Implementing Evidence-Based Practices in Community Corrections and Addiction Treatment

Springer Series on Evidence-Based Crime Policy

Series Editors: Lawrence W. Sherman Heather Strang

Crime prevention and criminal justice policies are domains of great and growing importance around the world. Despite the rigorous research done in this field, policy decisions are often based more on ideology or speculation than on science. One reason for this may be a lack of comprehensive presentations of the key research affecting policy deliberations. While scientific studies of crime prevention and criminal policy have become more numerous in recent years, they remain widely scattered across a wide range of journals and countries The Springer Series on Evidence-Based Crime Policy aims to pull this evidence together while presenting new research results. This combination in each book should provide, between two covers (or in electronic searches), the best evidence on each topic of crime policy. The series will publish primary research on crime policies and criminal justice practices, raising critical questions or providing guidance to policy change. The series will try to make it easier for research findings to become key components in decisions about crime and justice policy. The editors welcome proposals for both monographs and edited volumes. There will be a special emphasis on studies using rigorous methods (especially field experiments) to assess crime prevention interventions in areas such as policing, corrections, juvenile justice, and crime prevention. Published in Cooperation with the Campbell Crime and Justice Group

For further volumes: http//www.springer.com/series/8396

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Faye S. Taxman

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Steven Belenko

Implementing Evidence-Based Practices in Community Corrections and Addiction Treatment

Faye S. Taxman Criminology, Law and Society George Mason University Fairfax, VA, USA [email protected]

Steven Belenko Department of Criminal Justice Temple University Philadelphia, PA, USA [email protected]

ISBN 978-1-4614-0411-8 e-ISBN 978-1-4614-0412-5 DOI 10.1007/978-1-4614-0412-5 Springer New York Dordrecht Heidelberg London Library of Congress Control Number: 2011939835 © Springer Science+Business Media, LLC 2012 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)

Preface

For most of our careers, we have devoted our work to generating knowledge about “what works,” mostly aimed at improving criminal justice outcomes for offenders. Both of us have advanced new ideas and concepts in judicial and corrections programs to address the criminogenic needs of offenders, primarily substance abusers and high risk offenders. Steven Belenko conducted extensive research on treatment needs and substance abuse treatment interventions for drug-involved offenders including prosecutorial diversion programs, drug courts, and prison treatment. Faye Taxman has devoted extensive work toward developing, testing, and refining models of continuum of care and seamless system in probation, prison, and jail settings. And, she has worked on testing new models for facilitating the advancement of researcher–practitioner partnerships as well as interventions to promote organizational change. We both have worked extensively in collaboration with practitioners and policy makers to demonstrate that the criminal justice system can deliver effective interventions that improve the quality of life for offenders, their families, and communities. The implications of our work, along with other colleagues, are that it is important to offer services within the corrections and criminal justice settings as a tool to improve both public safety and public health. We strongly believe that the corrections system should be part of the service delivery system in the USA, including integrated behavioral and health services that promote boundaryless systems. The high concentration of offenders with substance use disorders, mental health problems, and infectious diseases demands a new paradigm. Along the way, we both realized that the issues were increasingly less about the research on “what works” (or identifying services that improve behaviors) and more about: (1) the degree to which the community corrections and other criminal justice organizations and society at large believe that research findings are useful for crime prevention efforts; (2) the techniques that community and institutional corrections agencies can use to reduce widespread barriers and resistance to organizational change; (3) the willingness of corrections and other justice agencies to consider effective ideas and strategies from other disciplines that seek to change behavior; and (4) the willingness of addiction treatment, mental health, and other behavioral services agencies to provide care for offenders. v

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The “aha” moment evolved slowly as both of us pursued our own work during an era of increasingly punitive sentencing policies and enormous increases in incarceration and community control. This era coincided with a growing recognition that the general punishment tools of the corrections system did little to promote a drugor crime-free lifestyle; in fact, in many ways it contributed to the growing cynicism about the intentions and effectiveness of the justice system. We noted that many of the offenders affected by these punitive policies had underlying drug abuse disorders. Our own work evolved as a result of being exposed to a health services framework and becoming practicing “health services criminologists.” The growing research on behavioral health interventions transformed our own contributions to criminology and criminal justice as we learned more about the stages of behavioral change and how different types of interventions or techniques can facilitate such change. Through this lens, we began to understand that the lessons from health services research and intervention science were applicable to the problems of interventions in targeted settings like the corrections and judicial systems. The growth of new research and tools to advance organizational change, and the emergence of a new science of implementation, also caught our attention. At the same time, the addiction treatment field was undergoing its own metamorphosis. This specialty field of care was the subject of several important and critical reports by the Institute of Medicine. The IOM “Bridging the Gap” report in 1996 emphasized the need to improve the type and quality of care offered to those that suffered from an addiction disorder. This report triggered many new studies devoted to the quality of addiction treatment, the infrastructure needs of the field, and the barriers to advancing clinical practice. The focus of the IOM report on improving the adoption of evidence-based practices in the addiction treatment system coincided with the needs and demands of the corrections and larger justice systems – the unmet needs of service delivery agencies given the unserved client-level needs. In our view, the similarities between the needs for change in addiction treatment and criminal justice/community correction agencies were glaring. More importantly, while a number of research-based and effective interventions to reduce recidivism and drug use had been identified over the years, it was clear that these evidencebased practices were not being disseminated widely, or being sustained over time once they were implemented. As the evidence-based practices and treatment methods gained momentum, it was apparent that renewed attention to implementation and methods to advance organizational change processes were sorely needed. This book actually started as part of an idea that Steven Belenko had to establish the Center on Evidence-based Interventions for Crime and Addiction (CEICA) (during his tenure at the Treatment Research Institute, and codirected by Drs. Belenko and Harry K. Wexler). They organized a CEICA conference in December 2006 that brought together researchers, practitioners, and policy makers to discuss the challenges of implementing effective addiction treatment programs for offenders. Shortly thereafter, the National Institute of Corrections provided a grant (PI, Dr. Belenko, Drs. Taxman and Wexler co-PIs, Cooperative Agreement 06PEI06GJN8) to produce a white paper on this topic that served as an impetus for this book and our ongoing work on implementation.

Preface

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At the same time, Faye Taxman was working with the Maryland Division of Probation and Parole on an implementation project revamping probation supervision, to include officers using adapted motivational interviewing and cognitive restructuring techniques as well as using risk and need assessments to inform supervision plans. This project is part of a 20 year agreement that Dr. Taxman has with this agency to implement innovations (EBP) and to engage in technology transfer efforts, and has brought to light many of the challenges confronting community corrections agencies trying to move from an enforcement model to EBP. Both of us have ongoing research that propelled further work in this area. Steven Belenko (Temple University) and Faye Taxman (George Mason University) each direct centers engaged in implementation research to test various implementation, organizational change and process improvement strategies to increase the use of evidence-based practice in corrections agencies; these are part of the Criminal Justice Drug Abuse Treatment Studies (CJDATS) cooperative agreement, funded by the National Institute on Drug Abuse. Dr. Taxman also directed the national surveys of the criminal justice agencies that revealed many of the issues addressed in this book regarding the low uptake of EBP, and the organizational dynamics that affect the inability for science to penetrate traditional practice. Our careers are turning now as we embark on new studies that build on this framework of intervention science and implementation science. This budding field builds upon our own training, and a research framework incorporating Patton’s (1987) utilization focused evaluation methods, action research, and policy focus. But our new research agendas allow for more attention to the methods and techniques to support organizational and systems change. This book is the culmination of many years of funding and research that we both share. Some of our funders have been the National Institute on Drug Abuse, National Institute on Alcohol Abuse and Alcoholism, Center for Substance Abuse Treatment, National Institute of Justice, National Institute of Corrections, Bureau of Justice Assistance, State Justice Institute, Edna McConnell Clark Foundation, and Robert Wood Johnson Foundation. Steven Belenko acknowledges the following people who have influenced his research and thinking about how to improve criminal justice practices and policies and reduce the harms caused by drug abuse: Tom McLellan, Richard Dembo, Jeremy Travis, Dean Fixsen, Ken Schoen, the late Jack Novik, Nancy Wolff, Joseph A. Califano, Jr., Anne Swern, his CJDATS colleagues, and the many drug court judges with whom he has had the pleasure to work. Faye Taxman acknowledges the following people that have shaped her own views including Judith Sachwald, Ernest Eley, Jasper Ormond, Tom Williams, Peter Luongo, Justin Jones, and others that each day try to import EBP into the justice and addiction treatment settings. Dr. Taxman’s mentors and collaborators in the field include Edward Latessa, Todd Clear, Tom McLellan, Doug Anglin, the late Doug Longshore, James Byrne, Dwayne Simpson, and the late Don Gottfredson. Navigating the pathway to study the issues related to adopting EBP has been Peter Friedmann, Doug Young, Craig Henderson, Jeff Bouffard, Susan Turner, David Weisburd, Danielle Rudes, Shannon Portillo, Karen Cropsey, and CJDATS collaborators, to name a few. We both acknowledge Redonna Chandler for her insights and

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contributions to our work. Both authors shared equally in the conceptualization, background research, and writing of this book. This book would have not been possible without the assistance of Judith Sachwald, who was an invaluable editor. Doctoral students Jennifer Lerch and Jill Viglione at George Mason University’s Criminology, Law and Society department and George Mason University law student, Carolyn Watson, assisted us in preparing figures, exhibits, references, and other parts of this book, and we thank them immensely. It is not surprising that implementation studies are receiving increasing attention. This book is dedicated to the practitioners, policy makers, and scholars that seek to improve the quality of addiction treatment and other behavioral health programming to reduce recidivism and relapse to drug use among the enormous numbers of offenders in need of services. Theirs is a noble venture, and one that demands our full attention and support. We are committed to advancing knowledge in this field and hope that this book stimulates new research, new synergies to implement EBP, and new organizational efforts to deliver the most effective services possible to the greatest number of people. The realization that the corrections system should be a service delivery system would fulfill our aspirations for an effective crime control policy that recognizes the value of community corrections and addiction treatment services. Fairfax, VA Philadelphia, PA

Faye S. Taxman Steven Belenko

Contents

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Introduction ............................................................................................. 1.1 The Promise of Science in Public Policy ......................................... 1.2 Why Community Corrections and Addiction Treatment? ............... 1.3 Building Knowledge in Community Corrections ............................ 1.4 The Focus on Technology Transfer.................................................. 1.5 Community Corrections Presents Unique Challenges for Addiction Treatment Interventions............................................. 1.6 Multistage Conceptual Model for Identifying and Selecting EBPs .......................................................................... 1.7 Evidence-Based Interagency Implementation Model (EB-IIM)...... 1.8 Conclusions and Outline of the Book .............................................. References ................................................................................................. Identifying the Evidence Base for “What Works” in Community Corrections and Addiction Treatment ........................ 2.1 Introduction and Overview .............................................................. 2.2 Basic Definitions and Concepts ....................................................... 2.2.1 Hierarchy of Levels of Evidence.......................................... 2.3 Efficacy vs. Effectiveness ................................................................ 2.4 Frameworks for Determining the Evidence Base ............................ 2.4.1 The Food and Drug Administration (FDA) Model .............. 2.4.2 Applying the FDA Model to Behavioral Interventions......................................................................... 2.4.3 Synthesizing Across Research Designs ............................... 2.4.4 Consensus Processes ............................................................ 2.4.5 Systematic Reviews and Meta-Analyses ............................. 2.5 Evidence-Based Repositories........................................................... 2.5.1 Cochrane Collaboration/Cochrane Reviews ........................ 2.5.2 Campbell Collaboration–Crime and Justice Group ............. 2.5.3 National Registry of Evidence-Based Programs and Practices ........................................................................

1 4 5 7 8 10 11 12 14 15 19 19 22 22 24 26 26 27 27 28 29 32 32 33 34 ix

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2.5.4 Blueprints for Violence Prevention ...................................... 2.5.5 Washington State Institute for Public Policy ....................... 2.6 NIDA Principles of Effective Drug Treatment ................................ 2.7 Defining “What Works” in Community Corrections ....................... 2.8 Standards of Evidence in Community Corrections and Addiction Treatment ................................................................. 2.9 Conclusions ...................................................................................... References ................................................................................................. 3

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Theories of Organizational Change and Technology Transfer ........... 3.1 The Implementation Quandary ........................................................ 3.2 Understanding Organizational Approaches: Three Different Models.................................................................... 3.2.1 Diffusion Models ................................................................. 3.2.2 The Conceptual Model ......................................................... 3.3 Expanding the Concept of Implementation ..................................... 3.4 Moving Past Initial Implementation: The Concept of Sustainability.......................................................... 3.5 Building Interagency Collaborative Supports: The Availability, Responsiveness, and Continuity (ARC) Model ............................... 3.6 Attention to Performance: Quality Improvement Processes, Performance Contracts, and Benchmarking .................................... 3.6.1 Plan-Do-Study-Act (PDSA)................................................. 3.6.2 Network for Improvement of Addiction Treatment (NIATx): Quality Improvement Processes ........................... 3.6.3 COMPSTAT and Feedback Loops ....................................... 3.7 Total Organizational Change Processes ........................................... 3.8 Conclusion ....................................................................................... Appendix: List of Organizational Change Models ................................... References ................................................................................................. Organizational Change – Technology Transfer Processes: A Review of the Literature ..................................................................... 4.1 Systematic Reviews of Change Strategies ....................................... 4.2 Outer Setting: The Environmental Context for Change................... 4.3 Inner Setting: Within a Specific Organization ................................. 4.3.1 Readiness for Change........................................................... 4.3.2 Alignment of Values............................................................. 4.3.3 Structure ............................................................................... 4.3.4 Professionalism and Staffing................................................ 4.3.5 Resources ............................................................................. 4.3.6 Summary of Inner Setting Findings ..................................... 4.4 Organizational-Level Models of Technology Transfer .................... 4.4.1 Preparing the Organization for the Change.......................... 4.4.2 Staff-Level Concerns Regarding Technology Transfer ............................................................

37 39 40 46 49 50 52 57 57 59 61 62 68 70 76 79 80 81 82 83 85 86 87 91 92 96 98 100 101 101 102 103 104 104 108 109

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4.4.3 Client Factors ....................................................................... 4.4.4 Change Actors ...................................................................... 4.4.5 Training ................................................................................ 4.5 Dissemination Efforts: Specialized Training by Researchers .......... 4.5.1 Piloting ................................................................................. 4.5.2 Fidelity and Program Integrity ............................................. 4.5.3 Performance Monitoring ...................................................... 4.5.4 Quality Improvement Models .............................................. 4.5.5 Summary .............................................................................. 4.6 Conclusion ....................................................................................... Appendix: Summary of Major Findings from Organizational Studies in Behavioral Health Examining Inner Setting Issues............................... References ................................................................................................. 5

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Community Corrections Addiction Treatment: Strategies to Adopt, Implement, and Sustain Effective Practices ........................ 5.1 Current State of Evidence-Based Practice in the Addiction Treatment Field ................................................................................ 5.2 Improving Treatment Processes ....................................................... 5.2.1 Federal and National Initiatives to Disseminate EBP in Treatment Agencies ......................................................... 5.2.2 Federal Initiatives to Define Quality and Key Outcome Measures for Treatment Agencies ........................ 5.3 Disseminating EBP: Lessons from the Centers for Disease Control and Prevention’s REP and DEBI Models for HIV Interventions ............................................................................ 5.3.1 Replicating Effective Programs ........................................... 5.3.2 Diffusion of Effective Behavioral Interventions (DEBI) ..... 5.4 Adoption of EBP in Community Addiction Treatment ................... 5.4.1 State Initiatives ..................................................................... 5.5 Conclusions ...................................................................................... References ................................................................................................. Current State of EBP in the Community Corrections Field ............... 6.1 EBP in Community Corrections Agencies: Results from the National Criminal Justice Treatment Practices Survey .............. 6.1.1 Best, Evidence-Based, or Strongly Supported Practices ............................................................................... 6.1.2 Adopting EBP ...................................................................... 6.1.3 Adopting EBP in Community Corrections Settings ............ 6.1.4 Important Constructs in Understanding Adoption Patterns ................................................................................. 6.1.5 What Factors Affect the Likelihood of Adopting EBP in Corrections Settings? ....................................................... 6.1.6 How Do Corrections Administrators Handle the Competing Values of Providing Treatment and Other Services? .............................................................

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141 142 143 144 144 146 147 151 152 153 154 154 155 157

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6.1.7

What Type of Reform Strategy Advances the Use of EBP in Corrections Settings? ........................................ 6.1.8 Conclusions from NCJTP Survey Findings ....................... 6.2 NIC Initiative to Expand the Use of EBP by Community Corrections Agencies ....................................................................... 6.2.1 Dissemination Materials for the Field ............................... 6.2.2 Initial NIC/CJI Adoption Sites: Maine and Illinois ........... 6.2.3 NIC Framework Garnering Support from Sister Organizations .................................................. 6.3 View from the Field: Results from Key Informant Interviews ........ 6.3.1 How Are Evidence-Based Practices Identified? ................ 6.3.2 Factors that Affect the Use of Evidence-Based Practice in Corrections Agencies ....................................... 6.3.3 Current Use of EBP ........................................................... 6.3.4 Current Level of Corrections Staff Knowledge about EBP .......................................................................... 6.3.5 What Constitutes Evidence in EBP?.................................. 6.3.6 Key Gaps in Knowledge about Evidence-Based Practice .............................................................................. 6.3.7 Are State and Federal Regulators Requiring EBP? ........... 6.3.8 Key Steps Required for Successful Implementation of EB Treatment................................................................. 6.3.9 Key Challenges for Implementation and Sustainability of EBP .................................................. 6.3.10 Organizational Changes and Conditions Needed for Implementing and Sustaining EBP............................... 6.3.11 Necessity of Protocol Fidelity ........................................... 6.3.12 Are Outcomes Regularly Obtained and Reported to Demonstrate Effectiveness? ........................................... 6.4 Conclusion ....................................................................................... References ................................................................................................. 7

The Idiosyncrasies of the Corrections and Treatment Environments........................................................................................... 7.1 Recognizing the First Hurdle ........................................................... 7.2 Opening the Door to Offender Change as a Goal of Corrections................................................................................... 7.2.1 Looking Through an Offender-Based Lens ....................... 7.2.2 Lack of Infrastructure, Knowledge, and Skills .................. 7.3 The Deficiencies of Addiction Treatment Programs........................ 7.3.1 Overcoming EBP Implementation Barriers to Achieve Improvements in Addiction Treatment .............................. 7.4 Conclusion ....................................................................................... References .................................................................................................

160 160 161 162 164 167 169 171 171 172 174 175 176 177 178 179 181 182 184 185 186 189 190 192 193 196 196 199 201 202

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Making Good Choices: A Multistage Conceptual Model for Identifying and Selecting Evidence-Based Practices ..................... 8.1 Overview of the Evidence Mapping Process ................................... 8.1.1 Tests of Scientific Rigor ....................................................... 8.1.2 Tests of Transportability ...................................................... 8.1.3 Tests of Organizational Capacity ......................................... 8.2 The Challenges Associated with Scientific Studies ......................... 8.2.1 Limitations of RCT and Quasi-Experimental Designs ........ 8.2.2 Selection Effects, Targeting, and Penetration ...................... 8.2.3 Population Impact and Penetration ...................................... 8.2.4 Statistical Significance and Effect Size ................................ 8.3 Transportability Assessment ............................................................ 8.3.1 Setting and Populations........................................................ 8.3.2 Fidelity and Program Integrity ............................................. 8.3.3 Incorporating Clinician and Other Staff Input ..................... 8.4 Organizational Capacity Assessments ............................................. 8.4.1 Perceived Value of EBP: Balancing Public Safety and Public Health ................................................................. 8.4.2 Improve Interagency Efforts Through Goal Alignment ....... 8.4.3 Inner Setting Issues .............................................................. 8.4.4 Building Interagency Systems of Care................................. 8.4.5 Considering Clients’ Perspectives and Treatment Needs.................................................................................... 8.4.6 Intervention Costs ................................................................ 8.4.7 Outer Setting ........................................................................ 8.5 Making the Decision to Adopt an EBP ............................................ 8.6 Conclusions ...................................................................................... References ................................................................................................. Conceptual Model: Evidence Based Interagency Implementation Model ........................................................................... 9.1 The Evidence-Based Interagency Implementation Model (EB-IIM) ............................................................................... 9.1.1 Develop Knowledge Stage ................................................... 9.1.2 Building Foundation (Improving the Capacity at Individual and Organizational Level)............................... 9.1.3 Set Expectations: The Use of Benchmarks for Performance.................................................................... 9.1.4 Align: Using the Pilot as a Learning Stage .......................... 9.1.5 Renovate and Sustain: The Ultimate Goals ......................... 9.2 Setting the Stage for Implementation: Core Components to Manage the Process ..................................................................... 9.2.1 Creating a Culture of Change: Techniques and Strategies ....................................................................... 9.2.2 Strategies to Build a Broad Base of Support: The Example of Social Marketing .......................................

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Techniques to Manage the Change Process ................................... 9.3.1 Executive Leadership........................................................ 9.3.2 Staff .................................................................................. 9.3.3 Facilitators of the Change Process.................................... 9.3.4 Implementation Change Teams Through Cross-Sectional or “Vertical Slice” Working Teams................................... 9.3.5 Stakeholders...................................................................... 9.3.6 Project Management Activities ........................................ 9.3.7 Clear Performance Goals and Measures Provide Objective Feedback on Progress....................................... 9.4 Conclusion ..................................................................................... References .................................................................................................

265 265 266 267

Evidence-Based Implementation Agenda ............................................. 10.1 Implementation Tools .................................................................... 10.1.1 Intervention or Evidence-Based Practice/Treatment ........ 10.1.2 Inner Setting ..................................................................... 10.1.3 Outer Setting ..................................................................... 10.1.4 Process: Evidence Mapping and Implementation Models .............................................................................. 10.2 Advancing a Research Agenda on Implementation in Community Corrections Settings ............................................... 10.2.1 Intervention Strategies ...................................................... 10.2.2 Implementation Strategies ................................................ 10.3 Council for Public Health-Safety Evidence-Based Practice .......... 10.4 Conclusion ..................................................................................... Appendix A: Interventions Checklist........................................................ Appendix B: Inner Setting Checklist ........................................................ Appendix C: Outer Setting Checklist ....................................................... Appendix D: Process Management Issues Checklist ................................ References .................................................................................................

275 281 281 284 286

267 268 268 269 270 272

288 289 292 295 298 299 301 304 306 308 310

Index ................................................................................................................. 315

Chapter 1

Introduction

With nearly eight million adults under correctional control in the United States, the numbers of persons incarcerated and under community supervision have exploded in the United States. This reflects public concerns over increasing crime rates, shifts toward incapacitative and just deserts sentencing policies, and frustration over the perceived failures of other crime prevention policies and programs. The latter perception implies that the only effective response to criminal behavior is to arrest more people and lock them up in prison or jail for longer periods of time. Robert Martinson’s famous “Nothing Works” paper (1974) is credited for fueling some of the discontentment with programs and services for offenders. His rejoinder a few years later that “some things work” (Martinson, 1979) did not alter the political landscape. The real story reported by Martinson was that few correctional programs had been implemented as intended, and even if implemented the program was not very different from existing services. But both of his treatises emphasized the bottom line of effectiveness – the failure to improve offender-level outcomes. The concerns about implementation were largely ignored in this seminal work. The emphasis on offender outcomes has dominated the last few decades in which punishment and incapacitation have been the focus of criminal justice policy. Treatment and other correctional programs have been viewed as luxuries with little potential for reducing recidivism. Although the research literature continues to highlight that evidence-based programs and treatments are effective in reducing recidivism and other negative outcomes (see MacKenzie, 2006; Nagin, Cullen, & Jonson, 2009), implementation of effective treatments and programs has taken a backseat in correctional practice. Even though some states report the expanded use of communitybased alternatives to incarceration, the programs that are in place are grossly underutilized and have a low capacity: fewer than 10% of offenders under correctional supervision are involved in programming on any given day (Taxman, Perdoni, & Harrison, 2007). The incarceration preference has come at a stiff price. Nearly eight million adults are under correctional control (Glaze, 2010), the United States holds nearly 25% of the world’s incarcerated population (Pew Center on the States, 2009), and nearly F.S. Taxman and S. Belenko, Implementing Evidence-Based Practices in Community Corrections and Addiction Treatment, Springer Series on Evidence-Based Crime Policy, DOI 10.1007/978-1-4614-0412-5_1, © Springer Science+Business Media, LLC 2012

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Introduction

70% of offenders recycle through the system within three years (Langan & Levin, 2002). Many states spend more funds on prisons and jails than college education (Pew Center on the States, 2008). The growing corrections population reflects law enforcement policies and mandatory sentencing laws over the past 25 years that have largely affected drug-involved offenders (Mauer & King, 2007; Tonry & Farrington, 1995). As a result of these policies and the close connection between substance abuse and crime (White & Gorman, 2000), 75% of offenders have substance abuse problems (Belenko & Peugh, 2005). Related health issues include extremely high rates of HIV/AIDS and other sexually transmitted diseases compared with the general population (CDC, 2005, 2006; Glynn & Rhodes, 2005; Maruschak, 2009), and high prevalence of co-occurring mental health disorders (Belenko, Lang, & O’Connor, 2003; James & Glaze, 2006; National Institute of Mental Health, 2008; Teplin et al., 2006). One impact of the expanded crime control policies that focus on arrest and incapacitation is that more people with social problems are being handled by the correctional system. During the same era that saw increased use of incarceration for drug-related behaviors, there has been a growing body of science about effective crime prevention policies. The report to Congress on Preventing Crime: What Works, What Doesn’t, What’s Promising (Sherman et al., 1997), along with a substantial body of research on effective interventions for inmates and other offenders (Andrews, Zinger, Hoge, & Bonta, 1990; MacKenzie, 2006; Mitchell, Wilson, & MacKenzie, 2007; Wilson, Mitchell & MacKenzie, 2006), proferred that drug treatment and certain interventions are effective tools to reduce criminal behavior. Moreover, a well-articulated body of research exists for evidence-based treatments for substance abuse disorders (National Institute on Drug Abuse, 2006) that provides a roadmap for reducing recidivism and drug use. Reducing drug abuse through effective treatment could have positive impacts on public safety and reduce the strains on state and local criminal justice systems occurring from the overuse of incarceration. But, as Martinson indicated more than three decades ago, merely making treatment available is not sufficient to achieve the delivered results. Guidance is needed as to which treatments are effective, which offenders would benefit from what types of treatment, how to improve access to effective treatment, how to change organizations to expand treatment capacity and access for offenders, how to implement treatment programs that can deliver the desired results, and how to overcome factors that negatively affect the delivery of effective addiction treatment in the justice setting (Taxman & Bouffard, 2000; Taxman et al., 2007). Accordingly, the failure to adequately implement interventions for drug-involved offenders has enormous implications for public safety and public health. The challenges associated with changing organizational culture and processes and improving program implementation are ever present. Little is known about how to expeditiously and successfully implement effective evidence-based treatments in real-world settings, including behavioral health and community corrections settings. An emerging science of implementation is designed to answer questions of how to best disseminate, implement, and sustain evidence-based treatments and practices in organizations and systems that typically struggle to do so. Theorists and

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researchers are now examining the process of changing organizational cultures, integrating behavioral health services across different systems, and improving the implementation of health services. Over the past three decades, in many areas of health and social services – medicine, education, social work, addiction treatment, mental health, and criminology – there has been increasing focus on the importance of promoting and assuring the use of evidence-based practices (EBP). EBP represent the idea that there is sufficient science in a given area to declare that a particular practice or treatment is efficacious and can be implemented as part of routine practice. The EBP movement has been facilitated by the development of: (1) scientific methods to summarize the state of knowledge and impacts of interventions, practices, and policies; (2) statistical tools to synthesize results across different studies and to measure the size of the effect; and (3) theoretical frameworks to classify studies to improve the practices. The term evidence-based practices is, in essence, a catchphrase or slogan for interventions or practices that should be widely used because research indicates that they positively alter human behavior. EBP are considered the holy grail for achieving desired outcomes. But, is the solution as simple as merely using science to identify and designate specific interventions or practices as evidence-based? When the EBP movement began, the assumption was that the main challenge was to conduct research to determine if a program was effective – did it improve outcomes compared with treatment as usual? Once an EBP was identified, it was believed that agencies and organizations would enthusiastically rush to implement these practices. The reality has turned out to be far more complex. The lessons from healthcare fields are that it takes many years for evidence-based medicine to work its way into routine practice, if it ever does. The same is true for behavioral health services, education, social services, and criminal justice settings where the institutional imperative is to continue to do business using familiar practices and processes. This book addresses the connected issues of knowledge development and utilization in the context of adopting and implementing EBP, particularly addiction treatment programs, in community corrections agencies. The intersection of EBP in community corrections and addiction treatment presents unique challenges because it affects two disciplines and requires community corrections systems to articulate and embrace a secondary mission of offender change (rehabilitation). A great need exists for researchers, organizations, and policymakers to understand the process for determining EBP and the even greater need to consider the viability of an EBP, given the organizational context and the alignment with the environment. The transportability of an EBP is seldom discussed, yet given the history of poor implementation in correctional settings (Gendreau, Goggin, & Smith, 1999), it is critical to consider and rethink the process toward routinization and sustainability of EBP. This book assesses the EBP movement in terms of its contribution to identifying practices and policies that should lead to improved outcomes at the individual and system level, and examines the research surrounding the adoption and implementation of EBP using an organizational lens. The organizational lens requires a commitment to the utilization of EBP in these settings as well as presenting models

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for identifying and selecting EBP and for advancing the integration of EBP into practice. In many ways this book expands the concept of EBP to consider evidencebased organizational research as well as management strategies to advance the uptake of EBP in community corrections settings.

1.1

The Promise of Science in Public Policy

The EBP framework is in many ways a common sense, practical perspective that a rational, data-driven strategy will help decipher what treatment or practice is worthwhile to use, what should be abandoned, and what needs to be improved. The whats can refer to a variety of practices in an organization – ranging from normal business practices to special programs. The EBP framework is theoretically apolitical. Decisions about what works are not (and should not be) guided by philosophical orientations, historical practices, politics, staff preferences, or managerial preference; instead the EBP framework emphasizes effectiveness, which is defined as the degree to which the improvement outperforms existing practices. In reality, these factors often intrude to prevent EBP from being more broadly implemented. Science is objective, but the scientific mind is framed in the community to which one belongs and includes the values, norms, and methods accepted within that community. Thomas Kuhn, in his famous Structure of Scientific Revolutions (1966), developed the concept of the paradigm to indicate that science grows by replacing one paradigm with another. Each paradigm provides the means to test existing theories or ideas. This process then serves to advance knowledge. In many ways, EBP represents the new paradigm since it provides a framework to safeguard objectivity by using science to define the practices or products that should improve the outcomes. The EBP paradigm gauges what is useful in the real world through scientific studies that measure objective outcomes. Evidence-based practice, however, is fraught with certain realities inherent in the process of defining and using knowledge. With respect to knowledge development, the objective questions are: (1) how many studies need to be conducted for a practice to be declared an EBP; (2) how many studies of a certain practice/intervention/ treatment have been conducted in which populations and settings?; (3) are the studies of sufficient scientific quality; and (4) are the components of the practice/ intervention/treatment adequately identified or defined so they can be replicated in the field? That is, the evidence-based foundation can only be constructed when there is sufficient knowledge about the setting, population, and/or intervention. Although the EBP field has determined that a minimum of two studies with similar findings constitutes sufficient evidence, this standard may or may not address the variation in setting, population, nature of the intervention, and adherence to the original intervention design. The potential to determine whether a research finding is robust is substantially increased when there are more studies across varied settings and populations. And, scientific knowledge is built on the presumption that replication increases confidence that research findings are not random or subject to biases.

1.2

Why Community Corrections and Addiction Treatment?

5

Knowledge utilization pertains to how practitioners and policymakers apply scientific knowledge, whether it is within an organization or within the stakeholder community. Application refers to the distillation of key concepts and core components, the alignment or fit within the organizations’ processes or culture, and likelihood of addressing recognized problem areas. The importation and continued use of new knowledge, whether it is a foreign concept/idea or a refinement of existing practice, is a field of study that is slowly evolving. A related concept is the notion that the knowledge will evolve or be modified in a manner to fit the environment. But an important concern is whether the evolving practice will be similar to the science-based practice that was studied. “Technology Transfer (TT),” the process of introducing new technologies, programs, or practices into organizations, addresses the area of knowledge utilization. An expanded concept of technology transfer is the new, emerging field of implementation science: the study of how organizations effectively implement and sustain new or modified practices. This is an area of increasing interest because the time lag between science development and utilization is estimated to be as much as 20 years (Proctor et al., 2009); there is, thus, great interest in increasing the rate of adoption and implementation of EBP in organizational settings to improve overall outcomes.

1.2

Why Community Corrections and Addiction Treatment?

The numbers are staggering. Nearly six million offenders are under community corrections (probation or parole) supervision in the United States, or about 1:23 adults 18–65 years old (Glaze, 2010; Taxman et al., 2007). This is about 3 times the number of offenders who are in prison (West & Sabol, 2010). Equally compelling is the estimate that nearly five million probationers and parolees have some type of substance use disorder, and nearly half of the probationers/parolees have supervision orders for drug treatment services (Taxman et al., 2007). Probationers and parolees have drug abuse disorders that are 4 times greater than the general population (Substance Abuse and Mental Health Services Administration, 2009), and 40–80% of the referrals to community substance abuse treatment services are from criminal justice agencies. More than one-third (35%) of state prison commitments are due to violations of parole or other conditional release (West & Sabol, 2010), mainly related to substance use and abuse. Stated simply, the largest concentration of substance abusers is found in the community corrections system, and they drive much of the recidivism and parole/probation violations. Research indicates that providing effective treatment services for offenders reduces recidivism, with estimates ranging from 10% to 30% depending on the type of treatment provided (Drake, Aos, & Miller, 2009; Mitchell et al., 2007; Taxman, Byrne, Pattavina, & Ainsworth, 2010; Wilson et al., 2006). The challenge is how best to provide effective treatment services in community correction settings. In response to the high numbers of offenders with substance abuse disorders, a number of treatment interventions have been implemented over the past decade in

6

1

Introduction

the criminal justice system, that have achieved reductions in recidivism; these include drug courts, treatment diversion, prison and jail treatment, and postincarceration aftercare (Belenko, 2002; Friedmann, Taxman, & Henderson, 2007; Knight, Simpson, & Hiller, 1999; Prendergast, Hall, Wexler, Melnick, & Cao, 2004; Taxman, 1998; Taxman et al., 2007; Wexler, De Leon, Thomas, Kressel, & Peters, 1999; Wexler, Melnick, Lowe, & Peters, 1999). However, such treatment has been able to serve relatively few offenders with drug problems (Belenko & Peugh, 2005; Bhati & Roman, 2010; Taxman et al., 2007). Only 24% of state and 8% of jail inmates reported receiving any treatment; including non-clinical interventions such as self-help groups or drug education (Belenko & Peugh, 2005). Among probationers, only 25% with histories of drug use receive treatment while on probation (Mumola & Bonczar, 1998). The percentage of parolees receiving clinically-based substance abuse treatment is unknown, but is likely to be low relative to need, given the low percentages of released inmates who engage in aftercare treatment following release from prison (Knight et al., 1999; Prendergast et al., 2004; Wexler et al., 1999). Despite the large number of drug courts (Huddleston, Marlowe, & Casebolt, 2008), most are small and have been estimated to serve well under 5% of the eligible population (Belenko, 2002; Belenko, Fabrikant, & Wolff, 2011; Bhati & Roman, 2010; Taxman et al., 2007). Given these high rates of substance abuse treatment needs but low rates of treatment access, it is likely that providing expanded access to evidenced-based interventions could contribute to public safety and to the reduction of the growing substance-involved population in the criminal justice system. As Petersilia (1999) has emphasized, achieving meaningful recidivism reduction is difficult without providing effective treatment and rehabilitation services. This is especially true in community corrections settings, where caseloads are high and substance-abuse related violations are common (Taxman et al., 2007), and research on the integration of treatment and community supervision has been lacking (Marlowe, Festinger, Lee, Dugosh, & Benasutti, 2006; Taxman, 1998; Taxman & Bouffard, 2000; Taxman & Thanner, 2004). The need to provide effective treatment services to offenders is clouded by consideration of the extent of support for the belief that addiction treatment services are appropriate and needed for substance abusing offenders. The concept of appropriate opens the door to personal opinions, political philosophies, societal values, and other factors that frame how those involved in the corrections system are handled. That is, even if corrections administrators supported the expansion of treatment for offenders, the external support from the criminal justice community (i.e., judges, prosecutors, defenders), treatment providers, and the community at large is required for substance abuse treatment to be part of the delivery system. Clarifying values must be part of any effort to advance the use of EBP in corrections settings. In many ways, it is the competing values that inhibit the adoption, implementation, and sustainability of EBP in community corrections settings. This is why an organizational approach that addresses both the internal (organization) and external (stakeholders) needs is crucial to the EBP debate.

1.3 Building Knowledge in Community Corrections

1.3

7

Building Knowledge in Community Corrections

The question of what works in corrections has captivated the attention of policymakers, practitioners, and researchers for nearly 50 years as the United States has struggled with finding the most appropriate strategies that were tough and punitive for punishing wrongdoers, held offenders accountable, and protected the community. The what works movement introduced in the late 1980s (Andrews et al., 1990), now subsumed under the EBP label, emphasizes the nature of correctional practices that should be in operation. By having science provide objective information about effective practices that change offender behavior, policymakers and practitioners can use that data-driven strategy to improve impacts and net economic benefits as a tool to frame informed decisions. The what works phenomenon offered this consensusbuilding approach to reduce the more reactive and crisis-driven decision making that has often characterized policy promulgation in the criminal justice system. Since the what works approach emerged, the methodology and techniques have evolved with the advent of statistical tools to facilitate meta-analyses or systematic reviews. Systematic reviews are now fairly common, including those supported by the Campbell Collaboration (www.campbellcollaboration.org), journals that are devoted to dissemination of experimental findings (i.e., Journal of Experimental Criminology), consensus and systematic reviews that are devoted to identifying best practices and EBPs, national repositories of information about evidence-based addiction treatment and prevention, and state legislation that requires the use of EBP to qualify for state funding. Complementary resources are available to the public that translates research into operational practice. The National Institute on Drug Abuse (2006) Principles of Drug Abuse Treatment for Criminal Justice Populations identifies 13 EBPs. The Substance Abuse and Mental Health Services Administration (SAMHSA) hosts the National Registry of Evidence-based Programs and Practices (NREPP) that identifies EBP in substance abuse and mental health prevention and treatment programs (http://www.nrepp.samhsa.gov/index.asp). Finally, the National Institute of Corrections has produced numerous publications on EBP (Crime & Justice Institute, 2004, 2010; Taxman, Shepardson, & Byrne, 2004). These resources illustrate how science and practice have merged for federal, state, and local governments to try to ensure that provided services are designed to achieve desired outcomes. The accumulation of knowledge in community corrections has paralleled the addiction treatment field – the stars have aligned in the identification of potential treatments that are applicable to people with addiction disorders, regardless of whether they are involved in the corrections system. A number of systematic reviews and meta-analyses have identified drug courts, in-prison therapeutic communities with aftercare, cognitive behavioral therapy, and other treatment approaches as likely to reduce relapse and recidivism. This is the good news. But the unanswered and necessary question is how to improve and expand their adoption and implementation of EBP in community corrections settings.

8

1.4

1

Introduction

The Focus on Technology Transfer

To a large extent, the efforts to date have focused on the dissemination and diffusion of knowledge about policies and practices that can improve offender outcomes. The diffusion process – the mechanism by which new or existing practices are communicated through certain channels within a social system and/or organization over time – has received less attention in the corrections field. Models of diffusion have been built primarily within the substance abuse field echoing the work of Everett Rogers (1983) to innovate, implement, and measure progress, and sustain the efforts. Different methods have been proposed with varying emphases, such as process improvements (Hoffman, Ford, Choi, Gustafson, & McCarty, 2008; McCarty, Gustafson, Wisdom, Ford, Choi, & Molfenter, 2007); organizational models of change (Addiction Technology Transfer Center, 2004; Klein & Sorra, 1996); addressing staff needs in technology transfer (Markus, 1983); and other organizational strategies such as fidelity and adherence models, value clarification, and leadership support. These models were built to be used within a specific discipline – primarily substance abuse – where the public health mission and emphasis on reducing drug abuse are clear, and the overall goals tend to be unified. In addiction treatment, the goals are to improve the health and well-being of a person. When considering TT across public health (addiction treatment) and public safety (community corrections) systems, a need exists to clarify mutual goals and to ensure that the stakeholders have similar views of these goals. Otherwise, these models are likely to fall short and need modification. Thus far, most dissemination efforts focus on the formative stages of defining EBP with the publication of systematic reviews or meta-analyses, listing evidencebased programs or best practices, providing manuals, or providing one-time training on EBP. These efforts are focused primarily on building knowledge by identifying EBP. Little attention is given to the more difficult issues related to dissemination of policies and practices, the feasibility of implementing key features of the EBP, sustainability (compromised by staff turnover, budget constraints, and staff skill levels), alignment with current policies and practices, and associated policy changes in real-world settings (Fixsen, Naoom, Blase, Friedman, & Wallace, 2005; Rogers, 1995; Taxman et al., 2004). The National Institutes of Health (NIH) has highlighted the importance of moving clinical findings to the field and transferring research to practice by emphasizing translational research in its Roadmap for Medical Research (NIH, 2006). The NIH has also introduced a policy to make research findings more available in the public domain through open access to scientific journal articles. An emphasis on EBP utilization would require significant attention to the challenges of innovation diffusion (Panzano & Roth, 2006; Patton, 1987) that ranges from developing organizational and staff capacity, disseminating EBP, translating evidence into operational components, retraining staff in key skills needed to conduct the intervention, enhancing organizational leadership at all levels to sustain change, monitoring fidelity and performance, and establishing new business practices that comport with the translation of research. As stated by Rogers in his seminal work on diffusion of innovations (Rogers, 1983, 1995, 2003), the implementation

1.4

The Focus on Technology Transfer

9

of a new practice(s) requires ensuring that the innovation fits within existing business processes. There is a need to synthesize the scientific knowledge in the context of practice and policy to move toward sustainability in real-world settings. Researchers, practitioners, and policymakers must be cognizant of the importance of sustainability, ongoing intervention fidelity (i.e., “ecological validity”), and transportability to different settings and populations. Consistent with the mission of public safety and accountability, community corrections agencies must balance the priorities of supervision with expanding referrals to evidence-based addiction treatment. However, identifying and using evidencebased addiction treatment is not typically a community corrections priority given that substance abuse is generally viewed as a public health issue. Community corrections agencies generally benefit from efforts in the public health system to identify effective treatments. Alignment of goals and missions between the community corrections and public health systems has progressed very slowly, and is often haphazard rather than deliberate. Community corrections administrators may also believe that the selection of a treatment program should be the decision of the treatment agency(s). In summary, the challenges of identifying EBP treatments that address offenders’ substance abuse and other criminogenic needs (i.e., antisocial values and peers, impulsivity and decision-making), fall between the cracks of the two systems. Attempting to bridge the chasm between the systems results in greater challenges in building organizational capacity to implement and sustain EBP and provide offenders under community supervision with evidence-based addiction treatment. As the value attached to EBP increases, the need to encourage an active dialogue among researchers, policymakers, practitioners, and clients becomes more important to the TT process. To date, the articulation of EBP has been primarily a top-down process, more aimed at meeting scientific concerns than clinical applications. Prior efforts to identify and disseminate EBP in criminal justice addiction treatment (such as NIDA’s Principles of Drug Abuse Treatment for Criminal Justice Populations – NIDA, 2006) have generally lacked a balanced perspective that integrates criminal justice practitioners’ perspectives with the views of researchers, other practitioners, policymakers, and clients. And, identification and dissemination of EBP in community corrections (such as the National Institute of Corrections/ Crime and Justice Institute’s model (2004)) has generally lacked the involvement of scientists and researchers in the process. Scant attention has been given to organizational and other barriers to implementation and sustainability (Brown & Flynn, 2002; Fixsen et al., 2005; Roman & Johnson, 2002; Simpson, 2002). Careful exploration is needed of the TT process for evidence-based treatment of offenders under community supervision, and the identification of potential new approaches to increasing TT. The translation of existing dissemination and diffusion models to addiction treatment in community corrections, with the conflicting and contradictory goals of public safety and health, has not been adequately considered. This book addresses the diffusion and implementation of evidence-based community corrections and addiction treatment and practices within the community corrections environment by presenting

10

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Introduction

a framework that reflects the unique characteristics and needs of both systems. In considering the limitations of simply having scientists designate EBP and assume that these programs and practices will be widely adopted while ignoring the steep uphill climb of implementation, this book outlines processes for defining EBP and for importing innovations into this setting. The Evidence-Based Interagency Implementation Model (EB-IIM) serves to outline a conceptual framework for fostering organizational change for expanding effective addiction treatment in community corrections settings.

1.5

Community Corrections Presents Unique Challenges for Addiction Treatment Interventions

The EB-IIM evolved from our review of organizational change processes and models in the corrections and substance abuse fields, as well as the general literature on adoption and implementation of new business practices. These efforts included reviews of : (1) the literature on EBP in community corrections and addiction treatment, including the criteria used to define evidence; (2) dissemination, diffusion, and organizational change research across disciplines; (3) studies on organizational factors that affect the quality of implementation of innovations in addiction treatment and correctional agencies; (4) survey findings on addiction treatment and corrections practices; (5) the lessons learned from the National Institute of Corrections Evidence-Based Practices project (Crime & Justice Institute, 2010) and other efforts at implementation of EBPs; and (6) interviews with key informants in the field regarding the implementation process. Taken together, this research indicated to us that an effective and useful TT model must address the unique facets related to the intersection of the addiction treatment and community corrections settings. This intersection is of much less concern in other disciplines. Stated simply, the interagency nature of the problem is not typically addressed in existing change processes where the missions are clearly aligned and participating organizations have a clearly defined role in delivering services. Neither of these two conditions exists when the community corrections and addiction treatment systems intersect; therefore a TT model must address the following issues: 1. New EBP need to be aligned into existing processes or procedures, which will require either adaptations of EBP or modifications in existing processes (i.e., the quality improvement model; see Ford, Green, Hoffman, Wisdom, Riley, & Bergmann, 2007). Often the introduction of an EBP will require an assessment of existing processes with an eye toward modifications, reductions in duplication, or clarity of importance assigned to these processes. This process is needed to overcome organizational barriers to innovation and changes in work practices. 2. Staff working in corrections agencies (i.e., managers, supervisors, and line staff) requires both the development of knowledge and the skills to use these practices. More attention needs to be given to an organizational strategy to engage the

1.6 Multistage Conceptual Model for Identifying and Selecting EBPs

11

organization as a whole in the change process. Work requirements in corrections settings generally mean that staff do not have the basic competencies in interviewing and interaction skills that are present in other disciplines (e.g., substance abuse, mental health), and that are needed to support rehabilitation efforts and offender change. The need exists to give more attention to the development of basic and advanced skills in EBP areas. 3. Improvements in feedback loops are critical to “incentivize” the system, and to provide the organization and stakeholders with information about the advances made and to fuel the momentum to change. Feedback loops can include management information systems, benchmarks, performance monitoring, testimonials, or public media messages to address the social networks associated with diffusion, and to ensure that the feedback builds momentum. An important component in this model is to identify performance objectives that can help the agencies monitor their progress. Within the community corrections setting, attention needs to be given to internal (i.e., staff, supervisors, other agencies) and external (i.e., judges, prosecutors, defenders, legislators, public health officials) stakeholders that are interested in improving outcomes.

1.6

Multistage Conceptual Model for Identifying and Selecting EBPs

Given the complexities of implementing evidence-based addiction treatment in community corrections settings, it should not be surprising that current models for designating EBP often fall short of providing a road map for selecting EBP that will both fit into local settings and will have the same positive impacts found in research settings. Although the scientific basis for designating an intervention/practice as EBP requires determination of effectiveness through multiple replications, few if any EBPs have been tested in a broad array of settings and populations. Very few addiction treatment EBPs have been tested with community corrections populations. In addition, the evidence base can sometimes have limitations due to concerns with selection bias, statistical vs. clinical significance, feasibility in real world settings, and applicability to a broader population. Aside from a careful review of the evidence base, two other issues need to be considered when agencies make decisions to adopt and implement an EBP. The first concerns whether the EBP is transportable to the local setting (Schoenwald & Hoagwood, 2001) – are the setting and population similar to those used in the research studies? Can the EBP be implemented with fidelity? Does the target population resemble the population that was studied? The second issue is the organizational capacity to implement the particular EBP. Are managers and staff ready to embrace this EBP and change their business practices to accommodate the innovation? Organizational capacity includes such factors as whether the staff perceives value in the EBP, resources and processes exist to implement the intervention, external influences are supportive, the costs are reasonable, and the organization is ready,

12

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Introduction

willing, and able to incorporate the EBP into the existing system. If the local conditions are not ripe for the implementation of EBP, it is not likely to be implemented well and achieve the desired outcomes. The decisive question is not just whether the local conditions are already present but rather can they be developed through use of sound organizational change strategies. We developed a multistage model that considers these issues and provides a framework for identifying EBP, critically assessing the evidence base, assessing transportability, and assessing and improving organizational capacity for EBP. By examining these issues during the phases of adopting, implementing, and sustaining an EBP, organizations can be more confident that the intervention or practice will be implemented in a manner that is likely to achieve the desired outcomes.

1.7

Evidence-Based Interagency Implementation Model (EB-IIM)

Our EB-IIM evolved from the existing literature and the unique features of correctional and addiction treatment agencies. It provides a framework for managing the change process through six actions: (1) knowledge development; (2) foundation building; (3) expectation setting; (4) alignment; (5) renovation; and (6) sustainability. Although the model is presented in a linear fashion, as shown in Fig. 1.1, it is recognized that it is not necessarily linear and organizations may have different starting places for different EBP areas. For example, an organization that contracts with a well-established substance abuse treatment provider that already delivers evidencebased interventions (e.g., cognitive behavioral therapy, family-focused interventions) with dedicated treatment slots for parolees, or one that has been using a second generation risk tool (i.e., Wisconsin Risk and Need), may need less work in knowledge development, given their prior efforts. And, this model underscores the processes of change that involve active leadership, staff involvement in change processes, staff with common knowledge in a given area, staff engagement in facilitated meetings and workshops to develop strategic and implementation plans,

Fig. 1.1 Conceptual model for evidence-based interagency implementation

1.7 Evidence-Based Interagency Implementation Model (EB-IIM)

13

project management that is clearly defined with authority and timeframes, working teams at multiple levels, cross-systems organizational collaborations, and clear performance goals and measures. The EB-IIM also recognizes an important lesson from the literature that effective TT must engage both the agency (inner) and stakeholder (outer) settings – the inner refers to the corrections agency whereas the outer refers to the layers of stakeholders and interested parties that influence the corrections agency. The TT process directly affects the community corrections agency but partners shape correctional initiatives including long-term sustainable change. Unlike mission-specific (public health) TT models, the EB-IIM preparation phase is separated into two components that include knowledge building and foundation setting. Knowledge building is designed to familiarize the organization with the EBP(s), including the nature of the scientific studies, the type of intervention, the measures used, and the key components of the practices. The goal is to build an appreciation for knowledge and a better understanding of EBP. The development of the skills of the individual and the organization to implement or support EBP is an important ingredient in this model. In some cases, the community corrections agencies will implement the innovation; in other cases, they will support a treatment agency. New skills such as motivational interviewing, use of geographical information systems, or other technologies may be important for the agency. Similarly, the organization will need to review its work processes and procedures and refine them to integrate the EBP. The third phase is expectation setting. Each new practice or innovation is coupled with a rationale and logic about the improvements that will occur. Expectation setting is designed to allow internal and external agencies to establish desired goals that are grounded in realistic benchmarks. This phase addresses the problem of unrealistic expectations such as organizations that promote EBP and expect recidivism reductions in the range of 50%. It is important to take modest, small steps in building the resiliency of the organization to implement EBP. Alignment is similar to a pilot that adjusts the agency’s processes and procedures to accommodate the change, and the impact of the changes on the offenders. The pilot or phase one introduction allows for all parties to work toward a common goal, and to address the barriers to full implementation of EBP. Both internal and external stakeholders should be involved in aligning the policies and procedures to create a renewed focus on desirable, and achievable, outcomes. Finally, renovation and sustainability are critical to lasting practices. This model recognizes that community corrections agencies must receive support from external agencies to implement EBP and treatments, and to develop internal capacity for change. Sustaining the innovation over time requires steadfast belief that the goals and objectives are worthy of continued investment. The initial evidence will become a launch pad for adopting and implementing other EBP. Refinement is a part of sustainability. The goal is to refine the practice to fit within the organization’s business process. Refinement focuses mainly on integration into the fabric of the organization, as well as system processes. The emphasis on sustainability throughout the process is focused on ensuring that innovation does

14

1

Introduction

not get diluted or morphed into another process. Refinement allows the agency to routinize the practice so that it is in place for the long term. The unique aspect of this model is that it outlines the inter- and intra-agency efforts that are important to adoption of EBP in this setting: clarity of mission and goals, interagency work groups, performance measures, social media campaign, and resources. These are important glues to bind the processes together. Based on the unique features of interagency efforts to adopt, implement, and sustain EBP, the major activities need to focus on the binding components to solidify support for EBP.

1.8

Conclusions and Outline of the Book

This book was motivated by a desire to provide new models to facilitate and encourage adoption, implementation, and sustaining the use of evidence-based addiction treatment in community corrections settings. The goal is to advance efforts to improve organizational strategies to implement sound, evidence-based addiction treatment and related programming. Ultimately, our interest is in improving the outcomes from the justice system, particularly substance-involved offenders. The model recognizes that addiction treatment providers and community corrections agencies are very different, and that there is a need for different implementation dynamics that must be addressed to facilitate change. These include: • The complexity of the community corrections field must be addressed in any implementation model. • The mission and goals that encompass EBP must be clarified to demonstrate cohesion with public safety and public health, and to demonstrate how offender change (abstinence from drug use as a result of successful treatment) improves public safety. • As a whole, basic skills that involve the dynamics of human services (e.g., assessment, communication/interviewing, engagement, treatment placement) are needed within corrections and treatment environments, and it cannot be assumed that these are currently available. • Performance measures provide wholesale support to the organization regarding the change model by ensuring that managers and staff link the change to the goals of the organization and continue the momentum associated with the change. • Community corrections agencies and treatment providers must be cross-trained and co-trained in order to more closely align their goals and expectations for offender management and progress, and to enable more informed choices about treatment placement and responses to offender progress in treatment. The value of this approach will be determined when community corrections agencies begin to systematically test the model as part of their strategies to implement EBP for addiction treatment.

References

15

This book contains nine additional chapters that analyze the issues raised in this introduction. Chapter 2 summarizes the techniques to identify EBP and discusses the strengths and weaknesses of these various approaches. Chapter 3 focuses on the theories of organizational change, and the major approaches in public sector organizations. Following the theories of change, Chapter 4 is devoted to distilling the research on organizational factors that impact the successful adoption of innovations. These include staff and managerial issues, characteristics of the innovation, characteristics of the organization, stakeholder involvement, and policy-related matters. Together, this set of chapters summarizes the importance of the organization in the discussion of using EBP in real world settings. Chapters 5 and 6 provide detailed updates on the state of EBP in addiction treatment and community corrections. The goal of these chapters is to detail advances in each field related to identifying, adopting, and implementing EBP. Chapter 7 then provides a summary of the unique and challenging environment issues that affect the adoption of innovations in addiction treatment and community corrections agencies. Chapter 8 provides a model for identifying the scientific, transportability, and organizational capacity issues that affect the identification and suitability of mapping evidence-based research into practice settings. Recognizing that the scientific basis for designating EBP has some limitations, and organizational, staff, and client factors affect the fit of an EBP into real world settings, this model moves the field further by incorporating scientific robustness, transportability, relevance, and capacity into the discussion. Chapter 9 presents an interagency evidence-based implementation model designed to address the needs of community correction and addiction treatment agencies. We present a six step process as well as managerial, facilitation, and policy level factors that affect the use of EBP. The chapter presents the heuristic implementation model as well as important planned change strategies to address implementation issues. Chapter 10 lays out an implementation and research agenda. This is a budding field that will proliferate in the future with proper nurturing, guidance, and assistance. Our goal is to identify the next steps needed to foster more attention to the importance of implementation strategies and implementation science in improving the integration of or increasing the utilization of effective addiction treatment programs by community corrections agencies.

References Addiction Technology Transfer Center (ATTC). (2004). The change book (2nd ed.). Kansas City: ATTC National Office. Andrews, D. A., Zinger, I., Hoge, R. D., & Bonta, J. (1990). Does correctional treatment work – A clinically relevant and psychologically informed meta-analysis. Criminology, 28, 369–390. Belenko, S. (2002). The challenges of conducting research in drug treatment court settings. Substance Use & Misuse, 37(12–13), 1635–1664.

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Introduction

Belenko, S., Fabrikant, N., & Wolff, N. (2011). The long road to treatment: Models of screening and admission into drug courts. Criminal Justice and Behavior, 38, 27–48. Belenko, S., Lang, M., & O’Connor, L. (2003). Self-reported psychiatric treatment needs among felony drug offenders. Journal of Contemporary Criminal Justice, 19(1), 9–29. Belenko, S., & Peugh, J. (2005). Estimating drug treatment needs among state prison inmates. Drug and Alcohol Dependence, 77(3), 269–281. Bhati, A. S., & Roman, J. K. (2010). Simulated evidence on the prospects of treating more druginvolved offenders. Journal of Experimental Criminology, 6(1), 1–33. Brown, B. S., & Flynn, P. M. (2002). The federal role in drug abuse technology transfer: A history and perspective. Journal of Substance Abuse Treatment, 22, 245–257. Centers for Disease Control and Prevention. (2005). Hospitalization by first diagnosis, all ages: U.S., 2002–2004. Atlanta: U.S. Department of Health and Human Services, CDC. Centers for Disease Control and Prevention. (2006). Sexually transmitted disease surveillance 2005 supplement. Atlanta: U.S. Department of Health and Human Services, CDC. Crime & Justice Institute. (2004). Implementing evidence-based practice in community corrections: The principles of effective intervention. Washington: National Institute of Corrections, Community Corrections Division. Crime & Justice Institute. (2010). Putting the pieces together: Practical strategies for implementing evidence-based practices. Washington: National Institute of Corrections. Drake, E., Aos, S., & Miller, M. (2009). Evidence-based public policy options to reduce crime and criminal justice costs: Implications in Washington State. Victims & Offenders, 4(2), 170–196. Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., & Wallace, F. (2005). Implementation research: A synthesis of the literature. Tampa: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network (FMHI Publication #231). Ford, J. H., II, Green, C. A., Hoffman, K. A., Wisdom, J. P., Riley, K. J., & Bergmann, L., (2007). Process improvement needs in substance abuse treatment: Admissions walk-through results. Journal of Substance Abuse Treatment, 33(4), 379–389. Friedmann, P. D., Taxman, F. S., & Henderson, C. E. (2007). Evidence-based treatment practices for drug-involved adults in the criminal justice system. Journal of Substance Abuse Treatment, 32, 267–277. Gendreau, P., Goggin, C., & Smith, P. (1999). The forgotten issue in effective correctional treatment: Program implementation. International Journal of Offender Therapy and Comparative Criminology, 43(2), 180–187. Glaze, L. E. (2010). Correctional populations in the United States, 2009. Washington: Bureau of Justice Statistics. Glynn, M., & Rhodes, P. (2005). Estimated HIV prevalence in the United States at the end of 2003. In National HIV Prevention Conference, Atlanta, June 2005 (Abstract T1-B1101). Accessed July 21, 2007. Hoffman, K. A., Ford, J. H., II, Choi, D., Gustafson, D. H., & McCarty, D. (2008). Replication and sustainability of improved access and retention within the Network for the Improvement of Addiction Treatment. Drug and Alcohol Dependence, 98(1–2), 63–69. Huddleston, C. W., Marlowe, D. B., & Casebolt, R. (2008). Painting the current picture: A national report card on drug courts and other problem-solving court programs in the United States. Alexandria: National Drug Court Institute. James, D. J., & Glaze, L. E. (2006). Mental health problems of prisons and jail inmates (NCJ 213600). Washington: Department of Justice, Bureau of Justice Statistics. Klein, K. J., & Sorra, J. S. (1996). The challenge of innovation implementation. Academy of Management Review, 21, 1055–1080. Knight, K., Simpson, D. D., & Hiller, M. L. (1999). Three-year reincarceration outcomes for inprison therapeutic community treatment in Texas. The Prison Journal, 79(3), 337–351. Kuhn, T. S. (1966). The structure of scientific revolutions (3rd ed.). Chicago: University of Chicago Press.

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Langan, P. A., & Levin, D. J. (2002). Recidivism of prisoners released in 1994. Federal Sentencing Reporter, 15(1), 58–65. MacKenzie, D. L. (2006). What works in corrections? Reducing the criminal activities of offenders and delinquents. Cambridge: Cambridge Press. Markus, M. L. (1983). Power, politics, and MIS implementation. Communications of the ACM, 26, 430–444. Marlowe, D. B., Festinger, D. S., Lee, P. A., Dugosh, K. L., & Benasutti, K. M. (2006). Matching judicial supervision to clients’ risk status in drug court. Crime & Delinquency, 52(1), 52–76. Martinson, R. (1974). What works? – Questions and answers about prison reform. The Public Interest, 35, 22–54. Martinson, R. (1979). New findings, new views: A note of caution regarding sentencing reform. Hofstra Law Review, 7(Winter), 243–258. Maruschak, L. (2009). HIV in prisons, 2007–08 (NCJ 228307). Washington: U.S. Department of Justice, Bureau of Justice Statistics. Mauer, M., & King, R. S. (2007). A 25-year quagmire: The war on drugs and its impact on American society. Washington: The Sentencing Project. McCarty, D., Gustafson, D., Wisdom, J., Ford, J., Choi, D., & Molfenter, T. (2007). The Network for the Improvement of Addiction Treatment (NIATx): Enhancing access and retention. Drug and Alcohol Dependence, 88, 138–145. Mitchell, O., Wilson, D. B., & MacKenzie, D. L. (2007). Does incarceration-based drug treatment reduce recidivism? A meta-analytic synthesis of the research. Journal of Experimental Criminology, 3(4), 353–375. Mumola, C. J., & Bonczar, T. P. (1998). Substance abuse and treatment of adults on probation, 1995. Rockville: Bureau of Justice Statistics. Nagin, D. S., Cullen, F. T., & Jonson, C. L. (2009). Imprisonment and reoffending. In M. Tonry (Ed.), Crime and justice: A review of research (pp. 1–91). Chicago: University of Chicago Press. National Institute of Mental Health. (2008). Statistics. Retrieved March 18, 2008, from http:// www.nimh.nih.gov/health/topics/statistics/index.shtml. National Institute on Drug Abuse. (2006). Principles of drug abuse treatment for criminal justice populations. (NIH Publication No. 06–5316). Rockville: National Institute on Drug Abuse. National Institutes of Health. (2006). Fact sheet: NIH roadmap for medical research. Bethesda: National Institutes of Health. Panzano, P. C., & Roth, D. (2006). The decision to adopt evidence-based and other innovative mental health practices: Risky business? Psychiatric Services, 57(8), 1153–1161. Patton, M. Q. (1987). How to use qualitative methods in evaluation. Newbury Park: Sage. Petersilia, J. (1999). Parole and prisoner reentry in the United States. Crime and Justice, 26, 479–529. Pew Center on the States (2008). One in 100: Behind bars in America. Washington, DC: The Pew Charitable Trusts. Retrieved April 20, 2011, from http://www.pewcenteronthestates.org/ initiatives_detail.aspx?initiativeID=56212#2011. Pew Center on the States (2009). One in 31: The long reach of American corrections. Washington, DC: The Pew Charitable Trusts. Retrieved April 20, 2011, from http://www.pewcenteronthestates.org/initiatives_detail.aspx?initiativeID=56212#2011. Prendergast, M. L., Hall, E. A., Wexler, H. K., Melnick, G., & Cao, Y. (2004). Amity prison-based therapeutic community: 5-year outcomes. The Prison Journal, 84(1), 36–60. Proctor, E., Landsverk, J., Aarons, G., Chambers, D., Glisson, C., & Mittman, B. (2009). Implementation research in mental health services: an emerging science with conceptual, methodological, and training challenges. Administration and Policy in Mental Health and Mental Health Services Research, 36(1), 24–34. Rogers, E. M. (1983). Diffusion of innovations (3rd ed.). New York: The Free Press. Rogers, E. M. (1995). Diffusion of innovations (4th ed.). New York: The Free Press. Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York: The Free Press.

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Roman, P. M., & Johnson, J. A. (2002). Adoption and implementation of new technologies in substance abuse treatment. Journal of Substance Abuse Treatment, 22(4), 211–218. Schoenwald, K. S., & Hoagwood, K. (2001). Effectiveness, transportability, and dissemination of interventions: What matters when? Psychiatric Services, 52, 1190–1197. Sherman, L. W., Gottfredson, D., MacKenzie, D., Reuter, P., Eck, J., Bushway, S. (1997). Preventing crime: What works, what doesn’t, what’s promising. A Report to the U.S. Congress. Washington: U.S. Department of Justice. Retrieved from http://www.ncjrs.gov/works/. Simpson, D. D. (2002). A conceptual framework for transferring research to practice. Journal of Substance Abuse Treatment, 22, 171–182. Substance Abuse and Mental Health Services Administration. (2009). Treatment Episode Data Set (TEDS) Highlights – 2007 National Admissions to Substance Abuse Treatment Services. OAS Series #S-45, HHS Publication No. (SMA) 09–4360, Rockville. Taxman, F. S. (1998). Reducing recidivism through a seamless system of care: Components of effective treatment, supervision, and transition services in the community. Washington: Office of National Drug Control Policy. Taxman, F. S., & Bouffard, J. A. (2000). The importance of systems issues in improving offender outcomes: Critical elements of treatment integrity. Justice Research and Policy, 2, 9–30. Taxman, F. S., Byrne, J., Pattavina, A., & Ainsworth, S. (2010). Analysis of criminogenic needs of offenders. Fairfax: Center for Advancing Correctional Excellence. Taxman, F. S., Perdoni, M., & Harrison, L. D. (2007). Drug treatment services for adult offenders: The state of the state. Journal of Substance Abuse Treatment, 32, 239–254. Taxman, F. S., Shepardson, E., & Byrne, J. (2004). Tools of the trade: A guide for incorporating science into practice. Washington: National Institute of Corrections. Taxman, F. S., & Thanner, M. H. (2004). Probation from a therapeutic perspective: results from the field. Contemporary Issues in Law, 7(1), 39–63. Teplin, L. A., Abram, K. M., McClelland, G. M., Mericle, A. A., Dulcan, M. K., & Washburn, J. J. (2006). Psychiatric disorders of youth in detention. U.S. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention. (NCJ-213600). Tonry, M., & Farrington, D. P. (1995). Strategic approaches to crime prevention. Crime and Justice, 19, 1–20. West, H. C., & Sabol, W. J. (2010). Prisoners in 2009. Washington: Bureau of Justice Statistics. Wexler, H. K., De Leon, G., Thomas, G., Kressel, D., & Peters, J. (1999). The amity prison TC evaluation: Reincarceration outcomes. Criminal Justice and Behavior, 26(2), 147–167. Wexler, H. K., Melnick, G., Lowe, L., & Peters, J. (1999). Three-year reincarceration outcomes for Amity In-Prison Therapeutic Community and Aftercare in California. The Prison Journal, 79(3), 321–336. White, H. R., & Gorman, D. M. (2000). Dynamics of the drug-crime relationship. In Crime and Justice 2000, vol. 1: The nature of crime: Continuity and change (NCJ 182408, pp. 151–218). Washington: U.S. Department of Justice, National Institute of Justice. Wilson, D. B., Mitchell, O., & MacKenzie, D. L. (2006). A systematic review of drug court effects on recidivism. Journal of Experimental Criminology, 2(4), 459–487.

Chapter 2

Identifying the Evidence Base for “What Works” in Community Corrections and Addiction Treatment

2.1

Introduction and Overview

The evidence-based practices (EBP) movement emerged in the 1990s as a strategy to reduce the gap between science and practice in many disciplines that involve the delivery of services: medicine, education, social services, substance abuse, mental health, and criminal justice. In the past, standards varied regarding the definitions of “best practices” and what might constitute an EBP; these were often defined in an idiosyncratic manner. The more recent interest in EBP focuses on improving outcomes by ensuring that direct service providers use proven techniques and technologies (defined by the results from scientific studies) in their daily practices. Professional organizations and federal agencies have been actively promoting the identification and implementation of EBP in health care, mental health (National Advisory Mental Health Council, 2006), substance abuse (NIH, 2004), community corrections (NIC, 2004), and other areas. This interest has spurred the creation of numerous initiatives to disseminate scientific knowledge through comprehensive literature reviews that synthesize and quantify the results using recognized metaanalysis and systematic review procedures. Synthesized findings are disseminated to the field via information sessions or websites, practitioner training, and publications. Prominent examples include the Office of Juvenile Justice Prevention and Delinquency (OJJPD) Blueprints for Violence Prevention, Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-Based Programs and Practices (NREPP) (http://www. nrepp.samhsa.gov/AboutNREPP.aspx), Cochrane Reviews (http://www.cochrane. org), and Campbell Collaboration (http://www.cochranecampbellcollaboration.org). These efforts focus primarily on methods for reviewing the literature, establishing criteria for labeling a treatment or practice as evidence-based, identifying and rating interventions, and producing summary papers that systematically review research findings. An example of efforts to simply translate findings and then disseminate to the field is the National Institute of Corrections Evidence-Based Practices for Community Corrections (http://cjinstitute.org/projects/integratedmodel). F.S. Taxman and S. Belenko, Implementing Evidence-Based Practices in Community Corrections and Addiction Treatment, Springer Series on Evidence-Based Crime Policy, DOI 10.1007/978-1-4614-0412-5_2, © Springer Science+Business Media, LLC 2012

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The term “evidence-based practice” has many definitions but generally requires a thorough review of the research for a given intervention or practice to identify studies that found positive outcomes in real-world settings. The preference is for scientifically rigorous studies using randomized controlled trial (RCT) designs or high quality quasi-experimental designs. The accepted standard of an EBP is that there must be at least two rigorous studies (i.e., randomized designs or high quality quasi-experimental designs) with similar findings on key outcomes. Two examples of EBP definitions are as follows: • “Evidence-based practice is the integration of best research evidence with clinical expertise and patient values… Patient values refers to the unique preferences, concerns, and expectations that each patient brings to the clinical encounter” (Institute of Medicine, 2001). • “Evidence-based practices are interventions for which there is consistent scientific evidence showing that they improve client outcomes” (Drake et al., 2001). Unlike the fields of medicine and other health care professions, identifying EBP in correctional practice and behavioral health (i.e., substance abuse, mental health) is a much more complex undertaking given that the findings are subject to more debate and controversy. This is because the degree of improvement in symptoms can be subjective as to whether an intervention or practice is “effective,” whether the positive effects are clinically meaningful, and whether the findings are statistically significant. For example, few studies are longitudinal in nature, and the findings often reflect short-term outcomes of 12 months or less. This raises concerns about the significance of the study findings given the limited information on duration of effect, with some arguing that progress in 12 months (or less) is significant while others find this timeframe too limited to make a judgment about effectiveness. In addition, one must consider that many treatment counselors and criminal justice practitioners are highly invested personally and professionally in delivering services or using clinical techniques with which they are familiar and comfortable; the criteria that the counselors or staff use may differ from the research findings. A core challenge for the EBP field involves the practicalities of conducting field research in behavioral health, substance abuse, and correctional interventions/ programs. The demarcation of a practice or treatment as an EBP is a lengthy and sometimes cumbersome process due to the difficulty and expense of conducting rigorous well-controlled scientific studies (primarily using randomized controlled trials) that have sufficient follow-up periods to detect differences in client outcomes. There is also considerable debate whether mental illnesses and substance abuse can be eradicated or whether reductions in symptoms are sufficient for a treatment to be deemed effective. The same is true for criminal conduct. Long-term abstinence for drug abusers can be quite difficult to achieve (McKay, 2001). For correctional interventions, the problems are even more exacerbated because justicerelated funding agencies at the federal (e.g., U.S. Department of Justice) and state levels generally do not provide funding for studies that exceed a few years. Criminal justice stakeholders are often reluctant to approve RCTs with offender populations because of concerns about due process, public safety, and interference with judicial, correctional, or prosecutorial authority. That is, in justice settings there is

2.1

Introduction and Overview

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much concern that randomized trials sacrifice the nuances of decisions made regarding the delivery of services and programs in correctional settings, and that correctional staff should not be bound to a RCT design, especially when that would constrain criminal justice decision making or when offender behavior may jeopardize public safety. The emphasis on RCTs, complicated by the realities of ensuring public safety, increases the complexity of conducting such studies in community corrections settings. RCTs and long-term follow-up studies are more common in addiction treatment research. Typical grants funded by the National Institutes of Health, particularly the National Institute on Drug Abuse and the National Institute of Mental Health, are five years in duration whereas funding from the National Institute of Justice tends to be under three years. Even with fewer barriers to conducting rigorous studies in addiction treatment research, the addiction treatment field struggles with relying totally on a scientific basis for recommending particular treatments or therapies. The addiction treatment profession still has a strong and influential organizational culture that values individual clinician experience and viewpoints in determining what type of treatment might work best for different types of clients in different treatment settings (Capoccia et al., 2007). The field is caught in a “Catch 22” given that clinical trials may reveal new therapies but the tendency is for the addiction treatment field to greatly value clinical experience and judgment over science-based research findings (Norcross et al., 2005). Counseling staff may be reluctant to adopt and implement an EBP that contradicts or interferes with the type of counseling or services they were trained on or have been delivering; this can often result in drift from the EBP-defined intervention and poor implementation of an intervention that in turn reduces the effectiveness of the EBP. Counselors in recovery may be motivated to use techniques that helped them overcome their substance abuse problems, regardless of whether those techniques have been designated as EBP. The question of whether clinician or patient input is necessary to designate an intervention or practice as evidence-based is controversial, as discussed in detail below. Another frequently mentioned concern is whether the strategies that researchers use in RCTs compromise some of the “real-world” conditions that can affect the delivery of EBP. These issues are unresolved but exemplify a significant tension that affects adoption of evidence-based practices in the field. For this reason, clinical researchers have proffered the need to conduct efficacy trials (using RCTs) to demonstrate the ability of a practice or treatment to improve outcomes followed by an effectiveness trial to demonstrate that the practice delivers similar outcomes in real-world settings (see below for more discussion). A similar tension exists in correctional and criminal justice settings where practitioners feel that their expertise and professional judgment are not adequately integrated into RCT or high quality quasi-experimental research designs. Regardless of strains between science-based identification of “evidence” and clinical practice, the correctional and substance abuse fields have defined a set of principles for identifying evidence-based practices and have designated some practices as EBP. This has allowed both fields to create taxonomies to designate practice or treatments according to the degree of scientific rigor. In this regard, clinical practice refers to accepted or consensus guidelines by the disciplines and best practices

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refers to practices that are well-respected by the field(s) and where some research has been conducted to affirm efficacy and effectiveness.

2.2

Basic Definitions and Concepts

Technology Transfer (TT) is about taking the findings from science (the laboratory) and applying them in real-world settings in a way that leads to meaningful change in practices and treatments provided. Knowledge development and knowledge utilization are processes embedded within TT. TT helps process the science (findings from studies) and churns it through organizational mechanisms to become reality, while maintaining the integrity of the originally defined intervention or practice. Many factors influence the TT process (e.g., sociopolitical environments, leadership, staffing, severity of the crime problem in the community, interagency efforts, historical efforts, resources) in ways that shape the resulting product, practice, or intervention. It is necessary to fully understand how the organizational, interagency, and personnel processes affect the outcomes both in terms of the nature of the intervention/practice and the outcomes at the organizational and client level. A new field of study, implementation science, is geared toward providing a scientific process to understand how to maximize implementation to achieve adherence to the science-based interventions/programs and to better understand the components of effective implementation processes (Fixsen, Naoom, Blase, Friedman, & Wallace, 2005; Proctor et al., 2009). Because many interventions enter into clinical or correctional practice and become well accepted over time without rigorous scientific evidence to support the intervention, TT must address the issue of compatibility of EBP with existing practices. Although this reflects that many clinicians and practitioners greatly value their own observations and experiences in assessing whether an intervention works, it also reflects the reinforcement that the treatment and justice/corrections staff receive from their supervisors, funding agencies or the public on the services they provide. However, there is scientific consensus that observation, anecdotes, and personal experiences, although important, furnish relatively low levels of evidence to support a determination that an intervention or practice is effective because such techniques rely on subjective and nonreproducible assessments of impacts. Figure 2.1 below shows the various levels of evidence ranked from lowest to highest scientific strength.

2.2.1

Hierarchy of Levels of Evidence

In addition to the variety of research designs (e.g., quasi-experimental and randomized experiments), there are different levels of evidentiary strength for drawing conclusions about research findings on interventions and practices. The highest standard, gold, has traditionally required randomized trials (preferably theory-driven)

2.2 Basic Definitions and Concepts

23

Multivariate Longitudinal Research Replications and Multisite Randomized Controlled Trials Single Site Experiment

Quasi-Experiments

Process Evaluations Qualitative information including focus groups, expert panels, key informant activities

Participant and Program Staff Observations, anecdotes

Fig. 2.1 Gradations of scientific methods and approaches

with multiple replications in different sites, controls for sample attrition, significant and sustained reductions in risk behaviors, and a preponderance of evidence supporting effectiveness across multiple studies. A less rigorous standard, silver, would include the same outcomes and replications as the gold standard but using a quasi-experimental design with strong statistical controls. Quasi-experimental designs include case control, statistically matched samples, regression discontinuity, time series, and single sample pre-post designs with or without longitudinal observations (Campbell & Stanley, 1963). A bronze standard would use matched comparison groups but without adequate statistical controls, and the lowest standard would entail inadequate research designs. The rigor of the studies signifies the degree to which the findings are subject to error or bias due to the methods or the variables, and to the level of internal validity. Despite the broad acceptance by research funders that RCTs are the gold standard for determining the effectiveness of interventions, some theorists and statisticians have raised warnings about the limitations of RCTs (Brown et al., 2009; Manski, 2011; Sampson, 2010). These concerns include the difficulty of drawing causal inferences about intervention effects from many RCTs (Sampson, 2010), the commonality of selection bias in experimental studies (Belenko, Fabrikant, & Wolff, 2011; Berk, 2005; Sampson, 2010), the lack of research on the effective components (or “active ingredients”) of interventions (Taxman & Thanner, 2006), concerns about small and homogeneous samples in the typical RCTs (Taxman & Rhodes, 2010),

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sample attrition problems and lack of information on the fidelity of the intervention (Taxman & Friedmann, 2009), sample contamination between experimental and control groups (Taxman & Rhodes, 2010), follow-up periods that are too brief to determine long-term intervention effects (Taxman & Rhodes, 2010), and the limitations of RCTs for informing policy (Sampson, 2010). To yield two or more studies of similar findings requires a sufficient time to conduct numerous RCTs to determine that an intervention is effective. Added to this is the need to extend the RCT to disparate populations in different settings to replicate the findings. For example, a single-site RCT with a sample of 150 offenders and a 2-year follow-up can take 5 years to complete; this can limit the value of the RCT model for policymakers who need to make relatively quick decisions about which interventions to adopt. For these reasons, some have called for a greater reliance on multicenter trials where there are simultaneous RCTs in different settings and with different populations (Weisburd & Taxman, 2000), rigorous observational studies, mixed methods approaches (Palinkas, Horwitz, Chamberlain, Hurlburt, & Landsverk, 2011), and multivariate longitudinal studies (Sampson, 2010; Tucker & Roth, 2006). The latter (longitudinal) design involves following one cohort through and after treatment, collecting frequent and comprehensive data that may allow the researcher to isolate the components of effective treatment and the factors that affect treatment success and failure along different time points. This model is specifically useful for substance abuse or mental health disorders, or criminal behavior, where the duration of the treatment impact may be affected by factors other than the specific intervention. Nonetheless, despite the above concerns, RCTs remain the standard exemplar by federal funders, researchers, and evidence-based repositories. These sources frequently make decisions about which interventions or practices are effective and evidence-based. The Food and Drug Administration (FDA) and NIH models retain their primacy and are likely to remain the preferred models for the foreseeable future given the focus on reducing harms to individuals, as discussed below. The FDA model requires at least two clinical trials with similar outcomes to indicate a medication or procedure is ready for public consumption. NIH employs a similar standard.

2.3

Efficacy vs. Effectiveness

Well-established standards for the scientific process also describe several stages that are needed to develop knowledge about the evidence base for interventions and practices. Efficacy refers to evidence that a treatment/practice has beneficial effects when delivered under carefully controlled conditions designed for experimentation. In efficacy studies (Phase II trials, see below), the researcher exerts considerable control over sample selection, delivery of the intervention, and the settings in which the intervention takes place. This best replicates the laboratory environment in the natural sciences where the scientist exercises the most control over every aspect of an experiment. Effectiveness refers to evidence that a treatment has beneficial effects when delivered to heterogeneous samples of clinically referred individuals treated in diverse clinical settings by clinicians rather than researchers (Phase III trials; see below).

2.3

Efficacy vs. Effectiveness

25

Efficacy trials usually involve randomized clinical trials while effectiveness studies may also include traditional evaluations as well as multisite replications using randomized trials. The question about whether an effective intervention is transportable (Schoenwald & Hoagwood, 2001) has been raised and has spurred interest in the resiliency of outcomes as the intervention or practices move from efficacy to formal effectiveness trials to more general use (diffusion and dissemination). A thorough discussion of transportability issues is in Chap. 8. Sustainability is another important issue, and refers to the extent to which an intervention remains effective over time and continues to be implemented with fidelity (Fixsen et al., 2005). When an intervention is sustainable, staff embraces it as being effective and preferable to previous or alternative approaches. To sustain an intervention, it is also usually necessary that local resources be used after the initial external or grant funding is completed. Comparative effectiveness research (CER) is a relatively new approach to health care research that seeks to compare evidence on the effectiveness and potential harms of different treatment options simultaneously (Sox & Greenfield, 2009). In contrast to the more traditional RCT model of comparing a new intervention to a placebo or standard care, CER seeks to use evidence from existing published research, including systematic reviews and meta-analyses, to provide information about the relative impacts of different (often comparable) treatment options or models. CER can also be conducted using new studies that randomize patients into two or more different treatment options to determine the effectiveness of either approach, and to ascertain whether one treatment is better suited for one type of patient. CER can fulfill an important goal for the federal government and health care professional in generating timely information about different treatments and disseminate the results in a way that is easily understood and usable by clinicians, policymakers, and patients. To promote RCTs that compare different treatment interventions to one another, the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services outlines seven steps for using CER to compare treatments and increasing the public health impact of the findings (http://www.effectivehealthcare.ahrq.gov/index.cfm/what-is-comparative-effectiveness-research1): 1. Identify new and emerging clinical interventions. 2. Review and synthesize current medical research. 3. Identify gaps between existing medical research and the needs of clinical practice. 4. Promote and generate new scientific evidence and analytic tools. 5. Train and develop clinical researchers. 6. Translate and disseminate research findings to diverse stakeholders. 7. Reach out to stakeholders via a citizen forum. CER can help clinicians and policymakers make more informed choices about which intervention to use with which population. Thus, although a relatively new approach, CER has potential utility for helping community corrections and addiction treatment agencies make decisions about which program or practice to implement with their population. The American Recovery and Reinvestment Act of 2009 created the Federal Coordinating Council for Comparative Effectiveness Research to coordinate CER throughout the federal government.

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In theory, and certainly in practice, all research strategies have some value for advancing science and knowledge. To be most useful for practice and policy decisions, researchers should maximize scientific rigor and use a systematic process for developing knowledge, starting with observation and qualitative research through randomized clinical trials with appropriate statistical analyses. The basic approach that underlies all levels of inquiry is systematic observation and objectivity and a set method for collecting and analyzing data. From a methods perspective, what hierarchically differentiates research designs is the extent to which potential threats to internal validity (i.e., nature of the intervention, techniques to recruit patient or collect data, comparability of experimental and control groups, sample attrition and missing data) and external validity (i.e., generalizability) are controlled. Moving up the scientific scale, process and implementation evaluation allows measurement of how an intervention is operating and its effects upon participants as well as fidelity of implementation (adherence to the original intervention and study design). Finally, rigorous designs that include well-designed control groups range from single site experimental and quasi-experimental studies to the gold standard of multisite randomized clinical trials. Adding multiple waves of data collection to increase the length of follow-up in longitudinal designs also strengthens the study findings by examining the duration of the effect or the patterns of decay in outcomes.

2.4

Frameworks for Determining the Evidence Base

A number of processes are available to determine the evidence base. This section will identify the different approaches for determining the evidence base and scientific processes to synthesize information. What are the procedures and process used to decide that an intervention or practice is effective (i.e., evidence-based)? What are the benefits and drawbacks of these methods? How is information about EBP disseminated to the field? What are some of the types of efforts used to promote the adoption and implementation of EBP? In this section, we address these questions.

