Flo A. SteinFlo A. Stein, MPH
NC PIC Project Manager
Deputy Director
Division of MH/DD/SAS


Evidence-based Programs and Practices

The mission for the NC PIC is to ensure that all North Carolinians will receive excellent care that is consistent with our scientific understanding of what works whenever they come into contact with the DMHDDSAS system.

To improve the lives of clients during the current era of system transformation, North Carolina must focus on the content and quality of services and supports that are offered. Research has found that even some of the most popular and well disseminated programs are not evidence based and in fact can be counterproductive. The provision of quality services and supports involve fidelity to proven intervention models.

To facilitate guidance in determining the future evidence-based services and supports that will be provided through our public system, the Director of the Division of Mental Health, Developmental Disabilities and Substance Abuse Services has developed the North Carolina Practice Improvement Collaborative (NC PIC). The NC PIC is comprised of representatives of all three disabilities and meets thrice yearly to review and discuss current and emerging best practices for adoption and implementation across the State.

NC PIC Updates

Scaling up of Evidence-Based Practices for Children & their Families

In recent years, researchers have developed numerous empirically supported interventions to assist individuals with mental health issues, intellectual and developmental disabilities, and substance use disorders, family members, and caregivers. Even though many of these interventions have demonstrated improved outcomes, few have been adopted and widely implemented due to challenges related to training, supervision, fidelity to the model, and cost. Yet, the need for scaling up evidence-based practices (EBPs) in public service systems remains a priority of the North Carolina Division of Mental Health, Developmental Disabilities, and Substance Abuse Services.

Last month, Lauren Supplee, Ph.D., Director, Division of Family Strengthening, Office of Planning Research and Evaluation, Administration for Children and Families, gave a keynote speech, The House that Evidence-Based Practice Built: Moving from Program Development to Real World Outcomes, for the Institute of Medicine. She suggested reasons why wide-scale implementation continues to be elusive:

• Most evidence still comes from small-scale tightly controlled efficacy trials with limited external validity.

• Little evidence has been provided on replication (or what replication means).

• Little empirical knowledge has been provided on the core components.

• Researchers have provided little evidence on why and how impacts vary by specific population groups, settings, and other variables.

Dr. Supplee embraced the need to build the infrastructure at both the local and state levels to support dissemination where interventions would be tested and result in a menu of evidence-based, high-demand, practice-ready interventions. She also felt that meaningful collaborations need to be developed and sustained between the practice community and the developers/researchers so that program design and efficacy would be improved. To view her presentation, click here. The accompanying slides may be downloaded here.

Articles of Interest

• Chamberlain P, Roberts R, Jones H, Marsenich L, Sosna T, Price JM. Three collaborative models for scaling up evidence-based practices. Adm Policy Ment Health, 2011

• Nadeem E, Gleacher A, Pimentel S, Campbell Hill L, McHugh M, Hoagwood KE. The role of consultation calls for clinic supervisors in supporting large-scale dissemination of evidence-based treatments for children. Adm Policy Ment Health, 2013;40:530-40

• Poduska J, Kellam S, Brown CH, Ford C, Windham A, Keegan N, Wang W. Study protocol for a group randomized controlled trial of a classroom-based intervention aimed at preventing early risk factors for drug abuse: Integrating effectiveness and implementation research. Implementation Science, 2009

Evidence-based Practices for Autism Spectrum Disorders

Earlier this year, Connie Wong and her colleagues at the University of North Carolina Frank Porter Graham Child Development Institute issued a report, Evidence-Based Practices for Children, Youth, and Young Adults with Autism Spectrum Disorder.  This report is a follow-up to a 2007 review by the National Professional Development Center (NPDC) on ASD,  which resulted in the identification of 24 practices that met the evidentiary criteria they had established. Briefs for each of the 24 practices may be downloaded here.

