1. WRAP as an Evidence-Based Practice: The Ohio Statewide WRAP Study
Judith A. Cook, Ph.D.
Professor
Center on Mental Health Services Research & Policy
Department of Psychiatry
University of Illinois at Chicago
May 19, 2011
Thank you Gary. Today I’m going to address my comments to the parallels between patient-centered care in physical health, and consumer-centered care in behavioral health.
I addressed this topic in a report I prepared for the IOM committee that prepared the report that is the focus of our meeting.
And because I am a researcher, I want to focus on the evidence base for CCC and its relationships to enhancing the quality of care.

2. A Word of Thanks to our Funders
U.S. Department of Education, National Institute on Disability & Rehabilitation Research
Substance Abuse & Mental Health Services Administration, Center for Mental Health Services
Funded by the U.S. Department of Education, National Institute on Disability & Rehabilitation Research; & the Substance Abuse & Mental Health Services Administration, Center for Mental Health Services & Consumer Affairs Program, under Cooperative Agreement No. H133B The views expressed do not reflect the policy or position of any Federal agency.

3. Important Question: How Can Scientists & Advocates Work Together?

4. The Type of Evidence Supporting an Intervention Determines its “Grade”

5. Evidence-Based Practice
An intervention that has been shown to be effective by causing pre-defined outcomes in people’s lives when tested in a randomized controlled trial

6. Randomized Controlled Trial (RCT)
People randomly assigned to experimental (E) or control (C) group
E group receives intervention, C doesn’t
Creates 2 equal groups to compare before & after receiving an intervention
Any changes (outcomes) are due to the intervention

7. Grading with the Evidence Pyramid
Guide to Research Methods-The Evidence Pyramid;

8. Typical Steps in RCTs
Create a manualized version of the intervention (a detailed, “how-to” manual) to be tested
Develop a fidelity assessment measuring extent to which intervention is delivered as intended
Train experienced providers of the intervention to deliver the manualized version
Recruit a large # of people into the study, interview, & randomly assign them
Deliver the intervention using the manual, & maintaining fidelity
Collect data from participants at multiple time-points, analyze it, & disseminate results

9. WRAP Intervention Tested in Our Study
Lasted for 8 weeks
Met for 2 and ½ hours every week
Followed a highly standardized curriculum designed by Mary Ellen Copeland and UIC
Facilitator curricular innovations discouraged
Used a detailed Facilitators Manual and Overhead Slides

10. WRAP Curriculum Session 1: Key concepts of WRAP & recovery
Session 2-3: Identify personalized wellness strategies. Engage in exercises to enhance self-esteem, build competence, & explore benefits of peer support.
Session 4: Create daily maintenance plan (simple, inexpensive strategies) to stay emotionally and physically healthy. Create plan for recognizing & responding to symptom triggers.
Session 5: Identify early warning signs and how these signal a need for additional support
Session 6-7: Create crisis plan specifying signs of impending crisis, names of individuals willing to help, & types of assistance preferred.
Session 8: Create plan for post-crisis support & learn how to retool WRAP plan after a crisis to avoid relapse. Graduation ceremony

11. Toledo
Lorain
WRAP
STUDY
SITES
Cleveland
Canton
Dayton
Columbus

12. Participatory Action Research Involved UIC Researchers Working with Dr
Participatory Action Research Involved UIC Researchers Working with Dr. Mary Ellen Copeland, Ohio WRAP Educators, Peer-Run Programs, & other Mental Health Organizations to Mount the Study

13. Facilitators in the Ohio WRAP Study

14. Why OHIO was chosen
Availability of Certified WRAP Facilitators state-wide as well as Advanced Level WRAP facilitators
Large population base from which to recruit study participants
Some regions were not “saturated” with WRAP
Cultural diversity in participants was possible
State includes rural, urban and suburban areas
Supportive state & county mental health authorities and organizations

15. WRAP Study Design
Targeted sample size was 500 people with severe mental health challenges
Recruited at CMHC & peer programs
Subjects were randomized to receive WRAP right away or 9 months later
Telephone interviews at study entry (baseline), 2 months post-baseline, & 8 months post-baseline by blinded interviewers from UIC Survey Research Laboratory
Participants were paid for their research time

16. Outcomes Assessed Recovery – Recovery Assessment Scale
Empowerment – Empowerment Scale
Self-Advocacy – Pt. Self-Advocacy Scale
Social Support – Medical Outcomes Study
Hopefulness – Hope Scale
Quality of Life – WHO QOL
Symptoms – Brief Symptom Inventory
Coping – Brief Cope Scale
Stigma – Mental Illness Stigma Scale
Physical Health Perceptions – MOS

17. WRAP Study Intervention Challenges
Finding qualified WRAP facilitators
Identifying locations for intervention delivery
Securing space on days and times that were convenient for participants
Establishing a network of support for WRAP facilitators
Doing “long-distance” research in another state

