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Iowa Consortium for Mental Health
Evidence-Based Practices in Iowa’s Performance
Partnership Block Grant Program: Information for
Applicants for FY2006 Block Grant Funds
Table of Contents
Introduction .................................................................................................................................................. 2
Why move to EBP’s? .................................................................................................................................... 2
What is meant by Evidence-Based Practice? ............................................................................................. 3
“Evidence-based practice” vs. practicing in an “evidence-based manner” ............................................. 4
Integrating a “top-down” and a “bottom-up” approach to evidence-based practice: Moving towards
an evidence-based culture ............................................................................................................................ 4
What does all of this have to do with real life and what does this mean for my agency? ....................... 5
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Iowa Consortium for Mental Health
Introduction
As you are hopefully aware by now, Iowa legislation passed in 2004 requires two types
of changes in how CMHS Performance Partnership Block Grant (formerly called the
Community Mental Health Block Grant, and herein referred to simply as block grant or
BG) funds are to be distributed and utilized beginning with the upcoming fiscal year (July
1 2005 – June 30, 2006). Briefly these two changes are:
1) 70% of the BG funds are to be distributed to county-designated Community
Mental Health Centers (CMHC’s), rather than 50% which had been the case in the
past.
2) All of those funds (all 70%) are to be used for “evidence-based practices”.
The first change is relatively straightforward and means that each CMHC should receive
more block grant funds this year than in years past. The second change, however is much
more open to interpretation and raises many obvious questions: e.g., What is meant be
“evidence-based practices” (EBP’s)? Who gets to decide on what is or is not EBP?
Based on what? What happens to CMHC’s who are not using their funds for EBP’s – do
they lose the funding? etc, etc.
Over the past several months, DHS and the Mental Health Planning Council (MHPC, the
stakeholder group that oversees use of BG funds) have been working to clarify these
types of fundamental questions and to develop the capacity to administrate BG funds in a
manner that is equitable, useful and consistent with the intent of the legislation. DHS has
contracted with the Iowa Consortium for Mental Health (ICMH) to enhance their
capacity to do so. A workgroup consisting of DHS staff, ICMH staff, CMHC directors
and MHPC members has been meeting monthly to develop the implementation plans.
The progress of this group has been reported back to CMHC directors through the
monthly Mental Health Advisory meetings, and to MHPC members through their
meetings.
The results of our efforts to date are reflected in the application materials. We recognize
and hope that this is an ongoing learning process for all involved.
Why move to EBP’s?
The move towards evidence-based practices is very much a national initiative, stemming
from a convergence of major recommendations of several comprehensive policy reviews
including:
 The Surgeon General’s Report on Mental Health (1999)
 The President’s New Freedom Commission on Mental Health Report (2003)
 The Institute of Medicine Report on “Crossing the Quality Chasm: A New Health
System for the 21st Century (2001).
Each of these reports emphasizes the importance of finding ways to bridge the so-called
“science to service gap”. That is, what is being learned from ongoing research is not
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Iowa Consortium for Mental Health
being efficiently translated into improving the quality of care for individuals with mental
illness in real-world community settings. Put in different terms, the lag time between the
development of effective treatment interventions, and their uptake or broad
implementation in the real-world community setting is simply too long. A host of
federal, state, local and private initiatives are currently underway to address this problem,
and this legislation around BG funds is but one way that it is being addressed here in
Iowa.
Additionally, as funding for public mental health services remains limited and is unlikely
to substantially increase in the foreseeable future, it is critical to ensure that those funds
that are available are being optimally utilized, i.e., are being preferentially directed to
those services that yield the best outcomes.
What is meant by Evidence-Based Practice?