The recently released EBP report provides the results of an updated review of the literature. Using five databases (EBSCO, EMBASE, Medline, ISI, Sociological Abstracts) and a range of descriptors (e.g., autism, Asperger), the initial search generated over 29,000 articles published between 1990 and 2011), which were winnowed down to 1,090 after screening to ensure investigators employed an experimental, quasi-experimental, or single case design. One hundred fifty-nine reviewers were selected to review the articles; they were expected to complete training and meet inter-rater agreement criteria.  These reviewers then determined whether a practice met the level of evidence necessary to be classified as an EBP using the following criteria: (a) two high quality experimental or quasi-experimental design studies, or (b) five single case design studies conducted by three different research groups and involving a total of 20 participants across studies, or (c) there is combination of research designs, which must include at least one high quality experimental/quasi-experimental design and three high quality single case designs. From the 1,090 articles, 456 articles were accepted as providing scientific evidence. Content analyses of procedures produced 27 different practices (see report for details).

Fact Sheets for each of the 27 practices may be downloaded here.

For a copy of the report, click here.

1  The NPDC on ASD is a multi-university center that operates through three sites: the FPG Child Development Institute at the University of North Carolina at Chapel Hill,  the M.I.N.D. Institute at University of California at Davis Medical School, and the Waisman Center at the University of Wisconsin at Madison.

Innovative Technologies Summit

On March 12, 2014, the North Carolina Practice Improvement Collaborative, in partnership with the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services, and the Governor’s Institute on Substance Abuse, hosted the Innovative Technologies Summit at the Raleigh Convention Center.  As the last of three meetings in 2013-14 under the banner, Improving Outcomes:  Improving Lives, this meeting featured three speakers; an interactive showcase of 12 vendors of assistive technologies; and a five-person panel on adoption and implementation.

H. Westley Clark, M.D., J.D., M.P.H., Director, Center for Substance Abuse Treatment, U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), gave the keynote address on Innovative Technologies: Improving Practice, Protecting Privacy.  SAMHSA has a health innovative technologies (HIT) strategic initiative, supported by nine goals.  SAMHSA currently funds East Carolina University for its project, Operation Reentry North Carolina: Veteran Resiliency and Reintegration Through Technology.  To facilitate the integration of standards-based HIT within the behavioral health field, SAMHSA recently hosted three regional HIT conferences.  Dr. Clark also addressed the challenges of privacy, confidentiality, and security.

Melissa Pinto, Ph.D., R.N., Assistant Professor, Nell Hodgson Woodruff School of Nursing, Emory University, addressed benefits and concerns about the use of behavioral health technology (BHT); how BHT impacts the clinical relationship and care; the state of the science of BHT; and eSMART technology in her presentation, Evolving Role of Technology in Behavioral Health and Developmental Disabilities.  She emphasized the growing importance of BHT in that 75% of patients identify one or more structural or psychological barriers to care and that access to care is more difficult for minority groups and individuals living in rural areas.  Through BHT, patients will gain more access, consumers and insurance companies will pay less, additional flexibility will be added, consumers will be empowered, and consumers will receive continuing and integrated care.

Rodney Bell, Principal, ASSET (Adopting/Applying Systems, Software, and Engineering Technology) Consulting, presented on Technology for People with Cognitive Disabilities: The Promise, Pitfalls, and Push.  He promoted the use of technologies for individuals with developmental disabilities through the web, smart mobiles, assistive apps, and residential supports.  These technologies will change providers’ practice, consumers’ lives, and governance (e.g., waivers, reimbursement, ethics).  Because technology is outpacing society and governance, there is a need for service providers to exercise caution and to always keep the end user in mind.  Privacy and reimbursement are issues to be addressed as personal information needs to be secure and technologies need to be financially feasible.  A workforce that is technologically competent, with corresponding job descriptions and salaries, must be developed and nurtured.

