North Carolina Improves Evidence-Based Practices
By Rebecca A. Clay
 Like
most states, North Carolina has limited financial resources. Things
are especially tough for those working to reduce alcohol and substance
abuse in the state. Substance abuse shares a state government division
with mental health and developmental disabilities, but its funding
is much more limited than the other two sections. Fortunately, the
state has found a way to overcome that problem.
"The way to get more out of your dollar is to improve your practices,"
explained Flo A. Stein, M.P.H., Chief of Community Policy and Management
at the North Carolina Division of Mental Health, Developmental Disabilities,
and Substance Abuse Services. "In fact, our legislature has taken
the lead in calling for a reformed system that pays for practices
that there's evidence to support. As a result, we've been actively
encouraging practice change."
Much of that support has come from SAMHSA's Center for Substance
Abuse Treatment (CSAT). Since 2001, the state has been using funding
from CSAT's Practice Improvement Collaboratives program (See SAMHSA
News, Volume IX, Number 3) to help bridge the gap between research
and practice. And now one community in North Carolina is taking
the next step to integrate evidence-based practices even further,
with a new CSAT grant called Strengthening Treatment Access and
Retention, as well as other SAMHSA-funded efforts.
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Improving Practices
According to Ms. Stein, the umbrella under which all of the state's
practice improvement activities for addiction take place is the
Practice Improvement Collaboratives grant. The 3-year project is
designed to help grantees set an agenda for improving addiction
services and adopting evidence-based treatment practices.
Bringing researchers and practitioners together plays a key role
in achieving these goals, explained project officer Susanne
R. Rohrer, R.N., a public health analyst in CSAT's Division of Services
Improvement. "The goal is to bring researchers and practitioners
together to lay the foundation for collaborative efforts," she said.
"It's a feedback loop: The researchers encourage the practitioners
to adopt best practices, and then the practitioners provide feedback
to the researchers."
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The way to get more out of your dollar is to improve
your practices.
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That's just what's happening in North Carolina, where the grantee
is a nonprofit organization called the Governor's Institute on Alcohol
and Substance Abuse, Inc., in Research Triangle Park. According
to principal investigator Wei Li Fang, Ph.D., Director for Research
and Development at the Institute, the project ensures that practitioners
are not only using best practices, but also using them correctly.
"We've had severe budget cuts in the last few years, so there's
not as much money going to continuing education," Dr. Fang explained.
"There are also problems with burn-out and staff turnover. What
we're trying to do is to identify practitioners' needs and provide
them with the necessary training, support, and encouragement to
adopt best practices."
The project has four specific objectives:
- Developing and implementing a statewide agenda to improve practices.
Dr. Fang and her colleagues have worked with substance abuse directors
and clinicians around the state to come up with a training agenda.
Training priorities identified so far are relapse prevention,
co-occurring substance abuse and mental health disorders, and
motivational interviewing. Motivational interviewing is a counseling
style designed to help clients change their behavior by exploring
and resolving their ambivalence about that behavior.
Once trained, practitioners are expected to spread the word
to others. After providing scholarships to an intensive training
program on co-occurring disorders, for example, the Practice
Improvement Collaboratives project expects the 17 participating
practitioners to make five presentations each to other clinicians
and members of the community in the next year.
- Expanding and strengthening the integration of a statewide network
of researchers, substance abuse treatment providers, educators,
policymakers, advocates, consumers, and others. The project has
created five regional consortia to help meet its goals.
- Conducting knowledge adoption studies. After the project trains
a site in a particular skill, it will go back and study how well
the site's practitioners have put that training to use. If they
still have questions or have drifted away from the standard, the
project will provide additional training or technical assistance.
- Conducting evaluations. The project evaluates every training
and technical assistance event it conducts.
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Strengthening Access and Retention
Now, one North Carolina community is taking the idea of practice
improvement one step farther. In October, CSAT awarded a Strengthening
Treatment Access and Retention grant to the state's Pitt County
Mental Health, Developmental Disabilities, and Substance Abuse Center
in Greenville. Building on the Practice Improvement Collaboratives'
work, this project will apply lessons learned in the field of quality
improvement to the provision of substance abuse treatment.
"We view this grant as the next step in the process begun by the
Practice Improvement Collaboratives grant program," explained Mady
Chalk, Ph.D., Director of CSAT's Division of Services Improvement.
"This grant is much more focused, in this case on evidence-based
practices having to do with improving access to services and retention
in treatment. I'm hoping that over the next few years, the program
will move on to other evidence-based practices."
In Pitt County, the 3-year project will work to ensure that alcohol
and substance abusers age 17 to 25 who live in this largely rural
area in the eastern part of the state get the treatment they need.
To improve access to substance abuse treatment, the project plans
to develop what it calls "process improvement teams." These teams
will receive training and technical assistance to help them improve various aspects of
treatment, such as enhancing the referral process or finding ways
to reduce waiting times.
To improve retention, the project plans to train treatment providers
in motivational enhancement therapy, an approach that helps clients
determine their own treatment goals and protocols. "It's a best
practice," explained Glenn Buck, M.S.W., Substance Abuse Program
Director for the Pitt County Mental Health, Developmental Disabilities,
and Substance Abuse Center in Greenville. "We're hoping that a well-trained
staff using an evidence-based approach will lead to better retention."
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Bringing researchers and practitioners together plays a key role in achieving these goals.
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Because the grant is administered in collaboration with the Robert
Wood Johnson Foundation's Paths to Recovery program, Pitt County
and other CSAT grantees will participate in a "learning community"
with the foundation's grantees. As part of the community, they will
attend two learning community meetings a year, participate in teleconferences
and Web-based educational events, and receive on-site technical
assistance from a learning community expert once a year.
"The
learning community will serve as a resource to the field on quality
improvement," said project officer Frances Cotter, M.P.H., a team
leader in CSAT's Division of Services Improvement. "Educational
events, case studies, and process improvement strategies will be
available from SAMHSA in the near future."
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Setting an Agenda for Improvement
That's not all Pitt County is doing to improve substance abuse
services. A nonprofit organization called the Eastern Carolina Council
on Substance Abuse—an offshoot of the county's substance abuse
center—is working to get the entire community involved in
reducing substance abuse.
 As part of SAMHSA's National Alcohol and Drug Addiction Recovery
Month in September, the council sponsored a community forum to discuss
the county's substance abuse problem, develop a community plan for
addressing the problem, and create a coalition that can put the
plan into action. The SAMHSA-funded event brought together substance
abuse counselors, the city manager, the police chief, the county
sheriff, physicians, attorneys, representatives from the public
school system and local university, people in recovery, and others.
"The coalition will provide a focus for improving our area's services,"
said Council President David Ames, M.D., Medical Director of the
Pitt County Mental Health, Developmental Disabilities, and Substance
Abuse Center in Greenville. "What I see the coalition doing is getting
to work on all the things that SAMHSA targets, such as promoting
prevention, improving access, and addressing stigma."
For Dr. Fang of the Governor's Institute, the coalition's
work is just another of the multiple efforts that add up to a more
effective whole. "We're all working toward the same goal," she said.
"We're all working to improve addiction services for clients." 
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