Federal spending on evidence-based practices (EBPs) provides significant returns by offsetting billions of dollars in societal impacts each year. Practices are deemed evidence-based because they have demonstrated their effectiveness in addressing various social and health-related challenges. Federal agencies often invest in EBP delivery through discretionary grants, but there is limited guidance on how to optimize these grants to support large-scale EBP implementation. To address this gap, the authors held focus groups with federal and state agency officials (using the findings from ongoing RAND research to frame their discussions) to gather and synthesize their recommendations on how to optimize federal grantmaking for EBP implementation. With the focus group participants, the authors identified seven policy recommendations for federal officials to consider when designing, awarding, and executing grants for EBP implementation, including capacity-building in service delivery organizations to sustain EBPs after grant funding ends. The authors also present real-world case examples to illustrate how funding agencies have put each recommendation into practice.

In this report, the authors present seven policy recommendations to optimize federal investment into large-scale implementation of evidence-based practices in health and social services that they identified with federal and state agency officials.

ObjectiveContextual factors exert dynamic influences on sustainment of evidence-based practice (EBP) after grant funding ends (ie, funding cliffs), but how these factors change over time remains poorly understood. Exploring the factors that affect EBP sustainment trajectories can help explain how community-based treatment organizations navigate funding cliffs.MethodThe study sample comprised 51 community-based treatment organizations drawn from national cohorts that completed federal grants to implement the Adolescent Community Reinforcement Approach (A-CRA), a youth substance use EBP. Interviews were conducted with clinical staff (N=129) across 2 or 3 annual waves. Interviews focused on staff perspectives about A-CRA sustainment. Based on interview field notes, a longitudinal thematic analysis was conducted to identify influences on organizational sustainment trajectories (ie, pivotal moments, transitions, driving forces, and slow burn processes).ResultsThe end of grant funding triggered numerous sustainment challenges. Pivotal moment events, such as receiving additional funding for A-CRA, helped mitigate the consequences of funding cliffs. Transitions, such as staff turnover, generally impeded sustainment, as organizations had to reinvest in A-CRA-trained staff. Other factors exerted effects that were either directly connected to A-CRA (driving forces), such as committed leadership that fostered staff buy-in, or were more indirectly related (slow burns), such as client population characteristics that made A-CRA delivery challenging.ConclusionThese results illustrate how interrelated processes influence EBP sustainment trajectories. Although organizations may exhibit a pattern of supports for sustainment of EBP, these factors can change over time and do not guarantee future sustainment. These findings also can inform strategies for strengthening EBP sustainment. Read More Subscribe to the Policy Currents newsletter Email Subscribe Related Content ResearchComparing Organization-Focused and State-Focused Financing Strategies on Provider-Level Reach of a Youth Substance Use Treatment Model: A Mixed-Method StudyOct 16, 2023 Topics Evidence Based Health PracticeSurvey Research MethodologyUnderage Substance Use Document Details Document Details Copyright: 兰德公司 ; Open AccessPublisher: Published by Elsevier IncAvailability: Non-RAND Year: 2024 Pages: 12 Document Number: EP-70439 Research conducted by RAND Health Care This publication is part of the RAND external publication series. Many RAND studies are published in peer-reviewed scholarly journals, as chapters in commercial books, or as documents published by other organizations. RAND is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND's publications do not necessarily reflect the opinions of its research clients and sponsors.

Background Little is known about clinician perspectives regarding the factors that support or hinder the long-term delivery (i.e., sustainment) of evidence-based treatments in community-based treatment settings. Methods Clinical staff from 82 community-based treatment organizations that received federal grant funding to support the delivery of the Adolescent Community Reinforcement Approach (A-CRA), an evidence-based treatment for adolescent substance use, were asked to participate in interviews focused on understanding their perspectives about the sustainment of A-CRA. Qualitative themes were identified using inductive and deductive approaches. Then the themes were dichotomized (present/absent) so that quantitative comparisons could be made between staff from organizations that sustained and did not sustain delivery of A-CRA. Administrative data about each organization in relation to federal funding support and their primary focus was also examined to explore whether these characteristics were associated with A-CRA sustainment. Results Staff (n = 134) representing 78 organizations participated in the interviews. Staff from organizations that had received multiple federal grants to support the delivery of A-CRA and whose primary focus was substance use rather than other conditions (mental health or primary care) were more likely to report sustaining A-CRA. Staff from sustaining organizations were more likely to report positive grant experiences and success with maintaining both organizational and external support in comparison to staff from non-sustaining organizations. Staff from non-sustaining organizations were more likely to report barriers to sustaining A-CRA, including more challenges with intervention delivery, and lack of internal support and external funding. Conclusions Our findings lend empirical support for implementation theories in that multiple factors appear to be associated with long-term delivery of an evidence-based treatment. Although A-CRA was generally perceived positively by staff from both organizations that sustained A-CRA and organizations that did not sustain A-CRA, inner setting factors (e.g., structural policies, leadership support and staff retention) along with outer setting factors (e.g., external funding support) were reported as key to A-CRA sustainment.