Aldona Zofia Wos, MD, Secretary, North Carolina Department of Health and Human Services discussed the technology Initiatives of the North Carolina Department of Health and Human Services.  She spoke of the need to collaborate with industry to harness technology so it facilitates independent living and recovery.  Secretary Wos asked the audience to identify what our constituents need, how to use the technologies, and how to fund them.  To the LMEs-MCOs, she said, “What are you waiting for?  Use the technologies to do the best that you can.”  In addition, she promoted a statewide telepsychiatry initiative in emergency rooms and a pilot mobile technology project to combat childhood obesity.  She concluded stating that she is open to all new projects and initiatives in behavioral health.  Click here for a press release from Sec. Wos’s office about our Summit.

The interactive showcase on innovative technologies featured twelve vendors:

  • ASI-MV and CHAT by Inflexxion – Tom Jackson and Mike Waldron
  • Assistance Technology Works – Dawn Sowers, M.A.
  • Coleman Institute for Cognitive Disabilities, University of Colorado – Rodney Bell
  • GSTS Designs, LLC – Lance Hatfield
  • North Carolina Assistive Technology Program – Sonya Clark
  • PHIT for Duty – Paul Kizakevich and Randy Eckhoff, Research Triangle Institute
  • Qualifacts – Dan Baron and Jenny Milose
  • Simply Home – Allen and Drue Ray
  • Smart Homes & Business – Jerry Tester, Whitney Hasson, and Erin Huddleston
  • Assistive Technologies for Veterans – Kelly Ramsey, US Department of Veterans Affairs
  • VGo – Lee Weinberg, MD and Mark Scheurlein
  • Alcohol Comprehensive Health Enhancement Support System (A-CHESS) – Fiona McTavish, University of Wisconsin

Moderated by Flo Stein, a five-member panel discussed the Advancement and Opportunities for Technology in North Carolina.  Panel members included:

  • Kenneth Bausell, North Carolina Division of Medical Assistance
  • Stephanie Gilliam, North Carolina Division of Health Service Regulation
  • Tammy Koger, North Carolina Assistive Technology Program
  • Sandee Resnick, North Carolina Resource and Regulatory Management
  • Cindy Ehlers, East Carolina Behavioral Health LME-MCO

Members of the panel addressed the identification of current assistive technologies, barriers hampering the utilization of innovative technologies, regulations, funding resources and reimbursement, application, and recommended future steps to support innovative technology.

One hundred forty-two individuals, representing family members, state agencies, LME-MCOs, provider agencies, and universities, attended the event.  Eighty-five respondents were asked to complete the question asking which technologies they would recommend for adoption.  Smart home technology topped the list (21 respondents), followed by mobile apps developed by the Department of Veterans Affairs (15), A-CHESS (12), and telepsychiatry and other therapeutic extenders (8).  Communication devices, electronic health records, PHIT for duty, myStrength.com, and VGo each received three mentions.

In order to prepare for the Summit, a resource handout was developed.  This handout is included here as well as materials submitted by vendors.  For the downloadable copy of each of the apps from the Department of Veterans Affair, here is the website. The Journal of the American Medical Association has recently published two opinion pieces on the use of online technologies and mobile apps in health.  The first was cited by Dr. Clark and addresses the utility of online technologies.  The second asks the question about the effectiveness of the new apps. Both may be downloaded directly from their site.

For additional information, please contact Leesa Galloway, LME-MCO Systems Performance, Community Policy Management, NC DMH/DD/SAS.

Presentations & Handouts from the Meeting
H. Westley Clark, M.D., J.D., M.P.H. – PowerPoint and video
Melissa D. Pinto, Ph.D. – PowerPoint and video
Rodney Bell – PowerPoint and video (begins at 42:00 minute mark)
Secretary Aldona Wos – video, with link to press release (see above)

Discourse SBIRT Flyer
VGo in the News
Innovative Technologies: Resource Handout
Mobile Apps released by the VA National Center for PTSD
NC Council Signs Agreement with myStrength.com
Software Advice Handout
The Fix – Recovery: There’s an App for That


Recent Resources on Substance Use Disorders

Standards of Care:  For the Addiction Specialist Physician
Funded by the Substance Abuse and Mental Health Services Administration, the National Institute on Drug Abuse, and the National Institute on Alcoholism and Alcohol Abuse, the American Society of Addiction Medicine (ASAM) developed Standards of Care:  For the Addiction Specialist Physician. Standards of care are outlined in six areas:  assessment and diagnosis; withdrawal management; treatment planning; treatment management; care transitions and care coordination; and continuing care management.  Even though North Carolina has 49 ASAM physicians, not all physicians who provide treatment and care of substance use disorders are members of ASAM.  They would find this guideline to be useful as well.