2.4.1

The Food and Drug Administration (FDA) Model

The evidence determination process has its roots in the FDA Model for reviewing scientific evidence to evaluate the effects of pharmaceutical treatments (FDA, 2010). The FDA guidelines dictate that in order for a medication and/or device to be considered appropriate and safe for public use, a series of clinical trials need to be completed. The evidence needs to be based in strong science and research design, and be able to determine whether the drug/product is both safe and effective. The FDA model requires: (1) methodological quality of the evidence; (2) findings of a positive treatment effect that are relevant to appropriate target groups (e.g., by gender, age categories, and disease); (3) findings replicated in a minimum of two different studies; and (4) an overall consistency of the evidence in terms of the

2.4

Frameworks for Determining the Evidence Base

27

direction of the effect. After assessing the totality of the scientific evidence, the FDA determines whether there is “Significant Scientific Agreement” to support the hypothesized effect. Given the overarching importance of scientific rigor, the FDA model calls for multiple, replicated randomized controlled trials before a drug/ product can be designated as effective and safe for human consumption. The resulting evidence is then used to develop information for both dosages and impacts.

2.4.2

Applying the FDA Model to Behavioral Interventions

In translating the FDA model into behavioral health interventions, Rounsaville, Carroll, and Onken (2001) proposed a staged model of intervention research. The process begins with intervention development, followed by a pilot randomized trial of intervention efficacy in one site under carefully controlled conditions (Stages 1a and 1b). The National Institutes of Health guidelines expand on this model and define four stages of clinical trials research for treatment interventions to determine whether an intervention is effective. The trials at each phase have different purposes and help scientists answer different questions. In Phase I trials, researchers conduct initial tests of an experimental drug or treatment in a small group of people (20–80) in order to evaluate its safety, feasibility and acceptability, determine dosages, and identify any unanticipated negative effects. Phase I trials provide early evidence of efficacy. In Phase II trials, the experimental treatment is given to a larger group of people (100–300) to determine efficacy in a controlled setting with a relatively focused target population and to further evaluate its safety and side effects. In Phase III trials, the experimental intervention is tested in large groups of people (1,000–3,000) in multiple settings and locations, with less researcher control over the intervention or the selection of the study subjects. This is referred to as a multisite trial, often using multisite longitudinal data to determine effectiveness over time. Phase III trials determine whether an intervention is effective, examine any unanticipated negative consequences, and compare the intervention to other commonly used treatments. The replicated RCTs can serve to determine the benefit–risk relationship of the intervention and assess its effects in different populations. Phase IV trials continue obtaining data on long-term effects of the treatment, assessing effectiveness in different populations, assessing costs and benefits, identifying optimal dosage, and measuring “active ingredients” (e.g., dismantling studies).

2.4.3

Synthesizing Across Research Designs

The FDA and modified behavioral interventions models are based almost exclusively on randomized clinical trials. But, in many disciplines like criminal justice and education, it is common for studies to use a broader range of methods that vary in rigor. In criminal justice studies, the Maryland Scientific Methods Scale (Sherman et al., 1997) and similar schemes have been used to accommodate the varying

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Table 2.1 Levels of evidence in the Maryland Scale Level 1 (weakest Correlation between a crime prevention program and a measure of crime evidence) or crime risk factors at a single point in time Level 2 Temporal sequence between the program and the crime or risk outcome clearly observed, or the presence of a comparison group without demonstrated comparability to the treatment group Level 3 Comparison between two or more comparable units of analysis, one with and one without the program Level 4 Comparison between multiple units with and without the program, controlling for other factors, or using comparison units that evidence only minor differences Level 5 (strongest Random assignment and analysis of comparable units to program and evidence) comparison groups

designs while rigorously assessing the evidence base. In this scheme, various studies are combined to determine the level of knowledge that exists across studies that range in design from no control groups to randomized trials. The Maryland Scientific Methods Scale was developed from a consensus process whereby researchers developed techniques to combine studies, regardless of rigor, to inform policymakers of the state of knowledge in a given area. This framework forms the basis for designation of interventions as evidence-based, as shown in Table 2.1, and has been used or adapted in various evidence-based repositories discussed in Section 2.5. A tension exists between internal validity (integrity of the intervention) and external validity (generalizability to broader populations in different settings). As one moves up the scale of scientific rigor, threats to internal validity of the evidence decrease, yielding more confidence in the findings. Relatively few addiction treatment programs and practices have been designated as evidence-based in criminal justice settings, as discussed below. This is largely due to the difficulty of conducting studies in justice settings that meet the highest standard of scientific rigor. For example, it is perceived to be unethical and sometimes legally impossible to randomly assign offenders to prison or probation, and ethically problematic to withhold treatment from an offender if that treatment could help the individual avoid incarceration. Accordingly, these issues as well as other factors (e.g., cost, feasibility and acceptability, transportability) may lead policymakers to adopt interventions with lower levels of evidentiary strength. This contributes to the selection and continued use of interventions that do not have the strongest evidence base.

2.4.4

Consensus Processes

The scientific process is different from consensus approaches. Consensus approaches can involve activities such as focus groups, panels of experts and key informant surveys that access the richness of clinical experience but do not include rigorous hypothesis testing. Consensus approaches are important from many dimensions, and in fact can be used in conjunction with the scientific process. Consensus approaches can be used to enhance the research by including stakeholders in the

2.4

Frameworks for Determining the Evidence Base

29

definition of interventions to study and to synthesize clinical and scientific information. Such strategies can be used to identify potential new interventions and practices, to identify key outcome measures as well as possible moderators and mediators, and to ascertain whether the findings are feasible and sustainable in real-world settings. Such approaches are insufficient for testing whether the idea or concept can actually affect client outcomes but they can garner support for the utilization of the findings after a study is completed. Although one dilemma is the sometimes nonrigorous process associated with the consensus approach, it is recognized that the consensus approach allows the field to have input, particularly when there are inconsistent findings or concern that the intervention or practice tested may not be suitable for the field. Many groups that support EBP to guide policy and practice recognize the value of the consensus model, and often include stakeholders in the EBP designation process. The general perception is that such a process will ease dissemination efforts and contribute to greater utilization of the research findings. Stated simply, the consensus approach is part of a process to reduce the gap from research to practice, a core goal of TT as well as the EBP movement.

2.4.5

Systematic Reviews and Meta-Analyses

Increasingly, scholars and EBP repositories are relying on systematic reviews and meta-analyses to rigorously summarize the conclusions that can be drawn from the empirical literature about the effects of specific programs or interventions for offenders in specific settings. Systematic reviews incorporate methodological criteria for synthesizing information across various studies that vary in terms of quality of the design and statistical methods. These reviews are important because there may be numerous existing program evaluations and intervention studies, including studies that have not been published in the scientific journal-based, peer-reviewed literature (referred to as gray literature). The challenge of the synthesis process is to draw meaningful and defensible conclusions across a number of studies where the quality of studies varies substantially including different instrumentation and measures, target populations, and statistical analysis methods; different studies may reach different conclusions about efficacy; studies may be done in different settings with different populations; different studies may include different types of bias that raise questions about the internal or external validity of the findings; or the number of publications and journals may be overwhelming and difficult to sift through or not be readily accessible to program staff or policymakers. For these reasons, program developers, policymakers, and researchers need help in understanding what can reasonably be concluded from existing research findings, what is unknown, and what is unclear. Systematic reviews are of increasing importance in the health care and justice fields. These reviews synthesize studies, using agreed upon standards for addressing methodological weaknesses, in a meaningful way that is also very “customer friendly.” The impetus for systematic review methods came from the Cochrane Collaboration, an international organization that seeks to improve health care decisions through the preparation, maintenance, and

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dissemination of systematic reviews of the risks and benefits of health care interventions (http://www.cochrane.org; see Sect. 2.5). These reviews involve complex procedures, and require many judgments to be made (Oxman, 1994); systematic reviews may introduce another set of biases given the decision criteria required in the synthesis process (see below). A good review needs to be explicit about the selection criteria, search strategies, coding methods, and study quality ratings. Even when the review is explicit, it is clear that the researchers are making decisions about which studies to include and the decision criteria to make determinations about “effectiveness.” Two sample definitions of systematic reviews are: “[Systematic] reviews … use rigorous methods for locating, appraising, and synthesizing evidence from prior evaluation studies. They contain a methods and results section and are reported with the same level of detail that characterizes high-quality reports of original research” (Farrington, Petrosino, & Welsh, 2001, p. 340). “Systematic reviews … answer a clearly formulated question, employing systematic and explicit methods to identify, select, and critically appraise relevant research and to collect and analyze data from the studies that are included in the review” (Mowatt, Grimshaw, Davis, & Mazmanian, 2001, p. 55).

General guidelines for summarizing results from the systematic review (see Box 2.1) include (Oxman, 1994): • Draw conclusions only from the evidence reviewed alone. • Recommendations should be linked to the strength of the evidence, based on design quality (but also relevance and concerns about attrition and missing data). • The review should be explicit about values and preferences. • Subgroup analyses should be interpreted with caution (these may have been post hoc, the subgroups may not be randomly selected) subgroups may not be appropriate targets for the intervention, etc. • Different statistical analyses may result in different conclusions. • Sensitivity analyses should be conducted if possible (e.g., unpublished vs. published studies, by rigor of included studies). How sensitive are the results to the methods used for the review, how robust are the findings across methods, populations? Provide confidence intervals around the effects to provide a good indication of the precision of the findings.

Box 2.1 Options for Reporting Systematic Review Findings • Percentage of studies (within study quality groupings, populations, settings, other subgroups, perhaps) that found a significant difference in outcomes. • Calculating the average effect size (a standardized measure of the difference in an outcome between the experimental and control groups). • Calculating the Odds Ratio (a standardized measure that indicates the direction and size of the impact between experimental and control groups). • A forest plot showing the range of effect sizes across studies. One can also calculate a weighted estimate of treatment effect but the plot illustrates the trend across studies.

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Systematic reviews and especially meta-analyses typically consolidate findings across disparate studies by calculating outcome differences into standard effect sizes. Some argue that effect size is more important than probability values, statistical significance or hypothesis testing (Grimshaw, Eccles, & Tetroe, 2004), since it standardizes differences between the experimental and control groups across different measures. However, the relative value of effect size vs. statistical significance has generated much debate in the field (Weisburd, Lum, & Yang, 2003). Statistical significance indicates the degree to which one can have confidence in the findings based on the probability that the difference between the groups was not due to chance, the size of the sample, and the variance. But effect sizes are easier to interpret given that they can be translated into a measure of magnitude of the effect: <0.20 is considered a small effect, <0.40 is considered a medium effort, and over 0.40 is considered a large effect (Cohen, 1988). However, effect sizes do not address the issue of the degree to which one can have confidence that the results are not due to error. Most criminal justice and behavioral health research tends to have a small effect overall. It can also be useful to convert effect sizes into percentage differences for ease of interpretation by policymakers and practitioners. Meta-analysis, in which outcome data are pooled across studies, is a subset of systematic reviews. If study designs, populations, and settings differ too much across studies, then it may not be appropriate to aggregate data. Pooled effect size may also mask important subgroup differences. It is important to look at variations in effect sizes and the factors that may affect the direction and size of the effect (this can be done statistically). Many systematic reviews now incorporate moderator and mediator analyses to examine the differential effects of an intervention across subgroups or in different settings. For example, in a meta-analysis of drug court research, Wilson, Mitchell, and MacKenzie (2006) reported that the pooled odds ratio for recidivism (another standard measure) was somewhat higher for diversion drug courts (1.93) compared with postadjudication courts (1.83), mixed model courts (1.24), and courts of unknown type (1.68), indicating that diversion drug courts have better overall outcomes than other types of drug courts. Researchers are often using these types of analyses to illustrate the differential outcomes from various processes that can be important to translational researchers to identify the settings and populations where certain practices and interventions are more likely to yield positive findings in real world settings. The following issues need to be considered when summarizing findings and drawing conclusions about the research in systematic reviews of research evidence: 1. Factors other than the efficacy of the intervention could be related to outcomes. These include heterogeneity in study locations, different populations, implementation fidelity, or subversion of the experiment. Intervention effects vary by offender risk level, probability of the outcome, demographic characteristics, treatment setting, or other factors. Some practices or interventions may have an impact on certain outcomes but not others. 2. It is important to note possible sources of bias in the systematic review. This includes publication bias where negative results are less likely to be written up or published (so excluding unpublished studies may inflate the real effect size),

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selection of studies to include, and measures. Although outcome studies that are conducted by program developers tend to have significantly greater effect sizes than studies conducted by independent researchers (Petrosino & Soydan, 2005), researchers can use this to identify moderators that are related to differential effect sizes. 3. Effect size must be weighed against practical or clinically meaningful effects (Lipsey & Wilson, 1993). One cannot necessarily conclude that a small effect size is not of practical or policy significance because it is possible that such a practice could be implemented widely, and therefore valuable from the perspective of incremental changes. As Oxman (1994) states, “no evidence of effect does not equal evidence of no effect.” 4. Systematic reviews should consider and compare the harmful as well as beneficial effects of the intervention, analyze the variations in relative effects and the reasons for these variations, and compute predicted effects by offender type (Centre for Reviews and Dissemination, 2009).

2.5

Evidence-Based Repositories

An important advantage for dissemination strategies that emanate from the synthesis process is that organizations have created readily accessible repositories of EBPs and syntheses that are available to the public. In the following section we summarize the goals and content of these repositories.

2.5.1

Cochrane Collaboration/Cochrane Reviews

An important advancement in the promotion of systematic reviews to address the research-to-practice gap is the Cochrane Collaboration, an international organization formed in England in 1993. Cochrane seeks to promote evidence-based decision making in health care and improve health care decisions through the preparation, maintenance, and dissemination of systematic reviews of the risks and benefits of health care interventions (http://www.cochrane.org). Although the primary focus is medical care, this international group paved the way for methods to synthesize research findings and to disseminate research findings. Cochrane has contributed significantly to the field through its methods and specialized field areas where international workgroups join together to address the knowledge development and utilization issues. The Cochrane Collaboration promotes evidence-based decision making in health care and disseminates these Cochrane Reviews to the public to foster the use of evidencebased medicine.

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Evidence-Based Repositories

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To date, more than 4,000 systematic reviews have been published online via the Cochrane Library (http://www.thecochranelibrary.com/view/0/index.html). A Cochrane Review is recognized as a publication of high significance in the field given the rigorous review criteria. Although review summaries are available free of charge, a subscription is needed to access the full systematic review. The Cochrane Collaboration has a section devoted to substance abuse, public health, HIV/AIDS, and justice health that contains information on addiction treatment and some correctional interventions. The Cochrane Collaboration has played an essential role in fostering the importance of evidence-based decision making and developing a detailed and rigorous protocol for conducting systematic reviews of research that has greatly impacted the field. Further, the Cochrane Collaboration spurred the development of other systematic reviews in social sciences, in particular the Campbell Collaboration devoted to social sciences.

2.5.2

Campbell Collaboration–Crime and Justice Group

The success of the Cochrane Reviews spurred interest in developing similar protocols for reviewing the effectiveness of social and educational interventions, resulting in the establishment of the Campbell Collaboration. The Campbell Collaboration was formed in 2000 to extend the Cochrane Collaboration model to social interventions. Campbell includes five Coordinating Groups: Social Welfare, Education, Methods, Crime and Justice, and the Users Group (http://www.campbellcollaboration. org/Library/Library.php). As with Cochrane, the main function of the Campbell Collaboration is to sponsor and disseminate systematic reviews of research on social interventions. Using methods similar to Cochrane Collaboration (Noonan & Bjørndal, 2010), the Campbell Collaboration Crime and Justice Group (CCJG) solicits topics from systematic review authors, conducts a peer review of the review procedures and the final systematic review, and hosts an online library. One difference from Cochrane is that Campbell reviews include unpublished studies to reduce publication bias and to extend the number and type of studies that can be included. The Campbell Collaboration recognizes the potential value of nonrandomized designs, particularly in disciplines such as crime and justice where RCTs are rare and more difficult to implement. Reviews are posted on the website (http://www.campbellcollaboration.org/crime_and_justice/index.php) and are available to the public at no charge. An effect size calculator for systematic reviews, including all of the different types of analyses (discussed above), is available on the website (http://www.campbellcollaboration.org/resources/effect_size_input.php) at no charge. In addition to the systematic reviews, the CCJG has adapted the CONSORT (Consolidated Standards of Reporting Trials) statement for crime and justice studies to standardize reporting of methodological information (Campbell, Elbourne, & Altman, 2004). This ensures a consistent methodology and content across reviews.

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Because Campbell reviews focus on social interventions, the research literature may be more diffuse, have multiple outcomes (e.g., drug use, criminal behavior, mental health) defined differently across studies, and have fewer randomized trials. As of December 2010, 25 reviews have been completed by the Crime and Justice Group. Three are related to substance abuse treatment (http://www. campbellcollaboration.org/reviews_crime_justice/index.php): • Effectiveness of incarceration-based drug treatment on criminal behavior. • Effects of drug substitution programs on offending among drug addicts. • Effects of drug courts on criminal offending and drug use. The Campbell Social Welfare Group has several protocols related to substance abuse including case management, domestic violence programs, parent training, multisystemic family therapy, and other areas of interest to the substance abuse and criminal justice disciplines.

2.5.3

National Registry of Evidence-Based Programs and Practices

The National Registry of Evidence-Based Programs and Practices (NREPP) is funded by SAMHSA and is the successor to the Center for Substance Abuse Prevention’s National Registry of Effective Prevention Programs which began in 1997. Under the old model, 150 prevention programs were designated as model, effective, or promising interventions depending on the extent of rigorous research on their effectiveness. In 2004, NREPP was remodeled and the rating system modified, and expanded to include treatment interventions. In place of the three categories of programs under the previous model, NREPP now provides an Intervention Summary that includes: (1) general information about the intervention, (2) a summary of the client outcomes reviewed, (3) reviewer ratings of the Quality of Research and Readiness for Dissemination (see below), (4) list of the materials and studies that were used in the review, and (5) information sources for learning more about the intervention. There is no specific designation as to whether an intervention is “evidence-based,” and NREPP specifically notes that the ratings do not necessarily reflect the effectiveness of the intervention. NREPP seeks to summarize the state of the evidence and rate its quality, but leaves it up to decision makers to use the ratings and other program information to determine whether the intervention should be adopted for their own particular needs. NREPP submissions are self-nominated by intervention developers, and are reviewed by an external panel of experts trained in the NREPP review criteria, using a multipart rating system. The Quality of Research rating indicates the strength of the evidence that the intervention has positive effects on client outcomes. Where there are multiple outcomes reported, a different Quality of Research rating will be

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applied to each outcome. The rating uses a scale from 0.0 to 4.0 for each component of the quality rating, with 4.0 as the highest rating. The rating is based on research design, quality of data, reliability and validity of measures, missing data and sample attrition, intervention fidelity, types and appropriateness of statistical analyses, potential confounding variables, internal validity, and other factors. A recent review of the process noted that the majority of studies were generated by the developers of the intervention, and their studies tend to have more positive findings than those conducted by outside reviewers (Wright, Zhang, & Farabee, 2010). A second set of review factors, also scored from 0.0 to 4.0, relates to Readiness for Dissemination. This rating summarizes the extent and quality of available resources to support intervention implementation. Specific criteria include the availability of implementation materials (e.g., manuals, other written materials), availability of training and support resources including technical assistance or coaching, and availability of quality assurance procedures (e.g., protocols for collecting process data, monitoring of fidelity, supervision feedback). Once a review of an intervention is completed, information is posted on the NREPP website. This includes a general summary of the intervention and the outcome measures that were reviewed by NREPP, summary ratings of the Quality of Research and Readiness for Dissemination, a list of the research studies and intervention materials that were reviewed, and contact information to obtain manuals and other materials about the intervention. NREPP suggests that treatment program officials review the materials and contact intervention developers before deciding whether to adopt the intervention. See Box 2.2 for a sample NREPP review. Although a number of interventions have been designated in the earlier version of NREPP as evidence-based, or have their review findings listed on the current NREPP website, very few are focused on criminal justice populations. A search of the NREPP database using the NREPP search categories “substance abuse, correctional, crime/delinquency, drugs” identified seven interventions: • Forever Free – Drug treatment in therapeutic community for incarcerated women. • Friends Care – Aftercare program for probationers and parolees leaving mandated outpatient treatment. • Living in Balance – Addiction treatment program emphasizing relapse prevention. • Moral Reconation Therapy – Cognitive–behavioral intervention for inmates and other offenders that addresses moral reasoning. • Multidimensional Family Therapy – Comprehensive family-based intervention for adolescents with substance abuse problems or co-occurring disorders. • Residential Student Assistance Program – Substance abuse prevention program for high-risk youth who are placed in a residential facility, including juvenile correctional facilities. • Texas Christian University Mapping-Enhanced Counseling – A communication and decision making technique to support treatment by improving client–counselor interactions.

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Box 2.2 Example of an NREPP Review (Excerpted from http://www.nrepp. samhsa.gov/ViewIntervention.aspx?id=118) Forever Free Program description. Forever Free is a 4–6 month drug treatment program for incarcerated women. The intervention aims to reduce drug use and improve behaviors during incarceration and while on parole. During incarceration women participate in individual substance abuse counseling, special workshops, educational seminars, 12-step programs, parole planning, and urine testing. Topics include self-esteem, anger management, assertiveness training, information about healthy vs. dysfunctional relationships, abuse, posttraumatic stress disorder, codependency, parenting, and sex and health. After graduation and parole discharge, women may voluntarily enter community residential treatment which includes individual and group counseling as well as family counseling and vocational training/rehabilitation. Outcome 1: Drug use (frequency of drug use over the past year and during the past 30 days) was measured using structured interviews. Key findings: In a study with 180 women 1 year after their release from prison, 8% of Forever Free participants reported drug use in the past 30 days, compared with 32% of the comparison group (p = 0.001). A total of 50.5% of Forever Free participants reported any drug use in the past year, compared with 76.5% of comparison group participants (p = 0.001). Study designs. Quasi-experimental Quality of research rating. 2.9 (0.0–4.0 scale) Outcome 2: Parole outcomes. “Discharged/active with no return” was considered success. “Discharged/active returned to custody” and “in prison” were considered failures. Key findings: In one study, 68.4% of Forever Free graduates who entered residential treatment had not returned to custody 1 year after parole; 52.2% of Forever Free graduates who did not enter residential treatment had not returned to custody, while only 27.2% of women in a no-treatment comparison group had not been returned to custody (p < 0.05). In a second study, 49.5% of Forever Free graduates compared with 74.7% of a no-treatment comparison group reported being arrested in the year following release from prison (p = 0.001). Study designs. Quasi-experimental Quality of research rating. 3.2 (0.0–4.0 scale) Readiness for dissemination ratings by criteria (0.0–4.0 scale) (continued)

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Box 2.2 (continued) Implementation materials

Training and support

Quality assurance

Overall rating

1.3

0.5

0.5

0.8

Dissemination strengths The program uses best-practice materials from a variety of expert resources targeted to this specific population. Some training materials are provided for topic areas relevant to the intervention. A client satisfaction survey and a standardized therapeutic community fidelity measure are provided to support quality assurance. Dissemination weaknesses The program materials are specific to one implementation site and may not be easily adapted or transferred to other implementation sites. The relationship between the submitted program materials is unclear. While implementation, program goals, and recommendations for staffing are addressed in some of the materials, the guidance across these materials is inconsistent. No support resources specific to the program and its implementation are provided. The connection between the quality assurance measures provided and the program model is unclear. Materials state that one implementation site was engaged in external quality reviews, but no standards or protocols for evaluation or quality assessment are provided.

2.5.4

Blueprints for Violence Prevention

Blueprints for Violence Prevention (Blueprints), is a program of the Center for the Study and Prevention of Violence at the Institute for Behavioral Science at the University of Colorado (Mihalic, Irwin, Elliott, Fagan, & Hansen, 2001). Since 1996, Blueprints has sought to identify and disseminate information about effective youth violence and drug prevention programs (http://www.colorado.edu/cspv/blueprints/ index.html). Most of the funding for Blueprints comes from the U.S. Department of Justice’s Office of Juvenile Justice Prevention and Delinquency (OJJDP). Two types of program designations are included: model programs and promising programs. Blueprints requires a rigorous review of the research by Blueprints staff, followed by external review and recommendation by an Advisory Board. To be certified, the intervention must demonstrate evidence of a deterrent effect on violence and recidivism based on a scientifically strong research design. Review categories include: 1. Evidence of deterrent effect (i.e., reduction in delinquency, violence, or drug use) with strong research design (RCTs, well-matched comparison group designs or

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studies with good statistical controls for comparison group differences). Studies need to address issues related to sample size, sample attrition, and consistent and valid measures must be used. 2. Sustained effects defined by follow-up periods of at least 1 year posttreatment. 3. Multiple site replications including diverse settings and diverse populations increase confidence in the effectiveness of an intervention. At least one replication with demonstrated effects is necessary to be designated a Blueprints model program. 4. Two additional factors are considered: First, whether the program conducted analyses of mediating factors (i.e., whether the program changed a targeted risk or protective factor that mediated changes in delinquency or violence). Second, whether the economic benefits of the program outweigh the costs, and whether program costs are “reasonable.” To be designated as a model program, a program must meet the first three of these criteria, while promising programs must meet only the first criterion. An important criterion is that the intervention must be studied by at least two researchers, of which one cannot be associated with the development of the intervention. This is a unique criterion compared to other synthesis processes. Given the relatively rigorous review criteria compared with other repositories, relatively few interventions have achieved this designation. Out of more than 900 programs reviewed to date, only 11 have been designated as Blueprints model programs, and 19 as promising programs. Two model and eight promising interventions are related to substance abuse prevention or treatment with youth at risk for delinquency. Model programs: • Multisystemic Therapy: intensive family-and community-based treatment addressing multiple determinants of serious antisocial behavior in juvenile offenders. MST targets chronic, violent, or substance abusing male or female juvenile offenders, ages 12–17, at high risk of out-of-home placement, and the offenders’ families. • Functional Family Therapy: outcome-driven prevention/intervention program for 11- to 18-year-old youth at risk for and/or presenting with delinquency, violence, substance use, or conduct disorders. Intervention sessions are delivered to youth and their families in various settings. Promising programs: • Behavioral Monitoring and Reinforcement Program: a school-based intervention that helps prevent juvenile delinquency, substance use, and school failure for high-risk adolescents. This is a two-year program beginning in seventh grade and targets youth with low academic motivation, family problems, or frequent or serious school discipline referrals. • Brief Strategic Family Therapy: a short-term (three months), problem-focused intervention emphasizing modification of maladaptive family interaction patterns. The target population is children and adolescents 8–17 years old at risk for behavior problems, including substance abuse.

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Evidence-Based Repositories

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• CASASTART (Striving Together to Achieve Rewarding Tomorrows), formerly the Children at Risk (CAR) program: targets youth aged 11–13 in high risk environments, and aims to reduce exposure to drugs and criminal activity. The program targets individual, peer, family and neighborhood risk factors through case management services, after-school and summer activities, and increased police involvement. • Linking the Interests of Families and Teachers: a school-based intervention to prevent conduct problems including antisocial behavior, involvement with delinquent peers, and drug/alcohol use. Targets first and fifth graders and their families living in at-risk neighborhoods with high rates of juvenile delinquency. • Preventive Treatment Program: provides training for 7- to 9-year-old males and their parents to decrease delinquency, substance use, and gang involvement. Targets children from low socioeconomic families assessed as having high levels of disruptive behavior. • Project Northland: a long-term, 6-year community-wide intervention designed to reduce adolescent alcohol use. The intervention is multilevel, involving students, parents, peers, community members, and organizations. • Strong African American Families (SAAF) Program: a 7-week family-centered program for 10- to 14-year-olds designed to prevent alcohol use and abuse among rural African American youth and improve the parenting practices of their caregivers. • Communities That Care: a coalition-based community prevention program using a public health approach to prevent youth problem behaviors such as violence, delinquency, school dropout, and substance abuse.

2.5.5

Washington State Institute for Public Policy

In 1983 the State of Washington Legislature created the Washington State Institute for Public Policy (WSIPP). The mission of WSIPP (http://www.wsipp.wa.gov) is to conduct research to support nonpartisan decision making by the Legislature to answer specific policy questions. Two key areas of expertise of WSIPP are criminal justice and health, and outside experts are also brought in to assist with different topical areas under review. Many of the Institute’s research reports involve systematic reviews or meta-analyses of research evidence. A number of reports include benefit-cost analyses that inform legislative policy and funding decisions. WSIPP criteria for designating interventions as evidence-based are based on and similar to the Maryland Scientific Methods Scale previously described, but extends the Maryland scale to include downward adjustments in estimated effect sizes based on lower methodological rigor (WSIPP only includes studies at level three or higher in its reviews; see Aos, Miller, & Drake, 2006). They also note that the effect sizes can be adjusted for fidelity problems. Additional adjustments to effect sizes are made for studies with relatively short follow-up periods, or where the researcher was involved in the development and implementation of the intervention.

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The following reports related to substance abuse or treatment in the criminal justice system have been published by WSIPP and are available to the public on their website (http://www.wsipp.wa.gov): • Evidence-based Treatment of Alcohol, Drug, and Mental Health Disorders: Potential Benefits, Costs, and Fiscal Impacts for Washington State (2006). • Evidence-Based Public Policy Options to Reduce Crime and Criminal Justice Costs: Implications in Washington State (2009). • Washington’s Drug Offender Sentencing Alternative: An Evaluation of Benefits and Costs (2005). • Washington’s Drug Offender Sentencing Alternative: An Update on Recidivism Findings (2006). • Drug Offender Sentencing Alternative (DOSA): Treatment and Supervision (2003). • Washington State’s Drug Courts for Adult Defendants: Outcome Evaluation and Cost-Benefit Analysis (2003).

2.6

NIDA Principles of Effective Drug Treatment

The National Institute on Drug Abuse (NIDA) published two documents ( http://drugpubs.drugabuse.gov) that promulgate a set of principles for providing effective addiction treatment. A general guide, Principles of drug addiction treatment: A research based guide was first published in 1999 and a second edition published in 2009 (NIDA, 2009). A similar document was developed for criminal justice populations, called Principles of drug abuse treatment for criminal justice populations: A research based guide and was published in 2006 (NIDA, 2006). Both reports are based on a consensus review of research findings that did not draw upon a rigorous systematic review or meta-analysis; this review reflects more of a consensus-driven summary of best practices in addiction treatment. In fact, only two of the principles (use of cognitive behavioral therapy and medication-assisted treatment) emanate from multiple RCTs, the others are considered good clinical or consensus-based principles or practices. These reports have been broadly disseminated to the public, researchers, practitioners, and policymakers, and therefore have had substantial influence on the development of state and federal policies toward addiction treatment standards. They even reflect performance measures for the field of addiction treatment, even though many of the principles have not been empirically validated. NIDA (2009) identified 13 principles of effective addiction treatment: 1. Addiction is a complex but treatable disease that affects brain function and behavior. The effects of drugs on the brain continue long after drug use has stopped and account for relapse. 2. No single treatment is appropriate for everyone. Successful treatment outcomes require matching the intervention setting and services to an individual’s particular problems and needs.

2.6

NIDA Principles of Effective Drug Treatment

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3. Treatment needs to be readily available. Drug abusers should be linked to treatment as quickly as possible. 4. Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. Effective treatment addresses a client’s other health, social, legal, and mental health problems, and is appropriate to the client’s age, gender, ethnicity, and culture. 5. Remaining in treatment for an adequate period of time is critical. Although the optimal length of treatment is dependent on the nature of a person’s drug problems, a minimum of 90 days is needed to reduce or stop drug use. In general, the longer the length of treatment, the better the outcomes. Long-term recovery from drug addiction may require multiple treatment episodes over a long period of time. Treatment programs should incorporate interventions to keep clients in treatment. 6. Counseling – individual and/or group – and other behavioral therapies are the most commonly used forms of drug abuse treatment. Both individual and group counseling are needed to address various aspects of a client’s clinical needs, such as motivation to stop using drugs, building resistance and relapse prevention skills, improving personal relationships, or providing incentives to maintain abstinence. Participation in group counseling and peer support programs during and following treatment can help maintain abstinence. 7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. Medication-assisted treatments such as methadone and buprenorphine are effective in helping those addicted to heroin or other opioids. Naltrexone is also an effective medication for some opioid-addicted individuals and some patients with alcohol dependence. 8. An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs. Service needs may change over time and also include medical care, family therapy, parenting skills, vocational rehabilitation, or social and legal services. A continuing care approach indicates that treatment intensity and type should vary as a client’s needs change. 9. Many drug-addicted individuals also have other mental disorders. Drug abuse disorders commonly co-occur with mental health disorders, so clients should also be assessed for the latter. For clients with co-occurring substance abuse and mental health disorders, integrated treatment approaches that address both conditions are needed. 10. Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse. Detoxification by itself is not effective for achieving long-term abstinence from drug use. Following detoxification, clients should be encouraged, using incentives or motivational enhancement techniques, to engage in treatment. 11. Treatment does not need to be voluntary to be effective. Contrary to common assumptions, clients who are coerced into treatment by family, employers, or the criminal justice system can do well in treatment. Coerced treatment can increase treatment engagement and retention and improve outcomes.

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12. Drug use during treatment must be monitored continuously, as lapses during treatment do occur. Ongoing detection of relapse or changes in a client’s status can indicate a need to modify the treatment plan or increase the intensity or type of treatment. 13. Treatment programs should assess patients for the presence of HIV/ AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling to help patients modify or change behaviors that place them at risk of contracting or spreading infectious diseases. Many drug abusers also are at high risk for infectious diseases. Assessment and prevention counseling can help clients reduce behaviors that put them at risk for these diseases, help prevent infection of others, and help maintain abstinence from drug use. Counseling can also help those who are already infected to manage their illness. NIDA’s Principles identify several interventions as evidence-based. These include several pharmacotherapies or medication-assisted treatments for opiate or opioid dependence. Methadone maintenance treatment prevents opioid withdrawal, blocks the psychoactive effects of opioids, and decreases cravings. Methadone maintenance is most effective when combined with behavioral counseling and provision of medical, mental health, vocational, and family services as needed (McLellan, Arndt, Metzger, Woody, & O’Brien, 1993). Buprenorphine is a partial opiate agonist that reduces withdrawal symptoms without euphoria or sedative effects of heroin and other opioids. Since the Drug Addiction Treatment Act of 2000, physicians who have special accreditation can prescribe buprenorphine in their offices, for up to 100 patients. They must also be able to provide patient counseling or refer to counseling when indicated. Buprenorphine can be prescribed in its pure form (Subutex®), or more commonly in the form of Suboxone® (a combination of buprenorphine and the opioid antagonist naloxone). Suboxone® produces severe withdrawal symptoms when addicted individuals inject it to get high, lessening the likelihood of diversion. Office-based prescription of buprenorphine can be cost-effective and provide access to treatment for patients living in areas without community-based treatment options. Naltrexone is a long-acting synthetic opioid antagonist that blocks the euphoric effects of opioids, and is usually prescribed in outpatient medical settings or following detoxification. Naltrexone is not addictive and does not produce euphoric effects, but patient compliance can be difficult. It can be an effective treatment for highly motivated clients or those who are closely monitored such as probationers or parolees. Motivational incentives, such as contingent rewards, can improve treatment compliance and efficacy of naltrexone (Carroll et al., 2001; Preston et al., 1999). The NIDA Principles also recognize several behavioral interventions as effective. These include cognitive–behavioral therapy designed to reduce relapse by teaching drug abusers skills to increase self-control and coping skills, recognize risky situations and other relapse triggers, develop coping mechanisms and alternative behaviors, and “unlearn” maladaptive behavioral patterns (Carroll, 1998; Carroll & Onken, 2005). The Community Reinforcement Approach (CRA) Plus Vouchers

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intervention is an intensive 24-week outpatient therapy intervention (Higgins et al., 2003; Roozen et al., 2004). Twice weekly counseling sessions emphasize family relations, learning skills to minimize drug use, vocational counseling, and development of new recreational activities and social networks. Patients submit urine samples two or three times each week and receive vouchers for negative samples. Contingency Management Interventions and Motivational Incentives have been found to be effective in a number of studies (Budney, Moore, Rocha, & Higgins, 2006; Higgins, Wong, Badger, Haug-Ogden, & Dantona, 2000; Prendergast, Podus, Finney, Greenwell, & Roll, 2006). Treatment clients earn low-value incentives (e.g., cash, prizes, movie passes, coupons) in exchange for producing drug-free urine specimens. Contingency management models increase treatment retention and abstinence, although long-term posttreatment effects after the incentives are removed are less certain. Motivational Enhancement Therapy (MET) seeks to spur changes in clients to internally motivate them to stop using drugs and initiate treatment (Miller, Yahne, & Tonigan, 2003). MET includes an initial assessment session followed by 2–4 individual counseling sessions in which the therapist provides feedback on the assessment results and uses motivational interviewing techniques to build selfmotivation for change. In general, MET seems to be more effective for engaging drug abusers in treatment than for producing changes in drug use, and appears to have larger effects for marijuana- or alcohol-involved individuals (Marijuana Treatment Project Research Group, 2004). The Matrix Model targets stimulant abusers (e.g., methamphetamine and cocaine) to engage them in treatment (Rawson et al., 1995). Trained therapists guide the clients to understand addiction and relapse, and to attend 12-step groups and regularly monitor clients with urinalysis drug tests. Therapists are trained to conduct treatment sessions in a way that promotes the patient’s self-esteem, dignity, and self-worth. The model emphasizes a supportive and nonconfrontational role for the therapist in an effort to build client–counselor alliance. The Matrix Model also incorporates aspects of relapse prevention, family and group therapies, and drug education. Other components of the model include family groups, recovery skills groups, relapse prevention groups, and social support groups. Behavioral Couples Therapy (BCT) provides a therapeutic model for drug abusers and their partners, and is generally utilized as an addition to individual and group counseling (Fals-Stewart, O’Farrell, & Birchler, 2001). The model involves 12 weekly couple sessions, and incorporates an abstinence contract and behavioral principles to reinforce abstinence. Studies support BCT’s efficacy with drug-abusing men and women and their significant others, resulting in greater treatment attendance, higher abstinence rates and fewer drug-related, legal, and family problems at 1-year follow-up (Fals-Stewart & O’Farrell, 2003; Fals-Stewart, Klostermann, Yates, O’Farrell, & Birchler, 2005; Winters et al., 2002). Principles of drug abuse treatment for criminal justice populations: A research based guide. Recognizing that a substantial proportion of offenders have substance abuse disorders, and that the delivery of effective addiction treatment in the criminal justice system can be much more challenging than in standard community settings,

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NIDA developed a research-based monograph summarizing key principles for effective treatment in the CJS. Building on the original set of NIDA treatment principles, this guide is based on a review of the research literature and consensus from experts in addiction research and practice. Most of the principles reflect what the field considers to be evidence-based practice or principles rather than specific programs. As with NIDA’s general treatment principles, some of these criminal justice treatment principles have a substantial research base, as well as being derived from what is considered effective clinical practice, but others have not been rigorously tested empirically. Similar to NIDA’s general set of principles, there are 13 NIDA Principles for criminal justice populations; many overlaps occur between the two documents. For criminal justice populations, NIDA (2006) recommends the following (items marked with an * are different than the general NIDA treatment principles listed above): 1. Drug addiction is a brain disease that affects behavior. Drug abuse and addiction alter brain chemistry and anatomy and these changes can last for a long time following cessation of drug use. These brain alterations help explain why people continue to use drugs despite the negative consequences, and relapse is common even after periods of abstinence. 2. Recovery from drug addiction requires effective treatment, followed by management of the problem over time. For drug abuse treatment to be effective it must engage clients for a sufficient period of time, and multiple episodes of treatment may be required. Offenders in the community should be monitored for drug use and participation in treatment encouraged. 3. Treatment must last long enough to produce stable behavioral changes. This is especially true for offenders, who often have co-occurring mental health disorders and other social and health problems that can be addressed in long-term treatment. 4. Assessment is the first step in treatment. Offenders need a comprehensive assessment to determine the nature and extent of their drug problems, and identify other areas of need in order to set up an appropriate treatment plan. Assessments should include mental health evaluations with associated treatment planning. 5. *Tailoring services to fit the needs of the individual is an important part of effective drug abuse treatment for criminal justice populations. Effective treatment addresses a client’s other health, social, legal, and mental health problems, and is appropriate to the client’s age, gender, ethnicity, and culture. Drug treatment for offenders should address issues of motivation and building skills for resisting drug use and criminal behavior. 6. Drug use during treatment should be carefully monitored. Drug use should be monitored through urinalysis or other objective methods, as part of treatment or criminal justice supervision, to determine treatment progress and form the basis for rewards and sanctions to facilitate change, and modify treatment plans.

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7. *Treatment should target factors that are associated with criminal behavior. “Criminal thinking” includes attitudes and beliefs that support a criminal lifestyle and criminal behavior. Cognitive skills training to help individuals recognize errors in judgment that lead to drug abuse and criminal behavior may improve treatment outcomes. 8. *Criminal justice supervision should incorporate treatment planning for drug abusing offenders, and treatment providers should be aware of correctional supervision requirements. Offenders often have supervision and monitoring requirements that may conflict with treatment schedules. Thus ongoing coordination between treatment and criminal justice staff can encourage treatment participation and assure that correctional requirements are supported in treatment goals. Treatment and criminal justice staff should collaborate to evaluate each individual’s treatment plan to ensure that it meets correctional supervision requirements and other service needs, and facilitates transition from custody to community-based treatment and postrelease services. 9. *Continuity of care is essential for drug abusers re-entering the community. Treatment outcomes are improved when inmates access continuing care in the community following release from incarceration. Continuation of treatment in the community is needed to sustain a process of therapeutic change begun in prison treatment and facilitate successful reentry to the community and continued abstinence and reduced criminal behavior. 10. *A balance of rewards and sanctions encourages prosocial behavior and treatment participation. It is important to reinforce positive behavior for offenders in treatment. Nonmonetary “social reinforcers” such as recognition for progress or sincere effort can be effective, as can graduated sanctions that are consistent, predictable, and provide clear responses to noncompliant behavior. Graduated sanctions use lower-level sanctions for initial and less serious noncompliance, with increasingly severe sanctions for repeated problem behavior. It is important that offenders perceive rewards and sanctions as being fair, proportionate to the behavior, and clearly linked to the behavior. 11. *Offenders with co-occurring drug abuse and mental health problems often require an integrated treatment approach. The high proportion of co-occurring mental health disorders among offenders suggests the need for an integrated approach that combines drug abuse treatment with psychiatric treatment, including the use of medication. Personality, cognitive, and other serious mental disorders can be difficult to treat and may disrupt drug treatment. 12. Medications are an important part of treatment for many drug abusing offenders. Medications such as methadone and buprenorphine for opioid addiction are evidence-based treatments and should be made available to offenders where appropriate, including those with co-occurring mental health problems. Behavioral strategies can increase adherence to medication assisted treatment. 13. Treatment planning for drug abusing offenders who are living in or re-entering the community should include strategies to prevent and treat serious, chronic medical conditions, such as HIV/AIDS, hepatitis B and C, and tuberculosis.

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The rates of infectious diseases, including HIV/AIDS, hepatitis, and tuberculosis, are substantially higher among drug-involved inmates and offenders under community supervision than in the general population. Drug-involved offenders should be offered testing for infectious diseases and receive prevention counseling on strategies to reduce their risk behaviors. Probation and parole officers who monitor offenders with serious medical conditions should link them with appropriate health care services, encourage compliance with medical treatment, and re-establish their eligibility for public health services (e.g., Medicaid, county health departments) before release from prison or jail. As indicated earlier, the above principles represent a combination of researchbased evidence, guidelines for good clinical practice, and consensus opinions. Evidence-based interventions such as contingency management and medicationassisted treatment are incorporated in this set of principles, although sufficient research has not occurred in justice settings to assess the transportability of the treatments. These principles also recognize the unique treatment and service needs of offender populations, who present with criminogenic risk factors, high rates of co-occurring mental health disorders and infectious diseases, and the challenges of reentry into the community following incarceration.

2.7

Defining “What Works” in Community Corrections

For the past two decades the National Institute of Corrections (NIC) has been active in translating the research literature for the community corrections field and promoting EBP for community supervision (NIC, 2004). NIC developed a strategic approach to advance practice and learn about these implementation issues through a community corrections initiative that focuses on the sustainability of planned change and resource investment at the policy, procedural, and operational levels in several jurisdictions (NIC, 2004). The NIC model focuses on programs, organizational development, and collaborations with other organizations, and is analyzed and summarized in Chap. 6. In a cooperative agreement with the Crime and Justice Institute (CJI), a technical assistance and research organization, NIC began an initiative in 2002 to advance the use of evidence-based practices in select community corrections agencies. This initiative was modeled after previous efforts in the state of Maryland, referred to as Proactive Community Supervision (see Taxman, Shepardson, & Byrne, 2004; Taxman, 2008). The first of these activities involved the development of materials to help the field understand the components of EBPs. In a 2004 report, NIC outlined the basic principles of evidence-based practices that were drawn from the existing literature on correctional principles (largely the work of Andrews and Bonta, 1998), metaanalyses of correctional interventions, and consensus from the field. These principles emanated from a consensus panel consisting of one academic and several practitioners in the field. These principles (see Box 2.3) are considered to be effective for reducing offender risk and recidivism.

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Box 2.3 Eight evidence-based principles for effective interventions 1. Assess actuarial risk/needs using a standardized instrument(s). 2. Enhance intrinsic motivation. 3. Target interventions. (a) Risk Principle: Prioritize supervision and treatment resources for higher risk offenders. (b) Need Principle: Target interventions to criminogenic needs. (c) Responsivity Principle: Be responsive to temperament, learning style, motivation, culture, and gender when assigning programs. (d) Dosage: Structure 40–70% of high-risk offenders’ time for 3–9 months. (e) Treatment: Integrate treatment into the full sentence/sanction requirements. 4. Skill train with directed practice (use Cognitive Behavioral treatment methods). 5. Increase positive reinforcement. 6. Engage ongoing support in natural communities. 7. Measure relevant processes/practices. 8. Provide measurement feedback. Source: Crime and Justice Institute (2009)

For each of these principles, NIC has outlined procedures and detailed practices needed for implementation (Crime and Justice Institute, 2009). These recommendations recognize the difficulty and complexity of changing staff and agency culture and practice, and the multiple levels at which change may be needed. These include the case (or offender) level, agency level (including staff and agency leadership), and system (policymakers, funders, other agencies). NIC proposes seven guidelines for implementing effective interventions in community corrections settings: 1. Limit new projects to mission-related initiatives. 2. Assess progress of implementation processes using quantifiable data. 3. Acknowledge and accommodate professional over-rides with adequate accountability.

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4. Focus on staff development, including awareness of research, skill development, and management of behavioral and organizational change processes, within the context of a complete training or human resource development program. 5. Routinely measure staff practices (attitudes, knowledge, and skills) that are considered related to outcomes. 6. Provide staff with timely, relevant, and accurate feedback regarding performance related to outcomes. 7. Utilize high levels of data-driven advocacy and brokerage to enable appropriate community services (Crime and Justice Institute, 2004:14). NIC also recognizes that simply disseminating information of evidence-based principles of community correctional supervision is insufficient for achieving meaningful changes in supervision and management practices (Crime and Justice Institute, 2004). Accordingly, NIC published documents about the need for organizational change and development in correctional agencies and the importance of collaboration across agencies and systems, as described in more detail in Chap. 6. In addition, NIC built a technical assistance program, focused on disseminating information about EBPs and guidance on how to implement EBPs. Intensive efforts were devoted to four community corrections agencies to educate and train agencies about these EB principles and practices (see Chap. 6 for more details). Although useful for framing the importance (as well as difficulty) of implementing evidence-based practices and principles, the eight NIC principles have somewhat limited benefits for improving delivery of addiction treatment for offenders under community supervision. First, no specific interventions to change offender behavior are proposed. For example, the common acceptance of the EBP cognitive behavioral therapy or contingency management is not endorsed. Second, the evidence-based principles represent a combination of consensus-driven factors that have not been rigorously tested; the list also represents complex ideas that may not be appropriate for all offenders in all settings, and includes relatively vague constructs. Thus, operationalizing these principles requires an innate understanding of the research literature in order to translate the broad concepts into operational practice. This could be a complex, lengthy, and difficult process that is likely to result in inconsistent and ineffective implementation without extensive technical assistance, monitoring, and coaching. It is not clear how these principles may interact with each other in real settings, what is the optimal timing for implementation, or which of the principles are most important to improve outcomes for offenders. For example, how and when should positive reinforcement be given to offenders in the context of cognitive behavioral treatment? This is a question that does not have a research basis, as of yet.

2.8

2.8

Standards of Evidence in Community Corrections and Addiction Treatment

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Standards of Evidence in Community Corrections and Addiction Treatment

A challenge for the community corrections field (and perhaps the criminal justice system in general) is to balance the need for rigorous scientific evidence and fidelity to the intervention with the need to incorporate real-world clinical experience. This includes modifying an intervention once it is implemented in real-world criminal justice settings. In addition, unlike carefully controlled research settings, treatment participants under community corrections supervision may self-select or be mandated into treatment that may or may not be appropriate for their type or severity of drug abuse problem. This complicates and may undermine the delivery of effective treatment. The targeting of offender needs with appropriate services is a major issue. As discussed earlier, the challenges of summarizing evidence and determining what interventions should be identified as “evidence-based” include: (1) quality of research design; (2) internal and external validity; (3) publication bias; (4) generalizability from research in controlled settings to implementation in community settings; (5) differences between statistical significance and clinical significance; (6) organizational issues; and (7) economic issues. A more thorough discussion of these issues is provided in Chap. 8. It can be difficult to implement RCTs in criminal justice settings, and such designs are associated with a potential lack of external validity (generalizability) because the conditions to conduct the RCT need to be so carefully controlled that they may not reflect real-world conditions for delivering the intervention. Because of these challenges, there are relatively few treatments that have been designated EBPs based on multiple RCTs. National review efforts such as the Campbell Collaboration and NREPP have helped to fill the void by providing a process for conducting such efforts, including systematic reviews. But the knowledge development process is different than the knowledge utilization process. It is in the utilization process where TT becomes very important, and where researchers and practitioners can and should merge their efforts. The components of EBP have been defined and will continue to be defined based on research. But the translation of these laboratory-based EBPs into action involves utilization of a different scientific process (implementation science) that is also laden with rigor and methodological steps (Fixsen et al., 2005). These processes must be more dynamic in that: (1) there is a need to make decisions quickly; (2) public safety concerns exist; (3) decisions about jail or prison overcrowding must be made; (4) agencies must respond to court orders to provide treatment; (5) treatment resources are limited, especially for intensive or long-term treatment; or (6) civil rights or due process concerns exist. Under these conditions, it may be possible to develop less rigorous review criteria and procedures, provided that these procedures are transparent, systematic, and objective. Of course, it is important to guard against the dangers of implementing quick fixes that circumvent a systematic TT process; the latter is much more likely to lead to more effective and sustainable changes in organizational and staff culture, attitudes, and performance.

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Accordingly, a key challenge for identifying EBPs that are salient for the field and community corrections populations and can be realistically implemented with fidelity and sustainability is maintaining scientific rigor while recognizing the real need to implement new programs and practices with relatively little lead time. To do this successfully requires that: (1) systems, organizations, and staff have the foundation and knowledge development in place; and (2) agencies are positioned and their staff trained to conduct evidence-based assessment, performance monitoring, regular program adjustments and outcomes monitoring, and collection of appropriate outcome information. Researchers, for their part, have to learn to focus on what is important for practitioners and policymakers. These and related issues are discussed in depth in Chap. 8. Another challenge for defining, identifying, and disseminating EBP for the field is encouraging professionalism that is respectful of research and data. National practitioner associations and corrections training academies should include basic training on understanding research and scientific principles (part of improving organizational readiness to change) and training on substance abuse and treatment as part of standard curricula. Organizational leaders and staff need to accept the idea of program evaluation as a key part of improving outcomes. Improvements are also needed in dissemination and utilization of research findings. A challenge is to overcome skepticism among practitioners and policymakers about research. In part this skepticism reflects that researchers do not always provide information that is useful and digestible, and because research evolves and is couched in equivocal terms. This places an onus on researchers to prepare user-friendly documents that summarize research findings in more user-friendly ways.

2.9

Conclusions

In this chapter we have highlighted the various processes to identify evidence-based practices. This primarily focuses on the study methods and quality, and the consistency of the findings. The specific intervention or practice needs of the field are usually secondary to the general selection process for EBPs, although NREPP does consider the readiness for dissemination in its rating process. The Research to Practice Dilemma. Although achieving the gold standard of rigor in EBP review is important for maintaining necessary scientific rigor and assuring validity, there is a price to pay. The higher one moves on the scale of scientific rigor, the more time consuming and expensive the research, and the more narrowly defined the target population. In addition, implementation (e.g., training costs, fidelity monitoring) may be more costly, thus affecting transportability to real-world settings. Rigorous RCTs are important but these limits are the reason why there may be a need for other types of evidence to be included in the systematic review processes. Although there may be pressures for less rigorous criteria for determining the evidence base because of political or operational pressures to implement new programs quickly, a danger exists because the resulting program may not

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generate positive findings across multiple settings. Such adapted interventions may lack internal validity (i.e., credibility of the findings within the study sample), sustainability, and effectiveness once implemented in multiple settings. No matter what the evidence base, implementation of an ineffective substance abuse treatment also carries with it serious implications for cost, public safety, and increasing negative attitudes toward treatment by corrections personnel. EBP designated through systematic reviews and EBP repositories may require a tightly administered protocol, but implementation in the real world may require clinical adaptation by practitioners. Realistically, even where rigorous scientific evidence has determined that an intervention is evidence-based and effective, the intervention is frequently altered when implemented in nonresearch, real-world settings. The resulting intervention is generally a product of a number of external, system, organizational, and staff factors that come into play to determine whether the research-based intervention will actually be implemented in the appropriate setting and with the appropriate population. Although it is important that clinical and other staff must view the EBP as acceptable and feasible in the first part of implementation, attention also needs to be given to how the EBP is adopted, implemented with fidelity, and sustained. Economic factors are also important: an EBP that requires expensive training, fidelity monitoring, or highly paid staff may not be sustainable, given the pressure for low-cost alternatives and the dearth of support for treatment. The intervention effect may vary by client characteristics, setting, or risk level, so if the EBP is delivered to the wrong population or in the wrong context it may no longer yield positive findings. Implementation Issues are Important. The designation of an intervention, program, or practice as evidence-based is the first step. But, the transfer from evidence to practice, the technology transfer process, requires effective implementation of an effective intervention, encompassing both EBP and a systematic implementation process. Without both the EBP intervention and a systematic implementation process, positive client outcomes are unlikely to be achieved. Ineffective programs can be implemented well, and effective programs can be implemented poorly (Fixsen et al., 2005). Positive client outcomes are achieved only when both the intervention and implementation practices are effective. The question to be addressed is how to improve implementation effectiveness. Organizational and implementation research suggests that identifying evidencebased practices and programs that yield positive client outcomes is only the first stage in improving health services for drug-involved offenders. If addiction treatment is to have positive effects on client outcomes, an effective intervention is necessary but not sufficient; the intervention also has to be implemented well and with fidelity (Fixsen et al., 2005). Evidence-based interventions are slow to be disseminated (Kilbourne, Neumann, Pincus, Bauer, & Stall, 2007), and are often poorly implemented (Bourgon & Armstrong, 2005) or difficult to sustain (Brown & Flynn, 2002; Miller, Sorensen, Selzer, & Brigham, 2006). There are particular challenges in introducing evidence-based practices and programs into criminal justice agencies (Farabee et al., 1999; Linhorst, Knight, Johnston, Trickey, 2001), given that federal government research funding is limited and few government agencies assist with

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helping the field integrate research into practice. Significant system barriers relate to cyclic funding, vacillating support for offender programs, and a focus on security and punishment, not treatment. Current implementation practice in criminal justice drug treatment hinders effective implementation: target populations are inappropriate; staff evaluations are not performance-based; organizational accountability for outcomes is nonexistent; there is high staff turnover; resources for implementation activities are lacking; and few incentives are provided to enhance program effectiveness (Taxman & Bouffard, 2000, 2002; Welsh & Harris, 2008). TT and implementation are challenging and complex processes, requiring a guiding conceptual framework and sustained and empirically supported approach to achieve successful results. It is important to identify the core influences on and specific components of implementation, to understand how the implementation process affects movement of evidence-based practices and programs toward sustainability, and to study how implementation interventions can improve the implementation process and outcomes. In Chap. 9, we provide such a TT framework that considers the unique challenges of community corrections and addiction treatment agencies. Preparing the Field to Implement. Another important lesson from implementation and organizational change research is that traditional dissemination, training, and implementation strategies (e.g., one-time training, dissemination of information only, implementation without changing staff roles, no assessment of organizational readiness) are often ineffective. In a meta-analysis of effects of different training levels on implementation, training demonstration alone produced skills acquisition in only 20% of teachers, practice and feedback techniques increased skills acquisition to 60% but resulted in little classroom use (Joyce & Showers, 2002). Only with the addition of on-site coaching were practices actually implemented in the classroom (95% using the practice). Thus, multistage training components which include coaching and consultation in the practice setting increase the likelihood of proper implementation of evidence-based practices and programs and thus more effective TT. A recent meta-analyses of training found that effective strategies should have three phases: (1) knowledge dissemination; (2) mapping to the business process; and (3) strategic implementation (Burke & Hutchins, 2007). A deeper discussion on these factors will be presented in Chap. 4.

References Andrews, D. A., & Bonta, J. (1998). The psychology of criminal conduct (2nd ed.). Cincinnati: Anderson. Aos, S., Miller, M., & Drake, E. (2006). Evidence-based public policy options to reduce future prison construction, criminal justice costs, and crime rates. Olympia: Washington State Institute for Public Policy. Belenko, S., Fabrikant, N., & Wolff, N. (2011). The long road to treatment: Models of screening and admission into drug courts. Criminal Justice and Behavior, 38, 27–48. Berk, R. (2005). Randomized experiments as the bronze standard. Journal of Experimental Criminology, 1, 417–433.

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Grimshaw, J., Eccles, M., & Tetroe, J. (2004). Implementing clinical guidelines: Current evidence and future implications. Journal of Continuing Education in the Health Professions, 24(Suppl 1), S31–S37. Higgins, S. T., Sigmon, S., Wong, C. J., Heil, S. H., Badger, G. J., Donham, R., et al. (2003). Community reinforcement therapy for cocaine-dependent outpatients. Archives of General Psychiatry, 60, 1043–1052. Higgins, S. T., Wong, C. J., Badger, G. J., Haug-Ogden, D. E., & Dantona, R. L. (2000). Contingent reinforcement increases cocaine abstinence during outpatient treatment and one-year followup. Journal of Consulting and Clinical Psychology, 68, 64–72. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington: National Academy Press. Joyce, B., & Showers, B. (2002). Student achievement through staff development (3rd ed.). Alexandria: Association for Supervision and Curriculum Development. Kilbourne, A. M., Neumann, M. S., Pincus, H. A., Bauer, M. S., & Stall, R. (2007). Implementing evidence-based interventions in health care: Application of the replicating effective programs framework. Implementation Science, 2, 42. Linhorst, D. M., Knight, K., Johnston, J. S., & Trickey, Myrna. (2001). Situational influences on the implementation of a prison-based therapeutic community. Prison Journal, 81(4), 436–453. Lipsey, M. W., & Wilson, D. B. (1993). The efficacy of psychological, educational, and behavioral treatment: Confirmation from meta-analysis. American Psychologist, 48, 1181–1209. Manski, C. F. (2011). Diversified policy choice with partial knowledge of policy effectiveness. Journal of Experimental Criminology, 7, 111–125. Marijuana Treatment Project Research Group. (2004). Brief treatments for cannabis dependence: Findings from a randomized multisite trial. Journal of Consulting and Clinical Psychology, 72, 455–466. McLellan, A. T., Arndt, I. O., Metzger, D., Woody, G. E., & O’Brien, C. P. (1993). The effects of psychosocial services in substance abuse treatment. Journal of the American Medical Association, 269(15), 1953–1959. McKay, J. R. (2001). Effectiveness of continuing care interventions for substance abusers: Implications for the study of long-term treatment effects. Evaluation Review, 25, 211–232. Mihalic, S., Irwin, K., Elliott, D., Fagan, A., & Hansen, D. (2001). Blueprints for violence prevention. Washington: U.S. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention. Miller, W. R., Sorensen, J. L., Selzer, J. A., & Brigham, G. S. (2006). Disseminating evidencebased practices in substance abuse treatment: A review with suggestions. Journal of Substance Abuse Treatment, 31, 25–39. Miller, W. R., Yahne, C. E., & Tonigan, J. S. (2003). Motivational interviewing in drug abuse services: A randomized trial. Journal of Consulting and Clinical Psychology, 71, 754–763. Mowatt, G., Grimshaw, J. M., Davis, D. A., & Mazmanian, P. E. (2001). Getting evidence into practice: the work of the Cochrane Effective Practice and Organization of care Group (EPOC). Journal of Continuing Education in the Health Professions, 21, 55–60. National Advisory Mental Health Council. (2006). The road ahead: Research partnerships to transform services. Bethesda: National Institutes of Health, National Institute of Mental Health. National Institute of Corrections. (2004). Implementing evidence-based practice in community corrections: The principles of effective intervention. Washington: National Institute of Corrections. National Institute on Drug Abuse. (2006). Principles of drug abuse treatment for criminal justice populations: A research based guide. NIH Publication No. 06–5316. Bethesda: National Institutes of Health, National Institute on Drug Abuse. National Institute on Drug Abuse. (2009). Principles of drug addiction treatment: A research based guide, second edition. NIH Publication No. 09–4180. Bethesda: National Institutes of Health, National Institute on Drug Abuse. National Institutes of Health (2004). State implementation of evidence-based practices: Bridging science and service. NIMH and SAMHSA RFA MH-03-007. Washington: National Institutes of Health.

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Taxman, F. S., & Thanner, M. (2006). Risk, need, & responsivity: It all depends. Crime and Delinquency, 52, 28–52. Tucker, J., & Roth, D. (2006). Extending the evidence hierarchy to enhance evidence based practice for substance use disorders. Addiction, 101, 918–932. Weisburd, D., Lum, C. M., & Yang, S. M. (2003). When can we conclude that treatments or programs “don’t work”? Annals of the American Academy of Political and Social Science, 587, 31–48. Weisburd, D., & Taxman, F. S. (2000). Developing a multi-center randomized trial in criminology: The case of HIDTA. Journal of Quantitative Criminology, 16(3), 315–339. Welsh, W. N., & Harris, P. W. (2008). Criminal justice policy and planning (3rd ed.). Cincinnati: LexisNexis, Anderson. Wilson, D. B., Mitchell, O., & MacKenzie, D. L. (2006). A systematic review of drug court effects on recidivism. Journal of Experimental Criminology, 2, 459–487. Winters, J., Fals-Stewart, W., O’Farrell, T. J., Birchler, G. R., & Kelley, M. L. (2002). Behavioral couples therapy for female substance-abusing patients: Effects on substance use and relationship adjustment. Journal of Consulting and Clinical Psychology, 70, 344–355. Wright, B. J., Zhang, S. X., & Farabee, D. (2010). A squandered opportunity? A review of SAMHSA’S national registry of evidence-based programs and practices for offenders. Crime and Delinquency. Published online. DOI: 10.1177/0011128710376302.

Chapter 3

Theories of Organizational Change and Technology Transfer

3.1

The Implementation Quandary

It seems so easy. A new idea for addiction treatment within a correctional setting – Marked Success ― is developed. The researchers, correctional partners, and maybe even a few clinicians create the Marked Success program, develop manuals and tools, and then test it out in one probation office. The offenders that went through the Marked Success program do exceptionally well. Nearly 85% complete probation at record rates and one year later they are still crime- and drug-free. Everyone is amazed. The researchers are successful in getting a federal grant to conduct a randomized controlled trial to determine whether Marked Success improves outcomes compared to existing substance abuse treatment programs. The experiment occurs in four probation offices with over 1,000 offenders. Once again it produced fewer arrests and higher treatment completion rates. A few other experiments are conducted testing the efficacy of Marked Success, using different researchers and applying the program in different probation offices. There are even follow-up studies to track the progress over five years. The Marked Success program continues to outshine other programs in terms of reductions in drug use and new arrests. A systematic review is conducted of the various interventions and the review confirms that the Marked Success probation program reduces recidivism and drug use. The Campbell Collaboration and the Cochrane Collaboration both report the results of a systematic review, and it is published in the Journal of Experimental Criminology. The highest levels of science have anointed the Marked Success program as an evidence-based treatment. From the scientific perspective, Marked Success should be rapidly disseminated and every probation agency should be preparing for its implementation. And yet, 10 years later, only a handful of probation offices have implemented Marked Success. Few probation offices have received dedicated funding for the program. Instead, researchers and probation agencies are continuing to search for the Holy Grail – the perfect substance abuse treatment for helping probationers through the process of becoming crime- and drug-free.

F.S. Taxman and S. Belenko, Implementing Evidence-Based Practices in Community Corrections and Addiction Treatment, Springer Series on Evidence-Based Crime Policy, DOI 10.1007/978-1-4614-0412-5_3, © Springer Science+Business Media, LLC 2012

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What went wrong? Why is Marked Success not widely implemented? The science is clear. This is a program that will address the various problems of probationers. And, yet there is little traction in the correctional field to implement this evidencebased treatment. This is an unambiguous case where there is general consensus among scientists, and even the gold-star rating from a systematic review indicating that the program is effective. Of course, there are numerous other examples of treatments or practices with positive scientific findings, with maybe a bit of disagreement regarding the clarity of the finding (i.e., a few studies found positive findings, a few did not, and therefore the science is less well-defined). A lot of speculation can occur, but the disconnect between science and practice can be defined in part as faulty utilization strategies. That is, the efforts to market this evidence-based treatment to the field have not included a sound strategy to transfer the knowledge or to import the technology of the program. It was assumed that positive research findings would automatically generate interest in the practice, and that interest would mushroom into adoption and implementation of the innovation throughout the country. Technology Transfer (TT) is essentially the process of taking science-based findings and moving the studied practice or program into general operations. The Institute of Medicine (Lamb, Greenlick, & McCarty, 1998), in their seminal report, Bridging the Gap between Practice and Research, highlighted the need for a sound TT process that focused on two paths from research findings to clinical practice and from research findings to policy. This report outlined the traditional barriers and challenges to the process and made recommendations for overcoming them. That is, it recognized that research findings are only as relevant as their utilization by policymakers, clinicians, and practitioners, and that dedicated efforts should be devoted to utilization-focused research (Patton, 1996) where the emphasis is on partnerships among vested audiences, such as researchers, agencies, and staff/practitioners. The research should be designed and developed so that it will be useful for advancing adoption and implementation after the studies are completed. Technology Transfer has generally been an aim of several federal government agencies such as the Center for Substance Abuse Treatment (U.S. Department of Health and Human Services), the Bureau of Justice Assistance (U.S. Department of Justice), and the National Institute of Corrections (Bureau of Prisons, U.S. Department of Justice). Brown and Flynn (2002) note that the efforts of the federal government have primarily been devoted to knowledge dissemination through print media and information whereas there is a greater need to assist organizations in knowledge utilization. Federal agencies have a specific mission to package the information about innovations or the “novel set of behaviors, routines and ways of working that are directed at improving outcomes, administrative efficiency, cost effectiveness or user’s experience” (Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004) and to provide technical assistance to willing agencies (upon request by the agency). The technical assistance is generally limited to: (1) describing the program; (2) sharing any curricula, manuals, or information about the intervention; and (3) working with a select group of individuals in an agency to ensure their understanding of the actual components of the program. This is generally referred to as knowledge dissemination – the planned and active

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sharing of information to increase an understanding of the core components of the program. Recent attention to TT models has increased when it was realized that the mere presence of knowledge (research) does not guarantee that it will be used. This problem is not just confined to correctional agencies; it affects any organization where an innovation or refined idea is being introduced (Damschroder, Aron, Keith, Kirsch, Alexander, & Lowery, 2009; Fixsen, Naoom, Blase, Friedman, & Wallace, 2005; Greenhalgh et al., 2004). The failure to implement new ideas is a long standing problem, and it generally relates to how the idea is introduced, processed, redefined, and produced that will determine the likelihood that it will be adopted by an agency. That is, being aware of successful programs may be insufficient to help the organization digest and process how to integrate the program into their core practices. Organizations often are unaware of what they should stop doing in order to create capacity for new practices. The issue is one of knowledge utilization, or the organizational processes that assist in transferring the new idea (disseminated knowledge) into practice. These organizational processes are defined by or constrained by the capacity of the organization to change, innovate, or import new ideas. The utilizationrelated processes are those that involve the nuts and bolts of the organization. In fact, researchers have identified how knowledge utilization can be characterized hierarchically as diffusion (passive spread), dissemination (active and planned efforts to persuade a target group to adopt an innovation), implementation (active and planned efforts to mainstream an innovation), and sustainability or the routinization of an idea (Greenhalgh et al., 2004). Thus, there are differences among idea sharing, adoption, implementation, and sustainability, and different TT processes are used in these efforts. A good TT model considers the compatibility of Marked Success or any other evidence-based practice or treatment program with the basic mission and goals of an organization, and then develops a plan to alter, even slightly, the business model to accommodate the new idea or program. This chapter provides an overall summary of existing theories of dissemination and implementation, and lays a foundation for future chapters about various strategies and challenges of TT. Probably the best way of conceptualizing the TT model is that it requires taking an evidence-based practice or program and transferring it into an expanded innovation. This includes the nature of the innovation, the external agencies (outer setting) and its impact on the innovation, and the organization itself (e.g., inner setting including staff, culture, leadership).

3.2

Understanding Organizational Approaches: Three Different Models

Organizational behavior is a field of study that cuts across many disciplines including psychology, social psychology, sociology, political science, management, marketing, and business. The interdisciplinary nature reflects the concept that the behavior of the organization is scrutinized, analyzed, and assessed as part of the study. Each

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discipline brings a slightly different focus and topics to the line of inquiry, The emphasis on an organizational approach fosters insight into the concept that there is a need to consider both the internal workings of an organization and the external stakeholders who serve to facilitate knowledge utilization. Organizational theories generally fall into three main categories. The rational system theories emphasize organizations as collectives that pursue specific goals reflected by the social structures of the organization. Activities within the organization are congruent to the specified goals, since the goals drive decisions and provide the rationale for those decisions. Given this perspective, the rational system in the organization responds to achieve these stated goals, and the internal processes reflect such end goals. In many ways the rational system approach focuses the goals of efficiency and productivity by altering the work processes and social structure to most effectively support accomplishment of the end goal. This reflects the spirit of Franklin Taylor’s scientific management approach (Taylor, 1911) where his focus on process improvements (how the end product is created through the process) is intended to maximize outputs or goals. The next major organizational theory, natural systems, recognizes that an organization may have multiple, often conflicting goals. The organization is structured to achieve these different goals. The internal workings of the organization, which generally refers to formal organizational structures and informal networks within an organization, impact which goals are achieved at any given time. The goals that are pursued can vary widely. The goals that are ultimately achieved by the organization evolve from natural systems that define the priorities on which players within the system focus their energies. Instead of being driven by formal stated goals, the internal workings and demands from the environment often define the outputs. The final theoretical foundation, open systems, recognizes that the organization is influenced by internal workings (natural systems) and external factors that influence decisions made by the organization. The internal and external stakeholders have a broader set of influences on the priority of goals and how the work processes are affected by these priorities. The external forces range considerably to include direct players such as those who fund an organization, those who provide political or social support, and those who are involved in similar processes or structure. Or external forces can be the larger constituency such as citizens, other agencies, or political systems. In contemporary implementation research literature, these are generally referred to as inner and outer settings (Damschroder et al., 2009; Greenhalgh et al., 2004). The importance of the theoretical framework is that it underscores the need to examine an organization from a multilayered approach, with attention to internal and external factors that may affect or influence how the organization behaves, how the organization makes decisions, and how products (outputs) are generated. Rational, natural, and open systems provide theoretical frameworks for the issues surrounding the different types of TT that will facilitate the adoption or implementation of innovations. TT relates to decisions by organizations to adopt, implement, and routinize practices that are considered novel or foreign to existing processes,

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particularly those that are designed to improve outcomes, efficiencies, or costs. Implementation of a new technology (innovation) affects the goals, processes, outputs, or outcomes related to the innovation and existing practices. The analytical framework considers the internal and external social structures, both formal and informal, as they relate to the acceptance of the innovation or “technology.” The strategy is to impart a new idea or a modification of an existing concept into the organization. As previously stated, the first part is the dissemination process to assist the organization in understanding the new idea or innovation. The transfer is the process of helping the organization through various other steps as outlined in a recent systematic review (Burke & Hutchins, 2007). Effective implementation should address three key components: (1) declarative knowledge (the facts); (2) procedural knowledge (the how to use); and (3) strategic knowledge (the when to use). TT models need to guide organizations through the initial stage of recognizing an idea before it is possible for the organization to respond to the idea. But “responding” requires attention to the inputs, processes, outputs, and outcomes that require analyses of how each component influences others. The underlying social structure of the organization can influence the inputs, processes, and outputs in how the final goal(s) can be achieved. TT should enable the organization to use the new innovation or technology for the purpose of improving outcomes or the better achievement of desired goals.

3.2.1

Diffusion Models

Any discussion of TT models must begin with the work of Everett Rogers and his treatise on diffusion. The Diffusion of Innovations (Rogers, 1995, 2003) recognizes that ideas must be marketed within an organization, and that the organization must make deliberative decisions about the validity of the idea for the organization. This rational systems approach acknowledges that diffusion occurs within an organization and that the value of an idea (innovation) is seeded in whether the organization finds it compatible with its goals, processes, and values. Rogers’ work was one of the first to recognize and identify the processes that underscore diffusion. As noted by Greenhalgh et al. (2004), diffusion is an informal process of transferring information within the organizational context whereas dissemination is the process of planned efforts to explore and examine the value of an idea (innovation). Rogers’ conceptualization of diffusion – the transfer of the knowledge into the environment – provided a framework to consider how to design dissemination processes. Rogers recognized that the diffusion must engage the goals of the organization, address internal communication channels, and be timely. The major contributions of his work are to recognize that knowledge awareness and utilization are distinct entities, and that there are different organizational processes that affect various phases of the process. Rogers’ insight into the social structure as a factor in the change process serves to move away from the declarative knowledge to the procedural and strategic

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knowledge that Burke & Hutchins (2007) identified in their systematic review. The following is a synopsis of Rogers’ work.

3.2.2

The Conceptual Model

The diffusion model is defined as “the process by which an innovation is communicated through certain channels over time among the members of a social system” (Rogers, 2003). This model recognizes that there are four different components: (1) the nature of the innovation; (2) the mechanism for communication; (3) the timing of the change process; and (4) the social structure, both informal and formal, that are part of a change strategy. Each requires its own set of actions, as well as activities that address the combined efforts. Type of Innovation. Not all innovations are alike. In fact the term “innovation” is a bit confusing since the concept refers to new ideas, but new ideas can range from minor deviations from everyday practice to totally new practices. Consider, for example, intake procedures in correctional agencies. Every correctional agency has an intake procedure which initiates a person (with a file) in the system (generally referred to as the period of correctional control). The correctional agency wants to alter the intake procedure to include a revised intake instrument or an actuarial risk tool. This would involve a new intake form and new procedures for the staff to use. Most would consider this a small adjustment to an already existing practice. However, under the Rogers’ model, the fact that this is a modest change in the process is recognized for its complexity – introducing something new in an existing environment. That is, the innovation should not be judged only by the content but rather by what it represents or introduces to the system: a change in procedures or practices. In the example of the intake process where an actuarial risk tool is being introduced (see Box 3.1 below), the new tool requires the staff to: (1) change from a paper instrument; (2) become acquainted and familiar with the new form; (3) gather information from various sources to complete the risk instrument; and (4) use the information in new ways. Each appears to be minor, but together they require multiple alterations in process and practice. The staff is also being asked to use different skills than are typically needed.

Box 3.1 Exploring the Use of Risk Tools in Correctional Agencies One evidence-based practice in the correctional field is the actuarial-based risk tool used to predict the likelihood of further criminal behavior. An actuarial risk tool identifies static risk factors that predict outcomes. The number of factors varies depending on the instrument, but the minimum is generally five. The most common are: age of first arrest, number of prior arrests, number of incarcerations, number of revocations from probation/ (continued)

3.2 Understanding Organizational Approaches: Three Different Models

Box 3.1 (continued) parole, number of escapes, and misconduct in prison. The risk score is used to identify the degree of control that is needed to alter the likelihood of recidivism. Peter Hoffman developed the salient factor scale for federal parole agencies in the 1970s as a means of allocating resources within the federal parole system (Hoffman & Beck, 1976); the model allowed for high-risk offenders to be supervised more frequently than low-risk offenders. A recent survey of correctional agencies found that fewer than 30% use an actuarial risk tool (Taxman, Perdoni, & Harrison, 2007), even though 30 years have passed since the concept was developed. We can examine Rogers’ concerns about adoption in this example: • What is the relative advantage of the new innovation compared to existing practice? The tool summarizes information collected during the traditional intake process of any correctional agency but requires a staff member to tally a score. • How compatible is the new innovation to the existing business process, organizational values, past experiences, and overall needs of the adopters? The actuarial risk tool requires the use of a form but it should be compatible with the intake process if the customary process collects information on criminal history. • How complex is the innovation to understand and comprehend? The scoring of the items can be complex because it requires a staff member to collect key information, score the information, and use the information to determine what level of supervision is appropriate for the offender who was assessed. • What type of pilot (trial) can occur to test the idea which will help others see its value, illustrate the compatibility with existing processes, and illustrate its ease of use? The tool can be tried by one or two people. • How visible (observable) are the results of the innovation to the users or stakeholders? The results may not be visible because staff do not see how well offenders at low, medium, and high risk levels do on supervision. In many cases, staff may not see the value of having a risk score or a level, and they may find the use of the instrument to be difficult to integrate into practice. So, why has it taken nearly 30 years for the correctional field to value the actuarial risk assessment tool? Looking at Rogers’ five questions, it is apparent that this tool may be too complex for the staff since they must interpret a risk score instead of simply looking at the length of a rap sheet. Also the question about how the risk score compares to criminal history has not been adequately discussed which may limit the utility of the risk score. These unanswered questions may be part of the puzzle as to why risk tools are not being widely used in practice.

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The type of innovation often affects the rate of adoption and implementation into routine practice. According to Rogers, five questions generally need to be asked to gauge the likely reception to the new idea, and the answers will affect the length of time needed to adopt the innovation. 1. What is the relative advantage of the new innovation compared to existing practice? The answer to this question lies in the organization assessing how the new innovation or refined practice will affect operations, and what is to be gained through these improvements. This answer is important because it helps define the value that can be ascribed to the new innovation. For most organizations, identifying a positive value increases the likelihood that the idea/innovation will be adopted. 2. How compatible is the new innovation to the existing business process, organizational values, past experiences, and overall needs of the adopters? The notion of compatibility is one that refers to “alignment” or “fit” within the organization’s goals and mission, as well as within the work processes. Innovations that require total reengineering of the work process are less likely to be adopted, and implementation is more likely to falter; relatively minor adjustments are more likely to be embraced by the organization’s staff. 3. How complex is the innovation to understand and comprehend? Most innovations, regardless of size or scope, are perceived to be complex. Generally the complexity derives from the change process. But innovations that are multilayered and have a number of different components have more difficulty getting traction. Complexity is important because it signifies that multiple skills are needed which can limit the staff capable of using the innovation. 4. What type of pilot (trial) can occur to test the idea that will help others see its value, illustrate the compatibility with existing processes, and illustrate its ease of use? Piloting is an important process because it illustrates the alignment to the organization’s mission as well as the ease of implementation. Although there is little research on piloting, it allows the organization to “try” the new idea. Pilots, due to their limited scope and timeframe, are generally an opportunity to “taste” the new idea/innovation without full commitment to routinization of the practice. The pilot provides an opportunity to identify areas in which new practices need attention to go scale as well as the relative advantage, fit, and ease of application. 5. How visible (observable) are the results of the innovation to the users or stakeholders? Staff and managers need to be convinced that the results are real. A major component of the social marketing of an innovation is to disseminate information about the innovation to constituents and stakeholders that informs them of the advantages of the innovation. A social marketing strategy is to canvas areas or markets that need information and to ensure that the information is useful. For example, if a pilot is conducted, it is important to broadcast the results

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in a manner that allows those that participated in the pilot to “tell the story.” This builds internal expertise, and demonstrates that the pilot was accepted by the staff. This result is important because it helps in marketing the concept by making the findings something that others in the organization can see and feel. The eyes and ears of the organization are multiplied as staff recognize that the new practice can achieve improvements in outcomes that fall nicely within the goals. Communication Channels. The transfer of information from one individual to another or within the organization is a communication channel. This exchange of information is critical, and in fact, may be more important than providing a copy of a study or systematic review of a particular innovation. The most favored place to obtain information is from colleagues, and social networks provide the most valued source of information. Practitioners tend to rely upon their personal networks as the source of credible information about a given topic. This is why the visibility of an innovation becomes important in the exchange of information because it provides an opportunity to demonstrate the existence of the idea in practice. The more that is known, the more the value of the innovation is apparent. A communication channel ensures that the information transmittal is at the correct level for the receiver – this is why it is important to translate technical information into userfriendly, easy-to-absorb material about the benefits and impacts of an innovation. To ensure that information is usable, it is important that it be shared in language and venues that are accessible to those who may use the information. Rogers described the communication channels as both the formal (hierarchical) and informal (social structure) mechanisms in an organization. He also recognized that there are key roles that serve as communication facilitators such as the opinion leader (internal actor who supports the innovation), champion (external actor that provides validation and support), and change agent (individual with a formal role to initiate the change). Time. Rogers recognized up front that timing is everything. The decision to adopt, implement, and sustain are all decisions made by organizations, and these decisions are made in the context of current events. In fact, Rogers outlined an innovation-decision process that is defined by the position that the organization is in as well as the conditions that affect decision-making. Each phase can occur at different time frames, and each can involve different steps that assess the utility of the innovation, the relevance, and the benefits. Most important in Roger’s perspective is that the rate of adoption indicates who adopts the innovation in a given time period. Rogers notes that early adopters are likely to be more creative whereas late adopters are looking for visible evidence that the innovation has merits. Late adopters are more hesitant and more reluctant to pursue new ideas; they are more concerned about alignment and fit within an organization than the improved value.

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The innovation-decision process articulated by Rogers consists of: Knowledge Persuasion Decision Implementation Confirmation

The process by which information is shared about the innovation and how it affects the work product or practices within an agency (business process) The process by which an impression is made of the innovation in terms of its value and utility A process by which an individual or organization engaged in a series of activities to make a decision about adopting, piloting, or rejecting an innovation The implementation decision is a complicated decision that involves various steps of using the innovation (i.e., pilot, limited use, then widespread use) The organization or individual needs reinforcement that the decision to adopt or pilot the innovation was worthwhile. Any contradicting information may negatively affect the further use of the innovation or reinforce initial impressions

It is not assumed that going through this decision process will result in implementing an innovation, but rather suggests where the organization is in the change process. Instead, each step can lead to the adoption, rejection, testing, or further information gathering to make a decision. Rogers has identified categories of adopters in terms of where different individuals or organizations fall on the spectrum of innovation: innovators (designers of the ideas), early adopters, majority adopters, late adopters, and laggards. Timing affects each component, and also affects how the innovation decision flows. Rogers put forth the concept of an “S” adoption pattern where the curve is steep and a full spectrum of patterns can be observed. Social Structure. An organization has two structures: the formal hierarchy of how decisions are made and how units are structured to work together, and the informal networks among members of the community. The formal structure represents the organizational bureaucracy whereas the informal structure represents the relationships that define the organization. It is important for understanding the climate of an organization to ascertain how decisions are made within the social system, and the degree to which formal or informal processes affect decision-making. Rogers (2003) notes that it is a “rather complicated matter to untangle the effects of a system’s structure on diffusion independent from the effects of characteristics of individuals that make up the system” (p. 25). Rogers has identified three key components that need to be considered in analyzing the social structure of an organization: System norms

The underlying values and beliefs that the organization holds that affect the types of decisions that are made Opinion leaders The ability of personnel to influence others, whether it is done informally or in a desired manner. These players generally exert their decisions on others Change agents The person(people) who assumes the role of influencing decisions in an organization. The change agent is generally charged with moving in this direction. Change agents are usually the buffer between the organization and the new ideas, filtering out the bad ideas and offering the new ideas. They often work toward refining the ideas to fit the setting, and work on alignment issues

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Different decision-making styles affect the diffusion, dissemination, and implementation processes. The optional innovation-decisions are made by individuals who are often influenced by the norms of the organization or interpersonal networks. In this model, the norms guide when and how decisions are made. The emphasis is on ensuring that the organizational values align and that decisions support the values. Collective innovation-decisions are a style of decision-making that is made through a consensus driven process. In the consensus process, the goal is to reach an agreement that is often negotiated among parties. The consensus strives to minimize the decision-making processes and to ensure that some agreement is made. Authority decisions are the “top down” approach where management makes decisions to adopt or reject an innovation. Rogers’ clarification of the diffusion concept has greatly advanced the field through attention to how information can be used. Identifying the four domains – from type of innovation to timing to communication channels to social structures – provided a foundation for the concept of TT. Ultimately the question is whether the diffusion is successful. The concepts outlined by Rogers speak to the need to have more thoughtfully planned strategies to pilot and implement innovations. This awareness has lead to a substantial increase in the number and type of dissemination, implementation, and sustainability models (see Table 3.1 below). The concept that diffusion is natural was well accepted, but the array of organizational scholars and practitioners seized the opportunity to craft more of an innovation implementation approach where the goal is to guide the organization through the various change processes. One of the earliest translations of Rogers’ model was a change management strategy developed by the Addiction Technology Transfer Centers (ATTC) and funded by the Substance Abuse and Mental Health Services Administration. The Change Book (http://www.nattc.org/pdf/The_Change_Book_2nd_Edition.pdf) is designed to provide a framework for implementing Rogers’ diffusion of innovations model by articulating ten principles (McCarty et al., 2007). The principles are: (1) identify the problem; (2) organize a team for addressing the problem; (3) identify the desired outcome; (4) assess the organization or agency; (5) assess the specific audience(s) to be targeted; (6) identify the approach most likely to achieve the desired outcome; (7) design action and maintenance plans for your change initiative; (8) implement action and maintenance plans for your change initiative; (9) evaluate the progress of your change initiative; and (10) review your action and maintenance plans based on evaluation results. The Change Book is accompanied by a workbook that allows teams to walk through the steps of the transfer process. Although The Change Book provides a formula, the focus is on dissemination through the use of a consensus decision-making model. That is, the recommended principles embrace that change requires a team process (and rejects the “top down” management driven approach) whereby the social structure of the organization can be involved. Added to this model is the notion of walking through Rogers’ five innovation-alignment concepts to ensure that the innovation is suited for the organization. Although this process is logical and has face validity, it has not been tested empirically. In one study, The Change Book model was used to train rural treatment programs to use buprenorphine treatment. Positive attitude changes toward

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buprenorphine were found, and most participants intended to prescribe the drug, but there were no comparison samples (McCarty, Rieckmann, Green, Gallon, & Knudsen, 2004).

