A conceptual framework for transferring research to practice

Addiction treatment outcomes, process and change: Texas Institute of Behavioral Research at Texas Christian University

For more than 40 years the Texas Institute of Behavioral Research (IBR) has given special attention to assessment and evaluation of drug user populations, addiction treatment services and various cognitive and behavioral interventions. Emphasis has been on studies in real-world settings and the use of multivariate methodologies to address evaluation issues within the context of longitudinal natural designs. Historically, its program of addiction treatment research may be divided into three sequential epochs-the first era dealt mainly with client assessment and its role in treatment outcome and evaluation (1969-89), the second focused upon modeling the treatment process and the importance of conceptual frameworks (1989-2009) in explaining the relationships among treatment environment, client attributes, treatment process and outcome, and the third (and current) era has expanded into studying tactical deployment of innovations and implementation. Recent projects focus upon adapting and implementing innovations for improving early engagement in adolescent residential treatment settings and drug-dependent criminal justice populations. Related issues include the spread of human immunodeficiency virus/acquired immune deficiency syndrome and other infectious diseases, organizational and systems functioning, treatment costs and process related to implementation of evidence-based practices.

Facilitating factors and barriers to the use of medications in publicly funded addiction treatment organizations

OBJECTIVES

Publicly funded addiction treatment organizations have been slow to adopt pharmacotherapies. Few studies have examined the organizational factors associated with adoption of different types of medication in this treatment sector. This study identifies organization-level facilitators and barriers to the use of medications in publicly funded addiction treatment organizations.

METHODS

Face-to-face interviews with a sample of 318 administrators of a representative sample of publicly funded addiction treatment centers in the US.

RESULTS

Only 23.4% of programs reported using any of the five FDA-approved pharmacotherapies for treating addiction. An additional 14.3% of programs only used medications approved for the treatment of psychiatric disorders. Multivariate multinomial logistic regression results revealed that the odds of adoption of addiction pharmacotherapies were significantly greater in government-owned programs and in programs with more medical personnel. Programs that relied more heavily on non-Medicaid public funding tended to be less likely to adopt addiction treatment medications. Greater contact with pharmaceutical representatives was positively associated with medication adoption.

CONCLUSIONS

Current public funding policies and lack of access to medical personnel are barriers to the adoption of medications by publicly funded addiction treatment organizations. Efforts to promote adoption may also benefit from greater detailing activities by pharmaceutical representatives. These findings suggest that the large research investment devoted to developing addiction treatment medications may have limited public health impact due to the characteristics of publicly funded service delivery system as well as the limited attention given to this system by commercial purveyors of medications.

Racial disparities in substance abuse treatment and the ecological fallacy

This study examined engagement in treatment in substance abuse treatment programs that treated primarily either African American or White clients. Findings showed higher levels of engagement in White programs; however, engagement of African Americans in White programs was similar to that of Whites and was greater than Whites in African American programs. No significant differences emerged when a mixed model analysis considered additional variables of staff consensus (regarding treatment elements), treatment climate, acceptance of Medicaid clients, the proportion mandated to treatment, and the quality of the physical space. Although African American programs may show poorer levels of engagement than White programs, attribution of engagement in treatment to client level race/ethnicity should be made with caution.

Site selection in community-based clinical trials for substance use disorders: strategies for effective site selection

BACKGROUND

The importance of conducting substance use disorder treatment research in real-world settings is now well recognized. While this approach to clinical trials research offers a variety of benefits, challenges also arise. Selecting high-quality sites to participate is critical to recruitment, retention, and overall trial performance when conducting multi-site, community-based clinical trials of treatments for substance use disorders.

OBJECTIVES

Over the past 10 years, the National Institute on Drug Abuse-sponsored National Drug Abuse Treatment Clinical Trials Network (CTN) has strived to conduct high-quality, well-managed clinical trials. This includes developing methods for site selection to be used by investigators conducting CTN trials.

METHODS

We review site selection strategies from two community-based multi-site clinical trials conducted under the auspices of the National Drug Abuse Treatment Clinical Trials Network.

RESULTS

Issues relevant to site selection include the clinical trial design, availability of appropriate clinical population, and organizational attributes of potential clinical research sites. Site selection strategies include reviewing regional epidemiologic data, collecting standard site selection surveys, evaluating clinic data on existing patient populations, and site selection interviews and visits.

CONCLUSION

This article describes considerations for selecting research sites and identifies specific strategies to employ when selecting community-based sites for participation in clinical trials.

