Feature Issue on Person-Centered Positive Supports and People with Intellectual and Developmental Disabilities

Implementing Evidence-Based Positive Support Practices in Applied Settings

Author

Rachel Freeman is Director of State Initiatives at the Research and Training Center on Community Living, Institute on Community Integration, University of Minnesota, Minneapolis. She may be reached at freem039@umn.edu.

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In the past decade, there has been an increasing value placed on using evidence-based practices to improve quality of life for children and adults with intellectual and developmental disabilities (IDD). While great strides have been made during this time in the develop­ment and identification of evidence-based practices, difficulties translating these research-based strategies into everyday settings continue to be problematic. In fact, some experts suggest that translation of research into practices that are meant to support people in real-world settings can be delayed up to 20 years or more (Metz & Bartley, 2012). A growing interest in improving the impact of evidence-based practices in home, school, work, and community settings has led to a science of implementation.

The purpose of this article is to describe how the principles of implementation science can help ensure the effective and sustainable use of evidence-based positive support practices by organizations working with persons with IDD.

The Meaning of Positive Support

The term positive support is used in this article to refer to practices that have these characteristics:

  • evidence-based and evidence-informed
  • person-centered
  • culturally competent
  • implemented in a manner that allows for ongoing evaluation and monitoring

Each of these characteristics is further described below.

Evidence-based Practices

Evidence-based practice is a term used across education, medical, and human service systems. The American Psycho­logical Association definition states that evidence-based practice is “…the inte­gration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (APA, 2002). According to the Asso­ciation for Positive Behavior Support, “Evidence-based practice….is defined as the integration of rigorous science-based knowledge with applied expertise driven by stakeholder preferences, values, and goals within natural communities of support.” (APBS, 2016). Although there are slight differences, many evidence-based practice definitions have the same ma­jor themes. Evidence-informed practices are strategies that have not established the amount of research necessary to be considered evidence-based, but have data collection systems in place to evaluate their effectiveness in applied settings.

Person-centered Values 

In the past, there was an assumption that people received services and, as consumers, should be placed into existing services and supports that were considered by others to be the best fit. The opinions and prefer­ences of people with disabilities were often ignored in this older paradigm of service provision. Person-centered values place the person at the center of important deci­sions that impact his or her life. In this new paradigm, people with IDD have the right to live life in the same manner as any other person within their communities. Supports are tailored to meet the needs of each person.

Culturally Competent 

The development of cultural competence refers to the ability of a person or system to respect, understand, appreciate, and interact with the people who live or work within a setting. Examples of cultural dif­ferences include age, abilities, religion, be­liefs, ethnicity, geographic or social groups, race, gender identity, sexual orientation, and socioeconomic status.

Ongoing Evaluation and Monitoring

Positive support practices include systems to assess whether practices are increas­ing quality of life over time. Fidelity of implementation, the extent to which a practice is being implemented in the manner intended, is an important tool in the evaluation process. Quality of life data, the frequency and intensity of incidents related to problematic events, staff climate, satisfaction levels of people being sup­ported, and staff and retention/tenure data are all examples of types of information used to evaluate a positive support.

A growing interest in improving the impact of evidence-based practices in home, school, work, and community settings has led to a science of implementation, which can help ensure the effective and sustainable use of evidence-based positive support practices by organizations working with persons with IDD.

The Multi-tiered Systems of Support Model

The term three-tiered systems of support refers to a concep­tual model from the field of public health, where it describes a strategy designed to prevent the spread of disease by outlining three levels of prevention (Gorden, 1983). The model has been adapted for education and human service settings as a way to encourage success and prevent failure in achieving positive academic, social, and/or quality of life outcomes for children and adults across a number of different settings including schools, mental health services, juvenile justice, and residential supports.

The terms primary, secondary, and tertiary prevention are used to describe each of the three levels. Primary Prevention refers to the use of universal strategies for all people within a setting. These universal strategies increase the use of positive supports and decrease the need for more intensive strategies. Secondary Prevention involves using data for early identification so that people can benefit from positive supports before aca­demic, social or quality of life problems are encountered. At the Tertiary Prevention level, people receive more intensive sup­ports based on their unique needs. When more than one type of practice is being implemented using a three-tiered model, it is referred to as multi-tiered systems of support. Figure 1 provides an example of person-centered practices and positive behavior support strategies implemented using multi-tiered systems of support.

Figure 1. Implementing Multi-Tiered Systems of Support

An infographic representing how to implement person-centered practices/planning and positive behavior support in a multi-tiered system. There is a triangle with three tiers. The first tier at the bottom is all people and represent primary prevention strategies. The second tier in the middle is some people and represents secondary prevention strategies. The third tier at the top reads few people and represents tertiary prevention strategies. To the left of the triangle are the person-centered practices and planning prevention strategies. To the right of the triangle are the positive behavior support prevention strategies.