3.3

Expanding the Concept of Implementation

Klein and Sorra (1996) spearheaded the focus on implementation in their seminal work, “The Challenge of Innovation Implementation,” expanding an understanding the concepts of alignment and organizational climate. According to their model, an innovation is considered useful when the strength of the organizational climate for implementation includes factors that help facilitate the integration of the innovation into daily operations, and the innovation fits the values of targeted users. The idea that the intervention needs to conform to organizational and staff values and norms was part of the fundamental tenet of innovation diffusion theory (Rogers, 1995) but insufficient attention had been given to the organizational climate as a key factor affecting this process. Klein and Sorra (1996) define organizational climate as the “targeted employees shared perceptions as to extent to which their use of the innovation is rewarded, supported, or expected within the organization” (p. 1060). Innovation implementation, in contrast, is “the transition period during which [individuals] ideally become increasingly skillful, consistent, and committed in their use of an innovation.” Implementation is the critical gateway between the decision to adopt the innovation and the routine use of the innovation (Klein & Sorra, p. 1057). In their view, the relationship between the climate and fit can result in three outcomes: (1) The implementation is successful since the climate and fit are aligned and desired organizational performance is improved; (2) The climate and fit are aligned but performance does not improve (faulty implementation); and (3) The climate and fit are not aligned and implementation does not proceed (stops at the decision to adopt). Attention to climate allows an analysis of the degree to which the policies and procedures of the organization support the innovation, the commitment to train staff in the needed skills, the use of motivational mechanisms for staff, the acquisition of people that can do the innovation, or the refinement of the innovation to “fit” within the existing business process. These factors vary by organization, and an analysis of the climate might explain the different outcomes and what type of climate can better prepare the organization to make a decision regarding implementation. The results of implementation may strengthen the climate due to the expected performance; this may shape the organization for further positive actions; whereas poor performance will weaken both the climate for change and the organization’s willingness to continue to improve operations. More recent attention has been given to the alignment of climate and organizational values in the dissemination of evidence-based substance abuse treatment (Eliason, 2003; Henderson, Taxman, & Young, 2008; Knudsen, Ducharme, & Roman, 2006; Schoenwald & Hoagwood, 2001; Taxman & Bouffard, 2000). Success in implementing an innovation may in

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Expanding the Concept of Implementation

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part depend on how program staff and administration perceive the differences between usual program or clinical practice and the new intervention (Schoenwald & Hoagwood, 2001). Further attention to implementation has evolved from interdisciplinary research focused on methodological issues in the conceptualization and measurement of implementation. While Klein and Sorra (1996) focus on the issue of alignment and defining degrees of successful movement from idea to practice, Proctor et al. (2010) recognize that there is a need for different measures of implementation. Implementation is more than a one-dimensional ending; rather there are levels of implementation and the degree of implementation can largely be tied to different outcomes at the system (organizational), staff, and individual client levels. Fixsen et al. (2005) summarize three broad types of implementation outcomes: (1) changes in adult professional behavior (e.g., knowledge and skills of practitioners and other key staff members within an organization or system); (2) changes in both formal and informal organizational structures and cultures (e.g., values, philosophies, ethics, policies, procedures, decision-making), designed to routinely bring about and support desired changes in adult professional behavior; and (3) changes in relationships (e.g., location and nature of engagement, inclusion, satisfaction) to consumers, stakeholders, and systems partners. Implementation outcomes are related to the chronological stage of implementation of a specific innovation (see also Klein & Sorra, 1996; Rogers, 1995). Proctor et al. (2009) provide a conceptual framework that expands Rogers’ concepts to capture not only the stage of implementation but also the degree to which the innovation has moved from idea to sustainable practice. They suggest the following domains as areas of implementation focus and measurement: Acceptability

Adoption Appropriateness

Incremental or implementation costs Feasibility

The degree to which the stakeholders or potential users of the innovation agree that the innovation is palatable or satisfactory. Acceptability relates to the notion that the users have knowledge of and experience with the innovation to assess the content, complexity, or comfort (all dimensions of Rogers’ model) The initial decision to pilot or use the innovation The alignment or fit within the current practice (business process). Alignment refers to relevance, compatibility, and coherence with the overall mission and goals. Proctor et al. (2009) distinguish acceptability and appropriateness: the former means that the idea or concept underscoring the innovation is suitable, whereas appropriateness refers to the perception that the practice is of value to the current setting Cost refers to a number of dimensions including acquiring the new innovation, training on the innovation, preparing the organization for the change, and maintaining the innovation. Each of these factors influences the total cost, and each has a separate cost Similar to Rogers’ conception of pilot, the concept of feasibility is that the innovation can be implemented or tried to a degree of satisfaction. The notion of feasibility is that the innovation can operate within existing practice; the question is whether it has added value or it introduces inherent operational problems

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Fidelity

Penetration

Sustainability

New ideas or innovations require adjustments in practice. Each innovation has a clear conceptual framework that can be translated into practice. The question is whether the translated practice resembles the original concept in terms of adherence to the protocol, dosage or amount of program service provided, and quality of the delivery. Each reflects the degree to which the practice maps to the original innovation As noted by Proctor et al. (2009), the concern is whether the innovation has passed the pilot phase and is being used within the organization or related systems. That is, has the innovation become more than a “niche” in that it is part of the routine practice of the organization Routinization as part of core practice within an agency is when an innovation ceases to become “new.” Instead, the innovation becomes part of the core practice that defines a business process

In the same spirit as Klein and Sorra (1996), Proctor et al. (2010) propose using the taxonomy to model implementation success. They consider implementation success to be a function of effectiveness plus various levels of implementation outcomes. Examples of implementation outcomes include using the technique for the majority of clients, ensuring that the technique is similar to the laboratory-test innovation, and improved client outcomes as a result of adherence to the intervention design. They propose a linear scale consisting of individual client levels of effectiveness and each of the eight categories of the taxonomy. Successful evidencebased practices would be the degree to which the EBP is effective (improves client outcomes) and has high scores on each of the eight constructs. Varying degrees of success would occur based on the ranking for each implementation construct.

3.4

Moving Past Initial Implementation: The Concept of Sustainability

Rogers treated implementation as one decision point influenced by prior efforts to adopt the innovation into practice. Dean Fixsen and colleagues at the National Implementation Research Network (NIRN) further elaborated on the decisionmaking process from a different perspective, proposing that implementation leads to efforts to routinize the innovation into practice. This is typically referred to as sustainability. Fixsen et al. (2005) recognized that organizations often do not make one decision to implement but rather make a series of incremental decisions moving toward that target, and that this process affects: (1) the degree to which the original innovation is implemented as a whole; (2) whether the innovation is reengineered to fit the climate; or (3) whether the innovation is piloted but not implemented. These decisions involve a series of activities that are designed to penetrate the use of the innovation throughout the organization. Fixsen et al. (2005) conceptualized implementation as a process and not as a single event. The NIRN conceptual model builds on Rogers’ core concepts but offers a slightly different perspective. Whereas Rogers focused on the conditions that affect the

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adoption of an innovation, the diffusion model stopped short of elaborating on implementation and sustainability processes. Fixsen et al. (2005) recognize that the process requires further modification of the organizational culture, monitoring fidelity of the innovation to ensure that the new idea is actually implemented, and overcoming barriers that might affect implementation. The emphasis is less on the pilot and trialability concepts and more on moving toward routinization of the innovation by focusing on implementation “drivers.” Attention to the culture of the agency, the staff needs, and processes to galvanize implementation are part of the NIRN approach. Culture refers to “the way things are done” to capture how decisions are made within the organization, and the factors that affect the business process. The NIRN model asks the questions about the issues that are likely to ensure uptake and adoption of the innovation over the long haul. Given that the NIRN model considers innovations that are evidence-based practices or clinical-related practices found to be efficacious, it focuses not only on the decision to adopt an evidence-based practice but also on how the organization can weave the innovation into the daily business practice. The NIRN model identifies the systematic and scientifically based principles of program implementation and positive organizational and systems change (Fixsen et al., 2005). Of key importance is the effective implementation of effective programs, encompassing both an evidencebased program or practice, and an implementation plan and process. Implementation components and outcomes exist independently of the quality of the program or practice being implemented. Ineffective programs can be implemented well, and effective programs can be implemented poorly (Fixsen et al., 2005). Desirable outcomes are achieved only when effective programs are implemented well. The work of Fixsen et al. (2005) suggests two overall themes derived from implementation research: (1) guidelines, policies, and/or educational information alone, or practitioner training alone are not effective; and (2) longer-term multilevel implementation strategies are more effective. The model clearly articulates that more research is needed to fully understand the value and importance of functional components of implementation (Fixsen et al., 2005). Fixsen and colleagues propose the following stages of implementation: Exploration and adoption The process of social marketing to assess the need for the change, and to garner support for the new initiative. This is the early phase which is similar to efforts to learn about new ideas Installation The pilot phase is designed to prepare for implementation through efforts to obtain funding, train staff, modify business processes, and adapt process. Here the effort is to “fit” into the organization Initial implementation In this phase, the efforts are to modify the organizational culture, begin implementation of the new practice and monitor fidelity, overcome barriers, galvanize stakeholder support, and report back on initial progress Full operation Full operation refers to integrating practice into daily business processes. The goal is to advance fidelity, to institute policies to support further implementation, and to meet clinical criteria if the practice is an intervention

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Sustainability

3 Theories of Organizational Change and Technology Transfer The innovation phase is to adapt to the environment and to monitor progress toward further implementation. The goal is to operate the program or intervention with fidelity before making improvements or furthering the innovation. The emphasis on fidelity is focused on the quality of the intervention – that is, set benchmarks need to be identified to ensure that the intervention is being delivered as intended. The goal of perfecting the model before making improvements to the practice is designed to ensure that the staff is working at optimum levels. The goal is to reduce “drift” from the core program components The goal of sustainability is “long term survival” and continued effectiveness. The sustainability efforts are to reduce drift from the core components of the innovation, especially given the likely changes in staff that will occur over time, the altered environment in terms of laws and regulations, and the efforts to improve outcomes. Sustainability efforts are devoted to ensure that the innovation is not diluted over time, which often occurs in the pressing world of daily program operations

To advance the concept of sustainability, the NIRN model identified a set of core implementation components that are important for evidence-based implementation of an intervention (Fig. 3.1). Given the concern with long term uptake of the innovation, along with attention to the fidelity of the innovation, these factors focus on strengthening the infrastructure of the organization. That is, these components are identified as important to advance the sustainability of the practice. The NIRN model recognizes several components needed in an implementation process that is geared to adopting an evidence-based practice. Key to the process is that the evidence-based practice maintains its core components to ensure that the new innovation is scientifically valid. Fixsen and colleagues are trying to avoid the problem of “reengineering” an innovation that does not adhere to the scientific principles, thus recognizing that attempts to align an innovation to an existing business environment may actually dilute the innovation. In that case the core components or key ingredients that are theoretically related to improved performance or outcomes are no longer recognizable. The focuses on fidelity in terms of the evidence-based practice as well as refining the organizational environment to adapt to the innovation are key components of the model. The following describes the organizational components that are posited as needed to ascertain fidelity, as well as contribute to sustained innovations that are embedded in the business model. Staff Evaluation: Staff is key to the delivery of any particular program or service. The question is what is expected of staff and how does the organization determine whether individuals are doing a good job? The mechanisms to evaluate staff performance (usually an annual review) are a tool of sustainability given that the core components of the innovation could be embedded in the performance measures for the staff.

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Fig. 3.1 Core implementation components (NIRN model). Adopted from NIRN, http://www.fpg. unc.edu/~nirn/implementation/07/07a1_selection.cfm,doi07102010

Program Evaluation: An important component is providing feedback of the outcomes from the innovation. The feedback loop is critical since it creates visibility for the outcomes from the innovation, as well as information to assess the benchmarks accomplished. There are numerous types of evaluations including process and outcome studies. To be useful in assessing implementation and sustainability, it is important that the evaluation provide feedback on core process and outcome measures. For example, the Washington Circle (Garnick et al., 2007), a think-tank of scholars and practitioners, has identified some core measures that are important to effective service delivery. These include: initiation (begin services within 14 days of referral), engagement (client participates substantively such as twice during the first month), retention or the client participates for a minimum period of time, and completion. These core measures are used to determine whether the innovation is being delivered in a manner that can improve client outcomes since it is based on the premise that unless clients “show up,” it is unlikely that they will make progress. The program evaluation is a tool to allow others to objectively view the progress of the program. Facilitative Administrative Supports and Systems Interventions: The management of the organization must be sensitive to and supportive of the difficulties that are involved in the innovation. Leadership support is critical not only to reinforce the value to the organization but also to ensure that communication is supportive of the goals. This often requires examining the policies and procedures of the organization, as well as the system overall, to ensure that the innovation is supported by the organization’s guiding principles, procedures, and regulations. It serves to align the organization to the innovation or vice versa. This extends to the pipeline system that brings the clients or inputs into the program or service. Staff Selection: A key component is whether the staff is required to participate in the innovation. While staff selection is seldom discussed, the important components

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fall into the categories of skills, qualifications (i.e., credentials, certifications), and competencies. These are important because they affect the degree to which the staff skill set is appropriate to conduct the innovation with fidelity, and whether the staff has the personal perspective or beliefs to support the underlying premise of an innovation. The staff engaged in delivering the program is just one part of the organization’s workforce involved. The NIRN model recognizes that managers, trainers, coaches, referring staff from other agencies, and other players are involved directly or indirectly in the delivery of services. Preservice or In-service Training: Organizations typically provide training to staff at the beginning of employment and routinely during the normal working period. The training usually focuses on dissemination of knowledge about innovations in the field at large and opportunities to practice or acquire new skills. Sometimes training is devoted to theory, philosophy, or values as part of the dissemination process. Training is the traditional mechanism to transfer information within an organization (besides memoranda or staff meetings), yet the organizational development literature has demonstrated that training is typically ineffective with less than 10% of the material presented in training being used in the workplace (Goldstein, 1997). Consultation and Coaching: Technical assistance is the major form of consultation provided to organizations, much of it funded through the federal agencies such as the National Institute of Corrections, Bureau of Justice Assistance, and Substance Abuse and Mental Health Services Administration. NIRN recognized that more work is needed to translate an innovation into operational parts and that consultation and coaching are tools to help achieve more effective implementation. Unlike classroom (training) settings, it provides the mechanisms to assist staff with using the innovation with “ease” or intrinsically as part of their normal response patterns. The NIRN model proffers that coaching should be work-based, opportunistic, readily available, and reflective in order to allow staff to absorb the information and skills needed to apply the innovation in the workplace (Spouse, 2001). The main roles of the coach are clinical supervision, teaching while staff is involved in practice activities, providing assessment and feedback, and providing a supportive environment to make the transition from practice to mastery of the skills. Integrated and Compensatory: The NIRN model underscores that innovations cannot be pilots that are merely hanging on a thread to the organization. Gains will occur only when the innovation is integrated within the organization and the system itself. This tenet therefore provides a formula for sustainability that is focused on a holistic approach to building a supportive infrastructure for the organization. It brings attention to all levels of the organization (from management to front line staff) as well as external stakeholders. This includes a close examination of the behavior of systems including policies, funding sources, workforce systems, external partners, and various levels of organizational support. This premise is that for the innovation needs to be recognized within the fabric of the organization and external supporting systems in order to be successful.

3.4 Moving Past Initial Implementation: The Concept of Sustainability

Box 3.2 Applying NIRN Concepts to Justice Treatment Initiatives Contingency Management is a recognized evidence-based practice (NIDA, 2000; Petry et al., 2010). Contingency management requires the use of a structured incentive process to reward positive behaviors toward achieving target goals such as reduced drug use or criminal behavior. That is, the application of CM in a justice setting requires the organization to recognize that parole officers should recognize and reward positive behaviors such as the offender being drug-free in 1 week, and that when the offender has been drug free for a period of time (such as a few consecutive weeks), then the person should be rewarded with some type of incentive. The incentive can be material (e.g., cash, vouchers, or movie tickets) or social (e.g., affirmations, recognition). Applying the NIRN framework, the implementation of CM in a justice setting will need consideration of the following components. These are part of the exploration and adaptation component of the NIRN framework. This is just a short list of items to consider: 1. What language will a probation or parole officer use to reward the offender? Parole officers frequently sanction offenders and through this process the parole officers are socialized as to how to confront offenders regarding negative behaviors. Probation/Parole officers are not typically trained as counselors which means they might not have the clinical skills including vocabulary to express the incentive because merely saying “you did well, here is your voucher” undermines the intent of the CM approach. 2. Will the probation/parole office allow officers to provide monetary or social rewards? Some correctional agencies do not allow correctional staff to recognize positive behavior since it is assumed that offenders know what they are “doing right.” In fact, some correctional agencies will not even allow researchers to pay research subjects to be in a study. 3. What type of messages will a correctional agency use to communicate the value of using CM to the staff? In one parole agency that attempted to use CM-like approach, the supervisors would send emails to the parole officers highlighting the officers that had the highest revocation rates each quarter. These emails reinforced for probation/parole officers that the leadership of the organization encouraged revocations. If CM is used to prevent revocations, then these mixed messages are problematic to implementation since it appears that the agency values revocations more than successful completion of parole. 4. Will the judges, prosecutors, defense attorneys, community, legislators, and others support the use of incentives for offenders? In one jurisdiction, the probation/parole agency acquired a grant commitment from a nonprofit organization to reward probationers/parolees who were drug-free. The probation/parole chief received a call from a legislator who thought rewarding “these people” was preposterous and threatened to pursue budget cuts if the agency accepted the funds. The CM project was never initiated in this agency.

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Building Interagency Collaborative Supports: The Availability, Responsiveness, and Continuity (ARC) Model

Open systems theories highlight how an organization or the initiatives of an organization are affected by both internal and external factors. The open systems theories are built on various assumptions about the relationship of the organization and the systems with which they interact. These theorists also recognize that in the provision of services to human beings, innovations impact systems. At the client level, individuals tend to access and require various human-related services simultaneously, given their needs. For example, many justice-involved individuals require substance abuse or mental health counseling, housing, employment, medical care, educational, and other services in the community. Given that each service has its own eligibility criteria and delivery system, clients are often caught in the “crossfire” among the organizations’ bureaucracies. Systemic policy changes are important to reduce organizational barriers to accessing care and to integrate or coordinate services to improve client performance (outcomes). Most of the system models highlight intra-organizational factors but TT recognizes the effects of system features on outcomes. Attention to how the decisions of one organization affect the system or the pathways to collaboration or coordination is important for reducing the barriers to organizational change and to improving the fidelity of the innovation. That is, one organization’s policies and procedures may have an impact, positive or negative, on another organization and therefore the TT model should consider how external factors affect the transfer process. In criminal justice, theorists have recently developed models of seamless systems of care (see Taxman, 1998; Taxman & Bouffard, 2000) where the emphasis is on coordinating or integrating services across systems to reduce redundancy and to support client involvement in healthy, supportive services that should lead to better outcomes. The seamless system of care recognizes the interdependency of organizations and how these factors affect each system. Examining social and mental health services for youth, Charles Glisson and his colleagues (Glisson & Schoenwald, 2005) recognized that implementation of key services was more of a systems issue than previously conceptualized. The Availability, Responsiveness and Continuity (ARC) model was developed to provide a framework to guide cross-system efforts through three deliberative stages: collaboration, participation, and innovation. ARC is guided by the following principles: (1) mission-driven – all actions and decisions would be focused on a single desired outcome that multiple agencies can agree upon; (2) results-oriented – measures of individual, team, and organizational performance level; (3) improvement directed – continually seek to be more effective in improving the well-being of clients; (4) relationship-centered – regarding the intra- and interagency network of relationships

3.5

Building Interagency Collaborative Supports…

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that are needed to achieve the desired goals; and (5) participation-based – including external stakeholders and partners in forming policies, designing strategies, and adopting technologies. The ARC model reinforces the importance of innovation adoption that focuses on a combination of social, technical, and strategic change. The technical nature of the intervention is guided by evidence-based practices literature where the focus is on programs and services known to be effective (see Chap. 2 for a discussion of such programs). The fidelity of the innovation should be maintained with an emphasis on the integrity of the core components (similar to Fixsen et al., 2005). The social context is recognized as extremely important since ARC values building intra- and interagency relationships that will affect longer term sustainability. The social context, as noted by Rogers (2003), lays the foundation for the attitudes and behaviors of the individual players. Attending to social context will yield collateral benefits such as reducing conflicts, addressing overload, and addressing cynicism – the climate issues that often shape and affect the perspective about the innovation. Strategic efforts are those guided by developing interagency actions such as mission definition, clarification of desired results, and interagency efforts to allocate resources and procedures that will strengthen the system. ARC uses a matrix of the implementation strategies (collaboration, participation, and innovation) that need to be adopted across the various dimensions of problemsolving in order to improve services: problem identification, direction setting, implementation, and stabilization, as shown below (Glisson & Schoenwald, 2005). These core components are built on developing a system that serves to support the implementation and sustainability of the innovation. Collaboration

Participation

Innovation

Relates to the goals of coalescing a number of support mechanisms within the agency and external agencies to define the mission pertinent to the problem, cultivate personal relationships across and within agencies, and access or develop networks among internal and external partners Build teamwork within work units: facilitating support and supplementary efforts; providing information and training about the intervention and supporting regulations and policies; establishing a feedback system to provide performance information to work teams and management; implementing participatory decision-making; and resolving conflicts that might occur Develop goal setting procedures for short- and long-term goals; use continuous quality improvement techniques; redesign job charac teristics of key staff positions; and ensure self-regulation and stabilization of change. Similar to Fixsen et al. (2005), this model recognizes that there are organizational activities that are important to maintaining the fidelity of the model

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Table 3.1 Outline of Availability, Responsiveness and Continuity (ARC) framework Problem Direction identification setting Implementation Stabilization Collaboration Personal relationships Network development Team building Participation Information and assessment Feedback Participatory decision-making Conflict resolution Innovation Goal setting procedures Continuous quality improvements Job redesign Self-regulation Glisson and Schoenwald (2005)

The ARC framework applies these strategies to the different phases of implementation, which are referred to as the problem-solving approach. The matrix (Table 3.1) guides the use of the different phases across problem-solving approaches. The shading means that this is the main function within that particular phase of the project, and that these activities occur within this particular area. The ARC model was tested in a child welfare-juvenile justice setting on caseworker teams (Glisson & Schoenwald, 2005). Change agents were assigned to work in study jurisdictions where the intervention was being implemented. The change agents had weekly case management team meetings for up to six weeks. Every six weeks a new block of the curriculum was introduced to the field. The change agents worked with the teams to implement ARC at each study site. At the management level, the study team implemented four workshops a year with agency managers and four specific meetings with regional director staff to facilitate policy changes. The study team also conducted “information dissemination” sessions to facilitate external support. A randomized controlled trial was conducted to examine the impact of the ARC process on staff turnover and found that ARC reduced the likelihood of turnover, controlling for characteristics of the staff (Glisson, Dukes, & Green, 2006). ARC also had positive impacts on reducing role conflict, overload, perception of a depersonalized environment, and emotional exhaustion of the staff. The findings confirm the importance of an approach focused on social context as the glue to advancing the diffusion process (Glisson et al., 2006).

3.6 Attention to Performance: Quality Improvement Processes…

3.6

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Attention to Performance: Quality Improvement Processes, Performance Contracts, and Benchmarking

Underscoring TT of an innovation is that there is an expected improvement in the performance of the organization, in terms of better client outcomes (along a few dimensions), reduced costs, and improved benefits to society. The underlying rationale for evidence-based practices is that the innovation has been tested in multiple field experiments and research studies and found to improve outcomes. The focus on performance is comparable to efforts to institute operational efficiencies in order to achieve organizational improvements and maximize the return on investment. But here, the efficiencies are tied to improved outcomes at the individual level. The organizational approach to performance is generally rooted in efforts to improve the business process to increase profits, serve more customers, or develop new products. Program development theorists have used the logic model to help explain the linkage between program components and expected outputs or short term benchmarks. The logic model sets up assumptions that link the processes to outputs and then to outcomes. That is, for an innovation to have an impact, it must be implemented in a manner that changes the process in measurable ways. Figure 3.2 illustrates how one evidence-based practice – the use of standardized risk and need assessment tools in justice settings – can affect the selection of individuals for targeted programs and services. The model outlines the expected gains that are hypothesized to increase access to appropriate services, to assist more offenders starting treatment, to improve offender engagement in treatment for more days, and to improve completion rates. The desired outcome is less drug use by the participants (for evidence-based substance abuse treatment) and less criminal activity.

Fig. 3.2 Logic model: using risk-need tools to assign drug offenders to treatment programs

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The management science field has devoted considerable attention to processes and outputs through a number of major initiatives over the last two decades. Beginning with Total Quality Management (TQM) in the 1980s, the focus was on recognizing that outputs are a product of quality. The TQM model indicates that: (1) products are the result of production processes that make something; (2) the operating principle is quality in the process (similar to the NIRN focus on quality) to ensure the desired outcomes; and, (3) the desired outcomes must be stated in such a manner that they can be measured. This requires the collection of good baseline data as well as continuous monitoring of outcomes. The TQM model laid an important foundation in recognizing that organizations need to set clear benchmarks and that the processes should be designed to achieve such benchmarks. The emphasis on quality focused attention on the notion that it is not how someone does a process but how well the process is done. That is, by paying attention to adhering to core principles, or the major theory driving the process, one can improve the outcomes. The quality message has been the focus of a lot of attention, particularly in the addiction treatment field where much attention has been given to the adherence or compliance with program design as a means of improving outcomes. And, the process recognizes that the organization should search for continuous improvement efforts to advance better outcomes. That is, while quality may be achieved in one area, there are other areas where attention may be needed. TQM has influenced three different initiatives within the field to help the organization improve its end products and address organizational change with a focus on achieving outcomes that are desired by the organization. Specific applications of performance driven methods are described below.

3.6.1

Plan-Do-Study-Act (PDSA)

The Institute for Healthcare Improvement, Inc. (IHI) adapted a quality improvement process called Plan-Do-Study-Act (PDSA) (Deming, 2000). The PDSA process (summarized in Fig. 3.3) centers on a systems approach by having teams work together to set benchmarks that should generate improved performance. Under this process, the (interdisciplinary) team must analyze the existing system and identify the changes needed to achieve the desired benchmarks. Typically these are considered short-term efforts devoted to achieving the benchmarks; the IHI model focuses on 90-day change processes. The change process is designed to allow for incremental implementation of change, with a series of sequential steps culminating in a larger change process. The notion is that the change team will define the mission, outline steps to implement the mission, and develop concrete benchmarks (process measures) to know if the change occurred, and then redefine the benchmarks to reset the process and continue to make improvements. The circular nature of the process is such that if the process improvements do not occur, then the team can alter the planned change processes or identify a new set of benchmarks. The team can select the options based on their collective experiences with implementing change. The PDSA is considered a rapid cycle process because it focuses on rapid

3.6 Attention to Performance: Quality Improvement Processes…

81

What are we trying to accomplish?

How will we know a change is an improvement?

Plan

Do

Study

Act

What changes can we make that can involve improvements?

Fig. 3.3 Overview of PDSA approach adapted from the IHI model. http://www.ihi.org/IHI/Topics/ Improvement/ImprovementMethods/HowToImprove/

decision-making in three areas: (1) the process to be altered; (2) the benchmarks to define progress; and (3) the desire to alter practice. The focus is creating norms about expected outcomes – only if the benchmarks are easy to obtain and identify. PDSA basically is built on the notion that work teams should be focused on work processes that are geared to changing how a “product” is produced. The assumption is that the focus on making improvements will address the culture that often serves as a barrier to change. The benchmark setting process serves to clarify the goals which are then designed to achieve better, more desirable outcomes.

3.6.2

Network for Improvement of Addiction Treatment (NIATx): Quality Improvement Processes

Another effort to improve the work process is to focus on predefined goals that will serve to achieve better outcomes. This national network was built to improve substance abuse treatment services by focusing on improvements in key outputs: initiation and

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engagement in treatment services. The foundations of the NIATx model (http://www. niatx.net) are TQM and PDSA. NIATx has a structured process that focuses on teams developing improvements to the quality of treatment by focusing on four predefined aims. The network includes standard measurement techniques, key principles about the process for quality improvements, and support for the work teams that includes webinars, learning collaborative meetings, coaches, and interest circles. The NIATx model incorporates five core principles: (1) understand and involve the customer; (2) fix key problems and help the executive sponsor sleep at night; (3) pick a powerful change leader; (4) get ideas and encouragement from others, both inside and outside the organization or field; and (5) use Rapid Cycle Testing to test effective changes (http://www.niatx.net). The underlying premise is that the individual client cannot improve their own personal outcomes due to organizational or system factors that interfere with progress. The focus is on achieving the main goals of showing up for and remaining in treatment. The four key benchmarks for improvement are: 1. Reduce waiting time between first request for service and first treatment session 2. Reduce no-shows by reducing the number of patients who do not keep an appointment 3. Increase admissions to treatment 4. Increase continuation from the first through the fourth treatment session The NIATx process begins with a learning collaborative meeting designed to assist local change teams to learn techniques to analyze their system and to work together. The NIATx process uses the “walk through” which is an opportunity for team members to “become clients” (Ford et al., 2007). The team members act as clients and go through the existing “system” to see how it works, examine areas of strength and weakness, and experience (like regular clients) all of the processes that affect decisions to access and participate in treatment. The goal is to provide a “human” face to the clients by helping system actors to experience the process. The value of the walk through is that the team members (often interdisciplinary) can see how overlapping systems issues create burdens on the clients trying to access care. To support the work team, NIATX has interest groups to allow teams to collaborate and learn from each other. External coaches are available to supplement internal expertise and build on the strength of the teams. The coaches focus on building the social support within the team as well as providing external consulting, subject matter expertise, and facilitation skills. Research findings have shown positive effects of NIATx efforts in reducing wait times, increasing admissions, and increasing retention in addiction treatment (Ford et al., 2007; McCarty et al., 2008).

3.6.3

COMPSTAT and Feedback Loops

In criminal justice, a major advancement in the policing field revolutionized management techniques applied to the problems of crime reduction and responsive

3.7 Total Organizational Change Processes

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leadership. The method involved the use of data to measure key benchmarks. COMPSTAT (COMPuterSTATistics) was initiated in New York City in the 1990s as part of an effort to reduce crime (Walsh, 2001). The basic premise is that supervisory managers should be held responsible for performance in their assigned areas (beats) by using real-time crime data to illustrate patterns and trends. As part of an evolution in police reforms and management, Police Chief William Bratton implemented weekly meetings where the local police supervisor had to report on crime incidents, changes in crime, and initiatives to address the crime. The effort was used by supervisors to focus attention on key problems areas (crime spots) and to place pressure on managers to quickly address problems. Like the PDSA rapid cycle process, the COMPSTAT process focused on outputs or the more immediate proximal outcomes. COMPSTAT has transformed public agencies with more attention to outputs as a means to understand how to achieve progress even for difficult, protracted problems. The Pew Foundation outlined how the COMPSTAT process could be used in community corrections in a similar fashion to improve offender outcomes (Burrell & Gelb, 2007), recognizing that community corrections agencies need the same process as the police to identify target performance goals, and that these should focus on client/offender level outcomes. For example, a performance measure could be the percentage of staff who use risk and need instruments to recommend treatment services, which should be monitored to improve overall outcomes of the agency. As discussed below, performance measures are important management tools to galvanize an organization to achieve certain outcomes and implement change.

3.7

Total Organizational Change Processes

The existing TT models center around different theoretical models of the factors that influence adoption or implementation of an innovation (evidence-based practice). In a systematic review of innovations in service organizations, Greenhalgh et al. (2004) advance the conceptual differences among diffusion (passive spread of innovations), dissemination (active spread), and implementation (planned translational efforts to embed the innovation within the organizational context). A new focus is on the implementation protocol since it has been clearly recognized that often it is not faulty innovations but rather faulty implementation that accounts for poor or neutral differences in client outcomes. TT has evolved to focus on implementation and several different conceptual models of organizational change have been articulated, such as those summarized in the Appendix to this chapter. Evolving research is suggesting new measures and conceptual frameworks to guide the development of knowledge in TT or implementation (Bhattacharyya, Reeves, Garfinkel, & Zwarenstein, 2006; Greenhalgh et al., 2004; Mowbray, Holter, Teague, & Bybee, 2003; Proctor et al., 2009; Proctor & Rosen, 2008; Stetler, Ritchie, Rycroft-Malone, Schultz, & Charns, 2009; Wilson, Petticrew, Calnan, & Nazareth, 2010). Chronologically, the first set of TT models emphasized a pipeline or linear approach where the TT progresses through various stages of creating the need for change,

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examining the functioning of the current system, assessing options, measuring integrity and quality, identifying benchmarks, measuring outputs, and using the data to continue to refine the system. An example is the Quality Enhancement Research Initiative (QUERI) at the U.S. Department of Veterans Affairs. The QUERI model (Stetler et al., 2009) was developed in the mid-1990s to identify gaps in performance and implement “fixes.” Its process consists of six steps: • Identify priority conditions and opportunities for improving the health of veterans • Identify effective practices for improving outcomes for priority conditions • Examine variations in existing practices, the sources of variation, and their relation to health outcomes • Identify and test interventions to improve the delivery of best practices • Evaluate the feasibility, adoption, and impact of coordinated improvement programs to spread best practices • Evaluate the effects of improvement programs on veterans’ health outcomes, including quality of life The QUERI model is based on the Promoting Action on Research Implementation in Health Services framework, or PARIHS (The Improved Clinical Effectiveness through Behavioral Research Group (Bhattacharyya et al., 2006); Helfrich et al., 2010). In the PARIHS model, the emphasis is on employing utilization focused evaluation strategies (Patton, 2003) throughout to have a data driven strategy. The PARIHS approach uses external facilitation techniques to enable and assist clinical opinion leaders with problem-solving; address challenges to intervention implementation (Helfrich et al., 2010) that are designed to advance the use of an evidence-based practice. The RE-AIM initiative (http://www.re-aim.org/what-we-do/framework-overview. aspx) developed at the Kaiser Permanente Colorado Region, Institute for Health Research, articulates a similar progression which includes: Reach into the target population; Effectiveness or efficacy; Adoption by target settings, institutions, and staff; Implementation – consistency and cost of delivery of intervention; and Maintenance of intervention effects in individuals and settings over time. Two other TT models will be briefly discussed: the Liddle et al. (2006) fourphase TT framework and Simpson’s TT model for substance abuse treatment agencies (Simpson, 2002). Liddle et al. (2006) considered the challenges of importing the evidence-based Multidimensional Family Therapy intervention into juvenile justice settings. This model has the following phases: Phase I: baseline/preexposure (12 months); Phase II: training (6 months); Phase III: Implementation, with clinical supervision (14 months); and, Phase IV: Durability/practice, without supervision (18 months). These timeframes demonstrate the effort to move toward sustainability with a greater focus on improving the staff skills to conduct the clinical intervention. Simpson (2002) identified an organizational model that focuses on important determinants of innovation adoption including leadership attitudes, resources for staff (Backer, 1993; Bero et al., 1998; Knudsen & Roman, 2002), organizational stress, regulatory or financial pressures, management style, an organizational tolerance for change (Ash, 1997; Lehman, Greener, & Simpson,

3.8

Conclusion

85

2002), and the personal characteristics of program leaders and staff. Positive management support for change has been found to be a factor in increased use of computer databases among health care professionals (Gosling, Westbrook, & Coiera, 2003), and Klein, Conn, and Sorra (2001) note that such support leads to better quality implementation of an innovation. Management support is also likely to result in investments in policies and resources that promote the use of the new technology (Klein et al., 2001). The focus in this model is on resources, and ensuring the capacity is available to implement the intervention. Another conceptual framework lies in the multilevel models of organizational change. In this approach, change is not pursued as a linear approach but rather involves multidimensional, multilevel efforts to ready and stabilize the organization and its supporting environment. These multilevel models recognize the internal and external factors that affect the success of TT in advancing improved practice. Shortell (2004) identified four levels that need attention to advance improvements: (1) policy environment including legal and regulatory systems; (2) organization or systems; (3) change team or group within the organization; and (4) individuals who are being requested to conduct business in a new way. In the next chapter (4), we will further investigate the factors that affect successful TT in each of these four areas regardless of the innovation that is being pursued or the change practice model.

3.8

Conclusion

In 1974, Martinson and Wilks declared that Nothing Works in correctional programs and services. This declaration had a rippling effect upon the field including demeaning the value of correctional programs. Hidden in this famous report was also the finding that “nothing is implemented” in that Martinson and colleagues noted that few of the correctional programs were actually implemented as planned. The programmatic components were so similar to traditional practice that it was difficult to see any innovation. Moreover, the failure to provide core services (the fidelity issue) largely accounted for the null findings. The problem of transferring new technology to correctional environments is thus not a new one. In this chapter we have outlined the theoretical frameworks for a TT environment, largely the result of research in the health services and business management fields. Behavioral health services, including addiction treatment, have been the subject of more dedicated attention to the issues of TT and implementation than the correctional field. This book uses the findings from the public health field to inform a model of TT that is built upon multidisciplinary research in moving research (evidence) to the field. This chapter highlighted some TT frameworks and the overarching principles that they address. It is beyond the scope of this book to examine all existing frameworks, but recent reviews by Damschroder et al. (2009) and Proctor et al. (2009) describe and critique a number of other initiatives. Readers are referred to these articles to learn more about the various models. We list them and their key citations in the Appendix.

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Appendix List of Organizational Change Models Author(s) Aarons, G. A., Wells, R. S., Zagursky, K., Fettes, D. L., & Palinkas, L. A. Brach, C., Lenfestey, N., Roussel, A., Amoozezar, J., & Sorensen, A. Edmondson, A. C., Bohmer, R. M., & Pisana, G. P. Feldstein, A. C. & Glasgow, R. E. Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M. & Wallace, F. Frambach, R. T. & Schillewaert, N. Glisson, C., Landsverk, J., Schoenwald, S., Kelleher, K., Hoagwood, K. E., Mayberg, S., & Green, P. Glisson, C. & Schoenwald, S. K.

Graham, I. D. & Logan, J. Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P., & Kyriakidou, O.

Grol, R. P., Bosch, M. C., Hulscher, M. E., Eccles, M. P., & Wensing, M. Grol, R. P., Wensing, M., & Eccles, M. Kilbourne, A. M., Neumann, M. S., Pincus, H. A., Bauer, M. S., & Stall, R. Kitson, A.

Klein, K. J., Conn, A. B., & Sorra, J. S. Klein, K. J. & Sorra, J. S. Kochevar, L. K. & Yano, E. M. Leeman, J., Baernholdt, M., & Sandelowski, M. Lukas, C. V., Holmes, S. K., Cohen, A. B., Restuccia, J., Cramer, I. E., Shwartz, M., & Charns, M. P.

Year Model 2009 Implementing EBP in Community Mental Health Agencies 2008 Will it Work Here? A Decisionmaker’s Guide to Adopting Innovations 2001 Technology Implementation Process Model 2008 A Practical, Robust Implementation and Sustainability Model (PRISM) 2005 Conceptual Framework for Implementation of Defined Practices and Programs 2002 Multilevel Conceptual Framework of Organizational Innovation Adoption 2008 Availability, Responsiveness and Continuity: An Organizational and Community Intervention Model 2005 Availability, Responsiveness and Continuity: An Organizational and Community Intervention Model 2004 Ottawa Model of Research Use 2004 Conceptual Model for Considering the Determinants of Diffusion, Dissemination, and Implementation of Innovations in Health Service Delivery and Organization 2007 Framework for Organizational Transformation 2005 Implementation of Change: A Model 2007 Replicating Effective Programs Framework 1996 PARiHS Framework: Promoting Action on Research Implementation in Health Services 2001 Conceptual Model for Implementation Effectiveness 1996 Conceptual Model for Implementation Effectiveness 2006 Diagnosis Needs Assessment (DN/A) 2007 Theory-based Taxonomy for Implementation 2007 Organizational Transformation Model

(continued)

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(continued) Author(s)

Year

Mendel, P., Meredith, L. S., Schoenbaum, M., & Sherbourne, C. D., & Wells, K. B. Pettigrew, A. & Whipp, R. Rycroft-Malone, J., Harvey, G., Kitson, A, McCormack, B., Seers, K., & Titchen, A.

2007 Framework of Dissemination in Health Services Intervention Research 1992 Dimensions of Strategic Change 2002 PARIHS Framework: Promoting Action on Research Implementation in Health Services 2002 TCU Treatment Systems 2007 Conceptual Framework for Transferring Research to Practice 2001 Stetler Model of Research Use

Simpson, D. D. Simpson, D. D. & Dansereau, D. F. Stetler, C. B.

Model

References Aarons, G., Wells, R., Zagursky, K., Fettes, D., & Palinkas, L. (2009). Implementing evidencebased practice in community mental health agencies: A multiple stakeholder analysis. American Journal of Public Health, 99(11), 2087–2095. Ash, J. (1997). Organizational factors that influence information technology diffusion in academic health sciences centers. Journal of the American Informatics Association, 4, 102–111. Backer, T. E. (1993). Information alchemy: Transforming information through knowledge utilization. Journal of the American Society for Information Science, 44, 217–221. Bero, L. A., Grilli, R., Grimshaw, J. M., Harvey, E., Oxman, A. D., & Thomson, M. A. (1998). Closing the gap between research and practice: An overview of systematic reviews of interventions to promote the implementation of research findings. British Medical Journal, 317, 465–468. Bhattacharyya, O., Reeves, S., Garfinkel, S., & Zwarenstein, M. (2006). Designing theoreticallyinformed implementation interventions: Fine in theory, but evidence of effectiveness in practice is needed. Implementation Science, 1, 5. Brach, C., Lenfestey, N., Roussel, A., Amoozegar, J., & Sorenson, A. (2008). Will it work here? A decisionmaker’s guide to adopting innovations. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved August 22, 2011 from http://www.innovations.ahrq.gov/ guide/guideTOC.aspx. Brown, B. S., & Flynn, P. M. (2002). The federal role in drug abuse technology transfer: A history and perspective. Journal of Substance Abuse Treatment, 22, 245–257. Burke, L. A., & Hutchins, H. M. (2007). Training transfer: An integrative literature review. Human Resource Development Review, 6(3), 263–296. Burrell, W., & Gelb, A. (2007). You get what you measure: Compstat for community corrections. Washington: The Pew Charitable Trusts. Damschroder, L., Aron, D., Keith, R., Kirsh, S., Alexander, J., & Lowery, J. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4(1), 50. Edmondson, A. C., Bohmer, R. M., & Pisano, G. P. (2001). Disrupted routines: Team learning and new technology implementation in hospitals. Administrative Science Quarterly, 46(4), 685–716. doi:10.2307/3094828. Eliason, M. (2003). Evidence based practices: An implementation guide for community based substance abuse treatment agencies. Iowa City: The Iowa Consortium for Substance Abuse Research and Evaluation. Feldstein, A. C., & Glasgow, R. E. (2008). A Practical, Robust Implementation and Sustainability Model (PRISM). Joint Commission Journal on Quality and Patient Safety, 34(4), 228–243.

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Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., & Wallace, F. (2005). Implementation research: A synthesis of the literature. Tampa: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network (FMHI Publication #231). Ford, J. H., II, Green, C. A., Hoffman, K. A., Wisdom, J. P., Riley, K. J., Bergmann, L., et al. (2007). Process improvement needs in substance abuse treatment: Admissions walk-through results. Journal of Substance Abuse Treatment, 33(4), 379–389. Frambach, R. T., & Schillewaert, N. (2002). Organizational innovation adoption: A multi-level framework of determinants and opportunities for future research. Journal of Business Research, 55(2), 163–176. doi:16/S0148-2963(00)00152-1. Garnick, D. W., Horgan, C. M., Lee, M. T., Panas, L., Ritter, G. A., Davis, S., et al. (2007). Are Washington Circle performance measures associated with decreased criminal activity following treatment? Journal of Substance Abuse Treatment, 33(4), 341–352. Glisson, C., Dukes, D., & Green, P. (2006). The effects of the ARC organizational intervention on caseworker turnover, climate, and culture in children’s service systems. Child Abuse & Neglect, 30(8), 855–880. Glisson, C., Landsverk, J., Schoenwald, S., Kelleher, K., Hoagwood, K. E., Mayberg, S., & Green, P. (2008). Assessing the organizational social context (OSC) of mental health services: implications for research and practice. Administration and Policy in Mental Health, 35(1–2), 98–113. doi:10.1007/s10488-007-0148-5. Glisson, C., & Schoenwald, S. K. (2005). The ARC organizational and community intervention strategy for implementing evidence-based children’s mental health treatments. Mental Health Services Research, 7(4), 243–259. Goldstein, I. (1997). Training in organizations. New York: Brooks/Cole. Gosling, A. S., Westbrook, J. I., & Coiera, E. W. (2003). Variation in the use of online clinical evidence: A qualitative analysis. International Journal of Medical Informatics, 69, 1–16. Graham, I. D., & Logan, J. (2004). Innovations in knowledge transfer and continuity of care. Canadian Journal of Nursing Research, 36(2), 89–103. Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P., & Kyriakidou, O. (2004). Diffusion of innovations in service organizations: Systematic review and recommendations. The Milbank Quarterly, 82(4), 581–629. Grol, R., Wensing, M., & Eccles, M. (2005). Improving patient care: The implementation of change in clinical practice. Waltham, MA: Elsevier Butterworth Heinemann. Grol, R. P. T. M., Bosch, M. C., Hulscher, M. E. J. L., Eccles, M. P., & Wensing, M. (2007). Planning and studying improvement in patient care: The use of theoretical perspectives. Milbank Quarterly, 85(1), 93–138. Helfrich, C., Damschroder, L., Hagedorn, H., Daggett, G., Sahay, A., Ritchie, M., et al. (2010). A critical synthesis of literature on the promoting action on research implementation in health services (PARIHS) framework. Implementation Science, 5(1), 82. Henderson, C. E., Taxman, F. S., & Young, D. W. (2008). A Rasch model analysis of evidencebased treatment practices used in the criminal justice system. Drug and Alcohol Dependence, 93(1–2), 163–175. Hoffman, P. B., & Beck, J. (1976). Salient factor score validation: A 1972 release cohort. Journal of Criminal Justice, 4, 69–76. Kilbourne, A. M., Neumann, M. S., Pincus, H. A., Bauer, M. S., & Stall, R. (2007). Implementing evidence-based interventions in health care: application of the replicating effective programs framework. Implementation Science, 2(1), 42. Kitson, A., Ahmed, L. B., Harvey, G., Seers, K., & Thompson, D. R. (1996). From research to practice: one organizational model for promoting research – based practice. Journal of Advanced Nursing, 23(3), 430–440. Klein, K. J., Conn, A. B., & Sorra, J. S. (2001). Implementing computerized technology: An organizational analysis. Journal of Applied Psychology, 86, 811–824. Klein, K. J., & Sorra, J. S. (1996). The challenge of innovation implementation. Academy of Management Review, 21, 1055–1080.

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Rogers, E. M. (1995). Diffusion of innovations (4th ed.). New York: The Free Press. Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York: The Free Press. Rycroft-Malone, J., Harvey, G., Kitson, A., McCormack, B., Seers, K., & Titchen, A. (2002). Getting evidence into practice: ingredients for change. Nursing Standard, 16(37), 38–43. Schoenwald, S. K., & Hoagwood, K. (2001). Effectiveness, transportability, and dissemination of interventions: What matters when? Psychiatric Services, 52, 1190–1197. Shortell, S. M. (2004). Increasing value: A research agenda for addressing the managerial and organizational challenges facing health care delivery in the United States. Medical Care Research and Review, 61(3 suppl), 12S–30S. Simpson, D. D. (2002). A conceptual framework for transferring research to practice. Journal of Substance Abuse Treatment, 22, 171–182. Simpson, D. D., & Dansereau, D. F. (2007). Assessing organizational functioning as a step toward innovation. Addiction Science & Clinical Practice, 3(2), 20–28. Spouse, J. (2001). Bridging theory and practice in the supervisory relationship: A sociocultural perspective. Journal of Advanced Nursing, 33(4), 512–522. Stetler, C. B. (2001). Updating the Stetler Model of research utilization to facilitate evidencebased practice. Nursing Outlook, 49(6), 272–279. Stetler, C., Ritchie, J., Rycroft-Malone, J., Schultz, A., & Charns, M. (2009). Institutionalizing evidence-based practice: An organizational case study using a model of strategic change. Implementation Science, 4(1), 78. Taxman, F. S. (1998). Reducing recidivism through a seamless system of care: Components of effective treatment, supervision, and transition services in the community. Washington: Office of National Drug Control Policy. Taxman, F. S., & Bouffard, J. A. (2000). The importance of systems issues in improving offender outcomes: Critical elements of treatment integrity. Justice Research and Policy, 2, 9–30. Taxman, F. S., Perdoni, M., & Harrison, L. D. (2007). Drug treatment services for adult offenders: The state of the state. Journal of Substance Abuse Treatment, 32, 239–254. Taylor, F. W. (1911). Scientific management. New York: Harper & Row. Walsh, W. F. (2001). Compstat: An analysis of an emerging police managerial paradigm. Policing: An International Journal of Police Strategies & Management, 24, 347. Wilson, P., Petticrew, M., Calnan, M., & Nazareth, I. (2010). Disseminating research findings: What should researchers do? A systematic scoping review of conceptual frameworks. Implementation Science, 5(1), 91.

Chapter 4

Organizational Change – Technology Transfer Processes: A Review of the Literature

Technology transfer (TT), as highlighted in the previous chapter, is a complex, multilevel process that requires an appreciation for both the innovation (i.e., evidence-based practice (EBP)) and the environment in which the transfer to practice occurs. The previous chapter describes various models of TT, including key conceptual frameworks and operative components. This chapter summarizes the state of knowledge about the factors that affect TT processes, particularly those that are successful and promising. The goal is to begin to conceptualize the factors that are important in the community corrections context given the unique features and demands of that setting. Over the past two decades, researchers have been examining the factors that result in successful adoption and/or implementation of EBP or innovation. The and/or is used to signify that this research is still in an embryonic stage regarding the methodologies employed, appropriate measures, types of innovations, and types of change strategies studied, in addition to the findings. The budding nature of the field demands that we begin to consider where further development – in research, in methodology, and in practice – is needed. A key concern for researchers, organizational leaders, and implementation scientists is the identification of the facilitators and barriers that affect the adoption and implementation of evidence-based principles and practices. This will unveil the tools to overcome the barriers and enhance the facilitators at multiple levels: individual (client), intervention, organizational, system, and policy. Further, it will allow a thorough study of the factors that advance the various stages of the transfer process, regardless of the TT model being considered. Most change process studies have been conducted within a single organization/agency that has a cohesive mission (e.g., improve the care of an individual, improve the health of an individual, educate youth); however, there is very limited understanding of change processes that occur within systems or large organizations with multiple goals, some of which may be secondary or foreign to the primary mission of one of the organizations or units. This is the immense challenge facing corrections and addiction treatment agencies that work together to provide treatment for drug-involved offenders. F.S. Taxman and S. Belenko, Implementing Evidence-Based Practices in Community Corrections and Addiction Treatment, Springer Series on Evidence-Based Crime Policy, DOI 10.1007/978-1-4614-0412-5_4, © Springer Science+Business Media, LLC 2012

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This chapter highlights findings from recent studies exploring the implementation of evidence-based practices. Many of the studies have occurred in the mental health or addiction treatment fields, where the goal was to improve the quality of treatment and services within the specific service sector. A more complete discussion and explication of these issues in correctional settings, relying upon the 2005 National Criminal Justice Treatment Practices (NCJTP) organizational surveys, will be discussed in Chap. 6. Using the substance abuse and mental health sectors’ frameworks will illuminate the factors that appear to be important in advancing adoption and implementation and will outline the list of constructs that may be salient in community corrections settings. In the latter, the goal is to advance the use of treatments for offenders with substance abuse disorders to reduce relapse and associated criminal behaviors. The challenges associated with importing knowledge into criminal justice settings have been recognized in light of the unique demands of interagency efforts between community corrections and addiction treatment agencies – evidence-based practices (treatment) are generally secondary to the overall mission of the corrections agency (Friedmann, Taxman, & Henderson, 2007; Grella et al., 2007; Henderson, Taxman, & Young, 2008; Oser, Staton Tindall, & Leukefeld, 2006; Young, Dembo, & Henderson, 2007). These complex issues are well documented and contribute to the challenges in advancing the uptake or routinization of high-quality effective treatment programs.

4.1

Systematic Reviews of Change Strategies

Systematic reviews of change strategies are rare given the limited number of quality research studies using randomized experimental and longitudinal designs. Damschroder et al. (2009) recently reviewed the organizational behavior literature and developed a conceptual framework for the field of implementation. As conceptualized by Damschroder et al. (2009) the Consolidated Framework for Implementation Research (CFIR) illustrates how an idea is translated into an adapted intervention. Figure 4.1 depicts the concept of translating a technology, as well as identifying the various parts of the process that need to be understood. These parts are included in other models, but the CFIR approach recognizes that four components have to be addressed for long-term success: innovation (intervention), inner setting, outer setting, and adapted intervention. The linear nature illustrates that the adapted intervention is shaped by the other components. They identified five areas where studies are being conducted: outer setting (i.e., organization’s economic, political, and social context), inner setting (i.e., structural factors, networks or communication, culture, climate, and readiness for implementation), characteristics of the individual players (i.e., knowledge, selfefficacy, organizational commitment, motivation, and other personal attributes); innovation or intervention characteristics; and type of change strategy. The goal of this CFIR framework was to provide an operational definition of key variables to assist with the development of the field.

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Fig. 4.1 Consolidated framework for implementation research process

The CFIR framework, similar to other efforts, identifies not only the major domains but some of the constructs involved in the process of implementation. The first domain is intervention or innovation characteristics. Damschroder et al. (2009) divide the intervention into core components (key principles) and adaptable periphery or the components that are amendable to alterations, such as the elements, structures, and systems related to the intervention and/or the organization. The periphery components are related to the concept of transportability (see Schoenwald & Hoagwood, 2001) that identifies the features of the setting, population, and organization that must be molded to fit the innovation. Inner and outer settings are the next domains. The outer setting represents the socio-political environment (i.e., structure, political, culture aspects) within which implementation proceeds. Damschroder et al. (2009) acknowledge that the lines between inner and outer settings are variable depending on the intervention or innovation, but both domains refer to tightly or loosely coupled entities involved in the implementation. Another domain of the CFIR is the characteristics of the individual involved in the process that includes managers, staff, and potentially clients (customers), whether they are in the inner or outer setting. It is important to address the underlying personal values and perspectives of the participants in order to assess the value of an innovation. This includes the norms, interests, affiliations, and perspectives that each person brings to the table. Addressing the participants is important in a TT process; this recognizes that the staff, administrators, and stakeholders need to understand the innovation in order to effectively implement it. Finally the focus is on the process of implementation (the change strategy) which is generally some type of structured and active change process directed at the inner and/or outer setting. In essence, implementation may require a series of processes or subprocesses that are important to help individuals, organizations, and systems move forward. These vary significantly in their approach, but the goal is to consider the socio-political (and legal) environment, as efforts are undertaken to refine, test, and pilot the new innovation. Three other systematic reviews provide useful guidance as to the impact of different factors on change outcomes. None provided effect sizes for any given facilitator or barrier, but they ranked the findings based on the number of studies and the general direction of the finding, while acknowledging that there are insufficient studies to make a determination about any one factor. For example, Greenhalgh, Robert, Macfarlane, Bate, and Kyriakidou (2004) conducted a comprehensive systematic review of the factors that are important in successful implementation of innovations in a myriad of service organizations. The review consisted of 495 sources

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(213 empirical studies, 282 nonempirical studies) that assessed TT models where “a novel set of behaviors, routines and ways of working that are directed at improving health outcomes, administrative efficiency, cost effectiveness, or users’ experience and that are implemented by planned and coordinated actions” (pg. 582). The researchers used meta-narrative techniques to trace the historical development of ideas, concepts, and methods that were used to study different aspects of the change management process and innovations. Given the brief existence of this field of study, this systematic review furnishes an important starting point to understand the state of knowledge about factors that lead to the successful adoption and implementation of evidence-based practice(s). Greenhalgh et al. (2004) conclude that “the findings presented … should therefore be seen as ‘illuminating’ the problem and ‘raising issues’ to consider rather than ‘providing the definitive answers’” (pgs. 613–614). Their study revealed that given the vast scope of TT, and the fact that studies tend to look at only a small part of the TT process, it is difficult to examine a total change process. Greenhalgh et al. (2004) believed that it was more important to acquire a comprehensive set of variables that might affect the TT process and therefore used this review to assemble an overall model (see Fig. 4.2) that reflects what others have done recently (Damschroder et al., 2009). The structure of the Greenhalgh et al. model recognizes that transfer involves a rather messy process where the organization pulsates through various cycles of initiation, development, and implementation that is “punctuated by shocks, setbacks, and surprises” (Greenhalgh et al., 2004, 601). Greenhalgh et al. (2004) used the World Health Organization Health Evidence Network (WHO-HEN) (see Øvretveit, 2003) strategy to rank knowledge in the following categories: SDE SIE MDE MIE LE None

Strong direct evidence in two or more rigorous empirical studies in a health service organization Strong indirect evidence or two or more rigorous empirical studies but not necessarily in a health service organization Moderate direct evidence is two or more empirical studies in studies of less rigor in health service organizations Moderate indirect evidence is two or more empirical studies in studies of less rigor Limited evidence is one rigorous study or inconsistent findings No studies have been conducted of scientific quality

They identified the state of knowledge and number of studies conducted in each area. A limitation of this approach is that the researchers do not identify the empirical studies or include the theoretical literature in ranking the state of knowledge. The review, however, highlights that there are limited empirical studies in the field in this area of TT and that more work is needed to further our understanding of the implementation of innovations. Highlights from this review are discussed in the following sections. Another helpful systematic review was recently conducted on the contextual factors influencing outcomes from quality improvement (QI) efforts in health care.

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SYSTEM ANTECEDENTS FOR INNOVATION THE INNOVATION Relative advantage Low complexity Trialability Observability Potential for reinvention Fuzzy boundaries Risk Task issues Nature of knowledge required (tacit/explicit) Technical support

Structure Absorptive capacity or new knowledge Receptive context for change Size/maturity Preexisting knowledge/skills base Leadership and vision Ability to find, interpret, recodify, Formalization Good managerial relations and integrate new knowledge Differentiation Risk-taking climate Enablement of information sharing Decentralization Clear goals and priorities via internal and external networks Slack resources High-quality data capture

User system Resource system

LINKAGE System antecedents

The innovation COMMUNICATION AND INFLUENCE

Knowledge purveyors

DIFFUSION i (informal, unplanned( Social networks Homophily Peer opinion Marketing Expert opinion Champions Boundary spanners Change agents DISSEMINATION (formal, planned)

OUTER CONTEXT Sociopolitical climate Incentives and mandates Interorganizational normsetting and networks Environmental stability

System readiness Diffusion

Adoption/assimilation

Dissemination

Change agency

SYSTEM READINESS FOR INNOVATION Tension for change Innovation-system fit Power balance (supporters v. opponents Assessment of implications Dedicated time/resources Monitoring and feedback

LINKAGE

ADOPTER Needs Motivation Values and goals Skills Learning style Social networks

ASSIMILATION Complex, nonlinear process “Soft periphery” elements

Implementation

Outer context

Consequences

LINKAGE Implementation Design stage Communication and innovation Shared meanings and mission User orientation Effective knowledge transfer Product augmentation, e.g. technical help User involvement in specification Project manager support Capture of user-led innovation

IMPLEMENTATION PROCESS Decision making devolved to frontline teams Hands-on approach by leaders and managers Human resource issues, especially training Dedicated resources Internal communication External collaboration Reinvention/development Feedback on progress

SOURCE: Greenhalgh, T., Robert, G., MacFarlane, F., Bate, P., & Kyriakidou, O. 2004. Diffusion of Innovations in Service Organizations. Milbank Quarterly 82(4), 581-629.

Fig. 4.2 Greenhalgh et al. (2004) model of technology transfer

As previously discussed, QI models cover a broad category of TT changes where team members assess, design, implement, and measure a small incremental change. This continuous process is used to improve procedures and processes. Kaplan et al. (2010) identified 47 articles summarizing studies of QI or “systematic, data-guided activities designed to bring about immediate, positive changes in the delivery of health care” (Baily, Bottrell, Lynn, Jennings, & Hastings, 2006, as cited in Kaplan et al., 2010, 502). The authors did not calculate effect sizes, but rather noted that the associations between the factors that affect success were deemed to be significant (p < 0.05). Success consisted of the extent of implementation of QI practices (n = 15, 32%), perception of success (n = 19, 40%), adoption of total quality management (TQM) (n = 7, 15%), superior organizational performance (n = 5, 11%), or pre-post process or outcome changes (n = 9, 19%). This systematic review helps to clarify the factors of success surrounding the myriad QI processes that are available. Garner (2009) summarized the literature on the adoption of evidence-based practices in addiction treatment agencies, identifying 69 studies examining factors

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that contribute to TT in the areas of staff and agency attitudes, adoptions, or implementation of evidence-based practices. Few studies were experimental; most were analyses of organizational survey data that examined patterns of factors that are related to adoption of evidence-based practices or innovations. The study examined both behavioral and pharmacological therapies as the main innovations of interest. Garner, similar to Greenhalgh et al. (2004) and Kaplan et al. (2010), was reluctant to make definitive conclusions about the organizational factors that were most important to adoption patterns given the relatively young nature of the field. Collectively these systematic reviews provide guidance as to factors that are important to consider when adopting/implementing evidence-based practices.

4.2

Outer Setting: The Environmental Context for Change

The external environment can either be supportive or distracting to moving forward with internal organizational change processes. Included in the outer setting are the socio-political climate, incentives, regulatory and legal mandates, interorganizational norm setting, interorganizational networks, and environment stability (Greenhalgh et al., 2004) as well as the nature of regulatory reform, competition from the environment, and pay for performance models. Similarly, Fixsen, Naoom, Blase, Friedman, and Wallace (2005) define external influences as a shifting ecology of community, state, and federal influences on the social, economic, cultural, political, and policy environments. These influences simultaneously enable and impede implementation and program operation efforts due to the impact on funding, political support, availability of skilled staff, and other related concerns. Research on the influence of external factors on TT has been limited (see Table 4.1 which shows the limited number of studies per concept). Kaplan et al. (2010) noted that a majority of QI studies found that a competitive environment, managed care penetration (use of health maintenance organizations), union influence, and accreditation (professionalism) did not significantly affect QI success. However, significant factors generating positive outcomes of organizational change include federal funding influences (from Medicare/Medicaid), federal regulations, and pay for performance models (paying incentives for outcomes; see Coiera, 2003; McLellan, Kemp, Brooks, & Carise, 2008). Although explicitly adopted changes can help minimize barriers to implementation and enhance facilitators, there has been little research on these issues. However, the degree to which the external environment supports the internal environment is hypothesized to be an important factor in successful change strategies (Damschroder et al., 2009; Greenhalgh et al., 2004). Specific influential outer setting factors were identified by Greenhalgh et al. (2004) and are summarized in Table 4.1. Also included are the numbers of studies that have been conducted in each area. Table 4.1 illustrates that few studies explore outer setting issues, indicating a great need for research to understand the impact of outer setting issues on change processes.

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Table 4.1 Outer setting: major research findings (Greenhalgh et al., 2004) Area: outer context Findings (number of studies) Networks SDE: other professional or similar organizations have adopted an innovation (4) SDE: organizations that tend to network are more likely to adopt (4) SIE/MDE: organizations support adoption only after the innovation is perceived as the norm; otherwise networks dissuade adoption (3) SIE/MDE: adoption of innovation is influenced by the structure and quality of their social networks (1) MDE/LDE: horizontal networks (across agencies) spread peer influence and support the construction of meaning for an innovation; vertical networks are more effective for sharing authoritarian decisions (2) MDE: professional associations, networked agencies, and provider organizations with common management and values can spread the innovation (1) MIE: complex implementation is more likely to be successful with support from interorganizational networks (1) Incremental Spread Strategies

MDE: quality improvement collaboratives aimed at sharing ideas and knowledge are inconsistent in affecting adoption (7) MDE: QI influenced by topic selected, capacity/motivation of the teams, motivation/receptivity of the organization, quality of facilitation, quality of support to the teams (1)

Wider Environment

MDE: small or no impact of wider environment on adoption/implementation of innovation (2) LE: competitive competition or higher social status of patients may affect innovation adoption (1)

Political Directives

SDE: policy “push” through national initiatives at the early stage or funding demonstration projects increases adoption (4) MDE: external mandates increase motivation but not the capacity, and capacity affects adoption (1) SIE/MDE: some mandates divert from adoption due to internal organizational concerns about future initiatives (2)

SDE strong direct evidence; MDE moderate direct evidence; SID strong indirect evidence; LE limited evidence

“Networkness” (defined as the working relationship and collaboration among agencies and organizations in a system) appears to be an important factor related to an organization’s willingness to pursue innovations. Working with support from stakeholders generally serves to support efforts to pursue evidence-based practices and treatments. Research on addiction treatment programs indicates that outcomes are improved when effective interorganizational working relationships exist (D’Aunno, 2006). Although there has been limited research on the influence of interorganizational relationships on the adoption of community-based addiction treatment, more research is needed on the interplay and characteristics of productive networkness between addiction treatment providers and criminal justice agencies (Fletcher et al., 2009; Taxman & Bouffard, 2000). This is an important area for the nexus of correctional agencies and addiction treatment providers because many corrections agencies contract

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for such services rather than provide them directly (Taxman & Bouffard, 2000). The concept of a seamless system (i.e., the integration of services across agencies) recognizes that there need to be supportive policies and procedures that support operations of “boundaryless systems of care” where the client is unsure which system is providing care (Taxman & Bouffard, 2000). In Chap. 6, we will review the findings on networkness or integration in correctional agencies. An important outer setting issue concerns the recognition of an innovation by key government agencies or top leaders in the field. Seven studies have found that a policy “push” advances the adoption of an initiative. A policy push may include a national demonstration project or stakeholder meetings at the national level. Several examples are available in the criminal justice-addiction treatment field. For example, the 1994 Crime Bill established specialized funding for drug courts through the Office of Justice Programs, U.S. Department of Justice (OJP). Since 1995, OJP has provided planning or implementation grant money to drug courts that have reinforced the importance of these models. Similarly, in the same period of time, the federal government provided grant funds for in-prison therapeutic community programs (referred to as Residential Substance Abuse Treatment (RSAT)) that have triggered the spread of in-prison treatment programs (see Taxman, Perdoni, & Harrison, 2007 for a discussion on the impact on in-prison substance abuse treatment programs). Young, Farrell, Henderson, and Taxman (2009) found that when state government articulates a policy that supports the adoption of evidence-based practices, either through legislation, regulation, or policy oversight, this action has a positive impact on the type and nature of addiction treatment programs available for offenders. In summary, the support from multiple stakeholder agencies is a desirable ingredient to affect the change processes of an organization. Support means more than just financial resources; in fact, external partners should be required to provide collateral agreement that the innovation or evidence-based practice would advance the attainment of goals and is consistent with overall political and social agendas. Although political climate and socio-political environmental factors have been explored in a few studies, a greater appreciation for the outer setting is needed as a key research agenda. The outer setting can be persuasive about the value of the innovation, and this is essential for generating the support needed for internal changes.

4.3

Inner Setting: Within a Specific Organization

The inner setting refers to the internal workings of the agency or organization where the TT will occur. As outlined by Greenhalgh et al. (2004), this includes the organizational goals, mission, priorities, culture and climate, staff and managers, readiness for change, and the business process. Organizational factors found to be important in treatment innovation include philosophical orientation that supports innovation, organizational resources, counselor credentials, and client characteristics (Ducharme, Knudsen, Roman, & Johnson, 2007). Other factors include the availability of knowledge purveyors, structure, capacity for knowledge, and receptivity (readiness) for change (Greenhalgh et al., 2004; Rogers, 1995). Scholars have

4.3

Inner Setting: Within a Specific Organization

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raised a concern about the organization’s “absorptive capacity,” or ability to identify and incorporate new information (Greenhalgh et al., 2004; Knudsen & Roman, 2004); this factor may also affect whether TT is successful. That is, some organizations do not have the capacity to absorb new knowledge, processes, or procedures given the existing workload or tensions within the agency. Another important factor may be an organization’s willingness to take risks; the higher the willingness to take risks, the greater the likelihood of adopting innovative mental health interventions (Panzano & Roth, 2006). Knowledge about the inner setting in the addiction treatment literature is available from three major research studies as well as from a series of individual studies that explored organizational issues. For the last two decades, researchers have tried to understand the organizational factors that affect the quality of treatment services delivered in the U.S. addiction treatment system. The Drug Abuse Treatment Outcome Study (DATOS) (1991–1993), led by Dwayne Simpson (Texas Christian University), examined the organizational factors of 96 treatment programs that provide outpatient methadone, outpatient drug free, long-term residential, and short-term inpatient services (Simpson, Joe, & Brown, 1997; see http://www.ibr.tcu.edu/projects/datos/datos.html). DATOS included an interview with the treatment agency director to learn about the structure of the organization and the characteristics of the agency. The Organizational Readiness for Change instrument (ORC, see Lehman, Greener, & Simpson, 2002) was developed as part of the DATOS study to measure different facets of the agency. The ORC instrument includes organizational structure, mission and goals, training, resources, management information systems, access to information about innovations, and other key domains that relate to factors that affect the inner setting. During 1994–2002, Dr. Paul Roman of the University of Georgia led the National Treatment Center Study (NTCS) of 450 private sector alcohol and drug treatment centers. The centers included in the study could be for-profit or nonprofit, but they had to receive no more than 50% of their funding from any type of government contracts. This longitudinal study included four in-person interviews followed by brief monthly calls to document the organizational factors affecting the types of treatment services offered including medication assisted treatments, use of evidencebased treatments (e.g., motivational enhancements, cognitive–behavioral treatment), and various supportive or augmentative care (e.g., smoking cessation, child care) (Roman, Ducharme, & Knudsen, 2006; Roman & Johnson, 2002). In 1999, the National Institute on Drug Abuse established the Clinical Trials Network (CTN), a collaborative research partnership between university-based researchers and community treatment programs (any addiction treatment program in a given area that was interested in participating in the network), to disseminate results from efficacy trials to increase the adoption of evidence-based treatments (http://drugabuse.gov/CTN/). The partnership consists of 17 nodes (researchers + community programs) representing 109 treatment organizations that provide 262 unique treatment services (Roman, Abraham, Rothrauff, & Knudsen, 2010). The community treatment partner network is an evolving group given that different research studies often require treatment programs tailored to specific populations or needs (see Roman et al., 2010 for a discussion). Longitudinal surveys were conducted including a baseline interview followed by surveys at 12, 24, and 48 months.

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Other research on the organizational factors in addiction treatment that affect adoption in addiction treatment programs include training studies from 800 treatment centers (Simpson & Flynn, 2007), specific studies of implementation of multidimensional family therapy programs (Liddle et al., 2002), and specific studies on training programs (Baer et al., 2007; Walters, Matson, Baer, & Ziedonis, 2005). The Appendix summarizes the main findings from these various studies, while the following discusses organizational factors in more detail.

4.3.1

Readiness for Change

Weiner (2009) recently summarized the concept of readiness for change, noting that this construct was not clear in most studies. He comments that the important ingredients for change include valuing the change, finding the change to be efficacious regarding demands of the new procedures, availability of resources for the innovation, and situational factors that affect the degree to which the staff and organization will embrace the innovation. For Weiner (2009), the concept of readiness is that the culture supports learning, risk-taking (Panzano & Roth, 2006), and new ideas. Organizational readiness for change is not only a multilevel construct, but a multifaceted one. Specifically, organizational readiness refers to organizational members’ change commitment and change efficacy to implement organizational change. This definition followed the ordinary language use of the terms “readiness” which connotes a state of being both psychologically and behaviorally prepared to take action (i.e., willing and able). Similar to Bandura’s notion of goal commitment, change commitment refers to organizational members’ shared resolve to pursue the course of action involved in change implementation. I emphasize shared resolve because implementing complex organizational change involves the collective action by many people, each of whom contributes something to the implementation effort. Because implementation is often a “team sport”, problems arise when some feel committed to implement but others do not. Herscovitch and Meyer (22) observe that organizational members can commit to implementing an organizational change because they want to (they value the change), because they have to (they have little choice), or because they ought to (they feel obliged). Commitment based on “want to” motives reflects the highest level of commitment to implement change. (Weiner, 2009: 67)

The ORC instrument (Lehman et al., 2002) was used in 249 substance abuse treatment programs to capture the perceptions of administrators and staff (n = 2,234) on the intended use of four evidence-based practices (manualized treatments, medications, integrated mental health services, and motivational incentives) as well as contemporary practices without empirical support (confrontation and noncompliance discharge). The ORC has several components including a motivational category that consists of three domains: perceived need for improvement, perceived training needs, and pressure for change. All three were found to be useful in the intended use of evidence-based practices (Lehman, et al., 2002). Another category is the support for evidence-based practices in treatment programs: organizations where staff perceive more need for improvement, have access to the internet (a measure of resources), show higher levels of peer influence, identify more opportunities for professional growth, identify with a stronger sense of organizational mission,

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and exhibit more organizational stress are more likely to adopt innovations. Support for confrontation therapies and the use of noncompliance discharge was more likely to occur when staff saw less opportunity for professional growth, weaker peer influence, less internet access, and perceived less organizational stress (Fuller et al., 2007). In treatment agencies, organizational readiness was an important factor overall, but only one construct – perceived program need for improvement – was useful in explaining intent to adopt the innovations (Fuller et al., 2007). The importance of motivation to implement is demonstrated in the recent review of QI studies where motivation to implement (42%) and motivation to change the organization (60%) were associated with positive organizational outcomes (Kaplan et al., 2010).

4.3.2

Alignment of Values

The idea that the innovation needs to conform to organizational and staff values and norms has been a fundamental tenet of diffusion theory (Rogers, 1995). If the innovation does not fit within the values of an organization, then individuals in the organization will not be committed to the innovations (Klein & Sorra, 1996). The importance of the alignment of values and norms has been cited by researchers in the diffusion of evidence-based substance abuse treatment (Eliason, 2003; Henderson et al., 2008; Knudsen, Ducharme, & Roman, 2006; Schoenwald & Hoagwood, 2001; Taxman & Bouffard, 2000). Success in implementing an innovation may in part depend on how program staff and administration perceive the differences between usual program or clinical practice and the new innovation and those that are closer in alignment are more likely to be embraced (Schoenwald & Hoagwood, 2001). In his systematic review of the literature on innovations in substance abuse treatment, Garner (2009) notes that attitudes toward evidence-based treatments consist of two dimensions: general impression of the need to adopt “new approaches” and more specific attitudes toward a given evidence-based treatment. Garner (2009) found that clinical staff tend to view psychosocial evidence-based treatment more favorably than medication, but this was generally affected by the degree of training provided to increase awareness about the research on a given topic. In fact, the amount and degree of training serves to increase awareness about the available research on different treatments and staff’s own professional identity. Staff attitudes affect the ability of the organization to be open to new ideas about ways to improve outcomes.

4.3.3

Structure

Organizational structure refers to the formal authority and power relationships in an organization. For treatment agencies, structure is important because the type of governing body may vary considerably including for profit, nonprofit, linked to a medical center or another agency or small independent therapist. Most correctional agencies are public entities, but they can be part of different levels of government

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(i.e., local, state, or federal). The government agency can also be housed with other similar agencies (i.e., prison, probation, parole) or the organizational structure can be segmented into several different agencies. Addiction treatment services can be operated by correctional agencies or can be administered by a vendor, or another government agency (behavioral health). Staff can be salaried, contractual or in-kind support from other organizations. All of these dimensions have the potential to impact the ability and capability of the organization to embrace a new innovation. The integration of clinical care into services is a function of how clinical services are structured. In their analysis of the effects of QI on outcomes, Kaplan et al. (2010) found that clinical integration was important in the studies that measured the concept (only a quarter included a measure of structure). Knudsen, Ducharme, and Roman (2007) found that structure was important in the adoption of medications in substance abuse treatment programs where privately owned clinics were more likely to adopt than public clinics. Adoption rates were highest for hospitalbased centers with detoxification and inpatient treatment, having a physician on staff, use of other medications, private clinics, and accredited or larger clinics (see Appendix). In fact, structure is important but can have varied impact depending on the organizational culture. In general, the NTCS found differences in adoption rates among private and public facilities, with the former more likely to adopt medication-assisted treatments (e.g., buprenorphine, naltrexone) larger centers were also more likely to use treatment innovations. Unfortunately, these settings are not typically used by community corrections agencies for treatment referrals (Latessa, Cullen, & Gendreau, 2002). Another structural variable is the accreditation of the program. Accreditation is a process that signifies that the agency meets certain standards. In the addiction treatment field, a number of accreditations exist such as Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and Commission on Accreditation of Rehabilitation Facilities (CARF). States typically license treatment providers based on certain standards, and community corrections agencies often limit their funding for treatment services to licensed providers (see Grella et al., 2007). The American Correctional Association offers accreditation of facilities and community corrections agencies. Knudsen et al. (2007) found that accreditation status affected the adoption of medications treatment accredited substance abuse treatment clinics are more likely to adopt medications. Despite a relatively strong evidence base including numerous randomized clinical trials over many years, the use of medications has been slow to be adopted in the substance abuse treatment field (Institute of Medicine, 1992, 2002, 2006).

4.3.4

Professionalism and Staffing

Type of staffing and professionalism are related to the adoption of innovations. In the NTCS study, Knudsen et al. (2007) found that staffing, funding type, and workforce professionalism affected the adoption of medication in addiction treatment

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programs. One CTN study of staff in treatment facilities found that staff with advanced graduate degrees were more open to supporting new innovations (McCarty et al., 2007). Managers tend to be more supportive of evidence-based treatments than counselors or administrative staff in the clinics. Medical staff also tend to be more supportive than counselors or other staff. This is similar to smaller studies of some clinics within the CTN network that found that more formally educated staff were more likely to support the use of evidence-based treatments while staff with less education supported the use of confrontational therapies and early discharge from programs, strategies that are not supported by the research (Arfken, Agius, Dickson, Anderson, & Hegedus, 2005; Fuller et al., 2007). The amount of education and the type of training of the staff affect the attitudes toward evidence-based treatments. McCarty et al. (2007) also note that administrative staff spend more time with clients than do professional staff, and they tend to have less supportive attitudes toward evidence-based treatments. Given the interaction with the clientele, efforts are needed to include these staff in training and in work within the organization to prepare for treatment. Increasing professionalism, particularly with training to educate the staff, appears to be an important component related to adoption of innovations.

4.3.5

Resources

Financial, space, and staff resources are important to an organization. Other resources include training and technical assistance available to the agency since they affect the support that staff have to perform job-related tasks. The amount of resources available to support critical services affects the degree to which the organization is open to innovations. For example, Eliason (2003) found that insufficient case management staff, high caseloads, and inadequate training and referral materials limited the willingness to pursue innovations. Another resource is the availability of researchers for the agency. The importance of fostering researcher–practitioner collaborations has been noted (Eliason, 2003), especially because staff may have negative attitudes toward or lack of knowledge about research, as well as substance abuse treatment, and the network establishes a partnership between the agency and the staff. Some evidence exists that involvement of a researcher improves the fidelity of the innovation and outcomes (Lipsey & Landenberger, 2006). The exposure or involvement in a research program may or may not be of value in the adoption of an evidence-based practice (Roman et al., 2010); in fact, different types of treatment innovations had different organizational variables that predicted the adoption of the treatment. Programs that were involved in a CTN trial involving buprenorphine were more likely to adopt buprenorphine than those that were not involved in the research protocol, especially for programs that also offered detoxification services and had specialized medical staff readily available (Ducharme et al., 2007). Yet staff involvement in a clinical trial did not predict the adoption of contingency management (reinforcers for positive behavior); the main predictor was the source of funding for the substance abuse

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treatment program including block grants, contracts, contracts from criminal justice agencies (see Ducharme et al., 2007 for further discussion). It appears that the value of participating in research may vary considerably depending upon the innovation and the life cycle of the innovation. Buprenorphine trials were conducted shortly after the medication was approved by the Food and Drug Administration (FDA) whereas contingency management has been in the public domain for many years. Therefore, the resources attached to “trialability” or Roger’s concept of piloting vary depending on the stage of adoption of the innovation, where research participation may be more valuable during the early stage of dissemination and not as valuable during later stages.

4.3.6

Summary of Inner Setting Findings

The inner setting is a complicated network of variables relating to the organization, and how these factors affect its operations. Thus far, various components have been conceptualized, with little known about the factors that heavily influence the issues of adoption, implementation, and sustainability. Much of the literature on these factors is from organizational surveys and, therefore, there have been no empirical tests of their direct effects on innovation adoption decisions. Table 4.2, adapted from Greenhalgh et al. (2004), summarizes the state of knowledge about these inner setting organizational factors and can be compared to findings from addiction research summarized in the Appendix. As noted, few studies have been conducted in a number of areas and, therefore, the evidence tends to be in a developmental stage. The majority of the studies are in the structure of the organization, where the two bodies of literature converge to suggest that larger organizations with greater tenure are more likely to be open to adoption of evidence-based practices. In addiction treatment studies, the data are from surveys instead of experiments or research testing varied inner settings on adoption and implementation of evidence-based practices. Further work is needed to understand these inner-setting issues, particularly as they relate to different stages of the implementation process.

