Thursday, April 9, 2020
In Attendance: Lillian, Laura, Sandy, Janet, Mary, Hugh, Ian, Catherine, Andrea, Heather
Action Items:
Send Laura the study from London about EPI referrals and program completion - Janet
Minutes
Janet Durbin and her team are part of the Implementation outcomes working group
Study Objectives:
1st Objective: assess whether implementing NAVIGATE improves fidelity to EPI standards
2nd Objective: does it help clients improve
3rd Objective: does it lead to reduced use of emergency services/inpatient admission
Fidelity = research done to develop evidenced based practices
When it’s shown that it’s better than other practices, it becomes an evidence-based practice, and want other programs to implement it
Don’t all doctors implement evidence-based care?
In theory they do, 14% of Americans receive evidence-based care in some studies
Doctors should be doing it, but the practice is maybe they aren’t/are
People do what they think is best, but may have been trained in a certain way, or may not have structures to do some of the things they think they should be doing
Ex. If they don’t have a family worker, they don’t deliver structured family education
It doesn’t happen because people are malicious, don’t always have time/resources to do what’s best
Fidelity assessment = articulate in a measurable fashion what programs should be doing, the measure used for early psychosis intervention is called the “First Episode Fidelity Scale” developed by Don Addington and colleagues in Alberta, reviewed literature about best practices, and had lots of expert clinician input
33 items defined as being important to deliver, to give best quality, evidence-based care
They took that scale and went to 17 EPI programs in Ontario, and assessed them to see how they were doing
Programs varied, overall meeting adherence to most items, saw patterns where many places had difficulties delivering care (particularly the “softer” areas, like psychoeducation)
Overall most programs had a good case load, had a team, saw people in their community
Many had issues delivering family support in a consistent way, along with psychosocial education and supported employment
Fidelity team wants to know - How can we help people do things better?
The fidelity review describes current practice relative to what we think it should look like
If you go to the emergency department with a heart attack, there’s a certain protocol they should follow, and they can measure to see if they’re doing that, but don’t know if they are until you measure and get results
A member of the implementation team mentioned that as a family member of someone going through the EPI program, she didn’t know there was a standard of care, and it didn’t feel like that in hospitalizations
This was all new to her when she learned about the EPION standards
She didn’t feel like a model was being delivered, and others mentioned that there was no referral to an EPI program after hospitalization for psychosis
However, there are international standards and Ontario standards
EPI standards are a 50 page document, but for fidelity we only use a 33 item scale, so it won’t be a perfect assessment, but it’s a start
Raised some items that aren’t covered well in fidelity scale
May add some things that are important to think about when understanding EPI care
Scale applied to existing programs about how they are delivering care
Fidelity is measuring how services are provided
Access matters, but these are system issues that occur before someone even gets into a program
Scale looks at how long it takes people to get into program, timely access to services is part of the standard
Also good to get input on what the scale is missing, and information for other research questions
A study in London compared people who did/didn’t get into EPI service, 50% of those referred got services
Raised important system issues for the project to consider
Janet to share documents with Laura
Other job is to look at how NAVIGATE is being implemented, and make sure it’s being implemented well, if programs can’t implement it well, need to know what the problem areas are
Implementation evaluation has a qualitative piece asking programs what they implemented, and what the problems were from their perspective, surveyed staff and leadership to see how they felt about implementing NAVIGATE
Need to know how they view it so leads can be supported
EPI Fidelity Scale
Scale is 33 items
Measured on 5 point scale, 1 point means it’s not really being implemented/not done by program, 5 points means it’s fully implemented or it’s an exceptional practice
The chart review part of the assessment done in person, otherwise mostly remote, 10 client charts meant to represent sample of clients in program and used with other data to inform ratings
Did telephone interviews with at least 4-5 staff per site
Included manager, psychiatrist, social worker, nurse
Enough to get sense of what’s going on in the program
Also gathered administrative data from each site, and statistics about the program they have
Combine all of the information acquired into ratings
A Slaight clinician is involved, each item in the scale is rated based on all of the data, they discuss ratings and had a ratings meeting where others that are familiar with the scale were present
They discussed each item for hours, and get a final rating
They then wrote reports, and are in the process of finalizing some of them; Niagara received theirs
In the reports they describe the rating and quality improvement opportunities with specific emphasis on NAVIGATE where applicable
It’s very labour intensive for the evaluation committee, and they try to make it less labour intensive for sites
Want to do it 3 times for each site involved in project
Completed the initial baseline for three phase 1 sites to describe practices before NAVIGATE
First Episode Psychosis Services Fidelity Scale
What the item is, what the standard is, what each of the ratings mean, example of the scale
Doesn’t measure quality, but measures if certain things are being done
Items within Psychosocial Treatment domain
Concerned about the 1s
Important to remember that part of the rating for this item is documentation
To score a higher rating, there has to be documented evidence that this is happening, from talking with the sites, know that a lot more psychoeducation and family support is happening than is being documented, may not be consistent and sites are not documenting it well OR what is being delivered it not structured or had specific training for it
Many areas where programs are doing a good job
Provincial System Support Program (PSSP)’s job is to help roll things out
Programs are told to deliver care and are funded for that, not to measure what they are doing
What can the FAC members do to help implementation and fidelity work?
Another meeting will be scheduled to finish this discussion.
Next Meeting: Thursday, May 12, 2020
Comentarios