CLINICAL HANDBOOK OF SCHIZOPHRENIA

542 VII. POLICY, LEGAL, AND SOCIAL ISSUESMany researchers do not believe that a simple theory of any kind can ever explainsuccessful implementation of a new practice. Health care systems, or even individualpractices, are complex microsystems governed by their own unique constraints and facilitators,and successful implementation probably requires several large-scale system changes,as well as local strategies.RESEARCHSeveral research findings are clear. No single model of practice change or implementationis strongly supported by empirical evidence. Research shows that education alone doesnot strongly influence the practice behaviors of health care providers. Additional efforts,such as increasing consumer demand for services, changing financial incentives and penalties,using administrative rules and regulations, and providing clinicians with ongoingsupervision and feedback on practices, are also necessary. In general, greater intensity ofeffort produces greater change. The more elements of the system of care that can bebrought to bear to support change and reduce resistance, the more likely practice improvementswill occur. As a corollary, complex changes, such as modifying the practice ofan entire clinical team, require a greater intensity of effort or supports than is needed toeffect a relatively simple change, such as shifting a single prescription pattern. Guidelinesare not self-implementing and must be adapted to the actual processes of services used ina specific center. Sustained change requires a restructuring of daily workflow and incentives,often based in information technology, so that routine procedures make it easyrather than difficult for the clinician to provide services in the new way.EVIDENCE-BASED MENTAL HEALTH INTERVENTIONSResearch on public mental health systems strongly supports the use of several evidencebasedpractices for persons with severe mental illness. These interventions improve clients’outcomes in recovery-oriented domains such as independent living, employment,avoidance of hospitalization and incarceration, family relationships, and subjective qualityof life. Research also indicates that when mental health programs attempt to implementevidence-based practices, the quality of the implementation strongly influences clientoutcomes. For example, when two programs offer a practice of care that is known tobe effective, the program with higher fidelity to the defined practice tends to produce superiorclinical results. This finding suggests that efforts to promote evidence-based practicemust include fidelity measures and self-correcting feedback mechanisms. Implementationefforts are most effective when they address the specific needs, values, andconcerns of the persons whose behavior the implementation aims to change. Specifically,administrative features of an implementation plan must be tailored for mental health administrators,providing clinical training elements for clinicians, and consumer and familyeducation to those groups.Evidence-based mental health practices include the following:• Illness management and recovery services, which help clients learn to manage theirown illnesses.• Systematic medication management services, which enable practitioners and clientsto use evidence-based guidelines, to engage in shared decision making, and touse medications effectively.