Effects of workshop training for providers under mandated use of an evidence-based practice

Workshops are a common strategy for fostering the adoption of evidence-based practices (EBP), but workshops alone may not change provider behavior. This study investigates the impact of a two-day training combined with an existing mandate for EBP use. Providers attending regional workshops showed improved attitudes toward the behavioral parent training model, but not EBPs in general. Participants were more accepting of behavioral techniques shortly after training, but the effect was not maintained. Examination of youth served prior to and after the training showed that providers increased their use of the EBP but overall outcomes were not improved.

Channels of change: contrasting network mechanisms in the use of interventions

This study informs community science, and seeks to narrow the research-to-practice gap, by examining how the interpersonal networks within a setting influence individuals' use of interventions. More specifically, it explores the role of two network mechanisms-cohesion and structural similarity-in urban elementary school teachers' use of interventions designed to improve academic and behavioral outcomes for students. Lagged regression models examine how position in advice giving networks influenced weekly use of the daily report card and peer assisted learning by kindergarten through fourth grade teachers in three schools. Results indicate that intervention use spreads among teachers with similar patterns of advice-giving relationships (i.e., via structural similarity), rather than from teachers who are sources of advice (i.e., via cohesion). These results are consistent with findings in other settings, and suggest that researchers wishing to increase the use of an intervention should select change agents based on their patterns of their relationships, rather than on their direct connections.

Advancing a conceptual model of evidence-based practice implementation in public service sectors

Implementation science is a quickly growing discipline. Lessons learned from business and medical settings are being applied but it is unclear how well they translate to settings with different historical origins and customs (e.g., public mental health, social service, alcohol/drug sectors). The purpose of this paper is to propose a multi-level, four phase model of the implementation process (i.e., Exploration, Adoption/Preparation, Implementation, Sustainment), derived from extant literature, and apply it to public sector services. We highlight features of the model likely to be particularly important in each phase, while considering the outer and inner contexts (i.e., levels) of public sector service systems.

Addiction treatment provider attitudes on staff capacity and evidence-based clinical training: results from a national study

This national study of addiction-treatment organizations' implementation of evidence-based practices examines: (1) organizational/leadership factors associated with director (n = 212) attitudes regarding staff resistance to organizational change, and (2) organizational/staff factors associated with staff (n = 312) attitudes regarding evidence-based clinical training. Linear regression analyses, controlling for type of treatment unit, leadership/staff characteristics and organizational readiness to change, identified that directors who perceived their organization needed more guidance and had less staff cohesion and autonomy rated staff resistance to organizational change significantly higher. Staff with higher levels of education and greater agreement that their organization supported change had greater preference for evidence-based trainings. Federal addiction treatment policy should both promote education and training of treatment staff and organizational development of treatment CBOs. 

THE DEVELOPMENT AND USE OF A MODEL TO PREDICT SUSTAINABILITY OF CHANGE IN HEALTH CARE SETTINGS

Innovations adopted through organizational change initiatives are often not sustained leading to diminished quality, productivity, and consumer satisfaction. Research explaining variance in the use of adopted innovations in health care settings is sparse, suggesting the need for a theoretical model to guide research and practice. In this article, we describe the development of a hybrid conjoint decision theoretic model designed to predict the sustainability of organizational change in health care settings. An initial test of the model's predictive validity using expert scored hypothetic profiles resulted in an r-squared value of .77. The test of this model offers a theoretical base for future research on the sustainability of change in health care settings.

A community planning process for the implementation of evidence-based practice

Over the past 10 years, increasing attention has been paid to the development and implementation of 'evidence-based' practices or EBPs. In 1998, the National Academy of Sciences' Institute of Medicine began drawing attention to the discrepancy between research findings and practice patterns in the treatment of substance abuse. The community coalition described in this study was developed to create a partnership between substance abuse treatment providers, policy makers, university-based researchers, and consumers to examine treatment advances and evaluate their possible application in local community settings. In the first year the community coalition conducted a needs assessment, with the goal of prioritizing areas for practice change. The needs assessment process included focus groups, key informant interviews, and a survey of substance abuse treatment providers. The questions addressed at each stage of the assessment varied, but collectively all methods formed the basis for consensus-building for a change in practice in substance abuse treatment. The results of the needs assessment were further refined and influenced the development and implementation of two evidence-based practices (EBPs) within multiple agencies. Implications for using a community needs assessment to highlight coalition building and identify and adopting EBPs are discussed.

A review of computer-based interventions used in the assessment, treatment, and research of drug addiction

Computer-based interventions are cost-efficient methods that may result in greater access to drug addiction treatment. We review recent findings from our laboratory where computer-based interventions have produced outcomes that are comparable to therapist-delivered interventions. We also examine how computer-based interventions targeting substance abuse disorders relate to cognitive functioning. This review will suggest that not only are computer-based interventions cost-efficient and accessible but that they are also effective methods for the motivation, engagement, and treatment of drug-dependent individuals. Moreover, computer-based interventions are compatible with a recently proposed biological mechanism implicated as the basis for drug addiction.