4.4

Organizational-Level Models of Technology Transfer

A number of scholars have proposed a systematic process for implementing and sustaining effective interventions. Lessons from organizational and implementation studies encompassing a number of health, mental health, and social interventions are instructive for thinking about the TT process, and the steps that go along with identifying the innovations (programs and practices) that are presumed to yield positive changes in client outcomes. The selection of the innovation is the first step in a number of endeavors to improve the outcomes and delivery of services. Despite the designation of a number of interventions and practices as

Table 4.2 Inner setting: summary of research (Greenhalgh et al., 2004) Area Findings (number of studies) Stage of adoptors None: little support for the concept of different adoption patterns (early, late) including the “S” shape pathway (1) General psychological Worthy: cognitive and social psychology of individual traits antecedents of staff associated with trying new innovations (1) Context-specific SDE: motivated and able individuals are more likely to adopt (3) psychological antecedents Nature of innovation SIE/MDE: meaning/value of the innovation influences adoption decisions (2) MIE: cohesion between managers and individual adopters is more likely to result in adoption (1) SDE: meaning of an innovation can be redefined by the individual or interagency workgroups is more likely to result in adoption (1) Concerns in SIE: intended adopters who are aware of the innovation, understand its preadoption stage components, and have sufficient training are more likely to adopt (1) Concerns during SIE: intended adopters who have access to information about the early use innovation, including training and task issues, are more likely to adopt (1) Concerns about SIE: adopters have adequate feedback on the consequences of the established users/ innovation (1) feedback SIE/MDE: accurate and timely review of the information increases utilization (3) Homophily of staff SDE: adoption is aided if individuals have similar backgrounds (i.e., SES, professional, cultural) with current users (3) Readiness for change SIE/MDE: receptive context of strong leadership, clear strategic vision, good management, visionary staff, climate for risk taking, and good data systems are more likely to lead to adoption (7) SDE: leadership that encourages risk taking and new ideas (1) Tension for change MDE: urgency that the current process is intolerable (1) Dedicated time/ SIE/MDE: innovation has a budget and allocation of resources are resources adequate and continuing (2) SDE: ongoing funding provides for implementation (5) Boundary spanners MDE: organizations that promote and use boundary spanners are more likely to adopt innovation quickly (1) Structure of the SDE: large, mature, functionally differentiated and specialized organization organizations will adopt innovations; availability of “slack” (discretionary resources; decentralized decision-making processes) (20) SDE: administrative intensity, complexity, external communication, functional differentiation, internal communication, positive management attitude toward change, professionalism, slack resources, specialization, technical capacity – each improves adoption; no impact from centralization or vertical differentiation (1) SID/SDE: decision-making by administrators on strategy and by operational on work process enhance success (2) None: organization structure can be made to be more innovative Absorptive capacity SDE: organizations that can absorb (identify, capture, interpret, share, for new reframe, recodify) new information will assimilate innovations (2) knowledge MDE: organic/natural interprofessional teamwork facilitates the development of shared meanings and values (1) SDE strong direct evidence; MDE moderate direct evidence; SID strong indirect evidence; LE limited evidence

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“evidence-based,” such interventions are slow to be disseminated to the field (Kilbourne, Neumann, Pincus, Bauer, & Stall, 2007), are often poorly implemented (Bourgon & Armstrong, 2005) or difficult to sustain (Brown & Flynn, 2002; Miller, Sorensen, Selzer, & Brigham, 2006). Successful TT must recognize the importance of improving program implementation to help drive the criminal justice delivered treatment services toward more sustainable interventions that improve offender outcomes. The widely recognized orientation is that TT will be most successful if it leads to the implementation of interventions that are fully implemented and sustainable (Fixsen et al., 2005; Schoenwald & Hoagwood, 2001). This involves ongoing organizational and systems collaborations to achieve the goal of sustainability. Liddle et al. (2002, 2006) consider technology transfer to be similar to designing an intervention, and outlined an organizational process for both the design and trial of the innovation. Their model includes the following components: (1) Organizational assessment that incorporates the rules, norms, practices, and policies of the organization; (2) Staff assessment that considers each staff member’s contribution to the new technology, such as how they might respond and be induced to accept it; (3) Preparing staff for change, such as explaining the rationale for the innovation, the steps involved, and new skills required; (4) Establishing priorities, deciding which aspects of the innovation are most likely to be adopted; and (5) Facilitating positive developmental processes, such as monitoring staff reactions, assessing progress, and making changes to implementation strategies as needed. Liddle et al. (2006) incorporate these phases into components of a new protocol for implementing Multidimensional Family Therapy intervention into these four phases, each with distinct components: Phase I: Baseline/preexposure (12 months) Phase II: Training (6 months) Phase III: Implementation, with clinical supervision (14 months) Phase IV: Durability/practice, without supervision (18 months) Simpson (2002) suggests that there are four key stages relating to staff factors in a process model of organizational change: (1) Exposure, in which staff are trained adequately and are motivated to change; (2) Adoption, indicating the intention to try an innovation at the individual staff or group level; group adoption is necessary for systemic implementation; (3) Implementation, referring to a period of trial use and testing of the innovation’s feasibility and utility in which there are appropriate institutional supports and climate for change; and (4) Practice, where the innovation has been incorporated into regular use; this may depend on staff attributes and incentives. Coiera (2003) proposed an economic framework for understanding innovation diffusion, arguing that the use of new clinical tools will be low as long as the costs of using them are perceived by staff to outweigh the benefits. Only when the benefitcost ratio shifts will the technology be accepted and used on a routine basis. New technology is also not effective if it is not readily or widely adopted. In addition, clinical staff may perceive existing practice as being just as effective as the innovation; thus the way in which staff perceive effectiveness is equally as important as an intervention’s actual impact – this is similar to Rogers’ diffusion constructs

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of compatibility and value added. Coiera (2003) notes that the impact of an innovation is a product of its adoption rate and its clinical impact. This is conceptually similar to the public health notion that the public health impact of an intervention is a product of the effect size on outcomes and its utilization rate or penetration into the target population (Tucker & Roth, 2006). Thus, a less than ideal innovation may be preferred if its adoption rate is higher than for an “ideal” system. The economic perspective suggests that incentives to use the technology may be needed to increase the perceived benefits to staff (Klein, Conn, & Sorra, 2001). Even where financial rewards are not possible, use of the new technology may increase job satisfaction and provide opportunities for professional development or advancement (Ash, 1997). Ongoing incentives (e.g., contingency management models) may help sustain the innovation once implemented (Andrzejewski, Kirby, Morral, & Iguchi, 2001). New systemic efforts to provide monetary incentives to treatment providers to achieve certain performance benchmarks is another model being tested in several jurisdictions with encouraging results; this “pay for performance” rewards staff for using the innovation in a very tangible way (McLellan et al., 2008). The success of any TT effort cannot be assured without a plan for long-term implementation and maintenance that will lead to sustainability (Fixsen et al., 2005). The ability to institutionalize new evidence-based practices into daily routine (the “durability/practice” Phase IV of the Liddle et al. (2006) technology transfer framework) is of crucial importance (Taxman & Sherman, 1998). A frequently cited barrier to the imposition of a new innovation is adding it to regular duties and tasks instead of taking into consideration the agency’s business practices and staff roles and responsibilities (Kaplan, 1997; Liddle et al., 2002). In theory, effective training and technical assistance should incorporate staff roles and responsibilities to enable staff to relate the technology to a particular role. Staff should be slowly engaged with the new technology, beginning only with what is necessary for his/her responsibilities and exposed over time to the full intervention or practice. Very little is actually known about the effectiveness of these components. Even the core components of the implementation process – preparing for implementation, adoption, and installation or sustainability phases – are relatively unknown. At this point, the stages are more theoretically than empirically derived, given the small amount of research that exists (see Table 4.3 for a summary from the Greenhalgh et al., 2004 systematic review). The ability of the staff to adopt and institutionalize the new innovation can determine whether or not implementation will be successful. A key challenge to implementing new technology is overcoming staff resistance to adopting new practices by those who are socialized into, and committed to, existing practice. To a large extent, these models are proposed to address three types of resistance that are likely to occur: (1) User-centered: resistance is due to factors related to the users, such as lack of knowledge or resistance to change. The characteristics of decision makers may determine the results. Staff are considered passive, resistant, or dysfunctional if they do not use the system as intended. (2) System-centered: the new innovation is viewed as problematic given that it does not fit well within the existing system. (3) Interactional resistance is a result of interrelationships and interactions among users, the system, and the organizational context in which the system is used (Markus, 1983).

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The following section examines the current state of knowledge around different key components. As discussed in Greenhalgh et al. (2004), little research exists in these areas of TT components, and, therefore, there is a need to expand studies to better understand what efforts will yield greater implementation success.

4.4.1

Preparing the Organization for the Change

Most often, discussions of technology transfer begin with a discussion about training. Backer (1993) suggests four necessary conditions for successful TT: (1) the innovation must be brought to the attention of the organization and made accessible for dissemination; (2) evidence must indicate that the innovation is feasible and effective; (3) there must be adequate resources available; and (4) interventions must be used to encourage staff and organizations to change. Program-level planning and preparation should be implemented before training to introduce staff to the innovation and its relevance to their jobs. This is part of what Burke and Hutchins (2007) refer to as declarative knowledge – preparing the organization to hear and accept the stark realities as to why change is necessary and then preparing the organization for the change process. It is through this process that leadership demonstrates support, determines that the organization has adequate resources, gauges how staff and partners will react, and determines the fit with the agency’s philosophy of care (Bartholomew, Joe, Rowan-Szal, & Simpson, 2007). As noted by Saldana, Chapman, Henggeler, and Rowland (2007), more clinical training and experience for counselors is related to acceptance of innovations, but caseload size may be an important barrier to their utilization and implementation of innovations. Innovations that are developed from a consensus process also may be more successful (Bero et al., 1998). Although it is important to have the support of senior management, innovations that are imposed from outside or above but that are not relevant to the daily work routines of line staff may not be implemented successfully (Kaplan, 1997). The innovation needs to be internalized by staff as important to their daily work (Liddle et al., 2002; Simpson, 2002). An important part of the preparation process is the focus on procedural knowledge and mapping to the business process. Knudsen, Ducharme, Roman, and Link (2005) report that besides diffusing knowledge about an innovation, staff must have positive attitudes toward the innovation. It is important for the leadership to build that positive support by involving staff and management in an effort to look at the innovations and assess their values. Knudsen et al. (2005) found that while several counselor characteristics were associated with perceived acceptability of buprenorphine treatment (i.e., included in training participation, internet use, 12-step orientation, education, and professionalism), their impression of whether the innovation is compatible with current practice, orientation, or values plays a large role. If a persuasion process does not exist, then it needs to be incorporated in training and access to information.

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Staff-Level Concerns Regarding Technology Transfer

Staff attitudes toward innovative treatment methods need further study and better understanding in order to develop strategies to deal with resistance (Knudsen et al., 2005; Taxman & Bouffard, 2002). Counselors may lack knowledge or may not believe in the effectiveness of an innovation; a low rate of knowledge may indicate that the innovation has not diffused. Staff professionalism and education level is related to more knowledge that in turn facilitates the acquisition of new knowledge (D’Aunno, 2006; McCarty et al., 2007). Staff with higher levels of education and more familiarity with a clinical approach are more accepting of evidence-based treatments. That is, if the clinicians had been trained in cognitive behavioral therapies, they are more likely to support innovations based on this foundation. Clinicians or counselors trained in self-help or directive counseling strategies would be less likely to welcome innovations based on these approaches. The literature on organizational absorptive capacity suggests that knowledge can be built by accessing information from external sources, suggesting a need to increase and improve external training and technical assistance for community corrections and treatment staff. More empirical research on training strategies is needed (Fixsen et al., 2005; Schoenwald & Hoagwood, 2001). Infrastructure problems within the substance abuse treatment field (discussed in Chap. 6) are another organizational factor that can negatively affect TT. The general lack of adequate and consistent counselor training, high staff turnover rates, low salaries, and low job satisfaction (Knudsen et al., 2006; McLellan, Carise, & Kleber, 2003; Øvretveit, 2003; Roman & Johnson, 2002) can readily undermine dissemination efforts. At the organizational level, lack of resources (especially for training and staff development), regulatory barriers, and administrative staff turnover may limit interest or capability to change treatment curricula or intervention designs. Turnover and resource constraints may also affect the stability of community corrections agencies but to a lesser degree. Low job satisfaction, staff resistance, cynicism, and lack of rehabilitative focus and interest among staff can be important barriers to dissemination, adherence, durability, and fidelity (Taxman & Bouffard, 2002). Knudsen et al. (2006) found that among treatment counselors, emotional exhaustion was related to one’s intention to leave the job as well as poor job performance. Counselors may be at high turnover risk because they are always dealing with people’s problems (Knudsen et al., 2006). The role of emotional exhaustion and workplace stress is important to examine for community corrections and treatment counselor staff. There is some evidence that emotional exhaustion is higher in organizations with a centralized decision-making structure, such as corrections agencies, than more horizontal organizations. Organizations in which staff perceive procedural or distributive justice may have lower levels of emotional exhaustion and thus lower turnover and better job performance (Knudsen et al., 2006; Taxman & Gordon, 2009).

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Client Factors

Although organizational and staff factors are central to an understanding of innovation diffusion, the client perspective tends to be entirely overlooked in the research and practice literature. Criminal justice interventions typically originate and are necessarily more aligned with public safety concerns than client needs and preferences, unlike health interventions where client concerns are primary and guide acceptance and application of specific treatments. The emerging and growing importance of patient-centered health are illustrative of this, but such a model would be a very difficult sell in the criminal justice system. Offenders move through the criminal justice system into community-based treatment under different levels of coercion (Young, 2002; Young & Belenko, 2002). Voluntary services (e.g., evidence-based substance abuse treatment interventions) for offenders must be able to recruit, engage, and retain offenders so that interventions can be delivered over time to engaged participants. A good example is found in prison treatment studies in California: only 20% of released offenders choose to attend aftercare programs and only 50% of that group remain the required 90 days or longer needed to produce the empirically verified recidivism reductions (Wexler, Burdon, & Prendergast, 2005). Increasing our understanding of the offender/client perspective related to treatment engagement will help to clarify barriers or facilitators to innovation diffusion. The growing recognition of patient choice and preference in treatment decisions and treatment outcomes (McKay, 2006) has little traction in the criminal justice system. The perceptions and preferences of offenders are rarely if ever considered in treatment referral decisions, although the involvement of the offender in the case management process is a recommendation to obtain greater offender commitment to treatment (Taxman, 2006, 2008). Offenders tend to come from marginalized and stigmatized populations; they come to treatment with a number of needs and barriers to successful outcomes that may need to be considered or may undermine the EBP effectiveness. These factors include poverty, limited education, high rates of mental and physical health problems, or low employment experience. They are stigmatized by media and politicized images that make it difficult to reintegrate into the community. Finally, criminal justice clients are often under the social control of multiple agencies and systems, which can make it difficult to adhere to treatment requirements. Decisions about treatment placements or level of treatment are rarely made with offender input, and the fit between an evidence-based treatment and offenders’ treatment and service needs is generally not part of the adoption and implementation decision process.

4.4.4

Change Actors

An important part of the change process is the array of players who are important to facilitate the change process. Rogers (1995) identified the need for opinion leaders (external stakeholders that are highly regarded by members of the organization),

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champions (internal leaders or key players that promote the innovation), facilitators (external or internal leaders that provide guidance for the organization), and social networks or structures that support the innovations. Fixsen et al. (2005) focused on organizational coaches who have the defined role of assisting the organization to commit to the change process and assisting the staff with the acquisition of needed skills to implement the innovation. These different hypothesized roles are believed to be important to assisting the organization during the various phases of the TT process. Yet, little research has been conducted on the type and amount of leadership or coaching support that is needed to advance the uptake of innovations. Fixsen et al. (2005) identified some guidelines for effective coaching based upon their review of the literature, while acknowledging that empirical research is not available on the actual components of coaching that are important. Coaches are needed to train, supervise, provide feedback, and provide support as the staff learns to implement innovations. Much of the literature on coaching is from the education field; for example, a meta-analysis by Joyce and Showers (2002) described coaches as being most effective when they are involved with the initial training of the staff and then continuing the learning after the initial session. In a study of physician improvements of their practices, an experiment compared physician-coaches and other-coaches (Wejnert, 2002). The study found that peer coaches (physician) outperformed the other coaches in terms of lessons acquired. That is, the staff were more likely to benefit from coaches that they perceive to be of a similar discipline than ones that are experts in a specific area but have never practiced as physicians. The importance of social networks and staff communication thus suggests that peer trainers may facilitate increased acceptance and use of an innovation (Wejnert, 2002). In a recent study of external facilitation, Kauth et al. (2010) found that providing external facilitation was most advantageous when the counselors had not been practicing the evidence-based treatment (in this case cognitive behavioral therapy) as compared to those that did not receive external facilitation. But the facilitator did not achieve greater utilization of CBT when the counselor was already using CBT in some of their counseling groups. Their results suggest that coaching may best be targeted for those that are novices at evidence-based treatment. In a clinical trial comparing the type of coaching services provided to caseworkers in a juvenile justice agencies, Taxman and colleagues compared two types of external coaches: (1) a consultant addressed the social climate for change by having line staff develop coaching material based on the needs and demands of the staff, as well as work with a small group of in-house staff who were to become experts on the material; and (2) a consultant providing in-office assistance to line staff in learning the material by provide “refresher” or booster sessions; compared with (3) no posttraining assistance provided (Taxman, Henderson, Young, & Farrell, 2010). The study found that staff benefited most from the social climate and social support facilitation rather than the skill-building, knowledge-building facilitation. This study is significant because it addresses more of what the coaches should do than merely the number of coaching hours or whether the presence of coaching makes a difference. Both coaches spent a similar amount of time with each office (at least four times post-training), but the social climate development achieved

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more uptakes since staff viewed that they had a stronger commitment to the change. Offices and staff assigned to the social climate development coach had a greater perception of commitment to the change, greater sense of organizational functionality, and lower perception of cynicism than the other two groups. Surprisingly, the knowledge builder coach did not achieve any more gains than no post-training facilitation (Taxman et al., 2010). Social networks within an organization that foster communication among users of the innovation can also facilitate successful implementation (Coiera, 2003; Kaplan, 1997; Klein et al., 2001; Wejnert, 2002). The seminal work of Rogers (1995) and others on innovation dissemination suggests that another type of support needed in organizations is a champion, or respected individuals who actively promote the innovation, build support, and overcome staff resistance (Howell & Higgins, 1990). Others note that the organizational climate (e.g., readiness) may interact with the presence of such a champion to determine whether dissemination is successful; it is also possible that a champion improves dissemination but not effectiveness, unless presence of a champion also is related to adherence to the protocol (Schoenwald & Hoagwood, 2001).

4.4.5

Training

Challenges related to implementation often emanate from staff training that is typically viewed as the main tool to introduce the new innovation and to prepare staff for the implementation journey. Unfortunately, training typically does not deal with the core needs of TT, such as building motivation, providing incentives to change practice, failing to provide ongoing training or booster sessions, and providing insufficient support to develop a core set of trained opinion leaders (Addiction Technology Transfer Center [ATTC], 2004; Eliason, 2003). Common barriers to using workshop-training materials include lack of time, insufficient training, lack of resources, and staff that are already using a similar approach (Bartholomew et al., 2007). Key elements of improving training effects that may be important are cognitive approaches (e.g., TCU’s node mapping techniques; see Dansereau, Dees, Greener, & Simpson, 1995), hands-on practice, feedback, rewards for progress, realistic expectations about skill requirements and limitations, organizational team building, peer support, and incentives for change (Coiera, 2003). As noted in a recent meta-analysis, training should have three major components: build knowledge about the innovation and the reason for the change; work on the procedures or processes that must be adapted; and attend to strategic knowledge to assist the organization to adapt the innovation to the workplace or business process (Burke & Hutchins, 2007). The focus on declarative, procedural, and strategic knowledge is critical to the transfer process, just providing staff with new skills will be insufficient if the training does not help the staff bridge across the organization’s operations. Training and skill development are important enhancements to the TT process. Researchers have shown that passive learning environments do not generally foster

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the adoption or use of innovations (Bero et al., 1998; Eliason, 2003). For example, the traditional workshop approach had minimal results in improving the skills of probation officers over the long term (Miller & Mount, 2001; Taxman, Shepardson, & Byrne, 2004). Trainees and new users can also be overwhelmed by too much information offered at one workshop (Coiera, 2003) and, therefore, cannot absorb too much training material in one session or series of sessions. This is why a focus on coaching and external facilitation is so important. An important component of the training process is organizational learning, or creating an environment where the organization is continually being exposed to new information. Typical techniques to improve the organization’s capacity to learn are interactions with other organizations and promotion of the use of external information sources, such as web-based materials (Knudsen & Roman, 2002), learning collaboratives, and communities of practice (see Chap. 8). As an example, Griffiths and Riddington (2001) found that health care professionals who used computers at home were more likely to use computerized databases at work and have more confidence in computerized databases. This suggests the need for providing resources and professional development opportunities to staff to increase their knowledge and skills about the innovations (Knudsen et al., 2005). In fact, since one-time training efforts are unlikely to increase skills and lead to successful technology implementation, an ongoing process, using interactive technology, is needed to foster the implementation of new technologies in criminal justice settings (Taxman et al., 2004).

4.5

Dissemination Efforts: Specialized Training by Researchers

Often, training refers to information sharing or knowledge awareness, and frequently researchers are asked to fill this role. The researchers typically review the current research findings and provide an indicator of what is the state of knowledge in a given discipline. A recent review by Wilson, Petticrew, Calnan, and Nazareth (2010) tackled the question about the effectiveness of different dissemination strategies in clinical settings. The review identified three dissemination strategies: persuasive communication, diffusion of innovations, and social marketing. Persuasive communication refers to a framework for providing key information, including the communication channels, the source of the material, the message, the characteristics of the audience, and the setting where the communication occurred. The review found that few studies examined all of the components of persuasive communication and that the techniques were multidimensional with the researcher and practitioner sharing information. In fact, knowledge transfer has been described to be an “interactive, multidirectional” process that focuses on problem identification, context, knowledge, intervention, and use (Ward, House, & Hamer, 2009). The second strategy is encompassed in the diffusion of innovations framework, modeled after Rogers (1995), with an emphasis on the rate at which practices are spread throughout the area of interest. The concept of rate is contextualized to examine how and why the spread occurs. It tests the knowledge → persuasion → decision → implementation → confirmation framework. For the most part, studies

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have only examined the knowledge and persuasion components. Generally, the findings are that efforts that consider the socio-political environment of an agency, including the weighing of costs and benefits, will yield greater uptake. One study found that efforts to improve dissemination of tobacco control were greatly aided by governmental policies that supported the efforts and provided funding for new initiatives in that area (Green et al., 2006 as cited in Wilson et al., 2010). The final dissemination framework is referred to as social marketing or the application of social and commercial marking and advertising principles. This involves a focus on the customers and their needs and desires. The emphasis is on “formatting evidence-based information so that it is clear and appealing by defined target audiences” (Wilson et al., 2010, 9). This is an evolving area of dissemination research that is geared to trying to understand the market and prepare material suited for that audience. See Chap. 9 for further discussion. Another area of dissemination is the use of guidelines for clinical practice. Guidelines are essentially a summary tool that interprets and assembles the scientific evidence and clinical practice into a framework to guide decision-making. An example is the American Society of Addiction Medicine (ASAM)’s Patient Placement Criteria (PPC) that provides a matrix of recommended placement based on an individual’s severity of substance use disorder (Mee-lee, Shulman, Fishman, Gastfriend, & Griffith, 2001). The matrix can assist users in making decisions about the appropriate level and type of care. A recent review by Grimshaw et al. (2004) examined the effectiveness and efficiency of guideline dissemination strategies. The review found 235 studies that used a variety of strategies including educational materials, reminder notices, audit, and feedback. Dissemination involved outreach efforts to target groups. No conclusions could be drawn about the effectiveness of various strategies, although it was noted that the dissemination strategies were generally supported through special initiatives instead of integrated into existing resources like training academies or lecture series. Grol (2001) found that more than 70 evidence-based guidelines have been developed. He generally found that knowledge and acceptance of the guidelines in the target group are high, particularly when the approaches are disseminated through written (scientific journal, support materials) and personal approaches (local consensus discussions, contact with colleagues, outreach visits by peers). He found that an average of 67% of the decisions rely upon the guidelines but there is variation by type of practice. Improvements in delivery included a “diagnostic analysis” of the target population’s needs before implementation. For more information on various guidelines, see the Agency for Healthcare Research and Quality (AHRQ) website (http://www.guideline.gov/).

4.5.1

Piloting

Rogers (1995) identified the concept of “Trialability” as important to diffusion but did little to expand upon what are the important components of a pilot that advance TT.

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Some agencies only pilot a small portion of a new innovation, while others conduct a pilot for a set length of time. If a new innovation can be tested first, it reduces uncertainty in the organization and can demonstrate feasibility and lead to initial implementation (see also Fixsen et al., 2005). As shown by the Ducharme et al. (2007) models that examine the participation in research studies of buprenorphine or contingency management, participation in research may or may not lead to adoption of an innovation; the question remains open as to the components of the TT process that are critical to advance adoption of the innovation, particularly if the goal is to expand sustainability after the trial period.

4.5.2

Fidelity and Program Integrity

Implementation and program fidelity go hand-in-hand. Fidelity refers to the degree to which the program implemented the innovation as intended regarding the dosage amount or the key components. Experienced program planners generally measure whether the new intervention was implemented, whether it was tried but poor clinical practice interfered with the implementation, whether implementation was faulty or whether the program was implemented but went adrift (Fixsen et al., 2005). All of these factors can determine whether or not the innovation was well received in the practice setting, as well as how to modify the program to improve outcomes. However, achieving and maintaining fidelity in real-world settings can be quite difficult (Bourgon & Armstrong, 2005; Morrison, 2004). For obvious reasons, maintaining fidelity may be more difficult in larger programs. Lack of program integrity in a large program may account for the lack of effect observed for cognitive skills training interventions implemented in larger corrections agencies (Van Voorhis, Spruance, Johnson Listwan, Ritchie, & Seabrook, 2004; see Chap. 8 for further discussion).

4.5.3

Performance Monitoring

Given the difficulties of defining EBP and the time and cost of determining treatment effectiveness using multiple randomized clinical trials, policymakers have begun turning to alternative approaches to improve treatment delivery. Such an approach focuses more on measuring how well a program specifies: what it is doing, how it is doing it, and whether it can demonstrate fidelity to the previous model. In other words, there is some movement away from clinical trials and more reliance on development of programs through fidelity monitoring as well as performance monitoring. One recent initiative in this area suggests that oversight agencies can obtain improved performance from treatment providers by establishing performance contracts that specify benchmarks to be met. Benchmarks, like QI methods, focus on

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the organization identifying their own goals and objectives. This approach deemphasizes central control over the design and content of an intervention but instead focuses on whether desired goals were achieved. In Delaware, the state substance abuse treatment agency instituted an experimental performance contracting system in 2002 that tied provider funding to the ability to meet performance goals. In place of the standard cost-reimbursement models, contracts with outpatient treatment providers required them to meet specified benchmarks in order to receive full reimbursement on their contract. Failure to meet these benchmarks meant that the provider would not receive full funding, which could jeopardize their continued operational viability. Achieving the performance goals meant that the full amount would be reimbursed, and providers that exceeded performance goals also received monetary performance bonuses. Incentive payments were calculated and paid on a monthly basis. An evaluation of the program found that contracted providers improved client outcomes in terms of capacity utilization, percentage of clients meeting treatment participation requirements, and program retention over a 4-year period (McLellan et al., 2008). Because Delaware did not mandate treatment techniques or clinical approaches, this experiment suggests that treatment outcomes can be improved solely by using incentivized performance contracts.

4.5.4

Quality Improvement Models

Kaplan et al. (2010) conducted a meta-analysis of the impact of QI models in health care settings. The analysis found that size of the organization, leadership from management, organizational culture, the number of years involved in QI models, and data infrastructure were related to successful implementation of QI. The authors also note that several areas are understudied but when included are found useful for positive QI outcomes: organizational structure, clinical integration across organizational units, customer focus, senior staff (physician) involvement in QI, focus on microsystem motivation to change, resources, and the nature of the QI leadership team. The authors note that for QI initiatives to be successful, the focus should be on organizational infrastructure, information systems, QI circles (leadership teams), and commitment to QI.

4.5.5

Summary

This section has focused on the mechanisms to facilitate organizational change and implementation. Table 4.3 summarizes the findings from Greenhalgh et al. (2004) with regard to dissemination in the innovation management process. As shown in this table, few studies have been conducted on the change processes that limit the

Table 4.3 Implementation efforts to advance adoption (from Greenhalgh et al., 2004) Area Findings (number of studies) Innovation SDE: does not guarantee widespread adoption (3) Relative MDE: long discourses on this topic do not guarantee perception of advantage advantage (in either direction) (1) Compatibility SDE: at the individual level increases adoption (4) SDE: organizational norms/values increase assimilation (3) Complexity SDE: perceived simple are easier to adopt (5) MDE: piloting may reduce perception of complexity (1) SIE/MDE: break the intervention and adopt incrementally Trialability SDE: pilot will lead to easier assimilation (4) SIE/MDE: allow “space” for trials (3) Observabilty SDE: benefits visible, easy to adopt (4) LE: demonstrations or other initiatives to increase visibility increase implementation (1) Reinvention SDE: allow adopters to adapt, refine, modify the innovation to suit own needs (3) Fuzzy boundaries MDE: organizational structures align with core components of innovation (1) Risk (uncertainty) SDE: perception of personal risk reduces adoption (1) MDE: the more the balance between organizational risk and benefits, the greater the adoption (1) Task issues MDE: innovation improves task performance and is relevant to existing work it will be adopted (1) LE: efforts to improve relevance improve adoption (1) SDE: feasible, easy to use will result in adoption (4) LE: efforts to improve workability of innovations improve successful adoption (1) Knowledge SIE/MDE: transportability from another setting/context will improve required to use adoption (3) Augmentation/ SME: help desks, customization, training will ease adoption (1) support SDE: adoption rate is affected by context (2) Opinion leaders MDE: expert opinion leaders influence through authority and status; peer opinion leaders influence through representativeness and credibility (2) SDE: trained opinion leaders can influence their peers (1) SIE/MDE: need to distinguish between opinion leaders who are influential for one innovation or across several (2) LDE: processes to identify and harness the energy of organizational champions (1) Capacity to evaluate SIE/MDE: time and appropriate skills to monitor and evaluate the impact of an innovation (3) Leadership/ SIE/MDE: top management support (advocacy and promotion) (3) management Planning SIE/MDE: involvement of staff at all levels through routinization assists with implementation success (2) SIE/MDE: high quality training and on-the-job training leads to success (4) MDE: team-based training is more effective (1) Intraorganizational SIE: effective communication across boundaries improves success (1) communication MIE/LDE: shared vision improves successful implementation (1) Adaption/reinvention SIE/MDE: if adapted in local context, more likely to be used (3) SDE strong direct evidence; MDE moderate direct evidence; SID strong indirect evidence; LE limited evidence

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amount of evidence available to guide implementation models and practice. It is clear that knowledge about change processes is evolving and more studies are needed to guide the field in the future. Given the importance of assisting organizations to advance their adoption and uptake of evidence-based practices, new emphasis needs to be on understanding the organizational factors and dissemination approaches that are useful toward improving organizational involvement. The best means to do that have yet to be determined.

4.6

Conclusion

Implementation knowledge is slowly evolving. This chapter identified four narrative systematic reviews that distinguished major themes in the existing research. The systematic reviews did not include calculations of effect sizes (or odds ratios) mainly due to the paucity of research in any given area as well as the lack of quality experimental studies. In fact, much of the research is the result of cross-sectional surveys that is useful for identifying trends in the literature. Few experiments, or strong quasi-experimental designs, exist which precludes the ability to make causal statements. The systematic reviews assisted in identifying the major areas where research has been conducted and the number of existing studies. Although the narrative analysis is useful in beginning to identify key organizational factors, the clear reality is that systematic reviews demonstrated the need for more research. The Greenhalgh et al. (2004) research that is depicted in tables throughout this chapter demonstrates that there is little conclusive evidence. Examining the state of knowledge within categorical areas draws similar conclusions as the systematic reviews. Again, in most areas, our knowledge is informed by a few studies. There are voluminous research topics within the major categories of implementation research: four areas within the outer setting, 15 within inner setting, 17 within organizational efforts, four within dissemination, and five within the intervention. Within each category there are few studies with most studies primarily dominated by research using organizational surveys, cross-sectional research, and quasi-experimental designs. Randomized trials are very rare. The area that we have the most research is within inner setting with the focus on staff skills and attitudes. Studies have found that the more educated the staff, the more likely the staff will accept and use evidence-based practices. Even more importantly, few studies have occurred in justice settings, have assessed the adoption of EBP that require a slightly different organizational goal or mission, or have examined the relative importance of inner vs. outer setting issues. The lack of studies in justice settings is critically important because it means that the unique characteristics of a legal environment or the emphasis on public safety are not being included in the existing literature. In Chap. 6, we use the NCJTP survey (similar to the surveys administered by Roman and his team in the NTCP and CTN studies) to explore the relative importance of organizational factors in justice settings. Of course, these are organizational administration surveys and not experiments.

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Few studies occur in settings where the EBP require a shift in organizational goals or a reordering of goals. This is unique to the justice system. The issues regarding competing or conflicting goals are an area that has not been researched. But, given the importance of goals for organizations, this undoubtedly should a priority for future research. And given that TT models recognize the importance of the outer setting, particularly for endorsing EBPs and for providing support for achieving goals, the priority should be to conduct research in this area. Finally, a major limitation of the existing body of knowledge is that all of the factors identified and raised in this chapter are considered equally important in the implementation process. The research to prioritize either the category or the research issues within each category has not been conducted. To advance implementation strategies, it is important to have good quality studies that identify organizational factors that are critical to implementation success. That is, understanding the balance among intervention characteristics, inner and outer settings, and organizational strategies will certainly advance the type of TT strategies that ultimately will be most effective. In the following chapters, we build on this knowledge to develop a model that incorporates the unique features of the community corrections and addiction treatment systems, and the challenges to implementing EBPS in these settings. The lessons from the existing research is that attention must be paid to all of the dimensions of an organization and the stakeholders, and that this demands attention in the areas where justice agencies tend to be deficit such as the technical skills to implement EBPs and an organizational culture that tolerates new ideas. A revised TT model presented in Chap. 9 illustrates new components that address these concerns.

Appendix Summary of Major Findings from Organizational Studies in Behavioral Health Examining Inner Setting Issues Staff training

Study author(s) Aarons, Sommerfeld, Hecht, Silovsky, and Chaffin (2009) Aarons, Wells, Zagursky, Fettes, and Palinkas (2009) Knudsen et al., (2005)a

Major finding(s) Adoption of SafeCare (EBP) and fidelity monitoring associated with less staff turnover

Staff development and support were important as a barrier to EBP adoption, but changeable

Receiving buprenorphine-specific training was associated with increased likelihood of buprenorphine diffusion, whereas counselors who received specialized training in buprenorphine were more likely to perceive buprenorphine as effective and acceptable Knudsen and Roman More licensed staff was associated with more environ(2004) mental scanning (continued)

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(continued) Staff attitudes

Study author(s) Major finding(s) Roman et al., (2010) Medical staff preferred not to use buprenorphine Aarons, Fettes, Flores, Adoption of SafeCare (EBP) associated with lower and Sommerfeld emotional exhaustion (2009)

Knowledge of staff

Knudsen et al., (2005)a

Greater use of the NIDA website was associated with increased likelihood of buprenorphine diffusion

Leadership

Roman and Johnson (2002)a

Programs with more tenured administrators in the treatment field were more likely to adopt naltrexone, but an administrator with a medical degree made implementation with alcohol-dependent patients more likely. Administrators with a business degree made implementation of naltrexone with opiate-dependent patients more likely Having an administrator with a medical background increased the likelihood of adopting pharmacotherapies

Roman et al., (2006)b

Management style Aarons (2006)

Transactional leaders increased openness to adopting EBPs, while transformational leaders were associated with increased willingness to adopt if required and decreased perceptions of divergence from current practice

Treatment philosophy

Roman et al., (2010)c Inconsistency of the practice with treatment philosophies prevented adoption of both buprenorphine and MI/CM Aarons, Wells, et al., Clinical perceptions were important barriers to EBP (2009) adoption, but changeable Knudsen et al., Endorsing 12-step programming was associated with (2005)a lower perceptions of buprenorphine as acceptable

Structure

Aarons (2004, 2005)

Aarons (2004)

Abraham, Knudsen, Rothrauff, and Roman (2010)c Ducharme et al., (2007)c

Roman and Johnson (2002)a

Treatment programs with less bureaucracy and more formalization appear to have more positive attitudes toward EBP adoption, whereas attitudes toward adoption vary by program type Case management programs had a lower appeal toward adoption of EBP as compared to outpatient programs, while wraparound programs were more open; day treatment programs had more positive attitudes when required to adopt Government-owned programs were more likely to use tablet naltrexone at follow-up Programs with detoxification services were more likely to adopt buprenorphine, while programs with primary funding from government grants and contracts, nonprofit, not accredited, and not outpatient-only programs were more likely to adopt voucher-based motivational incentives Treatment centers operating longer were more likely to adopt naltrexone and implement the medication with opiate-dependent patients (continued)

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(continued) Study author(s) Knudsen, Abraham, Johnson, and Roman (2009)c

Major finding(s) Programs which are private funded, larger, operate inpatient detoxification, and use methadone maintenance were associated with early adoption of buprenorphine; however being a for-profit program and having inpatient detoxification services were associated with adoption at the 24-month follow-up Knudsen et al., Programs which are private, accredited, use detoxifi(2006)a cation services, and use naltrexone were more likely to adopt buprenorphine early and at followup, while larger centers, and those using mixed inpatient and outpatient care were more likely to be early adopters and for-profit were more likely to be adopters at follow-up Knudsen et al., Working in a treatment center that had adopted (2005)a buprenorphine was associated with increased likelihood of buprenorphine diffusion and counselor perception of buprenorphine effectiveness and acceptability, while being surveyed post-FDA approval was associated with increased likelihood of buprenorphine diffusion Knudsen, and Roman For-profit, hospital-based, and larger centers are more (2004) likely to use treatment innovations and collect satisfaction data Roman et al., (2006)b Both public and private centers that are accredited provide detoxification services, and use of naltrexone was associated with the use of buprenorphine, while for-profit, private, and larger centers were more likely to adopt SSRIs Staff experience

Aarons (2004, 2005, 2006); Aarons and Sawitzky (2006) Aarons (2004, 2005, 2006); Aarons and Sawitzky (2006) Abraham et al., (2010)c; Roman and Johnson (2002)a Knudsen et al., (2005)a

More experienced staff appear to view EBP adoption as less appealing and more divergent from current practice, and are less open to adoption than interns Those with a higher education had improved attitudes toward adoption of EBPs

Programs with more counselors with master’s degrees were more likely to adopt acamprosate in 2006, as well as adopt naltrexone

Counselors in recovery and with more experience were associated with increased likelihood of buprenorphine diffusion Knudsen et al., Holding a master’s degree was associated with an (2005)a increased likelihood of perceiving buprenorphine as effective Knudsen and Roman Treatment centers with more master’s degree level (2004) counselors use more treatment innovations and collect satisfaction data, and more counselors in recovery were associated with more collection of satisfaction data (continued)

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(continued) Culture and climate

Caseload characteristics

Study author(s) Major finding(s) Aarons and Sawitzky A more constructive culture was associated with (2006) increased attitudes, openness, and overall perceptions of EBP adoption; whereas a negative climate was associated with greater perceived divergence from current practice Bride, Abraham, and More supportive, nonconfrontational programs that Roman (2011)a had prior research experience were more likely to use contingency management Aarons, Sommerfeld, Increased perceptions of job autonomy were associet al., (2009) ated with decreased risk of turnover Aarons, Fettes, et al., Increased caseload was associated with increased (2009) emotional exhaustion Bride et al., (2011)a Programs with outpatient, drug-court, or adolescent patients were more likely to use contingency management Ducharme et al., Programs with increased opiate dependent clients (2007)c; Knudsen were more likely to use buprenorphine et al., (2006)a Roman and Johnson Programs with more patients covered by HMOs, (2002)a PPOs, or managed care, or who have previously relapsed are more likely to adopt naltrexone, while more referral sources are more likely to implement to more alcohol-dependent patients Roman et al., (2006)b As the number of opiate-dependent clients increase for both private and public centers, than so does the use of buprenorphine

Other organizational factors Interorganizational Roman et al., (2010)c The CTN’s community treatment programs (CTP) interactions reported a high-quality relationship with the Regional Research and Training Center as well as improved communication with other CTPs about new substance abuse treatment techniques Abraham et al., Programs participating in CTN were more likely to (2010)c adopt and use acamprosate and tablet naltrexone at follow-up than non-CTN programs Ducharme et al., CTN programs exposed to clinical trials with (2007)c buprenorphine were more likely to use the medication for treatment Knudsen et al., CTN programs involved in buprenorphine protocols (2009)c were more likely to adopt early and at 24-month follow-up Knudsen et al., Staff who experienced increased perceptions of (2007)c organizational benefits from participation in CTN trials were associated with fewer intentions to leave the job, while increased perceptions of stress from participation were associated with increased intentions to leave Knudsen and Roman Treatment centers with more environmental scanning (external knowledge collection) and collection of (2004) satisfaction data use more treatment innovations (continued)

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(continued) Available resources and costs

Study author(s) Major finding(s) c Roman et al., (2010) Cost, access to the necessary personnel, regulatory barriers, and liability concerns were barriers to buprenorphine adoption, whereas cost, logistics, and perceived ineffectiveness blocked MI/CM adoption Aarons, Wells, et al., Funding rated as most important and least changeable (2009) barrier to EBP adoption, followed by staff resources, and research; outcomes supporting the EBP being important but changeable Abraham et al., Programs with access to a physician were more (2010)c likely to adopt acamprosate and tablet naltrexone at baseline, as well as being more likely to use buprenorphine Knudsen et al., Programs with access to physicians were more likely (2006, 2009)a, c to be an early adopter of buprenorphine Knudsen and Roman Having a physician on staff was associated with more (2004) environmental scanning Roman et al., (2006)b As the number of staff physicians increases so does the use of buprenorphine and SSRIs, and increased number of legal system referrals decreases use of SSRIs while increased number of workplace and employee assistance referrals increases use of SSRIs

Roman et al., (2010)c Approximately 86% of participating community treatment programs took part in at least one dissemination activity of the Clinical Trial Network a Indicates National Treatment Center Study (NTCS) b Indicates both CTN and NTCS data c Indicates a Clinical Trial Network (CTN) study Dissemination

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Chapter 5

Community Corrections Addiction Treatment: Strategies to Adopt, Implement, and Sustain Effective Practices

5.1

Current State of Evidence-Based Practice in the Addiction Treatment Field

Despite the recent emphasis on defining and identifying EBP, outlined in Chap. 2, implementing and sustaining these interventions and practices in real-world settings has been fraught with difficulty. Most of the emphasis has been on the formative stages of defining EBP with the publication of systematic reviews or meta-analyses, listing evidence-based programs or “best practices,” providing manuals, or providing one-time training or time-limited technical assistance. These efforts largely ignore the difficulties and limited effectiveness of the dissemination of policies and practices, the feasibility of implementing the key features of the EBP, sustainability (compromised by staff turnover, budget constraints, and staff skill levels), alignment with current policies and practices, and associated policy change in real-world settings (Fixsen, Naoom, Blase, Friedman, & Wallace, 2005; Rogers, 2003; Taxman, Shepardson, & Byrne, 2004). The National Institutes of Health has highlighted the importance of moving clinical findings to the field and transferring research to practice by emphasizing translational research in its Roadmap for Medical Research (NIH, 2006). Understanding how to improve the transfer of knowledge about effective researchbased treatment practices into community settings, particularly corrections-related organizations, requires a consideration of the ability of the addiction treatment system to improve its services and adopt evidence-based practices and programs. As in other types of health care services, there has been much emphasis over the past decade on the need to improve the delivery of addiction treatment and foster the use of evidence-based programs and practices. Recognizing gaps in treatment funding, treatment infrastructure, and use of evidence-based practices (Garner, 2009; Kaplan, 2003; Kimberly & McLellan, 2006; McLellan, Carise, & Kleber, 2003), the push for improvements in the nation’s addiction treatment system has been promulgated by government regulatory agencies, funders, professional associations, and scientific

F.S. Taxman and S. Belenko, Implementing Evidence-Based Practices in Community Corrections and Addiction Treatment, Springer Series on Evidence-Based Crime Policy, DOI 10.1007/978-1-4614-0412-5_5, © Springer Science+Business Media, LLC 2012

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panels (CSAT, 2009; IOM, 2006). An emphasis on use of evidence-based treatment practices has been the major theme. Programs that serve criminal justice clients face even more barriers. The offender substance abusing population has diverse and complex health and social needs that greatly complicate the delivery of effective interventions (Belenko, 2006; Belenko & Peugh, 2005; Taxman, Perdoni, & Harrison, 2007). And, as previously discussed in Chap. 2, many EBP were not developed with criminal justice populations. While some may assume that knowledge gleaned from similar drug-involved persons would transfer to offenders, this is an untested assumption. Some interventions may not transfer well to this population without considerable adaptation, as noted by Schoenwald and Hoagwood (2001) in their discussion of the need to assess transportability of innovations from one setting to another. Two major consensus panel reports from the National Academy of Sciences have highlighted both the gaps in the use of evidence-based practice and the need for improving researcher–treatment practitioner partnerships and collaborations in order to improve technology transfer (see Box 5.1). In Bridging the Gap Between Practice and Research (Institute of Medicine, 1998), an Institute of Medicine (IOM) consensus panel found that the delivery of treatment in community-based settings was largely disconnected from scientific evidence regarding effective treatment practices and the most effective clinical strategies and programs. In particular, this IOM report found that research findings about effective treatment were rarely incorporated into treatment practice by addiction treatment organizations and called for changing the addiction treatment system to foster stronger collaborations between researchers and practitioners to bring evidence-based practice into the provision of treatment in the community. The report noted that collaborations should be bi-directional, in that clinicians and intervention researchers should learn from each other, and that clinicians need to play an important role in identifying research questions, and making research findings more salient.

Box 5.1 Institute of Medicine (1998) Recommendations for Improving Technology Transfer 1. Linking research and practice 2. Linking research findings, policy development, and treatment implementation 3. Increasing knowledge development in program development and implementation 4. Improving strategies for dissemination and technology transfer to the organization 5. Improving consumer participation in the research and knowledge development processes 6. Enhancing training for researchers in community engagement techniques

5.1

Current State of Evidence-Based Practice in the Addiction Treatment Field

131

The IOM report made recommendations for knowledge development and improved technology transfer as part of the general call for stronger researcher– practitioner collaborations. Improving knowledge development in addiction treatment requires that much more research be conducted about effective treatment practices for different settings and population. In addition, funders and regulatory agencies need to monitor clinical service delivery to assess whether effective practices are being used and delivered in sufficient dosages. Such performance monitoring was seen as important for understanding how and to what extent addiction treatment programs are delivering research-based services. With respect to dissemination and technology transfer, the 1998 IOM report had two key recommendations. First, the federal agencies should work together to synthesize research findings, reduce the barriers to knowledge transfer, and provide research-based information to funders of addiction treatment. This is typically referred to as the translational process. Funders need to develop criteria and monitor treatment delivery to assure that evidence-based treatment is adequately funded and that ineffective treatment is not funded. Their second recommendation was that federal and professional agencies and organizations should have a process to identify evidence-based treatment based on sound science. The IOM reports on advancing the science-to-practice process emphasize the importance of partnerships. This has led to such programs as the Clinical Trials Network (CTN) (started in 1999 as collaborations among 17 research centers with community treatment providers) and the Criminal Justice Drug Abuse Treatment Studies (CJDATS), started in 2002 as a platform for creating partnerships among researchers and criminal justice agencies in ten research centers. The foundation for today’s efforts on diffusion and dissemination lie in the IOM report and its “wake-up” call to the science community. These problems largely remain today. In a follow-up report on gaps in the quality of health care for substance abuse and mental health disorders, Improving the Quality of Health Care for Mental and Substance Use Conditions (Institute of Medicine, 2006), the National Academy of Sciences once again noted that the addiction treatment system had numerous gaps in the delivery of effective treatment, that service systems were fragmented and inefficient, and that many barriers prevented the delivery of evidence-based treatments. Although research has identified numerous effective treatments, many studies found a gap between evidencebased practice and the care that is actually delivered. For example, a review of studies of the quality of behavioral health care (Bauer, 2002) found that only 27% of studies noted adherence to established clinical guidelines. Similar and substantial gaps in delivery quality were found in opiate treatment settings (D’Aunno & Pollack, 2002). McGlynn et al. (2003) found that only 10.5% of people with alcohol dependence received treatment that followed scientific principles or research findings. Of the six aims for high-quality health care noted by the National Academy of Sciences (IOM, 2006), three are directly relevant to the topic of this book: (1) treatment based on scientific knowledge should be delivered to those who can benefit from the treatment; (2) treatment should be delivered in a timely fashion; and

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(3) treatment should be delivered efficiently. This report also noted the importance of collaborations across agencies, information exchange, and evidence-based decision-making. Notably, the IOM pointed out that providing effective addiction treatment remains hampered by unique problems in that system. These include the stigma associated with substance abuse that may reduce willingness to enter treatment, the use of coercion to force people into treatment (which undermines the health care principle of patient choice and control), infrastructure problems noted above (lack of information technology, inadequately trained workforce, staff turnover), and problematic linkages across agencies and systems. In addition, funding caps on insurance reimbursement for substance abuse treatment also mean that even if appropriate evidence-based treatments are identified and accessed, health insurance may not cover the full course of treatment. The lack of adequate information technologies and computer support in the offices of addiction treatment providers, coupled with staff overburdened with local, state, and federal reporting requirements, make it more difficult to engage in many well-cited business processes (Kimberly & McLellan, 2006). That is, community treatment agencies are burdened by reporting requirements that limit the ability to share assessment, treatment progress, and treatment activity information with community corrections agencies. Such linkages among involved agencies and information sharing, however, are necessary for effective cross-systems collaboration and better client outcomes (Taxman & Bouffard, 2000). Evidence-based coordination models that include formal contractual and confidentiality agreements, as well as specific case management activities and responsibilities, are also recommended to formalize information sharing and expectations between addiction treatment and community corrections agencies. Service delivery and supervision should be coordinated, and agencies linked via technology to share information and resources. To further improve the treatment infrastructure, and following the recommendations of the 1998 IOM report, the 2006 report recommended improvements in the dissemination of evidence on effective addiction treatment. In addition to gathering information on evidence-based programs and practices (such as through NREPP, see Chap. 2), the IOM called for appropriate federal agencies to categorize and rate the strength of different interventions, and expand efforts to increase the adoption and implementation of evidence-based practices. The addiction treatment workforce often lacks the knowledge and training to provide evidence-based treatments, and this problem has persisted for many years and was highlighted in the McLellan et al. (2003) national study of addiction treatment infrastructure. The 2006 IOM report called on federal and state agencies to develop a comprehensive plan to improve training and workforce development for the addiction treatment field. Such problems have persisted despite a number of initiatives to address them. In summary, more research is needed on how to improve the effectiveness of implementation of research findings into clinical practice, and basic research is still needed on how to improve addiction treatment in real-world practice settings

5.2

Improving Treatment Processes

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(IOM, 2006). It is important to allow for local innovation as well, and foster partnerships between researchers and local treatment system stakeholders that can make research agendas and findings more salient for the treatment programs, community corrections agencies, and staff.

5.2

Improving Treatment Processes

Recognizing the need to increase treatment access, improve the delivery of basic addiction treatment services, and enhance the experience of clients trying to enter and stay in treatment, the Network for the Improvement of Addiction Treatment (NIATx) was created. The NIATx model seeks to improve the quality of addiction treatment by improving treatment processes and service delivery (McCarty et al., 2007). Process improvement strategies such as NIATx involve a structured set of activities that are directed toward organizational change. Underlying process improvement strategies is the assumption that carrying out change in organizational operations requires a sustained, multilevel, and coordinated effort that involves leadership, ongoing staff involvement, understanding the organization’s function from multiple viewpoints (especially that of the “consumer” of services), systematic efforts to test and measure new practices or interventions within the organization, and thoughtful decision-making regarding the results of the process improvement efforts. Process improvement strategies often have a broad focus; the goal of process improvement may be problems that keep the chief up at night rather than, for example, the implementation of a specific practice or intervention. NIATx has been applied successfully in drug abuse treatment facilities (Hoffman, Ford, Choi, Gustafson, & McCarty, 2008). The NIATx approach focuses on the role of the program administrator as the Executive Sponsor of the proposed change and a Local Change Team consisting of a Change Leader with access to the Executive Sponsor and members agreed upon by the Change Leader. A NIATx coach is involved in the initial formation and first meeting of the team and is then available by phone to facilitate the group process. Thus, the responsibility for carrying out the change activities rests with the team and the Executive Sponsor, who remains active by meeting periodically with the team and reviewing its activities. NIATx focuses on two key drug treatment goals: improving access to services and improving retention in treatment (Capoccia et al., 2007; McCarty et al., 2007). NIATx uses five principles to identify problems and to introduce and test organizational changes: (1) understand and involve the customer; (2) fix key, important problems; (3) pick a powerful change leader; (4) get ideas from outside the organization; and (5) use rapid cycle testing to test the effectiveness of changes (McCarty, Gustafson, Capoccia, & Cotter, 2009). Under NIATx, each of these principles is articulated as a well-defined, structured activity that contributes toward the identified organizational goals. See Box 5.2 for an example.

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Box 5.2 Using the NIATx Model to Improve Treatment Outcomes: A Case Study (http://www.niatx.net/Story/StoryDetails.aspx?id=136) Specialized Outpatient Services, Inc. is an addiction treatment provider in Oklahoma City. In response to an increase in treatment demand and subsequent increase in no-shows and waiting time for admission, the provider began a collaboration with NIATx and the Oklahoma Department of Mental Health and Substance Abuse Services under the NIATx State Pilot Program. After establishing the Change Team (which included line staff), it was decided that the focus of the process improvement effort would be on reducing the time between client contact and treatment admission. A walk-through exercise and collection of baseline data determined that it took an average of 29.9 days between initial contact and treatment initiation, including about two weeks between contact and initial assessment. Some of the reasons included delays in determining financial eligibility, duplicative paperwork, lack of trained assessment staff, limited capacity for individual counseling, and insufficient counseling space. Several discrete change cycles were conducted: (1) to first reduce the time between contact and assessment, and (2) to decrease the time from assessment to treatment. Changes implemented included (1) suspending the eligibility means test and offered treatment to all; (2) removing duplicate paperwork, (3) training additional staff to conduct assessments, (4) shifting from a focus on individual counseling to more group counseling, and (5) adding counseling rooms. As a result of these efforts, performance improved substantially within less than three months: the average time from first contact to assessment decreased from 14.7 to 4 days, the average time from assessment to treatment was reduced from 15.2 to 8 days, and the average overall time from first contact to treatment decreased from 29.9 to 12 days.

Recent research supports the importance of organizational-level interventions that focus on performance monitoring and enhancement by identifying targets for performance improvement guided by local stakeholders (Feldstein & Glasgow, 2008; Gustafson & Hundt, 1995). Studies point to the importance of local stakeholder involvement in implementation processes, and the importance of organizational support for evidence-based practices (McCarty et al., 2007). Research is needed on how these implementation practices work in the complex nexus of the criminal justice system and addiction treatment delivery systems.

5.2

Improving Treatment Processes

5.2.1

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Federal and National Initiatives to Disseminate EBP in Treatment Agencies

The Substance Abuse and Mental Health Services Administration (SAMHSA) of the Department of Health and Human Services has for several years worked toward emphasizing various aspects of quality assurance, performance measurement and monitoring, and encouraging the use of best practices in addiction treatment and other behavioral health services. Of its 10 “cross-cutting principles” for the effective delivery of behavioral health services, SAMHSA includes a focus on the use of evidence-based practices, and need for data on performance measurement and management (SAMHSA, 2011a). Two specific federal efforts to promote and expand the adoption of EBP in addiction treatment are the NIDA/SAMHSA Blending Initiative and the Center for Substance Abuse Treatment (CSAT) Technical Assistance Publication (TAP) series. The Blending Initiative (Condon, Miner, Balmer, & Pintello, 2008) is a joint project of NIDA and SAMHSA to disseminate findings from NIDA’s CTN and other research on effective interventions and promote the use of EBP by addiction treatment providers (http://www.nida.nih.gov/blending/). Begun in 2001, the Blending Initiative was informed by Rogers’ Diffusion of Innovations theory (Rogers, 2003), indicating the importance of considering technology transfer as a dynamic process driven in part by information exchange across stakeholder networks, the importance of opinion leaders in fostering innovation, the important role of practitioners in the implementation process, and allowing practitioners to modify the intervention to fit local conditions (Condon et al., 2008). In addition to disseminating evidence-based treatment practices to the field, the Blending Initiative involves feedback from practitioners and other stakeholders. Two components of the initiative are the Blending Conference and the Blending Teams. The Blending Initiative hosts a conference that brings together researchers, clinicians, and addiction professionals to present innovative findings about addiction treatment research and practice. To develop the products, teams are formed that include NIDA-funded researchers, treatment practitioners, and trainers from SAMHSA’s Addiction Technology Transfer Centers (ATTCs). The teams develop training curricula, manuals, toolkits, and other materials based on NIDA’s CTN and other research. These materials are disseminated to treatment providers through the CSAT-funded ATTCs. The Addiction Technology Transfer Center Network was established by SAMHSA in 1993, and continues today with CSAT funding, with the goal of being a local resource to addiction treatment agencies (http://www.attcnetwork.org/index. asp). The ATTC Network includes 14 Regional Centers and a National Office. The ATTC goals are to improve the quality of addiction treatment by disseminating the latest research findings, providing training on education and skills, online and distance education, conferences, workshops, and publications.

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To date, six Blending Teams have been developed with varying types of dissemination and training products: • Buprenorphine Treatment for Young Adults • Buprenorphine Treatment: Training for Multidisciplinary Addiction Professionals • Short-Term Opioid Withdrawal Using Buprenorphine: Findings and Strategies from a NIDA CTN Study • Treatment Planning M.A.T.R.S.: Utilizing the Addiction Severity Index (ASI) to Make Required Data Collection Useful • Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency (MIA: STEP) • Promoting Awareness of Motivational Incentives (PAMI) CSAT’s Knowledge Application Program (KAP) provides information to addiction treatment professionals about best practices through publications and online resources. Two key publication series are the Treatment Improvement Protocols (TIPs) and the Technical Assistance Protocols (TAPs) (http://kap.samhsa.gov/ general/about.htm), and both sets of publications are available for free download and dissemination. TIPs are developed through a consensus process that involves researchers, clinicians, policymakers, and treatment professionals to summarize the current state of the art on various treatment practices. To date, 52 TIPs have been published, available for free download, including several related to criminal justice populations. Table 5.1 below summarizes the criminal justice-related TIPs. TAPs gather information from different sources to provide more practical information on various aspects of addiction treatment delivery; 31 TAPs have been published to date. The most recent TAP, Implementing Change in Substance Abuse Treatment Programs (CSAT, 2009), is a practical guide for program administrators on how to integrate evidence-based practices into daily clinical practice. Only one TAP, Substance Abuse Treatment for Women Offenders: Guide to Promising Practices (TAP 23), is specifically focused on criminal justice issues.

5.2.2

Federal Initiatives to Define Quality and Key Outcome Measures for Treatment Agencies

More generally, SAMHSA and CSAT have embraced the development of standardized treatment outcome measures and collection of data on quality indicators by its grantees. The Government Performance and Results Act of 1993 (Public Law 10362) (GPRA; http://www.whitehouse.gov/omb/mgmt-gpra/index-gpra), requires all federal agencies to set annual performance goals, and collect annual performance data to monitor success in reaching those goals. All SAMHSA-funded programs, including addiction treatment programs receiving Substance Abuse Prevention and Treatment (SAPT) block grant funds, must collect and report GPRA performance data on a regular basis (SAMHSA, 2011b). This is an important advancement because it means that CSAT has a common set of criteria to assess the strides made in programs that receive CSAT funding. At the individual client level, CSAT requires

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Improving Treatment Processes

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Table 5.1 CSAT treatment improvement protocols focusing on criminal justice Name of TIP Brief description Substance Abuse Treatment for Adults in the Recommendations and best practice guidelines Criminal Justice System (TIP 44) for counselors and administrators for effective treatment in different parts of the criminal justice system Continuity of Offender Treatment for Guidelines for providing continuity of care from Substance Use Disorders from Institution incarceration to the community by treatment to Community (TIP 30) providers in prisons, jails, community corrections and other institutions, and community providers Treatment Drug Courts: Integrating Describes the structure and operations of drug Substance Abuse Treatment with Legal courts targeting offenders prior to trial, Case Processing (TIP 23) including strategies for integrating treatment into the drug court model Combining Alcohol and Other Drug Abuse Summarizes strategies for diverting youths with Treatment with Diversion for Juveniles in alcohol and other drug abuse problems into the Justice System (TIP 21) treatment from the juvenile justice system Planning for Alcohol and Other Drug Abuse Provides guidelines for administrators, Treatment for Adults in the Criminal policymakers, and staff in the criminal Justice System (TIP 17) justice and addiction treatment systems for creating more effective linkages between the systems Combining Substance Abuse Treatment with Provides information and guidelines for Intermediate Sanctions for Adults in the increasing cooperation and collaboration Criminal Justice System (TIP 12) between the criminal justice and addiction treatment systems to use intermediate sanctions with offenders whose crimes are related to their drug abuse Screening and Assessment for Alcohol and Presents guidelines for determining drug abuse Other Drug Abuse Among Adults in the screening and assessment services needed Criminal Justice System (TIP 7) for offenders, identifies specific screening and assessment tools appropriate for offender populations and treatment planning, describes use of screening and assessment tools to enhance treatment outcomes

federally funded addiction treatment programs to fill out detailed GPRA forms (http://www.samhsa.gov/grants/tools.aspx) for each client admitted (SAMHSA, 2006). The data include detailed information on: • • • • • • • •

Types of services planned Alcohol and other drug use Family and living conditions Education, employment, and income Criminal justice status Mental and physical health problems Social connectedness Services received during treatment

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CSAT has set specific GPRA goals for each of its specific program areas, including the SAPT block grants that fund many of the treatment providers used by community corrections agencies. For SAPT recipients, the program-level GPRA measures include: Measure 1 2 3 4 5 6

7 8 9

Goal Number of clients served Increase the number of states and territories voluntarily reporting performance measures in their SAPT block grant application Increase the percentage of states that express satisfaction with technical assistance provided (measured through the annual customer satisfaction survey) Increase the percentage of technical assistance events that result in systems, program or practice change Increase the percentage of block grant applications that include needs assessment data Increase the percentage of states that indicate satisfaction with CSAT customer service, throughout the entire block grant process (measured through the annual customer satisfaction survey) Increase the percentage of states reporting satisfaction with CSAT’s responsiveness to state suggestions on services (measured through the annual customer satisfaction survey) Increase the percentage of states in appropriate cost bands Percentage of clients reporting change in abstinence at discharge

CSAT collects performance data related to promulgation of evidence-based practice through its Best Practices Program. The goal is to promote the adoption of best practices to improve treatment effectiveness. This is accomplished through the collection of data on training and dissemination activities (number of staff trained, satisfaction with the training), especially those carried out by the regional ATTCs. SAMHSA (2005) has been developing a set of national outcome measures that are designed to guide the field toward performance monitoring and evaluation of key performance domains in addiction treatment (National Association of State Alcohol/Drug Abuse Directors, 2006). These measures are still in the development stages and have not been fully adopted by treatment agencies or state substance abuse agencies. The general outcome areas include: • • • • • • •

Abstained from alcohol and illegal drugs Increased or sustained employment or school enrollment Decreased criminal justice involvement Increased stability in family and living conditions Increased access to services Increased retention in substance abuse treatment Increased social connectedness to family, friends, co-workers

Specific measures and data sources have been developed for many of these domains, although others are still under development. State-specific data are available for some measures for selected states on the SAMHSA website (http://www. samhsa.gov). Box 5.3 describes one state’s efforts in performance monitoring. At the broader national level, the National Quality Forum (NQF), dedicated to improving the quality of health care, initiated a consensus panel effort in 2004,

5.2

Improving Treatment Processes

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Box 5.3 Implementing Data-Driven Performance Improvement in Addiction Treatment: The California Example Some States have begun to develop and institute measures to monitor the performance of state-funded addiction treatment providers. In California, the state Department of Alcohol and Drug Programs has been encouraging its publicly funded providers to monitor their services, set performance goals, and use process improvement strategies such as NIATx to improve performance outcomes (Wisdom et al., 2006). Despite this push, there have been a number of challenges for implementing these performance monitoring and improvement activities. These include resource constraints, poor information technology, staff resistance to data-driven monitoring, and lack of agency expertise (Wisdom et al., 2006). In a recent survey of county alcohol and other drug treatment (AOD) directors and treatment program administrators, Herbeck, Gonzalez, and Rawson (2010) found substantial variation in the use of performance measurement, and a number of remaining barriers to implementing and using performance monitoring more widely and effectively. A little more than half the counties routinely use performance and outcome measures for decision-making. The most important client outcome measures identified by county administrators include abstinence (40.5%), recidivism (32.4%), employment (27.0%), and stable housing (24.3%). Surprisingly, only 18.9% of the administrators cited treatment completion as the most important outcome measure. About half of the county administrators (47.6%) have used performance monitoring data to reduce or cancel contracts or would consider reducing funding based on performance data. Results of the treatment director survey by Herbeck et al. (2010) indicated some variation in performance data collection and use of performance improvement models. Most providers (84.5%) collect data on client services received, but fewer than half collect and store these data electronically. Only 42.3% implemented the NIATx process improvement efforts. With the exception of Motivational Enhancement Therapy (MET) training (31.7%), the percentage of providers attending training on specific evidence-based practices within the past year was less than 10%. Among both the county AOD administrators and treatment provider administrators, there was a lack of consensus on which treatment practices are effective, and which performance outcomes are the most important. Herbeck et al. (2010) concluded that many providers and county oversight agencies are not well-prepared to implement data-driven performance monitoring in California, and there remains much uncertainty among providers about which practices are evidence-based.

funded by the Robert Wood Johnson Foundation, to develop national performance standards for substance abuse treatment. The consensus report (NQF, 2007) identified four main areas of standards in addiction treatment practice. These included: (1) identification of substance use conditions; (2) initiation and engagement in

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treatment; (3) therapeutic interventions to treatment substance use conditions; and (4) continuing care management of substance use conditions. The NQF recognized that using evidence-based treatment interventions is only part of the solution for improving addiction treatment. Substance use disorders also have to be identified and assessed, and clients have to be assisted and motivated to initiate and engage in treatment. Finally, long-term coordinated care management is needed, with regular monitoring of treatment progress and service needs, once the client completes treatment. For identifying substance use conditions, the NQF consensus standards recommend use of multidomain, validated screening and assessment tools to guide treatment planning and identify treatment and other service needs. A number of practice specifications are noted to promote initiation and engagement in treatment. At the organizational level, organizational and system barriers to treatment initiation should be identified, and procedures or systems for promoting flexibility, efficiency, and continuity should be implemented. At the client level, multidimensional assessment should identify barriers to treatment initiation and engagement (e.g., treatment readiness, support system, co-occurring health conditions), other supportive services should be provided, and community support and resources should be encouraged. NQF consensus standards include the use of empirically validated psychosocial treatment interventions, such as cognitive–behavioral therapy, motivational enhancement therapy (MET), contingency management protocols, and family-focused interventions. Medication-assisted treatment should be made available for those with opiate or opioid dependence. As with treatment initiation and engagement, the NQF standards call for community supports, which could include probation or parole officers. The focus on treatment initiation is an important area, and this is where the encouragement and direction from probation/parole officers is often needed. More advanced supervision strategies focus on the probation/parole officer screening offenders, making recommendations to specific treatment programs, and initiating the contact by setting up appointments (Taxman et al., 2007). Finally, given that substance use disorders are chronic, relapsing conditions, continuing care management is needed to provide long-term coordinated services that are regularly monitored and adapted to changing conditions. Client progress should be monitored and the services adapted according to current needs; with client input, treatment plans should be modified as needed. Over time, clients should be given the support and skills needed to self-manage their substance use disorder. The Washington Circle is a group of researchers, treatment providers, policy makers, and representatives from behavioral health managed care companies that were asked by CSAT to develop performance measures for addiction treatment organizations (McCorry, Garnick, Bartlett, Cotter, & Chalk, 2000). Ultimately, the Washington Circle settled on three areas of performance at the health plan or health system level summarized in Fig. 5.1 (Garnick, Horgan, & Chalk, 2006). Like the NQF standards, these performance measures emphasize the importance of treatment initiation and initial engagement. A recent study of the Washington Circle performance measures found that attention to the reduced time to initiate care improved substance abuse treatment outcomes and reduced criminal justice arrests (Garnick et al., 2007).

5.3

Disseminating EBP: Lessons from the Centers for Disease Control…

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Fig. 5.1 Washington Circle areas of performance for behavioral health agencies

5.3

Disseminating EBP: Lessons from the Centers for Disease Control and Prevention’s REP and DEBI Models for HIV Interventions

The above sections describe the different sources for information about evidencebased interventions and practices. Of course, publishing and disseminating information about EBP is only one part of the TT process, and perhaps the easiest in some ways. The real challenges are to implement and sustain these EBP in the actual daily practice of staff and organizations, and maintaining fidelity to the intervention. To date, there have been relatively few systematic and well-established procedures for doing that in a way that results in meaningful and sustained changes in staff and organizational behavior. In part, this reflects that the implementation science literature is still in its early stages (Proctor et al., 2009), but also reflects the challenges of achieving organizational changes in complex, hierarchical, and incentive-poor systems such as community corrections and addictions treatment (see Chap. 3). Several efforts to identify and disseminate EBP and promote TT are discussed in Chap. 2. The Centers for Disease Control and Prevention (CDC) supports two efforts to more effectively promote use of evidence-based interventions in HIV prevention efforts: the Replicating Effective Programs (REP) and Dissemination of Effective Behavioral Interventions (DEBI) models (Kilbourne, Neumann, Pincus, Bauer, & Stall, 2007; Solomon, Card, & Malow, 2006). Although focusing on HIV prevention, these programs are important to consider because they represent systematic efforts by a federal agency to disseminate and implement EBP and best practices into widespread use in community settings. Many of the principles and procedures used are applicable for thinking about how to improve TT of addiction treatment into community corrections.

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Although effective program models have been identified (CDC, 2008; Kilbourne et al., 2007) moving HIV and other health services (as with addiction treatment) from carefully controlled trials into real-world practice is a very difficult process (Solomon et al., 2006; Sussman et al., 2006), and there have been few implementation studies that have examined fidelity or effectiveness in field settings (Kelly et al., 2000; Solomon et al., 2006). For example, the CDC Corrections Demonstration Project (CDP) was a national multisite effort to improve case management and transitional planning in correctional settings for inmates at risk for or infected with HIV (Braithwaite, Hammett, & Arriola, 2002; Robillard et al., 2003). CDP findings showed that case management services were not always delivered as planned, and systems linkage problems were common (Arriola et al., 2002). National surveys of correctional HIV programs have found many gaps in services, especially peer-led interventions, transitional case planning, and bilingual programs (Hammett, Harmon, & Maruschak, 1999; Laufer, Arriola, Dawson-Rose, Kumaravelu, & Rapposelli, 2002). Implementation and organizational change studies indicate that HIV service integration into institutional and community corrections systems have largely failed to follow the steps needed for successful diffusion and sustainability of interventions (Fixsen et al., 2005; Simpson, 2002). Similar issues apply in considering improving addiction treatment services in community corrections settings. Improving our understanding of the implementation phase and level of organizational readiness to implement and sustain HIV services will help to inform the development and testing of new implementation interventions to train and coach staff, increase administrative support and organizational readiness, maintain fidelity, and improve organizational culture and climate. The authors are not aware of any systematic research that has tested such efforts to improve the core implementation components for delivering HIV services. Recently developed frameworks for disseminating evidence-based HIV interventions (e.g., the REP framework; (Kilbourne et al., 2007)) are promising, but have not been tested in criminal justice or addiction treatment contexts, nor do they provide specific tools for improving implementation in actual field settings.

5.3.1

Replicating Effective Programs

The REP began in 1996 with the goal of bridging the gap between research and practice in disseminating effective HIV prevention interventions (Kilbourne et al., 2007). REP works in conjunction with the Diffusion of Effective Behavioral Interventions program. The REP uses scientific methods to test the effectiveness of interventions and designed intervention packages based on target populations. REP works collaboratively with the Prevention Research Synthesis (PRS) project as well as DEBI to disseminate effective HIV interventions into practice (http://www.cdc. gov/hiv/topics/prev_prog/rep/index.htm). The need for the REP programs arose out of the lack of existing implementation strategies that balance the need for adequate fidelity of the intervention with accommodating differences among organizations.

5.3

Disseminating EBP: Lessons from the Centers for Disease Control…

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The REP framework involves four phases: preconditions, preimplementation, implementation, and maintenance (Kilbourne et al., 2007). The preconditions phase involves identifying the need for a new intervention; identification of an effective intervention that is feasible within the local setting; identifying potential barriers to implementation; and packaging the intervention for the purposes of training and assessment. Part of the packaging process involves translating technical jargon from interventions into nonacademic language and creating a user-friendly manual (Kilbourne et al., 2007). The preimplementation phase includes obtaining information from Community Working Groups about needs for training and technical assistance for implementation and local customization. In addition, this phase involves packaging pilot tests, addressing aspects of orientation and preparation logistics for implementation, and creating evaluation strategies (Kilbourne et al., 2007). The implementation phase involves continuing the support of and partnership with community organizations, booster training sessions, a process evaluation, and feedback and refinement of the training protocol and intervention package. This phase includes access to technical assistance after the training process through regular telephone calls (Kilbourne et al., 2007). The fourth and final REP phase is maintenance and evolution. This includes identifying and making organizational and financial changes necessary to sustain the intervention. In addition, this phase includes preparing the package for national dissemination (Kilbourne et al., 2007).

5.3.2

Diffusion of Effective Behavioral Interventions (DEBI)

DEBI was created with the goal of enhancing state and local capacity to effectively implement interventions that reduce the transmission of HIV and sexually transmitted diseases (Solomon et al., 2006). DEBI seeks to use a science-based approach by incorporating community, group, and individual-level HIV prevention interventions to community-based providers through state and local health departments. Through the DEBI program, the CDC seeks to promote the efficacious replication of EBP in differing service agency contexts (Solomon et al., 2006). The DEBI project is a collaborative effort by the Division of HIV/AIDS Prevention at the CDC and the Center on AIDS & Community Health (COACH) at the Academy for Educational Development (AED) to disseminate effective interventions identified in the Replication of Effective Programs (REP) (http://effectiveinterventions.org/ en/home.aspx). The DEBI project has been far-reaching, in that, it has trained 10,000 people from some 5,000 different agencies. Currently, the CDC is providing funding for staff training in 150 community-based agencies. The DEBI project coordinates the dissemination of packaged interventions from REP and provides program training and technical assistance for implementation. DEBI training sessions have been designed

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for staff within the agencies who directly facilitate interventions with clients, and in some cases for managers who oversee the intervention. There are specific protocols for the training of facilitators and the training of trainers. Although there is no exact equivalent to REP or DEBI in addiction treatment, several initiatives have been developed to promote TT of effective addiction treatment, as discussed in Chap. 2. Those efforts have not been focused on community corrections or other criminal justice settings.

5.4

Adoption of EBP in Community Addiction Treatment

The discussion above and in Chap. 2 outlined a number of efforts to identify and disseminate EBP in addiction treatment. How successful have these efforts been? Throughout Chaps. 1–5, a number of barriers and infrastructure problems in our nation’s addiction treatment system have been described, thereby suggesting that adoption and implementation of EBP may still be somewhat limited. The National Criminal Justice Treatment Practices Survey (Taxman et al., 2007), described in Chap. 6, indicated many gaps in EBP utilization in correctional settings. This is the case in community-based treatment programs. A recent survey of a nationally representative sample of 766 private and public treatment providers collected data on use of various evidence-based interventions (Roman, Ducharme, & Knudsen, 2006). The survey asked about various services offered at the treatment centers drawn from EBP and NIDA’s Principles of Drug Addiction Treatment (NIDA, 2009), as well as counselors’ knowledge about EBP effectiveness. The results showed relatively low rates of use of EBP, especially in public sector providers, which are the programs primarily utilized by offenders. For example, only 9.2% of public sector programs offered naltrexone and 2.8% offered buprenorphine, compared with 32.2% and 11.4% of private treatment providers (Roman et al., 2006). MET was offered by 17.0% of the public programs (14.8% of private programs), and 32.8% offered voucher incentive services (i.e., contingency management). As another indicator of the low diffusion of EBP into the treatment field, the percentages of counselors in public programs that did not know about the effectiveness of naltrexone and buprenorphine were 53.6% and 68.7%, respectively; 20.5% did not know about MET, and 38.7% did not know about the effectiveness of contingency management (Roman et al., 2006). These findings suggest substantial gaps in the diffusion and use of EBP in the nation’s treatment system.

5.4.1

State Initiatives

In addition to the federal and national standards and guidelines, states have an important role to play in promoting the use of evidence-based practice, monitoring treatment services, and setting standards for treatment service delivery and client outcomes.

5.4

Adoption of EBP in Community Addiction Treatment

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This role includes a number of regulatory and policy factors. First, licensure of addiction treatment programs is a state function. Second, states allocate the payments for managed behavioral health care through Medicaid and other entitlement programs for underserved and needy clients. Third, federal SAPT block grant funds flow through and are managed by Single State Agencies (SSA). The investment in a good quality system is important for the states. States have various policies for overseeing, conducting quality assurance, and measuring performance of addiction treatment providers. The types of performance measures generally follow the structure described above for the NQF and SAMHSA National Outcome measures, covering aspects of recognition of treatment need (e.g., assessment), delivering treatment services, and maintaining treatment effects (Chriqui et al., 2006; McCorry et al., 2000). In a national survey of state quality assurance and monitoring policies for standard outpatient treatment, Chriqui, TerryMcElrath, McBride, and Eidson (2008) found that most states (88%) have some type of quality assurance provisions, although only 69% use criteria-based or measurable performance objectives. The most common type of performance measure required is for assessment (94% of states); 82% of states have performance measures related to counseling services, but only 57% have performance measures related to continuing care or aftercare, and 20% have such standards for relapse prevention (Chriqui et al., 2006). Of additional concern is that only 55% of states collect statistical data on treatment process measures. State-level monitoring and quality assurance is important because research suggests that states with policies requiring provision of specific treatment services do have more of these services. A national study of state oversight policies and treatment services found that in states that require comprehensive assessment, family counseling, substance and infectious disease testing, HIV services, and aftercare, treatment programs are significantly more likely to offer such services (Chriqui et al., 2008). State policies had no affect on counseling, probably because nearly all treatment programs offer such services. These findings suggest that states can play an important role in fostering the use of evidence-based practices and specific types of services. To illustrate, we describe an important model EBP initiative underway in Oregon (a similar state EBP effort has been initiated in North Carolina). In 2003, the Oregon State Legislature passed Senate Bill 267 mandating that a certain percentage of state treatment funding be used for evidence-based addiction treatments (Rieckmann, Bergmann, & Rasplica, 2011). The percentage has increased from 25% initially to 75% in 2011. The law is administered through the state Addictions and Mental Health (AMH) Division of the Department of Human Services, which provides web-based support and monitors the use of EBP. Because this is an unfunded mandate, treatment providers must use their own resources to access EBP training and manuals, and monitor use of the EBP (Rieckmann et al., 2011). The Oregon AMH is responsible for designating treatment interventions and practices as evidence-based using a set of standardized operational criteria. These criteria include scientific evidence from RCT or quasi-experimental studies, standardization of the intervention through a manual or toolkit, replication of research

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findings, and evidence of meaningful outcomes (http://www.oregon.gov/DHS/ aboutdhs/structure/amh.shtml). Potential EBP require both an internal and external peer-review process. Information about accepted EBP is maintained on the AMH website, from which treatment providers can download information about the intervention or practice, contact information, a list of counties in Oregon that are using the practice, and links for manuals. Although empirical data are lacking on the effects of Senate Bill 267 on the growth of EBP implementation in Oregon, qualitative data suggest that a number of barriers may exist to using this type of (unfunded) mandate to encourage use of EBP. Interviews and focus groups with state substance abuse staff, county officials, treatment administrators, and counselors revealed that while there was considerable support for the state’s promotion of the use of EBP in addiction treatment, the ultimate success in sustaining EBP and improving client outcomes may be dependent on engaging treatment counselors more effectively in defining, implementing, and monitoring the use of EBP. The input of counselors about the nature of their daily clinical practice and procedures is needed to prevent fidelity drift and increase sustained use of EBP (Rieckmann et al., 2011).

5.5

Conclusions

Since the Institute of Medicine began highlighting the substantial gap between research evidence and practice in its seminal 1998 Bridging the Gap report, there has been growing recognition and concern about the lack of adoption and successful implementation of evidence-based addiction treatment in actual practice settings. As in other health care, the use of EBP lags well behind the evidence, and a number of initiatives have been developed to improve training and dissemination, TT, knowledge development, and knowledge utilization in order to close this quality chasm (IOM, 2006). In this chapter, we have highlighted a number of federal, state, and local initiatives to disseminate EBP to the field and encourage agencies to use best practices. Some of these efforts have shown promise, and others have been limited by the infrastructure and resource gaps that exist in the addiction treatment field. Efforts such as the NIDA Principles, and CSAT TIP and TAP document series, are useful but have limited utility for changing practice in a sustainable way because they stop at the dissemination phase. Process improvement models such as NIATx have shown promise for helping addiction treatment programs achieve specific performance goals and improve some client outcomes, but focus mainly on process improvements rather than implementation of EBP. Emerging performance-based outcome measures being promoted by SAMHSA are also helpful for focusing the field on the importance of data-driven monitoring of core client outcomes. Similar efforts by the NQF and Washington Circle have helped the field recognize the importance of outcome standards and measures, and regular performance monitoring.

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Although these efforts are important and help agencies and policymakers identify treatment goals, monitor clinical performance, and gain knowledge about best practices, they fall somewhat short of providing the tools and processes for moving programs toward adoption and implementation of EBP. CDC’s REP and DEBI models provide promising frameworks that move beyond dissemination and training to work with local stakeholders to identify intervention needs and monitor implementation of the EBP. State EBP initiatives such as that in Oregon try to provide financial incentives for addiction treatment providers to adopt EBPs, but a number of hurdles must be overcome in order to achieve the State’s goals. The field is increasingly recognizing the importance, and difficulty, of moving research findings on effective addiction treatment into daily practice. But new models are needed to guide these efforts past dissemination and training and toward sustained implementation of EBP in addiction treatment in community corrections settings (Taxman, Henderson, & Belenko, 2009).

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Feldstein, A. C., & Glasgow, R. E. (2008). A practical, robust implementation and sustainability model (PRISM) for integrating research findings into practice. Joint Commission Journal on Quality and Patient Safety, 34(4), 228–243. Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., & Wallace, F. (2005). Implementation research: A synthesis of the literature. Tampa: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network (FMHI Publication #231). Garner, B. (2009). Research on the diffusion of evidence-based treatments within substance abuse treatment: A systematic review. Journal of Substance Abuse Treatment, 36, 376–399. Garnick, D. W., Horgan, C. M., & Chalk, M. (2006). Performance measures for alcohol and other drug services. Alcohol Research & Health, 29, 19–26. Garnick, D., Horgan, C. M., Lee, M. T., Panas, L., Ritter, G. A., Davis, S., et al. (2007). Are Washington Circle performance measures associated with decreased criminal activity following treatment? Journal of Substance Abuse Treatment, 33, 341–352. Gustafson, D. H., & Hundt, A. S. (1995). Findings of innovation research applied to quality management principles for health care. Health Care Management Review, 20, 16–33. Hammett, T. M., Harmon, P., & Maruschak, L. M. (1999). 1996–1997 update: HIV/AIDS, STDs, and TB in correctional facilities. Washington: U.S. Department of Justice, Office of Justice Programs. Herbeck, D. M., Gonzalez, R., & Rawson, R. (2010). Performance improvement in addiction treatment: Efforts in California. Journal of Psychoactive Drugs, S6, 261–268. Hoffman, K. A., Ford, J. H., Choi, D., Gustafson, D. H., & McCarty, D. (2008). Replication and sustainability of improved access and retention within the Network for the Improvement of Addiction Treatment. Drug and Alcohol Dependence, 98(1–2), 63–69. Institute of Medicine. (1998). Bridging the gap between practice and research: Forging partnerships with community-based drug and alcohol treatment. Washington: National Academy Press. Institute of Medicine. (2006). Improving the quality of health care for mental and substance-use conditions: Quality Chasm series. Washington: National Academy of Sciences. Kaplan, L. (2003). Substance abuse treatment workforce environmental scan. Rockville: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Kelly, J. A., Heckman, T. G., Stevenson, L., Williams, P., Ertl, T., Hays, R. B., et al. (2000). Transfer of research-based HIV prevention interventions to community service providers. AIDS Education and Prevention, 12(Suppl A), 87–98. Kilbourne, A. M., Neumann, M. S., Pincus, H. A., Bauer, M. S., & Stall, R. (2007). Implementing evidence-based interventions in health care: Application of the replicating effective programs framework. Implementation Science, 2, 42. Kimberly, J., & McLellan, A. T. (2006). The business of addiction treatment: A research agenda. Journal of Substance Abuse Treatment, 31, 213–219. Laufer, F. N., Arriola, K. R. J., Dawson-Rose, C. S., Kumaravelu, K., & Rapposelli, K. K. (2002). From jail to community: Innovative strategies to enhance continuity of HIV/AIDS care. The Prison Journal, 82, 84–100. McCarty, D., Gustafson, D., Capoccia, V. A., & Cotter, F. (2009). Improving care for the treatment of alcohol and drug disorders. Journal of Behavioral Health Services & Research, 36(1), 52–60. McCarty, D., Gustafson, D., Wisdom, J., Ford, J., Choi, D., Molfenter, T., et al. (2007). The Network for the Improvement of Addiction Treatment (NIATx): Enhancing access and retention. Drug & Alcohol Dependence, 88, 138–45. McCorry, F., Garnick, D. W., Bartlett, J., Cotter, F., & Chalk, M. (2000). Developing performance measures for alcohol and other drug services in managed care plans. Washington Circle Group. Joint Commission Journal on Quality Improvement, 26, 633–643. McGlynn, E. A., Asch, S. M., Adams, J., Keesey, J., Hicks, J., DeCristofaro, A., et al. (2003). The quality of health care delivered to adults in the United States. New England Journal of Medicine, 348, 2635–2645. McLellan, A. T., Carise, D., & Kleber, H. D. (2003). Can the national addiction treatment infrastructure support the public’s demand for quality care? Journal of Substance Abuse Treatment, 25(2), 117–121.

