The role of state mental health authorities in managing change for the implementation of evidence-based practices

Effects of Texas State Agency Integration on Mental Health Service Use Among Individuals with Co-occurring Cognitive Disabilities and Mental Health Conditions

This study uses Texas's 2017 integration of the state disability and mental health agencies as a case study, combining interviews with Texas agency and advocacy organization leaders to examine perceptions of agency integration and augmented synthetic control analyses of 2014-2020 Medical Expenditure Panel Survey to examine impacts on mental health service use among individuals with co-occurring cognitive disabilities (including intellectual and developmental disabilities) and mental health conditions. Interviewees described the intensive process of agency integration and identified primarily positive (e.g., decreased administrative burden) impacts of integration. Quantitative analyses indicated no effects of integration on receipt of mental health-related services among people with co-occurring conditions. While leaders identified some potentially beneficial impacts of state agency integration, the limited impact of integration beyond the agency suggests that interventions at multiple levels of the service system, including those targeting providers, are needed to better meet the mental health service needs for this population.

State Mental Health Authority Level of Involvement in Coordinated Specialty Care Clinics and Client Outcomes

OBJECTIVE

State mental health authorities (SMHAs) in all U.S. states and territories administer the Mental Health Block Grant (MHBG) set-aside funding for first-episode psychosis. Funds support implementation of coordinated specialty care (CSC) programs. The authors investigated the relationship between the level of SMHA involvement with CSC programs and clinical outcomes of clients in these programs.

METHODS

As part of a mixed-methods study of 34 CSC programs, SMHAs from 21 states and one U.S. territory associated with the 34 CSC programs participated in a 1-hour interview (between November 2018 and May 2019) focused on SMHA involvement in administration of MHBG set-aside funds and the SMHA's ongoing relationship with funded CSC programs. SMHA involvement was rated on a scale of 1 to 5, with 5 indicating the highest involvement. Client outcome data were collected at the 34 study sites over an 18-month period. Multilevel random-effect modeling was used, controlling for response propensity (propensity score), client demographic variables, and program-level covariates (i.e., fidelity score, staff turnover rates, service area urbanicity, and number of clients enrolled).

RESULTS

Clients in CSC programs with SMHAs that were the most involved (level 5) had significantly improved symptoms, social functioning, and role functioning, compared with clients in programs with which SMHAs were least involved (level 1).

CONCLUSIONS

The findings suggest that increased SMHA involvement in CSC programs is relevant for positive client outcomes. Levels of first-episode psychosis funding doubled in 2021 and 2022, and it is important to identify how SMHAs affect the success of CSC programs and the individuals served.

Why Do People with Severe Mental Illness Have Poor Cardiovascular Health?-The Need for Implementing a Recovery-Based Self-Management Approach

People with severe mental illness (SMI) die significantly earlier than their well counterparts, mainly due to preventable chronic conditions such as cardiovascular disease (CVD). Based on the existing research, this perspective paper summarises the key contributors to CVD in people with SMI to better target the areas that require more attention to reduce, and ultimately resolve this health inequity. We discuss five broad factors that, according to current international evidence, are believed to be implicated in the development and maintenance of CVD in people with SMI: (1) bio-psychological and lifestyle-related factors; (2) socio-environmental factors; (3) health system-related factors; (4) service culture and practice-related factors; and (5) research-related gaps on how to improve the cardiovascular health of those with SMI. This perspective paper identifies that CVD in people with SMI is a multi-faceted problem involving a range of risk factors. Furthermore, existing chronic care or clinical recovery models alone are insufficient to address this complex problem, and none of these models have identified the significant roles that family caregivers play in improving a person’s self-management behaviours. A new framework is proposed to resolve this complex health issue that warrants a collaborative approach within and between different health and social care sectors.

Understanding the implementation of evidence-informed policies and practices from a policy perspective: a critical interpretive synthesis

BACKGROUND

The fields of implementation science and knowledge translation have evolved somewhat independently from the field of policy implementation research, despite calls for better integration. As a result, implementation theory and empirical work do not often reflect the implementation experience from a policy lens nor benefit from the scholarship in all three fields. This means policymakers, researchers, and practitioners may find it challenging to draw from theory that adequately reflects their implementation efforts.

METHODS

We developed an integrated theoretical framework of the implementation process from a policy perspective by combining findings from these fields using the critical interpretive synthesis method. We began with the compass question: How is policy currently described in implementation theory and processes and what aspects of policy are important for implementation success? We then searched 12 databases as well as gray literature and supplemented these documents with other sources to fill conceptual gaps. Using a grounded and interpretive approach to analysis, we built the framework constructs, drawing largely from the theoretical literature and then tested and refined the framework using empirical literature.