18. Importance of Maintaining Fidelity
Establishing & maintaining fidelity assures that the critical ingredients of the intervention are being delivered
Fidelity prevents individual variations that lower the quality of the intervention
Fidelity protects of an intervention against negative influences such as personal biases or politics

19. How We Monitored Fidelity
Fidelity checklist reviewed after each session by WRAP experts & researchers
On-site observations conducted by WRAP Advanced Level Facilitator
Weekly supervision calls between facilitators, local project coordinator, and research staff to review fidelity scores & address any “drift”
Use of detailed Intervention Manual was important to this process
Experts=intervention developer, teacher trainers

20. How ODMH Supported the Study
Helped convene the initial kick-off meeting in Columbus to introduce researchers to stakeholders
Provided location for the research study training of WRAP facilitators
Linked researchers with county mental health boards
Helped study team identify recruitment sites & locate places to hold WRAP sessions

21. County MH Boards Actively Supported the WRAP Study
Cuyahoga County Community Mental Health Board
Mental Health and Recovery Services Board of Stark County
Mental Health and Recovery Services Board of Lucas County
Alcohol, Drug and Mental Health Board of Franklin County
Lorain County Board of Mental Health
Alcohol, Drug Addiction and Mental Health Services Board for Montgomery County

22. Study Process 850 individuals screened for Waves 1-5
680 eligible & agreed to participate
555 (82%) completed Time 1 interviews
276 randomized to E group, 279 C group; 7% combined attrition; E=251, C=268
Ss attended average of 5 classes (out of 8)
53% attended 6+ groups; 16% attended 0 groups (still counted as receiving WRAP)
Average fidelity=91% over all waves (90% wave 1-92% wave 5; no site differences)

23. Study Participant Characteristics
66% female, 34% male
Average age: 46 years, range from years old
63% White, 28% Black, 2.9% American Indian/Alaskan Native, <1% Asian/Pacific Islander, 7% other
4.8% Hispanic/Latino
82% High school graduate/GED or more
88% unmarried
67% living in their own home or apartment
76% had been hospitalized for psychiatric reasons
Most common self-reported diagnoses: 38% bipolar disorder; 25% depression; 21% schizophrenia spectrum
85% not employed; 51% expected to work next year
No sig. differences by study condition

24. WRAP Outcomes
In a multivariable longitudinal random-effects regression analysis, WRAP recipients improved more than controls from T1 to T3 on multiple outcomes:
Reduced psychiatric symptom severity
Increased hopefulness
Decreased coping through self-blame
Increased quality of life
Increased self-advocacy
Increased recovery
Increased empowerment

25. Additional Findings
The greater the # of WRAP classes attended, the greater WRAP participants’…
Reduction in overall symptom severity
Reduction in depressive symptoms
Reduction in symptoms of anxiety
Increased quality of life
Increased sense of recovery

26. Some Qualitative Findings

27. “WRAP has helped me to be more motivated and hopeful
“WRAP has helped me to be more motivated and hopeful.  Now I have definite ways to help me avoid a major crisis.”
-Sam

28. “Something I learned in the WRAP was helping me with my self-confidence.  It also helps me find triggers to keep me out of the hospital.  I also use a daily maintenance plan to help me with my every day life.”
- Steven

29. Additional Qualitative Findings
Positive impact on the WRAP facilitators…
Working on the research study enhanced their WRAP facilitation skills
Have used the research findings in their statewide advocacy
Became aware of how practical help provided to participants had a life-changing effect in addition to WRAP (e.g., transportation)
Facilitators told us that being in the study had changed their lives for the better

30. “I gave a lot and I took a lot out of this research project.”
-Tom, facilitator
“I developed a WRAP for dealing with the research study. As a result I lost over 100 pounds.”
-Rita, facilitator

31. First Journal Article
Reporting the Results of a Randomized Controlled Trial Study of WRAP Effectiveness

32. WRAP Selected for Inclusion in NREPP, to appear in late 2011
NREPP is the National Registry of Evidence-Based Programs and Practices

33. Rewards of Establishing an Intervention as an Evidence-Based Practice
More people learn about the intervention
It gains greater legitimacy & acceptance
Easier to make the case for funding
Enhances potential of replication in new forms for diverse audiences
Increases the field’s knowledge base
Attracts attention of the field’s researchers

34. HOW TO SUPPORT WRAP AS AN EBP
Shift Funding from Ineffective Services to Effective EBP Services
Look at what the state funds and how much it spends on different types of services
Advocate for implementing WRAP in place of services with little or no evidence base
Urge the state to practice parity in funding WRAP on a level with similar services
Be willing to demonstrate fidelity to the Copeland Center version of WRAP
Provide local support for WRAP facilitators

35. For more information about the study:
Information about WRAP:
Judith Cook
Schizophrenia Bulletin article link