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NASADAD. (2006). Issue brief: National outcome measures (NOMs) and substance abuse. Washington: National Association of State Alcohol and Drug Abuse Directors. National Institute on Drug Abuse. (2009). Principles of drug addiction treatment: A research based guide, second edition. NIH Publication No. 09-4180. Bethesda: National Institutes of Health, National Institute on Drug Abuse. National Institutes of Health. (2006). NIH roadmap for medical research: Fact sheet. Bethesda: National Institutes of Health. National Quality Forum. (2007). National voluntary consensus standards for the treatment of substance use conditions: Evidence-based treatment practices. Washington: National Quality Forum. Proctor, E., Landsverk, J., Aarons, G., Chambers, D., Glisson, C., & Mittman, B. (2009). Implementation research in mental health services: An emerging science with conceptual, methodological, and training challenges. Administration & Policy in Mental Health., 36, 24–34. Rieckmann, T., Bergmann, L., & Rasplica, C. (2011). Legislating clinical practice: Counselor responses to an evidence based practice mandate. Journal of Psychoactive Drugs, in press. Robillard, A. G., Garner, J. E., Laufer, F. N., Ramadan, A., Barker, T. A., Devore, B. S., et al. (2003). CDC/HRSA HIV/AIDS intervention, prevention, and continuity of care demonstration project for incarcerated individuals within correctional settings and the community: Part I, a description of corrections demonstration project activities. Journal of Correctional Health Care, 9(4), 453–486. Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York: The Free Press. Roman, P. M., Ducharme, L. J., & Knudsen, H. K. (2006). Patterns of organization and management in private and public substance abuse treatment programs. Journal of Substance Abuse Treatment, 31, 235–243. SAMHSA. (2005). National outcome measures. Retrieved March 20, 2011, from http://www. nationaloutcomemeasures.samhsa.gov SAMHSA. (2006). CSAT GRPA Client Outcome Measures for Discretionary Programs. OMB No. 0930-0208. Rockville: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. SAMHSA. (2011a). SAMHSA Performance Measurement/GPRA Tools. Retrieved December 28, 2010, from http://www.samhsa.gov/Grants/tools.aspx SAMHSA. (2011b). Strategic Plan FY2006-FY 2011. Rockville: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. Schoenwald, K. S., & Hoagwood, K. (2001). Effectiveness, transportability, and dissemination of interventions: What matters when? Psychiatric Services, 52, 1190–1197. Simpson, D. D. (2002). A conceptual framework for transferring research to practice. Journal of Substance Abuse Treatment, 22, 171–182. Solomon, J., Card, J. J., & Malow, R. M. (2006). Adapting efficacious interventions: Advancing translational research in HIV prevention. Evaluation and the Health Professions, 29, 162–194. Sussman, S., Valente, T., Rohrbach, L., Skara, S., & Pentz, M. A. (2006). Translation in the health professions: Converting science into action. Evaluation and the Health Professions, 29, 7–32. Taxman, F. S., & Bouffard, J. A. (2000). The importance of systems issues in improving offender outcomes: Critical elements of treatment integrity. Justice Research and Policy, 2, 9–30. Taxman, F., Henderson, C., & Belenko, S. (2009). Organizational context, systems change, and adopting treatment delivery systems in the criminal justice system. Drug and Alcohol Dependence, 103S, S1–S6. Taxman, F. S., Perdoni, M., & Harrison, L. D. (2007). Drug treatment services for adult offenders: The state of the state. Journal of Substance Abuse Treatment, 32, 239–254. Taxman, F. S., Shepardson, E., & Byrne, J. (2004).Tools of the trade: A guide for incorporating science into practice. Prepared for the Community Corrections Division, National Institute of Corrections, Washington. Wisdom, J. P., Ford, J. H., II, Hayes, R. A., Edmundson, E., Hoffman, K., & McCarty, D. (2006). Addiction treatment agencies’ use of data: A qualitative assessment. Journal of Behavioral Health Services Research, 33, 394–407.

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Chapter 6

Current State of EBP in the Community Corrections Field

In contrast to the addiction treatment field, evidence-based practices (EBP) in correction settings incorporate a wider variety of system and programmatic practices and principles. EBP in this setting refers to both the treatment practices and the systemic efforts to improve the management of individuals, to improve practices to place and monitor offender performance, and to enhance the nature of services delivered to offenders. The concept behind EBP is that new “ideas” or innovations are based on research findings where the empirical evidence demonstrates that the new practice or program improves outcomes over existing practices. In many disciplines, the identification of EBP is providing scientific support for clinical and procedural practices that are likely to generate positive findings at either the individual or the system level. The focus on evidence moves the discussion, program identification, and policy making away from ineffective sensationalistic public safety discussions about what to do with wrongdoers in society to criterion-based efforts designed to improve public safety and public health. For example, Scared Straight, the juvenile justice program that took youth into prisons to meet with individuals serving life sentences, has great face validity that youth can be scared into good behavior by exposing them to the consequences of law-breaking behavior. But the scientific evidence does not demonstrate that Scared Straight or short-term detention alters behavior (Finckenauer, Gavin, Hovland, & Storvoll, 1999) – even though the public perceives this as a valuable program. As noted in a recent report on the adoption of EBP in justice settings: The justice system – along with other public sector service systems – faces the 21st century challenges of understanding emerging science; translating empirical findings into policy and practice and, in so doing, retooling long-held approaches; and retraining a workforce to adopt more effective practices and embrace new skills. These challenges are daunting, but critically important. (Center for Effective Public Policy, 2010, p. 7).

For the corrections and justice systems, the EBP approach offers the methods and techniques to assess and analyze existing practice using clear, objective criteria. The EBP approach separates processes and procedures based on: (1) processes to

F.S. Taxman and S. Belenko, Implementing Evidence-Based Practices in Community Corrections and Addiction Treatment, Springer Series on Evidence-Based Crime Policy, DOI 10.1007/978-1-4614-0412-5_6, © Springer Science+Business Media, LLC 2012

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combine various study methodologies and examine the quality of the research conducted; (2) results from studies using objective criteria (i.e., number of studies, techniques to analyze different outcome measures); and (3) well-accepted methods for presenting findings. Together, this offers the potential to summarize the existing evidence-base in a manner that allows others to objectively review data. These techniques are well-accepted across disciplines and are supported by various scientific organizations such as the Cochrane Collaboration (http://www.cochrane.org) and Campbell Collaboration (http://www.campbellcollaboration.org), as previously discussed in Chap. 2. Systematic reviews and meta-analyses are favored techniques to synthesize the existing state of knowledge. A recent review in the corrections field identified no less than 180 systematic reviews that are available to inform the field of the existing knowledge base (Taxman, Henderson, & Lerch, 2010). This chapter builds on prior chapters by reviewing the use of EBP in community corrections, as detailed in data collected from the National Criminal Justice Treatment Practices (NCJTP) survey (Taxman, Young, Wiersema, Rhodes, & Mitchell, 2007). In addition, this chapter includes an examination of the context for adoption of EBP in community corrections through a review of two National Institute of Corrections (NIC) initiatives on evidence-based practices in community settings. Finally, we report on a series of interviews with stakeholders in the field regarding the use and importance of EBP and implementation process. The goal is to inform discussions about technology transfer and the needs of the corrections field for improving the adoption of evidence-based practices and evidence-based addiction treatments.

6.1

EBP in Community Corrections Agencies: Results from the National Criminal Justice Treatment Practices Survey

In 2004–2005, the National Institute on Drug Abuse’s Criminal Justice Drug Abuse Treatment Studies (CJDATS) initiative conducted a survey of community corrections agencies about the use of EBP (Taxman, Young, et al., 2007). The survey included a representative sample of community corrections agencies, prisons, and jails for both adult and juveniles to learn about the current state of practice. The organizational survey included a number of key variables regarding the nature and type of services provided as well as organizational characteristics that could be used to test different theories that affect adoption of evidence-based treatments and practices. The following is a summary of the survey findings from community corrections agencies (adults and juveniles), and the state of knowledge that explains the factors that impact the adoption of EBP in corrections agencies. Survey respondents were drawn from a nationally representative sample of communities and prisons. The community sample comprised probation and parole agencies, jails, community treatment programs, and other community corrections agencies in a stratified representative sample. A two-stage stratified cluster sampling strategy

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(Kish, 1965) was used to identify eligible facilities. In the first stage, counties (or county equivalents) were categorized into three strata based on their general population sizes, and into eight categories based on geographical region. In the second stage, a census of all criminal justice agencies and programs operating in the 72 selected counties provided a listing of 644 potential respondents. Survey instruments were sent to agency administrators and the directors of addiction treatment programs, if the correctional agency had a designated addiction treatment program. The survey polled respondents on issues such as the size of their facility, the average daily population of offenders, common practices, and their opinions on various organizational and treatment related topics. The response rate for the community sample was 71%.1

6.1.1

Best, Evidence-Based, or Strongly Supported Practices

Leading researchers, practitioners, and clinicians, informed by meta-analyses, systematic reviews, and consensus panel reviews discussed in previous chapters, articulated the set of effective practices and treatments that are derived from good clinical practice or from the scientific literature on improving offender outcomes. The CJDATS research collaborative defined the set of practices, either evidence-based (grounded in scientific outcomes), consensus-based (best collective advice), or clinically based (sound therapeutic practices). The consensus process was used to supplement the existing systematic reviews of the literature. As discussed in Friedmann, Taxman, and Henderson (2007), the operational definition of EBP followed the Institute of Medicine’s (2001) definition: practices that represent the integration of best research evidence with clinical expertise and client values: (1) use of a standardized risk assessment tool (Andrews & Bonta, 1998; Andrews, Zinger, Hoge, & Bonta, 1990; Lowenkamp, Latessa, & Holsinger, 2006; Peters & Wexler, 2005; Taxman & Marlowe, 2006; Taxman & Thanner, 2006); (2) use of substance abuse assessment procedures (such as DSM IV) and treatment matching (similar to the ASAM or other patient matching criteria); (3) use of techniques to motivate, engage, and retain clients in treatment (e.g., motivational interviewing [MI], engagement); (4) use of therapeutic community, cognitive-behavioral or other standardized treatment models which have been found to be effective for offender populations (see Andrews & Bonta, 1998; National Institute on Drug Abuse (NIDA), 1999); (5) addressing treatment and ancillary needs through comprehensive treatment services; (6) practices to address co-occurring disorders through specialized screening and treatment (Friedmann, Phillips, Saitz, & Samet, 2003); (7) use of family therapies or multisystemic family interventions; (8) treatment programs that are at least

1

In this chapter we discuss probation, parole, and other community-based criminal justice agencies. See Taxman, Perdoni, and Harrison (2007) for a more detailed discussion of the state of addiction treatment services across all adult corrections settings, and Young, Dembo, and Henderson (2007) for a discussion of juvenile findings.

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90 days or more in duration (Hubbard et al., 1989; Simpson, Joe, & Brown, 1997); (9) integration of multiple systems to optimize care and outcomes (Fletcher et al., 2009); (10) continuing care or aftercare to extend treatment (Taxman & Bouffard, 2000); (11) use of drug testing; (12) use of graduated sanctions for addressing noncompliance (Marlowe & Kirby, 1999; Sherman et al., 1997; Taxman, Soule, & Gelb, 1999); (13) use of contingency management or incentives to encourage progress; (14) qualified staff (Brannigan, Schackman, Falco, & Millman, 2004; Knudsen & Roman, 2004; Landenberger & Lipsey, 2005; NIDA, 2006; Taxman, 1998); (15) assessment of treatment outcomes; (16) use of medications to treat substance abuse; (17) use of detoxification programs; and (18) use of HIV/AIDS testing. The EBP translated NIDA’s Principles of Drug Abuse Treatment for Criminal Justice Populations (NIDA, 2006) (see also discussion in Chap. 5) into operational components.

6.1.2

Adopting EBP

The adoption of EBP and the extent to which they are used in community corrections agencies as part of routine practice and for a greater percentage of the population (penetration) are displayed in Table 6.1. The average number of EBP adopted by corrections agencies is five. The most frequently available practices are those that are more system-oriented such as the availability of a broad range of treatments within their jurisdiction (referred to as comprehensive treatment which reflects brokerage of services, and not necessarily services paid by the correctional agency) (85%) and systems integration (67%) where corrections agencies have some set policies in place to work with other agencies on providing treatment services. However, corrections administrators are much less likely to report having in place practices that support a particular treatment orientation like cognitive-behavioral therapy, therapeutic communities, or family involvement (14%), or employ motivational engagement techniques as part of the standard practice of working with offenders (22%). It should be noted that the practices identified as most common – comprehensive treatment and systems integration – are supported by long-standing probation and parole efforts to refer offenders to treatment services in the community offered by either public health agencies or contractual treatment services. That is, the corrections agencies do not provide the evidence-based treatment services but rather make recommendations to offenders to go to a particular treatment program, employment agency, or service program to achieve these benefits.

6.1.3

Adopting EBP in Community Corrections Settings

The question is why do some corrections agencies adopt more EBP than others? This is a critical question given the need to understand how best to facilitate the improvement in practice in the field. The NCJTP survey can assist in understanding the organizational and contextual factors that affect the adoption pattern. The NCJTP survey findings contribute to knowledge about the adoption of EBP in five general

6.1

EBP in Community Corrections Agencies…

Table 6.1 State of EBP in community corrections in 2005 Evidence-based practice (EBP): practices that should be in place in corrections settings to reduce recidivism and improve the criminal justice system’s ability to effectively manage the offender population Use of a standardized substance abuse assessment tool (agency adopts a standardized tool that can be used to screen offenders for substance use disorders, such as the ASI, SASSI, MAST, etc.) Use of a standardized risk assessment tool (agency adopts a standardized risk tool, such as the LSI-R, WRN, etc.) Employ techniques to engage the offender in treatment, such as motivational interviewing, motivational enhancements Use of evidence-based treatment, such as therapeutic communities, behavioral modification, or cognitive behavioral therapy Access to comprehensive treatment methods that address the multiple needs of offenders Address co-occurring mental health and substance abuse disorders through integrated treatment models Involve family in the treatment or corrections process Use of treatment programs that are a minimum of 90 days Have policies and procedures that integrate with other agencies to provide services for drug-involved offenders (systems integration) Continuing care that provides for multiple stages of treatment including aftercare Drug testing is used frequently to monitor progress of the offender Use a graduated sanctions schedule that ensures predictable, escalating responses to negative offender behavior Use an incentives schedule that ensures predictable responses to positive offender behavior Mean number of evidence-based practices adopted Source: Perdoni, Taxman, and Fletcher (2008)

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Community corrections administrators reporting EBP implementation 44%

34% 22% 14% 85% 21% 10% 40% 70% 42% 61% 39% 53% 5.0

areas: (1) the background, attitudes, and support from administrators; (2) the culture and climate of the organization; (3) the degree of external support from state agencies; (4) the type of resources available to the agency; and (5) the degree to which the organization engages in activities that support service integration or the development of programs and services with partnering agencies. The following section describes the major organizational constructs of culture, climate, organizational change processes, and techniques (Table 6.2). In many ways, these are consistent with the inner and outer settings that affect the adoption of EBP in other human service agencies, as discussed in Chap. 4.

6.1.4

Important Constructs in Understanding Adoption Patterns

A number of organizational factors were included in the survey to describe the culture, climate, leadership, and change processes that characterize corrections agencies. Corrections agencies are different than other human service agencies by the

Table 6.2 Key organizational variables: what factors should we consider in understanding adoption – key variables from the NCJTP 1. Transformative and transactional leadership (Arnold, Arad, Rhoades, & Drasgow, 2000; Podsakoff, MacKenzie, Moorman, & Fetter, 1990). These refer to two different leadership styles including leaders that show by doing (transactional) and those that are visionary (transformative). Prior organizational research in mental health found that both styles of leadership have an equal impact on the adoption of EBP (Aarons, 2006), but given the prominence of leadership in the discussion of organizational change, leadership styles were included as a means to isolate if a particular style is more effective in adoption of EBP in community corrections agencies. 2. Organizational climate measures the perception of the current environment in terms of emphasis on quality, improvement, and empowerment (Schneider, White, & Paul, 1998). Climate refers to how things are done. 3. Organizational culture refers to the behavioral norms and expectations of how the organization operates. Under this theoretical framework there are several different scenarios that define the culture – hierarchical, cohesive, performance and innovative (Cameron & Quinn, 1999; Denison & Mishra, 1995). A cohesive culture is one that is flexible and internally focused. The culture tends to support cooperation, coordination, and participation in decision-making. Trust and commitment tend to be strong in team-based cultures. A hierarchical culture is one that is stable and internally focused but relies upon structure and decision-making practices, which are more rigid and controlled. Performance achievement cultures are focused on short-term and long-term goals and objectives where the efforts to achieve these goals are well defined. The organization responds to these levers, and shifts emphasis to reach the goals. Innovativeadaptive cultures are externally focused and tend to be flexible. These types of cultures tend to emphasize risk-taking, experimentation, and flexibility in response to change. Freedom to try new things and creativity tend to be stronger in adaptable cultures. 4. Organizational learning refers to environments that promote the willingness of staff and managers to be involved in continued learning experiences. The learning is premised on the notion that the process of learning contributes to more flexible organizations, regardless of whether they are internally or externally oriented (the stakeholders or external partners such as judges, prosecutors, defense attorneys, or treatment providers) (Orthner, Cook, Sabah, & Rosenfeld, 2003; Scott & Bruce, 1994). That is, a learning culture creates an open environment for testing new ideas. 5. Training and resources measures were adapted from the resources and staff attributes subscales of the survey of organizational functioning for corrections institutions (Lehman, Greener, & Simpson, 2002). They assessed respondents’ views about the adequacy of funding, the capability of the physical plant to accommodate the new process, staffing, resources for training and development, and internal support for new programming. 6. Administrator’s personal perspectives on rehabilitation. The values and opinions of the administrator are considered important in that administrators that support rehabilitation will be more open to adopting evidence-based treatments. Given the long history of punishmentoriented corrections systems, reinforced by support from the public, the personal perspectives are a factor that affects the inner settings. The scales were similar to surveys of public opinion and justice system stakeholders developed by Cullen, Fisher, and Applegate (2000). 7. Network connectedness refers to the extent to which corrections agencies have formal and informal working relationships with various justice agencies (e.g., courts, law enforcement, corrections), substance abuse treatment or mental health programs, health clinics and hospitals, housing services, vocational support agencies, and victim and faith-based organizations. Another factor is systems integration or the extent to which corrections agencies have integrated services and systems with other key agencies such as the substance abuse treatment agencies, judiciary, or other agencies. The concept of systems integration is that corrections agencies have formal arrangements to provide treatment services in blended systems. These factors include the different ways that systems can work together such as sharing information, providing similar eligibility criteria, providing funding or sharing space, or other ways in which systems can collaborate. See Fig. 6.1 for a copy of the instrument on collaboration. Lehman et al. (2009) illustrated that the scale predicted uptake of EBP with agencies that had more items (six or more) tending to adopt more EBPs than those with under six items.

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nature of their mission and goals. That is, while other human service agencies usually have a goal focused on a specific outcome (i.e., mental health, substance abuse, medical care, employment, housing), community corrections agencies often have multiple goals and missions including: (1) enforce the conditions of release required by the court; (2) protect the safety of the community; and (3) assist the offender with addressing needs such as substance abuse, mental health, employment, and other factors that affect the ability to be crime free. The efforts devoted to offender rehabilitation are generally secondary matters for most community corrections agencies. Providing treatment for offender needs such as substance abuse, mental health, or employment into the primary mission is part of the challenge of the technology transfer in corrections settings. Part of understanding the factors that affect the adoption of evidence-based practices is that corrections agencies must alter their goals to include more treatment options. Given that the adoption of EBP affects an agency’s procedures for managing the offender in the community as well as the overall business process (how offenders are handled and processed), this requires altering, refining, or reshaping the business process to consider the identification and selection of offenders for different programs/services, tools to monitor offender progress, tools to share information across agencies, and types of services/ programs provided. Part of the challenge in the transfer process is to negotiate a revised mission in corrections agencies that have spent the last 30 years pursuing punitive strategies to control and monitor offender behavior.

6.1.5

What Factors Affect the Likelihood of Adopting EBP in Corrections Settings?

Friedmann et al. (2007) examined a linear scale of the number of evidence-based practices adopted (using the items specified in Table 6.2). The linear scale consists of the number of practices that the community corrections agency adopted. Henderson, Taxman, and Young (2008) used item response theory (IRT) – Rasch modeling – to consider the number of adopted items as well as the degree to which the EBP is used in the organization (the concept of uptake or penetration). The Rasch model had the advantage of not only looking at which EBP were adopted but it also considers the clustering of practices. And, it provides the opportunity to examine how the adoption of one EBP may affect the adoption of other similar EBP that Rogers (2003) refers to as the clustering of technologies. This is important because it can provide a formula for how organizations can use the opportunity of working on one EBP to create an environment that is open to implementing additional evidence-based practices. Essentially both studies identified a core set of factors that are influential in the adoption of EBP in community corrections settings. These core factors are: (1) supportive leadership; (2) administrators that have reported greater knowledge of EBP; (3) administrators that have education or experience in human services; (4) organizational cultures that are performance focused; and (5) organizations that subscribe

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Below is a list of common activities that sometime occur between agencies. In the columns, indicate the name of the organizations that your agency routinely works with; feel free to add more columns. Please check the activities that you routinely engage in with your service provider agencies regarding the treatment programs or services that that are provided to offenders in your jurisdictions. (Check all  that apply for each row.) Work with Substance abuse Work with Work with other Service Agencies treatment programs Judiciary

We share general information at a. meetings about the needs of the offender population. This is not specific to a person

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We share daily operational oversight i. of some treatment programs

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Our organizations cross-train staff j. on EBPs and services

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We have written protocols for k. sharing offender information such as HIPAA, CFR 42, and CFR 25.

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Our organizations have agreed to use b. similar requirements for program eligibility across our programs We have written agreements for c. space for (substance abuse) services for some programs in our facilities We hold joint staffings/case d. reporting consultations, involving players from many agencies We have developed joint policy and e. procedure manuals for our programs More than two organizations have f. pooled funding to offer offender (substance abuse) services We have modified some g. program/service protocols to meet the needs of other agencies We share budgetary oversight of h. some treatment programs

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Fig. 6.1 Measuring interagency collaboration at the operational level: the collaboration index tool (see Fletcher et al., 2009; Taxman, Young, et al., 2007)

to a learning culture. The Rasch model provided more information about factors that affect the uptake of EBP in corrections settings which include the administrators’ perception that they have sufficient training resources, the administrators’ perception that they have adequate resources for the EBP, the availability of physical facilities to support the EBP, the perception of internal support by staff for the EBP,

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and administrators’ attitudes that support rehabilitation efforts as compared to punishment. The analysis also included treatment directors who worked in corrections facilities or with corrections agencies and found that more system integration or working relationships with treatment agencies was related to EBP use; stronger working relationships with both criminal justice and noncriminal justice agencies correlated with more use of EBP. Figure 6.1 illustrates the tool used to measure the operational practices of corrections and other agencies in terms of defining the working relationship. The adoption and use of EBP varies considerably. Certain practices are generally found together, or technology clusters appear, where the use of one EBP may facilitate the use of others. The use of motivational engagement techniques, assessment of treatment outcomes, and treatment durations that exceed 90 days appear to cluster together which suggests that agencies that assess the impact of their treatment practices take additional measures to ensure that offenders are also appropriately engaged in treatment. These same agencies also subscribe to treatment programs that are at least 90 days in duration, which gives sufficient intensity and duration to produce more positive outcomes. The implications are that one should not consider each EBP to be an independent decision point; instead it appears that the experience with one EBP may directly affect other evidence-based practices. For those EBP that affect one part of a process such as intake and case planning, the clustering demonstrates that the different EBP can be bundled together in the implementation process. For others, they cannot because they represent wholesale change in the organization (i.e., use of medication-assisted treatment). The consideration of technology centers assists in the planning for implementation on a process rather than an individual set of practices.

6.1.6

How Do Corrections Administrators Handle the Competing Values of Providing Treatment and Other Services?

With the 30-year emphasis on punishment in corrections settings, the immersion of treatment programming, and the increased knowledge of the additive benefits of improving offender outcomes, the demand on corrections administrators is great. They must set priorities in their facilities regarding the inclusion of treatment in their array of services. Administrators, in their daily decisions, are frequently faced with making choices about priorities for their agencies. Henderson and Taxman (2009) examined how corrections administrators consider the importance of providing substance abuse treatment services to offenders compared to other typical programs and services available to offenders such as: (1) educational/GED training, (2) HIV/AIDS treatment, (3) mental health counseling, (4) vocational training, (5) life skills training, (6) transitional housing, (7) work assignment, (8) community service, (9) criminal thinking therapy, and (10) job placement. The concept of

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competing priorities is that administrators must weigh the costs and benefits of including these services. The study found that except for community service, transitional housing, and work release, approximately half of the administrators rated the remaining programs and services to be equally important as addiction treatment. This suggests that corrections administrators are doubtful about the value of addiction treatment, either because they are unconvinced that it is appropriate for offenders or that the offender level outcomes from providing such treatment will improve public safety. This is the inherent tension involved in resolving goals for a corrections agency. Considering all services equivalent suggests that administrators are unlikely to commit their organization to any one type of programming. This view conflicts with one of the underlying principles of EBP, that the organization should be committed to delivering services that will improve offender outcomes. This also has implications for the sustainability of an EBP because a lack of administrator commitment on the front end is unlikely to result in a commitment by the administrator to maintain the EBP, especially with declining resources or as new evidence becomes available.

6.1.7

What Type of Reform Strategy Advances the Use of EBP in Corrections Settings?

Over the last three decades, there have been three key strategies defining the efforts to reform the services and programs offered by corrections agencies: (1) a focus on treatment and treatment programming; (2) an emphasis on offender accountability where treatment is intertwined with control programming and the emphasis is on compliance; and (3) a general emphasis on punishment and control of offender behavior (status quo). Administrators that seek a style of reform that focuses on expanding the use of EBP are more likely to focus on a reform strategy that emphasizes treatment programming. Such administrators are more likely to have their organization adopt more EBP than those that focus on holding the offender accountable or have no particular focus (Taxman et al., 2010). Administrators that focus on clinical techniques (clinical innovators) are more likely to pursue treatment-related EBP whereas criminal justice reformers focus on accountability measures. Administrators who are late adopters or who do not have a certain philosophical orientation (clinical vs. security) did not appear to have any particular emphasis on EBP. Advancing the use of EBP therefore appears to be more likely when the administrator selects a strategy that emphasizes treatment and does not commingle treatment with controls (accountability) (see Taxman et al., 2010).

6.1.8

Conclusions from NCJTP Survey Findings

The NCTJP survey was designed to understand the use of EBP and specific treatments by corrections agencies. The survey considered factors related to inner and

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outer settings to see how they affect the implementation of EBP. Similar to the findings from organizational factors presented in Chap. 4, the NCJTP survey findings tend to cluster around the following inner setting issues that affect the implementation of EBPs: (1) attitudes and credentials of the administrators with a human service background and more knowledge about EBP positively affecting adoption; (2) an organizational learning culture where administrators are focused on improving the clinical components of the corrections agency; (3) an environment where staff are included in work teams, focus on performance objectives, and have a clear vision of the purpose of the EBPs; and (4) administrators perceive the resources and training to be important to the EBP. Structural components appear to be important in that community corrections agencies are more likely to adopt a broader range of evidence-based practices (Friedmann et al., 2007). Outer setting issues concern: (1) the importance of service integration or working formally with other agencies to provide services as well as to determine the type of offenders that are better suited for the services (Lehman, Fletcher, Wexler, & Melnick, 2009), and (2) the importance of state agencies supporting evidencebased practices in corrections agencies in a state pursuing the adoption of evidence-based practices (Young, Farrell, Henderson, & Taxman, 2009). The survey findings support the Greenhalgh, Robert, MacFarlane, Bate, and Kyriakidou (2004) conceptual map of dimensions that affect implementation regarding core inner and outer settings.

6.2

NIC Initiative to Expand the Use of EBP by Community Corrections Agencies

For nearly two decades, the National Institute of Corrections (NIC) has promulgated the importance of the evidence-based practice lens for the field of corrections. With funding from the NIC beginning in 2002, the Crime and Justice Institute (CJI; http://www.cjinstitute.org/) focused on the adoption of evidence-based practices in community corrections agencies. The initial phase involved three activities: (1) to develop technological tools for the field to understand the concepts of EBP and to define for the field the current set of evidence-based practices (see Table 6.2); (2) to work specifically for two years with two states (Maine and Illinois) on their implementation of EBP and then work with two counties (Maricopa County, Arizona and Orange County, California) on an immersion model or working on sustainability issues regarding EBP; and (3) to focus on the outer setting – justice and health agencies supporting the field of community corrections – to advance an understanding and appreciation for EBP. The second initiative involves the Framework for Evidence-based Practices (Center for Effective Public Policy, 2010) that is defined as a model to facilitate the advancement of EBP by criminal justice practitioners. The Framework borrows heavily from the quality process improvement models by focusing on the outer setting described in Chap. 3, and key factors described in Chap. 4 to illustrate how to integrate EBPs into the cultural fabric of the system.

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Fig. 6.2 NIC/CJI: Model of implementing evidence-based practices source: CJI, http://www. cjinstitute.org/

6.2.1

Dissemination Materials for the Field

As part of an initial set of products on EBP, CJI authored four short articles on EBP that defined the practices and the technology transfer process. A consensus panel was used by CJI to identify the EBP which included several practitioners and one researcher. This series of reports documents the process for advancing the use of EBP through an integrated model framework where well-defined evidence-based practices are supported by inner and outer settings. A special effort was devoted to the outer settings to provide the external collaborations and support to promote the use of EBP. The NIC/CJI model (summarized in Fig. 6.2) identified a three-legged approach involving the core EBP, internal processes (organizational development), and external processes (collaboration). The operating concept is that EBP will not be embraced in the corrections agency if the EBP are not integrated into core business practices (e.g., intake, monitoring, treatment planning) either within the agency or at the points where the agency engages in interagency practices. Altering the existing business process requires the staff to embrace new ideas and practices. Internally, the organization must embrace EBP and infuse them into the normal work process for how offenders are managed in the system. Externally, the community corrections agency must work with stakeholders to garner support for EBP, but also demonstrate that in order to implement EBP with fidelity new policies and procedures are needed from these supporting agencies. A companion set of manuals were developed to assist stakeholder (e.g., judges, prosecutors, defenders) groups in understanding EBP and also to visualize the relevance to their own work (see Table 6.3 below). The evidence-based practices described by NIC/CJI are similar to the general evidence-based practices identified earlier in Chap. 2 and shown in Table 6.4.

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Table 6.3 NIC/CJI stakeholder papers on EBP Community corrections: Implementing Evidence-Based Policy and Practice in Community Corrections, 2nd Edition, by Meghan Gueva & Enver Solomon, October 2009 Defense: Evidence-Based Practices and Criminal Defense: Opportunities, Challenges, and Practical Considerations, by Kimberly Weisbrecht, Esq. August 2008 Jails: Our System of Corrections: Do Jails Play a Role in Improving Offender Outcomes? by Gary Christensen, Ph.D., January 2008 Judiciary: Evidence-Based Practice to Reduce Recidivism: Implications for State Judiciaries, by (retired) Honorable Roger Warren, Esq. August 2007 Pretrial: Legal and Evidence-Based Practices: Applications of Legal Principles, Laws, and Research to the Field of Pretrial Services, by Marie Van Nostrand, Ph.D., April 2007 Prisons: Evidence-Based Practice: Principles for Enhancing Correctional Results in Prisons, by Ralph Serin, Ph.D., December 2005 Prosecution: Using Research to Promote Public Safety: A Prosecutor’s Primer on Evidence-Based Practice, by Jennifer Fahey, Esq. August 2008 Treatment: Effective Clinical Practices in Treating Clients in the Criminal Justice System, by Wayne Scott, LCSW June 2008 Table 6.4 Eight NIC principles of EBP for community corrections agencies 1. Assess actuarial risk/needs: the use of standardized risk and need tools to determine the level of public safety concerns (risk) and the criminogenic needs that should be addressed during the correctional timeframe (needs) 2. Enhance intrinsic motivation: the techniques to assist the offender in acquiring the skills to manage their own behavior through internal controls 3. Target interventions. Focus on the following principles in assigning offenders to appropriate treatment and control programs. The goal is to use the risk and need information to assign offenders to supervisory controls and programs that address the risk-need factors. The goals are: a. Risk principle: prioritize supervision and treatment resources for higher risk offenders b. Need principle: target interventions to criminogenic (correlated to crime) needs c. Responsivity principle: be responsive to temperament, learning style, motivation, culture, and gender when assigning programs d. Dosage: structure 40–70% of high-risk offenders’ time for 3–9 months e. Treatment principle: integrate treatment into the full sentence/sanction requirements 4. Skill train with directed practice (e.g., use cognitive behavioral treatment methods). EBP also provide a new framework for how the staff interacts with the offender. The goal of the interaction should involve helping the offender to learn new skills (Taxman, 2002) as well as helping the staff view their role in a different manner 5. Increase positive reinforcement. The use of incentives or rewards to assist the offender in making progress. Instead of using punishments (sanctions) which has been the tendency of the justice system, the use of rewards as a tool to encourage compliance 6. Engage ongoing support in natural communities. The use of natural supports in the lives of the offender as part of the control processes. The goal is to develop the role of grandparents, parents, partners, and other significant people to be a natural part of the process 7. Measure relevant processes/practices. The system needs to understand its current processes, both in terms of how the organization functions but how well the offenders are doing in the current system. Change is not likely to occur if the system does not understand where evidence based practices can improve outcomes. The first step is to gather baseline measures 8. Provide measurement feedback. After identifying the points where EBP can be implemented, provide feedback on the impact of the proposed change. The goal is to provide visible feedback on whether the change occurred and how it affected offender outcomes Crime and Justice Institute at Community Resources for Justice (2009)

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A major focus of the CJI approach was on organizational development aimed at the inner and outer settings. CJI recognized that the adoption of EBP in justice settings required the organization to be responsive to imposed changes. CJI identified four major themes: (1) a checklist to consider various elements needed for effective implementation; (2) quality assurance methods to ensure that the organization is committed to the fidelity of EBP; (3) performance measures and feedback on the impact of EBP; and, (4) instruments or tools to measure attitudes and effective interventions. The website of CJI (http://www.cjinstitute.org/projects/integratedmodel#Model) maintains various tools that support the adoption of EBP. NIC/CJI early on embraced the importance of systems collaboration (outer setting) with various agencies to provide treatment, reinforcing the importance of treatment requirements, or using the EBP tools at sentencing or at revocation. CJI commissioned a series of papers (see Table 6.3) directed to each main stakeholder. These products are authored by key stakeholders from various disciplines to demonstrate the robustness of the EBP concepts as they affect various components of the justice system. Each article: (1) defines EBP as it relates to an individual agency; (2) provides an overview for the specific component of the system (i.e., pretrial services, probation, defense, prosecution); and (3) illustrates how EBPs are valueadded given the current state of justice processing. These materials serve an important role of demonstrating the compatibility with the existing system but also establish a framework to value EBP for individual organizations, as well as for justice and treatment agencies overall. This process is consistent with effective diffusion efforts that allow each stakeholder to both understand the merits of an innovation, to assess how the innovation will exceed the current gains from existing practice, and to determine how useful the innovation is to that agency (Rogers, 2003). The NIC/CJI sponsored white papers evolved from discussions from members of the criminal justice community who wanted to better understand why EBPs are important to their discipline. More importantly they are written in language and concepts suitable for each stakeholder (e.g., prosecutor, judge, defense attorney, pretrial services), which contributes to early stage recognition of the acceptability of the ideas embedded in the EBP literature.

6.2.2

Initial NIC/CJI Adoption Sites: Maine and Illinois

The NIC/CJI focused their attention on two states as early adopters of this model: Illinois and Maine probation agencies. The initial work sought to lay the groundwork for organizational preparedness so that the agencies involved in the change process were making investments in ensuring that the EBP were viewed as valuable, acceptable, and feasible in their environments. Similar to the concept outlined by Fixsen, Naoom, Blase, Friedman, and Wallace (2005), the focus was on sustainability of the EBP in community corrections agencies. The NIC/CJI technical assistance differed in content from traditional projects. First, most typical NIC technical assistance consists of five days or less on-site, usually as part of an

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information-sharing workshop. The primary goal is to provide an overview of current research findings on a particular topic or part of providing on-site technical assistance on a particular topic, generally with little commitment from the requesting corrections agency to apply the new knowledge to practice. Generally the sites self-select to participate, and they may not be agencies that would most benefit from the technical assistance. Second, CJI had only a two year window to work with the selected states on a specific strategic agenda devoted to select EBP. Given the length of time it can take to move research to practice, this was a very short time frame in which to achieve sustainable organizational change. The emphasis on a strategic planning initiative was to develop a long-range plan for adoption and implementation of a specific EBP. Many of the tools discussed above (e.g., the implementation matrix, the attitudinal surveys) were tried as part of this effort to uncover strategies to learn about the community corrections agency and its work units. Third, the collaborative effort emphasized the working relationships among the state, CJI, and NIC where the needs of all organizations were balanced. The NIC and CJI partnership allowed for experimenting with an organizational approach for penetrating the EBP in the community corrections agency. The emphasis on organizational readiness was perceived as a multipronged strategy, mainly attending to the internal needs of the corrections agency to foster a long-term strategy and to build data systems that can be used to monitor the progress of EBP implementation. Part of the challenge is that Maine and Illinois are vastly different in terms of their organizational structure and their perceptions of needs to advance an EBP agenda. Similar to 29 states, Maine has a centralized corrections structure that administers all corrections services (probation, parole, and prisons); although it should be noted that even within these centralized systems, some states have local governments or contractual probation services for select populations. Illinois has a statewide prison and parole system, and the county governments administer probation. In Illinois, the state Judiciary provides oversight for probation services through establishing standards and statewide initiatives, but the state Administrative Office of the Courts does not have direct authority over the operations of the county-level probation agency. Instead, the Administrative Office of the Court can provide advisory material. Seven states are similar to Illinois with the Judiciary overseeing probation but the operations are the responsibility of a local county agency. The remaining 15 states have a wide range of other unique organizational structures. The NIC/CJI cooperative supported a three-level strategy for working with the two states on the dissemination of EBP. First, the cooperative provided support to the state-level leadership teams and assisted the teams in developing management teams, organizational strategies to improve communication within the selected agencies, trainings to inform the leadership teams about EBP, and trainings to assist the leadership teams with learning how to manage large projects. A number of training and information sharing sessions were provided to present EBP (NIC’s eight principles) at all levels of the organization. Second, each state undertook efforts to develop or refine their existing management information systems to facilitate a more data-driven decision-making process.

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Table 6.5 Example of benchmarks from Maine’s EBP project Intermediate measures 2004 (%) LSI completed in 60 days 43.9 Completed reassessment within 1 year 3.0 Medium to high risk offenders with case plan 11.4 Case plans addressing three criminogenic needs 55.5 Source: Rubin, Howe, Kane, and Faust (2008)

2005 (%) 42.6 6.6 16.5 62.1

2006 (%) 47.4 15.2 25.1 58.8

The goal was to transform legacy management information systems into producing offender and system-level reports that could be valuable to their field employees. The reports were also designed to describe how well they were doing in key benchmarks that reflected the level of use of EBP. In both states, efforts were undertaken to bring in the state’s Statistical Analysis Centers (SAC; funded by the U.S. Department of Justice to establish data centers to process criminal justice information). The SACs were designed to use management information systems to create state-level profiles. Prior to the current initiative, the existing state SACs had not used the local probation-related data and therefore, this process was designed to build an infrastructure. In each state, the existing management information systems had not been used to develop reports for the specific corrections agencies on offender characteristics, corrections processes, process outcomes in different initiatives, or rearrest and technical violation rates. The NIC/CJI initiative included a strategic process to identify the benchmarks that would be useful for characterizing how well the community corrections agency was meeting the EBP implementation milestones. Developing the capacity to use the existing management information system for performance reports was viewed as critical to providing the agency with datadriven tools that could facilitate other decisions and allowing other agencies to understand the needs and issues of the community corrections department. Table 6.5 illustrates the benchmarks that were used by the state of Maine. Third, the projects fostered efforts to improve the skills of agency employees to use EBP. A series of trainings were provided on various topics (depending on the state and the needs) in areas of motivational interviewing (MI), use of the Level of Service Inventory risk assessment instrument (Andrews & Bonta, 2006), quality assurance, and case planning. The trainings were designed to help managers and staff to understand EBP to allow everyone to assess the value of the EBP as well as provide for wider dissemination of information on the use of the EBP. The reports symbolized how the EBP efforts had translated into changes in the traditional work processes. The three-pronged strategy of evidence-based practices-collaboration-organizational development is a continuous process in each of these jurisdictions. The goal was to have the cooperative begin the effort but eventually to transfer the ongoing work to the state and/or local corrections organizations to further refine the strategies to implement EBP into their system. The design seeks to build the knowledge base in the organizations as well as provide tools for future decision-making and sustainability and to develop the change strategies that focus on inclusive team processes.

6.2

NIC Initiative to Expand the Use of EBP by Community Corrections Agencies

6.2.3

167

NIC Framework Garnering Support from Sister Organizations

While the NIC/CJI initiative articulated the importance of systems collaboration, the Maine and Illinois efforts were primarily devoted to developing the internal support for EBP adoption in the corrections agencies. The stakeholder papers (Table 6.3) illustrated commitment to the wide diffusion of information about EBP paradigm while also recognizing the diverse perspectives on the utility of EBP in justice settings. The original cooperative agreement did not openly engage the wider justice stakeholder groups, and the model used by NIC/CJI did not work on an alternative strategy for diffusing innovations. Subsequently, NIC convened a workgroup that met for 18 months to configure a social message about EBP that would appeal to a wide audience and to outline a process for engaging systems (multiagency, systemic partners) in a planning process that supports EBP implementation. With support from NIC, many technical assistance providers (e.g., the Center for Effective Public Policy, Justice Management Institute, Pretrial Justice Institute, and The Carey Group) hosted a series of meetings with a cross-section of justice system players – judges, prosecutors, defenders, jail administrators, probation/parole administrators, prison administrators, treatment providers – to craft core values related to the adoption of EBP into operational practice. This Framework proposes an interagency, systemic approach to support EBP. The Framework borrows heavily from the Institute for Healthcare Improvement (IHI) quality improvement process to advance the uptake of EBP by garnering support from related agencies. As noted in the Foreword to the Framework: The Framework identifies the key structural elements of a system informed by evidence. It defines a vision of safer communities. It puts forward the belief that risk and harm reduction are fundamental goals of the justice system, and that these can be achieved without sacrificing offender accountability or other important justice system outcomes. It both explicates the premises and values that underlie our justice system and puts forward a proposed set of principles to guide evidence-based decision making at the local level—principles that are themselves, evidence-based. The Framework also highlights some of the most groundbreaking of the research—evidence that clearly demonstrates that we can reduce pretrial misconduct and offender recidivism. It identifies the key stakeholders who must be actively engaged in a collaborative partnership if an evidence-based system of justice is to be achieved. It also sets out to begin to outline some of the most difficult challenges we will face as we seek to deliberately and systematically implement such an approach in local communities. (Thigpen, 2010, p. 2)

Included as part of the Framework are three key components. First, the Framework summarized the EBP literature, listing several studies and the associated documentation for these studies. The goal was to inform the field of the supporting evidence for each stated EBP. This was important since prior documentation did not routinely include a synthesis of the studies or the major findings. As seen in Table 6.6, the authors also reworked the original eight evidence-based practices into plain language that was agreed upon by the cross-section of justice stakeholders. The EBPs are restated in ways that echo the recidivism reduction principle but speak to a broader audience to clarify the core concepts that should be emphasized.

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Table 6.6 Seven ways to reduce recidivism Use risk assessment tools to identify risk to reoffend and criminogenic needs Direct programming and interventions to medium and higher risk offenders Focus interventions for medium and higher risk offenders on their individual criminogenic needs Respond to misconduct with swiftness, certainty, and proportionality Use more carrots than sticks Deliver services in natural environments where possible Pair sanctions with interventions that address criminogenic needs Center for Effective Public Policy (2010) Table 6.7 Key framework principles Principle one Principle two Principle three Principle four

The professional judgment of criminal justice system decision makers is enhanced when informed by evidence-based knowledge Every interaction within the criminal justice system offers an opportunity to contribute to harm reduction Systems achieve better outcomes when they operate collaboratively The criminal justice system will continually learn and improve when professionals make decisions based on the collection, analysis, and use of data and information

They also comport with the decision points discussed above to help systems identify the optimal locations where EBP can be inserted into the work processes. Part of the concept of social marketing of EBP is to link each practice with core values that underscore justice policies: fairness, public safety, individual accountability, and harm reduction. Instead of presenting the tensions among the four values, the Framework strives to demonstrate that a balancing act can be best achieved through more attention to how the values complement each other. The authors introduced the concept of harm reduction as a means to assess the costs and benefits of various initiatives based on issues about individual recidivism, community harm, and justice. While crime often results in the specific pain and suffering of individuals, all crime disrupts the fabric of our communities, jeopardizes our individual and collective sense of safety, and extracts a financial penalty by diverting public monies to the justice system that might otherwise support building the health of our communities (e.g., schools for our children, parks for our families). Everyone is a victim of crime. And while some suffer more than others, everyone benefits – directly and indirectly – from crime prevention and reduction efforts. (Center for Effective Public Policy, 2010, p. 20)

Harm reduction provides an alternative framework to assess whether our crime policies achieve a useful impact by combining multiple lens that consider the cost, the impact on the justice system, and the impact on the community overall. For example, services for mental health and substance abuse in the community are often sacrificed due to the costs associated with jail or prison. The harm reduction lens begs the question of whether these needed services would have a greater impact on reducing crime than a jail or prison bed. The four principles that are presented in the Framework (Table 6.7) serve to advance collective efficacy about EBP by providing interagency teams with four guiding principles for their actions.

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In summary, NIC recognized that TT was needed to advance the use of EBP in the community corrections field. Their model was designed to improve offender management as well as to prepare corrections agencies to implement EBP. Two major efforts occurred: the first tested the needs of corrections agencies in a technology transfer process, and the second developed a conceptual model for a dissemination strategy to stakeholders (outer setting) to garner support for the EBP. Both of these efforts are important in terms of increasing our understanding of the adaptation, transportability, and setting-specific issues that need attention as corrections agencies pursue EBP. The following section captures the insights and experiences of key leaders in the field who are involved in implementing EBP in their own jurisdictions.

6.3

View from the Field: Results from Key Informant Interviews

Leaders in the field of community corrections have had a number of experiences with implementing evidence-based treatments or practices in justice agencies. These leaders have both the experience in selecting evidence-based practices, organizational change, or TT approaches, and working with staff on the implementation of EBP. The lessons from these leaders are important and should be factored into how best to design a TT approach that is suitable for corrections environments. In this section, findings are presented from interviews with community corrections leaders and their staff. First, we held two focus groups with about 20 staff (including directors, line staff, and national leaders) at the January 2006 and July 2006 training conferences of the American Probation and Parole Association (APPA). We then conducted Key Informant interviews with 15 individuals in Spring 2007. These individuals were identified mainly through their participation as members of EBP advisory groups assembled by the Center on Evidence-based Interventions for Crime and Addiction (CEICA) (a research center that was at the Treatment Research Institute at the University of Pennsylvania) as part of CEICA’s collaborative work with APPA and the National Treatment Accountability of Safer Communities (TASC). Additional individuals were identified through either chain referral techniques or their participation in EBP focus groups held at the January and July 2006 APPA training conferences. The interviews were conducted by Drs. Steven Belenko, Faye Taxman, and Harry Wexler. Interviews were conducted by telephone and lasted approximately one hour. The respondents were probation chiefs at large county or state agencies, former directors of probation or parole agencies, consultants who have been administrators of corrections agencies, heads of national associations, and key leaders of the Treatment Accountability for Safer Communities (TASC) organizations. The interview guide is shown in Box 6.1.

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Box 6.1 Key Informant Interview Guide 1. What is the level of priority for community corrections agencies to implement and sustain more effective substance abuse treatment practices? 2. Does your agency/organization currently use any evidence-based practices? 3. How would you describe the current level of knowledge in your organization about EBP from the managers? From the line staff? 4. In the absence of multiple randomized clinical trials of an intervention’s effectiveness, what are the standards of evidence that are acceptable to you to determine that an intervention is evidence-based? 5. What are the key gaps in knowledge about evidence-based practice for offenders in your agency and the field? 6. What steps are taken to identify an evidence-based practice – how are you informed about what is an evidence-based practice? 7. In your view, what are the keys steps required for successful implementation of EBP in CJ treatment? 8. What are the key challenges/needs for training staff to implement evidencebased practices for offenders? 9. What are the key challenges/needs for training staff to sustain evidencebased practices for offenders? 10. What organizational changes are needed for the implementation of EBP? 11. What organizational conditions are needed for sustaining EBP? 12. Do you think it is necessary to be completely faithful to the protocol requirements? 13. How are criminal justice treatment programs and/or interventions currently being monitored for adherence to the program design? 14. Are state or federal regulators now requiring or requesting EBP? (a) If yes, what do regulators consider acceptable EBPs? 15. Are outcomes regularly obtained and reported to demonstrate effectiveness? (a) If yes, how is this done? 16. Lessons Learned (a) Have you encountered mistakes and problems when implementing EBP? (b) Do you have any recommendations for others based upon the problems you encountered? (c) Can you recommend techniques to engage staff?

The following sections contain a summary of the findings from the key informant interviews to understand the key gaps in EBP knowledge, the identification of EBP, steps required to implement EBP, challenges and changes needed for implementing and sustaining EBP, and lessons learned from previous experiences with EBP.

6.3 View from the Field: Results from Key Informant Interviews

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171

How Are Evidence-Based Practices Identified?

Several strategies were identified by the informants to identify evidence-based practices. Several routinely read research articles and papers either in trade journals or from federal agencies; larger community corrections agencies with a research department have an advantage of receiving more research articles and reports. Most rely upon publications from the NIC, or other federal government websites (such as the National Institute on Drug Abuse, Center for Substance Abuse Treatment, Office of Justice Programs) that are fairly widely distributed. Conferences are another source of information commonly cited, although these conferences often do not focus on evidence-based treatments or specific issues related to the delivery of treatment services. Technical assistance, or having experts or consultants come on site, was also a popular source especially with the availability of funding from NIC. NIC will provide funding to bring in trainers or outside speakers, to go on site visits to look at other programs, and to communicate with other stakeholders in their organizational or practice network. One site hired a half-time consultant to advise them on assessment, case management strategies, and identification of EBP. Ongoing identification strategies also include monitoring and quality assurance efforts. A connection with trusted researchers and publications was also cited as a frequent practice. Since the dissemination of knowledge is a key to increasing the awareness of evidence-based practices and research findings, the transfer of knowledge to line supervisors and staff is a major issue. Unfortunately, some offices do not provide Internet access to chief probation officers and line staff, which greatly limits access to information. The informants recognized that some reports and material may be too complicated and needs to be translated into “plain English” to increase the applicability of the information to corrections agencies.

6.3.2

Factors that Affect the Use of Evidence-Based Practice in Corrections Agencies

The general consensus from the informants was that evidence-based practices were a high priority for offender supervision but somewhat less important regarding addiction treatment. Criminal justice agencies are primarily interested in public safety issues while substance abuse agencies are more concerned with evidencebased treatments. This dichotomy suggests one challenge in the technology transfer process is that corrections agencies do not place a priority on understanding the issues of evidence-based practices for treatment programs. Several reasons exist for the disconnect between corrections and addiction treatment. First, concerns were raised that substance abuse is just one issue faced by offenders, and a focus on addiction treatment requires the corrections agency to address issues about broader practices that affect the delivery of services, such as classification and treatment assignment practices, monitoring, compliance, and risk reduction. And, while substance abuse may be important, it does not address many

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of the other needs of offenders. From the perspective of informants, a focus on the corrections delivery system requires understanding the risk principle framework (i.e., prioritize services for offenders that are high risk) and the NIC principles may facilitate more effective implementation of evidence-based substance abuse treatment. Second, although there may be statewide structural support from substance abuse or mental health (SA/MH) agencies, the support may break down at the local level (implementation). Staff may understand what evidence-based practices, but not use them. There is local variation on the practices employed by corrections agencies. Third, the support for and understanding of EBP by line staff is essential to make implementation work. The nothing works mentality may still exist with supervisors and administrative staff. Agencies and officers do not have the understanding of substance abuse treatment that is necessary to work effectively with treatment agencies; a collaborative model is needed because just making a referral is not adequate. On the other hand, treatment agencies also have to support and understand EBP for offender supervision, while maintaining responsibility for the effective delivery of treatment in their own agencies. Finally, the pressures caused by large caseloads were mentioned as a critical factor for EBP priority as well as political pressure and regulatory requirements.

6.3.3

Current Use of EBP

In terms of current use of EBP, the responses were mixed. Several agencies use manualized cognitive behavioral therapy (CBT), validated risk assessments, contingency management, and family-based and strength-based interventions. Use of motivational interviewing (MI) was commonly mentioned as an EBP by community corrections agencies. However, it was one respondent’s view that, nationally, a relatively small percentage (about 10%) is doing quality or systemic EBP. Most agencies use MI as a technique to facilitate the relationship with the offender (Taxman, 2008; Walters, Clark, Gingerich, & Meltzer, 2007). Some states include MI practice in their training for new officers, and provide some in-service training. Other states are less systematic in terms of MI training, although they recognize that MI can be used to improve support for treatment. That is, by having corrections staff use MI, they can support the involvement in treatment programs and the attention to substance abuse or mental health problems that affect overall functionality. While a few studies have reviewed the degree to which there is trust between the offender and the corrections staff (Skeem & Louden, 2006; Taxman & Ainsworth, 2009; Taxman & Thanner, 2004), it is a concern that effective treatment can only be offered within the community corrections system if there is trust and a working relationship between offenders and officers. The science of behavioral management emphasizes the importance of reinforcers, mostly positive, to assist the offender in making progress towards changing behavior (NIDA, 1999; Taxman et al., 1999). As discussed in Chap. 7, the emphasis in the field of corrections is on negative reinforcers. Punishment is more compatible with the mission of corrections agencies, particularly with the emphasis on

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enforcement, monitoring, and accountability over the last 30 years. Most corrections agencies emphasize sanctions, with little use of incentives (Friedmann et al., 2007). To get staff to move away from punishment-oriented monitoring that is strongly supported by an enforcement-oriented organizational culture requires a culture change including adoption of a new mission for the agency that acknowledges the value of treatment (or “rehabilitation-type” programming) in achieving the goals of increased public safety. An interesting paradox is that most community corrections agencies report having “structured” graduated responses, which was valued in the 1990s, but most of the administrators admitted that there is little to document that the agency has a structured sanctions policy and follows its requirements. They consider the graduated responses model of the 1990s to be an area not effectively implemented by correctional agencies. Most of the leaders recognized the value of the NIC eight principles that emphasize community corrections, and place less emphasis on addiction treatment. The value of these eight principles cannot be understated – they provide a formula for the underlying operations for community corrections programs that address a balanced approach to integrating treatment into corrections (punishment oriented) environments. The balanced approach allows corrections agencies to assess their current operations against a set of principles, and then consider how to organize and manage their staff to fulfill this tenet. It is plausible that movement towards these principles can prepare corrections agencies to be organizationally ready for evidence-based treatments, particularly substance abuse. For example, the eight principles emphasize the importance of using standardized tools to assess risk and need and then using that information in case planning. Most individuals interviewed reported that their agencies adopted a standardized risk and need tool, and that they believe that it is an important step towards moving the organization in a direction to implement evidencebased treatments. Few respondents reported that their agencies use the risk and/or need tool(s) to meet supervision and referral needs. Agencies are concerned that the tool (all use the LSI-R although one respondent’s state uses the COMPAS) has limitations that affect the utility for program referrals. To address this issue, the latter state worked with the developers of COMPAS to modify the tool. A shorter tool is better for corrections since it takes less time and allows the officer to focus on using the information. Administrators have not had similar experiences with other distributors of instruments that tend to merely market the instrument but do not work with agencies to modify the tool to adapt to their environment. Many respondents identified case planning as the linchpin that it is the hardest area to change since staff generally resists incorporating risk and needs assessment into case planning. They also reported that staff seem more focused on just using the conditions assigned by the court/parole board, instead of tailoring the case plan to the offender’s actual risk needs. Staff tend to want to avoid conflicts with the court or parole board regarding conditions, even if they conflict with the results from the risk and need tool. Further, respondents noted that often there are not services to address some criminogenic factors. Substance abuse treatment is not part of the NIC eight principles model, and it is generally underemphasized in corrections. While there is one principle devoted to generic treatment, more attention could be focused on the quality of treatment in a

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variety of settings. To address this gap, one respondent’s state developed a quality assurance model for treatment providers and uses the financial contract as leverage to monitor the use of evidence-based treatments by providers. Similar approaches are used or are under development in two other states. The state agency of another state focuses on treatment quality issues for all parolees and probationers. (Other probationers in that state are supervised by county corrections agencies.) Another state’s agencies have not dealt with this issue at the state level but the corrections agencies have initiated discussions with their state level Alcohol and Drug administration. Most treatment funding in another state is appropriated to the state substance abuse agency and therefore its community corrections agency does not believe that it has a meaningful role in monitoring treatment quality. Nationally, there may be a sense that community corrections agencies are not comfortable telling addiction treatment providers how to deliver their clinical services since this not their area of expertise. But corrections administrators understand the catch 22 since they know how well (or poorly) offenders are doing in treatment and think that they should be involved in discussions about the quality of treatment. After all, in most jurisdictions anywhere from 40 to 60% of the clients in treatment are under the control of the corrections agencies (Substance Abuse and Mental Health Services Administration (SAMHSA), 2009). The general sentiment among respondents was that treatment providers would not be open to discussions about treatment quality issues. Attention to EBP may not always translate into successful implementation or practice, and many community corrections agencies leave the evidence-based treatments to the treatment providers. Contract and compliance monitoring technqiues may be used, as suggested above. Nevertheless, treatment providers may not always be held to implementing evidence-based practices. Resource constraints may limit the number of slots available in evidence-based programs and such programs may be much less available in rural areas. It is important to be aware of the service limitations in rural areas, where there may be only one program that must be used, regardless of whether it is evidence-based.

6.3.4

Current Level of Corrections Staff Knowledge about EBP

Overall, administrators are well aware that they are more informed about evidencebased practices than their staff, and the staff’s knowledge may be rather superficial. Staff may know the basics. Respondents agreed that knowledge among line staff ranged from limited to moderate, and was relatively superficial. They may be familiar with the NIC eight principles, but staff typically does not understand much beyond that and certainly lack knowledge about evidence-based addiction treatment. In one jurisdiction, MI training helped improve understanding of the concept of EBP. Respondents stated that staff need to be more directly involved with researchers to gain a better appreciation for the issues and need more one-on-one training to improve their EBP understanding and knowledge. One state has adopted

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a policy of having management involved in at least one meeting a year to learn and apply. Another created a learning environment by having line staff and supervisors read research reports and present findings. The goal is to circulate research and stimulate engaging discussions. These strategies are designed to have the organization value research, as well as understand research findings. The interviews revealed that there is basic knowledge about core principles but that it is difficult to translate this knowledge into practice. For example, the principle that high risk offenders should be placed into more structured programs and receive priority is confusing to the corrections agencies. For example, what does it mean when you can have someone who has a substance abuse dependence disorder (e.g., opiate addict) but they are not high risk for criminal behavior? The NIC principles do not address these common issues with the risk and need principle. Another common issue concerns the value of CBT. Corrections administrators expressed concern that they are placing too much emphasis on CBT because the treatment providers are not actually doing this type of therapy, or that the treatment providers may indicate they are using CBT but are not actually implementing the practice with fidelity.

6.3.5

What Constitutes Evidence in EBP?

For leaders in the field of corrections, it does not appear that Campbell Collaboration (see Chap. 2) or other scientific standards are used to denote practices as evidencebased. The field actually has a different definition of “EBP.” Under certain conditions, respondents were comfortable with broader, less rigorous standards than the traditional focus on randomized controlled trials (RCT) or multiple RCTs. These circumstances include a manualized curriculum, fidelity to the protocol, some research evidence (with well-controlled comparison groups), use of validated assessments, practices recommended by respected authorities, and evidence of positive outcomes. Specific to addiction treatment, respondents look for a manual and fidelity to the protocol. “Name brands” such as the Matrix Model (http://www.isap.org) or a therapeutic community are enough to indicate to them that there is sufficient evidence. Many respondents expressed the need to feel comfortable with the identified protocol or intervention. This comfort level is increased if an intervention includes a process evaluation that can explain the implementation process and outcomes and if there are multiple outcomes. The study does not necessarily need an experimental design because the corrections agencies understand how difficult it is to do field experiments in criminal justice settings, and many of the agencies have been involved in studies where experiments were proposed but were ultimately abandoned due to real-world difficulties. Also, if a meta-analysis has been conducted and shows a significant effect, then this would be convincing to most corrections agencies even if the supporting studies in the review did not include any RCTs. While it was clear that the respondents value research and learn from studies done in their systems, they also recognize the need for their agencies to keep advancing

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practices. The lengthy timeline for studies, and confirmatory studies, is viewed as a deterrent to keeping practices moving forward. They feel the need to expand operations and services when they can, not just when the “science is available.” The absence of multiple RCTs should not be seen as slowing down progress. Given the current focus on the risk/needs/responsivity (RNR) framework and the eight NIC principles, this is viewed as sufficient “evidence” to continue to implement innovations such as a new intervention or practice, even if there is no RCT to support the innovation. The opportunity structure is valued since administrators are aware that they must keep improving operations at all times if they are going to be viewed as effective leaders. In many ways, the lack of research should not be seen as a deterrent to advancing practices. Another critical issue is the lack of understanding of research designs, particularly the difference between RCT and quasi-experimental studies. To some informants, any research is “valid.” A number of respondents indicated that they would be convinced by at least one study by a researcher they trusted, or a trend among community corrections agencies. A few were aware of the Campbell Collaboration (http://www.campbellcollaboration.org) but did not understand its value and did not agree that the reviews from this organization were more valuable than other reviews. It is clear that there is a need to expand and improve training for practitioners about research methods and designs as well as the standards for evidence. It is also clear that there is a tension between research-based standards of evidence (such as the FDA and NIH phased clinical trials models) and practitioner and administrator needs to rapidly implement programs and practices that they perceive to be more effective than current practice. Administrators, particularly this set of leaders, felt that the lag between science and demarcation of an EBP may not fit the opportunity structure; they have to make changes given that there are certain moments or pressures that often provide the impetus for moving in a particular direction. Some administrators identified that local performance indicators and measurable outcomes were considered more important than RCT-based evidence. Desirable performance measures included decreased waiting lists and greater retention in services while important outcome measures were reductions in recidivism and substance abuse. One administrator noted that RCT results were not especially impressive unless there was a big comparative effect and another commented that if a service is shown to improve staff/client relationships it would be considered an EBP.

6.3.6

Key Gaps in Knowledge about Evidence-Based Practice

A number of gaps in the scientific literature were cited by key informants. Several mentioned the need for knowledge about matching specific interventions to specific subpopulations including gender-based treatment, rural populations, sex offenders, high-risk/high-need offenders, various cultural groups, or offenders with mental health problems. Other gaps relate to factors that advance implementation and sustainability. Typical questions that appear to be unresolved are what happens when

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treatment providers mix populations, how to motivate the offender and build trust (by using supervision style, officer-offender relationship, and other techniques), how EBP are actually used in practice, how to move staff to change their attitudes to better support recovery, and how to improve development of case plans. Both officers and treatment staff have a quest for more practical tools for the toolbox. Knowledge gaps exist among community corrections staff as well as treatment staff. The laundry list of factors surrounding evidence-based practices that are unclear to the staff is rather long. A number of respondents suggested that staff do not understand criminogenic need factors, and that there is a tendency to confuse risk and needs factors. Also, line staff do not know how to manage and overcome resistance on the part of offenders, how to handle situations where direct services are not available, or what to do with offenders that relapse. All of these issues seem to fall in the gaps and appear to affect the values attributed to the literature on evidence-based practices. From an organizational development perspective, agency leaders are unsure how to address the public safety vs. soft on offender issue. This tension is not typically addressed in the literature, but it is a value clarification that needs attention in any TT or organizational development process. An important area of research that has not yet been conducted is what practices and policies should be in place to overcome the disconnects in goals and values regarding public safety vs. public health; administrators felt that this information might lead to reducing barriers to implement EBP. Other key informants focused more on the gap between knowing and doing and the inconsistent sharing of EBP knowledge. External partners such as judges and attorneys lag far behind in the knowledge about EBP and there is a need for reorientation through education and training. One exception may be one respondent’s state that is mandating EBP and trains all other agencies and criminal justice practitioners (judges, prosecutors, defense) (see Chap. 5). Internal supports are needed to bridge the gap between the initial introduction of EBP and training, and inadequate follow through by supervisors and supporting policies. Finally, it was generally recognized that most agencies have to deal with general staff attitudes, values, and beliefs regarding the lingering ethos that nothing works so why try so hard.

6.3.7

Are State and Federal Regulators Requiring EBP?

Several examples were given of states that are mandating EBP in their health and justice agencies. The following is the progress thus far: (1) One state has a statute requiring the use of EBP, particularly for county-funded programs; (2) another requires addiction treatment programs seeking block grants to use EBP from an approved list; and (3) another state requires use of CBT in offender treatment. One state level probation and parole agency was also noted as having made tentative inroads into EBP by training state parole staff on the LSI-R. Another state has more generic requirements in terms of EBP without specifying the programs (except for drug courts). Another state has begun performance contracting and encourages the use of EBP and at the minimum providers must make a case that their services are evidence based.

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Many states have some requirements and provide lists of EBP that agencies must use or provide evidence for what they are doing. Any funding from CSAT requires the grantee to use an approved interventions listed on the NREPP website (http:// www.nrepp.org). Finally, several states are requiring the use of standardized tools to guide assessment procedures. Even where states are mandating EBP, there is a challenge to introduce EBP at the local level.

6.3.8

Key Steps Required for Successful Implementation of EB Treatment

Three main categories were mentioned by the key informants as essential steps for the successful adoption and implementation of evidence-based treatment: (1) the need for strong leadership and political will, (2) the importance of staff training, and (3) quality monitoring. Other important facilitators for implementation cited by several respondents included adequate funding and available staff time. Leadership. In terms of leadership, there is a need to understand, embrace, and make a long-term commitment to EBP. Good leadership requires making changes in policies and procedure manuals to support EBP implementation; communicating to line staff; getting agency consensus; and providing ongoing exposure to reinforce EBP through training and front-line supervision. Respondents emphasized that there is a need for top–down endorsement to move ahead because they need administrators and leaders that can talk to political leaders and keep the organization focused on key issues. It is easy to get sidetracked, and the leadership must make a commitment to move in this direction. The leadership must be interested and invested in efforts to keep the momentum going. Investments in research and planning may improve the infrastructure (including the treatment system) to be ready for EBP. Other leadership issues mentioned by several respondents relate to communication between the corrections agency and external partners such as judges and community service providers. A shared vision, ongoing meetings (especially initially at implementation), and perhaps coordinated hiring strategies for new employees may be helpful. Keeping an ongoing communication loop that designates a mid-level or manager person to focus on substance abuse treatment is a strategy used by many administrators. Training. The major diffusion tool is the dissemination of information in training or workshops. The need for training is great in many areas including a variety of skills and knowledge but also in terms of collaboration of systems such as treatment and community corrections agencies. Training is needed at all levels of the organization: administrators, managers, and line staff. There are many potential topics for training including what are EBP, assessment instruments, case management, supervision practices, use of MI and motivational enhancements, graduated responses to monitor behavior, and a useful management information system.

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For the most part, the informants pursued training by beginning with general education about EBP and then moving towards incremental implementation of EBP in small steps. Leadership and staff need to first understand the concept of EBP to demonstrate that it is not something that can be tacked on, but can be embedded into current practices. Corrections staff and line supervisors need to understand the EBP and its relevance to their work. Corrections agencies must also learn what is needed for implementation. Many informants acknowledged that much of EBP is not geared for corrections and only within the last 5 years has training been more suited for the field, particularly the adaptations of the Maryland Proactive Community Supervision model (Taxman, 2008). EBP education should be provided at three levels: knowledge of core practices, problem solving, and skills to translate key findings. Quality and Fidelity. EBP requires attention to the quality of the services and programs that are being provided. Important components of good quality monitoring and follow-up include feedback to line supervisors, performance monitoring, outcomesbased contracting, and outcome measures to assist with case planning. Client considerations include identifying target treatment groups and finding relevant protocols for that group; identifying the desired results; matching the practice with the desired results; monitoring implementation for fidelity; evaluating results; and adjusting as needed. Collaboration among all stakeholders emphasizes the flexibility to adapt EBP to real-world conditions, and commitment to improved outcomes. Several respondents mentioned the need for fidelity checks, quality assurance activities, and tracking of outcomes (e.g., retention, completions, and drug/crime outcomes).

6.3.9

Key Challenges for Implementation and Sustainability of EBP

A number of challenges and needs, as well as strategies, were cited by respondents to improve the extent and effectiveness of staff training and EBP implementation efforts. One main challenge is the availability of resources and time to support training. Funders may need to be convinced of the importance of training and that it should be a priority; support for ongoing training, booster sessions, or retraining may be particularly difficult to find. But if EBP is mandated or encouraged by states or counties, then staff of various agencies should be trained. A major concern is that some of the treatment manuals must be purchased and also require funding for workbooks and training; certification to use the protocol may require expensive training and fidelity monitoring which increases the initial costs of the treatment protocols. Other major challenges for the implementation and sustaining of EBP include high caseloads, limited time, and high staff turnover. Large caseloads were seen as creating a number of challenges including allowing sufficient time for training on new EBP and ongoing supervision for sustaining intervention quality. Although it is

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recognized that caseloads may affect the adoption of EBP, many of the administrators also saw evidence-based practice as a tool to help address the workload issues of their staff. For example, with the EBP principles it is possible that the agency could develop work standards based on the risk and need levels of the offenders. This was seen as an advantage of adopting EBP. The overall strategy to prepare and train the office/agency was a major topic of discussion among some respondents. There was general support for the idea of training managers and line supervisors before training line staff. This train the trainer approach was endorsed by most respondents. But there is an important role for supervisors who need to relearn their jobs – they need to be trained so they can mentor and be supportive of EBP. It was pointed out that some senior staff may try to sabotage EBP or other change efforts. Instilling change at the supervisor level was perceived as critically important to advance the field. One drawback noted was that although management and line staff may be trained, high turnover requires the agency to invest more time and effort in recruiting, hiring, and training new staff. There was general agreement that sustaining the knowledge and skills gained from training requires booster sessions and ongoing refresher training. This may require designating or hiring a staff person to maintain and monitor EBP efforts. Booster training should be made acceptable and low-risk for staff. MI techniques can help staff listen and reflect, but there is also a need to focus on general interviewing and other skills. Providing opportunities for staff to observe and view other programs and services was also seen as useful. Others felt that to maintain gains, professional trainers should provide ongoing technical assistance and training. Performance monitoring was viewed as an important adjunct to training; in order to assess the effectiveness of training, trainers had to make sure that staff performance has changed or improved as desired, and ensure that staff are documenting what they are doing (e.g., supervision plans). In one jurisdiction, a feedback system generates trimester reports on EBP, such as timely risk and needs assessments and employment referrals. Annual performance assessment is another strategy. Although not focused on addiction treatment, this is an important tool for letting staff know that training is taken seriously. Another jurisdiction gives incentive awards that tie into training on EBP, use of risk assessments, and EBP practices. One jurisdiction hired quality assurance supervisors to monitor results. Several ideas for techniques and strategies to improve training were suggested. These include using outside trainers or training academies, using adult learning techniques, and getting away from traditional classroom-style passive training. Training content must be prioritized so that agencies focus on key issues; it was also suggested that agencies take remedial steps to improve EBP training. In one state, EBP is now part of standard training for new staff. Finally, the general challenge of implementing permanent changes in staff behaviors was noted as a challenge. Not surprisingly, younger staff appear to be more amenable to change and more flexible. Resistance from line staff must be overcome and training needs to be more supportive.

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6.3.10

181

Organizational Changes and Conditions Needed for Implementing and Sustaining EBP

At the agency level, most respondents indicated a need for a clear mission and a shift away from the traditional public safety approach to one that emphasizes the need to change offenders’ behavior (or at least allow both approaches to coexist). Because implementing EBP involves a complex set of principles and strategies to change offender behavior, the agency needs to be aligned and implement performance benchmarks. The mission and focus of the treatment providers may also have to be changed. At the system level, stakeholders need to be realistic about what needs to be changed, and EBP work needs to be supported by research and endorsed by credible outside experts. It must be recognized that implementing and sustaining EBP is difficult and slow and involves a sustained multiyear effort. On the other hand, agencies cannot wait for perfection to roll out a new initiative. Another concern is if the EBP is too complex, an organization may need to focus on prioritizing what is needed, and implementing changes in a step-by-step fashion. There is also a more general lack of understanding about the organizational change process. Some agencies do not have the organizational skills to either develop EBP or to facilitate organizational readiness. Agencies need to understand how organizational change will impact staff for an extended period of time. The informants indicated that organizational change is often related to leadership issues – there is lack of development of leaders in the field and this results in a number of problems. A second set of issues involves resources. Several respondents again mentioned the need for lower caseloads; nearly all respondents felt that high caseloads affect the agency’s mission. Incorporating the risk principle will enable agencies to focus resources on medium to high-risk offenders, and steer more resources toward addiction treatment. Another respondent noted that treatment resources are insufficient. Behavioral health care reimbursement models may not allow for long-term or residential treatment even where it is needed. Although many offenders may need a continuum of care over time, resources and staff are lacking to accomplish this goal. It was also noted that community corrections agencies do not always control their caseloads or workloads, emphasizing the importance of system-wide approaches. Courts put unnecessary conditions on offenders (especially low risk), which affect the ability to implement EBP. Costs and budgets need to be allocated differently to free up resources for EBP. Another organizational change issue is the need to seek and strengthen support from politicians, judiciary, and defenders (and maybe other law enforcement actors) for these changes. But prosecutors, defenders, judges, and legislators may have different agendas, and bringing them on board to support innovation and EBP may be quite difficult. Organizational change is difficult because of the issues related to the tenure of the average leader in corrections agencies, knowledge of the leaders, interference from the political system, and the tug and pull from others. Respondents also felt that often agency leaders wear so many hats that they cannot focus on one issue.

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Organizational changes in policies and procedures that support EBP are needed, which will require adequate funding, staff time, and management information system (MIS) support. The organization must deal with basic barriers of time restrictions that most activities are done in a crisis-oriented environment with the ongoing threat of high staff turnover. Increased salaries, lower case loads, and higher quality staff are crucial. There may be a need to move to a proactive vs. reactive orientation within an organizational culture that is forward-looking and supports change and growth. There is a need for clear understanding at all levels as to why a certain EBP is being used, along with value/ethic of openness and related job evaluations. Staff can be helped to see the practical and clinical usefulness of EBP and that it can make them more effective in their job. There may be a need to give up something in order to adopt new evidence-based practices. Several respondents discussed the supportive role of research and funded research projects that include an integrated evaluation design, close researcher-practitioner collaboration, and well-planned launch with rapid formative feedback and outcome information. Finally, a number of respondents mentioned the importance of improvements in staff hiring practices and involving staff in EBP and organizational change decisions. More attention should be paid to improving hiring practices. Who is being hired and will they be able to adapt to EBP as well as emerging evidence-based practices? Should preemployment training be implemented? What are the expectations of the job and on what will they be evaluated and rewarded? Younger staff may have broader training and be more open to EBP (and thus easier to train); however, young staff do not just want to follow orders, and may question why changes are made. Managers should be prepared and able to explain. Staff appreciate feedback, and it is helpful for not changing too much at once. Managers and supervisors should walk around and talk to staff. They should not ignore the complexity of the job and the implications for line staff of changes in programs or practices. If additional requirements are added to an officer’s workload, then other duties ought to be taken away. It is a mistake to make major organizational plans solely from the top, and strategies are needed to increase line staff and supervisor involvement in decision-making. Line staff can be engaged through committees, focus groups, and regular and frequent town hall meetings (Lerch, James-Andrews, Eley, & Taxman, 2009).

6.3.11

Necessity of Protocol Fidelity

There was fairly clear consensus that fidelity is important and necessary but is difficult to maintain in the real world, where conditions are very likely to differ from those in the research studies. Corrections agencies must recognize that fidelity should be the goal and be careful about drift, but interventions need to also be flexible. Programs may be set up for failure if they are forced to adhere to the manual and cannot, or the protocol is too rigid. Too much focus on protocol fidelity rather than client needs and outcomes can be problematic. The EBP needs to be appropriate to

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the target population, fit the time frame (duration of client participation), and be supported with sufficient funding and staff quality and expertise. If the manual and the intervention are mastered, then some deviation is acceptable. For some evidencebased interventions, the curriculum is less important than for others (such as some family-focused interventions), so fidelity to the protocol may be more necessary. However, if fidelity is not appropriately maintained then poor outcomes may be erroneously attributed to the EBP, instead of their being recognized as an implementation problem. One respondent noted that protocols could still be effective if not entirely faithful to the proven model. Another thought that it was important to communicate changes in application of a protocol and track the results. Another suggestion was that fidelity was more important in research projects, in contrast to actual treatment delivery efforts that need to get clients’ attention, participation, and engagement. Some felt that it might be better to focus on client participation and outcomes than fidelity to the manual. Other key informants discussed fidelity in terms of EBP in general and not addiction treatment. They recognized that the keys are quality of the interaction with the offender and the issues related to risk and need assessment. The emphasis was on these actions but they are difficult to measure because such measurement tools do not exist. Respondents felt that more emphasis is needed on fidelity in supervision but that there needs to be more consensus about these protocols. Monitoring fidelity was viewed as important but was not always adequately done. Several efforts to monitor EBP were mentioned with respect to supervision or public safety related interventions: current or planned use of the Corrections Program Assessment Inventory (CPAI) (Gendreau, 1996) to help monitor contracted programs; building in components of the CPAI to vendor contracts; state contract monitoring (allocating a certain percentage of contract funds to EBP); recidivism studies; and contract monitoring through a research and evaluation division. Performance monitoring was seen as occurring more with corrections staff, less so with contracted agencies. Some states have a quality assurance system in place and computerized assessment processes, with a reporting tool, to facilitate the identification of risk factors and help to draft treatment plans. Others noted that monitoring is a shortcoming in community corrections that is not being done well by supervisors – it is more of a clinical supervisor’s approach; large supervisor caseloads (e.g., 6–8 or 10–12 officers per supervisor) may prevent adequate monitoring. It is important to provide feedback to staff on what is working and what is not. Staff can be motivated by showing improved outcomes, that the EBP produces better outcomes than current practice (similar to the perceived value concepts suggested by Rogers (2003) and Proctor et al. (2009)), and that EBP makes their jobs easier and heavy caseloads more manageable (less time in court and doing paperwork related to violations). On the other hand, several respondents noted that outcomes are almost always lower than anticipated. There is a tendency to rely too heavily on EBP instead of focusing on building healthy long lasting and respectful relationships with clients.

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It appears that monitoring of substance abuse treatment programs tends to be even more haphazard (except if the community corrections agency is contracting directly for slots). Most probation and parole officers do not have the expertise to monitor contracts. Parole/probation officers can decide to which program to refer offenders, and will make referrals if they are happy with the treatment program. It was noted that parole/probation officers might take on faith how well the treatment program is doing as they don’t have the time to monitor. Communication between parole/probation officers and treatment programs is often inadequate, and monitoring is reactive (only if there is a problem). Agencies should work collaboratively with treatment providers and improve relationships between parole/probation officers and treatment staff. Implementing EBP can be a problem for providers. More forums are needed for treatment and corrections staff to meet to share issues and talk about solutions, such as through case conferences, to make sure parole/probation officers are notified about problems. More outside treatment evaluators may be needed, and community corrections agencies need to recognize funding and turnover problems in treatment programs; but adequate resources are not available to do so. In the absence of internal contract monitoring units, most community corrections agencies refer to existing resources where they have little input into the quality of the services. Personnel working in corrections agencies also may not feel comfortable engaging substance abuse treatment providers in discussions about service delivery, supervision, clinical needs, or performance monitoring. Other respondents noted that monitoring for adherence to EBP program design was commonly done systematically in research projects, but rarely under nonresearch conditions. As noted above there are almost no resources for adherence monitoring activities and there is little pressure except from state agencies that are beginning to address adherence. However, a few respondents noted that their agencies monitor EBP implementation, process and outcomes including retention, completions, how clients leave, achievement of program goals, and limited drug and crime outcomes. Generally, there is less concern with protocol fidelity and more concern about outcomes. Finally, one person observed that adherence is more likely when there are manuals and when supported by specific policy and procedures related to job evaluation.

6.3.12

Are Outcomes Regularly Obtained and Reported to Demonstrate Effectiveness?

Although there was general agreement about the importance of outcomes monitoring, whether by the state or county, the responses to the issues about routinely reporting outcomes were quite mixed. The motto what gets measured, gets done was clearly embraced by the respondents, and they acknowledged that feedback on performance and implementation will most likely drive the use of EBP. But, three major issues regarding process and outcome reporting were noted. First, overall

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the group thought that generally there was a big hole in the system in terms of outcome monitoring, even though criminal justice funders generally require some outcomes reporting. This may especially be true for treatment retention and other outcomes, although in one state treatment program funding is contingent on providing reporting forms. Even where outcomes are monitored, the reporting is infrequent and often they are required to report on outcomes that are not that significant to EBP. Second, the reporting of outcomes is generally at the global level and therefore is not provided by unit or officer, which can undermine the utility as part of a performance monitoring strategy. Third, computer technology has not advanced to make outcome reporting easy and a web-based and automated system for routine measures (i.e., recidivism, technical violations) would be advantageous. More generally, a number of key informants talked about their difficulty getting management information systems to deliver reports that can be useful. Many agencies have some form of computerized system to track service outcomes, although many organizations have some difficulty tracking client progress (e.g., drop-outs and completions). But management information systems were seen as too inflexible, and updates and improvements generally take too long.

6.4

Conclusion

While clarity about correctional and addiction treatment practices has emerged from science over the last two decades, community corrections agencies have equally started absorbing how to emphasize EBP in their daily work. NIC has supported a number of critical initiatives to assist the field in a diffusion process, notably with an emphasis on dissemination and social marketing of the concepts. The NIC/CJI initiative followed by the stakeholder-driven framework report (Center for Effective Public Policy, 2010) demonstrates efforts devoted to assisting vested partners to understand the core components of EBP. This effort has mainly focused on the issues of offender classification and management; fewer efforts have been devoted to addiction treatment. That is, the emphasis on addiction treatment was subsumed under an effort to define the global concept of “interventions” without a clear focus on the differences among different offender criminogenic needs. Addiction treatment, as its own discipline, has unique EBP that warrant slightly different attention to justice agencies. But as the informant interviews indicated, community correctional administrators generally have their “hands full” and priority is given to the larger issues confronting their agency such as managing compliance. The informant interviews confirmed that many core EBP were of interest to the field of community corrections but there was a need to transport them into their organization. Many were struggling with the best method to do so. In all, the concept of EBP is wellrespected in the field, with an appreciation that science-based findings can assist community corrections agencies to fully achieve their goals. The search for better TT models is of interest to practitioners in the field.