RESULTS

A total of 11,434 documents were retrieved and assessed for eligibility and 35 additional documents were identified through other sources. Eighty-six unique documents were ultimately included in the analysis. Our findings indicate that policy is described as (1) the context, (2) a focusing lens, (3) the innovation itself, (4) a lever of influence, (5) an enabler/facilitator or barrier, or (6) an outcome. Policy actors were also identified as important participants or leaders of implementation. Our analysis led to the development of a two-part conceptual framework, including process and determinant components.

CONCLUSIONS

This framework begins to bridge the divide between disciplines and provides a new perspective about implementation processes at the systems level. It offers researchers, policymakers, and implementers a new way of thinking about implementation that better integrates policy considerations and can be used for planning or evaluating implementation efforts.

Understanding the implementation of evidence-informed policies and practices from a policy perspective: a critical interpretive synthesis

BACKGROUND

The fields of implementation science and knowledge translation have evolved somewhat independently from the field of policy implementation research, despite calls for better integration. As a result, implementation theory and empirical work do not often reflect the implementation experience from a policy lens nor benefit from the scholarship in all three fields. This means policymakers, researchers, and practitioners may find it challenging to draw from theory that adequately reflects their implementation efforts.

METHODS

We developed an integrated theoretical framework of the implementation process from a policy perspective by combining findings from these fields using the critical interpretive synthesis method. We began with the compass question: How is policy currently described in implementation theory and processes and what aspects of policy are important for implementation success? We then searched 12 databases as well as gray literature and supplemented these documents with other sources to fill conceptual gaps. Using a grounded and interpretive approach to analysis, we built the framework constructs, drawing largely from the theoretical literature and then tested and refined the framework using empirical literature.

RESULTS

A total of 11,434 documents were retrieved and assessed for eligibility and 35 additional documents were identified through other sources. Eighty-six unique documents were ultimately included in the analysis. Our findings indicate that policy is described as (1) the context, (2) a focusing lens, (3) the innovation itself, (4) a lever of influence, (5) an enabler/facilitator or barrier, or (6) an outcome. Policy actors were also identified as important participants or leaders of implementation. Our analysis led to the development of a two-part conceptual framework, including process and determinant components.

CONCLUSIONS

This framework begins to bridge the divide between disciplines and provides a new perspective about implementation processes at the systems level. It offers researchers, policymakers, and implementers a new way of thinking about implementation that better integrates policy considerations and can be used for planning or evaluating implementation efforts.

Process and Product Innovations from a Statewide Capacity-Building Initiative for Substance Use Treatment and Recovery

Statewide behavioral health collaborative capacity-building initiatives are designed to support substance use agencies in strengthening their behavioral health services delivery and implementing evidence-supported practices. This study explored the types of innovations resulting from one such statewide behavioral health initiative, as well as the facilitators and barriers to implementing these innovations, from the perspective of the substance use agencies involved in the initiative. Data were collected through semistructured interviews with 67 agency stakeholders and 93 agency progress reports. Results indicated that 161 innovations emerged through this project for the substance use agencies, including staffing; policy, procedure, and technology; partnerships; training and media products; and service innovations. Agency facilitators included collaboration/partnership, project buy-in, and quality of agency staff. Barriers to implementation included lack of collaboration or partnerships, agency infrastructure or climate, lack of project buy-in, and funding and billing issues. The article concludes with a discussion on implications for social work practice in behavioral health.

An Exploration of Factors that Effect the Implementation of Peer Support Services in Community Mental Health Settings

This study explored the integration of peer services into community mental health settings through qualitative interviews with peer-providers and non-peer mental health workers. Results show peer job satisfaction was contingent upon role clarity, autonomy, and acceptance by non-peer coworkers. Mental health workers reported the need for organizational support for peer services and guidance about how to utilize peers, negotiate their professional boundaries and accommodate their mental health needs. Effective peer integration requires organizational readiness, staff preparation and clear policies and procedures. Consultation from consumer-based organizations, enhanced professional competencies, and professional development and career advancement opportunities for peers represent important resources.

Learning from New York City : a case study of public health policy practice in the Bloomberg administration

OBJECTIVES

To ascertain any lessons learned about how public health reforms undertaken in New York City during the Bloomberg Administration were shepherded through the public policy and administration gauntlet. The question is, how feasible is this approach and would it work outside of New York City?