Workforce professionalism in drug treatment services: impact of California's Proposition 36

This article investigates whether California's Proposition 36 has promoted the workforce professionalism of drug treatment services during its first 5 years of implementation. Program surveys inquiring about organizational information, Proposition 36 implementation, and staffing were conducted in 2003 and 2005 among all treatment providers serving Proposition 36 clients in five selected California counties (San Diego, Riverside, Kern, Sacramento, and San Francisco). A 1-hour self-administered questionnaire was completed by 118 treatment providers representing 102 programs. This article examines five topics that are relevant to drug treatment workforce professionalism: resources and capability, standardized intake assessment and outcome evaluation, staff qualification, program accreditation, and information technology. Results suggest that Proposition 36 had a positive influence on the drug treatment workforce's professionalism. Improvements have been observed in program resources, client intake assessment and outcome evaluation databases, staff professionalization, program accreditation, and information technology system. However, some areas remain problematic, including, for example, the consistent lack of adequate resources serving women with children.

A Framework for Implementing Sustainable Oral Health Promotion Interventions

The present paper addresses basic evaluation and procedural concepts that are involved in the process of implementing sustainable oral health behavioral and social interventions. It is part of a series of thematic articles describing cutting-edge methods for conducting oral health interventions research. Core components for effective intervention implementation are presented as part of a comprehensive model composed of four stages (training, adoption, implementation, and practice), along with sustaining influences involving preparation and maintenance. This model systematically addresses common barriers that can reduce innovation success and permanence. Special attention is given to the measurement and impact of organizational and related contextual influences across stages of the implementation process. Assessment tools and research strategies are recommended and illustrated based on evaluations of interventions implemented in addiction and mental health treatment systems. These tools and research strategies also hold promise for use within the National Institute of Dental and Craniofacial Research Practice-Based Research Networks, as well as other systems of oral health care delivery.

Diffusion of contingency management and attitudes regarding its effectiveness and acceptability

Substance abuse counselors are critical as the key arbiters of clients' acceptance and use of innovative treatment techniques, with their potential support embedded in their knowledge of and attitudes towards particular innovations. In this analysis the authors examine the role of substance abuse counselors in the adoption of a psychosocial treatment innovation, contingency management (CM). Using data collected from 1140 counselors employed in a national sample of 318 public treatment centers, the authors examine theoretical predictors of counselors' knowledge of CM, and their attitudes regarding CM's effectiveness and acceptability. Findings suggest that lack of exposure to CM through program use and innovation-specific training is the most salient barrier to CM adoption and diffusion. The study also highlights the importance of social networks in the diffusion and acceptance of treatment innovations.

Improving the mental health of children in child welfare through the implementation of evidence-based parenting interventions

Any comprehensive approach to children's mental health should consider services systems such as Child Welfare that provide services to children with high rates of emotional and behavioral disorders. This paper will review what is known about efficacious parent-focused interventions that can improve the lives of children in Child Welfare and explore possible reasons why such interventions are rarely used by Child Welfare agencies. Data from a pilot study suggest key features for increasing the implementation of efficacious practices to improve children's mental health.

Factors that influenced county system leaders to implement an evidence-based program: a baseline survey within a randomized controlled trial

BACKGROUND

Despite the burgeoning number of well-validated interventions that have been shown in randomized trials to produce superior outcomes compared to usual services, it is estimated that only 10% of public systems deliver evidence-based mental health services. In California, for example, more than 15,000 children are placed in group homes or residential centers with some evidence of iatrogenic effects. The present study evaluates the willingness among county leaders of child public service systems to adopt a new evidence-based model, Multidimensional Treatment Foster Care, (MTFC), as a way to decrease the prevalence of out-of-home placements. Specifically, the study examines how county-level socio-demographic factors and child public service system leaders' perceptions of their county's organizational climate influence their decision of whether or not to consider adopting MTFC.

METHODS

Two levels were examined in this study: Stable and historical factors from 40 California counties gathered from public records including population size, number of entries into out-of-home care, financing of mental health services, and percent minority population; and system leaders' perceptions of their county's organizational climate and readiness for change measured via a web-based survey. The number of days-to-consent was the primary outcome variable defined as the duration of time between being notified of the opportunity to implement MTFC and the actual signing of a consent form indicating interest in considering implementation. Survival analysis methods were used to assess the predictors of this time-to-event measure. The present study is part of a larger randomized trial comparing two methods of implementation where counties are randomized to one of three time cohorts and two implementation conditions.