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References Aarons, G. A. (2006). Transformational and transactional leadership: Association with attitudes toward evidence-based practice. Psychiatric Services, 57(8), 1162–1169. Andrews, D. A., & Bonta, J. (1998). Classification of treatment: The risk principle, the need principle, the responsivity principle. In D. A. Andrews & J. Bonta (Eds.), The psychology of criminal conduct (2nd ed., pp. 242–245). Cincinnati: Anderson. Andrews, D. A., & Bonta, J. (2006). The psychology of criminal conduct (4th ed.). Newark: LexisNexis. Andrews, D. A., Zinger, I., Hoge, R. D., & Bonta, J. (1990). Does correctional treatment work – a clinically relevant and psychologically informed meta-analysis. Criminology, 28, 369–404. Arnold, J. A., Arad, S., Rhoades, J. A., & Drasgow, F. (2000). The empowering leadership questionnaire: The construction and validation of a new scale for measuring leader behaviors. Journal of Organizational Behavior, 21(3), 249–269. Brannigan, R., Schackman, B. R., Falco, M., & Millman, R. B. (2004). The quality of highly regarded adolescent substance abuse treatment programs: Results of an in-depth national survey. Archives of Pediatric and Adolescent Medicine, 158(9), 904–909. Cameron, K. S., & Quinn, R. E. (1999). Diagnosing and changing organisational behaviour: Based on the competing values framework. Massachusetts: Addison-Wesley. Center for Effective Public Policy. (2010). A framework for evidence-based decision making in local criminal justice settings (3rd ed.). Washington: National Institute of Corrections. Crime and Justice Institute at Community Resources for Justice. (2009). Implementing evidencebased policy and practice in community corrections (2nd ed.). Washington: National Institute of Corrections. Pub No. 05C45GJI. Cullen, F. T., Fisher, B. S., & Applegate, B. K. (2000). Public opinion about punishment and corrections. Crime and Justice: A Review of Research, 27, 1. Denison, D. R., & Mishra, A. K. (1995). Toward a theory of organizational culture and effectiveness. Organization Science, 6(2), 204–223. Finckenauer, J. O., Gavin, P. W., Hovland, A., & Storvoll, E. (1999). Scared straight: The panacea phenomenon revisited. Prospect Heights: Waveland Press. Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., & Wallace, F. (2005). Implementation research: A synthesis of the literature. Tampa: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network (FMHI Publication #231). Fletcher, B. W., Lehman, W. E., Wexler, H. K., Melnick, G., Taxman, F. S., & Young, D. W. (2009). Measuring collaboration and integration activities in criminal justice and substance abuse treatment agencies. Drug and Alcohol Dependence, 103(Suppl 1), S54–S64. Friedmann, P. D., Phillips, K. A., Saitz, R., & Samet, J. H. (2003). Linking addiction treatment with other medical and psychiatric treatment systems. In R. K. Ries, S. C. Miller, D. A. Fiellin, & R. Saitz (Eds.), Principles of addiction medicine (3rd ed., pp. 401–412). Philadelphia: Lippincott Williams & Wilkins. Friedmann, P. D., Taxman, F. S., & Henderson, C. E. (2007). Evidence-based treatment practices for drug-involved adults in the criminal justice system. Journal of Substance Abuse Treatment, 32, 267–277. Gendreau, P. (1996). The principles of effective intervention with offenders. In A. Harland (Ed.), Choosing correctional options that work (pp. 117–130). Thousand Oaks: Sage. Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P., & Kyriakidou, O. (2004). Diffusion of innovations in service organizations: Systematic review and recommendations. The Milbank Quarterly, 82(4), 581–629. Henderson, C. E., & Taxman, F. S. (2009). Competing values among criminal justice administrators: The importance of substance abuse treatment. Drug and Alcohol Dependence, 103(Suppl 1), S7–S16.

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Henderson, C. E., Taxman, F. S., & Young, D. W. (2008). A Rasch model analysis of evidencebased treatment practices used in the criminal justice system. Drug and Alcohol Dependence, 93(1–2), 163–175. Hubbard, R. L., Marsden, M. E., Rachal, J. V., Harwood, H. J., Cavanaugh, E. R., & Ginzburg, H. M. (1989). Drug abuse treatment: A national study of effectiveness. Chapel Hill: University of North Carolina Press. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington: National Academy Press. Kish, L. (1965). Survey sampling. New York: Wiley. Knudsen, H. K., & Roman, P. M. (2004). Modeling the use of innovations in private treatment organizations: The role of absorptive capacity. Journal of Substance Abuse Treatment, 26(1), 51–59. Landenberger, N. A., & Lipsey, M. W. (2005). The positive effects of cognitive – behavioral programs for offenders: A meta-analysis of factors associated with effective treatment. Journal of Experimental Criminology, 1(4), 451–476. Lehman, W. E. K., Fletcher, B. W., Wexler, H. K., & Melnick, G. (2009). Organizational factors and collaboration and integration activities in criminal justice and drug abuse treatment agencies. Drug and Alcohol Dependence, 103(Suppl 1), S65–S72. Lehman, W. E., Greener, J. M., & Simpson, D. D. (2002). Assessing organizational readiness for change. Journal of Substance Abuse Treatment, 22, 197–209. Lerch, J., James-Andrews, S., Eley, E., & Taxman, F. S. (2009). “Town hall” strategies for organizational change. Federal Probation, 73(3), 2–9. Lowenkamp, C. T., Latessa, E. J., & Holsinger, A. M. (2006). The risk principle in action: What have we learned from 13,676 offenders and 97 correctional programs? Crime & Delinquency, 52(1), 77–93. Marlowe, D. B., & Kirby, K. C. (1999). Effective use of sanctions in drug courts: Lessons from behavioral research. National Drug Court Institute Review, 2, 1–31. National Institute on Drug Abuse. (1999). Principles of drug addiction treatment: A research based guide. Rockville: National Institutes of Health (NIH Publication No. 99–4180). National Institute on Drug Abuse. (2006). Principles of drug abuse treatment for criminal justice populations. Rockville: National Institute on Drug Abuse (NIH Publication No. 06–5316). Orthner, D. K., Cook, P., Sabah, Y., & Rosenfeld, J. (2003). Measuring organizational learning in human services: Development and evaluation of the program style assessment instrument. Paper presented at the annual meeting of the Society of Social Work and Research, Washington. Perdoni, M., Taxman, F. S., & Fletcher, B. W. (2008). Treating offenders in the community: An overlooked population and a lost public health and public safety opportunity. Perspectives, 32(2), 46–53. Peters, R., & Wexler, H. K. (2005). Substance abuse treatment for adults in the criminal justice system (TIP 44). Rockville: SAMHSA. DHHS Publication No. (SMA) 05–4056. Podsakoff, P. M., MacKenzie, S., Moorman, R., & Fetter, R. (1990). Transformational leader behaviors and their effects on trust, satisfaction, and organizational citizenship behavior. Leadership Quarterly, 1, 107–142. Proctor, E., Landsverk, J., Aarons, G., Chambers, D., Glisson, C., & Mittman, B. (2009). Implementation research in mental health services: An emerging science with conceptual, methodological, and training challenges. Administration and Policy in Mental Health and Mental Health Services Research, 36(1), 24–34. Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York: The Free Press. Rubin, M., Howe, M., Kane, M., & Faust, D. (February 2008). A Tale of Two States: An EBP Report Card. Presentation at the American Probation and Parole Association, Phoenix, AZ. Schneider, B., White, S. S., & Paul, M. C. (1998). Linking service climate and customer perceptions of service quality: Tests of a causal model. Journal of Applied Psychology, 83(2), 150–163. Scott, S. G., & Bruce, R. A. (1994). Determinants of innovative behavior: A path model of individual innovation in the workplace. The Academy of Management Journal, 37(3), 580.

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Sherman, L. W., Gottfredson, D., MacKenzie, D., Reuter, P., Eck, J., Bushway, S. (1997). Preventing crime: What works, what doesn’t, what’s promising. A Report to the U.S. Congress. Washington: U.S. Department of Justice. Retrieved from http://www.ncjrs.gov/works/. Simpson, D. D., Joe, G. W., & Brown, B. S. (1997). Length of stay in treatment and follow-up outcomes in DATOS. Psychology of Addictive Behaviors, 11, 294–307. Skeem, J. L., & Louden, J. E. (2006). Toward evidence-based practice for probationers and parolees mandated to mental health treatment. Psychiatric Services, 57(3), 333–342. Substance Abuse and Mental Health Services Administration. (2009). Treatment Episode Data Set (TEDS) Highlights – 2007 National Admissions to Substance Abuse Treatment Services. OAS Series #S-45, HHS Publication No. (SMA) 09–4360, Rockville. Taxman, F. S. (1998). Reducing recidivism through a seamless system of care: Components of effective treatment, supervision, and transition services in the community. Washington: Office of National Drug Control Policy. Taxman, F. S. (2002). Supervision – exploring the dimensions of effectiveness. Federal Probation, 66, 14–20. Taxman, F. S. (2008). No illusion, offender and organizational change in Maryland’s proactive community supervision model. Criminology and Public Policy, 7(2), 275–302. Taxman, F. S., & Ainsworth, S. (2009). Correctional milieu: The key to quality outcomes. Victims & Offenders, 4(4), 334–340. Taxman, F. S., & Bouffard, J. A. (2000). The importance of systems issues in improving offender outcomes: Critical elements of treatment integrity. Justice Research and Policy, 2, 9–30. Taxman, F. S., Henderson, C. E., & Lerch, J. (2010). The socio-political context of reforms in probation agencies: Impact on adoption of evidence-based practices. In F. McNeill, P. Raynor, & C. Trotter (Eds.), Offender supervision (pp. 409–429). New York: Willan Publishing. Taxman, F. S., & Marlowe, D. B. (2006). Risk, needs, responsivity: In action or inaction? Crime & Delinquency, 52(1), 3–6. Taxman, F. S., Perdoni, M. L., & Harrison, L. D. (2007). Drug treatment services for adult offenders: The state of the state. Journal of Substance Abuse Treatment, 32(3), 239–254. Taxman, F. S., Soule, D., & Gelb, A. (1999). Graduated sanctions: Stepping into accountable systems and offenders. The Prison Journal, 79(2), 182–204. Taxman, F. S., & Thanner, M. H. (2004). Probation from a therapeutic perspective: Results from the field. Contemporary Issues in Law, 7(1), 39–63. Taxman, F. S., & Thanner, M. (2006). Risk, need, and responsivity (RNR): It all depends. Crime & Delinquency, 52(1), 28–51. Taxman, F. S., Young, D. W., Wiersema, B., Rhodes, A., & Mitchell, S. (2007). The national criminal justice treatment practices survey: Multilevel survey methods and procedures. Journal of Substance Abuse Treatment, 32(3), 225–238. Thigpen, M. (2010). Foreword. In the Center for Effective Public Policy (Ed.), A framework for evidence-based decision making in local criminal justice settings (3rd ed., pp. 2–3). Washington, DC: National Institute of Corrections. Walters, S. T., Clark, M. D., Gingerich, R., & Meltzer, M. L. (2007). Guide for probation and parole motivating offenders to change. Washington: National Institute of Corrections. Young, D. W., Dembo, R., & Henderson, C. E. (2007). A national survey of substance abuse treatment for juvenile offenders. Journal of Substance Abuse Treatment, 32(3), 255–266. doi:10.1016/j.jsat.2006.12.018. Young, D. W., Farrell, J. L., Henderson, C. E., & Taxman, F. S. (2009). Filling service gaps: Providing intensive treatment services for offenders. Drug and Alcohol Dependence, 103(Supp. 1), S33–S42.

Chapter 7

The Idiosyncrasies of the Corrections and Treatment Environments

The foundation for technology transfer (TT) models is that: (1) the innovation is consistent with the primary mission of a specific organization; and (2) diffusion efforts are mainly internal to the organization. The classic research-to-practice model promoted by the Institute of Medicine (IOM) (1998) and the Institute for Healthcare Improvement (http://www.ihi.org; Massoud et al., 2006) draws from the concept that the innovation has been shown to have relative advantage over existing practices and that these improvements are consistent with the goals, values, and aims of an organization and its staff. As highlighted in the preceding chapters, these assumptions may be only partially valid in addiction treatment and community corrections settings. Recent advances in TT models (see Chaps. 3 and 4) recognize that organizations are influenced by the demands of the inner setting characteristics (i.e., mission and goals, leadership, staff qualifications, work processes, existing resources), but the outer setting (i.e., stakeholders, public values, systems features) provides a protective layer that can either assist or detract from pursuing, maintaining, and/or sustaining the innovation. The fields of addiction treatment and community corrections have unique, and often conflicting, environmental factors that affect the ability to transfer innovations or new technologies into practice. This chapter will explore the unique attributes of each field that that should be considered in TT efforts, particularly given the environmental factors that can be marshaled to assist these organizations in the implementation of EBP. The complexity of EBP adoption and implementation derives from whether the emphasis is on: (1) integrating addiction treatment into corrections agencies; (2) having corrections agencies rely upon addiction treatment to reduce recidivism; and (3) finding the augmenters or internal and external environmental supports to have a successful transfer process. The effort needs to draw from the strengths of the organizations while recognizing the idiosyncrasies of the current environment.

F.S. Taxman and S. Belenko, Implementing Evidence-Based Practices in Community Corrections and Addiction Treatment, Springer Series on Evidence-Based Crime Policy, DOI 10.1007/978-1-4614-0412-5_7, © Springer Science+Business Media, LLC 2012

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Recognizing the First Hurdle

Corrections environments present challenges to the basic approaches of TT models because substance abuse treatment is generally not part of the fundamental mission or goal of the agency and the core diffusion assumptions of compatibility and added value may not necessarily apply. Because corrections agencies typically do not have primary responsibility for providing addiction services, and few agencies have a proportion of their operating budget allocated to these services (Taxman, Perdoni, & Harrison, 2007), only a small number of corrections staff may have skills and knowledge in addiction treatment. The larger external community may also debate whether treatment services for offenders are essential or the responsibility of taxpayers. The debate within the larger community may signal that there might not be a consensus that the corrections agency should venture into service provision or that offenders deserve to be provided with prevention and treatment services. Accordingly, TT models for corrections agencies must begin from the starting point that the external (outer) setting may not be supportive of advancing an EBP agenda that focuses on improving treatment-related outcomes for offenders in the hopes of reducing recidivism. The implementation process must be attentive to these disconnects, and be modified to address the nuances of community corrections agencies. Likewise, the addiction treatment system and many providers are wary of serving large numbers of offenders. This reflects a lack of mission alignment (public health vs. public safety), concerns about additional paperwork and reporting burdens, biases against offender-clients who may be considered more difficult to treat or disruptive to group counseling sessions, or concerns about corrections or judiciary staff interference in clinical decisions (Duffee & Carlson, 1996). Many addiction treatment agencies are specialty operations that are not affiliated with large service provider agencies that have an infrastructure for mental health services, case management, medical care, or other needs of the client base. For example, many addiction treatment agencies do not have the capacity or staff support to provide medication-assisted treatments (i.e., methadone, buprenorphine, naltrexone; see Knudsen, Ducharme, & Roman, 2007). Given the limited number of funded treatment slots, treatment agencies and their staff may prefer to admit nonoffender clients given that the needs of the criminal justice system may be too burdensome for a small agency with limited resources. A dilemma about providing treatment to offenders is that the customers are people who have wronged society and who are being punished, even if their behavior is caused by a substance abuse or psychological disorder. Offenders are typically considered lesser citizens due to their behavior and interactions with the legal system (Duffee & Carlson, 1996). Some offender behaviors are considered to be indicative of bad choices, such as substance abuse, and the public may believe that these behaviors are morally wrong and self-inflicted, rather than a result of a disease or mental health disorder. Offenders are afforded limited citizenship including diminished civil liberties and civil responsibilities (i.e., limitations on voting, employment, access to public housing). These factors may affect the responsiveness and

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empathy of general society to the offender population and may affect the attitudes of public and private treatment agencies toward offenders. Implementation of new innovations in this setting and environment thus creates friction for corrections agencies and addiction treatment agencies because there is a substantial need to garner support from the wider community. The agencies must be in a position to offer services that facilitate that change. The public appears to be conflicted – they want punishment to be the goal of corrections agencies and yet they also desire the same organizations to correct behaviors (Cullen, Fisher, & Applegate, 2000), albeit with limited resources devoted to such efforts (see Box 7.1). Although public opinion polls over the last decade have indicated more support for offender change (Cullen & Gendreau, 2000; Pew Center on the States, 2009) and use of expanded alternatives to incarceration using drug treatment services (Hartney & Marchionna, 2009), the allocation of sufficient resources to achieve these goals does not reflect this change in public opinion. The discrepancy of funding is even greater between community corrections and incarceration; the average daily cost to keep an individual on probation in the community is $3.82 a day vs. $78.95 for imprisonment (Pew Center on the States, 2009). In this context, agencies need to be aware of the environmental constraints that affect implementation steps and dynamics as part of the change process. In Chap. 9, a new TT model will be suggested that illustrates how to be sensitive to the environment in order to facilitate implementation of evidence-based practice.

Box 7.1 National Research on Public Attitudes on Crime and Punishment September 2010 The Pew Foundation’s Public Safety Performance Project In a national public survey, the following were the key issues regarding public safety in the United States. The public preference is for the use of expanded community corrections for nonviolent offenders, as long as the correctional agencies can be held accountable for making the public safe. 1. Voters are concerned with keeping people safe. 2. Voters want a strong public safety system where criminals are held accountable and there are consequences for illegal activities. 3. Voters believe a strong public safety system is possible while reducing the size and cost of the prison system. 4. Voters believe the primary purpose of prisons is to protect society (31%), followed by rehabilitating (25%) and punishing offenders (20%). 5. Voters want offenders held accountable for their actions, especially by ensuring they pay child support (79% cite as a high priority) and restitution to their victims (72%). 6. Voters approach violent and nonviolent offenders differently. Focus groups found that there is often considerable empathy expressed for nonviolent (continued)

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Box 7.1 (continued) offenders and their life circumstances, such as those suffering from mental health and substance use disorders. Citizens want punishments that do not include prison, opting for community service or other punishments. Substance abuse treatment and job training are often considered appropriate. Source: PEW Center for the States (2010). National Research of Public Attitudes on Crime and Punishment. http://www.pewcenteronthestates.org/ initiatives

7.2

Opening the Door to Offender Change as a Goal of Corrections

The public expects that corrections agencies will satisfy the main goal of public safety. This creates a dynamic where punishment, rehabilitation, and deterrence may be commingled, and where any or all of these goals can be accomplished under the label of public safety. Public safety can be a labile concept in that its definition varies considerably depending on the setting, timing, and sociopolitical climate. In addition, the concept has different meanings for elected officials, the general public, public administrators, and line probation/parole staff, senior staff, and community-based treatment service providers. The lack of a common understanding of public safety means that it is open to wide (mis)interpretation – to some it refers to violence prevention, to others it refers to protection from heinous acts, to others it refers to safeguarding the public, and to others it means controlling any aberrant behavior. The concept of public safety forces the state to act in the spirit of parens patriae to ensure consideration of public welfare. The focus on safety generally refers to aberrant behavior where unhealthy behaviors such as substance abuse, mental health disorders, or physical health problems may be construed as falling into this category, or at least increasing public safety risk. In the past three decades, substance abuse has increasingly been criminalized (Belenko, 1993; Blumstein & Beck, 1999; Mauer & King, 2007; Tonry, 1995), bringing more pressure on corrections agencies to deal with substance abusers in a similar fashion as other criminal behaviors (Husak, 2003). Deviating from their core mission by marrying public safety with other goals requires the acceptance and commitment of two types of agencies external to the corrections agency: other justice-related organizations (e.g., judiciary, prosecutors, defense attorneys, parole boards, prisons, jails, and other corrections agencies) and health-related agencies (e.g., substance abuse, mental health, other health care providers). The need for the outer setting to support such policy change was the impetus for the National Institute of Corrections’ Framework model discussed in Chap. 6. Traditionally, the closed system model of corrections was convenient because it protected corrections agencies from dealing with too many public demands, and allowed the corrections system to remain out of the public eye. To move away from

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Opening the Door to Offender Change as a Goal of Corrections

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a punishment-dominated corrections system requires the support of both justice and health constituencies. Legislative bodies and elected officials will also have to support the notion that corrections agencies should be involved in activities that focus on offender change, including reductions in drug use. This is a major difference from other innovation diffusion and implementation efforts in terms of the need to adopt secondary or tertiary goals as part of the mission of a corrections agency.

7.2.1

Looking Through an Offender-Based Lens

The corrections system is sensitive to the legal status of the offender, including whether an offender can be mandated into services based on whether he or she has been convicted and sentenced or is awaiting trial, and whether corrections agencies must provide health services. Under Estelle v. Gamble (1976), prisons and jails are constitutionally mandated to provide basic health care whereas there is no equivalent mandate for community corrections agencies. Because far more offenders (nearly five million) are under community supervision than incarcerated (2.1 million; Glaze, 2010), this has serious public health consequences given that offenders under community supervision have similar rates of substance abuse, HIV risk, and mental health disorders as inmates (Belenko, Langley, Crimmins, & Chaple, 2004; James & Glaze, 2006; Mumola & Bonczar, 1998; Mumola & Karberg, 2006; Taxman, Perdoni, et al., 2007). Pretrial defendants, either in jail or released to the community, must either volunteer for treatment or be mandated by the court as part of their pretrial release conditions before they are accepted into jail diversion programs. Another factor that affects the delivery of services is the length of time that the offender is under the control of the system – sentences less than 12 months are often considered too short to make it worthwhile to connect an individual to services, and those sentenced to long periods of incarceration are considered to be unlikely candidates given their tenure in the system. Two exceptions to this are drug courts, many of which provide long-term treatment (at least 12 months) for offenders sentenced to relatively long probation terms (Belenko, 2002; Huddleston, Marlowe, & Casebolt, 2008) and the Drug Treatment Alternative to Prison program diverting felony offenders from prison into long-term residential treatment (Belenko et al., 2004; Belenko, Sung, Swern, & Donhauser, 2008; Hynes, 2010). The emphasis on legal status, length of sentence, and constitutional responsibilities to provide basic health services often affects how an offender population is deemed eligible for services. These operational factors are part of the organizational climate regarding determinations of whether offenders are good candidates for treatment services. As part of TT efforts, legal status and mandates impact how offenders are perceived by insiders or staff in the corrections agency. These obstacles cannot be ignored in TT models because they are barriers that affect how the justice system handles offenders with substance abuse disorders. A related issue is the corrections system’s tendency and tradition to be offense focused. The dilemma of the offense vs. offender focus has long affected criminal justice policies. Offense-focused policies base eligibility for programs and services

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on the severity of the legal charges. Offenders with serious legal charges or convictions are considered as high stakes for the corrections system – providing services to these offenders may backfire if an offender commits another serious crime and the newspaper headlines blame lenient parole agencies or soft on crime judges. For the most part, sentencing guidelines, the judiciary, and parole boards are offense-driven in that their decisions are substantially influenced by the current offense and criminal history. Plea bargaining and setting of supervision conditions are examples of offense-based practices. As previously discussed, the EBP movement embraces an offender-based system that relies upon standardized risk and needs tools to identify factors that affect involvement in criminal behavior. Moving toward a client-driven system, where the focus is on the behavior of the offender and not the legal offense (charge or conviction) would make the corrections system more compatible with a social or behavioral health service system that focuses on individual needs. Moving toward an offender-based system would create challenges for the operations of corrections systems. No longer will services be able to be based on voluntary participation. As noted by the recent National Criminal Justice Treatment Practices (NCJTP) survey many corrections agencies provide educational, substance abuse, and mental health services but few offenders actually can avail themselves of the services (Taxman, Perdoni, et al., 2007). For example, although 53% of state prison inmates are classified as having a drug abuse or dependence disorder (Mumola & Karberg, 2006) only about 10% of inmates participate in clinical treatment in prison (Belenko & Peugh, 2005). Even though 40% of the corrections population lacks a high school diploma, an average of 8% of prison inmates, 3.7% of jail inmates, and 1.5% of probationers/paroles can participate in educational services on any given day (Taxman, Perdoni, et al., 2007). There is an enormous gap between service needs and capacity of the system with less than 10% of offenders being able to access services on any given day (Taxman, Perdoni, et al., 2007). Corrections agencies struggle to provide core services. However, the corrections system does not have the basic tools in place to make routine decisions to place offenders in appropriate services (see Taxman, Cropsey, Young, & Wexler, 2007 for a discussion of risk and substance abuse screening tools), which hampers the ability to assign offenders to the limited programming based on need. This will be a major challenge to moving toward an offender-based system in TT efforts. Box 7.2 below illustrates a core problem in corrections about the political context of policy reform and management of offender behavior. The newspaper article about the reaction to a crime committed by an inmate released early from prison reflects a typical problem – if a negative incident happens, then the traditional reaction is to re-emphasize public safety concerns and reduce the use of more rehabilitative options. An incident such as this triggers substantial policy debate throughout the agency regarding the soundness of the policy change. These are the types of incidents that often serve as a barrier to TT. As noted above, the concerns about public safety associated with offenders heavily affects policies, even for the nonviolent drug-involved offender.

Box 7.2 Early-Release Program in N.J.: Concerns About Public Policy Adapted from: Early Release in New Jersey. Jersey News By Chris Mergerian/Statehouse Bureau, Thursday, March 24, 2011, 6:00 am http://www.nj.com/news/index.ssf/2011/03/shell_criticism_of_early_relea.html TRENTON – The controversy over the state’s new early-release program was sparked last week by the revelation that a Jersey City man was accused of murder just 6 weeks after being allowed out of prison months ahead of schedule. But records reveal that was not the first slaying attributed to an inmate who was released early. More than 2 weeks before Rondell Jones was charged with pulling the trigger in Jersey City, Brandon Isler allegedly shot and killed a teenager in Camden on Feb. 18, 1 month after being released early from prison. It was Isler’s second stint in state prison and his sentence on drug and weapons charges had been scheduled to end June 27. The killing fuels an already fierce dispute involving the early-release program, sponsored by Assemblywoman Bonnie Watson Coleman (D-Mercer), signed into law by then-Gov. Jon Corzine, and harshly criticized by Gov. Chris Christie. “This just shows what a disaster for public safety this early-release program is,” Christie said in an interview with The Star-Ledger. “People are being killed because of it.” Coleman, in a statement, said Christie was wrong to blame early releases for the killings. “Legislation doesn’t kill people,” she said. “No murder is acceptable, but so far it seems most people are using this program to try to positively turn their lives around.” From the beginning of the program on Jan. 3 through March 18, 239 inmates have been released early. Parole Board records requested by The Star-Ledger show seven people, including Jones and Isler, were arrested in connection with new crimes, such as domestic violence and theft, since their release. Three others have ducked supervision. Coleman has said the program should improve public safety because inmates would be released with parole supervision rather than finishing sentences with no strings attached. Now she is raising concerns that the Parole Board is not being vigilant enough and too few inmates are being sent to residential facilities. It is becoming painfully clear that the administration may not be up to the task of implementing this law properly, Coleman said. Parole Board Executive Director David Thomas said it is too early to tell if inmates released early are committing more crimes than other ex-offenders. Despite his criticism, Christie said he wants to work with Sen. Raymond Lesniak (D-Union) on his proposal to move drug addicts out of prison and into treatment programs. Lesniak is pushing a proposal to cut some prison sentences by 2 years but emphasized differences between his plan and Coleman’s. Only offenders diagnosed with addiction problems would be eligible, and they would be placed in residential treatment programs only after completing courses in prison. “I hope inflammatory political rhetoric stays out of our efforts to change the face of corrections in New Jersey,” he said. Christie supported Lesniak’s focus on drug treatment, saying, “I’d like to work with him to come up with a bipartisan approach to this issue.”

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Lack of Infrastructure, Knowledge, and Skills

In the punishment and public safety culture of corrections agencies, there is an assumption that clinical practices and standards are inconsistent with the mission and operations of corrections agencies. This is reflected in the hiring standards and practices of the agencies as well as the training provided to staff. Few staff members are required to have clinical skills, and many employees (e.g., corrections officers) are only required to have a high school diploma. Training programs to help corrections/supervision staff develop people skills and become proficient in the tasks of assessment, matching needs to services, compliance management, and building trust in the justice system are rare. The nonclinical nature of the corrections systems, and its corresponding policies and procedures, creates a substantial gulf between practice and the concepts underscoring EBP. This premise negatively affects the ability to implement treatment-related innovations that focus on behavioral change since these efforts are foreign to the culture of the agency, the knowledge of the staff, and the skills of the staff. In many ways, this presents a tremendous challenge to corrections agencies because it requires the early steps of organizational change to develop these basic skill-sets in order to have a critical mass of staff that is comfortable with the innovations. Training for both corrections and treatment staff therefore needs to be enhanced to incorporate several new areas. These include basic tools for reading and understanding research reports, cross-training in other relevant disciplines and missions, comportment with offenders/clients (Taxman, Shepardson, & Byrne, 2004), and assessment. For corrections staff in particular, the overriding punishment and retribution frameworks for corrections management that characterize the current era of corrections philosophy suggest that there is a need for leaders who are willing to promote a more rehabilitative focus and promote the importance of public health interventions to improving public safety (Cullen & Gendreau, 2000).

7.3

The Deficiencies of Addiction Treatment Programs

The ability of the addiction treatment system to successfully implement and sustain evidence-based treatment may be somewhat limited at the present time. This is because the addiction treatment infrastructure in the United States has a number of structural characteristics and deficiencies that work against innovation, expansion, and delivery of effective treatment to offenders. As noted in a survey by McLellan, Carise, and Kleber (2003), the core deficiencies include funding gaps, low credentials and standards for addiction staff, poorly trained and underpaid staff, high counselor and administrative staff turnover, organizational instability, inadequate facilities, and lack of technological innovation. Improving technology transfer of evidencebased treatment into community corrections settings cannot avoid the elephant in the room: the overall quality and capacity of addiction treatment programs must be addressed if there is a desire to obtain the same outcomes as reported in the

7.3

The Deficiencies of Addiction Treatment Programs

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scientific literature, particularly randomized controlled trials. For many years, there was been a consensus that substantial improvements are needed in the addiction treatment system and that treatment providers and systems need to expand their incorporation of research-based treatment interventions and practices. Despite the recognition that the addiction treatment system needs to expand its use of evidencebased practice and programs, this system has been particularly slow to adapt and successfully implement EBP (Center for Substance Abuse Treatment, 2009; Sloboda & Schildhaus, 2002; see Chap. 2 for the degree of adoption of EBP in addiction agencies). The treatment system in general has organizational, structural, and resource problems that can undermine its ability to support organizational change, or implement and sustain effective treatment using evidence-based practices (Kimberly & McLellan, 2006; Taxman, Henderson, & Belenko, 2009). Resource constraints and competing priorities can limit uptake of evidence-based practice (Henderson & Taxman, 2009; Simpson, 2002), affect intervention fidelity, and make it difficult to hire and retain a skilled workforce. Implementation efforts are often unstructured, under-planned or piecemeal. McLellan et al. (2003), reporting results from a nationally representative survey of 175 treatment providers, noted many problems in the treatment infrastructure. There is no evidence that this situation has substantially improved since this study was undertaken nearly 10 years ago. Problems included inadequate and unreasonable staff–client ratios, high staff turnover, underpaid and poorly trained staff, lack of computers and other infrastructure needs, burdensome paperwork, and administrative instability. McLellan et al. (2003) estimated that 1 year after an initial survey, 15% of communitybased treatment providers had shut down or ceased providing substance abuse treatment annually, and 25% had undergone organizational restructuring. The annual staff turnover rate was estimated at more than 50% for counseling staff and program directors. CSAT has estimated staff turnover rates at 19–33% per year (Kaplan, 2003). The credentialing system used by many regulatory agencies certifies at the organizational level, but this means that individual counselors are free to use idiosyncratic or eclectic counseling approaches unless there is strong management and leadership. Counselors are seldom given adequate performance feedback or evaluated on their clinical-related responsibilities including the use of EBP. Counselors in recovery may be resistant to change clinical approaches that helped them maintain their own sobriety. Another impediment to implementing and sustaining EBP is that many treatment programs lack client-based information systems or internet access that could be used by counseling staff. Only 30% of the programs (mainly those that were based in hospitals or large health systems) have well-developed information systems (McLellan et al., 2003). This limitation affects the ability to monitor performance and track outcomes. Moreover, as in the corrections field, personal values often affect the ability to implement science-driven policies. The debate about use of needle exchange highlights the conflict where the scientific evidence is strong but political will and an understanding of the science limits the degree to which staff support the use of needle exchange programs. Needle or syringe exchange programs may be an important

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public health strategy for opiate addicts, but they have been controversial because they are promoting better health management and harm reduction rather than abstinence. At the federal level, legislation prohibits federal funds for needle exchange programs, even though scientific studies tend to find that they reduce transmission of HIV (IOM, 2006). The political landscape must provide support to move ahead but unfortunately this does not occur (see Box 7.3). Given the concerns about the limitations associated with the inner setting of addiction treatment agencies, achieving support from the outer setting (stakeholders) is important in making strides to addressing infrastructure issues.

Box 7.3 Science vs. Personal Beliefs in Addiction Treatment: A Debate about Needle Exchange Adapted from: Needle exchange and the New Drug Czar By Maia Szalavitz, Dec 3, 2008. http://stats.org/stories/2008/needle_exchange_ drug_czar_dec03_08.html Is the Obama administration choosing ideology over scientific consensus in its pick for the new drug czar? President-elect Obama’s staff recently floated the name of Rep. Jim Ramstad, a Republican from Minnesota who is a recovering alcoholic, as the possible “drug czar.” While the nomination of someone with personal experience of addiction to this post is, in principle, something worthy of applause, Ramstad appears to see addiction and recovery through too personal a lens, putting, in the process, ideology ahead of science. Crucially, he opposes needle exchange programs to prevent the spread of HIV among addicts, which is one of the best-studied interventions in public health. He even voted against allowing Washington, DC to use its own money to fund these programs. And yet, every single medical, scientific, and legal body ever to look at the data has come down in favor of it and other programs to expand access to syringes. Here is just a small sampling of the research which shows that not only does needle exchange reduce HIV infections, it also does not increase injection drug use or crime and steers addicts toward treatment, not away from it: The first international review of the data, conducted in 2006, concluded: “There is compelling evidence of effectiveness, safety, and cost-effectiveness,” of needle exchange programs. A 2003 study of 99 cities around the world compared HIV rates in addicts in cities with and without needle exchange programs. In cities which started needle exchanges, HIV prevalence in addicts fell by 18.6%, while those which failed to do so saw an 8.1% increase [Strathdee S.A, Bastos F.I. 2003. Sterile Syringe Access for Injection Drug Users in the 21st Century: Progress and Prospects. International Journal of Drug Policy 14(5–6):351–353; MacDonald M, Law M, Kaldor J, Hales J, Dore G.J. 2003. Effectiveness of needle and syringe programmes for preventing HIV transmission. International Journal of Drug Policy 14(5–6):353–357].

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The Deficiencies of Addiction Treatment Programs

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Another example is the controversy regarding medication-assisted treatment (MAT) among addiction treatment and correctional personnel. As noted by Knudsen, Ducharme, and Roman (2006), few addiction treatment agencies use MAT even though there is strong scientific evidence regarding their effectiveness in increasing treatment compliance and reducing drug use and criminal behavior (Gordon, Kinlock, Schwartz, & O’Grady, 2008). A recent survey of staff from 12 probation and parole departments participating in NIDA’s CJDATS cooperative (Wexler & Fletcher, 2007) found that only 18.2% provide MAT to opiate-dependent offenders, and none provide or fund methadone treatment. However, two-thirds of the agencies stated that they were open to introducing or expanding use of methadone, and 83% were open to expanding use of buprenorphine or naltrexone (Friedmann et al., 2011). The most common barriers to implementing MAT in community corrections noted by the respondents included preference for abstinence-based treatment, lack of qualified medical staff, inadequate information about MAT, and the perception that MAT was already adequately accessible in the community. A new study is underway (see Chap. 10, Box 10.6) to examine the factors that affect the attitudes and opinions of probation and parole officers in the use of MAT. The study’s goal is to assess whether improving the attitudes of correctional personnel will translate into greater client compliance. The study uses two different approaches to determine how to best affect the attitudes of the community corrections and addiction treatment personnel: a training session or a training session with a local council devoted to improving access to MAT. This study design illustrates related potential strategy for introducing a new innovation into the community corrections and addiction treatment fields.

7.3.1

Overcoming EBP Implementation Barriers to Achieve Improvements in Addiction Treatment

The above discussion highlights the issues that concern the capacity of the existing addiction treatment and corrections systems. Given these unique environmental factors, the question regarding the degree to which either or both systems can attend to the needs of the innovation must be considered. More specifically, the key questions center on the mission and goals of organizations, support for innovation, and the knowledge and skills available in the organization. The TT literature highlights a model that has a critical goal to overcome internal barriers to new innovations but also focuses on garnering external support to ensure sustainability. Given the inherent differences between public health and corrections agencies, and the capacity issues confronted by both, more attention is needed to build a foundation for facilitating EBP implementation. This can involve assessing each agency’s readiness to change; assessing staff, organizational, and system needs; and then reviewing the substance abuse assessment, treatment referral, and treatment monitoring process within the corrections agency and the public health system (Friedmann, Taxman, & Henderson, 2007). The same is true for addiction treatment agencies

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where there is a need to examine the type of staff available to deliver services, the training needs of the staff, the skill level and comfort level with new treatment technologies, and the understanding about how the EBP will improve operations and client outcomes (Bartholomew, Joe, Rowan-Szal, & Simpson, 2007; Knudsen, Ducharme, Roman, & Link, 2005). This lays the foundation for developing realistic expectations about EBP and reframing perceived threats as challenges to be overcome. Ensuring readiness to change can be accomplished through a process that includes new technology exposure (e.g., demonstrations, training, coaching) and gathering support for the adoption of the innovation within the agency and its key stakeholder groups. Another consideration is the need to institutionalize and align new practices into daily staff routines (Taxman & Sherman, 1998) which is part of the focus on sustainability (Fixsen, Naoom, Blase, Friedman, & Wallace, 2005); this is often a barrier to the adoption of new technology, where technology is too often implemented without consideration of an agency’s business practices and staff roles and responsibilities (Kaplan, 1997; Liddle et al., 2002), and is instead imposed in addition to regular duties and tasks. Training and technical assistance is important and should incorporate staff roles and responsibilities to enable staff to relate the technology to their particular role. Staff should be slowly engaged with the new technology beginning only with what is necessary for his/her responsibilities, exposed over time to the full intervention, and taught how it helps improve outcomes for offenders. Finally, no innovation can be successfully sustained without a plan for long-term utilization. Not only is it important to plan for and implement innovation, but it is also important to plan for ongoing training and technical assistance, fidelity monitoring, and performance feedback (Taxman et al., 2004) to sustain the innovation. After implementation, agencies need to continue ongoing oversight that includes technical assistance, maintenance of the intervention’s fidelity,1 retraining of existing staff and new staff, and performance monitoring or benchmarking. Similarly the agency should develop an ongoing data collection plan to document program performance. Sustaining EBP over time may require changes in daily practice, organizational and systems change, and the active involvement and support of agency leadership. For community corrections agencies, pressure has increased in recent years to implement EBP and consensus-based best practices as a technique to improve offender outcomes. Emphasis has been placed on four areas that most affect the business practice of community corrections agencies: assessment, treatment services, deportment, and compliance management (sanctions/rewards) (National Institute of Corrections, 2004; Taxman et al., 2004; see Chap. 6). Assessment, deportment, and compliance management are designed to improve the infrastructure of corrections agencies to support offender change. For example, the importance of using actuarial risk assessment tools has been a core component because it provides an objective

1

The term “fidelity,” sometimes overused and misunderstood, is used here to include maintaining protocol rigor in different clinical environments, and incorporating protocol principles in the context of real-word clinical needs and environments.

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Conclusion

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means to identify risk level, manage the risk and then allocate resources accordingly (i.e., provide high risk offenders with more control and treatment resources than medium to lower risk offenders), and link services to the needs of the offender (Lowenkamp, Latessa, & Holsinger, 2006; Taxman & Thanner, 2006). Another component is attention to the organizational culture or the ecological setting for the supervision services that are focused on risk management, where the emphasis is on using processes of deportment that allow staff to develop rapport and trust with offenders (Taxman et al., 2004; Taxman & Thanner, 2004). Finally the use of behavioral management tools (including both positive and negative reinforcers) may be needed to improve compliance and retention in appropriate services and offender recidivism outcomes (Gendreau, 1996; Marlowe & Kirby, 1999). The goal of these efforts is to support offender involvement in treatment services, whether they are delivered by corrections agencies, through a contract with treatment providers, or through available community-based treatment providers. Involving offenders in quality evidencebased substance abuse treatment services, such as social learning models, cognitive behavioral, or therapeutic communities with aftercare in the community (Belenko, Houser, & Welsh, 2011; Gendreau, 1996; Lipsey & Landenberger, 2006; Prendergast, Hall, Wexler, Melnick, & Cao, 2004; Sherman et al., 1997; Taxman et al., 2004) is the key to improved outcomes. This model must be clear to the external stakeholder agencies and to the management and staff of the corrections agency. A similar effort is needed in addiction treatment agencies with a focus on screening and assessment, case planning, type of clinical services, involvement of the family and/or support system of the client in the treatment process, and use of performance reports. As shown by studies of the NIATx process improvement model, an emphasis on the overall performance of the agency – having clear and visible goals – is important in the process to help the addiction treatment agency focus on benchmarks (McCarty, Gustafson, Capoccia, & Cotter, 2009). This is the impetus to change practice, since a visible report card can illustrate how well the organization is doing overall. Similarly client-level performance tools (Walters, Vader, Harris, & Jouriles, 2009) are helpful to inform counselors and clients of the progress. The improvements in treatment including MAT, motivational enhancements, contingency management (positive reinforcers), and standardized tools, are challenges to the organizations unless the staff and managers understand and agree to the rationale for the change. These are some of the issues that addiction treatment agencies must address in the foundation-building component.

7.4

Conclusion

The nuances of the community corrections (and corrections overall) and addiction treatment fields are both different and similar. The differences mainly occur in the perception of the goals and mission of these organizations. In the addiction treatment field, most agencies are more closely aligned to public health and public welfare missions. The goal is to reduce drug and alcohol use to improve the person’s quality

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of life, with added societal benefits of reduced costs. Correctional agencies, however, are aligned with public safety – staff are not required to adopt practices that are more likely to occur in the medical or behavioral health fields. But the similarities are that, at the individual level, corrections has responsibility to manage the person; the techniques are similar to how behavioral health programs manage people, with screening, assessment, treatment placement (including reducing risk management), and compliance management. These are familiar and needed components. However, expectations from the outer setting clearly affect addiction treatment and corrections agencies in that they define the scope of their activities as well as the expectations of outcomes. The idiosyncracies of infrastructure or the inner setting relate to the general organizational issues of organizational goals, mission, priorities, and managerial and staff issues. Both fields must address these factors in a TT model in order to address the barriers and resistance toward the adoption of EBP. In the next two chapters we present models to address the evidence mapping component and the activities associated with a TT model, designed around an understanding of these deficits and strategies for overcoming them.

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Chapter 8

Making Good Choices: A Multistage Conceptual Model for Identifying and Selecting Evidence-Based Practices

Build a better mousetrap, and the world will beat a path to your door, says the old adage. Late night television advertisements offer marketing help to inventors, giving examples of people who had an innovative idea and made millions by marketing the product or selling it to a large corporation. In the movie Field of Dreams, a farmer hears a mysterious ghostly voice in his cornfields saying, “If you build it, he will come.” The farmer builds a baseball field that helps him connect with his past and contemplate the meaning of life. Similarly, many intervention developers assume that once an evidence-based treatment or practice is developed and tested, the users will come to that intervention and implement it in their local settings. Of course, the reality is much more complex. Many people have designed and built better mousetraps or other products that nobody bought. At the end of commercials for inventor services, there is invariably a rapidly spoken disclaimer reminding viewers that only a very small percentage of inventions actually become commercially viable. And, given the relatively low rate and slow pace of dissemination and uptake of evidence-based practice (EBP), the mantra from Field of Dreams may more accurately be restated when applied to implementation of EBP as “If you build it, no one may come, unless you show people how to build it in their setting.” Previous chapters have highlighted both the processes for identifying EBPs (Chap. 2) and the challenges of implementing EBP into complex organizations and systems (Chaps. 3 and 4). Despite the presence of models for using rigorous scientific processes for determining the evidence base, and mechanisms for disseminating information about EBP to the field, it is not a straightforward process to decide which innovation or EBP is appropriate to use in which settings. Organizations, systems, and policymakers in the corrections and addiction treatment systems face a number of challenges in identifying the appropriate innovation or EBP. How should such decisions be made? What level of scientific rigor is needed to assure that similar results will occur when the intervention is replicated? To what extent can an EBP be taken off the shelf and implemented in new settings such as a jail, probation office, or other criminal justice setting? What factors should be considered by agency

F.S. Taxman and S. Belenko, Implementing Evidence-Based Practices in Community Corrections and Addiction Treatment, Springer Series on Evidence-Based Crime Policy, DOI 10.1007/978-1-4614-0412-5_8, © Springer Science+Business Media, LLC 2012

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administrators, clinical directors, criminal justice stakeholders, and policymakers in making decisions about adopting, implementing, or modifying an EBP? We have discussed how most systematic review procedures prioritize results from sets of studies using different research designs, tending to give the greatest weight to evidence of positive effects from RCTs (see Chap. 2). Less rigorous evidentiary standards are generally not considered valid, and few, if any, interventions tested only in quasi-experimental or observational studies have received official designation as EBPs. The focus on RCTs, the gold standard, is built on the notion that this research method is best for ensuring internal validity – that the intervention is responsible for the outcomes. The emphasis on RCTs has been the subject of much debate and discussion in recent years (Sampson, 2010). What sometimes gets lost in the discussion about the value of RCTs, and in the repository-based model for dissemination of EBP, relates to: (1) the transportability (Schoenwald & Hoagwood, 2001) of evidence-based interventions; and, (2) the importance of the organizational and system capacity to absorb, implement, and sustain the innovation. The designation of an intervention as evidence-based is only the first stage in moving from research to effective implementation and sustainability. In contradistinction to this scientific process requiring multiple well-controlled studies to indicate that a practice or treatment improves outcomes, is the consensus or bottom up approach (see Chap. 2). This approach can involve activities such as focus groups, panels of experts and key informant surveys, or staff workgroups that access the richness of clinical experience or expert judgment. None of these approaches depend on rigorous hypothesis testing. Consensus approaches do have value – they give weight to clinical experience and they provide a tool to fine-tune interventions and identify potential new interventions and practices, as well as obtain staff buy-in. But, consensus approaches may be insufficient for testing whether an idea or concept has merit and can impact desired outcomes. Numerous practices and interventions have been widely disseminated and routinized into daily practice in many behavioral health and community corrections settings, based largely on consensus processes, but there is little to suggest that these practices generate the desired outcomes at the organizational or individual level. This chapter addresses one major concern in the evidence-based policy debates: the process of identifying an EBP and moving it into practice within an organization is more complex than using findings from a RCT, obtaining a manual for an EBP designated by one of the repositories, and training staff on that intervention. This is considered the bench to bedside to public health/safety applications dilemma. In order to move EBP into field settings, the implementation process must consider that issues such as the feasibility, appropriateness, and organizational capacity need to be addressed, before an EBP can be implemented appropriately and in a way that can be sustainable over time. In this chapter, we present a conceptual evidence mapping model (Fig. 8.1) to expand beyond either the traditional science-based EBP designation or consensus approaches. The goal is to address the many unmet issues in the current EBP designation and adoption system (i.e., largely dependent on RCTs) by incorporating the

8.1

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utility to the field, external validity, transportability and absorptive capacity, fidelity, and organizational strategies into the decision process of selecting and implementing an EBP into a given setting. The importance of expanding implementation of effective addiction treatment in community corrections settings raises the stakes for considering how best to broadly disseminate and implement EBP to both reach the largest number of offenders and have the most significant impact on public health and public safety. From an organizational theory perspective, innovative programs and practices are less likely to be adopted and implemented unless the organizations are convinced that the intervention has added value within that specific environment (Glisson & Schoenwald, 2005; Proctor et al., 2009; Rogers, 2003). As discussed below, the multidimensional and multilevel nature of implementation suggests that identifying EBP is one of the first stages of successful implementation and improved client outcomes.

8.1

Overview of the Evidence Mapping Process

Figure 8.1 summarizes the Evidence Mapping Model for Organizational Fit that will be described in the remainder of this chapter. As the model shows, designation of an intervention or practice as evidence-based typically occurs from RCTs and systematic reviews. Yet this is only the first stage of moving to effective dissemination, diffusion, and implementation (Fixsen, Naoom, Blase, Friedman, & Wallace, 2005). During stage two, a number of other factors should be considered to facilitate adoption and implementation. The results of the scientific process of EBP designation must be assessed with a critical eye and recognition of some of its limitations given that it does not take into consideration the concerns of transportability. The goal of our model is to provide a framework for using science-based determinations of evidence and map the evidence in terms of relevance to the setting through an assessment of transportability and organizational capacity. This process can provide a strong platform to advance implementation. The Evidence Mapping Model for Organizational Fit is premised on the notion that having an RCT with confirmatory evidence is insufficient for an implementation decision because it addresses only whether the intervention potentially improves the outcomes and does not attend to its suitability for particular settings. An expanded concept of identifying EBP that incorporates implementation and the field experience derives from the following issues: (1) the adequacy of the RCT model, given the complexities of field research and the likelihood that even the most rigorous research designs have important biases when carried out in field settings; (2) the advent of new methodologies that try to address validity concerns (such as patient preference designs, comparative effectiveness trials, regression discontinuity designs); (3) the need to adapt EBP that maintain a core integrity for different populations and settings including the integration of clinician or practitioner input; (4) the transportability of research findings across sites, given the unique features of each setting; and, (5) the organizational factors that affect the ability to deliver the

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2+ RCTswith similar outcome measures

Quasi Experimental Designs

Systematic Review · Promising · Effective

STAGE 1

Tests of Scientific Robustness ·

Bias in Primary and Systematic Studies · Bias in Populations · Statistical Significance and Effect Sizes · Population Impact and Penetration

STAGE 2

Tests of Transportability · Setting · Populations · Fidelity of Intervention, Manualized · Clinician/Practitioner Buy-in · Core Outcomes · Organizational Fit

No Sig Effects

Not an EBP

Tests of Organizational Capacity · Value · Inner Setting − Staff − Managers − Clients − Costs · Outer Setting − System − Interagency − Support − Resources

Identify EBP for Specific Settings and Organizations Scientists Practitioners Clinicians Policymakers

Not Feasible

Dissemination and Implementation Learning Collaborative Communities of Practice Organizational Change

Fig. 8.1 Evidence mapping model for organizational fit

treatment or practice in a manner that is consistent with the research-tested practice and treatment (intervention) design.

8.1.1

Tests of Scientific Rigor

Any research design, but particularly a RCT, has some limitations that affect the utility of translating science into practice in real-world settings. It is important for

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users to be aware of and understand the scientific issues, because: (1) a study affects the features of the innovation; (2) a study targets a specific population or problem behavior; and; (3) the design affects the generalizability of the research to various settings and populations that were not included in the primary studies. The research process itself presents dilemmas for organizations considering which source of evidence to use in making EBP adoption decisions. In conducting research to determine whether an intervention or practice is evidence-based, the higher one moves on the scale of scientific rigor, the more time consuming and expensive the research, the more costly the implementation (training costs, fidelity monitoring), and the more narrowly defined the target population (which can limit external validity). Less rigorous designs present different challenges that generally focus on whether a practice can generate positive findings in the real world.

8.1.2

Tests of Transportability

The question of transportability is seldom addressed in determining the EBP; resource and time constraints may limit its testing in all populations and settings. In the criminal justice system, each setting (e.g., prison, jail, probation, parole, diversion, drug court) is unique and may affect how an intervention or practice is delivered – which impacts the potential outcomes. The external validity (or generalizability) of EBP developed from RCTs can often depend on transportability, organizational capacity, staff skills and attitudes, and other inner and outer setting factors.

8.1.3

Tests of Organizational Capacity

As discussed in Chap. 4, the organization must be ready and able to implement the EBP. A better understanding of the science should foster a series of questions about the capacity of the organization and/or system, and the areas where future work should be devoted if a decision is made to implement the EBP. For example, Proctor et al. (2009) distinguish between intervention strategies and implementation strategies as they relate to implementation, service, and client outcomes. The Proctor model suggests that implementation strategies might target one or more levels of the service delivery environment, including individual providers, supervisory practices, group learning, organizational, and systems environment. We consider these factors to be relevant during Stage 2 for mapping EBP for transportability and organizational fit. Our two-stage Evidence Mapping Model for Organizational Fit model considers two dimensions of the problem: whether the intervention has an impact on client level outcomes (efficacy and effectiveness) and whether the intervention can be implemented with fidelity in the given setting (implementation outcomes) to achieve research based findings. This process is designed to result in evidence-based implementation. Our model considers the multiple stages and inputs needed to determine whether an EBP is suitable and adaptable for a particular setting and target population.

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The Challenges Associated with Scientific Studies

In this section, we review some of the limitations of current standards for identifying EBP that are implementation ready for community corrections. These limitations reflect challenges and realities of transportability including the conflicts between the need to adapt interventions to local conditions and clinical preferences, and the importance of maintaining fidelity in order to assure that the EBP is being implemented properly. We discuss organizational capacity factors that need to be considered if an EBP is to be effectively and appropriately implemented. Our proposed Evidence Mapping Model for Organizational Fit model for identifying EBP seeks to overcome some of the limitations of relying solely on the RCTbased approach to identifying EBPs. The RCT is an extremely powerful tool and we are not in any way suggesting that it should be discarded; but its limitations raise cautions about relying solely on a single stage process for determining EBP applicability and assessing fit within various criminal justice settings. As previously discussed, in real world contexts where community corrections and addiction treatment intersect, even when agencies and programs adopt and implement EBP, organizational, staff, and client characteristics, can yield inappropriate adoption or adaptation of the intervention (planned or unplanned), or poor implementation, which may ultimately have a negative effect on client outcomes.

8.2.1

Limitations of RCT and Quasi-Experimental Designs

As discussed in Chap. 2, designations of interventions as EBP typically come from a series of RCTs and/or systematic reviews that follow the FDA and NIH models of evidence. Quasi-experimental studies are also included in many systematic reviews and meta-analyses, such as those sponsored by the Campbell Collaboration’s Crime and Justice Coordinating Group, but are commonly given lesser weight than RCTs. EBP repositories that designate interventions as model or EBPs rely on these science-based determinations. Although commonly considered the gold standard of scientific evidence, randomized controlled trials of behavioral interventions are not free from limitations and biases that can reduce their external validity in real-world practice settings. The main benefit of RCTs is that the design facilitates the ability to make causal inferences about the efficacy of a treatment/intervention by eliminating confounding factors (i.e., characteristics of individuals or organizations) that are theoretically linked to client outcomes. For determining intervention efficacy, RCTs are the strongest design. However, RCTs have some important limitations that have been well articulated by methodologists (e.g., Brown et al., 2009; Carr & Eidelman, 2009; Sampson, 2010; Tilley, 2009; Tucker & Roth, 2006). These issues are germane to our concerns about identifying EBP and assessing the utility of the scientific evidence base for real world criminal justice settings. Sampson (2010) recently questioned several assumptions made in considering RCT as the gold standard of science: (1) randomization solves the casual inference problem; (2) experiments are assumption-free; and (3) experiments are more policy

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relevant than observational studies. Although RCTs require eligible participants to be randomized into treatment conditions, treatment is never delivered randomly in the real world. Even in an experiment, people often self-select into treatment by being recruited, self-selected through actively or subtly coerced into treatment (Taxman & Rhodes, 2010; Wild, Roberts, & Cooper, 2002; Young & Belenko, 2002), or make their own choices, based on personal preferences, social network pressures, and environmental factors (Sampson, 2010). Typically, samples included in RCTs are much more homogeneous than actual client populations, and are less representative of the target population than one might desire (Tucker & Roth, 2006). Even in the criminal justice system, where offenders may be required to go to treatment, they can refuse a specific treatment and accept the consequences. Issues of treatment motivation, readiness for treatment, and contextual factors affect whether a person enters treatment, how long one stays, and whether treatment is completed. Such selfselection into any research study as well as into treatment, along with contextual factors, can greatly influence outcomes especially with broader dissemination of an EBP (Moos, 1997). RCTs are artificial in a way because the researcher exercises greater control over the selection and assignment of subjects involved in the study and the nature of the intervention delivered; these both affect the applicability of the findings to real world implementation. This partially explains the growing focus on implementation science. The bottom line is that the results from RCTs, as well as quasi-experimental studies, cannot necessarily be generalized to broader community populations that have not been studied. Besides the selection of the population, RCTs require closer control over and standardization of the intervention in order to maintain internal validity of the experiment. A key requirement for evidence-based treatments is that they can be replicated with fidelity (see below). For example, one core dimension that the SAMSHA-sponsored evidence repository NREPP uses to rate programs is the presence of manuals and program documentation that can facilitate replication. Intervention developers believe that fidelity to the intervention is needed to assure positive outcomes following implementation. Intervention training and fidelity monitoring are the mechanisms through which intervention developers seek to maintain adherence to the protocol. Counterbalancing the need for fidelity and adherence to the manual, is the concern that strict adherence to a manual does not allow for adaptation to local client characteristics, local conditions, counselor experience and training, or changing environment.

8.2.2

Selection Effects, Targeting, and Penetration

Participants in research studies may be different than the general population of people that present with a specific disorder or need that might benefit from a program. RCTs in behavioral health studies exclude large numbers of potential patients who might benefit from the treatment (Humphreys & Weisner, 2000; Kraemer, Glick, & Klein, 2009). The same is true in criminal justice settings. A recent evaluation of

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three jail-based reentry programs for persons with mental illness leaving jails found that less than 10% of eligible clients were enrolled in the reentry programs (Wolff, 2006) and very little is known about the characteristics of those that did not participate in the program. For drug court and treatment diversion programs, it is typical for only about one-third of paper-eligible offenders to be admitted to the drug courts, with one-third being rejected at some point in the recruitment process and one-third refusing to participate (Belenko, 2002; Belenko, Fabrikant, & Wolff, 2011). Less than 3% of drug-involved offenders can participate in drug courts (Taxman, Belenko, Perdoni, Hiller, & Young, 2009). Mental health courts serve about 10–20% of offenders with mental health problems and nonfelony charges (Wolff, 2002). Potential Selection Bias. The robustness and external validity of the research evidence base, no matter what type of research design is used, also depends on the extent to which biases in the selection of participants in the research and the allocation of treatment are minimized. Much of the experimental evidence for positive impacts of addiction treatment programs is based either on studies with relatively small numbers of participants that are not necessarily representative of the larger substance abusing population, a relatively limited number of studies in a few settings, or on evaluations conducted within the first 2 years of a program’s implementation (Belenko, Wolff, & Holland, 2009; Tucker & Roth, 2006). Positive findings about an intervention, or even its designation as an EBP, are often interpreted to suggest that if we took any random offender with a substance abuse problem and a range of offending behavior that the intervention would produce outcomes in accordance with the published evidence. This is only likely to occur if the target population that participated in the original RCT or quasi-experimental studies is representative of the broader group of offenders with substance abuse problems. This can affect transportability because of the implications for the potential size of the target population, the selection effects, and the ability to match the intervention to the general needs of the local offender population. Intervention effects are related both to the characteristics of the offenders admitted to the program and the appropriateness of the services they receive. Formative evaluations and efficacy trials often leave unexplored the extent to which programs are targeting appropriate populations, penetrating the target population in sufficient numbers, or providing equal access to the intervention (Belenko et al., 2009). To answer the question of for whom an EBP works, it is important to understand and document how participants are selected and the process through which they are screened and admitted. This type of evidence is central to assessing research designs that measure the effectiveness of these programs on outcomes such as substance abuse, mental health, and crime. This is why the movement towards using Consolidated Standards of Reporting Trials (CONSORT) flow charts showing the selection process is so critical to the development of the field to allow for better documentation of the target population studied (Altman et al., 2001; see http://www. consort-statement.org; Taxman & Rhodes, 2010). Accordingly, despite designation of some treatment interventions as EBP, it is not known how the participants in RCTs and other studies differ from the general target population for the intervention. An important transportability question is whether the people targeted for and admitted to an intervention are the most appropriate

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offenders. Other operational questions are: Are treatment services appropriately matched to the types of offenders admitted into the program? Could outcomes be improved through better screening and assessment that identifies those offenders most suitable for the program? How does the program admission process affect the composition of program participants? Both research studies and implemented programs have a similar problem of demonstrating that an EBP can be more broadly disseminated with equally positive outcomes. New programs have an incentive to select participants who have characteristics that predict success (and to avoid those that are likely to fail). By carefully selecting predominately low-risk offenders who are likely to do well regardless of the type of supervision or treatment (referred to as creaming or cherry picking), the program biases its outcomes towards positive outcomes. Cost effectiveness is reduced when expensive intensive services are allocated to low-risk offenders. Selection bias is common in formative evaluations of any design and can lead to misleading conclusions, premature expansion or dissemination of the program, and distortion of the evidence base. Selection bias also limits the penetration into the intended target population. Another research issue lies in the bias that comes from attrition due to early dropout from a program or a research study. The original target population may look substantially different than the population that is observed at follow-up or at the end of the intervention. The growing use of CONSORT charts should help illuminate this problem. None of the issues above have been rigorously studied, and issues of selection bias are routinely ignored in the effectiveness and evaluation literature. For implementation and evaluation research of treatment interventions in community corrections to reliably inform practice and policy in meaningful ways, there is a need to address the above limitations. It is important to use study designs for case assignment and analyses that control for selection effects and the measurement of contextual variables likely to interact with the intervention. Further, because process is a critical component of socially complex interventions like treatment in corrections settings, qualitative components are necessary to examine the internal workings of and the external influences on the intervention in order to identify the active ingredients within the proverbial black box.

8.2.3

Population Impact and Penetration

Implementation science is concerned in part with penetration as an indicator that an intervention is feasible to employ. It is worthwhile to consider this issue because theories of public health impact suggest that increasing the penetration of addiction treatment services into at-risk population would increase the overall positive public health impact. Of interest is the program’s ability to penetrate the target population (i.e., offenders with behavioral health needs with particular charges/convictions). If innovative evidence-based interventions can only effectively penetrate 10% or less of the target population, does it make economic sense to invest in these programs? This has been the experience with drug courts (Belenko et al., 2011; Bhati & Roman, 2010); see Box 8.1 below. On the other hand, an evidence-based addiction treatment

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intervention that has a lower impact on relapse and recidivism but can be broadly implemented with large numbers of offenders could yield important public health impacts. The overall public health (and by extension) public safety impact of an evidencebased intervention is thus related not only to its effects on outcomes of interest but its penetration into the target population (Tucker & Roth, 2006). That is, public health impact is a product of an intervention’s effect size, and the rate of utilization of the intervention (Tucker & Roth, 2006): Population impact = [Intervention effect size]*[Intervention utilization] Whether the evidence from RCTs is applicable to a local target population of offenders depends on who was included in the studies that comprise the evidence base. How subjects are recruited into these efficacy and effectiveness studies can lead to low rates of participation, nonrandom recruitment, high dropout rates, lack of equity, or ethical problems. These problems are common in health studies (Tucker & Roth, 2006) and can be particularly problematic for criminal justice clients, who may feel coerced into participating, do not understand the research project or their rights as research subjects, are not given enough information to make an informed

Box 8.1 Relative Penetration into the Target Population: An Illustration Two models for delivering addiction treatment to offenders in the community are drug courts and probation-supervised treatment. Drug courts have been demonstrated in multiple studies (including RCT and meta-analyses) to have positive effects on postprogram recidivism (Belenko, 2001; Gottfredson, Najaka, Kearley, & Rocha, 2006; Wilson, Mitchell, & MacKenzie, 2006). Yet drug courts have limited penetration into the target population of nonviolent offenders with substance abuse problems; it is estimated that less than 5% of this population is served by drug courts (Belenko et al., 2011; Bhati & Roman, 2010). Because of the intensity and high staffing needs and costs of drug courts, it is unlikely that this level of penetration will increase much. Treatment under probation supervision has been found to be effective, but only with certain types of drug-involved offenders and with relatively small effect sizes (Thanner & Taxman, 2003). Yet with an estimated 4.2 million adults on probation (Glaze, 2010), of whom 69% have histories of illegal drug use (Mumola & Bonczar, 1998), the potential for treating large numbers of offenders may be greater than in drug court. Questions for policymakers and program administrators include: Which model is preferable for maximizing overall public health impact? Which model would be easier to effectively implement? Which model has greater transportability? Which model is more politically tenable?

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choice, receive different messages about the project from different staff, or do not fully understand that participation may affect their due process rights.

8.2.4

Statistical Significance and Effect Size

In general, intervention effects are not considered statistically significant if there is more than a 5% probability that the observed differences were due to chance and not a real effect (type I error). This threshold of p < 0.05 is the accepted standard for confidence that the findings are real and that the null hypothesis of no difference between the groups can be rejected. To some extent, intervention research can be considered to be under the tyranny of the p < 0.05 standard. Studies in which outcome differences are observed between experimental and control groups, but the p-level is even slightly higher than 0.05, would not be considered to be statistically significant, even if the results are consistent across multiple studies and clinically meaningful. On the other hand, achieving statistical significance of an outcome does not necessarily mean that a study was well designed or had internal validity, or that the outcome measures were appropriate. And, there is no guarantee that the intervention was implemented with fidelity (see below) or that there were no experimenter effects such as the Hawthorne effect (people responding to the treatment because they are aware they are being studied). Thus, the statistical significance level may not necessarily relate to the practical significance of the findings. Statistical significance is also affected by a number of statistical factors. First, significance is affected by the size of the sample. Larger samples (e.g., more than a few hundred cases per condition) are more likely to show statistically significant differences between experimental and control groups than are smaller samples, even if the findings are not clinically meaningful. Studies with large outcome effects that were based on relatively small samples might not reach the 0.05 threshold even though they may be clinically meaningful and a good fit for an organization. Statistical significance is a function of both the effect of an intervention and the size of the sample used in the study. With relatively small sample sizes, a significance level of p <. 10 may signify a meaningful effect, although it would be prudent to replicate such findings. Journal publication bias means that experimental effects of p <. 10 may not get published. Effect sizes are standardized measures that summarize the size of the difference between experimental and control groups. As a standardized measure, effect size allows more direct comparison across studies with different sample sizes or populations. Effect sizes are commonly used as a metric in systematic reviews and metaanalyses to compare and consolidate findings across multiple studies in different settings with disparate outcome measures. Effect sizes can be classified as small, medium, or large (Cohen, 1988) although these designations are somewhat arbitrary. There is some disagreement in the literature about whether systematic reviews should focus on effect sizes, significance of group outcome differences, or percentage changes attributable to the intervention. Some argue that effect size is more important than p values or statistical significance or hypothesis testing (Grimshaw

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et al., 2004). Lipsey and Wilson (1993) argue that effect size must be weighed against practical or clinically meaningful effects. One cannot necessarily conclude that a small effect size is not of practical or policy significance. Other possible biases inherent with effect sizes (see Wilson, Lipsey, & Soydan, 2003) include: (1) lack of similarity between experimental and control groups increases effect size; (2) unpublished technical reports show smaller effect sizes; (3) studies in which the evaluator was not involved in the design or delivery of treatment have smaller effect sizes; (4) studies in which the control group received more services have smaller effect sizes; and (5) studies in which outcome data collectors were blind to study conditions have larger effect sizes.

8.3

Transportability Assessment

Schoenwald and Hoagwood (2001) propose several key multilevel factors for moving EBP from efficacy studies (such as RCTs) to broader dissemination: the nature of the intervention itself, practitioner and client characteristics, model of service delivery, organizational characteristics, and service system. The transportability model is based on clinical treatment development models (e.g., Drake, Gorman, & Torrey, 2002) that include organizational factors and research on dissemination and sustainability. Schoenwald and Hoagwood (2001) argue that it is important to distinguish the different stages of adoption and implementation and between diffusion and dissemination, because the literature tends to focus on the unplanned or natural adoption of innovation rather than proactive or directed dissemination. As shown in Fig. 8.1 above, decisions about appropriate EBP and implementation should consider transportability and organizational/system factors. In the initial stages of discussing transportability (i.e., after initial efficacy trials), some treatments will not be considered effective in real world settings. Many community-based treatment settings cannot adequately implement all components of an innovation. This raises certain questions about what impact the modifications on the intervention will have on outcomes or what aspects can be changed without reducing the impact of an intervention. These are important issues that can affect implementation and sustainability, and there is a need to study these issues and learn from the experiences of different types of agencies. The latter stages of discussing transportability require effectiveness studies that explore the differences in clients, programs, and service delivery financing (inner and outer settings) that may occur after broader dissemination. For example, structural barriers to service access (e.g., eligibility, costs, transportation) may conflict with other probation supervision requirements or special offender needs. Accordingly, it may be useful to consider factors related to transportability before dissemination occurs (see Box 8.2 for an illustration). In the end, interventions that are adopted prematurely can undermine credibility and give the false impression that the intervention is not effective (Schoenwald & Hoagwood, 2001). The following sections examine issues related to transportability.

8.3

Transportability Assessment

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219

Setting and Populations

Consideration of EBP requires preliminary work to assess transportability to the local setting and population. Formative evaluations, needs assessments, and pilot studies can play an important role in this process if they focus on the early stages of adoption an innovation, rather than intervention efficacy. If structured consistently and completely, these strategies could provide critical information about: (1) feasibility of identifying, recruiting, and engaging subjects; (2) ability of programs to penetrate the intended target population; (3) characteristics of clients willing and not willing to participate in the program and the reasons for their choices; and (4) ability to implement the program and the practical local barriers to and facilitators of implementation. In a community corrections context, if selected offenders are low risk and low need, the program may widen the net of social control without being cost effective. Other relevant client-level considerations include whether clients have co-occurring mental health or physical disorders, and treatment programs may not be comfortable admitting violent or sex offenders. Special community corrections populations such as juveniles and females present challenges for treatment providers who may

Box 8.2 Case Study of Transportability: Contingency Management in Two Different Settings Contingency Management (CM) is an EBP that has been tested in a number of different community-based treatment settings. CM generally involves providing incentives to treatment clients in the form of cash payments or vouchers (redeemable for gifts or cash) for achieving various abstinence or treatment attendance goals. It has been found in numerous RCTs to reduce drug use during and after treatment, improve attendance at group counseling, and increase treatment retention (Petry, Alessi, Marx, Austin, & Tardif, 2005; Petry, Martin, & Simcic, 2005; Petry, Peirce, et al., 2005; Stitzer & Petry, 2006). Despite this strong evidence base, a test of the CM model in a criminal justice setting found no positive effects. Prendergast, Hall, Roll, and Warda (2008) conducted a RCT of the use of vouchers to reward negative drug tests and adherence to their drug treatment plan within a drug court environment; research assistants provided the vouchers and the drug court judge was blind to the study conditions. The results indicated that in contrast to numerous studies in noncriminal justice settings, CM had no significant effect on treatment retention, drug use, or psychosocial functioning compared with the standard drug court treatment protocol. The authors speculated that the null findings may be due to the strong influence of the drug court judge on clients (e.g., drug court judges impose sanctions and rewards for behaviors and treatment progress), or the fixed reinforcement schedule used (instead of the escalating voucher system used in most drug treatment CM studies).

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lack adolescent or gender-specific programming, which could affect implementation. Whether public investment is warranted to sustain and replicate the EBP depends in part on the characteristics of the people who are engaged, the cost effectiveness relative to other innovations, and the ability to reliably translate the outcome evidence into practice. The setting where an EBP will be implemented is another important consideration. The evidence base may be derived from one setting that is similar but sufficiently different from the local setting. An important example is that relatively few addiction treatment efficacy or effectiveness studies have been conducted in community corrections settings. The question of transportability of EBP to community corrections settings is largely unanswered. Probation and parole supervision requirements, correctional staff attitudes, treatment staff attitudes, and other factors may interact with the intervention delivery in ways that affect outcomes, as discussed in Chaps. 4, 6 and 7. Issues related to clinical decisions may not always rest with the counselors in these settings, leading to treatment placement decisions that might undermine program effects. As a simple example, community supervision requirements may indicate that relapse to drug use will trigger a violation hearing and possible reincarceration. But clinically, relapse is expected and might result in changes in drug treatment programs such as intensifying treatment services or using medications.

8.3.2

Fidelity and Program Integrity

Implementation and program fidelity go hand-in-hand. Without knowing whether an EBP has been implemented in a way that retains the integrity of the evidencebased intervention, there is no guarantee that an EBP will deliver and achieve a similar degree of effectiveness in either a new setting or with a different population. Experienced program planners will want to know whether the new intervention was implemented, whether it was tried but poor clinical practice interfered with the implementation, whether implementation was faulty, or whether the implemented program went adrift (Fixsen et al., 2005). All of these factors can determine whether or not the innovation was well-received, as well as how to modify the program to improve outcomes. Achieving and maintaining fidelity in real world settings can be quite difficult (Bourgon & Armstrong, 2005; Morrison, 2004). Interventions frequently undergo adaptation and modification over time. Therapist values and intentions, and patient-therapist interactions, lead to changes in the intervention that can influence outcomes (Norcross, 2002). A number of inner setting issues (e.g., leadership, staff, resources) and outer setting pressures can compromise the intervention components (Rhine, Mowhorr, & Parks, 2006). Maintaining fidelity may be more difficult in larger programs. Lack of program integrity in a large program may account for the lack of effect observed for cognitive skills training interventions implemented in larger corrections agencies (Van Voorhis et al., 2004).

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Transportability Assessment

221

Manualized interventions have certain advantages in that they offer a set curriculum for the intervention, provide guidance for the counselor, and articulate a certain treatment philosophy. And, they provide a training tool that is clear to the group. This may contribute to more organizational cohesion and consensus about the model of recovery, and may improve outcomes by providing a more consistent treatment intervention than other counseling strategies that largely depend on the qualifications of the counselor. Manualized treatments facilitate outcomes but may be undermined by staff that is too rigid to change or prefer existing practices with which they are familiar and comfortable. On the other hand, treatment manuals may inhibit counselor creativity and may conflict with local conditions such as a gap between the number of sessions or length of the program, and the resources available (Eliason, 2003). In determining effectiveness under real world conditions, it is important to determine the degree to which the treatment adheres to key requirements or how it was modified to respond to client needs and environmental conditions. Even when manuals are produced and disseminated, there is little research on whether or how they are used; moreover, training and coaching are needed to supplement manuals (Baer et al., 2007). As discussed in Chap. 4, successful and sustained implementation may require ongoing support including booster training, retraining, training of new staff, fidelity monitoring, and other forms of technical assistance. Fidelity drift is a real concern and must be measured and addressed regularly if the intervention is to be considered evidence-based (Rhine et al., 2006). This may be compounded by such issues as staff resistance to change (NIC, 2005; Taxman, Shepardson, & Byrne, 2004) and high staff or counselor turnover rates (Knudsen, Ducharme, & Roman, 2006; McLellan, Carise, & Kleber, 2003). Maintaining fidelity through the adaptation process. Manualizing treatment and monitoring fidelity can be viewed as limiting counselor creativity and discretion. Although the manuals can increase accountability, they can also lead to practitioners losing confidence in their own intuition compared with scientific evidence, having EBP counselors face an information overload due to an overabundance of manuals being produced, and leading counselors to become rooted in their current practices. This can result in new EBP counselors being unsure how to prioritize information. Several processes are possible for addressing fidelity challenges and managing the adaptation process: (1) designating staff as an EBP specialist at the program level found that internal experts in a juvenile justice agency assisted in creating a culture that supported the innovation (Taxman, Henderson, Young, & Farrell, 2010); (2) providing incentives to staff asked to identify, adapt, and help implement EBP in an agency, especially by coaching; (3) establishing a network or coordinating body at the state or system level to mobilize opinion leaders to identify EBP, see what fits the identified gaps, and communicate the results statewide (Young, Farrell, Henderson, & Taxman, 2009); and (4) finding sources of funding to support these changes. In the research laboratory, the intervention is delivered as prescribed. But many of the dosage issues are not well articulated. This refers to the minimum number

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and length of sessions, type of staff needed to deliver the intervention, use of userfriendly workbooks and videos, and emphasis on technology rather than quality of services. All of these delivery factors affect the dosage of the intervention and fidelity. It is also likely that adaptability can be improved through skills enhancement, monitoring treatment outcomes rather than number of sessions, and providing more effective training and skills development tools. During the last two decades, more emphasis has been placed on professional certification, training via manuals, and required training programs. These were premised on the expectation that professionalization efforts would improve fidelity and adherence to the therapeutic goals. One negative side effect is that cottage industries to provide training have sprung up around many manualized programs. Such efforts can add substantially to implementation costs, which many treatment providers cannot afford. More research is needed on the value of certification and training procedures to increase adherence to the treatments.

8.3.3

Incorporating Clinician and Other Staff Input

The Institute of Medicine adopted a broader definition of EBP that incorporates clinician expertise and patient values in addition to scientific research evidence (IOM, 2002; Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000, see Chap. 2). As previously discussed, successful TT requires buy-in from corrections and treatment counselor staff at all levels. Staff-related factors can be one of the thorniest problems for achieving successful EBP implementation in organizations (see Chap. 3). All managers realize that dedicated and knowledgeable staff is essential for successful TT. In the area of addiction treatment, it is important to try to build capacity for clinician input into adaptation of the intervention to increase feelings of ownership and shared mission and goals. This input can be valuable in assisting corrections staff to understand the value of the new treatment as well as to create a seamless system of care among corrections and treatment agencies (Taxman et al., 2010). Building capacity for clinician input into the transportability of an intervention requires increasing opportunities and developing feelings of ownership and shared mission and goals. Achieving successful implementation of EBP could also include identifying (and perhaps rewarding) staff who demonstrate better than average results with their caseloads (analogous to master teachers). Indicators for these results could be fewer offender rule infractions, lower violation and rearrest rates, and higher treatment retention and employment. Their behaviors, deportment, and procedures could be codified and such staff could participate in trainings. On the other hand, staff turnover, burnout, and negative work attitudes (both in corrections and treatment agencies) work against successful EBP implementation and must be monitored and corrected.

8.4

Organizational Capacity Assessments

8.4

223

Organizational Capacity Assessments

Evidence-based implementation is in part about taking the findings from science and applying them in real-world settings in a way that is sustainable. Organizational factors that surround the TT process (e.g., leadership, staff knowledge and attitudes, interagency collaboration and communication) need to be understood because they affect implementation outcomes (Fixsen et al., 2005; Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004; Proctor et al., 2009). Even after an EBP is identified, and assessed for transportability, it is important to simultaneously assess the organizational capacity to implement the EBP, and take ameliorative steps to improve this capacity if gaps exist. These steps are important to develop a strategy to increase the acceptance and feasibility of implementing the EBP. A number of factors can affect implementation of EBP. These factors relate to the program’s organizational capabilities in the context of the external environment, interacting with the organization’s mission, leadership, and culture. Specific issues and principles that facilitate EBP adoption relate to staffing and management. In terms of staffing, issues include skill sets, workload and caseload size, staff education, gender and racial composition of the staff, and level of professionalism. These factors can be addressed by skills enhancement strategies, role clarification, use of incentives to implement EBP, and a focus on performance outcomes or benchmarks. The goal of the organizational capacity assessment is to identify such factors to develop a realistic plan to successfully implement EBP.

8.4.1

Perceived Value of EBP: Balancing Public Safety and Public Health

In the Proctor et al. (2009) model of implementation research a critical domain is the acceptability and feasibility of an EBP to the organization. This can be considered as the value that staff perceives in adopting and implementing a new practice or program. Selection of an EBP and preparation for the implementation of that EBP needs to consider how to assist the staff and organization to view the intervention as having value. This can include such dimensions as the appropriateness of the EBP given the history of the agency and the population it serves, acceptance by the staff, perceived effectiveness, and relative costs. Some general measures of perceived value are available and potentially useful for assessing the staff’s capacity and readiness to adopt an EBP. For example, the Barriers to Research Utilization Scale, developed by Funk, Champagne, Wiese, and Tornquist (1991) contains subscales for characteristics of the adopter, characteristics of the organization, characteristics of the innovation, and characteristics of the communication. The Usage Rating Profile-Intervention (URP-I, Chafouleas, Briesch, Riley-Tillman, & McCoach, 2009) was originally developed to study the acceptability of school-based interventions. It contains subscales for acceptability, knowledge, feasibility, and systems support. Feasibility can be measured with the

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Evidence Based Practice Attitudes Scale (EBPAS, Aarons, 2004) that includes subscales for requirements, appeal, openness and divergence. A core tension in the TT process for addiction treatment in criminal justice settings is the inherent conflict between public safety and public health goals. The design, development, adoption, and implementation of evidence-based addiction treatment are driven exclusively by the goal of expanding effective treatment for substance abuse disorders. This goal and evidence-based treatment may or may not fit neatly within the structure and operations of a community corrections or other criminal justice agency. Whereas the criminal justice and corrections agency tend to emphasize security, control, and public safety, there is a general consensus that effective treatment requires collaboration between clinicians and clients to achieve maximum program participation and adherence (Peters & Wexler, 2005). Although there has been little research in this area, it is possible that criminal justice environments that focus primarily on control are more likely to deliver more rigid and controlled treatment protocols but less likely to adequately engage treatment staff and clients in the clinical recovery process.

8.4.2

Improve Interagency Efforts Through Goal Alignment

More effective dissemination and educational efforts can help public health and criminal justice practitioners improve their mutual understanding of each system’s goals and philosophies. Several components of educational efforts might be useful to advance more efforts to create cohesive goals. First, it is important to educate criminal justice staff about the different languages in treatment and criminal justice systems and about tools for understanding and using EBP. Although the drug court movement has created a subset of judges that have been educated about these issues, the majority of judges still need to be informed. Other criminal justice staff could be trained on treatment issues and treatment protocols. Similarly, public health staff and officials need to understand criminal justice system language and procedures. For example, criminal justice information could be integrated into certification programs for treatment counselors, especially given that a large proportion of their caseloads are or have been under criminal justice supervision. Correctional training academies and other current training efforts are generally limited in providing information to staff about substance abuse, criminogenic needs, treatment, research findings, or best practices. This is a major limitation given the high percentage of offenders with substance abuse problems. For treatment staff, especially those in recovery, implementing a new EBP that does not align with their existing attitudes and experiences in treatment counseling can be quite difficult and likely to meet with active or passive resistance. Careful attention to training, incentives, and clinical supervision is important for achieving staff buy-in, maintaining fidelity, and reducing the possibility that implementation will be compromised. Public health officials and treatment staff need to understand that public safety issues are always of primary concern, even in the courtroom and in community

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corrections systems. Second, it would be helpful to integrate social science courses or training into law school and bar association training curricula. Criminal justice departments in universities can also expand curricula to include treatment and other public health issues. Criminology faculty can also have joint appointments in social work, public health and medical schools. The alignment of values between the community corrections and addiction treatment systems, and important elements of collaboration and integration, create an environment in which a new EBP can thrive and be sustained (Fletcher et al., 2009; Taxman & Bouffard, 2000).

8.4.3

Inner Setting Issues

As discussed in previous chapters, inner setting factors can present barriers or facilitators to successful implementation. The organizational culture and climate (both among staff and managers) may be resistant to EBP, innovations and change; imposing change too quickly could generate staff resistance. When organizations and staff are risk averse, adoption and implementation of EBP is less likely (Panzano & Roth, 2006).The criminal justice system in general tends to be risk averse, because one error (e.g., paroling an offender into community treatment who then commits a heinous act such as murder) can lead to front-page newspaper headlines and a quick retreat back to punitive and nonrehabilitative policies. Accordingly, strategies to promote willingness to innovate and take risks, through training or staff incentives, can be useful to stimulate innovation. Organization Management and Staff. In Chap. 4, we discussed the important influence of organizational factors, and staff behaviors and attitudes on adoption and implementation of EBP. The components that research and theory have determined to drive organizational change are important for assessing the capacity of the organization, within its systems environment, to adopt and implement a specific EBP. For organizations, the readiness to change and innovate allows management and staff to test new interventions and change daily business practices to support a new EBP. The alignment of values between the community corrections and addiction treatment systems, and important elements of collaboration and integration, create an environment in which new EBP can thrive and be sustained (Fletcher et al., 2009). The presence of respected change agents who can push managers and staff to accept a new EBP is another important component. Staff attributes can also determine whether an organization is ready, willing, and able to adopt an EBP. These include level of professionalism and credentials (Knudsen, Ducharme, & Roman, 2007), staff attitudes toward innovation and EBP (Aarons, 2004), staff resources such as training and professional development opportunities, and level of burnout (especially problematic among addiction treatment staff; see Bartholomew, Joe, Rowan-Szal, & Simpson, 2007). As discussed in Chap. 4, growing evidence suggests that organizational capacity can be enhanced by these staff related factors.

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Within the community corrections environment, management and staff confidence in an evidence-based treatment can be affected by concerns about its effects on public safety and social control more than its effects on recovery. For example, the consequences of relapsing in treatment can be dire for an offender (e.g., probation/parole violation, incarceration) with the potential for additional restrictions on liberty. Thus, an offender participating in an ineffective or inappropriate intervention can face an increased likelihood of loss of freedom. The consequences of treatment failure can reverberate throughout a community corrections system by convincing the public and policymakers that offenders are not being supervised adequately. That is why, other things being equal, community corrections officers are likely to favor more intensive treatment models such as intensive outpatient or residential treatment.