DESIGN/SETTING/PARTICIPANTS

Using a theoretically grounded case study approach, 3 initiatives were examined that were proposed and/or implemented during a 10-year period of the Mayoralty of Michael Bloomberg (2002-2011): transfats restrictions, clean bus transportation policies, and a sugar-sweetened beverages tax (as a counterfactual). The investigation began by performing a comprehensive public documents search and was followed with interviews of 27 individuals involved in the selected policy initiatives. Interviews were coded in Nvivo using an iterative, grounded methodology.

RESULTS

Using a theoretical lens, the case study illustrates that the multifaceted role of leadership was not confined to the executives in the City or the Agency. Instead, leadership extended to other administrative officials within the agency and the Board of Health. Second, New York City used reorganization and coordinative mechanisms strategically to ensure achievement of their goals. This included creation of new departments/bureaus and coordinating structures across the City. Evidence of the explicit use of incentives, as initially anticipated from the theoretical framework, was not found.

CONCLUSIONS

While some aspects of this case study are unique to the context of New York City, 2 approaches used in New York City are feasible for other jurisdictions: harnessing the full scope and breadth of authority of the agency and its associated boards and commissions, and remobilizing existing workforce to explicitly focus on and coordinate targeted policies for issues of concern. Questions for further consideration are posed at the conclusion of the article.

Role of state mental health leaders in supporting evidence-based practices over time

State administrative supports of evidence-based practices (EBPs) may critically affect sustainability. As part of a larger follow-up to the multistate National Implementing Evidence-Based Practices Project, 13 leaders from eight States reported on recent statewide policies and resources that influenced the maintenance of 49 EBP programs 6 years after implementation. Nearly three-quarters (71 %) of the programs were currently operational and adhering to State fidelity standards. Most of the programs had level or increased funding over the last few years, and most received other State support and resources, such as training and technical assistance. Steady State funding as well as State-sponsored training and expertise appear critical to long-term EBP program maintenance.

Implementing a continuum of evidence-based psychosocial interventions for people with severe mental illness: part 2-review of critical implementation issues

OBJECTIVE

In North America and internationally, efforts have been made to reduce the gaps between knowledge of psychosocial evidence-based practices (EBPs) and the delivery of such services in routine mental health practice. Part 2 of this review identifies key issues for stakeholders to consider when implementing comprehensive psychosocial EBPs for people with severe mental illness (SMI).

METHOD

A rapid review of the literature was conducted. Searches were carried out in MEDLINE and PsycINFO for reports published between 1990 and 2012 using key words related to SMI, and psychosocial practices and implementation. The Consolidated Framework for Implementation Research (CFIR) was used to structure findings according to key domains and constructs known to influence the implementation process.

RESULTS

The CFIR allowed us to identify 17 issues reflecting more than 30 constructs of the framework that were viewed as influential to the process of implementing evidence-based psychosocial interventions for people with SMI. Issues arising at different levels of influence (intervention, individual, organizational, and system) and at all phases of the implementation process (planning, engagement, execution, and evaluation) were found to play important roles in implementation.

CONCLUSION

The issues identified in this review should be taken into consideration by stakeholders when engaging in efforts to promote uptake of new psychosocial EBPs and to widen the range of effective psychosocial services available in routine mental health care.

Organizational factors influencing implementation of evidence-based practices for integrated treatment in behavioral health agencies

Objective. In recent years, New Mexico has prioritized integrated treatment for cooccurring mental health and substance use disorders within its public behavioral health system. This report describes factors likely to be important when implementing evidence-based practices (EBPs) in community agencies. Methods. Our mixed-method research design consisted of observations, semistructured interviews, and surveys undertaken with employees at 14 agencies at baseline and after 18 months. We developed four-agency typologies based on iterative coding and analysis of observations and interviews. We then examined survey data from employees at the four exemplar agencies to validate qualitative findings. Results. Financial resources and strong leadership impacted agency capacity to train providers and implement EBPs. Quantitative analysis of service provider survey responses from these agencies (N = 38) supported qualitative findings and demonstrated significant mean score differences in leadership, organizational climate, and attitudes toward EBPs in anticipated directions. Conclusion. The availability of strong leadership and financial resources were key components to initial implementation success in this study of community agencies in New Mexico. Reliance only on external funding poses risks for sustainment when demoralizing work climates precipitate employee turnover. Strong agency leadership does not always compensate for deficient financial resources in vulnerable communities.