RESULTS

The number of entries into care was the primary predictor of days-to-consent. This variable was significantly correlated to county size. System leader's perceptions of positive climate and organizational readiness for change also contributed to but did not mediate or moderate the days-to-consent.

CONCLUSIONS

System leaders' decision to consider implementing a new evidence-based model was influenced most by their objective need for the program and next by their perception of the county's organizational climate and motivation to change. These findings highlight the importance of understanding the fit between the needs of the systems or agencies and the potential for addressing those needs with the proposed new program.

Barriers to Implementing Individualized Substance Abuse Treatment: Qualitative Findings from the CASPAR Replication Studies

Problem-to-services matching is critical to patient-centered care. Further, the extent to which substance abuse treatment is individualized to meet specific client needs is a key predictor of success and represents "best practice" in substance abuse treatment. The CASPAR Resource Guide, an electronic database of local free and low-cost services, is an evidence-based tool designed to help counselors easily and quickly provide offsite referrals to services not available in most community treatment programs to increase problem-to-service matching. This paper examines system-level barriers to using the CASPAR Resource Guide among 30 counselors and 21 site directors across 16 sites in two different studies. Results from qualitative implementation analyses found that key program components needed to support the implementation of this evidence-based practice (e.g., individualized treatment planning, individual treatment sessions, and individual counselor supervision) were lacking, which jeopardized successful adoption of the CASPAR research interventions and prompted a redesign of the studies in order to enhance each program's ability to support individualized care.

Adoption of motivational interviewing and motivational enhancement therapy following clinical trials

The National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) is designed to test drug abuse treatment interventions in multisite clinical trials and to support the translation of effective interventions into practice. In this study, qualitative methods were applied to examine adoption of motivational interviewing and motivational enhancement therapy (MI/MET) in five clinics where these interventions were tested. Participants were clinic staff (n=17) who were interviewed about the MI/MET study, and about whether MI/MET was adopted after the study ended. Although clinics' participation in a clinical trial includes many elements thought to be necessary for later adoption of the intervention, we found that there was "adoption" in one clinic, "partial adoption" in one clinic, "counselor adoption" in one clinic, and "no adoption" in two clinics. These findings highlight a distinction between adoption at the organizational and counselor levels, and suggest that a range of adoption outcomes may be observed in the field. Findings are relevant to clinical staff, program directors, administrators and policy makers concerned with improvement of drug abuse treatment systems through adoption of evidence-based practices.

Adoption of medications in substance abuse treatment: priorities and strategies of single state authorities

Research has confirmed the effectiveness of medications, when used in conjunction with ongoing counseling, to treat substance abuse disorders. This article describes a national, mixed-methods research project designed to investigate single state authorities' (SSAs) perceptions of adoption of evidence-based practices in substance abuse treatment. Results are focused specifically on medication-assisted treatment, one of five evidence-based practices defined by the National Quality Forum. Medication-assisted treatment (MAT) is an important and effective part of comprehensive care options available to clients who are chronically ill with alcohol and other drug disorders. Despite mounting clinical evidence and increased availability, overall rates of implementation and sustained adoption of medications to treat addiction remain limited. The results illustrate that the SSA representatives who fund public treatment programs believe MAT is a priority and worthy of system-wide implementation. Current strategies utilized by SSAs to support the adoption of MAT are detailed, as are barriers to adoption and implementation.

Telehealth readiness assessment tools

In planning a telehealth project, a readiness assessment can help to improve the chances of successful implementation by identifying the stakeholders and the factors that should be targeted. We conducted a literature search and identified six questionnaires on readiness that can be used when implementing telehealth projects. Only one of them was sufficiently generic to be used with all kinds of telehealth projects and with different groups of participants (patients and public, health-care practitioners and organization personnel like health-care managers and technical support managers), but it had rather limited psychometric evaluation. Two of them had had good psychometric evaluation but they were specific to particular telehealth projects and groups of stakeholders. All six published questionnaires were in English. We have developed and validated a French-Canadian version of the practitioner and organizational telehealth readiness assessment tool.