Person-Centered Practices and Planning

All People – Primary Prevention

  • Person-Centered Thinking
  • Encourage Self Expression
  • Self-Determination and Choice Making
  • Predictable and Proactive Settings
  • Meaningful Participation in the Community

Some People – Secondary Prevention

  • Add Supports to Improve QOL
  • Independence and Community Involvement Encouraged
  • Mental Health and Wellness Strategies

Few People – Tertiary Prevention

  • Individualized Integrated Plans (PBS, Trauma-informed Therapy)
  • Person-Centered Plans
  • Teams Monitor Progress

Positive Behavior Supports

All People – Primary Prevention

  • Teach and Encourage Communication
  • Encourage and Reinforce Social Skills
  • Consensus-Based And Team-Based Planning
  • Emphasis on Using Data For Decisions
  • Integrated with Other Positive Support Practices (PBS, Trauma-Informed Care, Etc.)

Some People – Secondary Prevention

  • Use Data to Identify People At Risk
  • Additional Supports for Key Social Communication Skills
  • Group and Individual Interventions
  • Simple Function-Based Interventions
  • Mental Health and Wellness Interventions

Few People – Tertiary Prevention

  • Individualized PBS Plans
  • Integrated with Other Positive Supports (PCP, Trauma-Informed Care, DBT, Etc.)
  • Plans Are Evaluated to Ensure Fidelity
  • Outcome Measures
  • Teams Monitor Progress

Effective and Sustainable Implementation of Positive Supports

A review of research on evidence-based practices (Fixsen, Naoom, Blasé, Friedman, & Wallace, 2005) was conducted in order to identify the most important features of effective and sustainable implementa­tion. These implementation features are becoming better understood. Indeed, many of the important principles of implemen­tation are like “gravity”: They apply across human service sectors (U.S. Department of Education, 2012). The findings from the 2005 review by Fixsen and his colleagues (2005) resulted in the development of four implementation frameworks:

  • Implementation stages
  • Implementation drivers
  • Policy-practice feedback loops
  • Infrastructure for implementation support

The information below provides a summa­ry of these implementation frameworks (see the National Implementation Re­search Network’s Active Implementation Hub for more detailed information).

Figure 2. Implementation Stages

Four circles lined up horizontally. Each circle has an arrow to the next. Each circle represents one of the four implementation stages. The first circle on the left has the words exploration, the second circle has the words installation, the third circle has the words initial implementation, the fourth circle has the words implementation.

Implementation Stages

Strategies used to launch a positive sup­port do not remain fixed and unchanging. The initial efforts to implement a new practice will start with an exploration stage (see Figure 2). Teams assess how well practices will fit the culture of an agency or organization. Once exploration has been completed, a great deal of energy is dedicated to installing a new practice by allocating financial resources and developing capacity of staff members via training and coaching systems. The initial implementation stage is established once a positive support has been installed. This is an important time for agency and organi­zational teams as a new positive support is being implemented and is expanding across an organization.

Teams successfully completing the first three stages move into full implementa­tion using data to make modifications to training and communication systems. Full implementation is in place when practices are embedded across all levels of an orga­nization. Issues related to sustainability be­come the focus of attention as an organi­zation moves into the full implementation of a positive support practice.

Sustainability refers to the long-term im­plementation of a positive support practice that includes evidence that high levels of fidelity of implementation have been documented and where valued outcomes are achieved (Macintosh, Horner, et al., 2009). A key mechanism for sustaining a positive support practice is the extent to which performance assessments are conducted to evaluate implementation (McIntosh, Filter, Bennett, Ryan, & Sugai, 2010). Ongoing performance assessment allows trainers to identify problems and intervene before implementation falters. Ongoing progress monitoring, data-based decision making, and capacity-building activities are used to encourage sustainable implementation efforts.

Sustainability refers to the long-term im­plementation of a positive support practice that includes evidence that high levels of fidelity of implementation have been documented and where valued outcomes are achieved

Implementation Drivers

A core element of any training and technical assistance effort is referred to as implementation drivers (Metz & Bartley, 2012). Three types of drivers are used concurrently to implement positive sup­ports with a high level of fidelity and in a sustainable manner: competency, organiza­tional, and leadership drivers.

Competency Drivers. These drivers focus on strategies that will develop and improve staff and supervisor skills in implementing a positive support. Effective training starts with the selection of staff members who are the best fit for different roles related to implementation. Readiness of staff members to participate in imple­menting a new positive support is assessed before implementation begins. Training and strategies for providing staff members with coaching on an ongoing basis is an important part of any implementation effort. Performance assessments are used regularly to ensure sustainable and effec­tive practice.