8.4.4

Building Interagency Systems of Care

Bridging the public safety-public health disconnect is an important challenge to assist community corrections staff and management, as well as addiction treatment agencies, to embrace evidence-based treatment. Management may not have a sufficient commitment to rigorous program evaluation that can support EBP. Treatment agencies also have to be encouraged to adopt EBP for criminal justice populations. Many providers are reluctant to involve criminal justice clients because of public safety fears or the additional burden that such clients may place on the program staff. In community corrections-based interventions, it is common for probation or parole officers to be involved in many parts of offender management processes including eligibility screening, referral to treatment or advising the offender about the appropriate treatment, drug testing, and treatment monitoring. Staff attitudes toward the causes of addiction can also influence their views about EBP and willingness to embrace new interventions and practices. The dynamics of these interactions can affect linkages to EBP; the comportment of the supervision officer has important implications for intervention participation. For example, in the Maryland Proactive Community Supervision project, parole/probation officers were trained to use a modified version of motivational interviewing to assist with motivating the offender to change. Focus groups and observational research revealed that parole/probation officers were using verbal and body language to dissuade offenders from participating in treatment, and motivational interviewing or communication proved to be a vehicle to assist probation officers to use motivational strategies, an EBP (Taxman, 2008). Corrections staff can have an important influence on whether offenders participate in treatment, or the types of treatment to which they are referred. When staff see EBP as fitting the organization mission and business practice (increasing the perception that it is valuable, appropriate, and feasible – see Proctor et al. (2009)), they are more likely to support it and use it for their clients. One example is the underutilization of medication-assisted treatment in community corrections. Although methadone and buprenorphine are considered EBP and recommended by NIDA as an effective treatment, community corrections staff are resistant to

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referring their clients to such treatment because of lack of knowledge and biases toward these medications (Friedmann et al., 2011). Learning Collaboratives and Communities of Practice. Some change team and process improvement approaches (see Chaps. 3, 4 and 5) seek to develop a Learning Collaborative Model (Sudsawad, 2007) that helps to facilitate a culture of process improvement (McCarty et al., 2007; see Chap. 3). The notion is that many practitioners within or across jurisdictions are tackling similar issues and can benefit from systematic contacts and exchange of information. It is a technique to build organizational resiliency and capacity to assist with implementation and ability to sustain the EBP. In essence, the process focuses on: (1) building a high-functioning team; (2) cultivating leadership support and involvement; (3) setting up systems to monitor data on implementation of the EBP and its outcomes; (4) opening lines of communication; and (5) using expert coaches and program leaders. A similar concept is communities of practice, which bring together individuals from different organizations to share expertise, information, and strategies (Wenger, McDermott, & Snyder, 2002). These groups interact on a regular basis and can inform one another about identification and adoption on EBP. Both of these models are discussed in more detail in Chap. 9.

8.4.5

Considering Clients’ Perspectives and Treatment Needs

The role of the client or consumer in the selection of EBP and innovation or even in moving from research to practice is seldom considered. This is especially true in criminal justice settings, where offenders are not seen as customers who can or should make informed decisions about behavioral health service issues. Because a probationer or parolee is mandated to attend a certain program (receive a given treatment) with severe consequences for noncompliance, many consider the offender’s perspective to be of little value. Yet, just as in addiction treatment and other behavioral health services, these requirements may be made without consideration as to whether the intervention or service is appropriate, culturally relevant, convenient, or desirable for the offender. As noted in The Change Book (ATTC, 2004), the involvement of customers may enhance service delivery. Research on treatment engagement and retention points to the importance of client attitudes toward treatment, and their motivation to deal with substance abuse problems, for improving both proximal and distal treatment outcomes (Hiller, Knight, Broome, & Simpson, 1998; Simpson, Joe, Rowan-Szal, & Greener, 1997; Taxman, 1998). A more patientcentered approach, in which selection of an intervention may be affected by the client’s choices or preferences, although shown to be effective for decreasing relapse (Dennis & Scott, 2007; McKay, 2006, 2009), could be difficult for community corrections staff to accept. Aside from their focus on punishment and control, implementing a patient-centered chronic care model in community corrections would require supervision officers and other criminal justice decision makers to allow offenders, after failing in one treatment program, to reengage in a different

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treatment setting without penalty. As in the drug court model, relapse would not automatically result in filing of a violation, but could trigger a change in treatment intensity or modality, program transfer, or mild sanction. Another technique to advance organizational capacity is to move from an episodic acute care model to a continuing care approach. Continuing care models focus on patient choices and adaptive responses to patient behaviors, which are considered crucial for long-term recovery (McKay, 2006, 2009). The traditional acute care model is common in the criminal justice system: in this model, a substance-abusing patient enters treatment, receives evidence-based treatment in an accredited program, and completes the treatment as a nonsubstance abuser. The continuing care model addresses the unrealistic assumptions of the acute care model, including the fact that a fixed amount or duration of treatment may not resolve the client’s problem; clinical and supervisory efforts should be put toward placing patients and getting them to complete treatment; effectiveness is evident from observing the patient’s status following completion of treatment; and poor outcomes for the patient implies treatment failure. The implications of the continuing care model for selecting an evidence-based treatment intervention in community corrections are that: (1) the effects of treatment may not last very long after a treatment episode ends; (2) patients who are out of treatment or clinical contact are at higher risk for relapse;(3) an EBP may only be appropriate or fit during a specific phase of the criminal justice process; and, (4) treatment may need to be adjusted or stepped up or down depending on the client’s engagement and progress. These issues can affect the ability to maintain intervention fidelity.

8.4.6

Intervention Costs

Cost effectiveness is another important dimension in public policy and the selection of appropriate EBP; it is based on practical considerations that often do not involve statistical significance or effect sizes. Interventions vary greatly in the cost of implementation (e.g., training costs, manuals, level of staff needed, length of the intervention, number of sessions required, individual vs. group counseling). In the real world, the selection of an EBP is likely to be driven as much by cost as by effect sizes. Especially in tight budget times, a relatively inexpensive intervention with a smaller effect size or marginally significant impact may be preferred to a more expensive intervention that has a larger effect size. Cost effectiveness analyses, which compare the incremental costs of interventions per unit outcome (e.g., cost per one percent reduction in recidivism) can be a useful tool for policymakers and administrators weighing the relative worth of different EBP. Similarly, benefit cost analyses (i.e., comparing the economic benefits of an intervention to its costs), indicate that interventions with a ratio greater than one can be considered cost beneficial or a positive return on the investment. Economic analyses generally find that addiction treatment interventions, including criminal justice interventions such as prison treatment and drug courts,

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have net economic benefits due to their effects on reducing high incarceration and other criminal justice costs (Belenko, Patapis, & French, 2005).

8.4.7

Outer Setting

The realities of the environmental context for implementing EBP can intrude on the traditional, strictly science-based determination of EBP. The components of EBP will continue to be defined based on research. But the translation of these laboratorybased EBPs into action involves consideration of a different scientific process (implementation science) that has its own rigor and methodological steps (Fixsen et al., 2005; Proctor et al., 2009). Addressing the needs of the outer setting, the knowledge utilization processes must be more dynamic in that: (1) there is a need to make decisions quickly; (2) public safety concerns exist; (3) intervention adoption decisions may be driven by system needs such as jail or prison overcrowding; (4) agencies must respond to court orders to provide treatment; (5) treatment resources are limited, especially for intensive or long-term treatment; and (6) civil rights or due process concerns exist and may affect which offenders can access which types of treatment. As reviewed in Chap. 4, factors related to the outer setting can affect decisions about adoption of a new EBP in general, and whether a specific EBP is selected over other alternatives. These factors include the socio-political climate, policy or funding incentives to the organization to adopt an EBP, regulatory and legal mandates, interorganizational norm setting, interorganizational networks, and environment stability (Greenhalgh et al., 2004) as well the nature of regulatory reform, and competition for resources. These issues can reflect community, state, or federal policy, funding, or regulatory influences (Fixsen et al., 2005). The nature and severity of local of crime and substance abuse problems can also influence the appropriateness of a particular EBP. Many of these issues must be confronted by organizations relatively quickly, and decisions about EBP adoption cannot wait a decade or more to conduct the efficacy and effectiveness RCTs required under the FDA and NIH clinical trials models. Given these factors, it may not be possible to select an EBP based solely on scientific reviews. Outer setting influences may push policymakers or management to rely on less rigorous review criteria and procedures, or make suboptimal EBP choices that are driven by external pressures. There may be political or operational pressures to implement a new program quickly. Of course, it is not ideal to implement quick fixes that circumvent systematic EBP and implementation process. On the other hand, implementing an EBP that does not fit the local organizational capacity is likely to lead to poor implementation and thus poor client outcomes. Mapping the evidence base to the organization’s capacity and its environment raises the likelihood of more effective and sustainable changes in organizational and staff culture, attitudes, and performance. It also assists in identifying the areas where organizational-level strategies are needed to advance implementation.

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A key challenge driven by external pressures is the need to select scientifically determined EBP while recognizing the reality of implementing programs and practices, often with relatively little lead-time. To do this successfully requires that agencies are positioned and their staff trained to conduct evidence-based assessment, performance monitoring, regular program adjustments and outcomes monitoring, and collection of appropriate outcome information. Proper needs assessments should assess the fit between the EBP, the local setting and offender (client) population, availability of resources and organizational and staff readiness to implement a new program. For example, with the recent budget crisis, jurisdictions are looking to de-incarcerate offenders and move offenders into addiction treatment programs in the community. This requires having the infrastructure in place to identify appropriate offenders and programs, staff to run the programs, and cooperation of probation/ parole/judicial agencies to refer offenders to these programs instead of using traditional punishment strategies. These are issues that researchers, for their part, do not focus on but they are the realities that practitioners and policymakers confront. Accordingly, there may be a need for alternative intervention testing and TT processes that decrease the length of time between an intervention/treatment development and its broader utilization. Information needs to be delivered to practitioners in a concise manner so it is understood and can be effectively shared. Relying solely on traditional scientific standards of having two experimental studies with similar outcomes can lead to misleading or nongeneralizable conclusions about the efficacy or effectiveness of interventions. First, once an intervention has achieved designation as EBP, there may be pressure to implement the programs quickly before effectiveness or cost-effectiveness has been determined. A recent example is Project HOPE in Hawaii (the use of swift judicial sanctions to address noncompliance on probation supervision) which has not been designated as an EBP, but has received recent attention due to the appeal of the concept. This model is being promoted even though there is only one small RCT and there has not yet been a replication of the initial study (Bulman, 2010). Federal funding may expand Project Hope without further testing the concept by offering sites demonstration funds. Second, pressure to implement the EBP or new ideas quickly, and limited funding for local replication studies (both process and outcome studies) at the point of implementation, can result in small sample sizes with inadequate power to test the EBP with local populations and under local contexts, short follow-up periods, and/or a limited set of outcome measures. Relying on an evidence base that has been tested under other environments means that crucial issues related to the appropriateness and size of an intervention’s target population, ability to penetrate the target population, the local assessment and referral processes, and equal access to services, should first be discussed as part of the EBP adoption decision. To advance the consideration of inner and outer setting needs, an interagency research network is a potential tool to foster discussion (Palinkas et al., 2009; Roman, Abraham, Rothrauff, & Knudsen, 2010). Similar to the idea of Learning Collaborative or Community of Practice, the research network typically entails structured and regular exchange of information between researchers and practitioners collaborating in social or peer networks. Consistent with Rogers (2003) diffusion of innovations theory, research networks ideally include two-way exchanges of

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information in which practitioners and clinicians learn about research findings and EBP from researchers, who in turn gain knowledge from practitioners about needs and challenges in the field and real-world clinical practice. Interagency research networks can foster knowledge utilization and incorporate a number of key components of organizational and systems change including social influence and peer norms (Ajzen, 1991; Godin, Bélanger-Gravel, Eccles, & Grimshaw, 2008), the role of change leaders (Damschroder et al., 2009), and access to resources and knowledgeable experts. For staff and management, participation in research networks can build capacity and readiness to adopt and implement EBP by promoting knowledge transfer, increasing understanding of scientific methods and intervention development and testing procedures, and increasing access to data-driven performance monitoring tools and strategies (Knudsen, Abraham, Johnson, & Roman, 2009). Researchers and intervention developers should also be considered part of the outer setting since their involvement can be beneficial to both the research community and the community corrections agencies. The broader dissemination of evidence-based treatment in community corrections may be increased if intervention developers and researchers design and test treatments and address questions that are important to criminal justice policymakers and practitioners. Researchers need to communicate clear and concise information to policymakers in ways that will resonate with and be understandable to legislators as well as practitioners. This can help addiction treatment programs overcome the soft on crime label, gain political support, and be perceived as fitting within the mission of the local community corrections system.

8.5

Making the Decision to Adopt an EBP

As discussed in Chap. 2, the traditional mechanism for identifying EBP is to rely upon the scientific process. The two-stage evidence-mapping model presented in this chapter is designed to address the related questions regarding the appropriate matching of EBP to a given setting. That is, the assessment of scientific evidence (taking into account the internal and external validity of the evidence base) should be coupled with consideration of its applicability to the local setting and population, and its fit to the local organizational and systems contexts. The identification and selection of an EBP for dissemination and implementation is conceptualized as a two-stage systematic process involving multiple stakeholders: researchers, agency managers, practitioners, clinicians, and policymakers. The end goal is to determine the steps and priorities that are needed to achieve successful implementation. This two-stage model should be conducted by a local stakeholder or change team (Hoffman, Ford, Choi, Gustafson, & McCarty, 2008; McCarty et al., 2007). The team should be charged by leadership with undertaking a formal EBP Implementation Needs Assessment and Strategy. Preferably this should be an interagency team that includes a researcher. As with other needs assessment processes, this should be a systematic, team-driven approach that is informed by data. This process involves a number of steps: (1) identification of the goals and outcomes that the EBP should

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address; (2) assessment of transportability and organizational fit; (3) collection of data to inform review of transportability and organization capacity; (4) interviews and/or focus groups with key informants; (5) identification and initiation of steps to improve transportability and organizational capacity; and (6) preparation of an EBP Needs Assessment and Strategy report for review by agency management and policymakers. In the first stage, the team charges the researcher with reviewing the evidence– based systematic reviews, meta-analyses, or EBP repositories to identify one or more evidence-based interventions that could potentially fit the local intervention needs. This would involve assessing such factors as potential selection bias, clinical impact, and potential for penetrating the target population. The next steps in the process require careful examination and assessment of the transportability of the EBP to the local setting and population and the organizational capacity to implement and sustain the EBP. This process is similar to a formal needs assessment (Goldstein, 1993; Gupta, 1999) and will serve to determine the fit of the EBP to local population, services, outer settings, and inner settings. Examples of questions are: Is the local target population similar to those included in the research studies? Are there sufficient treatment resources in the community, including trained counseling or clinical staff, to support the EBP? What needs to be changed or enhanced to improve the transportability of the EBP and are these changes feasible? Are management and staff knowledge, values, and attitudes supportive of the EBP and, if not, is training and coaching available to address those issues? Is the sociopolitical environment supportive of the EBP in terms of resources, mission, and community readiness? The team would conduct a needs assessment and meet regularly to review data collection activities and reach consensus on strategies to address gaps in organizational capacity or improve transportability. Prioritization of needs and solutions, as well as final decisions on selection of EBP and its adaptation for this environment, could use strategies such as Nominal Group Technique (Delbecq, Van de Ven, & Gustafson, 1986) to generate ideas related to a key problem area and to reach a consensus on solutions.

8.6

Conclusions

The ultimate value to society of science-based interventions and practices lies in the ability to implement them effectively in real world settings. The scientific process for identifying EBP, as discussed in this and previous chapters, is focused on scientific rigor and standards of replication. Ideally, the laboratory findings can be easily replicated in the field, even with the wide variations in practice (e.g., target population, setting, staff skills, resource limitations) that exist. Normally, the problem of moving from bench to bedside is couched in terms of fidelity and adherence to the intervention design in practice. However, we recognize that this is just one aspect that should be considered. As presented in the Evidence Mapping process in this chapter, implementation needs to be informed by scientific rigor, transportability,

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233

and organizational capacity issues to ensure that the bedside is as prepared as possible to implement the EBP. This two-stage model can serve the greater good by providing a process to develop the EBP Needs Assessment and Strategy to guide jurisdictions. This is similar to the incubator process used by Travis County, Texas in their reengineering of probation supervision (Eisenberg, Byrl, & Fabelo, 2009) where each step was guided by a team that considered the operational components related to the EBP. This process assists in providing a data-driven decision making process to sift through the large amount of available information and make more informed decisions (Shenk, 1998). The Evidence Mapping Model for Organizational Fit captures the realities that improvements in client outcomes are dependent not just upon the EBPs and treatments (e.g., in addition to client factors such as adherence to a treatment), but also factors related to systems, organizations, and staff. This concept provides a framework to further the development of implementation along the dimensions outlined by Proctor et al. (2009). Underlying the Proctor et al. (2009) model is the assumption that successful implementation will result in improved service outcomes (e.g., efficiency, safety, equity, timeliness) which in turn will lead to better client outcomes. Service outcomes, in turn, are dependent on implementation strategies that affect the systems environment (outer setting), organization, group learning, supervision, and other factors. Proctor et al. (2009) imply that successful implementation depends upon achieving satisfactory implementation outcomes including those shown in Box 8.3. The appropriate outcome measures in each category (implementation, service, client), depends upon the specific EBP and local context. In the next chapter, we will present the Evidence Based Interagency Implementation Model (EB-IIM) to transform an EBP into an operational, sustainable practice. Here we have shown that it is important to consider the concepts of scientific rigor, transportability and organizational capacity to identify the key issues that need attention in the EBP implementation process. The EB-IIM incorporates this strategy in working through the stages of implementation. The unmet needs of bench to bedside will need to be accommodated in the implementation process. An important part of the implementation model is to lay a foundation for the organization to create a learning culture – this is important because corrections agencies tend to be closed settings where tradition dominates. Altering the culture will be important to the long-term prospects of implementing sound programs and practices that will improve offender outcomes. These two models working in tandem may help to achieve the balance between rigorous scientific evidence and evidence-based implementation processes that align the EBP with the strengths of the organizations and systems within which the EBP will operate. Many of the concepts embedded in stage two of the Evidence Mapping Model for Organizational Fit comprise areas where further research is needed. In Chap. 10 we detail these areas that are ripe for further study. In particular, little is known about the concepts associated with transportability in corrections or addiction treatment settings. The importation of EBP from other disciplines meets with certain challenges in a nonservice environment such as community corrections. A better appreciation for these issues can serve to foster better alignment between EBP developed

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Box 8.3 Key Implementation Outcomes Fidelity

Acceptability

Feasibility

Uptake Cost

Penetration Sustainability

Do criminal justice and treatment staff adhere to the EBP manual and other public health best practices and guidelines for addiction treatment? How do agency and provider staff perceive value in the EBP and addiction treatment that are the focus of the implementation efforts? What dimensions of acceptability (including appropriateness, fairness, reasonableness, and perceived effectiveness) are used? Can the EBP intervention be incorporated into organizational practice? Are the staff and client burdens reasonable? Can the practice be implemented without major modification/adaptation? Does the staff responsible for implementing the new practices or practice improvements do so? Are the opportunity costs of the EBP acceptable to the organization? Will the organization continue to provide resources to support the EBP or other innovations needed to sustain the new practices? Do criminal justice and community treatment agencies adopt the EBP? Does staff use the new intervention? Do new EBP practices and improvements become routine, usual practice?

in human services or public health contexts and applied in correctional settings. The same is true for assessments of organizational capacity. Few tools exist to provide for a thorough assessment process. The value of examining transportability and organizational capacity cannot be understated – good documentation and research in these areas will create the next generation of ideas and concepts.

References Aarons, G. A. (2004). Mental health provider attitudes toward adoption of evidence-based practice: The evidence-based practice attitude scale (EBPAS). Mental Health Services Research, 6(2), 61–74. Addiction Technology Transfer Center (ATTC). (2004). The change book (2nd ed.). Kansas City: ATTC National Office. Ajzen, I. (1991). Theory of planned behavior. Organizational Behavior and Human Decision Processes, 50, 179–211.

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Chapter 9

Conceptual Model: Evidence Based Interagency Implementation Model

This book highlights the different technology transfer (TT) models that have been tried over the last two decades, and the factors that affect successful efforts to change organizations and implement EBP. The discussion also highlights those factors that are less important to implementation. These lessons are especially pertinent to the corrections field where attention to evidence-based practice (EBP) requires the recognition of a new goal related to offender change as well as embracing offender change as an integral part of the primary mission of public safety. Given the emphasis on offender accountability as a dominant public safety theme, the recent interest in de-incarceration policies provides an opportunity for correctional programming to embrace treatment and offender change. A major shift in corrections policy and practice appears imminent (Taxman, 2011). And, given that few corrections agencies have staff to provide addiction treatment services, building inner setting capacity is needed. More attention must be given to goal clarification and infrastructure as critical ingredients of the change process. Prior chapters laid the foundation for a specific TT model tailored to the unique and complex environment(s) of community corrections. Chapters 3 and 4 sculpted the groundwork for the components of a TT model while Chap. 8 underscored the need for a process to translate and synthesize the research to produce content that is usable in practice. A dynamic TT model has different layers to manipulate the transfer process including attention to the innovation (intervention), the inner organization such as mission/goal, managers, staff, and administrators, and the outer setting of stakeholders, constituency, and policymakers. The lessons gleaned from prior efforts are that community corrections should pay attention to addiction treatment organizations and other external stakeholders to support the goal of offender change. Collectively it is important to improve the capacity of agencies to handle the change processes. For the inner setting, it is important to consider the attitudes, perspectives and skills of all organizational actors such as staff and managers. Building knowledge is critical to forming a strong foundation and garnering confidence in the capability of the organization. For the outer setting, it is important to impart knowledge about the value of the innovation, identify areas of support, work on integrating F.S. Taxman and S. Belenko, Implementing Evidence-Based Practices in Community Corrections and Addiction Treatment, Springer Series on Evidence-Based Crime Policy, DOI 10.1007/978-1-4614-0412-5_9, © Springer Science+Business Media, LLC 2012

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processes and treatments, and provide for continued support. Unlike disciplines that have a clear foundation to support the primary goal (i.e., health care or addiction treatment fields that are interested in recovery and individual change), in community corrections the external setting is equally important to ensure momentum supporting various phases of adoption, installation, routinization and sustainability. In contrast to health-related organizations, EBP affects all aspects of community corrections agencies as well as the judicial and correctional environments. The four main areas that have been identified as part of correctional evidence based practices – assessment, treatment services, deportment, and compliance (incentives/sanctions) – affect operations from intake to discharge. Most TT models have generally been developed to respond to a single innovation (i.e., a new treatment such as cognitive behavioral therapy [CBT] or contingency management [CM]). But, most innovations require modifying work processes, procedures, and policies that affect the overall business model and basic functions of the agency to make “room.” For example, the Travis County, Texas Community Impact Supervision Initiative (TCSI) identified no less than 11 activities summarized in a series of incubator reports (see http://www.co.travis.tx.us/community_supervision/TCIS_ Initiative.asp) that describe each component of the change. Unlike other TT efforts discussed in Chaps. 2–5, improvement in community corrections is often not about a single innovation but rather the entire offender management process. This requires comprehensive change, similar to the steps identified in the Change Book (Addiction Technology Transfer Center, 2004) where the emphasis is on the organization at large as well as the unique needs associated with a particular intervention or EBP. This chapter is organized around two major themes. First, an evidence-based implementation model is presented that is better suited to complex interventions in settings where many decisions are influenced by multiple partners. Second, some of the techniques needed to manage the change process are described. The management of the change process is critically important to any TT model since it addresses the how to steps for facilitating implementation. Most corrections agencies adopt boutique programs or services that may be isolated from the core business process. In the Evidence-Based Interagency Implementation Model (EB-IIM) described in this chapter, the emphasis is on implementation tools to develop and integrate EBP within the fiber of community corrections agencies.

9.1

The Evidence-Based Interagency Implementation Model (EB-IIM)

The EB-IIM for community corrections agencies encompasses scientific and technology transfer literature as well as lessons gleaned from two decades of TT efforts. This model (see Fig. 9.1) accommodates the unique features of the community corrections environment, especially related to the integration of addiction treatment, and

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Fig. 9.1 Conceptual model for evidence based interagency implementation model

takes into account the procedures needed to manage change. The conceptual model has six main interagency efforts that tie together the inner and outer setting (as shown in the ribbons tying the concentric circles together). Unlike other heuristic models, EB-IIM recognizes the importance of different layers being threaded together through visible, dynamic activities. We describe these ribbons in Fig. 9.1 and Box 9.1:

Box 9.1 Key Activities in the EB-IIM Goal and mission setting

The operating agency and the interrelated system components need to recognize that the goals have been altered to incorporate offender change as a vital ingredient for achieving the agency’s primary mission of public safety. Interrelated goals and a refined mission statement articulate the commitment to EBP as well as its role as part of public safety. (continued)

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Box 9.1 (continued) Internal The internal work team should have a visible role throughout work team the implementation process from design of the refined EBP to monitoring performance to championing the EBP. A strong internal work team will ensure that EBP aligns with the organization but also that it is supported by the organization over time. Intervention The innovation, program, services, or refined practice that is being introduced into the setting. This is the EBP. Interagency Similar to the internal work team, an interagency team that workgroups works with or supports internal work teams will bolster support and visibility of EBP as well as help align system components. Unlike other TT models, the support and assistance from other criminal justice and treatment agencies will strengthen internal and external efforts. Resources Any new concept requires resources – staff, space, and equipment, at a minimum – to support EBP. Some of these resources may be reallocated, and some may be new resources. Visible support sends a clear message about the value of EBP to the organization and system. Performance An important management and communication tool of monitoring implementation is the use of performance benchmarks. Benchmarks make the initiative visible and provide feedback on the progress. The benchmarks can be used to identify and address system issues, address complementary training and assistance, and build internal and external support. Public media Communication about the design, progress, and needs are messages important messages to initiate and enhance support for EBP. A concerted public media message within each layer is important to support the implementation work. Such messages provide reinforcing guidance.

The preparation phase is separated into two components that include developing knowledge and building foundation. These are designed to engage stakeholders (both inner and outer settings such as other justice agencies, community organizations, or health agencies) early in the change process. It is important to discuss, understand and agree on the core components of the new innovation as well as the improvements over current practice that are anticipated. This process requires examination of the existing system and the innovation to understand gaps that exist. Overall, the organization should ensure that offender supervision includes

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responsivity to treatment conditions for the offender (i.e., problem recognition, needs assessment). Key agency leaders should become educated about effective interventions, and understand the requirements for implementation and sustainability. Build foundation is distinct from developing knowledge. Organizations should build or enhance their foundation and improve their capacity to implement new practices (e.g., by developing better communication skills, case planning, problem solving or other core processes). The emphasis should be on building skills that are necessary for long-term resiliency. As recognized in the research literature on uptake of EBP, the type, qualifications, and skills of corrections staff are issues that require devoted efforts to build, enhance, and upgrade the skills to incorporate EBP within the existing work processes; many employees in corrections agencies have not been trained in human service skills. The integration of evidence-based treatments requires all staff – correctional officers, probation officers, security staff, case managers, and others – to use people skills based on building motivation instead of traditional authoritarian techniques for enforcing the rules and telling people what to do. Set Expectations (e.g., benchmarking, staff measures, client performance) is designed to pilot the innovation to allow internal and external agencies to establish desired goals for the change. Here the organization, internal staff, and interagency work teams determine how the evidence-based treatment or intervention will assist the agency to achieve better outcomes. This phase is critical because it marries the innovation with the organization, and allows managers and staff to collectively form an opinion about the advantages of this new practice. Align (e.g., adherence, fidelity, feedback and review, examine organizational outcomes) serves to use the pilot implementation phase to align the agency’s policies, processes, and procedures to accommodate the change, and the impact of the changes on the offenders. Renovate (e.g., organizational and systems change, staff leadership and buy-in, identify staff for development) allows the innovation to fit and mold into the involved agencies (i.e., community corrections, addiction treatment). It also serves to link each change with other changes. It is this stage where the intervention or practice “design” is patterned to fit within the agency. This model recognizes that community corrections agencies must receive support from external agencies to implement EBPs and treatments, and to develop internal capacity for change. Here, the focus is on refining the EBP to fit the agency and system needs, and maximizing positive clinical and public safety outcomes. The goal is to recognize that the springboard of knowledge is generated by both seeing and feeling the desired outcomes. Sustain is the glue. Similar to Fixsen, Naoom, Blase, Friedman, and Wallace (2005), this model recognizes the importance of nurturing the innovation/EBP to keep it in place, and to maintain the core components of the model. While there may be some drift from the original design, the essential ingredients should be identified and preserved in order to continue to obtain the desired outcomes. The focus on sustainability and utilization, instead of mere adoption, emphasizes the need to attend to the attitudes of individuals and/or organizations that can impact implementation. Although attitudes early on may interfere with readiness for change, they often reflect ambivalence or insecurity and cynicism about the

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organization’s commitment to change. As noted in Chap. 6, it is important to recognize that the EBP can change the face of community corrections by focusing on how community corrections are part of a service delivery process, including matching offenders to appropriate services. The model’s focus on skills as a foundation for sustainable innovation reflects the need to emphasize organizational and staff capabilities, supported by ongoing training, coaching, and other professional development efforts. In contrast to traditional TT models that focus on mere attitudes and perceptions pertaining to the views about crime, offenders, and rehabilitation, the EB-IIM model emphasizes the importance of new skills, at the individual staff, agency and system level. The ribbons are the areas that require attention to ensure that there is continued support for EBP implementation such as goal and mission setting, performance monitoring, intervention, resources, interagency workgroups, internal teams and public media messages. Each represents an investment in the organization that builds long-term capacity. The visible efforts in these areas both sends reassurance and social messages that the focus is on utilization and sustainability of the EBP, as compared to the typical focus on merely piloting a new idea.

9.1.1

Develop Knowledge Stage

Why is a separate stage needed for knowledge development in this context? The field of corrections is a diverse discipline devoted to the care, custody and control of people under various legal statuses within the criminal justice system. The actual goals vary based on the legal status of the individual and the laws and regulations of the corresponding state/jurisdiction. Supervision and service requirements may differ at each stage in the process – pretrial/preadjudication, jail, prison, probation, parole – and for different types of offenders (i.e., juvenile, adult) – that may have specific needs (i.e., young offender, sex offender, drug offender, chronic offender, mental health offenders). Often, requirements are a product of court cases, new laws or regulations, and new policies and/or procedures. The practice of corrections integrates knowledge across multiple disciplines (i.e., medicine, psychology, sociology, criminology, social work) and contexts (i.e., policy, business processes, organizational research). Scientific knowledge about human behavior is rapidly expanding in a number of areas including behavioral therapy, behavior distributed on geography, and neuroscience – each affects the traditional concepts of adherence to the laws as a voluntary choice or driven by neurological influences that may affect behaviors (e.g., substance abuse, mental illness, etc.) (Jones & Goldsmith, 2005; Volkow & Fowler, 2000). As discussed in Chapter 4, a factor that facilitates the uptake of EBP is having staff with higher educational credentials. Since most community corrections staff is required to have a four-year university degree, with proper training they should be able to use the evidence-based tools. Thus, building knowledge about complex human behavior and techniques requires a commitment to initial and ongoing staff development. Although this knowledge building should

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ideally occur within standard required continuing education training hours mandated by most corrections agencies, it is not typically included. Besides a greater understanding of human behavior, there is a need to focus on a better appreciation of specific innovations or components of EBP. The field of corrections requires an adequate understanding of human behavior to achieve many of the desired goals (i.e., punishment, rehabilitation, deterrence). Given that each area of EBP has its own research and practice literature, part of the challenge for corrections agencies is to keep abreast of the literature spanning a multitude of disciplines. The second demand is to assess useful literature and determine which aspects are relevant to their operations. In Chap. 8 the evidence mapping model identified the need for corrections agencies to understand and digest the research literature, particularly the studies that are used to define EBP. This is an important part of the transportability process given that corrections staff need to understand how the EBP fits within the local setting, the conditions that will facilitate fit, and the core ingredients of an EBP. Finally, the direction of community corrections agencies is often affected by hot button issues or external political pressures. For example, negative events (e.g., a murder committed by a parolee leads to legislation requiring harsher penalties, see Chap. 7) require immediate attention that can affect the fidelity of an EBP. Sex offender legislation prohibiting offenders from being within a certain distance of a school may require relocating treatment providers that are situated in that area. The need to respond to these red flags often pushes knowledge development initiatives in an organization to the background. Dedicating sufficient time and resources to consistent learning is critical in organizations that are under tremendous pressure to respond to crisis situations. The complex world of corrections necessitates the recognition that knowledge development is an on-going process where new information must be identified, distilled, and permeated throughout the agency. The research base for most of this information is found in scientific journals, now more easily obtainable through the internet and listservs. The National Institutes of Health (NIH) recently adopted a new policy that all journal articles generated from their grants must be made available at no cost for at least 1 year after the article has been published. This is part of the overall NIH effort to disseminate scientific findings to practitioners through easier access to the scientific literature. A major, existing limitation in the field of corrections is that the traditional corrections training academies have not taken responsibility for transmitting or even translating research findings as part of standard preservice and continued training opportunities. Instead, traditional corrections training academies generally focus on job duties. Community corrections agencies overall place little emphasis on acquiring scientific knowledge and applying it to daily operations. There is a need for the scientific community, practitioners, staff, and trainers to work together to distill research findings into material appropriate for practitioners, known as translational research. Sound interagency workgroups provide this platform. The drawback to the training currently provided to most corrections personnel is that the focus is on answering what should they do instead of why and how. As discussed in Chap. 8, this is the critical issue regarding tests of scientific robustness where the goal is to be able to

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assess the scientific literature and then apply it to their own setting (transportability). Yet, the knowledge about why has been shown to be an important component of using information in work settings (Burke & Hutchins, 2007). A greater appreciation for scientific findings can serve to prepare staff to be more open to new ideas as well as considering the options of using information in the workplace. As previously discussed, the addiction treatment field has some built-in efforts to transport new information into the field, including the Addiction Treatment Technology Centers (ATTCs), NIDA’s Blending Initiative products and conferences, and online staff development tools provided by NIATx. Similar vehicles do not exist in community corrections which lead to gaps in the knowledge transfer process. This is why a general need exists within the corrections field to have a special focus on knowledge exchange and translation within training academies where the majority of the line and managerial staff acquire information. In our community corrections TT model, a special focus is placed on preparing staff, managers, and partners to understand, decipher, and translate scientific findings into useable components. A Knowledge Development phase serves to assist staff in moving away from staunch attitudes and opinions (or personal philosophies) that interfere with change or appreciation for scientific findings (Box 9.2). For example, CM interventions that reward positive behavior have repeatedly been found to be effective for improving treatment engagement and retention in addiction treatment (Lussier, Heil, Mongeon, Badger, & Higgins, 2006; Prendergast, Podus, Finney, Greenwell, & Roll, 2006) but research has found that counselors are less likely to use CM because of their personal values (Kirby, Benishek, Dugosh, & Kerwin, 2006). That is, some counselors do not agree with the premise of rewarding behaviors that the addict should be doing. To be more accepting of CM, one must understand the theory of behaviorism, the techniques of identifying target behaviors, and the techniques of using rewards as well as have the skills to engage clients in the treatment process. Understanding the theory fosters a greater appreciation for the CM protocol, and it can then help the staff identify how to modify the business process to accommodate CM. Understanding CM in such depth helps understand how CM fits into treatment engagement and delivery. It also addresses the personal values that may conflict with using an EBP focused on incentives and rewards to shape client behavior.

Box 9.2 Areas for Knowledge Development • • • • • • •

Theory and goals Fit with mission Technical and clinical skills Networks with other jurisdictions Fidelity of the EBP or tools used Procedures for use of EBP Scientific research findings

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Knowledge Building Tasks. The knowledge building tasks should address two major areas: (1) pertinent research findings, theory and literature about effective practices that affect human behavior pertinent in offender processing issues; and (2) existing agency policies and procedures. The first area is critically important since it addresses the focus on scientific knowledge. A review of the literature, the findings from studies, and the types of offenders studied can assist in answering basic questions about the relevance of scientific findings to a given area. This is important since it will assist in developing an appreciation for the research literature and contributes to the transportability of research findings to practice. And, it serves the purpose of helping users gain a working knowledge of research methods to appreciate and have confidence in research findings. This includes an understanding of the distinction between efficacy and effectiveness studies (see Chap. 2), and having experience in reading systematic reviews and meta-analyses. But, it is equally important to appreciate the organizational capacity (one of the tests of transportability) issues. Burke and Hutchins (2007) refer to the need to connect the knowledge to strategic and procedural appreciation as part of the knowledge development phase. Procedural knowledge refers to the existing practices including policies and procedures and how to adapt these to facilitate implementation of an innovation. Rogers (2003) discusses the importance of communication channels or how information is transmitted. Formal agency policy is generally covered in preservice training (usually requirements or mandates) and through periodic memoranda or briefings. As previously discussed, informal networks within an organization are very powerful and the use of champions or change agents within these informal networks is an important step to facilitate the processing of scientific findings and assessing the relative advantage associated with changing practices or implementing EBP. Given that business processes in community corrections are generally governed by regulations and government structure, it is important to assess how current policies and regulations affect the use of an EBP. Many employees are unaware of the regimen for crafting policy, legislation, and procedures, and they are frequently misinformed about the genesis for policy as well as the process for making modifications. Part of the knowledge development phase is to help staff to understand how policies and changes can be made. The key informants indicated that they feel it is imperative that their staff learn about policy-making since it can influence their attitudes regarding fairness and equity. Tools to Advance Knowledge Development. The standard tools to develop knowledge about EBP are guest speakers, seminars, and training workshops. As previously reviewed, studies on the most prevalent form of information sharing – didactic training – have basically found that single session trainings do not result in utilization of the innovation or ideas (Goldstein, 1993; Joyce & Showers, 2002). The sessions are more useful to increase awareness about science and research findings, but usually do not assist staff in learning to apply the information in their work environment (Burke & Hutchins, 2007; Joyce & Showers, 2002). Given that practitioners and policymakers often judge scientific knowledge in terms of the calculus of utility as well as relative advantage to their own work, it is important to couple didactic training sessions with process sessions. Process sessions involve applying knowledge through case studies and other work related assignments to help staff learn to apply new knowledge.

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Process sessions are critical to translating knowledge into how to change or alter existing processes like assessment, case planning, treatment, monitoring, and compliance. This type of knowledge application cannot occur in a single session; instead a series of internal sessions is needed that require staff to use the information. These types of work processes facilitate the creation of a learning organization where staff can vet new procedures and where risk-taking is valued as a means to improve the performance of the organization. A goal is to create what Senge’ (1990, p. 3) defines as a learning organization: …organizations where people continually expand their capacity to create the results they truly desire, where new and expansive patterns of thinking are nurtured, where collective aspiration is set free, and where people are continually learning to see the whole together.

As part of a learning organization, sessions should be devoted to mapping a concept and then outlining how policies, practices, and procedures utilized daily are affected by the new information or procedure. These sessions should be independent from other strategic planning efforts and can be used to address readiness to change and identifying the barriers (i.e., people, processes, or things) that will affect the implementation and sustainability of the effort, and the strengths of the organization. Finally, researchers must bear responsibility for translating their findings into more digestible lay language, producing shorter policy versions of academic journal articles and reports, and presenting findings at practitioner trainings and conferences. Given that scientific knowledge grows in tandem with improvements in operations, both researchers and corrections agencies must become more comfortable with piloting new interventions as part of a contribution to the evidence base. This type of collaboration builds a stronger partnership between researchers and practitioners. In summary, a number of important steps are needed to create environments where new ideas can percolate into action. Knowledge development is a mechanism that provides access to and dissemination of research findings to all levels of the organization. Building this infrastructure into the organization (e.g., through training academies) provides an important step towards opening the communication channels in support of improvements and change as well as building internal support. But it also extends to the outer setting by demonstrating a commitment to acquiring new knowledge; the knowledge development efforts offered within an agency can be expanded to provide a ready-made forum for partners and stakeholders to also learn about pertinent issues related to behavioral change and managing behavior.

9.1.2

Building Foundation (Improving the Capacity at Individual and Organizational Level)

While knowledge building is an ongoing process to keep the system informed of scientific information, the task of building skills is another formative stage. Evidencebased addiction treatment interventions requires clinical, interpersonal, or technical

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Box 9.3 Contingency Management: What Does It Require? Throughout this book we have discussed CM as an EBP given the positive findings in primary studies and systematic reviews. However, the translation into the justice setting requires attention to the core principles (Taxman, Henderson, & Lerch, 2010). CM represents rewarding behavior. But what are the “rules” for rewarding? This is the core principle question. In the JSTEPS CM study (Taxman, Rudes, et al., 2010), the researchers developed the core principles to designing a system that fits within the local socio-political-legal culture. These are: 1. Providing positive incentives to clients via a point system that identifies the behaviors that will be rewarded. 2. Establishing clear guidelines about the required behaviors and which behaviors earn points. 3. Emphasizing abstinence as a key objective. 4. Providing adequate incentives early in the program to get clients started in the right direction. 5. Using point escalation to promote sustained good performance. 6. Integrating the point system into the normal operation of the court (e.g., phase systems). 7. Using bonuses to reinforce incentives for positive behavior. 8. Requiring that offenders are not required to attend to more than three behaviors at a time. 9. Choosing the areas where the client is falling down and shifting to a positive approach by rewarding his or her efforts to improve in that area.

skills that may not be readily available in corrections agencies. These are often not required as part of the job; without a change in workforce requirements it will be necessary to help staff to obtain these important skills. Recognizing that many community corrections staff are not likely to have competent skills in the areas related to evidence-based technology, the organization should make a major investment to provide staff with technical skills associated with the delivery of EBP (see Box 9.3). In addictions treatment, the ATTCs serve as a vehicle to develop competency in critical skills; community corrections does not have a similar infrastructure. As discussed in Chap. 8, the issues surrounding transportability of an innovation to an environment assesses the capabilities of the staff to implement the new EBP. Direct attention must be given to the core components of the EBP and how the environment can embrace and implement the EBP. In this process, the underlying core principles of the EBP are needed to define the key components of the EBP. It is then that the designers can ensure that there is sufficient fidelity to the EBP so that it has the core ingredients to produce laboratory-like outcomes. Within each of the foundation building arenas – technical, procedural, resources – it is critical to be as true

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as possible to the EBP, while recognizing that improving the capability of inner and outer settings to integrate the EBP may require some modifications of the EBP protocol (see discussion in Chap. 8). Technical. Given that the field of community corrections requires people to wear multiple hats, it is likely that staff will need assistance in learning key skills as part of their ability to incorporate EBP into traditional delivery. An examination of the eight NIC evidence-based principles reveals a need for an array of clinical and working alliance skills (rapport building or interaction) as part of using EBP while working with an offender. The process of facilitating change requires a certain degree of trust between staff and the offender (client); this type of trust is usually not included in an authoritarian relationship focused solely on punishment (Taxman & Ainsworth, 2009). Instead the staff needs to balance the use of the stick within the context of facilitating change. Such skills can be used in assessment of initial risk and needs, assessment of offender performance or progress in terms of addressing risk and need factors, using clinical engagement (throughout the process) techniques, matching offender risk and needs to appropriate programs and services (as well as controls), and engaging the offender in this change process. In the perfect setting, staff would have these technical skills and abilities to handle decisions. Given that many of these skills are not required in most corrections positions, a concerted effort is needed to develop and enhance these skills among key employees and recruit future employees who are inclined to utilize these techniques. In any situation involving change, the assessment of transportability requires a capacity assessment for the organization regarding the clinical and technical skills of staff. From an organizational perspective, the foundation building process is needed to ensure that staff has the necessary skills before implementing a new EBP or practice. Without such skills, it is unlikely that the EBP will achieve the same desired outcome given that staff will likely deliver a diluted or adulterated EBP. Even if the workload is adjusted, if the staff do not have the basic skills needed to implement the required change, then the resulting product is unlikely to achieve the desired outcome. This point cannot be understated-- many of the new EBP require staff to carryout processes and procedures for which they do not have formal skills or knowledge – yet, these skills are needed for staff to feel like they can adequately do the tasks. For example, the use of motivational interviewing (MI) or incentives (CM) requires client rapport building skills that probation staff generally do not have. Without being exposed to skills and having an opportunity to develop competency, staff may not have confidence in their own skills which contributes to obstacles such as staff resistance, uncertainity about the impact, fear about job loss, and concerns about suitability or fit within the agency. Each obstacle can be overcome by providing staff with training to help develop their core competency to do the job. For example, MI is recommended as a skill to use the interview to gather information gleaned from traditional processes such as risk and needs assessment tools, supervision planning, incentivizing offenders, and adjusting plans based on client progress, and to assist the offender in developing intrinsic motivation. But MI skills also include learning counseling skills and empathetic behavior that usually is not present in justice settings. A good model for

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Table 9.1 Competencies implict in NIC’s evidence-based principles NIC principle Skills needed Assess offender risk and needs Proficient use of instrument(s) Proficiency in assessing offender needs such as substance abuse, criminal peers, criminal thinking, antisocial behavior Diagnostic skills to screen for key problem behaviors Enhance offender motivation

Motivational engagement skills Engaging interviewing skills Use motivational and incentive skills

Target interventions

Diagnostic skills of matching offender needs to interventions Case planning Assess intervention strengths and weaknesses Problem solving to adjust interventions based on staff skills

Address cognitive-behavioral functioning

Clinical skills in motivational enhancements and incentives Clinical skills in cognitive functioning Clinical skills in behavioral management

Provide positive reinforcement

Clinical skills in motivational enhancement Use of structured responses

Provide ongoing support

Clinical skills in clinical progress and monitoring strategies Case management skills of service integration Clinical skills in client interaction skills Clinical skills in rapport building

Measure outcomes

Use of performance-based management Management identification of benchmarks and improvements Management skills to use graphs of processes

applying MI to probation and parole settings was developed by Dr. Scott Walters, and includes a workbook and videotape where the goal is to enhance the core competency skills of probation officers (Walters, Clark, Gingerich, & Meltzer, 2007). Table 9.1 illustrates the competencies embedded in the skills needed to implement the eight NIC principles. At a minimum, in the foundation setting stage the organization should assess the staff and agency for these technical skills and develop a strategy to ensure that more staff are competent in these skills. Policy and Procedural Capabilities. A core component of mapping an EBP to the local setting is the degree to which the organization has the capability to implement the EBP. Tests of organizational capacity include the nature of existing policies and procedures that may affect implementation including external stakeholder support for the EBP. This involves an environmental scan to assess how the EBP can be mapped into the system. A policy and procedural assessment should examine the current infrastructure, possible barriers or resistance, protective factors, and other contextual attributes that may impact both the fidelity of the EBP or implementation. The environmental scan should consider such issues as: (1) an analysis of the organization’s prior attempts to innovate; (2) the needed organizational structure to oversee fidelity of the EBP; (3) existing policies and procedures that may affect or be affected by the new knowledge; and (4) modifications or

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refinements needed to actualize the innovation into the current system. These issues sow seeds in the organization as to where policies and procedures should be refined, or addressed. The concepts of transportability include setting, population, fidelity of intervention, clinical or practitioner buy-in, core outcomes and organizational fit. The first effort should be devoted to understanding the organization’s prior experience with similar programs/services. The goal of this discussion is to illuminate the lessons learned from previous failed attempts to implement EBP or the factors that influenced positive prior experiences with EBP. Strategically this discussion helps to unveil the myths regarding prior efforts. Because the past influences future efforts, it is important to have a constructive discussion about prior implementation efforts. Part of the reason that the Travis County Texas Adult Probation Department documented their implementation process in incubator reports was to provide a detailed description of the process and the outcomes for each EBP area. Reviewing documented history can assist in facilitating discussions about where possible changes are needed, including inter-and intra-agency change in the criminal justice environment. Some capabilities derive from internal resources, while others draw upon external stakeholders. A thorough assessment can be useful to strengthening the internal capability of the organization to integrate other services, procedures, or stakeholders to expand capacity for the EBP. Second, the environmental scan needs to assess the current work environment, workload, and priorities attached to each function. Workload related issues usually complicate the implementation of EBP, especially if they require external agencies to modify their processes to implement or support implementation of an EBP. These essentially are organizational issues that need attention to ensure that the new/modified idea or concept has a place at the table, and that it is feasible to alter the current environment. Another component of the environmental scan is to examine the general trends in the field to support the validity of the EBP. Looking at the national organizations and trends in other states can point to the consistency of the approach among the early adopters or trendsetters in the field. For example, the Pew Charitable Trust’s Public Safety Performance Project (PSPP) (http://www.pewcenteronthestates.org/ initiatives_detail.aspx?initiativeID=31336) established a focus on reforming policy in community corrections and correctional policy overall. This Pew project is a vibrant effort to impact national attitudes towards punishment options as well as to enhance criminal justice policy at the state and local level. The Pew PSPP embraces EBP at the policy level. As noted by Pew, the goal is to offer “…state policymakers a menu of five provisions that help corrections agencies implement ‘EBPs’ by providing fiscal incentives, clearing obstacles, enhancing their authority, and tracking their results” (http://www.pewcenteronthestates.org/report_detail.aspx? id=47134, February 21, 2011). The PSPP set benchmarks to implement the eight NIC principles for EBP by stating a goal of 75% uptake in 4 years as well as policies devoted to the implementation of: (1) earned compliance credits for offenders to incentivize good performance by reducing sentence length, (2) administrative sanctions to

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manage negative behaviors; and (3) financial incentives to organizations that pursue an EBP environment. State and local agencies can use the policy framework articulated by the PSPP to support their own local initiatives and provide validation of the importance of the approach for internal and external stakeholders. By engaging staff and external partners in this environmental scan, it is possible to demonstrate that the innovation is compatible with the mission, values, and goals of the organization; and that the existing practice can be enriched by this process. The use of vertical teams (described below) to identify the procedures and operations affected by the EBP/innovation and to recommend changes (including the elimination of existing procedures that are not valuable) is a tool in the environmental scanning work. For example, an EBP implementation team in New Jersey’s Parole Office used the vertical team to examine both how to integrate risk and need assessment into practice and identify what practices will free up staff resources. The committee identified redundant forms, duplicate procedures, and disconnects among difficult work processes. The recommendations to improve the procedures served to clarify the line supervisor’s responsibility, define quality assurance procedures, and prioritize responsibilities. The review led to organizational changes that aligned the EBP with their process and streamlined their efforts. Table 9.2 displays a sample of procedural issues associated with the eight NIC principles. Organizations should review their existing policies to identify areas where they need to strengthen their efforts. Resource Capabilities. Often, organizations over-reach regarding their capacity to simultaneously implement one or more EBP. An important part of the foundation building is to ensure that there are sufficient resources in appropriate places to adopt and sustain the innovation. The resources include: physical space, training and staff development, enhancements to existing technology (e.g., automation systems, assessment instruments, intervention contracts), staffing, services, and contractual funds for treatment or other services. Although most new innovations appear to have an substantial list of needs, the review of the resource capabilities should focus on building the existing structure. It is anticipated that new resources or reallocation of resources might be needed to make an investment in the organization and staff. Often in these reinvention processes, a review of resource distribution provides a solid framework for assessing the parts of the processes that need more attention to improve performance. The environmental scan should include a review of the resources needed to support the EBP, both internal and external to the organization. For example, Justice Reinvestment is a concept for transferring resources from one allotment (such as prison) to the community (e.g., community corrections, services, employment training). Another example is to move staff out of prisons to handle offenders in the community. The foundation building process allows for a review of how the resources are distributed, and an assessment of the adequacy of this distribution in light of the needs associated with an EBP. This builds the inner setting and reduces barriers to change.

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Table 9.2 Policies, regulations, operational abilities needed to implement NIC’s principles NIC principle Procedural capability Assess offender risk and needs Select standardized instrument(s) to address risk and/or needs Validate the tool on the offender population Identify procedures to ensure that offenders with various risk and/ or need levels are linked to given and appropriate services Identify staff capabilities in this area Enhance offender motivation

Identify policies and regulations regarding fraternization with offenders; assess how the concept of rapport building/ working alliance can be integrated Select curriculum for training staff on motivation Implement competency building Refine agency procedures as to how they affect efforts to engage the offender in treatment

Target interventions

Identify services needed and determine whether they use NIDA’s evidence-based practices. Modify the standard contract for procuring services to include EBP treatments and quality assurance Establish performance benchmarks for the use of the services. Develop or refine procedures for dealing with offender lack of progress in a given program

Address cognitive-behavioral functioning

Assess the adequacy of cognitive behavioral therapy (CBT) competency for staff Implement CBT competency training Use the cognitive behavioral model to review how staff interact and work with offenders

Provide positive reinforcement

Identify staff incentives and rewards Review and refine policies and procedures related to using incentives with offenders

Provide ongoing support

Review capacity of management information system to produce reports on benchmarks of performance Review quality assurance procedures Refine and review existing policies and procedures that use benchmarks

Measure outcomes

Identify goals and objectives Develop performance benchmark reports Review how performance reports for staff can be integrated into staff evaluations

9.1.3

Set Expectations: The Use of Benchmarks for Performance

In the third phase of the model, the goal is to clarify the expected gains from the EBP and to test the initial design. Unlike prior TT models that are based on installation as the first step, the unique setting of criminal justice and community corrections requires more attention to expectation setting. The process of expectation setting is to set realistic goals and objectives as to the gains expected from the adoption of EBP. Too often, wild and unrealistic promises are made. For example, in the

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recent legislation to establish the Second Chance Act, some members of Congress desired to see 50% reduction in recidivism or 100% eradication of drug use – while desirable, these types of projections are totally unrealistic. To avoid disappointment from unrealistic expectations or myths about potential EBP effects, it is important to establish benchmarks for the innovation that are realistic based on the evidence and resources available. This process also serves to clarify the values, both internal to the agency as well as of the external stakeholders, regarding the importance of EBP. It also facilitates the expectations from the EBP to improve the management of offender-related goals, and the realistic temperament regarding offender outcomes.

In corrections, the demand for altered behavior in short periods of time are notorious. Setting expectations results in partners aligning on what will be required to change behavior in a reasonable period of time. The key is to ensure that there is agreement as to realistic timeframes.

Benchmarks as well as Goals and Objectives. The finish line can be rather obscure for a new innovation and this can create organizational inertia. The adoption of new technologies can be perceived as a never-ending process, creating the cynical view that improvements are not useful since they are overly burdensome or take to long to implement. To avoid these emotional drains on the organization, benchmarks are a common and useful tool to define the series of interim goals to instill a sense of accomplishment. Without set goals for performance milestones, and a means to assess the degree of accomplishment, is it difficult for organizational momentum to continue. These performance benchmarks are important since they signify when the organization has achieved set goals – and also when the organization has moved along the continuum of adoption, installation, implementation and sustainability (Fixsen et al., 2005). The benchmarking process for workgroups provides a clarification of what the expectations will be, and how the organization will become aware of the accomplishments (see Box 9.4). By involving team members in the definition, analysis, and interpretation process, the implementation process is strengthened. Also this serves to clarify the goals and objectives.

Box 9.4 Benchmarks 1. Allow teams to identify the process of change and the indicators of progress towards that process. 2. Provide objective measures that are visible, and thus allow the team to mutually assess their achievements. 3. Serve to assure that the larger organization is committed to this progress as well as external stakeholders.

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Table 9.3 Steps in benchmarking from development to alignment Steps Questions to ask Identify benchmarks For each goal, identify the desired steps to achieve that goal Identify the measures of progress, and how this progress will be determined Specify the timeframe to expect the findings Achieve consensus on the measures to improve outcomes Identify and collect data

Keep primary users informed of the data to be collected and the progress made Involve primary users in data collection, management of the process Assist primary users to understand how data collection can advance their efforts Use data to expand knowledge about change

Conduct mutual analysis of the data using the work team and outside stakeholders

Outline analysis for the primary users and their interests Facilitate data interpretation by the primary users to increase understanding of findings, ownership of findings, and commitment to results Involve users in interpreting findings and generating recommendations Involve a broad spectrum of users and stakeholders in the examination of the findings Help users distinguish among findings, interpretations, judgments and recommendations Inform primary users of important findings and/or decisions Focus on analysis of various data sources to encourage an open discussion, and to guide knowledge utilization. Help users distinguish among varying degrees of certainty in the findings, being open and explicit about the limitations, weaknesses, strengths Source: adapted from Patton (1982)

Through the benchmarking process, the workgroup (see below) can facilitate a review of information sources available to the agency, assess the validity of the data, and determine the difficulty or ease of capturing quality data. The assessment of the data collection and management process contributes to a shared understanding of how the organization functions, and helps to determine processes that need clarification. And, the team can work together to analyze and interpret the data, an important step because it allows the team to develop a consensus on the experience, including findings that are inequitable and those that are interpretable. These discussions are important because they lead to a more thorough assessment of the organization, and can contribute to making adjustments to align to the organization (see below). The benchmarking process essentially sets expectations and galvanizes the organization around these expectations. Table 9.3 outlines steps that should engage the internal and external stakeholders in the benchmarking process, and is based upon the recommendations by Patton (1982). In this model, processes of defining, analyzing, and refining can be used by the organization to enhance outcomes, an important concept for our model. Table 9.4 is an example of sample benchmarks that could be used by community corrections agencies as they begin to implement EBP during the different phases of

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Table 9.4 Sample benchmarks to measure implementation of NIC principles Adoption Implementation Sustainability NIC principle benchmarks benchmarks benchmarks Assess offender % staff trained % new intakes where % new intakes where risk and needs to use the tools tool was used tool was used % new intakes identified % new intakes where with various needs/ needs are identified risk level Enhance offender % staff trained in MI % staff using % staff using motivation or motivational motivational tools motivational tools enhancements % offenders flow process % offenders that attend % offenders that attend where motivational services within services for 90 days enhancements can be 30 days of referral/ after referral used intake Target Identify service gaps % services that match % services that match interventions Identify where improved offender needs offender needs (can (can be done by be done by need treatment services can need category) category) after 180 be used days of % service providers implementation that embrace evidence-base % service providers that treatments introduce new evidence-base treatments each year Address % service sessions % service sessions that cognitivethat are CBT are CBT behavioral % correctional sessions % correctional sessions functioning that are CBT that are CBT Provide positive Staff trained in contin- % staff that use CM % offenders in reinforcement gency management practices compliance Staff use CM rewards % rewards that are % interactions that schedule given out use incentives Agency devotes % rewards given out resources to rewards or incentives Provide ongoing Develop continuum % case plans with % offenders with support of care continuing noncriminal peers policies support in the community Develop linkages % diverse case plans % offenders that use with service NA/AA % case plans specific providers to offender needs Measure Identify benchmarks Use of outcomes by % reports used to outcomes workgroup target new activities Identify data sources Visibility of outcomes Workgroup assesses in the organization outcomes

the implementation process: adoption or the decision to implement, installation (the first 6–9 months after implementation), and sustainability (9–18 months after adoption). The benchmarks at the beginning of the process tend to be related to staff activities during adoption and implementation whereas in the sustainability

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phase the effort is more devoted to client or offender level outcomes. In the later stages, the client-level measures indicate degree of penetration into the target population.

9.1.4

Align: Using the Pilot as a Learning Stage

The preceding steps are taken to prepare the organization for a period of trial and error, after the decision to adopt an EBP. Although there may be a desire to move ahead with innovations at full scale, it is advisable to begin in smaller increments to test the foundation in the organization. The pilot allows the inner setting to adjust, and to demonstrate its organizational resiliency. This reliance test is designed to determine: (1) strengths; (2) how the organization responds to the innovation; and (3) unanticipated barriers or issues, at the policy, procedural or skill level, that will need further attention. The goal of the pilot period is to decide whether the design for the innovation needs to be aligned to the culture of the organization or the needs of the outer setting. The alignment process should use the vertical teams (see below) to conduct a situation analysis of the effort to determine the saliency of concept, design, and EBP innovation. It is important at this point to assess adherence and to further identify areas where the foundation building needs to be developed further. The steps, as identified below, provide a formula to align early adoption and implementation as the organization considers taking new practices to scale: (1) pilot; (2) conduct a situational analysis; (3) communicate to primary users and leaders in the organization; (4) identify areas of change; and (5) identify processes to integrate change. These steps help the organization to move towards aligning the early results with desired outcomes, as shown in Table 9.5 below.

9.1.5

Renovate and Sustain: The Ultimate Goals

The preceding formative stages of the process serve to identify whether the EBP is aligned and useful to the organization and its external stakeholders. These actions serve to facilitate two decisions: (1) whether the innovation should be implemented at full scale; and (2) whether changes should occur to ensure optimal performance at the designated scale. The challenge of implementation focuses on molding the innovation into the organization and then determining that there are sufficient benefits to warrant further installation and uptake. The TT model then identifies three separate phases to increase the penetration of the innovation into practice: (1) renovation of the EBP driven by pilot findings; (2) furthering the dispersion of EBP into daily practice; and (3) sustainability or the efforts to maintain the EBP that maintains its core components. The process of going to scale within the organization uses the trial period as the galvanizing mechanism to marshal the

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Table 9.5 Steps and techniques of alignment to the setting Steps Techniques Simulate use through a trial Guide primary users through a trial period, and use that trial to generate discussion about refinements (or disregard if it does not work) Determine whether design changes are needed Have team/primary users make explicit decisions on how to proceed Conduct situational analysis

Examine agency’s infrastructure of processes (e.g., intake, programs) Examine this experience in light of similar programs/services Examine possible barriers or resistance to use Examine facilitators and areas of support Identify upcoming decisions, deadlines (i.e., funding decisions) or timelines Evaluate the stakeholders’ interests and contributions, and ensure that they are involved in many aspects of the alignment process

Communicate to primary users

Consider how the innovation will contribute to the main mission of the agency Discuss how the trial innovation can contribute to staff knowledge and job development/enlargement Consider how the innovation contributes to major decisions being made in the organization Consider how the innovation affects the existing workload (and look for ways to reduce unnecessary paperwork or activities) Use the process to generate lessons learned at all levels to contribute to an open environment, and risk-taking

Identify areas and methods of change in CJ environment

Select processes that are believable, credible, and valid to the users, and identify the steps to ensure that they are believable, credible, and valid Assure that each step is documented to allow for review, lessons learned, and results that are visible to others Involve primary intended users and stakeholders to enhance use

Identify strategies to integrate the change (if renovation is to occur)

Guide the pilot through internal champions to advance implementation Identify where changes should occur to accommodate the EBP Guide the development of processes where internal staff serves as experts on the implementation model

organization’s energies to pursue full operation and implementation of the innovation. Renovation, as the term implies, refers to the effort to pay more attention to building and improving the foundation, and using the team members and/or staff involved in the pilot to function as internal champions for the innovation. The former activities serve to spread the champions throughout the organization, especially line staff that often shoulder more of the demands during implementation. Renovation. In the renovation phase, processes similar to the expectation setting and pilot phases are used to adapt existing EBP into the larger system. Going to scale implies that the innovation design has been set and is constant. However, as

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noted in other fields, adaptations often are required to address issues of location, population served, and organizational climate issues (e.g., nature of the stakeholders, political influence, local traditions), as discussed in Chap. 8 in the tests of organizational capacity. The alignment process is then considered relevant to whether the reframed design is consistent with the EBP. This is a question that needs to be consistently addressed during renovation to assess the degree to which implementation decisions affect adherence to the EBP concept. For example, a jurisdiction implements CBT using paraprofessionals and a manual. The paraprofessionals did not understand the importance of relying on the manual’s content and guiding principles and deviated in their client interactions to be more instructive (i.e., didactic) and incorporate their own experiences. Although the manual had been officially adopted, the pilot demonstrated large drop-out rates in the first 30 days. A review of the process revealed these flaws. The organization engaged in quality assurance to emphasize to the paraprofessionals the importance of using the manual. Efforts were also undertaken to provide the staff with processing skills (part of a component of CBT) to improve their understanding and use of the manual. Similar examples are modifying cut-offs for supervision level assignments or assigning offenders to treatment programs based on intuition instead of offender behavior assessment tools. Both are examples where the adaptation altered the integrity of the EBP and that in turn diluted the impact of the EBP on the organization. Renovate allows for the use of quality assurance tools to refine the process and ensure that the innovation’s core components are upheld. As stated earlier, these quality assurance tools are more appropriate for implementation with corrections agencies since they will focus on two major challenges: (1) ensure that the operation proceeds; and (2) ensure that the intervention continues to deliver positive outcomes. The latter is needed because it is possible that routinization can result in passivity; ongoing quality assurance can ensure that the organization remains committed to the desired outcomes. Quality assurance techniques are important for sustainability and utilization efforts because they provide feedback to the organization on how well the change has achieved its goals and objectives (Howe & Joplin, 2005). Similar to benchmarking or expectation setting, these quality assurance measures can be used to assess the degree to which the innovation is being implemented as intended and with the appropriate dosage and units to achieve the desired outcome. The quality assurance techniques are important in the renovation process to guard against dilution and to ensure that the design meets the expectations of EBP. Sustain. Proctor et al. (2009) indicated that part of the implementation process is to focus on penetration into the larger system. Penetration refers to the EBP becoming a common application where the largest number of staff are using the EBP and appropriate offenders are exposed to the EBP. In the EB-IIM, this effort begins with renovation where the focus is on the process of uptake and penetration. The costs of the EBP are assessed to be worth the effort. The reason for separating sustainability from renovation is that additional attention is needed when decisions are made to expand past initial installation. Implementation is a long and arduous process, and

9.2

Setting the Stage for Implementation: Core Components to Manage the Process

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given the complexity it is necessary to separate out into two phases where the focus on sustainability is a unique effort itself. These phases serve to allow the organization and systems to push past absorptive capacity where the efforts are focused on continuing to deliver the desired outcomes. Benchmarking is also an important tool in the sustainability phase. Because innovation decay is common, it is important at this phase to ensure that mechanisms are in place to further sustainability. Performance benchmarks serve to provide feedback to the organization, which is critical to visualizing the benefits of the EBP. The performance measures also may be useful in identifying system barriers that continue to limit the progress. In the sustainability phase, it is equally important to assess the inner and/or outer setting (layers) to determine the likely source of the deterioration. An example is a drug court that may initially identify impressive outcomes, but over time client level performance deteriorates. This could be from changes in a treatment provider, modification in the schedule of the status hearings, assignment of a new judge, changes in prosecutors or defenders, reduction in drug testing schedule, change in type of offenders participating in the program or other components of the model. Many of these issues are system related – changes in the system partners and their contributions to the model – and these factors can only be identified if there are benchmarks that assess the degree to which all parts of the model are in place. The sustainability phase also draws attention to the inner setting such as staff, managers, and the costs of the innovation. Sustainability is best achieved when staff and managers have inculcated the knowledge and skills needed to deliver the innovation, as per earlier phases. But it is possible during sustainability that there is a need for further competency development to ensure that staff can maintain the innovation. Measures of fidelity should continue to be gathered during this phase. It is also possible that staff, due to turnover or deterioration of skills, may need boosters and reinforcers, or external coaching, to increase the capacity to deliver the innovation. Sustainability is essentially absorption into the daily fabric of the organization as part of routine processes. Changes in policies and procedures, new benchmarks, and system partners are key indicators that sustainability has occurred.

9.2

Setting the Stage for Implementation: Core Components to Manage the Process

The EB-IIM is only as fitting and robust as the strategies and techniques for enabling the inner and outer settings to work on implementation issues. Community corrections agencies need to prepare themselves to engage in a change process that will facilitate implementation of innovations. Although the preference may be to allow the innovation to evolve into practice, prior chapters have shown that percolation is not synonymous nor will it facilitate organizational readiness, either within the

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organization or among external partners. The change process requires administrators/ managers to organize strategies to move the organization along to acquire, integrate, and expand to include external partners. The techniques to engage the organization are essential for the ultimate success of the change, particularly to the efforts to routinize or sustain the efforts within normal business practice. In the first steps, a need exists to weave change into the fabric of the agency, and within the supporting partners. Stand-alone (a single effort for one initiative) or top–down (management driven) initiatives are unlikely to be implemented or sustained. As seen in the intermediate sanctions movement of the 1990s, the organization at large will resist anything new, increasing the importance of addressing the culture to avoid this reaction (Cochrane, 1992). Readiness counteracts the natural instinct of the agency to reject new ideas. But, as highlighted by many scholars, a need exists to work on the readiness of the organization and the system at large (see Fixsen et al., 2005; Greenhalgh, Robert, MacFarlane, Bate, & Kyriakidou, 2004; Simpson, 2002; Taxman, Shepardson, & Byrne, 2004). Previous TT models underscore that management and staff must be involved in the EBP implementation process, and that work teams should include a mix of different types of staff to ensure that the change fits within the organization and the system. The work (change) teams provide a forum to discuss existing practice, review evidence-based literature, consider adaptations in the environment, and shape the implementation to fit the environment. Empowerment is one key principle underscoring the process – empowerment provides the framework for the organization, at its various levels and agencies, to consider how this innovation will impact operations, and the steps that must be changed to alter the process. By extending the work team to include members of the outer setting, it is possible to focus on the backing from stakeholder groups. Traditional “top down” or bottom up approaches have been replaced by a hybrid model that engages the whole organization and system partners in deliberative efforts to work towards organizing change with an emphasis on sustained change. In essence, traditional methods should be replaced by an organizational strategy consisting of a series of steps that: (1) build knowledge and efficacy; (2) analyze existing processes and design alignment between the organizational processes and the innovation(s); (3) try, adjust, and refine to align into the organization; (4) maintain the core principles and ingredients of the EBP to ensure that there is little decay from the original design; and, (5) use the change team to continue to adjust, assess for fidelity, and adjust to continue to make improvements in organizational processes.

9.2.1

Creating a Culture of Change: Techniques and Strategies

Underscoring the implementation process is organization and stakeholder involvements that are designed to facilitate change. The concept of a learning environment is one where the goal is to test out new ideas. Creating an organizational culture of learning is considered fundamental to sustainability of new ideas.

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Learning Collaborative. The Learning Collaborative Model used in the NIATx projects helps to facilitate a “culture of process improvement” (McCarty et al., 2007). Many practitioners within or across jurisdictions are tackling similar issues, and can benefit from systematic contacts and exchange of information. The learning collaborative model suggests the importance of sharing innovative ideas among members, and including strategies such as learning sessions, webinar or live trainings, interest circles, coaching, and weekly/monthly electronic newsletters. The learning collaborative can provide motivation for staff to grow and learn new skills and strategies, build common ground across agencies, and improve communication and systems integration efforts. This model draws from and has some parallels to the Plan-Do-Study-Act or NIATx process improvement approaches described in Chaps. 3–5. In the Institute for Healthcare Improvement model, these collaboratives are short-term (6- to 15-month) projects bringing together teams from different health care settings to work on focused health care improvements (Institute for Healthcare Improvement, 2003). Each organization may contribute several staff that participates in several face-to-face learning sessions over a period of 6–8 months, and other staff work on process improvement initiatives within their own organization. The Learning Collaboratives typically focus on specific goals; are client services (e.g., reducing waiting times, improving treatment outcomes), organizational efficiency (e.g., reducing costs), or staff productivity (e.g., reducing absenteeism). The learning sessions may involve expert consultants who help staff develop strategies for making their improvements and attendees share their progress with the other members. Between sessions, the teams work on implementing the strategies and procedures they have learned, gathering and analyzing data to monitor their improvements (similar to the Plan-Do-Study-Act or NIATx Rapid Cycle testing). At the end of the collaborative the teams disseminate their model through the organization. The advantages of creating these learning teams are: (1) building a highfunctioning team; (2) cultivating leadership support and involvement; (3) tracking data and mapping the process from the patient’s perspective; (4) opening lines of communication; and (5) using the expertise of coaches and program leaders. Learning Collaboratives can play a role in gathering information about EBPs, conducting needs assessments, doing pilot tests to examine the fit of the EBP to their organization’s target population and resources, and setting up procedures to monitor implementation of the EBP and its outcomes. Community of Practice. Another technique is to create a “community of practice” or “groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly” (Wenger, 2006). This approach builds on collective learning strategies. In the context of improving the identification of EBP, increasing organizational capacity to implement EBP, and generally improving the implementation process, a community of practice could be formed across agencies (and perhaps involving community representatives and policymakers)

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committed to identifying, adopting, and implementing the most appropriate EBPs. It is important that members of a community of practice share common goals and areas of interest. It is more informal than a workgroup or task force (National Center for the Dissemination of Disability Research, 2005). The community of practice model is an active learning process. Members do more than attend a webinar or read the same training materials; it is not necessary that they work for the same organization. They share resources and information and interact on a continuing basis. Some of the specific activities might involve sharing frequently asked questions, combining staff activities across units or agencies, documenting and sharing strategies to solve problems, sharing program information, visiting different programs, and sharing expertise. In the process, everyone is involved in learning, sharing, and creating. The shared experiences allows the systems to grow together as well as develop a sense of collective efficacy (Wenger, McDermott, & Snyder, 2002).

9.2.2

Strategies to Build a Broad Base of Support: The Example of Social Marketing

Social marketing in public health is the application of commercial marketing methods to encourage health promotion behaviors among consumers (e.g., youth antidrinking campaigns, antismoking campaigns). Recent efforts have expanded to include public health practitioners and policymakers to enact policies and practices that utilize evidence-based principles (Grier & Bryant, 2005). The approach adopts private sector marketing principles to influence the adoption of a new behavior. Critical elements of public health social marketing include exchange, competition, audience segmentation, promotion, consumer orientation, continuous monitoring, and marketing mix (Grier & Bryant, 2005; Kotler & Andreasen, 1996; Kotler & Zaltman, 1971). Exchange refers to the notion that for a given health-related behavior (or policy) to be adopted, the consumer (or policymaker) must derive a discernible and meaningful benefit that at least equals the price (real or perceived) of adoption. Exchange theory indicates that in order for social marketing to be successful, the benefits of the new behavior must be at least equal to the benefits associated with the extant (competing) behavior. Similarly, the costs associated with adopting the new behavior cannot exceed the costs associated with the extant behavior. The more favorable the benefit/cost ratio for the target behavior, the greater the likelihood it will be adopted. The costs of a new policy may not just be economic; there may be political costs to be weighed, for example, for expanding treatment access and costs to an administrator if staff is not happy about adopting a new EBP. Thus an assessment of the perceived costs (appearing to be soft on crime) vs. benefits (public safety is enhanced by implementing evidence-based addiction treatment) can be important.

9.2

Setting the Stage for Implementation: Core Components to Manage the Process

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Social marketing efforts must also be aware of and account for other behaviors (or policies) that present competition for those that are being promoted and have a strategy for responding to that competition. In the context of marketing increased use of EBP in addiction treatment, the competition might include other types of treatment or traditional public safety oriented supervision. Audience segmentation refers to the process of identifying distinct subsets of the population to be targeted by the social marketing message and tailoring specific messages as needed to each segment. Such audience segmentation is critical for effectively influencing the target audience. For example, different social marketing strategies might target addiction treatment directors, probation supervisors, judges, and line staff. Promotion is perhaps the most visible element of social marketing. It is the delivery of persuasive messages to the target audience aimed at influencing adoption of the targeted behavior or policy. This requires the use of the media that shows the greatest promise for getting the message out to the audience (e.g., distribution of written documents or promotional DVDs vs. Direct Marketing Approaches that involve more one-on-one interaction of the messenger with the audience). Marketing activities directed to policymakers and practitioners range from training, community based activities, networking, face-to-face meetings between members of the target audience and opinion leaders who can influence thinking. Consumer orientation refers to the importance of thoroughly researching and understanding the wants and needs of the consumer as well as their perceptions of the behavior or product being promoted and sources of resistance. This research should be directed at determining extant knowledge, attitudes and intentions related to/ associated with the target behavior. This includes identifying and understanding the perceived costs and benefits associated with maintaining current practices relative to the adoption of a new target behavior. Formative research (using semi-structured interviews and focus groups) can identify barriers to implementation, and help inform the marketing messages and marketing plan to enable stratification of the target audience, ideally into those that are amenable/not amenable to adopting the new behavior, and then specifically tailoring messages for each segment related to this marketing research. Continuous monitoring is essentially the quality control aspect of public health social marketing. Successful social marketing requires on-going monitoring of the target audience to judge the impact of the marketing campaign. For example, periodic focus groups with members of the target audience can gauge the extent to which the message is being received and attended to by the audience, their reactions to the messages, as well as insights on how to tweak the message to improve impact. The complexity of the community corrections and addiction treatment systems presents interesting opportunities to use social marketing strategies for improving dissemination and implementation of EBP. Clearly there are wide ranges of interest in and knowledge about EBP across stakeholder groups.

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Techniques to Manage the Change Process

A critical proximal outcome from the TT process is to create a strategy regarding empowerment of the organization to address quality and outcomes. The following components are part of organizational strategies that can be used to manage the change process. 1. Executive leadership: support the change process and provide needed resources. 2. Staff efforts: design and implement change to integrate into the business process as well as to alter the process to improve outcomes. 3. Change teams: cross-section (vertical slice) of the organization that can learn, apply, assess, redefine, and, reinvent to integrate the EBP into the business process. 4. Project management activities: key task driven efforts to outline major tasks, to assign responsibility, to measure progress and outcomes, and to identify the steps in the process to keep the momentum going. 5. Facilitators: guide the change process including external facilitators which keep the change process focused (Kauth et al., 2010) and internal facilitators that are devoted to the process. 6. Clear performance goals and measures: identify quantifiable expectations that provide objective feedback to the organization about each stage of the implementation process in terms of attaining the goals, and the impact on the work processes. 7. External Partners and Stakeholders: garner support within the organization and provide needed resources to ensure long-term success.

9.3.1

Executive Leadership

Change requires a commitment by the organization and support from leadership to both the new innovation(s) and crafting of the process of change. To implement EBP, executives must recognize the full range of change that is needed throughout the organization to support the innovation including removing of existing processes that interfere with or contradict EBP (Box 9.5). That is, executives must be willing to rid the organization of paperwork, requirements (regulatory or otherwise), and bureaucratic or organizational structures that interfere with new innovation. The executives should focus on enhancing both internal and external capabilities to increase the organization’s ability to adopt EBP. In particular, executives should extend their effort to engage external stakeholders to ensure that they understand the reason for the innovation, how the change process can improve outcomes and performance, how the change process benefits the stakeholders, how the stakeholder can support the change process, and how the external support can augment internal changes. The executive needs to foster growth in both the internal processes as well as external partnerships. Support from the executive leadership is important, including the highest levels of the federal government and/or state government. This provides reassurance at the local

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Techniques to Manage the Change Process

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Box 9.5 Executive Leadership needs to: • Reframe agency goals and mission to reflect the importance of the organization’s commitment to change • Identify policies, procedures, and resources relevant to the change process • Provide direction and support for the agency through the various change processes • Garner support from external partners for the change process by building knowledge, support, and integrating involvement with internal change teams

level to sheriffs, probation chiefs, treatment managers, administrators and others involved in the daily business of community corrections and addiction treatment to understand that EBP implementation is valued. In a survey of corrections administrators, states that showed strong leadership regarding EBP appear to influence the decisions of managers in various levels, including organizations that do not directly report to the administrator (e.g., the state Department of Correction administrator has influence over a local sheriff that runs the jail). When strong state leadership on EBP is evident, the actions and decisions of local administrators, who report to local government are more supportive of implementing EBPs (Young, Farrell, Henderson, & Taxman, 2009).

9.3.2

Staff

Any change in practice requires mid-level supervisors and line staff to: (1) understand the rationale for change, (2) acknowledge that operations can be improved; and (3) design and inculcate change into daily practice. The staff must be engaged in the change process to achieve these three goals. As discussed in Chap. 4, traditional methods of informing staff of an EBP/change (an example of the “top–down” approach) are much less effective than engagement strategies where the staff is part of the process of crafting the change (Greenhalgh et al., 2004; Taxman, Henderson, Young, & Farrell, 2010). The latter allows the staff to obtain ownership and investment in change as well as tailor the EBP components to the environment or existing business process. That is, every office has a different process for handling typical business activities (e.g., intake, appointments, report days, sanctions, supervision meetings, treatment referral) as well as supporting socio-political factors that affect this work. The staff is in the best position to craft procedures that are responsive to the demands associated with EBP, as the local practices are revised to accommodate EBP. An important rule of thumb is that staff and supervisors should be empowered to recommend and guide work processes to incorporate the EBP. This includes inventing new processes and eradicating outdated ones that do not add value.

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Conceptual Model: Evidence Based Interagency Implementation Model

Facilitators of the Change Process

Change involves a facilitator to manage the process and maintain the momentum. This person needs to understand the organization’s policies, procedures, and practices and be able to answer key questions about how to translate EBP into actions. A recent randomized controlled trial supports the use of external facilitators for the change process to manage tasks and deadlines, draft new policies or procedures, and monitor incremental progress. Having a facilitator improves the attention to change oriented tasks; groups without a facilitator made less progress (Kauth et al., 2010). The advantage of the external facilitator is that the person does not have other day-to-day operational responsibilities for the agency. Internal facilitators are needed to be change agents and opinion leaders that work inside the organization to ready the environment (Rogers, 2003). The characteristics of good facilitators are: intimate understanding of the EBP literature and studies, ability to help understand how to translate evidence into work processes, and skills to guide the executive and staff through implementation steps (Fixsen et al., 2005; Kauth et al., 2010). Careful attention should be given to the skills of facilitators because they need to have insight into the needs of the organization as well as the ability to allow others to assume ownership for the process. Facilitators must work with others in a productive manner but also allow the organization to take credit for their efforts. In addition, facilitators must handle conflict as well as negotiate and mediate issues regarding differences that are likely to occur among staff and internal groups regarding implementation issues.

9.3.4

Implementation Change Teams Through Cross-Sectional or “Vertical Slice” Working Teams

Change teams are more than work groups. They are charged with the important efforts of: (1) readying the organization for change, and working on knowledge building and foundation setting activities; (2) analyzing the innovation and existing practices (3) designing and implementing new processes; and (4) to some degree, piloting the innovation. The change teams should have responsibility for engaging the organization through the various TT stages – knowledge development through renovation. This makes it more likely the organization will embrace the change and the innovation will be actualized. The most effective work teams involve a cross-section (vertical slice) of the organization (Moore & Safford, 2004), and consist of three parts: the old guard that serves to protect existing practices, the staff who are excited by the new prospects, and those that are assigned to the project. A mix of staff and managers working together develops cohesion, furthers an understanding of the goals and purpose, and crafts the EBP to ensure that the EBP both maintains the core components and is aligned to the environment. Extending the change team to include external partners serves to reap support from

9.3

Techniques to Manage the Change Process

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the outer setting. In addiction treatment, change teams may sometimes include clients to ensure that the voice and perspective are included. Often former clients (“customer”) can assist others in examining how to improve the process based on an “insiders view.”

9.3.5

Stakeholders

Criminal justice policy and practice is a multidimensional effort where decisions often require involvement of multiple agencies. These agencies provide backing or external concurrence for the changes. One example is the parole decision where the parole board determines the release decision and defines the conditions of release. The parole agency is responsible for monitoring the offender’s compliance with the conditions of release including controlling behavior, linking with treatment providers to obtain the services required to fulfill release conditions, monitoring fines and fees, and other conditions of release. In the criminal justice system, collaborating agencies include law enforcement, prosecutors, defenders, service providers, educators, and community stakeholders. These agencies are often involved in many aspects, and can become critical in advancing the change process. Community corrections agencies need to engage these organizations during the change process to ensure that sufficient support is provided by external agencies. For example, if a corrections agency is interested in operating a therapeutic community then the community and other agencies can provide support for the treatment programs. Many strategies are available to keep the stakeholders engaged including: (1) informing them of the change; (2) involving the agencies in the crafting of the change; (3) working on integrated policies and procedures that fulfill the change process; and, (4) modifying laws, regulations, or other policy initiatives that impact the operations of the corrections agency. At a minimum the change team should keep external partners informed of the progress. This can be done through existing interagency organizations on a routine basis (e.g., Criminal Justice Commission, Community Corrections Acts) or through special meetings.

9.3.6

Project Management Activities

Within complex organizations, the challenges of daily activities often interfere with change processes. Change requires management of the process that includes identifying key tasks, steps to be taken to fulfill each task, and measurable performance at each step. Good project management underscores the change process by providing a task management structure that allows each step to be documented, described and assessed. This is where external facilitators can be important since they tend to assume more responsibility for managing tasks; while internal staff has a bit more difficulty given their other responsibilities within the organization. The importance of a project management approach cannot be understated; the nature of

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Box 9.6 Key Tasks to Manage for Work Teams • • • • • •

Tasks to Complete Clear measurement of the impact of each task Work on building support within the team Informing management of the progress Ensuring that the team identifies the “get rid of” list Works with management to obtain results

planned change is that there is a need to identify the deliberative steps for work teams to define, develop, implement, and refine efforts (see Box 9.6). Project management activities need to set time-task plans, allow the teams to monitor and measure their accomplishments, and identify the steps in the process to keep the momentum going. The external facilitator is usually responsible for guiding the time-task plan.

9.3.7

Clear Performance Goals and Measures Provide Objective Feedback on Progress

Performance measures are important as a tool to specify expectations, assess progress, provide feedback, and illustrate success – all components that Rogers (2003) identifies as crucial to assess and value the innovation. The performance measures provide an avenue to determine the factors that affect the desired goals and objectives, provide feedback, and to advance implementation. Major initiatives in criminal justice reform have been guided by performance measures including the COMPuter STATistics (COMPSTAT) approach in law enforcement (Weisburd, Mastrofski, McNally, Greenspan, & Willis, 2003) and a modified version for correctional agencies (Gelb, 2006; Gelb & Burrell, 2007). The NIATx and Washington Circle models have identified performance measures for treatment systems that focus on stages in the treatment process such as initiation, engagement, and retention (Garnick et al., 2007; Hoffman, Ford, Choi, Gustafson, & McCarty, 2008; McCarty et al., 2007). These are helpful because they provide a standardized approach to measure progress, and can be used to ascertain whether the innovation has a marked improvement (see Table 9.4 for benchmarks for the NIC EBP and Table 9.6 for Washington Circle measures). As previously discussed in Chap. 2, the Delaware performance contracting system for substance abuse treatment providers used performance measures to determine progress including active participation in treatment based on a minimum number of counseling sessions attended and program retention (defined as active participation in treatment for at least 60 days, achievement of major treatment plan

9.4

Conclusion

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Table 9.6 Examples of key performance measures in substance abuse treatment based on the Washington Circle Initiation

% clients who have start outpatient services in the previous 60 days and received a second meeting within 14 days after the first service Engagement % clients initiating treatment who received two additional services within 30 days of initiation Continuity of care % of clients with an additional 14 days of services in different levels (detoxification, residential, etc.) Initiation (from first request) Time from first request for services until first treatment session Retention % clients receiving four sessions within 30 days of first treatment Sources: Garnick et al. (2007); see http://www.washingtoncircle.org/pdfs/pp_3.pdf

goals, and a minimum of four consecutive clean weekly urine samples) (McLellan, Kemp, Brooks, & Carise, 2008). As demonstrated in the Delaware model, such a focus on performance benchmarks can improve treatment outcomes including serving more clients (McLellan et al., 2008).

