Toward a policy ecology of implementation of evidence-based practices in public mental health settings

George Warren Brown School of Social Work, and Department of Psychiatry, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA.
Implementation Science (Impact Factor: 4.12). 02/2008; 3(1):26. DOI: 10.1186/1748-5908-3-26
Source: PubMed


Mental health policymaking to support the implementation of evidence-based practices (EBPs) largely has been directed toward clinicians. However, implementation is known to be dependent upon a broader ecology of service delivery. Hence, focusing exclusively on individual clinicians as targets of implementation is unlikely to result in sustainable and widespread implementation of EBPs.
Policymaking that is informed by the implementation literature requires that policymakers deploy strategies across multiple levels of the ecology of implementation. At the organizational level, policies are needed to resource the added marginal costs of EBPs, and to assist organizational learning by re-engineering continuing education units. At the payor and regulatory levels, policies are needed to creatively utilize contractual mechanisms, develop disease management programs and similar comprehensive care management approaches, carefully utilize provider and organizational profiling, and develop outcomes assessment. At the political level, legislation is required to promote mental health parity, reduce discrimination, and support loan forgiveness programs. Regulations are also needed to enhance consumer and family engagement in an EBP agenda. And at the social level, approaches to combat stigma are needed to ensure that individuals with mental health need access services.
The implementation literature suggests that a single policy decision, such as mandating a specific EBP, is unlikely to result in sustainable implementation. Policymaking that addresses in an integrated way the ecology of implementation at the levels of provider organizations, governmental regulatory agencies, and their surrounding political and societal milieu is required to successfully and sustainably implement EBPs over the long term.

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Available from: Ramesh Raghavan, Jul 24, 2014
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    • "Finally, contextual variation often has immense implications for the selection of implementation strategies [42]. For instance, settings are likely to vary substantially with regard to patient characteristics [43,44]; provider-level factors such as attitudes toward EBPPs [45]; organizational-level characteristics such as culture and climate [46], implementation climate [47], organizational readiness for change [48], leadership [49,50], capacity for sustainability [51,52], and structural characteristics of the organization [53]; and systems-level characteristics such as policies and funding structures that are facilitative of the EBPP [54]. It is likely that implementation strategies will need to be tailored to address the specific barriers and leverage existing facilitators in different service settings [2,55,56]. "
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    ABSTRACT: Identifying feasible and effective implementation strategies that are contextually appropriate is a challenge for researchers and implementers, exacerbated by the lack of conceptual clarity surrounding terms and definitions for implementation strategies, as well as a literature that provides imperfect guidance regarding how one might select strategies for a given healthcare quality improvement effort. In this study, we will engage an Expert Panel comprising implementation scientists and mental health clinical managers to: establish consensus on a common nomenclature for implementation strategy terms, definitions and categories; and develop recommendations to enhance the match between implementation strategies selected to facilitate the use of evidence-based programs and the context of certain service settings, in this case the U.S. Department of Veterans Affairs (VA) mental health services. This study will use purposive sampling to recruit an Expert Panel comprising implementation science experts and VA mental health clinical managers. A novel, four-stage sequential mixed methods design will be employed. During Stage 1, the Expert Panel will participate in a modified Delphi process in which a published taxonomy of implementation strategies will be used to establish consensus on terms and definitions for implementation strategies. In Stage 2, the panelists will complete a concept mapping task, which will yield conceptually distinct categories of implementation strategies as well as ratings of the feasibility and effectiveness of each strategy. Utilizing the common nomenclature developed in Stages 1 and 2, panelists will complete an innovative menu-based choice task in Stage 3 that involves matching implementation strategies to hypothetical implementation scenarios with varying contexts. This allows for quantitative characterizations of the relative necessity of each implementation strategy for a given scenario. In Stage 4, a live web-based facilitated expert recommendation process will be employed to establish expert recommendations about which implementations strategies are essential for each phase of implementation in each scenario. Using a novel method of selecting implementation strategies for use within specific contexts, this study contributes to our understanding of implementation science and practice by sharpening conceptual distinctions among a comprehensive collection of implementation strategies.
    Full-text · Article · Mar 2014 · Implementation Science
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    • "124). Raghavan et al. (2008) asserted that planning complex interventions requires attention to the policy ecology surrounding program adoption, including mental health organizations and government funding and regulatory environments. For instance, planning at the organizational level can be a challenge because resources, such as ongoing training and technical assistance provided by government departments, are often lacking (Wandersman et al. 2008). "
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    ABSTRACT: This research focused on the relationships between a national team and five project sites across Canada in planning a complex, community intervention for homeless people with mental illness called At Home/Chez Soi, which is based on the Housing First model. The research addressed two questions: (a) what are the challenges in planning? and (b) what factors that helped or hindered moving project planning forward? Using qualitative methods, 149 national, provincial, and local stakeholders participated in key informant or focus group interviews. We found that planning entails not only intervention and research tasks, but also relational processes that occur within an ecology of time, local context, and values. More specifically, the relationships between the national team and the project sites can be conceptualized as a collaborative process in which national and local partners bring different agendas to the planning process and must therefore listen to, negotiate, discuss, and compromise with one another. A collaborative process that involves power-sharing and having project coordinators at each site helped to bridge the differences between these two stakeholder groups, to find common ground, and to accomplish planning tasks within a compressed time frame. While local context and culture pushed towards unique adaptations of Housing First, the principles of the Housing First model provided a foundation for a common approach across sites and interventions. The implications of the findings for future planning and research of multi-site, complex, community interventions are noted.
    Full-text · Article · Sep 2012 · American Journal of Community Psychology
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    • "Multiple factors at system, organizational, and individual levels influence the implementation of evidence-based practices (EBPs) and other innovations in public sector social service and mental healthcare settings [1-4]. These factors include policy, social and economic characteristics, characteristics of the innovation itself, characteristics of the organization attempting to implement the innovation, and characteristics of service providers and clients [1,3-8]. "
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    ABSTRACT: Background Evidence-based practices have not been routinely adopted in community mental health organizations despite the support of scientific evidence and in some cases even legislative or regulatory action. We examined the association of clinician attitudes toward evidence-based practice with organizational culture, climate, and other characteristics in a nationally representative sample of mental health organizations in the United States. Methods In-person, group-administered surveys were conducted with a sample of 1,112 mental health service providers in a nationwide sample of 100 mental health service institutions in 26 states in the United States. The study examines these associations with a two-level Hierarchical Linear Modeling (HLM) analysis of responses to the Evidence-Based Practice Attitude Scale (EBPAS) at the individual clinician level as a function of the Organizational Social Context (OSC) measure at the organizational level, controlling for other organization and clinician characteristics. Results We found that more proficient organizational cultures and more engaged and less stressful organizational climates were associated with positive clinician attitudes toward adopting evidence-based practice. Conclusions The findings suggest that organizational intervention strategies for improving the organizational social context of mental health services may contribute to the success of evidence-based practice dissemination and implementation efforts by influencing clinician attitudes.
    Full-text · Article · Jun 2012 · Implementation Science
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