Partnerships and pathways of dissemination: the National Institute on Drug Abuse-Substance Abuse and Mental Health Services Administration Blending Initiative in the Clinical Trials Network

Since 2001, the National Drug Abuse Treatment Clinical Trials Network (CTN) has worked to put the results of its trials into the hands of community treatment programs, in large part through its participation in the National Institute on Drug Abuse-Substance Abuse and Mental Health Services Administration Blending Initiative and its close involvement with the Center for Substance Abuse Treatment's Addiction Technology Transfer Centers. This article describes (a) the CTN's integral role in the Blending Initiative, (b) key partnerships and dissemination pathways through which the results of CTN trials are developed into blending products and then transferred to community treatment programs, and (c) three blending initiatives involving buprenorphine, motivational incentives, and motivational interviewing. The Blending Initiative has resulted in high utilization of its products, preparation of more than 200 regional trainers, widespread training of service providers in most U.S. States, Puerto Rico, and the U.S. Virgin Islands and movement toward the development of Web-based implementation supports and technical assistance. Implications for future directions of the Blending Initiative and opportunities for research are discussed.

Searching for excellence & diversity: increasing the hiring of women faculty at one academic medical center

One opportunity to realize the diversity goals of academic health centers comes at the time of hiring new faculty. To improve the effectiveness of search committees in increasing the gender diversity of faculty hires, the authors created and implemented a training workshop for faculty search committees designed to improve the hiring process and increase the diversity of faculty hires at the University of Wisconsin-Madison. They describe the workshops, which they presented in the School of Medicine and Public Health between 2004 and 2007, and they compare the subsequent hiring of women faculty in participating and nonparticipating departments and the self-reported experience of new faculty within the hiring process. Attendance at the workshop correlates with improved hiring of women faculty and with a better hiring experience for faculty recruits, especially women. The authors articulate successful elements of workshop implementation for other medical schools seeking to increase gender diversity on their faculties.

Moving empirically supported practices to addiction treatment programs: recruiting supervisors to help in technology transfer

Federal and state funding agencies are encouraging or mandating the use of empirically supported treatments in addiction programs, yet many programs have not moved in this direction (Forman, Bovasso, and Woody, 2001 ; Roman and Johnson, 2002 ; Willenbring et al., 2004 ). To improve the skills of counselors in community addiction programs, the authors developed an innovative Web-based course on Cognitive Behavioral Therapy (CBT), a widely accepted empirically-supported practice (ESP) for addiction. Federal funding supports this Web course and a randomized controlled trial to evaluate its effectiveness. Since supervisors often play a pivotal role in helping clinicians transfer learned skills from training courses to the workplace, the authors recruited supervisor-counselor teams, engaging 54 supervisors and 120 counselors. Lessons learned focus on supervisor recruitment and involvement, supervisors' perceptions of CBT, their own CBT skills and their roles in the study, and implications for technology transfer for the addiction field as a whole. Recruiting supervisors proved difficult because programs lacked clinical supervisors. Recruiting counselors was also difficult because programs were concerned about loss of third-party reimbursement. Across the addiction field, technology transfer will be severely hampered unless such infrastructure problems can be solved. Areas for further investigation are identified.

Adoption of practice guidelines and assessment tools in substance abuse treatment

Background

The gap between research and practice limits utilization of relevant, progressive and empirically validated strategies in substance abuse treatment.

Methods

Participants included substance abuse treatment programs from the Northeastern United States. Structural equation models were constructed with agency level data to explore two outcome variables: adoption of practice guidelines and assessment tools at two points in time; models also included organizational, staffing and service variables.

Results

In 1997, managed care involvement and provision of primary care services had the strongest association with increased use of assessment tools, which, along with provision of counseling services, were associated with a greater use of practice guidelines. In 2001, managed care involvement, counseling services and being a stand-alone drug treatment agency were associated with a greater use of assessment tools, which was in turn related to an increase in the use of practice guidelines.

Conclusions

This study provides managers, clinicians and policy-makers with a framework for understanding factors related to the adoption of new technologies in substance abuse treatment.

When Technology Fails: Getting Back to Nature

Research on substance use disorders has produced a slew of disappointments in studies designed to confirm basic principles of the technology approach to treatment dissemination. These setbacks should inspire addictions science to pursue complementary paths of inquiry that focus on evidence-based practices delivered under naturalistic conditions. This will require larger accommodations to, and closer partnerships with, the indigenous cultures of everyday care.

The Reinforcing Therapist Performance (RTP) experiment: study protocol for a cluster randomized trial

Background

Rewarding provider performance has been recommended by the Institute of Medicine as an approach to improve the quality of treatment, yet little empirical research currently exists that has examined the effectiveness and cost-effectiveness of such approaches. The aim of this study is to test the effectiveness and cost-effectiveness of providing monetary incentives directly to therapists as a method to improve substance abuse treatment service delivery and subsequent client treatment outcomes.

Design

Using a cluster randomized design, substance abuse treatment therapists from across 29 sites were assigned by site to either an implementation as usual (IAU) or pay-for-performance (P4P) condition.

