N = 410) RCT of couple therapy ever done, found that feedback clients reached clinically significant change nearly four times more than non-feedback couples. The feedback condition maintained its advantage at 6 month follow-up and achieved a 46% lower separation/divorce rate. Feedback improved the outcomes of nine of ten therapists in this study. Finally Reese, Toland, Slone, & Norsworthy, 2010; Psychotherapy) replicated the Norway study with couples. These studies, as well as all the references cited in this summary are available at www.heartandsoulofchange.com. Two other RCTs are underway, one in a group treatment setting for substance and PTSD problems with returning Iraq and Afghanistan veterans, and the other in school based setting with children and adolescents.From Research to Practice: Current Applications and ResultsAll of the results below are reported in: Bohanske, R., & Franczak, M. (2010). Transforming publicbehavioral health care. In B. Duncan, S. Miller, B. Wampold, & M. Hubble (Eds.), The heart and soulof change: Delivering what works (2nd ed., pp. 299–322). Washington, DC: APA.The Center for Family Services, West Palm Beach, FL, Dave Claud, Clinical Director: Conductedthe first systematic analysis of “efficiency” after implementation of PCOMS, and compared theaverage number of sessions, cancellations, no shows, and % of long-term cases before and afterimplementation on a sample of 2130 closed cases seen in a public CMHC. Average number of sessionsdropped 40% (10 to 6) while outcomes improved by 7%; cancellation and no show rates were reducedby 40% and 25%; and % of long term null cases diminished by 80% (10% to 2%). Resulted in anestimated savings of $489,600; such cost savings did not come at the expense of client satisfactionwith services—during the same period satisfaction rates improved significantly.
  • 3. Southwest Behavioral Health, Phoenix, AZ, Bob Bohanske, Chief of Clinical Services: State of Arizona noted CDOI/PCOMS as a “Best Practice.” Improved Perfect Attendance in Addiction Services from 22% to 69%; Improved Perfect Attendance in Co Occurring “Disorder” Program from 27% to 70%; Reduced length of stay across programs by 50%, reduced cancelations and no shows by 30%; Outcomes improved by 20%; Length of stay with youth decreased by 180 days. Community Health & Counseling Services, Bangor, ME, Mary Haynes, Clinical Director: Using PCOMS and CDOI since 2003 with clients diagnosed with “severe mental illnesses”—dramatically improved retention and efficiency of services with perhaps the most difficult to serve clients. The length of stay was reduced by 72% in case management services, 59% in psychotherapy services, and 47% in residential treatment; The number of no shows and cancellations has reduced by 30%; Satisfaction with rendered services has improved while complaints have reduced resulting in a decrease in liability. Successful Implementation of PCOMS Successful implementation of PCOMS requires organizational commitment at all levels (see Readiness Checklist at www.heartandsoulofchange or www.slideshare.com) . Implementation also requires an attention to front-line clinicians. For some who have been in the field for a while, outcome management is a totally foreign concept while others have been turned off by cumbersome measures that seem far removed from their day-to-day work with clients. Still others are fearful that "pay for performance"  or similarly m arbitrary standard. Implementation is enhanced when it makes sense to therapists and appeals to their nearly universal desire to do good work. In an attempt to motivate practitioners to consider the benefits of feedback, the implementation process of the Heart and Soul of Change Project also includes an attention to: 1) the common factors; 2) a nuanced clinical process; and 3) therapist development. The common factors, those elements of psychotherapy running across all models that account for change (Duncan, 2010; Duncan et al., 2010), provide an overarching framework for the PCOMS intervention. Integrating the use of PCOMS within the larger literature about what works in therapy promotes therapist understanding of the feedback process and adherence to the feedback protocol. PCOMS is presented as the tie that binds these healing components together, allowing the factors to be expressed one client at a time. Soliciting systematic feedback is a living, ongoing process that engages clients in the collaborative monitoring of outcome, heightens hope for improvement, fits client preferences, maximizes chances for a strong alliance, and is itself a core feature of therapeutic change (Duncan, 2010). An attention to common factors also reflects the recommendations of SAMHSA regarding recovery.. Although the over 300,000 administrations of the ORS/SRS has yielded invaluable information regarding the psychometrics of the measures, trajectories, algorithms, etc., PCOMS remains a clinical intervention embedded in the complex interpersonal process called psychotherapy. For successful implementation and ongoing adherence, PCOMS must appeal to therapists in ways that the numbers or data or even the research never can. Consequently, PCOMS is described as the clinical process that it is—one that requires skill and nuance to achieve the maximum feedback effect. PCOMS speaks toPO Box 6157, Jensen Beach., FL 34957; 772.204.2511; 561.239.3640; barrylduncan@comcast.net