9.4

Conclusion

Community corrections agencies are unlike other human service organizations. Of course, because they are affiliated and part of the punishment (justice) system, there is some debate about whether they are human service organizations. The difference is typically seen in the goals of the community corrections agency where offender change is secondary to public safety. But another major difference lies in the interdependence among justice organizations in which community corrections is influenced by practices of the judiciary (e.g., conditions of release, type of offenders placed on supervision), the jail (e.g., type of programs offered, when a person is released), and the prosecutor (e.g., eligibility for diversion programs). Recognizing the interdependence of community corrections organizations on other agencies, places a higher burden and demand on any TT model that integrates inner and outer setting issues as part of the transfer process. The heuristic EB-IIM attends to the interdependence issues as part of the TT process as well as recognizing the capacity building needs in community corrections and addiction treatment. The first step in the model – knowledge building – is a recognition of a major deficit confronting the organization: there is a greater need to create an organizational learning culture and this can be done best by infusing knowledge building steps into the organization. As discussed in Chap. 6, informed community corrections leaders recognize that line staff and managers in their organizations may not have access to the latest scientific findings on human behavior. Therefore more attention is needed to developing and nurturing a continuous learning environment.

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The model also expands the concept of a pilot phase to include demonstrating the value and support for sustainability of an EBP. In prior models, the goals of the pilot were less clear and were often subsumed under early stage development. But here we recognize that the pilot is a turning point where the organization can build momentum for sustained change. The pilot can become the focal point for the transfer process by identifying the existing policies and procedures that require elimination or change for the innovation to be fully implemented. Finally the ribbons that tie the stakeholders and organizations together illustrate pivotal efforts to build sustainability. In the justice environment, long-term stability and sustainability requires the support of the system of interconnected agencies at large. Without the system support, it is unlikely that an innovation can be sustained. Attention to specific issues related to the intervention, clear goals and mission, interagency workgroups, public messages, and resource allocation are critical to the success of the effort. Leaders need to contemplate these crucial efforts that bind organizations together. A focus on clarifying the mission and goals as well as resources can be considered facilitators of the change process. This EB-IIM also recognizes the value and importance of facilitating change through addressing the organizational culture (both inner and outer settings) and the structure of the change process. To achieve sustainability, a renewed focus is needed to create stakeholder and constituency support, both internal and external to the key organization. Learning collaboratives and communities of practices are two mechanisms available to address culture issues. Building greater appreciation and enthusiasm for the initiative can be achieved through social marketing efforts, promotional campaigns, training sessions and workshops, and other tools that are focused on the message. Finally, as highlighted in Rogers (2003) and discussed extensively in the organizational change literature, the change process should have a structure that is visible, active (and actively disseminating messages), and measurable. An important component is to help others learn from the pilot or early experiences. This includes building change agents, champions, and advocates within and across the various agencies that participate in the work teams. Managing change is important. A favored tool which seeks to galvanize support is the collection and monitoring of benchmarks – frequent reporting of key milestones and outcomes provides visibility and tells the story about how implementation is proceeding. Correctional administrators can use the EB-IIM to guide their own efforts to implement EBP. The stages of this model can be used to assess an agency’s current strategies as well as to identify the recommended tools for change. This model is sensitive to the sometimes checkered history of adopting treatments and innovations in justice settings, and it addresses issues within both internal and external settings. More importantly, the model provides criteria by which corrections administrators can determine whether they are advancing in their own practices. The value of a heuristic model is in its flexibility to allow others to consider the challenges faced in achieving successful EBP implementation to improve practice and outcomes.

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Chapter 10

Evidence-Based Implementation Agenda

Why are evidence-based practices and treatment so critical to public policy in general and to the fields of community corrections and addiction treatment in particular? The evidence-based practices movement provides a rational framework for identifying practices and treatments that are effective in producing changes in difficult behaviors such as drug use and criminal conduct. The EBP movement, therefore, provides the tools and methods to assess the ability of existing policies, programs, and services to achieve desired outcomes. We are emerging from a 30-year experiment with punitive policies that emphasize incarceration as the main tool to deal with substance abusers. Within the incarceration-based policy framework there is a growing recognition that incarceration has not produced the desired deterrence results and, instead, has utilized scarce public dollars that have only exacerbated the problems, with unintended consequences. In 2006, the Pew Center on the States launched a Public Safety Performance Project “to help states advance fiscally sound, data-driven policies and practices in sentencing and corrections that protect public safety, hold offenders accountable and control corrections costs” (http://www. pewcenteronthestates.org/initiatives_detail.aspx?initiativesID=31336). Some states are starting to examine options, including pursuing policies to reduce costs through early release from prison to drug-treatment programs, to alter sentencing options to expand community corrections, and to create more alternatives to incarceration even during a period of economic recession. A Right on Crime (http://www.rightoncrime.com) movement, championed by conservatives, has embraced these EBP strategies given the fiscal and psychological costs of incarceration to our society, as well as the failure of punitive policies to prevent crime and reduce recidivism. The time is ripe for new policies. But the reality is that this places tremendous demands on the community corrections system to produce better outcomes (i.e., reduced recidivism), while protecting public safety. The stakes are high – if this current experiment to rely on community corrections and addiction treatment fails to deliver better outcomes, then the tide can easily return to punitive policies. It is imperative that the new policies should adequately punish and treat the offender. More effective implementation of EBP is an important part of the insurance package to ensure that this current experiment succeeds. F.S. Taxman and S. Belenko, Implementing Evidence-Based Practices in Community Corrections and Addiction Treatment, Springer Series on Evidence-Based Crime Policy, DOI 10.1007/978-1-4614-0412-5_10, © Springer Science+Business Media, LLC 2012

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The boom in evidence-based programs and practices available for community corrections agencies has great potential for improving outcomes for drug-involved offenders – the use of science-based strategies, practices, or treatments should provide agencies with interventions and practices that work to reduce recidivism and relapse. That is, we have the evidence that these interventions and practices reduce recidivism in tightly controlled studies. The challenges do not occur with identifying EBP or what works; as we have shown, there is an existing and welldocumented process involving systematic reviews, meta-analyses, and replication of RCTs. The real work is in implementing and sustaining the beneficial effects of evidence-based practices in real world settings. What are the real challenges to the community corrections and addiction treatment fields in terms of implementation and sustainability? The what works (i.e., evidencebased practices) movement has led to the development of standards, techniques, and repositories for identifying EBP, and a number of efforts have been made to promote the use of such practices (see Chaps. 2, 5, and 6). Throughout this book, we have shown that to achieve broader adoption and implementation of EBP, a better understanding is needed of the theoretical mechanisms and organizational components of the various facets of implementation (see Chaps. 3 and 4). The multiple and overlapping factors that affect organizational capacity to implement innovations are becoming clearer from theory and research. Coupled with the specific nuances of the community corrections and addiction treatment fields (see Chap. 7), which provide additional barriers to implementing and sustaining new practices, it should not be surprising that evidence-based addiction treatment has not been widely adopted in community corrections. As we consider implementation and organizational change theory and research, with a dose of the reality of policy and practice in community corrections and addiction treatment, it becomes clear that expanded use of EBP is very much needed and possible. The demands are in assisting organizations to alter their practices to accommodate the EBP. In this final chapter, we propose an agenda for moving research, practice, and policy in new directions to achieve the goal of improving uptake of EBP across community corrections and addiction treatment agencies. Before we detail this plan, we need to envision three typical scenarios that can occur from the translation of scientific findings to public health and public safety applications. Scientific findings identify the interventions or practices that should be effective (or ineffective). The challenge is in the choices that community corrections or addiction treatment agencies have where the options are generally to: 1. review and modify their practices to accommodate the scientific findings. 2. use the scientific findings to redefine the purpose of the agency. The new purpose aligns with the study’s outcomes. 3. acknowledge the findings but continue to use their same practices. They desire to wait till the next study to determine which path to pursue and continue using practices that are inconsistent with what works research. In the best of all worlds, the first scenario underlies the ideal evidence-based policy approach where EBP knowledge is used to improve practices and interventions. But, scenarios 2 (redefine the goals of the organization) and 3 (ignore the evidence) are plausible. Recent history has shown many examples where scientific

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findings were not considered, not used, or misused. The heuristic models presented in this book – Evidence Mapping for Organizational Fit and Evidence-Based Interagency Implementation – commingle the identification of EBP with greater attention to the intervention and implementation factors that will galvanize the organization and stakeholders to identify, select, and use the appropriate EBP while also serving to address socio-political issues in the implementation process. The effort is to lay a foundation where science can be more easily transitioned into practice. The Evidence-Mapping (see Chap. 8) and Interagency Implementation (see Chap. 9) models featured in this book are designed to shift away from the singular focus on individual (client/offender) level outcomes with more attention to the context in which EBP interventions or innovations can thrive and be utilized. We use examples from community corrections and addiction treatment EBP research to illustrate these points. One example is where the mission and goals of community supervision have evolved as a result of extensive research: Intensive Supervision Programs (ISPs). Petersilia and Turner (1993) conduced the largest criminal justice experiment in community corrections to date, a 15-site study (13 probation and 2 parole agencies) of intensive supervision. The experiment was based on the hypothesis that more face-to-face contacts between the offender and supervision officer, coupled with drug testing, will reduce new arrests. ISPs offer more control over an offender with more information about the offender’s compliance with conditions. The study revealed that intensive supervision: (1) did not increase the average number of contacts between the officer and probationer; (2) increased the frequency of drug testing; (3) increased the detection of technical violations for those being observed more frequently; and (4) had no impact on arrests for new criminal behavior (Box 10.1). Other ISP studies analyzing caseload size and face-to-face contacts have had similar (null) findings (Taxman, 2002). And the current consensus in the metaanalysis literature is that control-based ISPs (i.e., the increased use of monitoring

Box 10.1 The Impact on Research, Policy, and Science from the Largest Randomized Controlled Trial on Intensive Supervision Petersilia and Turner’s (1993) 15-site study of intensive supervision was based on the hypothesis that more face-to-face contacts between the offender and supervision officer will improve offender outcomes. Significance: The significance of this large RCT generated a great debate about the role of community corrections, a debate that persists today. The debate includes three points: 1. Declare ISP as ineffective because face-to-face contacts do not affect recidivism. 2. Declare ISP as effective because face-to-face contacts serve a public safety and enforcement purpose to identify technical violators. 3. Declare ISP as the only tool available even if science does not support the findings. Wait for the next study to determine whether ISP really “works.” (continued)

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Box 10.1 (continued) Response: Point 2 prevailed because it championed ISP. Community corrections agencies detected more technical violators and therefore were able to restate the value of ISP as a core tool of public safety agencies. Agencies did not focus on recidivism reduction role. Rather the public safety role was emphasized. Evolution of New ISP Models: Over the next decade, researchers focused on trying to assess ISP-type models under different theoretical frameworks: 1. Control ISPs focused more on liberty restrictions that had no impact on outcomes but increased technical violations (Aos et al., 2006; Byrne & Kelly, 1989; MacKenzie, 2006). 2. Referral to services and increased face-to-face contacts had some impact but results were inconsistent across study sites (Petersilia & Turner, 1996; Gendreau, Cullen, & Bonta, 1994). 3. EBP-based models incorporating assessment, case planning, appropriate services, and sanctions tend to have some impact but results again vary across study sites (Clawson, 2006; Jalbert, Rhodes, Flygare, & Kane, 2010; Taxman, 2002). 4. An integrated EBP model of supervision in collaboration with treatment providers that focuses on using incentives had some impact in some study sites (Friedmann et al., 2009). Lacking in these ISP models is the integration of evidence-based treatments as a core component of supervision (Taxman, 2011), partially due to the silos that exist between the EBP community corrections and addiction treatment literature. Different Implementation Approaches. Good implementation studies were not conducted in the studies that had promising outcomes. However, researchers and practitioners documented the process for implementing the Maryland Proactive Community Supervision project (Taxman, 2002, 2008; Taxman, Shepardson, & Byrne, 2004); the Travis County Impact Supervision Initiative (http://www.co.travis.tx.us/community_supervision/tcis_initiative.asp), and the Collaborative Behavioral Management study on incentives (Friedmann et al., 2009). They are the beginning of efforts to conceptualize new methods to implement change in community corrections agencies.

strategies such as face-to-face contacts) does not change offender behavior (Aos, Miller, & Drake, 2006; MacKenzie, 2006; Taxman, 2002). Yet today, control-based intensive supervision programs persists as one of the main community corrections models (Taxman, Perdoni, & Harrison, 2007). Shortly after the Petersilia and Turner (1993) study was released, the community corrections field largely concluded that ISPs were an important tool. ISPs allowed probation/parole agencies to identify offenders that either were increased risks to

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the community or did not comply with conditions of release and to label them as a public safety risk. This is an example of agencies redefining their goal(s) to justify their practices. In fact, this restatement fueled an increase in technical violations whereby nearly one-third of prison admissions are now from technical violators, not convictions for new crimes (West & Sabol, 2010). As shown in Box 10.1, the controversy challenged scientists to begin to test new models, including models adapted from addiction treatment. These models have evolved into evidence-based supervision. ISP can thus have many new shapes (theoretical frameworks) with varying degrees of evidence to support their effectiveness. But, from an implementation perspective, we know very little about how to implement EBP in ISP programming. Future work is needed in understanding how to implement evidence-based supervision. Another example is contingency management (CM), a major EBP in addiction treatment which has a strong research base of multiple RCTs in various community treatment settings. CM is included as a best practice in NIDA’s Principles of Effective Drug Treatment (NIDA, 2009), is listed in the NREPP EBP repository, and has been found to have beneficial impacts on drug relapse and treatment attendance (Stitzer, Petry, & Peirce, 2010). Tests of the efficacy and effectiveness of CM have primarily been conducted in research-based, controlled settings with various types of drug users (Petry, Alessi, Marx, Austin, & Tardif, 2005; Stitzer & Petry, 2006), and in conjunction with other types of therapies such as cognitive behavioral therapy (Budney, Moore, Rocha, & Higgins, 2006) or vocational workshops (DeFulio, Donlin, Wong, & Silverman, 2009). In the majority of RCTs, research assistants delivered the protocol. A key question that flows from this body of research is whether CM can work in community corrections settings: can it be implemented with fidelity (including the important intervention component of maintaining the schedule of reinforcement and appropriate contingencies), will the rewards work with offenders under probation or parole supervision, and will the impact last throughout the offenders time under correctional supervision? None of these questions has been answered by the research thus far; the J-STEP (Justice STEPS) study that currently is being conducted is examining these issues in re-entry courts, with probation officers, and at re-entry centers for offenders under supervision (Taxman, Rudes, et al., 2010). In the one RCT on the impact of CM in a treatment center serving drug court clients, it was seen that CM had no impact on treatment retention, drug use, or psychosocial functioning compared with the standard drug court treatment protocol (Prendergast, Hall, Roll, & Warda, 2008). Thus, despite a relatively large evidence base, and wide acceptance that CM is an EBP, the key questions raised about transportability in justice and corrections settings have not been answered. Do community corrections and its partner addiction treatment providers have the organizational capacity to implement this EBP? Is CM an EBP that can fit well into a multistage implementation process such as that framed in the Evidence-Based Interagency Implementation Model? There is a long history in community corrections in which new ideas have resulted in the same program with a new name (Martinson, 1974; Taxman, 2011),

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or in which community corrections agencies continue to pursue punishment goals as the main focus of supervision. To line staff, agencies, and the public, this only serves to increase skepticism about the value of innovations or using EBP. The same is true in addictions treatment where the demand exists for new effective programs, including medications, but the agencies and staff do not always support the advancements (Knudsen, Ducharme, Roman, & Link, 2005; Knudsen & Roman, 2002). The current attention to the issues of intervention design and fidelity, as well as implementation, is a step forward for promoting use of EBP. Given the contexts of correctional and addiction treatment settings, EBP are only relevant if the existing practices and interventions are altered to be compatible with the science. What needs to be done to increase the focus on effective implementation approaches? This book has addressed the question of what remains to be done after the identification of an EBP and its designation and promotion in an EBP repository: what comes next in terms of taking the EBP off the shelf and installing it in the field? Scientists and practitioners typically heed insufficient attention to: (1) the nature and effective components of the EBP (Collins, Dziak, & Li, 2009; Michie, Fixsen, Grimshaw, & Eccles, 2010) and (2) the components and process of implementation (Fixsen, Naoom, Blase, Friedman, & Wallace, 2005; Proctor et al., 2009). Without more attention to the nuts and bolts of interventions and implementation, we will continue to constrain efforts to translate science into practice, especially at the intersection of public safety and public health. Absent effective and evidencebased dissemination, diffusion and implementation strategies or interventions, community corrections agencies will continue to rely mainly on the punishment-only toolkit. The Institute of Medicine recognized this problem in their 1996 Bridging the Gap report on addiction treatment, but community corrections has not benefited from similar efforts to study and understand how to determine which effective intervention can be transported and implemented to achieve desired and expected outcomes. The budding growth of new sciences devoted to behavioral interventions (Abraham & Michie, 2008; Czajkowski, 2011; Schulz, Czaja, McKay, Ory, & Belle, 2010) and implementation (Fixsen et al., 2005; Proctor et al., 2009) are focused on better appreciation of the scientific processes. We are emphasizing translational science methods to facilitate the bench to bedside to public safety/health applications for scaling-up EBP into general practice. Embedded in the complementary mapping and implementation models presented in this book are the related issues of how to identify the core principles that make certain evidence-based programs and practices feasible and effective, and how to facilitate and assess implementation when the end goal is sustainable practice. In the remainder of this final chapter, we examine the future directions of implementation to improve the quality of services provided to positively affect offender outcomes. We focus on three main themes: (1) implementation tools; (2) future research needs; and (3) an infrastructure to advance implementation, a Council for Health-Safety EBP. We conclude this chapter by projecting the future of community corrections and addiction treatment in light of a renewed focus on broader and more sustainable implementation of EBP for druginvolved offenders.

10.1

Implementation Tools

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Implementation Tools

Implementation is a comprehensive and complex series of decisions and actions, covering a wide-range of interventions, inner and outer setting factors, and processes. This broad concept refers to various steps or decision points in a process specified in our Evidence-Based Interagency Implementation Model (EB-IIM): develop knowledge, build foundation, set expectations, align, renovate, and sustain. The Evidence Mapping model outlines the issues that should be assessed to determine transportability and organizational capacity that may affect the ability to uptake science-based findings into practice. The term implementation refers to various processes – such as team building, organizational readiness, performance monitoring, EBP translation, coaching, and others – involved in moving from introduction of and initial training on an EBP, to embracing the EBP, to communicating with stakeholders, to adopting the EBP, and all the many other big and small steps that lead to full scale installation and sustaining of the EBP. This book has highlighted the concept of implementation from a number of perspectives. In this section, we provide a structured process for organizations and systems to attend to the details of the implementation process. In the appendices to this chapter, readers will find checklists to facilitate the EBP/innovation adoption and implementation process. These checklists complement the two models proposed in this book, and identify the nuts and bolts that link a specific concept to realization. These tools can also be used to gather pertinent information during the course of implementation to assess progress and focus on key factors related to implementation.

10.1.1

Intervention or Evidence-Based Practice/Treatment

The labeling of an EBP often fails to characterize the precise details of the intervention in a manner that allows others to replicate it. For example, the standards for drug courts consists of ten key components that include status hearings with the judge, prompt placement in drug treatment, a nonadversarial approach that promotes both public safety and public health, sanctions and incentives, and drug testing (Office of Justice Programs, 2004). But each component is not well described, and may be defined differently from one drug court to another (Hiller et al., 2010). What is the optimal sequence and severity of sanctions for promoting compliance with drug court requirements? Should status hearings be held once a week, twice a week, or at what frequency? Marlowe, Festinger, Lee, Dugosh, and Benasutti (2006) conducted an RCT to assess the frequency of status hearings on positive offender outcomes. They found no differences in offender outcomes (positive drug test rates or arrests) between ad hoc status hearings (no set schedules) and weekly status hearings. But, quasi-experimental analyses found that routine status hearings were more effective for higher risk offenders (Marlowe et al., 2006). Other key questions relate to the delivery of drug treatment in drug courts. Which modality of drug treatment works best for drug court participants? What is the optimal frequency of counseling? How should self-help groups be integrated into treatment?

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How long should treatment last? Is cognitive-behavioral therapy an essential component of treatment for drug court participants? Although drug courts tend to refer offenders to treatment available in the community or to programs that are affiliated with the drug court, recent work has found better outcomes when drug treatment programs are dedicated to drug court participants (Taxman & Bouffard, 2005). Yet, there is no specific guidance on the nature and type of drug treatment that works best for drug court clients. The same is true for drug testing, with little research on the frequency of drug testing needed for optimal outcomes. Recent advances in intervention science have promoted the use of taxonomies to describe the core components of an intervention. Although EBP has been the focus of this book, another evolving area of science pertains to developing and testing theoretically driven interventions. Abraham and Michie (2008) and Schulz et al. (2010) propose different models that describe the mechanism of action, the programmatic components, the tools used, the duration and intensity of the program, and the nature and type of staff required to deliver the intervention. That is, instead of merely naming an intervention as a EBP, such as cognitive behavioral therapy, intervention scientists are promoting the need to provide detailed specifications on the EBP in terms of the antecedents or behaviors that the intervention is designed to change, the core techniques (e.g., process groups, self-talk) associated with the mechanisms of action, and desired outcomes. Schulz et al. (2010) identify three dimensions of interventions that can be adaptable: • What can be modified (location, schedule, mode of delivery, content, dosage)? • On what basis is the modification made (needs of target population, clinical judgment, events)? • What is the point(s) where modifications occurred (intake, baseline, and at specific intervals)? Michie et al. (2009) argue that studies should be more precise in describing the nature of the intervention or practice during each phase of the implementation, thereby recognizing that interventions are changed at the design, adoption, implementation, and sustainability phases. It is important to specify what components of an intervention are operational, in order to track how the characteristics of the intervention change over time. Box 10.2 (see also accompanying implementation tool for interventions in Appendix A) borrows from these scientific taxonomies to present issues that need to be considered in the design, assessment, and refinement of the intervention. This list is informed by the need to detail the key components that are operational at each phase. The design of an intervention is generally influenced by the history underlying existing programs and services offered by that agency. Often interventions or EBP are modeled after other existing programs and services. Knowledge of the features of existing programs can be used to inform the new EBP or innovation, as well as to understand how the organization affects the fidelity of the EBP, barriers to implementation, or potential decay factors. The historical experiences relate to concerns raised by Rogers (2003) – trialability, compatibility, complexity, and relative advantage (see discussion in Chap. 3) – in that interventions that are similar to longstanding previous efforts are more likely to be well received in the organization. The intervention description should also include the nature and types of ingredients expected to lead to behavioral change. A generic intervention such as cognitive behavioral

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therapy should be characterized by the various components to demonstrate its unique features, such as motivational enhancement, skills building, recovery management, or communication (Abraham & Michie, 2008; Schulz et al., 2010). The same details are needed for social control interventions such as curfews, electronic monitoring or GPS, drug testing, and other tools that are used to monitor behavior. Dosage and intensity as well as orientation are needed to ensure that sufficient data are available to inform others as to the guiding principles of the intervention. It is expected that the intervention will evolve during the stages of implementation. During the initial phases of Evidence-Based Interagency Implementation (i.e., develop knowledge and build skills/foundation), the organization and partners are learning about similar interventions. During other stages of implementation, such as the align period, the components of the intervention will be modified during the expectation setting and alignment stages of implementation. It is at this stage that one might see a greater need to attend to issues related to the therapeutic or control components as well as changes in the manuals or phases. Finally, during the renovate or sustain phases, it will be important to document the key features of the intervention as it currently exists. Stated simply, the implementation of an intervention’s core components may decay over time, so it is important to examine and document the measures of adherence and fidelity to assess the degree to which the EBP’s core components are intact. Otherwise, the organization needs to reassess the utility of the EBP given how the intervention has matured or decayed.

Box 10.2 Design, Assess, and Refine Interventions (See Appendix A) • Characteristics of the specialists delivering the intervention in terms of job title, degrees, prior experience, and type of funding (i.e., direct, contractual, in-kind). • Characteristics of the agency managing the EBP or the innovation, if different than one delivering the intervention. • Characteristics of the target population for the intervention in terms of age, gender, demographics, problem severity, history of the problem behavior, and involvement in the justice system. These characteristics should be provided for the original sample and for any follow-up samples (to demonstrate differences between original sample and clients not lost due to attrition). • Setting for the intervention including type of office, time of the day, and place of the intervention. • Mode of delivery of the intervention including face-to-face contacts, group (size and nature), use of web-services or internet, use of support systems. • Intensity and duration of the services in terms of number of contact hours per week, number of sessions per week, number of augmented support systems, length of the intervention, and change in frequency of sessions over time. • Mechanism of action or the key component that is designed to bring about change. (continued)

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Box 10.2 (continued) • Adherence or fidelity measures to determine how the intervention is actually delivered. • Manualized curriculum to document the components and sessions of the intervention. • Phases of treatment including supplementary services such as housing, case management, employment, and mental health. • Characteristics of the management information system and benchmarks for the implementation of the intervention.

10.1.2

Inner Setting

This book has focused on the organizational factors that may affect the implementation of a given EBP or innovation. The intraorganizational factors include leadership, staff, mission/goals, capacity, culture, climate, infrastructure (i.e., resources, policies, procedures), and existing processes. These factors help determine what inner setting issues need further attention to accommodate the EBP/innovation. A major question to address is the absorptive capacity or the degree to which the individuals and/or the organization can comprehend and use the EBP or innovation. Box 10.3 is designed to assist organizations in considering factors to address during the Evidence-Based Interagency Implementation Model including dimensions of structure, readiness for change, change climate and organizational learning, performance benchmarks and feedback loops, communication channels, goals, and knowledge and skill development. The first three phases of the implementation process – knowledge development, foundation building, and expectation setting – affect the organization’s readiness for change. Readiness occurs at multiple levels – leadership, managers, supervisors, and staff. The Evidence-Based Interagency Implementation model devotes the early phases to readiness – both in terms of information exchange and skill development – for the purpose of putting the organization into an early learning state. Two solidifying components are communication methods and organizational feedback. Communication is important because it demonstrates that the agency’s leaders and managers are committed to sharing information that typically was not available to staff, an important feature of organizational learning. The information also provides a continuous feedback loop to the organization on progress; it is through this process that expectations can be modulated in order to gather continued support for the EBP. The incubator reports used by the Travis County (Texas) Adult Probation Department in their EBP adaptation process (http://www.co.travis.tx.us/community_supervision/tcis_initiative.asp) were a tool to furnish information, demonstrate progress, and outline next steps. These reports are visible and can be used to generate discussion within the organization and among staff at various levels about progress, barriers, and future steps. Similarly, the reports can be used with external partners to illustrate efforts to

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implement EBP as well as garner support from stakeholders to improve activities. An important feature is the communication channels, including the informal social networks. Feedback loops are important for the formal process of work teams but they also ensure that informal networks receive similar information. The informal networks of an organization are important to ensure that critical information is being provided to these networks to both satisfy their concerns about the organization as well as maximize information sharing. Another key factor is the incentives that the organization can use during the implementation of EBP. In many public sector organizations, the incentives are to identify outdated or unnecessary processes that can be discarded or modified as part of adopting the EBP. In Travis County, as part of their EBP adoption process, a work team identified several forms and procedures that were deemed unnecessary in the implementation process: the agency reduced the paperwork while implementing EBP. Other incentives include notifying staff that the best suggestions will be rewarded by recognizing staff or units that meet benchmarks in EBP implementation such as providing partial or full scholarships to attend conferences to present on EBP, providing administrative leave days, or hosting well-known speakers to support EBP implementation. Some public agencies have used Pay for Performance techniques that are believed to motivate staff and supervisors by providing a reward at the individual staff level and to renegotiate performance norms in an organization (Marsden, 2004). The technique is a visible and observable indicator of top management support that reinforces desirable behaviors. Coiera (2003) has proposed an economic framework for understanding innovation diffusion, arguing that the use of new clinical tools will be low as long as the costs of using them are perceived by staff to outweigh the benefits. This approach suggests that only when the benefit–cost ratio shifts will the EBP be accepted and used. The economic perspective suggests that the organization needs to identify incentives to use the technology: these incentives may be needed to increase the perceived benefits to staff (Klein, Conn, & Sorra, 2001). Even though financial rewards may not be possible, other benefits of using EBP may be to increase job satisfaction and provide opportunities for professional development or advancement (Ash, 1997). At the organizational level, McLellan, Kemp, Brooks, and Carise (2008) recently found that a pay-for-performance system used in outpatient programs in Delaware’s treatment system improved utilization of program slots by nearly 100% and improved patient participation in treatment by over 30%. In other public settings, including those with unions, pay-for-performance models are feasible and useful in improving organizational outcomes (Martin & Groesch, 2005). The incentive system provides a motivator for the agency to use evidence-based treatments to boost client outcomes. In the Evidence-Based Interagency Implementation Model, internal factors are relevant at each phase. Knowledge building, skill development, and expectation setting parts of the model pertain to issues surrounding readiness to change, staff resistance, organizational commitment, and using work teams to solicit input from varied parties. To a large degree, these can contribute to the ability of the organization to increase its absorptive capacity (Knudsen & Roman, 2002). The later phases of alignment, refinement, and sustainability are designed to use the strength of the

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Box 10.3 Inner Setting Factors in the EB Implementation Model (See Appendix B) • EBP fits within the primary and secondary mission and goals of the organization as well as the existing priorities of the organization. • Staff and managers recognize that new knowledge and skills will be needed to implement an EBP; special sessions devoted to building knowledge and skills are made available to staff. • The organizational structure is aligned to the EBP including revisions to the business process where the EBP is going to implemented. • The role of supervisors is redefined to enable them to serve as EBP champions, change agents, and knowledge and skill coaches. • Performance benchmarks are established to reinforce the implementation of EBP or innovations including providing feedback loops and using organizational incentives. • A learning culture is created that allows staff and managers to handle the risks associated with trying new innovations. • Readiness for change in the organization is created by providing leadership support, resources, and access to knowledge. • Multiple communication channels are established to inform, update, and seek feedback from the leadership, supervisors, and staff.

organization to further embed the EBP in routine practice. Box 10.3 lists the inner setting factors critical to implementation, and the corresponding checklist appears in Appendix B.

10.1.3

Outer Setting

The Evidence-Based Interagency Implementation Model recognizes that in the fields of addiction treatment and community corrections, external partners should be heavily engaged in successful TT processes. Both disciplines address marginalized target populations that require costly services, longer duration of care, and additional cycles of treatment. Support is needed at all levels from policy (both legislation and general regulations) to operational procedures to collaborating system features. This can involve all levels of government. A recent study found that local government criminal justice agencies such as sheriffs or jail administrators are influenced by state level policy initiatives that support EBP (Young, Farrell, Henderson, & Taxman, 2009). The external support provides validation that the EBP policies and practices are worthwhile, and that organizations will be supported in their efforts to adopt and implement EBP. While traditional TT models focus on the inner setting, the EvidenceBased Interagency Implementation Model recognizes how integral the outer layer is to implementing intraorganizational practices. Box 10.4 summarizes the critical outer setting factors, and Appendix C provides the related checklist.

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As previously discussed, there are several different models that exist for hosting and engaging external partners in the EBP implementation process: Learning Collaborative and Community of Practice models are the two most common. Another important component is the involvement of researchers or scientists in the process to create a research network (Palinkas et al., 2009; Roman, Abraham, Rothrauff, & Knudsen, 2010; Sullivan et al., 2005). Research networks should be structured to include twoway exchanges of information in which practitioners and clinicians learn about research findings and EBP from researchers, and researchers learn about the needs and challenges in the field and real-world clinical practice. A key advantage is to foster knowledge utilization, provide for social influence and peer norms (Ajzen, 1991; Godin, Bélanger-Gravel, Eccles, & Grimshaw, 2008), expand the role of change leaders (Damschroder et al., 2009), increase access to data-driven performance tools (Knudsen, Abraham, Johnson, & Roman, 2009), and provide access to resources and knowledgeable experts. These are all capacity-building efforts. Both models discussed in this book, evidence mapping and implementation, heavily rely upon creating work teams and groups that have genuine, nonsuperficial responsibilities during all stages of the implementation processes. A unique feature of evidence mapping is that the group, teamed with scientists and clinical experts, should include the external stakeholders in all phases of the process including the discussions about and assessment of scientific rigor, transportability, and capacity. These activities can overlap with the foundation building and expectation setting components of the implementation process. The Evidence Mapping and EvidenceBased Interagency Implementation Models concurrently serve to engage the outer setting in the process to ensure that the system-at-large is supportive of the new practices and interventions and adapt their own practices to accommodate the EBP. As shown in Box 10.4, the checklist activities for the outer setting support adaptation of existing policies and practices, and responsiveness to general needs of the target population.

Box 10.4 Outer Setting Factors in the Evidence-Based Interagency Implementation Model (See Appendix C) • General needs of the target population that are not currently being addressed should be addressed by EBP. • Resources (whether pooled, reallocated, or new) should be identified. • External policies and procedures that support EBP should be drafted and vetted. • Participation in work teams by all external stakeholders is vital. • There must be foundation building and outreach to each agency’s respective communities. • Partners such as researchers must be included to build capacity. • Systemic changes must be emphasized. • Multiple communication channels are established to inform, update, and seek feedback from the leadership, supervisors, staff, and external partners.

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Process: Evidence Mapping and Implementation Models

Chapters 8 and 9 described two processes to build the infrastructure for moving from a scientific bench to bedside (daily practice) process in corrections settings. Throughout these processes, there is a need for agency staff to better understand the research literature; building knowledge will not lead to utilization unless there is a planned change effort such as dealing with organizational norms, reeducating the staff, or reallocating power/authority to support the innovation/EBP. The two models concurrently work through a series of processes devoted to expanding knowledge about EBP, setting expectations about specific gains from using EBP, and aligning or adjusting priorities to emphasize EBP. Further, there is a need to have structures in place to facilitate learning, practicing, refining, and implementing, such as Learning Collaboratives, Communities of Practice, and Interagency Research Networks (see Chap. 9). They each have slightly different goals and objectives but they serve to galvanize people with different interests and skills towards a common goal. As previously discussed, this is critically important in implementing addiction treatment services for offenders given the disparate and conflicting goals within community corrections agencies as well as between the overall public health and public safety systems. Box 10.5 (and the related checklist in Appendix D) identifies key components of the change mechanisms. Change requires attention to the processes to support initiatives surrounding EBP. As noted by Rogers (2003), Fixsen et al. (2005), and Glisson, Dukes, and Green (2006), there is a need to have internal and external partners focused on spreading the message and championing the needed change. In Chap. 9, we discussed the use of social marketing strategies to build collective efficacy around the concepts. But even more important are external facilitators, champions, coaches, opinion leaders, and formally appointed team managers to the process. These are key players needed in both evidence mapping and implementation processes to support the effort. The Evidence-Based Interagency Implementation Model has different components to promote organizational learning. Organizational learning, supported by data or benchmarks, can build resiliency in the organization to withstand setbacks (such as an offender in treatment committing a heinous crime), or changes in political support for community-based treatment programming. Feedback loops at each stage of the process are important to allow individuals, teams, and systems to learn and reflect on the progress. This is modeled after the Plan-Do-Study-Act (PDSA) and other quality improvement models and should be part of each component of the planned change process. Besides organizational learning, attention to performance goals is critical to assess progress and success.

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Box 10.5 Managing the Change Process (Appendix D) • Plan-Do-Study Act Model ensures that there is time to plan, do, act and reflect upon the results, and move forward. • Set up internal change teams to oversee the process. • Make internal and external champions available, including opinion leaders, change agents, social marketers to work on change processes. • Engage systems to garner the resources, support, and commitment for the EBP. • Create benchmarks and performance goals to provide a feedback loop.

10.2

Advancing a Research Agenda on Implementation in Community Corrections Settings

Despite its clear importance for understanding how to improve TT, implementation is a very young science and rigorous research is lacking. Few meta-analyses have been conducted because there are too few experiments and too few rigorous studies. Descriptive analyses and conceptual work have been useful for generating new ideas and identifying research and practice needs, but it is clear that much more work needs to be done. And, at the nexus of community corrections–addiction treatment, the research literature primarily focuses on the efficacy of interventions instead of best practices in implementation. As noted by the practitioners in the field (Chap. 6), there is a need for timely research that can assist practitioners in their efforts to improve practice and understand how to select and effectively implement EBP. If EBP are to be of value then there is a great need to implement them in a manner that will positively improve offender outcomes. In 1974, Martinson identified both the nature of interventions and their implementation as key issues because many correctional programs were indistinguishable from traditional practice. In 2011, with nearly eight million adults under correctional control, interventions and implementation remain key issues, given that EBP for community corrections and addiction treatment have been identified but are not being woven into daily practice. In the past, scientists focused on studies of efficacy and effectiveness of interventions or programs, and concerns about operations (i.e., implementation) were left to practitioners. But a sea change is occurring to support a greater need for action research (Patton, 1987; Rossi, Lipsey, & Freeman, 2004) that merges the research and operations processes. Action research can integrate researcher–practitioner partnerships to advance knowledge on how to move from bench to bedside in a variety of settings. For example, the author Dr. Faye Taxman has had a research–practitioner partnership with the Maryland Department of Public Safety and Correctional Services for the last 20 years, which has been used to develop and test new ideas. These include (1) an expedited case assignment system for misdemeanors in the district court that demonstrated the value of joint prosecutorial and defense screening (Taxman & Elis, 1999);

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(2) a specialized parole/probation-based Break the Cycle initiative that included testing, treatment and sanctions which showed that a rigorous testing schedule reduced drug use and that treatment should be reserved for those with dependence disorders (Taxman, 1998); (3) a continuum of care model for prison-based therapeutic communities that outlined the policy and operational areas of integrated services (Taxman & Bouffard, 2000); (4) an EBP community supervision model that focused on assessment, case planning, graduated responses, and deportment (Taxman, 2002, 2008; Taxman et al., 2004); and (5) a transformation of a correctional facility into a re-entry facility with a focus on using correctional staff as role models (Lerch et al., 2009). This research network has been fruitful in developing organizational strategies as well as serving as a laboratory for new techniques. Strategically, though, the question remains as to the research needed to build knowledge around some of the common implementation issues that confront the addiction treatment–community corrections intersection. From our perspective, there are five priority areas where future research should assist in the implementation of EBP. These areas are based on findings from the National Survey on Criminal Justice Treatment Practices (NCJTP) (Chap. 6), interviews with key informants (Chap. 6), and our review of the gaps in knowledge (Chap. 4). We believe that the implementation research model of Proctor et al. (2009), distinguishing between intervention and implementation strategies for improving outcomes at the implementation, service, and client levels, is highly valuable at the nexus of community corrections–addiction treatment. The Proctor et al. model suggests that implementation strategies might target one or more levels of the service delivery environment, including individual providers, supervisory practices, group learning, and organizational and systems environment. Our two-stage evidence mapping model builds on this to consider whether the intervention has an impact on client level outcomes (efficacy and effectiveness) and whether the intervention can be implemented with fidelity in the given setting (implementation outcomes) to achieve research-based findings. The description of the medication-assisted treatment (MAT) study (Box 10.6) illustrates the link between intervention and implementation studies. The MAT study is designed to determine which implementation effort will improve probationer/parolee access to MAT for opioid dependent offenders. MAT is a well-recognized intervention that has been shown to improve offender outcomes (Gordon, Kinlock, Schwartz, & O’Grady, 2008). However, there is currently limited access to MAT in the justice system, where there is low support for using medications to treat addiction disorders (Friedmann et al., in press), and the role of the probation/parole officer is unclear. This study is testing the effects on staff attitudes and willingness to make MAT referrals under two different implementation strategies: knowledge awareness through training and consultation and a linkage intervention that includes formation of a stakeholder team and appointment of a change leader. In the following sections we propose a research agenda for both intervention strategies and implementation strategies. The intervention strategies include evidence-based treatments, dosage, and types of clients. The implementation strategies are organizational learning, integrated service delivery and network models, performance models, attitudes toward behavioral health services, and process improvement models.

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Box 10.6 Medication-Assisted Treatment (MAT) in Community Corrections Environments A Project of the Criminal Justice Drug Abuse Treatment Studies Cooperative (Funded by the National Institute on Drug Abuse) Overview: Previous research has shown that opioid-dependent individuals are extensively involved in the criminal justice system, resulting in high public safety costs. When they receive traditional treatment it is usually counseling. Opioid addicts are more likely than other substance abusers to relapse and return to drug use and crime. Researchers have identified several common barriers to the use of MAT with criminal justice populations, including a lack of staff knowledge about the effectiveness of addiction pharmacotherapy, and a lack of both formal and informal linkages to community-based providers of addiction pharmacotherapy treatment. MAT is an EBP in which opioid substitution medications (e.g., methadone, buprenorphine, naltrexone) are used in combination with traditional counseling and behavioral therapies. The purpose of this study is to examine and facilitate linkages among community corrections agencies and community-based drug treatment providers involved in the supervision, assessment, and treatment of drug-involved offenders. Treatment options may include outpatient and inpatient treatment services, independently or in combination with MAT. Benefits: By strengthening assessment and treatment of opioid addiction, agencies can reduce the number of opiate addicts going through repeated arrest–reincarceration–release cycles. MAT could also slow down the cycles by lengthening the time between relapse events. Both situations may result in decreased crime and therefore lower public safety costs. In addition, formal linkages with MAT agencies could simplify supervision and lower parole/ probation supervision costs. Study Design: The study is a multisite randomized experiment with measures at both the organizational and offender level. Study sites are randomized to either a three-hour staff training to address knowledge, perceptions, and information about MAT (Standard Condition), or (Enhanced Condition) the threehour training plus a Linkage Intervention. • Standard Condition: Participate in a three-hour Staff Training on MAT, supplemented by ongoing analyses of data and consultation with researchers. • Enhanced Condition: Participate in a 12-month Linkage Intervention consisting of meetings and on-site activities designed to enhance system linkages. The Linkage Intervention includes formation of a local Pharmacology Exchange Council, a stakeholder team that will meet regularly and work on increasing MAT referrals from probation or parole officers, and facilitate performance monitoring and information exchange between community corrections and treatment staff. This group will be assisted and facilitated by a local change leader.

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Intervention Strategies

A number of intervention-related issues deserve priority research attention, especially: (1) evidence-based treatments that work for justice-involved clients; (2) dosage and intensity for interventions; and (3) matching appropriate treatments for different types of offenders. In part, this reflects that the existing research does not yet adequately identify the effective components of an intervention, or the mediators and moderators of treatment effects; this limits the ability to determine the effectiveness of the treatment in different settings. Even when evidence-based treatment is implemented, there is wide variation in long-term relapse and recovery patterns (Witkiewitz & Marlatt, 2004). Evidence-based treatments for justice-involved clients. NIDA’s 13 principles for effective treatment (NIDA, 2009; see Box 10.7 for those principles related to the treatment delivery) covers a range of treatment process issues. Five of the principles are related directly to treatment delivery: varieties of counseling strategies, medications, treatment planning, treating co-occurring disorders, and use of detoxification. For criminal justice clients, NIDA also included medications, treatment planning, coping with co-occurring disorders, and a continuum of care (NIDA, 2006). Offenders have complex needs that include mental health disorders, medical illnesses, infectious diseases (e.g., HIV/AIDS, Hepatitis C, sexually transmitted infections), and lack of education. Although NIDA included criminal thinking in the core principles for drug-involved offenders (NIDA, 2006), specific behavioral therapies for criminal conduct or offending were not recommended. However, there is a growing recognition that the therapies should include the primary disorder (such as substance abuse) and criminal thinking (Taxman, Rhodes, & Dumenci, 2011). But the main questions regarding interventions are the degree to which the behavioral interventions and medications are suitable for those involved in the justice system. Studies of therapeutic communities have emphasized how the model can be adapted to fit within a justice environment (Harrison & Martin, 2003). Yet similar research on the adaptability of cognitive behavioral therapies for offender populations has not been conducted. That is, the transportability for important evidencebased treatments is largely unknown. As previously discussed, adaptations of EBP to justice settings can affect the fidelity of the intervention. For example, CM is a structured intervention to reward clients for achieving small milestones such as consecutively providing clean samples of urine or attending treatment sessions. The goal is to set weekly targets and to reward frequently and immediately. In justice settings, however, the probation staff may only have monthly contact with an offender, where the officers provide feedback on urinalysis tests, treatment attendance, and supervision. It is difficult if not impossible to deliver rewards on a weekly basis. The questions are whether CM delivered monthly will have similar positive outcomes compared with CM delivered weekly in community treatment settings, and whether having probation/parole officers deliver rewards will work as well as having researchers deliver the CM rewards (Stitzer et al., 2010). This provides an example of some of the unanswered adaptability

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and capacity questions that need more research regarding the delivery of evidencebased treatments in justice settings. Dosage and Intensity of Treatment. Another NIDA principle states that: Remaining in treatment for an adequate period of time is critical. The appropriate duration for an individual depends on the type and degree of his or her problems and needs. Research indicates that most addicted individuals need at least 3 months in treatment to significantly reduce or stop their drug use and that the best outcomes occur with longer durations of treatment. Recovery from drug addiction is a long-term process and frequently requires multiple episodes of treatment. As with other chronic illnesses, relapses to drug abuse can occur and should signal a need for treatment to be reinstated or adjusted. Because individuals often leave treatment prematurely, programs should include strategies to engage and keep patients in treatment. (NIDA, 2009)

There is relatively little research on effective models or principles for adaptation of evidence-based treatment in any setting, let alone criminal justice settings. Scientific guidance is needed on optimal dosage, even though most effectiveness studies do not analyze dosage effects. This is particularly important given reimbursement restrictions for addiction treatment and limited funding for treatment: insurance company policies and organizational pressures exist to minimize the number and length of treatment sessions. The optimal length for a treatment intervention may conflict with other priorities such as court-ordered conditions or supervision needs or requirements. For example, an intervention manual may require two group counseling sessions per week for six months, but there is no evidence as to whether similar outcomes would occur if the intervention were provided over a four-month period. Issues of dosage and treatment intensity have important implications for penetration to the target population as well as for cost-effectiveness. Public health effects are maximized when an intervention can reach larger numbers of affected individuals. Thus, considering resource constraints, the field needs guidance as to whether a treatment can be effective with shorter duration or lower dosage. Even if the treatment effect size is lower (but still reduces recidivism and relapse), a more streamlined intervention could reach a larger number of offenders and thus have a greater overall public health (and public safety) impact (Tucker & Roth, 2006). Given the policy importance of the economic benefits of treatment, reducing dosage and intensity (while maintaining effectiveness) will lower treatment costs and thus increase the benefit–cost ratio (Belenko, Patapis, & French, 2005). Similarly, research is needed to identify the core components or active ingredients of EBP. Treatment costs can be reduced (and thus able to serve more offenders) and client outcomes improved if ineffective or redundant components of the intervention are eliminated and effective components emphasized. Understanding the active ingredients of interventions (see Appendix A for a list of mechanisms of action in interventions) will improve the efficiency of an EBP as well as its transportability. Matching Services to Offenders. Offenders are not a homogenous population. They vary considerably in terms of the severity of their substance use disorders, concurrence of mental health disorders, medical challenges, literacy, employability, and

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other social factors. Twenty years ago, the Institute of Medicine report on treating drug problems (Institute of Medicine, 1990) recognized that the different levels of severity and types of drug problems suggested the importance of matching client needs to treatment type and intensity. The benefits of matching patient to treatment levels and modalities have also been promoted as a way to contain costs in the wake of managed care (Gastfriend & McLellan, 1997) and limits in treatment capacity (Hser, Polinsky, Maglione, & Anglin, 1999) – issues that remain salient today. The notion of matching stems from the idea that no treatment is effective for all clients, but that all treatment is effective for some clients (Gastfriend & McLellan, 1997); determining which clients will do better in which settings remains a challenge and high priority for research. The American Society of Addiction Medicine (ASAM) developed Patient Placement Criteria as guidelines for placement of patients in a hierarchy of five treatment settings ranging from early intervention through intensive inpatient treatment (Mee-Lee, Shulman, Fishman, Gastfriend, & Griffith, 2001). Despite the wide dissemination of the ASAM and other matching protocols, evidence of their predictive validity in terms of treatment outcomes is still limited (Belenko & Peugh, 2005; Melnick, De Leon, Thomas, & Kressel, 2001; Thornton, Gottheil, Weinstein, & Kerachsky, 1998; Turner, Turner, Reif, Gutowski, & Gastfriend, 1999). However, there is evidence that persons with higher severity of drug use have better outcomes in residential/inpatient or more intensive or highly structured treatment (Melnick et al., 2001; Rychtarik et al., 2000; Simpson, Joe, Fletcher, Hubbard, & Anglin, 1999). Those with a higher level of drug-related problems and consequences may also need longer or higher intensity services (Belenko & Peugh, 2005). Researchers have also recognized the importance of treatment matching for offenders (Belenko, 2006; Belenko & Peugh, 2005; Taxman & Marlowe, 2006) or identifying programs and services based on individual level risk and need factors (Andrews & Bonta, 2010). A major need in the literature is to identify which treatments are more effective for what type of clients. This is especially important for determining the use of residential (or inpatient) treatments and outpatient treatments in terms of which offenders would benefit from residential programming. The criminal justice community does not endorse a more patient-centered approach where the selection of an intervention may be affected by the client’s choices of treatment program. As discussed in Chap. 8, such techniques have shown to be effective in reducing drug abuse relapse (Dennis & Scott, 2007; McKay, 2006, 2009). Although a patient-centered approach is embedded in the EBP supervision models (Clawson, 2004; Taxman et al., 2004), little research has been conducted in justice settings to determine what impact such approaches might have on the organization and clients. Of interest is whether client-centered approaches (such as those used in motivational interviewing) would contribute to better outcomes than traditional control-oriented supervision that tends to focus on coercive treatment models.

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Box 10.7 NIDA’s Treatment-Related Principles (NIDA, 2009) http://www. nida.nih.gov/podat/Principles.html • Counseling – individual and/or group – and other behavioral therapies are the most commonly used drug abuse treatment. Behavioral therapies vary in their focus and may involve addressing a patient’s motivation to change, providing incentives for abstinence, building skills to resist drug use, replacing drug-using activities with constructive and rewarding activities, improving problem solving skills, and facilitating better interpersonal relationships. Also, participation in group therapy and other peer support programs during and following treatment can help maintain abstinence. • Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. • An individual’s treatment and service plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs. • Many drug-addicted individuals also have other mental disorders. Because drug abuse and addiction – both of which are mental disorders – often cooccur with other mental illnesses, patients presenting with one condition should be assessed for the other(s). • Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse.

10.2.2

Implementation Strategies

Both the Evidence Mapping and Evidence-Based Interagency Implementation Models encompass a number of implementation strategies, many of which have not been empirically tested in community correctional settings or even generally (Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004). But, based on the review of the community corrections and addiction treatment fields, we recommend rigorous research of five strategies to assess their impact on organizational, system, and client-level outcomes. The main goal is to learn about implementation strategies or interventions that foster different organizational attributes conducive to effective EBP adoption and implementation. Organizational Learning. An underlying premise of both models presented in this book is that open and rational data-driven systems are more likely to advance the adoption of EBP and improved practices. The experiments that Glisson (2007), Glisson et al. (2006) conducted in child welfare and juvenile justice illustrate how change agents can be used to create a more open environment for addressing

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problem behaviors. A recent experiment in a juvenile justice agency using external facilitators to create a social climate supportive of change, to re-educate the staff on core skills, or to not provide any post-training reinforcement illustrates the importance of the organizational culture to adoption of EBP. In this study, cynicism about change was common at onset of the study and the staff did not feel committed to the organizational goals (Farrell, Young, & Taxman, 2011). But the organizational intervention that focused on building a social climate to support change and alignment to organizational values demonstrated improvements in the staff perception of the organization (the other two conditions did not have an effect) and in reductions in recidivism rates (Taxman, Henderson, Young, & Farrell, 2010; Young, Taxman, Farrell, Henderson, 2010). As shown in Box 10.6, a current study is examining the use of a Pharmacology Exchange Council to facilitate greater engagement in MAT for opioid-dependent offenders on probation or parole. This is another example of a strategy to create change agents, stakeholder change teams in a system, and feedback loops. Little research exists on the techniques to create learning environments, and given the importance of open communication to testing of new ideas, this is an area of critical importance to the field. Similarly, research on the optimal design and activities of Learning Collaboratives, Communities of Practice, and Interagency Research Networks is lacking. Research is needed on using these models in community corrections settings to promote use of evidence-based treatment. If these models are found to increase adoption, implementation, and sustainability of EBP, they could represent important low-cost frameworks for advancing effective implementation. Integrated service delivery and network models. Most community corrections agencies do not administer their own addiction treatment programs and many rely upon referrals or access to care in the public health system. The underlying concept of collaboration and integration of services is a continuous theme in the EBP adoption literature. As discussed in Chap. 4, a new scale has been developed (Fletcher et al., 2009) that details the degree to which service integration occurs at the operational level. Several studies based on this scale have found that correctional administrators who reported having more integrated services with addiction treatment agencies tended to adopt more EBP (Henderson & Taxman, 2009; Taxman & Kitsantas, 2009; Young et al., 2009). The question is what are the best network models or team building exercises to create integrated service delivery? We have identified several models such as Learning Collaborative, Community of Practice, and Research Networks but other models exist such as coaches or policy councils (such as the one used in the MAT study above). The importance of network models cannot be understated, and the federal government now requires Re-entry Councils for all reentry grants (http://www.ojp.usdoj.gov/BJA/grant/SecondChance.html). The best strategies for developing and maintaining such groups have not yet been determined. Additional research is also needed to assess whether integration of services improve client-level outcomes. Performance models. The old cliché what gets measured, gets done symbolizes the importance of using benchmarks in the performance monitoring process. As noted in the expectation-setting phase of the Evidence-Based Interagency Implementation

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Model, the process of having a work team (preferably an interagency work team) specify expectations along the implementation process lays the foundation for feedback loops and communication, two critical organizational variables. Feedback loops essentially serve as the glue for assessing and refining practice to achieve desired outcomes – without the performance measures it is difficult to assess the progress of implementation. Yet there are no studies that test different models of performance in an organizational context, such as whether the results are distributed widely among team members or whether the performance measures include organizational milestones and/or individual offender (client) level outcomes. Unknown factors that remain to be studied are: (1) the timing of the communication reports on implementation progress, and whether more frequent (e.g., weekly, monthly) reports contribute to greater awareness or commitment to EBP implementation; (2) the role of supervisors, staff, or senior leadership in using the performance reports to improve operations; (3) the optimal type of measures used in performance reports in terms of facilitating implementation or moving along the continuum of implementation progress; and (4) the impact of overall availability of performance reports for obtaining resources for EBP. Appreciation for human service issues. The NCJTP found that administrators with human service backgrounds were more inclined to adopt EBP than correctional administrators with law enforcement, military, or other backgrounds (see Chap. 6; Taxman, Henderson, & Belenko, 2009). This implies that an understanding of human service issues affects the various stages of implementation specified by Proctor et al. (2009). A growing trend in the field is for administrators of corrections agencies to be former law enforcement or military officials, and corrections agencies generally do not consider themselves to be human service agencies. This partially explains the need for the knowledge development and foundation setting phases of the EvidenceBased Interagency Implementation Model. However, this raises more research questions such as: (1) How does a human service orientation affect EBP adoption and implementation? (2) If community corrections agencies accept their role as a human service agency, how does this impact the speed and progress of implementation? (3) Do the knowledge development or foundation setting phases of implementation contribute to greater appreciation for corrections as a human service agency, and do these impact offender outcomes? (4) Do correctional organizations that adopt more principles and goals of a human service agency improve offender level outcomes? Process Improvement Interventions. In contrast to many training approaches, process improvement strategies involve a structured set of activities that are directed toward organizational change. The assumption is that achieving organizational change requires a sustained, multilevel, and coordinated effort that involves leadership, ongoing staff involvement, understanding the organization’s function from multiple viewpoints, systematic efforts to test and measure new practices or interventions within the organization, and thoughtful discussion and decision-making regarding the results of the process improvement efforts. These principles and activities are important in both the Evidence Mapping and Evidence-Based Interagency Implementation Models described in this book.

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One such model was highlighted in Chap. 4, the Network for the Improvement of Addiction Treatment (NIATx). NIATx has been applied successfully in addiction treatment facilities (Hoffman, Ford, Choi, Gustafson, & McCarty, 2008). The NIATx approach focuses on the role of the program administrator as the Executive Sponsor of the proposed change, and a Local Change Team consisting of a Change Leader with access to the Executive Sponsor and members agreed upon by the Change Leader. A NIATx coach helps the team form and provides guidance throughout the change process. Responsibility for carrying out the change activities rests with the team and the Executive Sponsor, who remains active by meeting periodically with the team and reviewing team activities. Central to the NIATx model is the use of baseline data to define gaps in service delivery, and Rapid Cycle Testing to collect data on the results of process improvement strategies. Despite their promise in addiction treatment and other health care settings (see the Institute for Healthcare Improvement, http://www.ihi.org), process improvement models for addiction treatment have not yet been tested in community corrections and other justice settings or used to improve implementation of EBP. Thus, research is needed on how NIATx and other models such as the Veterans Health Administration’s Quality Enhancement Research Initiative (QUERI; see Hagedorn et al., 2006; Stetler, McQueen, Demakis, & Mittman, 2008) can be used to facilitate the implementation process for evidence-based addiction treatment in community corrections settings. These types of approaches have potential utility for the Align, Renovate, and Sustain phases of the EvidenceBased Interagency Implementation Model, but research is lacking on their effectiveness in these activities and settings.

10.3

Council for Public Health-Safety Evidence-Based Practice

Teamwork is critical to advance science, policy, and practice. A key element that has hindered the development and proliferation of sound addiction treatment in community corrections is the lack of infrastructure to support interagency change. Establishing such an infrastructure can improve the bench to bedside problem in community corrections, particularly with the integration of addiction treatment. A model for this is available in addiction treatment where the Center for Substance Abuse Treatment and National Institute on Drug Abuse have committed to a series of blending products to advance practice. These include support of the NIATx initiatives, Clinical Trial Networks, and Addiction Treatment Technology Centers (ATTCs) (see Chap. 5 for descriptions). The same type of infrastructure does not exist for the community corrections system, although a model exists for drug courts. A national advocacy office (National Association of Drug Court Professionals) promotes the drug court model and works with all levels of government to advance the use of drug courts and other problem solving courts. The federal government funds the National Drug Court Institute (NDCI), an arm of NADCP, to deliver standardized training to drug courts including a core curriculum for initiating and sustaining a drug court. The Office of Justice Programs and the Center for Substance Abuse

10.4

Conclusion

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Treatment fund planning and demonstration projects for drug courts. That support and the work of NADCP and NDCI have helped disseminate the drug court model, with more than 2,000 now in operation. A comparable infrastructure is not in place for other offender-related programming initiatives. The Council for Public Health-Safety Evidence-Based Practice could advance policy, practice, research, and implementation in community corrections, and at the nexus with addiction treatment and other services that are pertinent to achieving recidivism reduction. The goal of the Council would be: (1) to establish priorities for research to advance implementation and issues related to organizational capacity; (2) to host the Evidence-Based Mapping process with attention to the issues of scientific rigor and transportability; (3) to continuously develop materials for corrections agencies to support the knowledge development and foundation-building components of the TT process; (4) to monitor the utility of implementation checklists and other tools to advance implementation; (5) to develop a series of measures of implementation that can be considered standards for the field; and (6) to provide a forum for advancing EBP for community corrections and addiction treatment. Such a Council has the potential to fill the huge gap by joining scientists with practitioners and using implementation science to promote more effective use of EBP. An important goal would be to develop the infrastructure for long term commitment to advancing community corrections. Symbolically this is important because it provides an important and visible tool to focus on intervention and implementation issues. The Council of Public Health-Safety Evidence-Based Practice could avoid the mistakes of the past – failing to revise community corrections mission and goals to align with public health needs, and ignoring the science.

10.4

Conclusion

Up until the 1970s, programs, services, and treatment dominated the community corrections field. The nothing works sentiment helped to push the pendulum towards punitive policies for the last 40 years. Crime control efforts then focused on public safety with punishment (i.e., incarceration) dominating the policy. This attention to the bottom line of outcomes has come full circle, with current discontent with high recidivism outcomes from the punitive policies. The recent literature (Clear & Austin, 2009; PEW Center for States, 2008, 2009, 2010, 2011) acknowledges that incarceration-based policies also have poorer offender outcomes than community corrections. A sole focus on outcomes, without attention to the nature of the interventions or implementation, will not be productive in improving public safety. Policymakers are now looking toward EBP as a tool to reduce recidivism (and drug use), and this requires attention to the nature of the interventions and implementation strategies to ensure that the current challenges are met. Strengthening community corrections has been a public policy goal since the early 1990s when Morris and Tonry published their landmark book, Between Prison and Probation (1990). That book articulated the need for programming that is more intensive than traditional community supervision, and which is needed to avoid overusing

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incarceration. The legacy of punitive incarceration policies in the U.S. since the mid1980s, as well as the escalation of penalties for drug possession and sale of small quantities of drugs, has been an escalating corrections population, to nearly 8 million in 2010. During this era, the interest in exploring alternative solutions for druginvolved offenders led to the creation of drug courts, intensive supervision with treatment, in-prison therapeutic community with aftercare, prosecutor-based treatment diversion, seamless systems, and other initiatives directed at incorporating addiction treatment into the corrections system. Scientific knowledge about this series of initiatives confirms that the addition of drug treatment improves offender outcomes (MacKenzie, 2006; Mitchell, Wilson, & MacKenzie, 2007; Wilson, Mitchell, & MacKenzie, 2006). But few programs exist, and the existing capacity to provide drug treatment is limited, with less than 10% of offenders involved in treatment services (Belenko et al., 2011; Taxman et al., 2007). Just as Martinson advised in 1974, the concern about implementation of effective addiction treatment programs and practices clouds the discussion since there is general concern about the fidelity of treatment programs and the ability to deliver the same findings found in research studies. The two models proposed in this book address the critical issues associated with: (1) assessing the scientific knowledge in the context of transportability and organizational capacity; and (2) furnishing a framework to advance technology transfer that addresses issues of organizational and system capacity to sustain the utilization of EBP. Unlike the focus on dissemination and diffusion, the emphasis is on engaging the organization and system in a change process that will improve implementation and sustainability. The models assist in progressing through the domains of implementation outlined by Proctor et al. (2009): acceptance, feasibility, fidelity, uptake, penetration, costs, and sustainability, as well as the stages of implementation outlined by Fixsen et al. (2005) through full implementation, innovation, and sustainability. The models were framed by existing research, much of which was conducted outside of community corrections and addiction treatment agencies for the explicit purpose of advancing uptake of EBP. Implementation of EBP should be the priority along with the need to improve the delivery of service. With recent trends toward more alternatives to incarceration, the soundness of our community corrections system will be the ultimate test. Historically, probation, parole, alternatives to incarceration, and graduated sanctions have been undervalued and underfunded. Yet within these settings there is the potential to prevent crime and to address criminogenic needs with addiction treatment. Armed with new techniques to implement and sustain EBP, community corrections agencies can meet the challenge. This book has sought to examine the process of defining, selecting, and implementing EBP for addiction treatment in community corrections, and to provide the framework for developing and studying rigorous implementation of interventions and practices. The remaining question is whether community corrections and addiction treatment, and their key stakeholders, are invested in the pursuit of expanding the adoption and improving the implementation of EBP, and whether if we build the programs they will be embraced and supported over time. This is the true test of the EBP framework; achieving these goals should improve organizational functioning, improve outcomes for offenders, reduce system costs, and achieve the capacity of the community corrections and

Appendix A: Interventions Checklist

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addiction treatment systems to reduce drug use and criminal behavior among drug-involved offenders. The end game is seamless public safety and public health practices using EBP, a goal that is within reach.

Appendix A: Interventions Checklist Evidence-Based Interagency Implementation Model Proposed Intervention:

Scientific Articles: Phase of Implementation (the checklist can cover one or more areas; but as the process evolves different areas will be addressed):  Align  Refine  Sustain

 Develop Knowledge  Build Foundation  Set Expectations

Key Ingredient

Key Characteristics of the Intervention

Agree with internal/external parties Need to explore or discuss with internal/external parties

A. Characteristics of the target population for the intervention

Age Gender Other demographics Problem severity History of problem behavior Involvement in the justice system B. Desired characteristics for those delivering the intervention Job title Education Prior experience Skills required Additional training needed C. Characteristics of the agency managing the EBP or the innovation, if different than the one delivering the intervention Correctional Agency Substance Abuse Agency Other D. Preferred setting for the intervention Type of correctional facility Type of office Time of day Location of the intervention E. Mode of delivery of the intervention Face-to-face contacts

(continued)

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Appendix A (continued) Key Ingredient

Key Characteristics of the Intervention

Agree with internal/external parties

Need to explore or discuss with internal/external parties

Telephone Internet Video/CD Mailing materials Group composition Type of group Support system F. Materials for Delivery Manuals Information sheets Pamphlets Video/DVD Audiotapes Other Therapy Devices such as reminders, text messages Internet Therapies G. Manualized curriculum to document curriculum sessions Name Expected training Method to monitor fidelity H. Intensity and duration of services Number of contact hours per week Number of sessions per week Number of augmented support systems Overall length of the intervention Change in frequency of sessions based on participant’s progress I. Treatment includes critical supplementary services Case management Employment services Housing Mental health services Physical health services Other, specify

(continued)

Appendix A: Interventions Checklist

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Appendix A (continued) Key Ingredient

Key Characteristics of the Intervention

Agree with internal/external parties

Need to explore or discuss with internal/external parties

J. Identify components of the intervention 1. General information 2. Information on consequences 3. Information about approval 4. Prompt intention formation 5. Specific goal setting 6. Graded tasks 7. Barrier identification 8. Behavioral contract 9. Review goals 10. Provide instruction 11. Model/ demonstrate 12. Prompt practice 13. Prompt monitoring 14. Provide feedback 15. General encouragement 16. Contingent rewards 17. Teach to use cues 18. Follow up prompts 19. Social comparison 20. Social support/ change 21. Role model 22. Prompt self talk 23. Relapse prevention 24. Stress management 25. Motivational interviewing 26. Time management 27. Process groups 28. Social Learning/Peers K. Mechanism of action or key component designed to bring about change Ability to assess risk/goals Knowledge Behavioral Skills Problem-solving skills Motivation Self-Efficacy Self-Determination Social support Social engagment Environmental motivations Change in policies/regulations Biologic pathways External controls Incentivizing L. Indicate the strategies to ensure Adherence to Original Intervention Design

M. Benchmarks for intervention outcomes; capacity of management information system MIS or other computer system to generate benchmark Computer system allows for multiple agencies to share data Main outcome anticipated Process measures Summary Reports Progress Reports Case Plans Other MIS capacity Other, specify

Intervention categories were adapted from Schultz et al. (2010); Michie & Prestwich (2010); Abraham & Michie (2008).

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Appendix B: Inner Setting Checklist Evidence-Based Interagency Implementation Model EBP or Innovation:

Phase of Implementation (the checklist can cover one or more areas; but as the process evolves different areas will be addressed):  Align  Refine  Sustain

 Develop Knowledge  Build Foundation  Set Expectations Key Ingredient

Key Needs

Agree with internal/external parties Need to explore or discuss with internal/external parties

A. Mission and Goals Fits within primary goal Fits within secondary goal Need to revise mission/goals Need to clarify with partners Other (specify) B. Identify EBP Related Knowledge Gaps Staff Managers External partners Skills required Additional training needed C. Identify EBP Related Skills

Staff Managers External partners D. Organizational Structure Where does EBP fit? What, if any, regulations, policies and/or practices need to be changed? Overlap with other agencies/units Line of authority Potential for boundary spanning Appropriate resources E. Organizational Culture Performance driven Hierarchical Innovative Risk averse Create open culture F. Communication Mechanisms Key champions Change agents Style Frequency

(continued)

Appendix B: Inner Setting Checklist

305

Appendix B (continued) Key Ingredient

Key Needs

Type of material available to staff Type of material available for external partners G. Role of Supervisors Quality Control Quality Assurance Handle red flags H. Performance Measures and Benchmarks Establish quarterly measures Have readily available data for the measures Establish long-term measures Establish link between measures and process (logic model) Committee/work team reviews the measures Provide for refinement of measures based on progress I. Leadership Support Involved in teams Allows teams to make recommendations Transactional role Transformative role

Agree with internal/external parties

Need to explore or discuss with internal/external parties

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Appendix C: Outer Setting Checklist Evidence-Based Interagency Implementation Model EBP or Innovation: Phase of Implementation (the checklist can cover one or more areas; but as the process evolves different areas will be addressed):  Align  Refine  Sustain

 Develop Knowledge  Build Foundation  Set Expectations Key Ingredient

Key Needs

Agree with internal/external parties Need to explore or discuss with internal/external parties

A. Perception of Needs of the Target Population that are not being addressed Services needed Criminal justice process Issues Service system eligibility issues Identification of needs Information needed to make a more informed decision B. Resources, either pooled, reallocated, or new Correctional Agency Service Agency External partners--Judiciary External partners--Legal

External partners—Housing, Faith-based, etc Grants C. External Policies Correctional Agency policy Service Agency policy Criminal Justice policies State or Federal level policies External partner policies D. External Regulations/Procedures Correctional Agency Service Agency Criminal Justice State or Federal level External partner E. Work Team Participation Which teams: Leaders Managers Staff Interagency benchmarks Researchers involved Community partners Customers/former offenders

(continued)

Appendix C: Outer Setting Checklist

307

Appendix C (continued) Key Ingredient

Key Needs

Agree with internal/external parties Need to explore or discuss with internal/external parties

F. Social Marketing or other Tools of Communication Key champions Change agents Style Frequency Type of material available to staff Type of material available for external partners G. Incentives or Mandates Financial Recognition Other (specify) H. Performance Measures and Benchmarks to Establish System Reforms Establish quarterly measures Have readily available data for the measures Establish long-term measures Establish link between measures and process (logic model) Committee/work team reviews the measures Provide for refinement of measures based on progress I. Environmental Factors Involved in teams Allows teams to make recommendations Stability of resources Stability of support

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Appendix D: Process Management Issues Checklist Evidence-Based Interagency Implementation Model EBP or Innovation: Phase of Implementation (the checklist can cover one or more areas; but as the process evolves different areas will be addressed):  Align  Refine  Sustain

 Develop Knowledge  Build Foundation  Set Expectations Key Ingredient

Key Needs

Agree with internal/external parties

Need to explore or discuss with internal/external parties

A. Work Teams Who is on the Internal Team Who is on the Interagency Team Shared leadership Need to clarify with partners Other (specify) B. Absorptive Capacity Pre-existing system knowledge Ability to find, interpret, codify and integration Expand the information systems to accommodate benchmarks Create risk taking climates Clear goals and priorities C. Communication Strategies Type of Information to share Mechanism Frequency of communication Who receives what type of information D. Type of Change Process Total Quality Management [TQM) Continuous Quality Improvement [CQI] Plan_Do_Study_Act NIATx Performance Contracts Feedback Loops Availability, Responsiveness, and Continuity (ARC) Model or similar interagency approach Policy Change including regulation, financial regulations, etc. Total System Approach Other (specify) E. System Culture Building Performance driven

(continued)

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Appendix D (continued) Key Ingredient

Key Needs

Hierarchical Innovative Risk adverse Create open culture F. Change Tools External facilitators Key champions Change agents Style Frequency Type of material available to staff Type of material available for external partners G. Other

H. Performance Measures and Benchmarks Establish quarterly measures Have readily available data for the measures Establish long-term measures Establish link between measures and process (logic model) Committee/work team reviews the measures Provide for refinement of measures based on progress I. Leadership Support Decision making authority Power balances Management relationships Other (specify)

Agree with internal/external parties

Need to explore or discuss with internal/external parties

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Index

A Addiction Society of Medicine (ASAM) criteria, 114, 153, 293 Addiction treatment, 2, 3, 5–12, 14, 15, 19–52, 57, 80–82, 85, 91, 92, 97–100, 102, 104, 119, 129–147, 150, 153, 183, 185, 189–191, 196–202, 207, 209, 212, 214–216, 220, 222, 224–228, 231, 233, 234, 239, 240, 243, 246, 248, 264, 265, 267, 269, 271, 275–280, 286, 288–289, 293, 295, 296, 298–301 Addiction treatment infrastructure, 132, 196 Addiction treatment staff, 225 Align, 3, 5, 7–10, 12–14, 63, 65–69, 72, 73, 101, 110, 117, 129, 181, 190, 200–202, 224–225, 233, 242, 243, 253, 255, 256, 258–260, 262, 268, 276, 281, 283, 285, 286, 288, 296, 298, 299, 301, 304, 306, 308 Alignment of values, 101, 225 Appreciation for human service issues, 297

B Behavioral therapies, 7, 12, 40–42, 48, 109, 111, 139, 154, 155, 172, 240, 244, 254, 279, 282, 291, 292 Build foundation, 243, 281, 301, 304, 306, 308

C CFIR. See Consolidated Framework for Implementation Research (CFIR) Change agents, 65, 66, 78, 95, 225, 247, 268, 272, 286, 289, 295, 296, 304, 307, 309

Clinical trials, 21, 24–27, 99, 102, 103, 111, 115, 122, 123, 131, 170, 176, 229, 298 Clinical trials networks (CTN), 99, 103, 118, 122, 123, 131, 135, 136 CM. See Contingency management (CM) Coaching, 35, 48, 52, 74, 111, 113, 200, 221, 232, 244, 261, 263, 281 Communication channels, 61, 65, 67, 113, 247, 248, 284–287 Community corrections, 2–11, 13–15, 19–52, 83, 91, 92, 102, 109, 119, 129–147, 151–185, 189–193, 196, 199–201, 208, 209, 212, 215, 219, 220, 224–228, 231, 233, 239, 240, 243–247, 249, 250, 252–254, 256, 261, 265, 267, 269, 271, 275–280, 286, 288–300 Competing values, 6, 159–160 Consolidated Framework for Implementation Research (CFIR), 92, 93 Contingency management (CM), 43, 46, 48, 75, 76, 103, 104, 107, 115, 120, 122, 123, 139, 144, 154, 172, 201, 219, 240, 246, 249, 250, 257, 279, 292 Correctional staff, 21, 76, 220, 290 CTN. See Clinical trials networks (CTN)

D DATOS. See Drug Abuse Treatment Outcome Study (DATOS) Diffusion, 8–11, 25, 59, 61, 62, 66–68, 71, 78, 83, 86, 95, 101, 106, 110, 113, 114, 119–121, 131, 135, 142–144, 164, 167, 178, 185, 189, 190, 193, 209, 218, 280, 285, 300

F.S. Taxman and S. Belenko, Implementing Evidence-Based Practices in Community Corrections and Addiction Treatment, Springer Series on Evidence-Based Crime Policy, DOI 10.1007/978-1-4614-0412-5, © Springer Science+Business Media, LLC 2012

315

316 Dissemination , 7–10, 25, 29, 30, 32, 34–37, 50, 52, 58, 59, 61, 67, 68, 74, 78, 83, 86, 87, 95, 104, 108, 109, 112–118, 123, 129–132, 136, 138, 141, 143, 146, 147, 162–166, 169, 171, 178, 185, 207–210, 213, 215, 218, 231, 248, 264, 265, 280, 294, 300 Dosage, 27, 47, 70, 115, 131, 163, 221, 222, 259, 282, 283, 290, 292, 293 Drug Abuse Treatment Outcome Study (DATOS), 99

E EBPs. See Evidence based practices (EBPs) Efficacy and effectiveness, 211, 216, 229, 247, 279, 289, 290 Evidence-based decision-making, 32, 33, 132, 167 Evidence based practices (EBPs), 3–15, 19–22, 26, 29, 32, 44, 46, 48–52, 59, 64, 70–72, 75, 77, 79, 83, 84, 86, 91, 92, 94–98, 100, 103, 104, 107, 110, 115, 118–123, 129–136, 138, 141–147, 151–185, 189–191, 194, 196, 197, 199–202, 207–234, 239–247, 249–256, 258–268, 270, 272, 275–290, 292–301, 304, 306, 308 Evidence-based repositories, 24, 28, 32–40 Evidence mapping, 202, 208–212, 231, 233, 234, 245, 277, 281, 287–290, 295, 297 Expectation setting, 12, 13, 254, 259, 260, 283–285, 287, 288, 296

F Facilitation, 15, 82, 84, 97, 111–113 Feasibility of innovations, 219 Federal initiatives, 136–141 Fidelity, 8, 9, 11, 24–26, 31, 35, 37, 39, 49–51, 70–72, 74, 76, 77, 85, 103, 109, 115, 119, 141, 142, 146, 162, 164, 175, 179, 182–184, 197, 200, 209–213, 217, 220–222, 224, 228, 232, 234, 243, 245, 246, 249, 251, 252, 261, 262, 279, 280, 282–284, 290, 292, 300, 302 Field experiments, 79, 175

G Goal setting, 77, 78, 303

Index I Implementation science, 5, 15, 22, 49, 141, 213, 215, 229, 299 Infrastructure, 72, 74, 109, 116, 129, 132, 144, 146, 166, 178, 190, 196–198, 200, 202, 230, 239, 248, 249, 251, 259, 280, 284, 288, 298, 299 Inner setting, 59, 92, 98–105, 118, 119, 156, 161, 189, 198, 202, 210, 220, 225–226, 232, 239, 253, 258, 261, 284–286, 304–305 Innovations characteristics, 15, 77, 93, 196, 223, 283, 301 Institute Of Medicine (IOM), 20, 58, 102, 130–133, 146, 153, 189, 198, 222, 280, 294 Integrated service models, 290, 296 Intensive supervision programs (ISPs), 277–279 Interagency efforts, 14, 22, 77, 92, 224–225, 241 IOM. See Institute Of Medicine (IOM) ISPs. See Intensive supervision programs (ISPs)

K Key informants, 10, 23, 28, 169–185, 208, 232, 247, 290 Knowledge development, 3, 4, 12, 22, 32, 49, 50, 130, 131, 146, 244–248, 268, 284, 297, 299

L Learning collaborative, 82, 113, 210, 227, 230, 263, 272, 288, 296 Levels of evidence, 22–24, 28 Linkage, 79, 95, 132, 137, 142, 226, 257, 290, 291

M Meta-analysis, 7, 8, 25, 29–32, 39, 40, 52, 111, 112, 116, 129, 152, 153, 175, 212, 216, 232, 247, 276, 289 Motivational interviewing (MI), 13, 43, 120, 123, 136, 153, 155, 166, 172, 174, 178, 180, 226, 250, 251, 257, 294, 303

N National Criminal Justice Treatment Practices (NCJTP), 92, 118, 144, 152–161, 194, 290, 297

Index National Institute of Corrections (NIC) integrated model, 162 National Treatment Studies, 99, 102, 123 Natural systems, 60 NCJTP. See National Criminal Justice Treatment Practices (NCJTP) Network connectedness, 156 NIC integrated model. See National Institute of Corrections (NIC) integrated model

O Offender change, 3, 11, 14, 191–196, 200, 239, 241, 271 Offense focus policies, 193 Open systems, 60, 75 Opinion leaders, 65, 66, 84, 110, 112, 117, 135, 221, 265, 268, 288, 289 Organizational capacity, 9, 11, 12, 15, 208–212, 223–234, 247, 251, 260, 263, 276, 279, 281, 299, 300 Organizational change, 10, 12, 15, 48, 52, 57–87, 91–123, 133, 141, 142, 155, 156, 165, 169, 170, 181–182, 196, 197, 210, 225, 253, 272, 276, 297 Organizational climate, 68, 112, 156, 193, 260 Organizational culture, 2, 3, 21, 71, 102, 116, 119, 142, 156, 157, 173, 182, 201, 225, 262, 272, 296, 304 Organizational fit, 209–212, 232, 233, 252, 277 Organizational learning, 113, 156, 161, 271, 284, 288, 290, 295–296 Organizational mission, 100 Organizational policies and procedures, 68, 73, 76, 182, 251, 261, 272 Organizational structure, 60, 69, 99, 101, 102, 116, 117, 165, 252, 266, 286, 304 Outer setting, 13, 59, 60, 92, 93, 96–98, 118, 119, 155, 161, 162, 164, 169, 189, 190, 192, 198, 202, 210, 211, 218, 220, 229–233, 239, 241, 242, 248, 250, 258, 261, 262, 269, 271, 272, 281, 286–287, 306–307

P Pay for performance models, 96, 285 PDSA (quality improvement). See Plan-Do-Study-Act (PDSA) (quality improvement) Performance contracting, 116, 177, 270 Performance monitoring, 11, 50, 115–116, 131, 134, 138, 140, 141, 146, 179, 180, 183–185, 200, 230, 231, 242, 244, 281, 291, 296

317 Performance standards, 139 Pharmacological therapies, 96 Piloting, 63, 66, 104, 114–115, 117, 244, 248, 268 Plan-Do-Study-Act (PDSA) (quality improvement), 80–83, 263, 288 Principles of effective community corrections, 48, 163 Principles of effective drug treatment, 40–46, 279 Professionalism, 50, 96, 102–103, 105, 108, 109, 223, 225 Public media messages, 11, 242, 244 Punishment, 1, 51, 156, 159, 160, 163, 172, 173, 191, 192, 196, 227, 230, 245, 250, 252, 271, 280, 299

Q Quality improvement processes, 79–83, 167

R Randomized controlled trial (RCT), 20, 21, 23–25, 27, 33, 37, 40, 49, 50, 57, 78, 145, 175, 176, 197, 208–214, 216, 218, 219, 229, 230, 268, 276, 277, 279, 281 Rational systems, 60, 61 Readiness for change, 98–100, 105, 243, 284, 286 Rehabilitation, 3, 6, 11, 36, 41, 102, 156, 157, 159, 173, 191, 244, 245 Renovate, 243, 258–261, 281, 283, 298 Researcher practitioner collaboration, 103, 131, 182 Research to practice, 8, 29, 32, 50, 87, 129, 165, 189, 227 Resources, 7, 11, 14, 22, 25, 33, 35, 37, 46–49, 51, 64, 77, 84, 85, 95, 98–100, 103–105, 108, 109, 112–114, 116, 123, 132, 135, 136, 139, 140, 145, 146, 155, 156, 158, 160, 161, 163, 174, 179, 181, 184, 189–191, 197, 201, 210, 211, 220, 221, 225, 229–232, 234, 242, 244, 245, 249, 252, 253, 255, 257, 263, 264, 266, 272, 284, 286, 287, 289, 293, 297, 304, 306, 307 Risk-need-responsivity (RNR), 176

S Seamless systems, 76, 98, 222, 300 Selection bias, 11, 23, 214, 215, 232 Social marketing, 63, 71, 113, 114, 168, 185, 264–265, 272, 288, 307 Socio-political environment, 93, 98, 114

318 Staff issues, 202 State initiatives, 144–146 Sustainability of innovations, 59, 70, 72–74, 77, 104, 106, 115, 199, 208, 218, 260, 261, 272, 300 Systematic reviews, 7, 8, 19, 25, 29–33, 39, 40, 49–51, 57, 58, 61, 62, 65, 83, 92–96, 101, 107, 118, 129, 152, 153, 208–210, 212, 217, 232, 247, 249, 276

T Technology transfer (TT), 5, 8–10, 13, 22, 29, 49, 52, 57–87, 91–123, 130, 131, 135, 141, 144, 146, 152, 157, 162, 169, 171, 177, 185, 189–191, 193, 194, 196, 199, 202, 222–224, 230, 239, 240, 242, 244, 246, 254, 258, 262, 266, 268, 271, 286, 289, 299, 300

Index Total quality management (TQM), 80, 82, 95, 308 Transportability, 3, 9, 12, 15, 25, 28, 46, 50, 93, 117, 130, 169, 208–212, 214, 216, 218–223, 232–234, 245–247, 249, 250, 252, 279, 281, 287, 292, 293, 299, 300 Treatment intensity, 41, 228, 293 Treatment outcome measures, 136 Trialability, 71, 95, 104, 114, 117, 282 TT. See Technology transfer (TT) Type of change strategy, 92

W Work teams, 77, 81, 82, 161, 242, 243, 256, 262, 268, 270, 272, 285, 287, 297, 305–309