Implementation of Evidence-Based

Models: Improving Processes

Jeanne L. Obert, MFT, MSMExecutive Director, Matrix Institute

UCLA Integrated Substance Abuse Programs

History of Matrix Model Clinical Services

• 1984 – Adult Intensive Outpatient Treatment Program began in Los Angeles – The Matrix Model

• 1986 - San Bernardino County program begins with 60% of clients abusing methamphetamine

• 1990 – Became affliated with UCLA• 1994 - First Adolescent Treatment Program

started at YMCA in Ontario, CA• 1998 - Rick Rawson left – CSAT MTP began• 2000 – Officially became totally nonprofit• 2005 – 5 Clinical Sites in the Greater Los Angeles

Area

Treatments Available Medical & Behavioral

Drug Classes

SedativesStimulantsOpioidsAlcohol

Medical Treatments

– Sedatives

– Opioids– Alcohol

Behavioral Treatments

– Sedatives– Stimulants– Opioids– Alcohol

MATRIX MODEL AN ORGANIZED

COLLECTION

OF SELECT

EVIDENCE-

BASED

INTERVENTIONS

Cognitive-Behavioral

Motivational Interviewing

Contingency Management

Family Therapies

Defining Features of Matrix Model Treatments

• Comprehensive, manual-driven, one year program with simple, well-organized instructions.

• Developed from grassroots, clinical program with empirically-based interventions added where they seem to work.

• Patient handouts accompany each session and patient workbook contains written and illustrated concepts.

Matrix ModelEvidence-Based Treatments

delivered withinIndividual SessionsEarly Recovery GroupsRelapse Prevention GroupsFamily Education Group12-Step MeetingsSocial Support GroupsRelapse AnalysisUrine Testing

3 Large Scale Dissemination Efforts

Richard Rawson Ph.D.

U.C.L.A. Integrated Substance Abuse Programs (I.S.A.P.)Funded by the Center for Substance Abuse Treatment

The CSAT Methamphetamine Treatment Project

A Multi-site Trial of a Manualized Psychosocial Protocol for the Treatment of Methamphetamine

Dependence

Goals of the Methamphetamine

Treatment ProjectTo study the clinical effectiveness of the Matrix ModelTo compare the effectiveness of the Matrix model to other locally available outpatient treatmentsTo establish the cost and cost effectiveness of the Matrix model compared to other outpatient treatmentsTo explore the replicability of the Matrix Model and challenges involved in technology transfer

Motivational Enhancement Therapy (MET) for Outpatient Retention and

Substance UseProtocol 005

Kathleen M. Carroll, Ph.D.

(Lead Investigator)

Samuel A. Ball, Ph.D.

Yale University School of Medicine

Primary Aims

• To evaluate the effectiveness of MET in:

• Retaining diverse clients in outpatient treatment

and reducing their substance use …

• …when delivered by diverse community clinicians in the first month of treatment in different practice settings relative to counseling-as-usual (CAU)

Secondary Aims

• Evaluate whether programs treating predominantly alcohol vs. drug abusers have better outcomes

• Evaluate the discriminability of MET from Counseling-as-Usual (CAU)

• Evaluate client gender and race differences in response to MET vs. CAU

Matrix goes to Thailand

The Ultimate Train-the-Trainer Project

Walter Ling, MD

12 well-trained sites in Thailand

resulted in

4,000 Matrix Centers in less than 2 years

Issues in Disseminating Evidence-based Models

• Dealing with modifying human interactions with peer-oriented staff, research-oriented trainers, and business-oriented administrators

– Suspicion of research– Conflicting priorities– Process of creating change (mandated?)– Accepting “manualized” treatments – Modifying protocols – adaptation vs. fidelity

Law Enforcement Officials in 500 US Counties asked

“What is your primary drug problem?

National Association of Counties - 2005

The DilemmaHow to Disseminate the

Information ?

ContinuumSpeed Effectiveness

Train-the-Trainer(s)Model

Highly-SelectiveHighly-IntensiveTraining Model

Stages of Adaptation*

• Step I - Exposure (to new ideas)

• Step 2 - Adoption (formal decision to try change)

• Step 3 - Implementation (provider tests use of innovation)

• Step 4 - Practice (incorporation of innovation into regular use)

* D. Simpson, 2002

Implementation Research: A Synthesis of the Literature

2005

Matrix Model Key Supervisor

• Strong champion who can serve as a change agent/purveyor in the adoption process

• Serves as a liaison between Matrix and adopting program

• Helps educate staff and administrators about new program

• Clinical leader who knows the Model well and can help others learn

Step 1 – Exposure(to new ideas)

CSAT STUDYTECHNOLOGY TRANSFER

• 3-day trainings with all sites together bi-annually

• On-site visits and consultations at start-up

MATRIX COMMUNITYTECHNOLOGY TRANSFER

• One 2.5 day core workshop limited to 30 participants with a Matrix-experienced trainer

• Key Supervisors identified and scheduled for further training

• Manuals available with recommendation for training

Step 2 – Adoption(formal decision to try change)

CSAT STUDYTECHNOLOGY TRANSFER

• Site adoption occurred through RFP process

• Individual therapist chosen at site was voluntary

• (Post study recommendation: Hold retreat with all participants held at start-up to establish good working relationships)

MATRIX COMMUNITYTECHNOLOGY TRANSFER

• Returning workshop participants will recommend (or not) adoption

• Selection of Key Supervisor will help actualize organizational commitment

• (Future? Meet with key program administrators and leaders prior to commitment)

Characteristics of Ideal Key Supervisor

• Respected clinical leader who is both credible to clinicians and savvy about organizational dynamics

• Possess excellent communication and clinical skills

• Committed to actively working to implement the Matrix Model with fidelity and good effect

Policy Recommendations

( University of South Florida, Implementation Research: A Synthesis of the Literature)

• Encourage program-centered service delivery rather than practitioner-centered. (Use of manuals aids this process.)

Policy Recommendations

• Invest in development and use of implementation strategies and methods that are grounded in research and elaborated through accumulated experience.

(Similar to recent investments made in information systems.)

Policy Recommendations

• Develop funding strategies to support implementation of evidence-based programs

• Start up costs• Purveyor support (Change agents and/or

organizations)• Adequate funding for services• Ongoing support of infrastructure for

sustainability