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With ten years of implementation experience under his belt including four of the largest public behavioral health agencies in their respective states as well as national implementation across couple and family centers in Norway, Barry presents what he has learned about the successful implementation of PCOMS—the four secrets: 1) In It for the Long Haul—organizational commitment at all levels; 2) Love Your Data—collection and use of data right out of the gate; 3) Inspire the Front-Line Clinician—connecting PCOMS to therapists’ desire to do good work and improve over the course of their careers; and 4) Supervision for a Change—using the data to improve outcomes and accelerate therapist development. This presentation covers the first three secrets and the next will address supervision

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  1. 1. www.heartandsoulofchange.com January, 2013 The Four Secrets of Successful Implementation Barry Duncan, Psy.D. Psy.D. www.heartandsoulofchange.com 561.561.3640 barrylduncan@comcast.netbarrylduncan@comcast.net 1
  2. 2. www.heartandsoulofchange.com January, 2013 What’s Up 3 of the 4 Secrets 1) In It for the Long Haul— organizational commitment at all i ti l it t t ll levels; “We Want to Implement” 2) Love Your Data—collection and use of data right out of the gate; Nothing Organic! 3) I Inspire the Front-Line Clinician— i th F t Li Cli i i connecting PCOMS to therapist’s desire to do good work & improve over their careers… research on 11K therapists PCOMS Implementation General Comments Change is g Hard! Staff need structure and support to make it happen.barrylduncan@comcast.net 2
  3. 3. www.heartandsoulofchange.com January, 2013 Validate Front Line Struggles Life is Tough •Always Something Always •Skeptical for Good Reason •But This Time Is Different PCOMS Implementation General Comments Be a Hero: Commit to Paperwork Reduction…barrylduncan@comcast.net 3
  4. 4. www.heartandsoulofchange.com January, 2013 People Are Afraid of Change And Sometimes Angry Takes too much time The “latest” latest “mangled- “mangled-care” Management will use the gimmick results against therapists Nice theory, doesn’t work in the real world This gets in the way of forming a good therapeutic relationship Clients will get How will more paperwork make bored or object me more efficient? PCOMS Implementation: 4 Secrets 1. In It for the Long Haulbarrylduncan@comcast.net 4
  5. 5. www.heartandsoulofchange.com January, 2013 HSCP Readiness Checklist In It for the Long Haul 1. Board of Directors approval of & pp support for PCOMS. 2. Consensus among senior managers that consumer partnership, accountability, & PCOMS are central features of service delivery. 3. A business/financial plan that incorporates PCOMS. 4. Regular communication w/funders about PCOMS data 5. A HR training & dev. plan that supports ongoing PCOMS ed., including i l di a core group of internal fi l PCOMS trainers, & seeks to integrate PCOMS into therapist dev. plans, performance appraisals, & hiring practices. gp 6. Infrastructure (support staff, IT, hardware, etc) to support the collection & analysis of PCOMS data at consumer to agency levels.barrylduncan@comcast.net 5
  6. 6. www.heartandsoulofchange.com January, 2013 7. Supervisory infrastructure that uses data to identify at risk clients, proactively address needs, & improve therapist performance. 8. A structure & policy for addressing clients who are not progressing that ensures rapid transfer and continuity of care. 9. 9 Incorporates consumer partnership, accountability, & PCOMS as central features in both “Mission Statement” and “Client Rights documents.” PCOMS Implementation: 4 Secrets 2. Love Your Data Data Is More than Just J ta Friend…barrylduncan@comcast.net 6
  7. 7. www.heartandsoulofchange.com January, 2013 Love Your Data Collect Data from the Beginning  Used to think it could happen organically h i ll  What was I thinking!  Collecting data allows: knowing who is and who isn t isn’t doing it; who is and isn’t doing it correctly; data integrity (more on this later); real agency benefit Love Your Data Start However You Can Start by entering data into Excel, & tracking outcome l k with simple calculations: ave. intake & final session scores, # of sessions, & ave. change score (diff. b/w ave intake & final ave. session scores), & ultimately the % of clients who reach reliable or clin. significant change.barrylduncan@comcast.net 7