Alcohol-Attributable Deaths and Years of Potential Life Lost — 11 States, 2006–2010
According to a study released by the Centers for Disease Control and Prevention in the March 13 issue of Morbidity and Mortality Weekly Report, excessive alcohol use is a leading cause of preventable death and years of potential life lost in the 11 states that were studied.  North Carolina was one of the states that contributed to the sample and fell in the middle of average annual alcohol-attributed death rate of 28.5, compared to New Mexico at 50.9 and Utah at 22.4.  The median death rate for North Carolina was highest for American Indian and Alaska Natives (35.2), followed by African Americans (29.3), white non-Hispanic (28.6), white Hispanic (20.5), and Asian, Native Hawaiian, and Pacific Islanders (8.8).  According to the study, a median of 1,600 deaths and 43,000 years of life lost annually are due to excessive drinking. About 70% of these deaths and 80% of the years of life lost involved working-aged adults, on pages 213-216.

Resources on Teen Substance Use
Common Sense for Drug Policy, a nonprofit organization dedicated to educating its readership about drug policies, hosts a website that provides research, statistics, and resources on substance use by youth.  It may be particularly useful for those interested in preparing grant applications or educational materials for legislators.  For example, current posts include prevalence rates, lifetime use of specific illegal drugs, and availability of specific drugs.

CASA of Columbia University offers useful reports and other publications on addiction prevention and substance abuse.  In 2011, it released the report, Adolescent Substance Use: America’s #1 Public Health Problem.

Resources for Indiv. with Intellectual and Developmental Disabilities

Psychotropic Medication Use and Polypharmacy in Children With Autism Spectrum Disorders:

On November 19, 2013,. Jarrett Barnhill, MD, presented on MH-ID: Misuse of Psychotropic Medications to the IDD-PIC (Click here for a copy of the PowerPoint presentation).  We recently came across this article published by Spencer and her colleagues in the October 2013 issue of Pediatrics and are sending out the results of this study as a follow up.  Spencer and her colleagues reported on a study in which they examined rates and predictors of psychotropic medication use and multiclass polypharmacy in over 33,500 commercially insured children with autism spectrum disorders (ASD). They found the following:

  • 38% of the children took antidepressants and ADHD medications
  • 28% took antipsychotics and ADHD medications
  • 20% took antipsychotics and antidepressants
  • 18% took antipsychotics, antidepressants, and ADHD medications

The researchers noted that the number of prescriptions per child increased with age–33% of children age 10 and younger and 60% of older children took more than one medication. The likelihood of psychotropic use and/or polypharmacy was highest among older children, those who had a psychiatrist visit, and those with evidence of co-occurring conditions. The researchers said the results indicate the need to develop standards of care around the prescription of psychotropic medications to children with ASD.  For a copy of Spencer’s article, Psychotropic Medication Use and Polypharmacy in Children With Autism Spectrum Disorders, please click here.

Financing Long-term Services and Supports for Individuals with Disabilities and Older Adults:

In June 2013, the Forum on Aging, Disability, and Independence of the Institute of Medicine and the National Research Council hosted a workshop on Financing Long-term Services and Supports for Individuals with Disabilities and Older Adults. Participants examined the financing of long-term services and supports for working-age individuals with disabilities and among individuals who are developing disabilities as they age. The National Academies Press recently released the workshop proceedings, which may be downloaded for free by clicking here.