The term “evidence-based practice” is actually relatively new (only appearing in the
medical or mental health literature with any frequency over the last decade or so) and has
been variably defined. One definition, that has been adopted by SAMHSA, is:
Interventions for which there is consistent scientific evidence showing that they
improve client outcomes.1
Unfortunately, to date there are a fairly limited number of mental health practices or
interventions that fit this definition. SAMHSA has identified 6 practices for adults with
serious mental illness that meet these criteria. These include:
 Assertive Community Treatment
 Supported Employment
 Family Psycho-education
 Integrated Treatment of Co-occurring Mental Health and Substance Use Disorder
 Illness Management and Recovery
 Algorithm-driven Medication Management
Even fewer EBP’s have been identified for children with serious emotional disturbances
(SED). There is emerging consensus on Multi-Systemic Therapy (MST) and therapeutic
foster care, but it is less clear what other practices for children with SED meet a clear
EBP threshold.
So, does that mean that these are the only practices we should be offering? Of course
not. It simply means that these are the only practices that: 1) lend themselves to research
with rigorous methodology; 2) have been researched with rigorous methodology; and 3)
have been repeatedly been shown to yield desired outcomes in those studies.
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Drake RE et al, Psychiatric Services, 52:179-82, 2001
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Iowa Consortium for Mental Health
The limited menu of EBP’s is not unique to mental health. Indeed, even in other aspects
of health care, it has been estimated that less than 5% of all practice would meet such a
definition. So what is the rest? The rest is sometimes referred to as “consensus-based”
practice, reflecting the real-world manner in which any field evolves its standard of care from a mix of clinical experience, peer-to-peer networking, educational activities,
marketing (especially when it comes to pharmaceuticals), as well as available research of
variable quality.
“Evidence-based practice” vs. practicing in an “evidence-based
manner”
Given that there is a limited menu of EBP’s, is it possible to practice in an evidencebased manner, and still offer a wide array of services, both time-tested and innovative?
It has been argued that any practice or intervention can be delivered in an evidence-based
manner if the following are a part of the process:
1.
2.
3.
4.
5.
6.
The core components of the intervention are clearly defined
The target population is clearly defined and identifiable
The most important outcomes are clearly defined and are assessable
Methods are in place that allow for an ongoing assessment of those outcomes
A process is in place to process those outcomes on a regular basis
Processes are in place through which lessons learned from the outcomes can
inform potential changes in the core components of the practice.
The resulting evidence-based cycle (as #6 feeds back to #1) essentially boils down to
good quality assurance and quality improvement processes. And, we would argue that
practices that are done in the context of meaningful and ongoing quality improvement are
practices delivered in an evidence-based manner.
Integrating a “top-down” and a “bottom-up” approach to
evidence-based practice: Moving towards an evidence-based
culture
We refer to the implementation of practices that have achieved a rigorous threshold of
evidence-basis (e.g., implementing an ACT program) as the “top-down” approach to
practicing in an evidence-based manner. We refer to adherence to meaningful ongoing
quality improvement for all other practices as the “bottom-up” approach. Clearly these
are not mutually exclusive, and are indeed complimentary and equally critical to
achieving high quality in any field. Further, we would argue that prioritizing both results
in movement towards an evidence-based culture.
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Iowa Consortium for Mental Health
What does all of this have to do with real life and what does this
mean for my agency?
For better or worse, the Iowa legislature has mandated that block grant dollars be spent
on evidence-based practices. The implementation workgroup has painstakingly tried to
recognize the value of both the top-down and bottom-up approaches, and to incorporate
both into the implementation plan. Therefore, the criteria that will be used in assessing
the degree to which an application for block grant funds is consistent with that mandate
will be: Does this program reflect evidence-based practice, either in the top-down or
bottom-up sense (or both)? If the proposed use of block grant funds is to support an
intervention that has been recognized as evidence-based, fine. If not, it must be clear that
the program is being delivered in an evidence-based manner, e.g., that the core
components of quality assurance and improvement are there.
The application form was developed in order to help the applicant explain their
proposed program in one or the other of these categories.
We, at the Iowa Consortium of Mental Health, sincerely hope that this effort to gently
nudge the system towards an evidence-based culture will prove worthwhile for all
stakeholders. We look forward to working with you on this.
Michael Flaum
[email protected] 319-353-4340
Beth Troutman
[email protected] 319-356-1193
Brenda Hollingsworth
[email protected] 319-353-5436
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