Step Therapy and Step Therapy Exceptions: A Review of the Research Evidence and State Policies

The 2018 Washington State Legislature directed the Washington State Institute for Public Policy (WSIPP) to conduct evidence reviews on step therapy and step therapy exceptions and to summarize step therapy exceptions codified in other states. One goal of the assignment is to determine whether this type of prescription drug utilization management practice has an effect on health outcomes. In this report, we describe the results of our evidence reviews on step therapy and step therapy exceptions and describe the limitations of the research evidence. We also summarize the step therapy exceptions codified in other states and describe Washington’s codified step therapy exception.

Outcomes of Referrals to Child Protective Services: Comparing Reporters

The 2008 Legislature directed the Office of the Family and Children's Ombudsman (OFCO) to analyze referrals of child abuse and neglect to find out whether the source of the referral influenced the response by the Child Protective Services (CPS) at the Department of Social and Health Services (DSHS). OFCO contracted with the Institute to perform the study. We examined a total of 96,000 referrals made between January 2006 and February 2008 and found that educators and social services professionals make more reports to CPS than other types of reporters. Compared with other reporters, referrals from law enforcement were more likely to both be accepted for investigation and result in removal of a child from his or her home.

The study also found variations in the outcomes of referrals from the various types of reporters. The largest variations in outcomes were determined by DSHS region and the risk assignment history of individual intake workers. Intake workers with a history of assigning higher levels of risk than their peers were more likely to continue to assign higher levels of risk.

Family Team Decision-Making: Does it Reduce Racial Disproportionality in Washington's Child Welfare System?

Washington’s Children’s Administration uses Family Team Decision Making (FTDM) meetings to involve parents and other family members, the child (when appropriate), friends, foster parents, caseworkers, and other professionals. Ideally, FTDM meetings are held for all decisions involving child removal, change of placement, and reunification or other permanency plan. In 2008, DSHS convened 6,600 FTDM meetings regarding nearly 8,000 children.

An earlier Institute study demonstrated over-representation of Indian, Black and Latino children in Washington’s child welfare system. Following referrals to Child Protective Services (CPS), Indian and Black children (but not Asian or Latino children) were more likely to be placed in foster care, and to remain in care significantly longer than White children. In 2009, the Legislature directed the Institute to study the effects of the implementation of FTDM on racial disproportionality.

When we studied outcomes for the child welfare caseload statewide, we found that FTDM had no effect on out-of-home placement, time to permanency, or new referrals to CPS.

When we examined outcomes by racial groups, however, we found three positive results for FTDM. 1) Latino children experienced decreased rates of placement. 2) Asian children achieved permanency more quickly than those in non-FTDM offices. 3) Black children exiting to permanency were less likely to be the alleged victims of new accepted CPS referrals.

With the exception of these three favorable results, FTDM as implemented in Washington did not affect disproportionality for Indian or Black children with respect to placement in foster care or time to permanency.

Wilderness Therapy Programs: A Systematic Review of Research

Wilderness therapy programs are set in natural or remote settings and embed therapeutic elements into daily outdoor activities like camping and backpacking in order to build program participants’ personal and interpersonal skills. Some programs serve individuals with behavioral, mental health, and substance use disorders.

In 2021, the Washington State Legislature directed WSIPP to conduct a research review of wilderness therapy programs and assess stakeholder interest in Washington. We identified 88 studies evaluating programs serving youth and adult populations in need of behavioral, mental health, and substance use support. Due to limitations in the literature, we could not estimate whether or not wilderness therapy programs are effective or determine if the approach is cost beneficial. In this report, we describe our systematic literature review and summarize the main themes from the literature including program models, populations served, and general findings.

A second report, due December 2022, builds on this report and will focus on the interest of stakeholders who currently participate in wilderness therapy programs in Washington or want to in the future.

Wilderness Therapy Programs: Stakeholder Perspectives in Washington

This is the second report in a two-part series focused on wilderness therapy programs. Wilderness therapy combines therapeutic elements with outdoor activities in a natural setting to help support individuals with a range of behavioral, emotional, and substance use issues.

