Issue Brief 58 -Ensuring Quality in Children's Mental Health: Certification in Evidence-Based Practices

November 13, 2017

Ensuring Quality in Children's Mental Health: Certification in Evidence-Based Practices

The number of effective treatments for children’s mental health conditions has dramatically increased over the past 15 years. This progress is largely due to hundreds of new evidence based practices (EBPs), broadly defined as programs that research has shown are effective for targeted health problems. Researchers, policymakers, and providers alike have called for improving access to EBPs within community-based agencies serving children and youth. In Connecticut, CHDI has worked with the Connecticut Department of Children and Families and others to disseminate nine trauma-focused EBPs, which have been provided to more than 10,000 children since 2008. As states invest in EBPs as a strategy to improve care, they need to ensure that mental health providers are trained and equipped to deliver EBPs successfully.  Certification is one such strategy for improving access to and quality of EBPs.

Training is Necessary but Insufficient for Ensuring Strong Outcomes

The proliferation of EBPs has led to an increase in the number of clinicians attending EBP training. However, use of EBPs in the community remains low and the majority of children and families receiving mental health services still do not receive an EBP. Training is necessary but insufficient for ensuring effective use of an EBP, and many clinicians trained in an EBP may not actually use the model. Reasons for this vary, but include lack of a defined pathway to competency for clinicians following training, competing demands, or limited agency infrastructure or support. In the absence of clear standards it is difficult for professionals and the public to differentiate between clinicians who simply attend training and those who have sufficient training, consultation, experience, and/or competency to effectively provide the EBP as intended. EBP developers vary considerably in whether and to what extent they have defined minimum requirements for certification[1]; many have no formal certification, some have minimal training requirements, and others have a more extensive process. 

Of EBPs that have a defined certification process, requirements often include in-person training, post-training consultation from a sanctioned trainer, supervision by a trained supervisor, and successful use of the EBP with a specified number of children. Some EBPs have additional requirements such as submission of audio or video taped clinical sessions for fidelity review, written aptitude testing, advanced clinical training, certification fees, and ongoing quality assurance and monitoring by model developers or their designees.

Balancing Cost, Accountability, and Scalability is Important for Developing EBP Certification

While there are benefits to having rigorous standards for clinicians providing EBPs, such requirements can be costly and challenging for providers, especially when EBPs are not reimbursed at higher rates than usual care. To balance the needs of developing meaningful standards with limited resources, some states are developing more basic EBP certification processes for large-scale EBP efforts.

For example, many states are developing standards for agencies and/or clinicians who provide EBPs, including:

• In Texas, the Department of State Health Services created certification requirements for clinicians implementing Cognitive Behavioral Therapy (CBT) that include training, competency testing, supervision from a certified CBT provider, and video submission of two clinical sessions for review.
• North Carolina requires clinicians to complete training requirements and demonstrate clinical competency and adherence for a number of EBPs.
• In Ohio, the state’s Coordinating Centers of Excellence (CCOEs) requires clinicians seeking certification in Assertive Community Treatment (ACT) to attend comprehensive training and to work closely with a certified supervisor to create an individualized supervision plan.
• New York has a more general process by which agencies and clinicians can apply for state designation as an EBP provider by submitting documentation of their training and evidence that they have used the model with clients.

As part of the certification process, many states have begun to create public websites listing clinicians certified in an EBP. These lists provide professionals and the public with a resource for identifying providers who meet basic EBP training requirements and provide recognition to clinicians for completing certification requirements.

Connecticut’s Experience Suggests that EBP Certification Can Improve Outcomes

In Connecticut, CHDI has partnered with the Department of Children and Families and EBP developers to establish a state certification process for several outpatient EBPs, including Trauma Focused Cognitive Behavioral Therapy (TF-CBT) and Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems (MATCH-ADTC). Development of State certification procedures was prompted by early Connecticut data showing that approximately 35% of clinicians trained in one EBP did not report using the EBP at all following training; thus efforts were needed to ensure that scarce resources were supporting providers that put EBPs into practice, while also recognizing and distinguishing clinicians who completed the EBP certification requirements. Certified clinicians may be recognized by their agency (e.g. promotion, salary, productivity reduction) and can allow their agencies to be recognized (e.g. the number or proportion of certified clinicians can be used as an agency quality indicator). State certification also provides an interim milestone for clinicians who are not yet eligible for national certification, which may have more stringent requirements or additional costs. 

Connecticut EBP certification requirements vary somewhat by EBP, but typically require completing training and clinical consultation from a sanctioned trainer, evidence of providing the EBP to several children, and evidence of achieving good clinical outcomes. CHDI maintains a public registry that includes an interactive searchable map for the public to search for agencies with certified clinicians in or near their community.

Preliminary analysis shows that clinicians who met TF-CBT requirements for state certification provided TF-CBT to 19% more children, successfully completed TF-CBT with more than twice as many children, and had 13% higher rates of improvement, compared with TF-CBT clinicians who were not certified.

Certification in EBPs is an important strategy for ensuring that Connecticut’s children and families have access to the highest quality mental health treatment and that providers are competent to provide EBPs with fidelity. Ultimately developing standards for EBP certification will require balancing the need to assess competency, fidelity, and outcomes with making certification accessible and affordable to community-based providers on a large scale. Connecticut can continue to build on its reputation as a national leader in EBPs by implementing reasonable and affordable EBP certification processes that promote optimal treatment outcomes. 

Recommendations for continuing to improve children’s mental health outcomes through EBP certification include:

1. Continue to invest in EBPs and include EBP clinician certification processes in all EBP dissemination efforts in ways that are efficient and cost effective for providers.
2. Identify a core set of certification criteria for all EBPs, such as: sanctioned training and consultation in the EBP, a minimum number of clients served, fidelity, and the achievement of consistently high child outcomes.
3. Consider higher reimbursement rates for EBPs that can help cover the costs to clinics for getting clinicians trained and certified in EBPs, and higher pay for certified clinicians that deliver those EBPs.
4. Ensure that current and future efforts around payment reform and value-based purchasing include an emphasis on delivering EBPS and clinician certification in EBPs.
5. Use available data and research to better understand the most efficient and effective certification requirements for improving outcomes.

 

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