We have manualized evidence-based treatments, but no one uses them. How can we improve attendance rates?

You are not alone. Many clinics have the problem that they train staff to deliver evidence-based treatments that have amazing results in research studies, but very few patients attend when it is delivered in usual care clinics. We see this in Supported Employment programs, weight loss services, and family services, for example.

Critical to improving uptake is tailoring (or adapting) the evidence-based practice to local context and the target population while still retaining key elements of the treatment. The first step in tailoring the treatment is to ask patients who would be eligible for the treatment (for example, obese patients with serious mental illness) why they do not attend the sessions. Second, ask providers who see the eligible population what they consider to be aspects of the delivery that make it difficult for their patients (for example, need to attend weekly sessions) and difficult to deliver (for example, rooms available for large group sessions). These data can guide the tailoring to improve uptake of evidence-based practices. Once tailored, it is always important to reassess the program and collect data in order to decide whether or not the tailoring improved the identified problems. Do more individuals attend? Are outcomes better?

Here are some tips from clinicians and researchers who have tailored interventions with success:  
Individuals with a serious mental illness often have trouble with regular transportation and also have limited income making attendance at weekly in-person sessions difficult. These barriers require adjusting delivery of the service. For example, maybe the service could be delivered in the community where many eligible individuals live (maybe at a church, community center, barber shop). Or, maybe the service could be delivered by phone or at least sometimes by phone. Maybe the service could be delivered online—many patients have cellphones with internet access and anyone can access the internet at the local library. Another option is to deliver the service at the clinic on a day that has a high volume of patient appointments (e.g., Clozapine clinic day).

Individuals with a serious mental illness often have cognitive deficits that accompany their illness. These deficits may impede their ability to plan for sessions, follow-through on homework, or understand complicated handouts. This requires a serious look at the handouts and simplifying the messages by reducing distracting details that are unneeded (like lots of color and shifting font styles and sizes), using simple sentence structure, bolding the main messages. Active learning strategies should be used in group sessions including patients teaching each other, reading aloud, and working in pairs. Reading level of handouts should be 8th grade or lower.

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