  8. 8. www.heartandsoulofchange.com January, 2013 Love Your Data Key Performance Indicators 1. Average Change: ag a g Is it above 6? 2. % reaching reliable and significant change 3. Effect Sizebarrylduncan@comcast.net 8
  9. 9. www.heartandsoulofchange.com January, 2013 Love Your Data MyOutcomes.com  The single bit of information that tells you the most is the % who reach target—the mean trajectory for clients entering services with the same intake score. PCOMS Implementation: 4 Secrets 3. Inspire the Front Line Clinician Therapists Do the Work Because They Want to Make a Difference Therapists Want to Improve over Their Careers Therapists Need to Grow to Avoid Burnoutbarrylduncan@comcast.net 9
  10. 10. www.heartandsoulofchange.com January, 2013 Inspire the Front Line Clinician Orlinsky & Rønnestad  Captures the heart of our aspirations and the very soul of our identity. Massive 20 year study of 11,000 providers of all stripes and flavors from many Orlinsky, D. E., Rønnestad, M. H. (2005). How psychotherapists develop: Washington, DC: APA. countries Inspire the Front Line Clinician It’s a Tough Job Let’s face it… sometimes being a therapist feels like the worst job on earthbarrylduncan@comcast.net 10
  11. 11. www.heartandsoulofchange.com January, 2013 Worse that Tarring Roofs and Draining Septic Tanks Or Being the New Crewmember Who  Just beamed down to a hostile planet with Kirk, ith Ki k Bones, and Spock.barrylduncan@comcast.net 11
  12. 12. www.heartandsoulofchange.com January, 2013 Media Depictions Cast Us as Kooks & Crackpots  Often blamed for creating a nation of wimps or otherwise causing the decline of western civilization with our encouragement of self t f lf indulgence, preoccupation with feelings, and Stuart Smalley daily affirmations. Then There Is the Economic Situation  The typical agency therapist faces many hardships—seemingly unattainable productivity, insurmountable i t bl paperwork, more funder oversight, threat of layoffbarrylduncan@comcast.net 12
  13. 13. www.heartandsoulofchange.com January, 2013 And Does Not Even Speak To  The emotional downsides, the sometimes overwhelming tragedy of the human condition that seems inured to our best efforts—the stories of suffering that are hard to shake. Inspire the Front Line Clinician But We don’t do don t this work because we thought we would acquire the lifestyles of the rich and famous.barrylduncan@comcast.net 13
  14. 14. www.heartandsoulofchange.com January, 2013 And We Knew  atthe outset that mixing it up in the morass of human misery would not be a walk in the park. No Rags to Riches More of a Calling Golly! I just want  That smart, creative to help people indvs ind s make the sacrifices sac ifices only to earn far less says something  Only makes sense b/c it is more of a calling than a job—the study says we are on a quest to make a meaningful difference in those we servebarrylduncan@comcast.net 14
  15. 15. www.heartandsoulofchange.com January, 2013 And We Never Lose the Desire To Get Better  Even with the struggles, we have an inextinguishable passion to get better  86% “highly motivated” to p pursue prof. dev. p  No profession more committed—Therapists want to get better over their careers But Over Time, Many Become Shell-Shocked & Battle Weary  In the face of media ridicule, cultural devaluation, & financial uncertainty, therapists may forget why they enlisted in the therapy rank & file in the first place. How do we keep going?  The answer may surprise youbarrylduncan@comcast.net 15
  16. 16. www.heartandsoulofchange.com January, 2013 Inspire the Front Line Clinician Currently Experienced Growth  Reward for doing the work & our greatest ally for sending the grim reaper of burnout packing.  Most striking aspect of study: our growth is primary way to fend off disenchantment. Currently Experienced Growth  Here & now growth remoralizes us, repairs abrasions & stressors of the work & fights routinization, disillusionment, & loss of empathy.barrylduncan@comcast.net 16