Organizational Drivers. The organi­zational support systems that are identified by a team implementing a positive support create an environment where change can occur. Data-based decision-making systems are established to assess overall performance. Quality assurance, fidelity of implementation, outcome, and orga­nizational data are reviewed regularly.

Successful teams build data-based decision making into meetings in a manner that encourages sustainable routines. These data are used by teams to create actions for improving positive support practices. Fa­cilitative administration within an organi­zation is used to make sure that problems are solved, staff members are organized, policies and procedures align with positive supports, and resources are allocated in a manner that supports implementation efforts. Teams focus on aligning external systems (partner organizations, sources of funding) that impact an organization.

Adaptive leadership involves reaching out to staff, listening to people express their feelings and beliefs, and working together with a group to identify solutions that will eliminate resistance to implementing a positive support.

Leadership Drivers. Two types of leadership are involved in systems change: technical and adaptive. Technical leadership is used to manage positive support training systems by overseeing competency and organizational drivers described above. Adaptive leadership is needed when tradi­tional problem-solving strategies are not effective. An adaptive leadership approach is needed when resistance is encountered by staff members implementing a positive support. Adaptive leadership involves reaching out to staff, listening to people express their feelings and beliefs, and working together with a group to identify solutions that will eliminate resistance to implementing a positive support. A com­mon mistake that is made by leaders who are implementing a new positive support practice is to attempt to apply technical leadership strategies in situations requir­ing adaptive leadership skills (Heifetz & Laurie, 1997).

Policy-Practice Feedback Loops 

Strategies for assessing and connecting policies that are related to positive support practices can be key factors for effective implementation. Without a process for aligning practices with the policy level, trainers, organizational leaders, and staff members may experience barriers while implementing positive supports. Creating internal cycles of communication that in­tersect with organizational, regional, and/or state processes will assist organizations in aligning person-centered values and positive support practices.

Infrastructure for Implementation Support

Traditional strategies for implementing evidence-based and evidence-informed practices have often left organizational leaders on their own to figure out how to implement a practice. Establishing an implementation team within the organi­zation is one way to avoid relying on one-shot workshops to introduce new practices. This organization-wide team includes rep­resentatives across key stakeholders who, together, provide oversight and leadership to implement a new practice over time.

Effective implementation teams share progress regularly with all stakeholders and engage in celebration of successes. Es­tablishing feedback loop systems for com­munication within organizations improves technical assistance when it is provided by external trainers and provides a way in which information can be systematically shared across the organization.

Conclusion

Evidence-based and evidence-informed practices must be identified and imple­mented by organization-wide teams who have clearly articulated the values import­ant to the people who will be implement­ing new changes. The term positive sup­port has been used in this article to refer to evidence-based and evidence-informed decision making practices that include core values of person-centeredness and cultural competence. Organization-wide teams may add additional values that are meant to guide practices within a system. Once these practices are identified, teams can use implementation science to help ensure effectiveness and sustainability.

References

  • American Psychological Association (APA). (2016). Policy statement on evidence-based practice in psychology. Retrieved from http://www.apa.org/practice/guidelines/evidence-based-statement.aspx

  • Association for Positive Behavior Support (APBS). (2016). APBS evidence-based practice information. Retrieved from http://www.apbs.org/evidence-based-practice.html

  • Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., & Wallace, F. (2005). Implementation research: A synthesis of the literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, National Implementation Research Network. (FMHI Publication No. 231).

  • Gordon, R. S. (1983). An operational classification of disease prevention. Public Health Reports, 98, 107–109.

  • Heifetz, R. A., & Laurie, D. L. (1997). The work of leadership. Harvard Business Review, 75, 124–134.

  • McIntosh, K., Filter, K., Bennett, J. L., Ryan, C., & Sugai, G. (2010). Principles of sustainable prevention: Designing scale-up of school-wide positive behavior support to promote durable systems. Psychology in the Schools, 47(1), 5–21.

  • Metz, A., & Bartley, L. (2012). Active implementation frameworks for program success: How to use implementation science to improve outcomes for children. Zero to Three, 32, 11–18.

  • National Implementation Research Network . (2016). Module 2: Implementation stages. Retrieved from http://implementation.fpg.unc.edu/module-1/implementation-stages

  • U.S. Department of Education . (2012). Adult Education Great Cities Summit: Implementing literacy programs to improve student achievement. Retrieved from U.S. Department of Education, Office of Vocational and Adult Education website: http://fpg.unc.edu/node/4732

Resources

Implementation Research: A Synthesis of the Literature PDF