Advancing the state-level tracking of evidence-based practices: a case study

Revisiting the policy ecology framework for implementation of evidence-based practices in mental health settings

BACKGROUND

Over the past three decades, policy actors and actions have been highly influential in supporting the implementation of evidence-based practices (EBPs) in mental health settings. An early examination of these actions resulted in the Policy Ecology Framework (PEF), which was originally developed as a tactical primer for state and local mental health regulators in the field of child mental health. However, the policy landscape for implementation has evolved significantly since the original PEF was published. An interrogation of the strategies originally proposed in the PEF is necessary to provide an updated menu of strategies to improve our understanding of the mechanisms of policy action and promote system improvement.

OBJECTIVES

This paper builds upon the original PEF to address changes in the policy landscape for the implementation of mental health EBPs between 2009 and 2022. We review the current state of policy strategies that support the implementation of EBPs in mental health care and outline key areas for policy-oriented implementation research. Our review identifies policy strategies at federal, state, agency, and organizational levels, and highlights developments in the social context in which EBPs are implemented. Furthermore, our review is organized around some key changes that occurred across each PEF domain that span organizational, agency, political, and social contexts along with subdomains within each area.

DISCUSSION

We present an updated menu of policy strategies to support the implementation of EBPs in mental health settings. This updated menu of strategies considers the broad range of conceptual developments and changes in the policy landscape. These developments have occurred across the organizational, agency, political, and social contexts and are important for policymakers to consider in the context of supporting the implementation of EBPs. The updated PEF expands and enhances the specification of policy levers currently available, and identifies policy targets that are underdeveloped (e.g., de-implementation and sustainment) but are becoming visible opportunities for policy to support system improvement. The updated PEF clarifies current policy efforts within the field of implementation science in health to conceptualize and better operationalize the role of policy in the implementation of EBPs.

Observed Engagement in Community Implemented Evidence-Based Practices for Children and Adolescents: Implications for Practice Delivery

OBJECTIVE

This observational study characterizes youth and caregiver behaviors that may pose challenges to engagement within a system-driven implementation of multiple evidence-based practices (EBPs). We examined links between Engagement Challenges and therapist EBP implementation outcomes.

METHOD

Community therapists (N = 102) provided audio recordings of EBP sessions (N = 666) for youth (N = 267; 71.54%, Latinx; 51.69%, female; Mage = 9.85, Range: 1-18). Observers rated the extent to which youth and/or caregivers engaged in the following behaviors: Caregiver and/or Youth Expressed Concerns about interventions, and Youth Disruptive Behaviors. Multilevel modeling was used to identify predictors of observable Engagement Challenges, and examine associations between Engagement Challenges, and therapist-reported ability to deliver planned activities, and observer-rated extensiveness of EBP strategy delivery.

RESULTS

At least one Engagement Challenge was observed in 43.99% of sessions. Youth Engagement Challenges were not associated with outcomes. Caregiver Expressed Concerns were negatively associated with therapist-reported ability to carry out planned session activities (B = -.21, 95% CI[-.39-(-.02)], p < .05). However, Caregiver Expressed Concerns were positively associated with extensiveness of EBP Content strategy delivery (B = .08, 95% CI[.01-.15], p < .05).

CONCLUSIONS

Results suggest that Youth Engagement Challenges have little observed impact on EBP delivery. In contrast, although therapists perceive that Caregiver Expressed Concerns derail their planned activities, Caregiver Expressed Concerns are associated with more extensive delivery of content about therapeutic interventions. Community therapists' implementation of EBPs appear unaffected by common youth in-session behavioral challenges, but future research is needed to clarify whether caregivers' concerns about interventions prompt, or are prompted by, more intensive therapist EBP content instruction.

Exploring perceptions of implementation practice capacity in community-based behavioral health organizations

Community-based organizations (CBOs) must have the capacity to adopt, implement, and sustain evidence-based practices (EBPs). However, limited research exists examining CBOs' ability/capacity to implement EBPs. The purpose of this preliminary study was to investigate how staff of CBOs perceive implementation practice capacity, determine factors needed for adequate capacity for implementing EBPs, and examine which perspectives of capacity are shared across organizational levels. Ninety-seven administrators and practitioners of CBOs were surveyed using the Implementation Capacity Survey, which examines perceived importance, presence, and organizational capacity of the CBO in nine implementation practice areas (IPAs) (e.g., leadership). Results revealed participants rated IPAs on the importance scale higher than IPAs on the present scale. Presence and organizational capacity scales were strongly correlated, and results showed significant differences between administrators and practitioners on ratings of presence and organizational capacity. Implications for future research aimed at examining/building implementation practice capacity in community settings will be discussed.