  • 4. 4therapists "where they live"  by providinfrom their services.Similarly, a focus on therapist development provides a positive motivation for therapists to invest timeand energy in PCOMS. There will always be organizational motivations for PCOMS in terms ofimproved outcomes and reduced cost—the language of "return on investment" and "proof ofvalue." But there is abusiness in the first place: to make a difference in the lives of those served. The groundbreakingresearch by Orlinsky and Rønnestad (2005) about therapist development (now over 11,000 therapistsincluded) demonstrates that nearly all therapists want to continue to improve throughout their careersand harnessing this motivation is part and parcel to successful implementation. PCOMS appeals to thebest of therapist intentions and encourages therapists to collect ORS data so that they can track theirdevelopment and implement strategies to improve their effectiveness (Duncan, 2010).Including these additional aspects allows therapists to see that the intentions of PCOMS go wellbeyond management or funders cost or efficiency objectives—client based outcome feedback is aboutclient privilege and benefit, and helping therapists get better at what they do. In addition, it is alsocritical that therapists know that management only intends to use data to improve the quality of carethat clients receive, that there will be no punitive use of the data in any way, shape, or form. Given thatmost therapists improve their outcomes with feedback (9 of 10 therapists improved in the Anker et al.trial), a positive, non-competitive approach goes a long way to assuage therapists fears.After an initial two day training for all staff, implementation relies heavily on a "training of trainers"model, encouraging agencies to build a core set of therapists, managers and/or supervisors to provideongoing training and supervision. Collecting data and ongoing supervision are of primary importanceto successful implementation. The data tell all, allowing rapid information about not only who is usingthe measures but also whether the measures are being used properly thus allowing data integrity. Dataindicators of correct and incorrect use are easily taught and integrated into the supervisory processallowing supervisors to monitor and build therapist skill level. A four step supervisory process(Duncan & Sparks, 2010) that focuses first on ORS identified clients at risk, and then on individualclinician effectiveness and how improvement can occur, strengthens the possibility of successfulimplementation.About the Heart and Soul of Change ProjectThe Heart and Soul of Change Project (hereafter the Project) is a practice-driven, training and researchinitiative that focuses on what works in therapy, and more importantly, how to deliver it on the frontlines via client based outcome feedback, or what is called the Partners for Change OutcomeManagement System (PCOMS). The Project features an international community of providers of allstripes and flavors as well as researchers and professors, all dedicated to privileging consumers andimproving psychotherapy and substance abuse outcomes. Researchers at the Project conducted allthree RCTs described above as well as the noted child and adolescent study and upcoming veteran andinner city school investigations. The RCTs led to the designation of PCOMS as an evidence basedpractice in SAMSHA’s NREPP. In addition to the RCTs addressing PCOMS and the benefits ofconsumer feedback, researchers and scholars at the Project have published 15 other studies and papersregarding improving psychotherapy outcomes and the training of mental health and substance abuseprofessionals. The Project is distinguished by its commitment to ongoing research and dissemination tofront line practitioners.
  • 5. About the Director, Barry Duncan, Psy.D. Barry L. Duncan, Psy.D., is a therapist, trainer, and researcher with over 17,000 hours of clinical experience. Dr. Duncan has over one hundred publications, including fifteen books addressing systematic client feedback, consumer rights and involvement, the power of relationship, and a risk/benefit analysis of psychotropic medications. His work regarding consumer rights and client feedback has been implemented across the US and in 20 countries including national implementation in couple and family centers in Norway. His latest books: the 2nd edition of the Heart and Soul of Change (APA, 2010); and On Becoming a Better Therapist (APA, 2010). Because of his self help books, he has appeared on "Oprah," "The View," and several other national TV programs. Barry co-developed the ORS/SRS family of measures and the Partners for Change Outcome Management System (PCOMS) to give clients the voice they deserve as well as provide clients, clinicians, administrators, and payers with feedback about the clients response to services, thus enabling more effective care tailored to client preferences. He is the developer of the clinical process of using the measures and PCOMS, first articulated in the first edition of Heroic Clients, Client Agencies (Duncan & Sparks, 2002). Barry implements PCOMS in small and large systems of care and conducts agency trainings, workshops, and keynote presentations on all of the topics listed above for both professional and general audiences. Drawing upon his extensive clinical experience and passion for the work, Barrys trainings speak directly to the front line clinician. His presentations not only cover consumer based outcome feedback or PCOMS—which improves outcomes more than anything since the beginning of psychotherapy—Barry also talks about what it means to be a therapist and how each of us can re-remember and achieve our original aspirations to make a difference in the lives of those we serve. His trainings integrate the nuances of the work, our dependence on the resources of clients, and an appreciation of the hard work required for strong alliances across clients with the systematic use of outcome and alliance feedback. Video examples from a wide variety of clients demonstrate both the ideas and practices of CDOI—and moreover show that Barry doesnt just talk the talk.PO Box 6157, Jensen Beach., FL 34957; 772.204.2511; 561.239.3640; barrylduncan@comcast.net