  17. 17. www.heartandsoulofchange.com January, 2013 In Other Words Currently Experienced Growth rescues us from burnout. We need to Grow d This is how we inspire therapists Getting Better & Growth Are Part & Parcel of Therapist Identity  A continual retrospective evaluation of where we are versus where we have been, looking for evidence of our mastery of the work, & an ongoing filtering of our here and now clinical experiences, mining for the golden moments that replenishes us.barrylduncan@comcast.net 17
  18. 18. www.heartandsoulofchange.com January, 2013 Inspire the Front Line Clinician Monitor & Quicken Your Development Feedback tailors services based on response, provides an early warning system to prevent negative outcomes, & solves helper variability—feedback i bilit f db k improves performance and it both monitors and quickens developmentbarrylduncan@comcast.net 18
  19. 19. www.heartandsoulofchange.com January, 2013 Inspire The Front Line Clinician Keep in Mind  For some, OM is a foreign concept while others have been t hil th h b turned off by cumbersome measures far removed from day- to-day work. Still others fear P4P or strategies sounding punitive  Implementation enhanced when it makes sense & appeals to their nearly universal desire to do good work and get better at it Inspire the Front Line Clinician Motivate Those in the Trenches  So to inspire practitioners to consider the benefits of id th b fit f 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.barrylduncan@comcast.net 19
  20. 20. www.heartandsoulofchange.com January, 2013 1. The common factors of change and the evidence  demonstrating that most of therapist variability is  accounted for by alliance abilities Client/Extratherapeutic Factors (87%) Feedback Effects 15‐31% Alliance Effects Treatment Effects 38‐54% 13% Model/Technique 8% Model/Technique Delivered: Therapist Effects Expectancy/Allegiance ll 46‐69% Rationale/Ritual (General  Effects) Duncan, B. (2010). On Becoming a 30‐?% Better Therapist. Washington DC: APA. The natural fit between common factors research & PCOMS is integral to the implementation process of HSCP; Provides a Clinical Context for Understanding Feedback As A Common Factor  Overlaps with & affects all factors—tie factors tie that binds  Soliciting feedback is a living, process that engages clients in monitoring outcome, heightens hope, , g p , fits client preferences, maximizes therapist-client fit re the alliance, & is itself a core feature of change.barrylduncan@comcast.net 20
  21. 21. www.heartandsoulofchange.com January, 2013 2. The clinical nuances to get the max feedback effect.  Although over 400K admins has yielded invaluable info,  PCOMS remains a clinical process embedded in the  complex interpersonal endeavor, psychotherapy  The ORS Is Different: Requires Nuance and Cli i l A li ti N d Clinical Applications • Administering, But Don’t Get It. Clients must understand purpose (monitoring outcome, privileging their perspective); Therapists must understand same + make them meaningful • Administering, Using Some. But not the clinical cutoff or numbers…Heuristic clinical use but no continuity or coherence; Questionable data integrity • Ad i i t i Administering, U i S Using Some. B t not But t connecting to the client’s experience or reasons for service; No data integrity • Administering the SRS. But seeing it as reflective of competence, not alliance building tool The HSCP keeps this in mind and therefore appeals to the clinician in ways the numbers never can. The ORS Is Different Than Other Outcome Measures  Co-constructed with client  Goes from general look at client distress to specific representation of p client’s experience & reason for service  Requires nuance & skill in applicationbarrylduncan@comcast.net 21
  22. 22. www.heartandsoulofchange.com January, 2013 3. Therapist Development provides a positive motivation  for therapists to invest time & energy in PCOMS. Will  always be org. motivations—“ROI” & “POV.”  But therapists  aspire to make a difference in  those  we serve. Therapists want to improve and successful  implementation harnesses this motivation  PCOMS Implementation 4 Secrets 1) In It for the Long Haul— organizational commitment at all i ti l it t t ll levels; 2) Love Your Data—collection and use of data right out of the gate; 3) Inspire the Front-Line Clinician— connecting PCOMS to therapist’s ti t th i t’ desire to do good work & improve over their careers; 4) Supervision for a Change--in both clients and therapistsbarrylduncan@comcast.net 22