The implementation potential of a method to monitor empirically-supported children's mental health treatment through claims data

Background

The delivery of evidence-supported treatments (EST) in children’s mental health could be a valuable measure for monitoring mental healthcare quality; however, efforts to monitor the use of EST in real world systems are hindered by the lack of pragmatic methods. This mixed methods study examined the implementation and agency response rate of a pragmatic, claims-based measure of EST designed to be applied as a universal quality measure for child psychotherapy encounters in a state Medicaid system.

Methods

Implementation potential of the EST measure was assessed with healthcare leader rankings of the reporting method’s acceptability, appropriateness and feasibility (n = 53), and post-implementation ratings of EST rate accuracy. Ability of the healthcare system to monitor EST through claims was measured by examining the agency responsivity in using the claims-based measure across 98 Medicaid-contracted community mental health (CMH) agencies in Washington State.

Results

The analysis found the reporting method had high implementation potential. The method was able to measure the use of an EST for 83% of children covered by Medicaid with 58% CMH agencies reporting > 0 ESTs in one quarter. Qualitative analyses revealed that the most significant barrier to reporting ESTs was the operability of electronic health record systems and agencies’ mixed views regarding the accuracy and benefits of reporting.

Conclusions

Measurement of child mental health ESTs through Medicaid claims reporting has acceptable implementation potential and promising real world responsiveness from CMH agencies in one state. Variation in reporting by agency site and low to moderate perceived value by agency leaders suggests the need for additional implementation supports for wider uptake.

Funding Diversity: A Case Study of A State-initiated, Funding-driven Program to Diversify Mental Health Service Provision in Minnesota

Human service organizations are reconfiguring to address diversifying populations and widening inequality. However, institutional change is challenging to implement and fund; resource scarcity and stakeholder buy-in are barriers. In this case study, we analyze a funding-driven, state-initiated program that supports mental health professionals who are people of color in order to decrease health disparities. Analyses of interviews and documents depict how the program struggled with high turnover and uninspired, halfhearted messaging, but was nevertheless well loved. Findings illustrate how the 'pitch' and leadership matter in programming for institutional change and its contested nature, a contestation that funding alone cannot temper.

Race and Equity in Statewide Implementation Programs: An Application of the Policy Ecology of Implementation Framework

Although the literature is growing regarding large-scale, system-wide implementation programs, the broader political and social contexts, including race and ethnicity, are frequently ignored. Using the Policy Ecology of Implementation framework (Raghavan et al., Implement Sci 3:26, 2008), Minnesota's CEMIG is examined to investigate the role of social and political contexts in the implementation process and the barriers they create. Data from 22 interview transcripts from DHS administrators, agency grant managers, university educators, advocacy group representatives, and mental health board members, along with more than 1000 grant documents were qualitatively analyzed using content analysis to reveal three themes concerning how the participants experienced program implementation: invisibility, isolation, and inequity. Findings demonstrate the participants perceived that the grant program perpetuated inequities by neglecting to promote the program, advocate for clinicians of color, and coordinate isolated policy ecology systems. Strategies for future large-scale, system-wide mental health program implementation are provided.

The role of the outer setting in implementation: associations between state demographic, fiscal, and policy factors and use of evidence-based treatments in mental healthcare

Background

Despite consistent recognition of their influence, empirical study of how outer setting factors (e.g., policies, financing, stakeholder relationships) influence public systems’ investment in and adoption of evidence-based treatment (EBT) is limited. This study examined associations among unmodifiable (e.g., demographic, economic, political, structural factors) and modifiable (e.g., allocation of resources, social processes, policies, and regulations) outer setting factors and adoption of behavioral health EBT by US states.

Methods

Multilevel models examined relationships between state characteristics, an array of funding and policy variables, and state adoption of behavioral health EBTs for adults and children across years 2002–2012, using data from the National Association for State Mental Health Program Directors Research Institute and other sources.

Results

Several unmodifiable state factors, including per capita income, controlling political party, and Medicaid expansion, predicted level of state fiscal investments in EBT. By contrast, modifiable factors, such as interagency collaboration and investment in research centers, were more predictive of state policies supportive of EBT. Interestingly, level of adult EBT adoption was associated with state fiscal supports for EBT, while child EBT adoption was predicted more by supportive policies. State per capita debt and direct state operation of services (versus contracting for services) predicted both child and adult EBT adoption.

Conclusions

State-level EBT adoption and associated implementation support is associated with an interpretable array of policy, financing, and oversight factors. Such information expands our knowledge base of the role of the outer setting in implementation and may provide insight into how best to focus efforts to promote EBT for behavioral health disorders.