Participants

Substance abuse treatment therapists participating in a large dissemination and implementation initiative funded by the Center for Substance Abuse Treatment.

Intervention

Therapists in both conditions received comprehensive training and ongoing monitoring, coaching, and feedback. However, those in the P4P condition also were given the opportunity to earn monetary incentives for achieving two sets of measurable behaviors related to quality implementation of the treatment.

Outcomes

Effectiveness outcomes will focus on the impact of the monetary incentives to increase the proportion of adolescents who receive a targeted threshold level of treatment, months that therapists demonstrate monthly competency, and adolescents who are in recovery following treatment. Similarly, cost-effectiveness outcomes will focus on cost per adolescent receiving targeted threshold level of treatment, cost per month of demonstrated competence, and cost per adolescent in recovery.

Trial Registration

Trial Registration Number: NCT01016704

Assertive outreach strategies for narrowing the adolescent substance abuse treatment gap: implications for research, practice, and policy

In any given year, only about 10% of the nearly two million adolescents exhibiting substance abuse or dependence in the United States receive substance abuse treatment. Given this state of affairs, it is unlikely that the massive effort and expenditure of resources over the past decade on developing, testing, and disseminating effective treatments for adolescent substance abuse will have an appreciable impact on the prevalence of substance use disorders among the adolescent population. In order to substantially diminish the pervasive gap between levels of need for and utilization of adolescent substance abuse treatment, specialized assertive outreach strategies may be needed. This paper outlines a framework for assertive outreach for adolescents with substance use disorders and proposes specific types of strategies for identifying and enrolling such adolescents into treatment. Implications for practice and policy pertaining to adolescent substance abuse treatment service delivery are considered.

Using Organizational Change Strategies to Guide Peer Support Technician Implementation in the VA

OBJECTIVE

The Veterans Administration (VA) mental health system is in the process of hiring "Peer Support Technicians" or PSTs-individuals in recovery from serious mental illnesses hired as clinical team members. The purpose of this article is to demonstrate an implementation process that has potential to improve the deployment of the Peer Support Technicians to existing clinical teams within the VA.

METHODS

As part of a larger randomized trial called PEers Enhancing Recovery (PEER), research staff collaboratively planned the deployment of PSTs with three case management teams serving those with serious mental illnesses. Clinical staff received significant opportunity to participate in defining the PST role. PEER staff took extensive notes during planning meetings about the discussions held and decisions made about the PST role.

RESULTS

PEER and clinical staff discussed and came to a consensus on several elements that comprise the PST job including goals for employing PSTs, desired characteristics of PSTs, job duties, training to be provided to PSTs, PST access to medical records, supervision, boundaries, confidentiality, how PSTs are to discuss their mental illness with veterans, and a sick leave policy.

CONCLUSIONS

It is critical to solicit and use input from team providers and leaders when establishing PST services. This approach using input and solicitation can be a model to implement a wide range of clinical interventions in which existing providers and teams will be asked to do something new.

Evidence-based practice implementation: the impact of public versus private sector organization type on organizational support, provider attitudes, and adoption of evidence-based practice

BACKGROUND

The goal of this study is to extend research on evidence-based practice (EBP) implementation by examining the impact of organizational type (public versus private) and organizational support for EBP on provider attitudes toward EBP and EBP use. Both organization theory and theory of innovation uptake and individual adoption of EBP guide the approach and analyses in this study. We anticipated that private sector organizations would provide greater levels of organizational support for EBPs leading to more positive provider attitudes towards EBPs and EBP use. We also expected attitudes toward EBPs to mediate the association of organizational support and EBP use.

METHODS

Participants were mental health service providers from 17 communities in 16 states in the United States (n = 170). Path analyses were conducted to compare three theoretical models of the impact of organization type on organizational support for EBP and of organizational support on provider attitudes toward EBP and EBP use.

RESULTS

Consistent with our predictions, private agencies provided greater support for EBP implementation, and staff working for private agencies reported more positive attitudes toward adopting EBPs. Organizational support for EBP partially mediated the association of organization type on provider attitudes toward EBP. Organizational support was significantly positively associated with attitudes toward EBP and EBP use in practice.

CONCLUSION

This study offers further support for the importance of organizational context as an influence on organizational support for EBP and provider attitudes toward adopting EBP. The study demonstrates the role organizational support in provider use of EBP in practice. This study also suggests that organizational support for innovation is a malleable factor in supporting use of EBP. Greater attention should be paid to organizational influences that can facilitate the dissemination and implementation of EBPs in community settings.