In 2021, the Washington State Legislature directed WSIPP to research wilderness therapy programs in the context of behavioral health treatment and prevention. As part of this assignment, we were asked to assess the “interest and likelihood of support” for wilderness therapy programs among interest groups like “state prevention coalitions and tribes.” We interviewed ten individuals representing a variety of stakeholder perspectives in Washington.

Generally, we found that interview respondents view wilderness therapy as potentially beneficial for the individuals they serve or those who live in their communities. However, we found that most respondents had concerns about cost, safety, access, and the lack of information about programs. Respondents also expressed wanting legislators to be aware of issues related to program flexibility, equitable access, and ongoing outreach if they consider policy decisions related to wilderness therapy in the future.

The first report on this topic was published in June 2022 and can be found here.

Involuntary Civil Commitments: Common Questions and a Review of State Practices

The 2014 Washington State Legislature directed the Washington State Institute for Public Policy to investigate state practices regarding different aspects of the involuntary commitment process. This paper discusses common questions related to civil commitments and includes detail on commitment laws in each state.

Washington's Sexually Violent Predator Law: Legislative History and Comparisons With Other States

In 1990, Washington State enacted a law authorizing civil commitment of individuals found to be “sexually violent predators” at the end of their criminal sentence. This civil commitment law was part of an omnibus bill, the 1990 Community Protection Act. In order to increase the state’s knowledge about effective strategies with sex offenders, the legislature directed the Institute to evaluate this law’s effectiveness. This publication updates information on the implementation and background of sexual predator laws.

Updated Inventory of Evidence-Based, Research-Based, and Promising Practices

Inventory of Evidence-Based, Research-Based, and Promising Practices
For Prevention and Intervention Services for Children and Juveniles
in the Child Welfare, Juvenile Justice, and Mental Health Systems

The 2012 Legislature passed E2SHB 2536 with the intention that “prevention and intervention services delivered to children and juveniles in the areas of mental health, child welfare, and juvenile justice be primarily evidence-based and research-based, and it is anticipated that such services will be provided in a manner that is culturally competent.”

The bill directs the Washington State Institute for Public Policy (WSIPP) and the University of Washington Evidence-Based Practice Institute (UW) to publish descriptive definitions and prepare an inventory of evidence-based, research-based, and promising practices and services, and to periodically update the inventory as more practices are identified. This is the first update to the September 30, 2012 publication. The accompanying report describes the inventory update process, as well as the ongoing technical assistance process by UW.

Special Commitment Center for Sexually Violent Predators: Potential Paths toward Less Restrictive Alternatives

Washington State law provides for indefinite civil commitment of persons found to meet criteria as sexually violent predators (SVPs). The Special Commitment Center (SCC) on McNeil Island houses persons who are detained and/or committed as SVPs. The Institute was directed to study several aspects of SCC. Major findings include:

Releases: As of CY 2012, 86 residents have been released from SCC.

Treatment: 37% of residents actively participate in sex offense treatment.

Annual Reviews: A survey of legal practitioners revealed concerns about the timeliness of reviews, with mixed reports regarding the quality.

Senior Clinical Team: SCC’s group of senior clinicians and managers plays a key role in residents’ treatment progression and decision-making regarding readiness for a less restrictive alternative. Some practitioners in the legal community expressed confusion and/or concern about the team’s role.

Less Restrictive Alternatives: Confinement at the state’s Secure Community Transition facilities costs significantly more than confinement at the main facility.

The report includes a response from the Special Commitment Center.

Revised on 1/28/2013 to modify Exhibits 1 and 17.

What Works and What Does Not? Benefit-Cost Findings from WSIPP

For the last 20 years, the Washington State Institute for Public Policy (WSIPP) has conducted systematic evidence reviews and economic analysis on a variety of topics for the Washington State Legislature. Over time, we have improved and refined the methods we use to conduct this research.

When WSIPP undertakes an economic analysis at the direction of the legislature, we use a standardized set of procedures to collect and analyze research literature. We then apply consistent methods to translate the research findings to dollars and cents, asking, “What are the overall benefits and costs?” of each program or policy option. Finally, we use information about the uncertainty in the research findings and economic assumptions to compute the risk associated with each policy option.

The primary goal of this research is to provide the legislature with objective information about the long-term economic consequences of each program or policy option reviewed. In this report, we summarize our current findings.