The employment of nurses in publicly funded substance abuse treatment programs

Little is known about the organizational and environmental factors associated with the employment of nurses in substance abuse treatment programs. Using data collected from the administrators of 250 publicly funded substance abuse treatment programs, this study examined the organizational and environmental correlates of nurse employment in these settings. Negative binomial regression models indicated that the number of nurses employed by treatment programs was positively associated with government ownership, location within a healthcare setting, and the availability of detoxification services. Outpatient-only programs employed fewer nurses than programs with inpatient/residential services. Two environmental factors were associated with nurse employment. Programs that more strongly endorsed a scale of financial barriers employed significantly fewer nurses, whereas programs indicating that funding from state contracts could be used to pay for healthcare providers employed significantly more nurses. These findings suggest that organizational decisions about employing nurses may reflect both the characteristics of the program and the funding environment. Future research should continue to examine the employment of nurses in substance abuse treatment settings, particularly given the shifting environment due to the implementation of healthcare reform.

Learning and change in a community mental health setting

This article offers methodological reflections and lessons learned from a three-year university-community partnership that used participatory action research methods to develop and evaluate a model for learning and change. Communities of practice were used to facilitate the translation of recovery-oriented and evidence-based programs into everyday practice at a community mental health agency. Four lessons were drawn from this project. First, the processes of learning and organizational change are complex, slow, and multifaceted. Second, development of leaders and champions is vital to sustained implementation in an era of restricted resources. Third, it is important to have the agency's values, mission, policies, and procedures align with the principles and practices of recovery and integrated treatment. And fourth, effective learning of evidence-based practices is influenced by organizational culture and climate. These four lessons are expanded upon and situated within the broader literature and implications for future research are discussed.

Coverage of mental health and substance misuse topics in the Cochrane review system

Aims. To assess the breadth of mental and substance coverage in the Cochrane review system. Methods. All mental health and substance entries were identified from the 2005 to April 2012 Cochrane Database of Systematic Reviews. Results. A total of 1019 entries focused on mental health or substance misuse, with 698 (68.5%) being completed reviews. One out of every five entries focused on serious mental illness/psychosis. Systematic reviews addressing unipolar depression, dementia and certain substance disorders also appeared well-represented. In contrast, a number of impairing disorders frequently seen in practice received less attention, with bipolar disorder, obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD) and autism spectrum disorders each accounting for less than 2% of the entries. The majority of interventions reviewed involved medication (57.1%), although this was not the case for a number of childhood-onset disorders. Some diagnostic areas (sleep, anxiety, mood and substance) were addressed by multiple Cochrane review groups (CRGs). Conclusions. The Cochrane Collaboration is well poised to be a strong guiding influence to those seeking to employ evidence-based mental health care. Broadening its diagnostic coverage and diversifying types of intervention reviewed would probably further maximize its impact. A more centralized and directed approach of prioritizing topics could help ensure more comprehensive coverage.

Testing use of payers to facilitate evidence-based practice adoption: protocol for a cluster-randomized trial

Background

More effective methods are needed to implement evidence-based findings into practice. The Advancing Recovery Framework offers a multi-level approach to evidence-based practice implementation by aligning purchasing and regulatory policies at the payer level with organizational change strategies at the organizational level.

Methods

The Advancing Recovery Buprenorphine Implementation Study is a cluster-randomized controlled trial designed to increase use of the evidence-based practice buprenorphine medication to treat opiate addiction. Ohio Alcohol, Drug Addiction, and Mental Health Services Boards (ADAMHS), who are payers, and their addiction treatment organizations were recruited for a trial to assess the effects of payer and treatment organization changes (using the Advancing Recovery Framework) versus treatment organization changes alone on the use of buprenorphine. A matched-pair randomization, based on county characteristics, was applied, resulting in seven county ADAMHS boards and twenty-five treatment organizations in each arm. Opioid dependent patients are nested within cluster (treatment organization), and treatment organization clusters are nested within ADAMHS county board. The primary outcome is the percentage of individuals with an opioid dependence diagnosis who use buprenorphine during the 24-month intervention period and the 12-month sustainability period. The trial is currently in the baseline data collection stage.

Discussion

Although addiction treatment providers are under increasing pressure to implement evidence-based practices that have been proven to improve patient outcomes, adoption of these practices lags, compared to other areas of healthcare. Reasons frequently cited for the slow adoption of EBPs in addiction treatment include, regulatory issues, staff, or client resistance and lack of resources. Yet the way addiction treatment is funded, the payer’s role—has not received a lot of attention in research on EBP adoption.

This research is unique because it investigates the role of payers in evidence-based practice implementation using a randomized controlled design instead of case examples. The testing of the Advancing Recovery Framework is designed to broaden the understanding of the impact payers have on evidence-based practice (EBP) adoption.