Implementing evidence-based practice in community mental health agencies: a multiple stakeholder analysis

OBJECTIVES

We sought to identify factors believed to facilitate or hinder evidence-based practice (EBP) implementation in public mental health service systems as a step in developing theory to be tested in future studies.

METHODS

Focusing across levels of an entire large public sector mental health service system for youths, we engaged participants from 6 stakeholder groups: county officials, agency directors, program managers, clinical staff, administrative staff, and consumers.

RESULTS

Participants generated 105 unique statements identifying implementation barriers and facilitators. Participants rated each statement on importance and changeability (i.e., the degree to which each barrier or facilitator is considered changeable). Data analyses distilled statements into 14 factors or dimensions. Descriptive analyses suggest that perceptions of importance and changeability varied across stakeholder groups.

CONCLUSIONS

Implementation of EBP is a complex process. Cross-system-level approaches are needed to bring divergent and convergent perspectives to light. Examples include agency and program directors facilitating EBP implementation by supporting staff, actively sharing information with policymakers and administrators about EBP effectiveness and fit with clients' needs and preferences, and helping clinicians to present and deliver EBPs and address consumer concerns.

Public health in the emergency department: overcoming barriers to implementation and dissemination

This article is the outcome of a consensus building workshop entitled, "Overcoming Barriers to Implementation and Dissemination" convened at the 2009 Academic Emergency Medicine Consensus Conference, ''Public Health in the ED: Surveillance, Screening, and Intervention." The participants were asked to address potential methods for overcoming barriers to the dissemination and implementation in the emergency department (ED) of evidenced-based practices to improve public health. The panel discussed three broad areas of interest including methods for disseminating evidence-based practices, barriers encountered during the process of implementation, and the importance of involvement in activities outside the ED including engagement in policy development and improvement. Four recommendations were discussed in detail and consensus was reached. The recommendations included 1) researchers and advocates should disseminate findings through multiple forums beyond peer-reviewed publications when an ED-based public health intervention has enough evidence to support integration into the routine practice of emergency care; 2) local barriers to implementation of public health interventions should be recognized and well understood from multiple perspectives prior to implementation; 3) innovation must be put into place and adapted based on local institutional context and culture as barriers and the best methods for overcoming them will vary across institutions; and 4) use of legislation, regulation, and incentives outside of the ED should support and strengthen ED-based interventions. For each area of interest, research dimensions to extend the current understanding of methods for effectively and efficiently implementing evidence-based public health interventions in the ED were discussed and consensus was achieved.

Strengthening prevention performance using technology: a formative evaluation of interactive Getting To Outcomes

Communities face challenges implementing evidence-based prevention programs. To help, policymakers are exploring how to build community-level capacity for prevention for thousands of organizations or communities across the United States. This article reports on a formative evaluation within 2 states' prevention systems of an Internet system designed to build capacity on a large scale, interactive Getting To Outcomes(R) (iGTO). In Tennessee, 30 coalitions were randomly assigned to receive either the iGTO system or nothing. In Missouri, 18 coalitions receiving iGTO were compared with 8 like coalitions who did not receive iGTO. The primary outcome was iGTO's impact on the performance of the coalitions' programs, assessed through interviews at baseline and after a year of iGTO implementation. Analyses suggest that iGTO-programs improved their performance of prevention practices over non-iGTO programs. Semi-structured interviews of iGTO users and state-level stakeholders showed that iGTO was adopted by most iGTO-assigned coalitions, albeit in mostly an elementary fashion. Perceptions of the iGTO system were mixed. The findings suggest that more comprehensive integration requires that state leadership also use iGTO and provide more support for its use at the local level.

Evidence-based public health: a fundamental concept for public health practice

Despite the many accomplishments of public health, a greater attention to evidence-based approaches is warranted. This article reviews the concepts of evidence-based public health (EBPH), on which formal discourse originated about a decade ago. Key components of EBPH include making decisions on the basis of the best available scientific evidence, using data and information systems systematically, applying program-planning frameworks, engaging the community in decision making, conducting sound evaluation, and disseminating what is learned. Three types of evidence have been presented on the causes of diseases and the magnitude of risk factors, the relative impact of specific interventions, and how and under which contextual conditions interventions were implemented. Analytic tools (e.g., systematic reviews, economic evaluation) can be useful in accelerating the uptake of EBPH. Challenges and opportunities (e.g., political issues, training needs) for disseminating EBPH are reviewed. The concepts of EBPH outlined in this article hold promise to better bridge evidence and practice.

Associations among state and local organizational contexts: Use of evidence-based practices in the criminal justice system

This study used hierarchical linear modeling (HLM) to examine the extent to which the organizational characteristics of state corrections agencies and local criminal justice facilities interacted in their associations with the extent to which local facilities are using evidence-based substance abuse treatment practices (EBPs). The study used data collected from two nationally representative surveys - one of state executives and the other of local prison wardens, justice administrators, and treatment directors - which were conducted as part of the National Criminal Justice Treatment Practices survey [NCJTP; Taxman, F.S., Young, D., Wiersema, B., Mitchell, S., Rhodes, A.G., 2007. The National Criminal Justice Treatment Practices Survey: Multi-level survey methods and procedures. J. Subst. Abuse Treat. 32, 225-238], and includes both adult criminal and juvenile justice samples. Results indicated that several state organizational characteristics were either associated with more EBP use or interacted with local organizational characteristics in associations with EBP use, including: (1) systems integration at the state level was associated with greater EBP use; (2) state staffing adequacy and stability accentuated the association between local training and resources for new programs and EBP use (i.e., in states with better staffing, the relationship between training/resources and EBP use in local facilities was stronger); and (3) state executives' attitudes regarding the missions and goals of corrections tended to diminish the extent to which corresponding local administrator attitudes were associated with EBP use. The study has implications for future research focused on EBP diffusion and implementation in correctional environments, particularly attempts to influence EBP use by working through state agencies.

Evidence-based medicine and knowledge dissemination, translation, and utilization: challenges of getting evidence-based treatments to patient care and service delivery

The aim of this article is to explore challenges associated with effective utilization of best available scientific evidence on what works and what is potentially harmful in health, mental health, and social care. A gap exists between the production of high quality evidence on what has proven to be successful and the utilization of this evidence in human services. Patients and service users do not always receive interventions supported by the best available scientific evidence. Methods of evidence-based medicine and evidence-based practice have emerged as promising approaches to remedy this deficit. Furthermore, implementation and translational research, supported by multi-disciplinary efforts, is emerging as another approach to bring best available evidence to service delivery settings. Although these approaches are promoted by diverse stakeholders in many countries, we are still waiting for rigorous evaluations of these approaches to understand their effectiveness in comparison to traditional ways of delivering interventions and other types of services in human services organizations.

The adoption of wraparound services among substance abuse treatment organizations serving criminal offenders: The role of a women-specific program

Women's substance abuse treatment outcomes are improved when women-specific needs are addressed through wraparound services, such as the provision of child care, employment assistance, or mental health counseling. Despite a higher prevalence of pre-incarceration drug use, women in prison report receiving fewer services than their male counterparts, suggesting they likely have greater service needs upon release. It is unknown whether community-based treatment organizations with a women-specific program offer more wraparound services than programs without a focus on women. This study uses data from the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) research cooperative's National Criminal Justice Treatment Practices Survey (NCJTPS), a nationally representative sample of community-based treatment programs serving predominantly criminal offenders (n=217). First, bivariate analyses identified differences between organizations with and without a women-specific program on the number of wraparound services adopted as well as organizational-level characteristics (i.e., organizational structure, personnel characteristics, culture, sources of information, and systems integration) related to their adoption. Second, Poisson regression was used to identify the organizational characteristics associated with the number of adopted wraparound services, with having a women-specific program being the primary covariate of interest. Results indicate larger organizations that utilized a greater number of treatment approaches and believed that treatment could reduce crime were more likely to offer a greater assortment of wraparound services. In an effort to improve behavioral treatment outcomes, it is imperative to examine organizational-level contextual factors that shape the availability of wraparound services for female offenders in community-based substance abuse treatment settings.

Characteristics of Opinion Leaders in Substance Abuse Treatment Agencies

OBJECTIVE

This study was part of a larger effort to test the effectiveness of technology transfer approaches related to evidence-based treatment of co-occurring substance abuse and mental health disorders. Specifically, this study examined characteristics of "opinion leaders" as technology transfer agents.

METHOD

A network analysis was conducted within four large substance abuse treatment agencies to identify individuals that other counselors sought out for consultation on co-occurring issues. The identified opinion leaders were then compared with other counselors on demographic variables, education and experience, and attitudes and knowledge about working with individuals with co-occurring disorders.

RESULTS

The analyses demonstrate that opinion leaders differed from other counselors in competency-related characteristics including more postgraduate education, relevant professional credentials, and years of experience in mental health treatment. They also had greater knowledge of the dynamics and treatment of co-occurring disorders as well as a greater willingness and confidence in working with such clients.

CONCLUSION

These results suggest that opinion leaders are used within agencies for information and consultation regarding treatment issues. Therefore, opinion leaders may provide an important vehicle for dissemination and adoption of evidence-based treatment practices in community treatment settings.