Trial registration

http://NCT01702142 (ClinicalTrials.gov registry, USA)

Physicians in the substance abuse treatment workforce: understanding their employment within publicly funded treatment organizations

The employment of physicians by substance abuse treatment organizations is understudied, despite physicians' importance in implementing pharmacotherapy and integrating treatment into the broader system of medical care. Drawing on data collected from 249 publicly funded treatment organizations, this study examined organizational and environmental factors associated with the employment of physicians in these settings. A negative binomial regression model indicated that greater numbers of physicians were employed when organizations offered detoxification services, were embedded in health care settings, and were larger in size. Funding barriers, including the costs of physicians and inadequate reimbursement by funders, were negatively associated with physician employment. Programs unaware that they could use state contract funding to pay for medical staff employed fewer numbers of physicians than programs aware of this type of state policy. Attempts to increase physician employment in substance abuse treatment may require attention to both organizational and environmental factors rather than simply trying to attract individuals to the field. Increasing physician employment may be challenging in the current economic climate.

Employing policy and purchasing levers to increase the use of evidence-based practices in community-based substance abuse treatment settings: reports from single state authorities

State public health authorities are critical to the successful implementation of science based addiction treatment practices by community-based providers. The literature to date, however, lacks examples of state level policy strategies that promote evidence-based practices (EBPs). This mixed-methods study documents changes in two critical state-to-provider strategies aimed at accelerating use of evidence-based practices: purchasing levers (financial incentives and mechanisms) and policy or regulatory levers. A sample of 51 state representatives was interviewed. Single State Authorities for substance abuse treatment (SSAs) that fund providers directly or through managed care were significantly more likely to have contracts that required or encouraged evidence-based interventions, as compared to SSAs that fund providers indirectly through sub-state entities. Policy levers included EBP-related legislation, language in rules and regulations, and evidence-based criteria in state plans and standards. These differences in state policy are likely to result in significant state level variations regarding both the extent to which EBPs are implemented by community-based treatment providers and the quality of implementation.

Evidence-based practice implementation in Kansas

Over the last 8 years, Kansas has been successful in the implementation of evidence-based practices. This paper describes the strategies used at multiple levels of the mental health system including: state policy, provider agency management, fidelity and outcome monitoring, supervisor training and support, and practitioner training. The challenges going forth are described.

Implementation of evidence-based practices for treatment of alcohol and drug disorders: the role of the state authority

The current climate of increasing performance expectations and diminishing resources, along with innovations in evidence-based practices (EBPs), creates new dilemmas for substance abuse treatment providers, policymakers, funders, and the service delivery system. This paper describes findings from baseline interviews with representatives from 49 state substance abuse authorities (SSAs). Interviews assessed efforts aimed at facilitating EBP adoption in each state and the District of Columbia. Results suggested that SSAs are concentrating more effort on EBP implementation strategies such as education, training, and infrastructure development, and less effort on financial mechanisms, regulations, and accreditation. The majority of SSAs use EBPs as a criterion in their contracts with providers, and just over half reported that EBP use is tied to state funding. To date, Oregon remains the only state with legislation that mandates treatment expenditures for EBPs; North Carolina follows suit with legislation that requires EBP promotion within current resources.

Implementing evidence-based practices for people with schizophrenia

Over the last decade, a consensus has emerged regarding a set of evidence-based practices for schizophrenia that address symptom management and psychosocial functioning. Yet, surveys suggest that the great majority of the population of individuals with schizophrenia do not receive evidence-based care. In this article, we review the empirical literature on implementation of evidence-based practices for schizophrenia patients. We first examine lessons learned from implementation studies in general medicine. We then summarize the implementation literature specific to schizophrenia, including medication practices, psychosocial interventions, information technology, and state- and federal-level interventions. We conclude with recommendations for future directions.

The State Health Authority Yardstick (SHAY)

State mental health authorities have a leadership role in implementing evidence-based practices (EBPs), but few instruments are available to assess the impact of this role. We describe the development of the State Mental Health Authority Yardstick (SHAY), a behaviorally anchored instrument designed to assess state-level facilitating conditions associated with successful implementation of EBPs in community mental health centers. The SHAY assesses the SMHA role in seven domains: Planning, Financing, Training, Leadership, Policies and Regulations, Quality Improvement, and Stakeholders. Preliminary evidence from the National Evidence-Based Practices Project partially supports the construct and criterion-oriented validity of this instrument for rating state-level activities supporting or blocking the implementation of evidence-based practices.