Little is known about clinician perspectives regarding the factors that support or hinder the long-term delivery (i.e., sustainment) of evidence-based treatments in community-based treatment settings.,Clinical staff from 82 community-based treatment organizations that received federal grant funding to support the delivery of the Adolescent Community Reinforcement Approach (A-CRA), an evidence-based treatment for adolescent substance use, were asked to participate in interviews focused on understanding their perspectives about the sustainment of A-CRA. Qualitative themes were identified using inductive and deductive approaches. Then the themes were dichotomized (present/absent) so that quantitative comparisons could be made between staff from organizations that sustained and did not sustain delivery of A-CRA. Administrative data about each organization in relation to federal funding support and their primary focus was also examined to explore whether these characteristics were associated with A-CRA sustainment.,Staff (n = 134) representing 78 organizations participated in the interviews. Staff from organizations that had received multiple federal grants to support the delivery of A-CRA and whose primary focus was substance use rather than other conditions (mental health or primary care) were more likely to report sustaining A-CRA. Staff from sustaining organizations were more likely to report positive grant experiences and success with maintaining both organizational and external support in comparison to staff from non-sustaining organizations. Staff from non-sustaining organizations were more likely to report barriers to sustaining A-CRA, including more challenges with intervention delivery, and lack of internal support and external funding.,Our findings lend empirical support for implementation theories in that multiple factors appear to be associated with long-term delivery of an evidence-based treatment. Although A-CRA was generally perceived positively by staff from both organizations that sustained A-CRA and organizations that did not sustain A-CRA, inner setting factors (e.g., structural policies, leadership support and staff retention) along with outer setting factors (e.g., external funding support) were reported as key to A-CRA sustainment.

An evidence-based measure of implementation (EBMI) is an implementation outcome measure shown to have predictive validity with one or more future-measured constructs of importance. The current study sought to identify correlates and predictors of an EBMI called procedure exposure. Garner et al. (2016) found procedure exposure to be an EBMI for the Adolescent Community Reinforcement Approach (A-CRA).,The dataset included 76 community-based substance use treatment organizations located across the United States. Organizational-level regression analyses, which were framed within the context of Chaudoir et al. (2013) framework for predicting implementation outcomes, were used to examine predictors of A-CRA procedure exposure.,The Washington Circle's treatment initiation performance measure (B = 5.05 [SE = 1.60], p = 0.002), as well as session exposure (B = 0.18 [SE = 0.06], p = 0.003), were significant predictors of A-CRA procedure exposure in the backward stepwise regression analysis (Adjusted R-square = 0.55). The Washington Circle's treatment engagement performance measure (B = 7.93 [SE = 0.77], p < 0.001), as well as time-to-proficiency (B = −0.04 [SE = 0.02], p = 0.02), each had significant bivariate relationships with A-CRA procedure exposure but were not retained in the final model.,Organizations implementing A-CRA are encouraged to make the following high priorities: (a) scheduling and completing a subsequent treatment session within 14 days of their index session (treatment initiation) and (b) providing a targeted number of treatment sessions to each client (session exposure). To the extent organizations do this, they may be more likely to achieve higher levels of A-CRA procedure exposure.

Implementation support models are increasingly being used to enhance the delivery of evidence-based treatments (EBTs) in routine care settings. Little is known about the extent to which these models lead to continued EBT use after implementation support ends. Moreover, few empirical studies longitudinally examine the hypothesized factors associated with long-term psychosocial EBT use (i.e., sustainment). In an effort to address this gap, the current study examined sustainment of an EBT called the Adolescent-Community Reinforcement Approach (A-CRA) following the end of implementation support.,Between 2006 and 2010, the Substance Abuse and Mental Health Services Administration awarded 3 years of A-CRA implementation support to 82 community-based organizations around the USA. The extent to which A-CRA was sustained following grant end and the hypothesized factors associated with EBT sustainment were collected using both retrospective and prospective data. We examined the extent to which 10 core treatment elements of A-CRA were sustained and the associations between the extent of A-CRA sustainment and hypothesized factors using a pattern-mixture longitudinal modeling approach.,Staff from 76 organizations participated in data collection for a 92.86% response rate. On average, about half of the 10 core treatment elements were sustained following the loss of implementation support. Factors that appeared most important to A-CRA sustainment included characteristics that were related to the outer setting (communication, funding, and partnerships), inner setting (political support, organizational capacity, and supervisor turnover rate), implementation support period (number of clinicians and supervisors certified and employed at support end and number of youth served), and staff perceptions of the intervention (implementation difficulty, relative advantage, and perceived success).,Even with multiple years of implementation support, community-based organizations face challenges in sustaining EBT delivery over time. Consistent with implementation theories, multiple factors appear related with EBT sustainment, including the degree of implementation during the initial support period, as well as adequate funding, infrastructure support, and staff support following the end of funding.

Developing consistent, valid, and efficient implementation outcome measures is necessary to advance implementation science. However, development of such measures has been limited to date, especially for validating the extent to which such measures are associated with important improvements in client outcomes. This study seeks to address this gap by developing one or more evidence-based measures of implementation (EBMIs; i.e., implementation outcome measure that is predictive of improvements in key client outcomes) for the Adolescent Community Reinforcement Approach (A-CRA), an evidence-based practice (EBP) for adolescent substance use.,Data for the current study were collected as part of a large-scale federally funded EBP dissemination and implementation initiative. The multilevel dataset included 65 substance use treatment organizations, 308 clinicians, and 5873 adolescent clients. Adjusted multilevel regression analyses were used to examine the extent to which client-level outcome measures assessed at 6-month follow-up (i.e., substance use, emotional problems) could be predicted by four implementation outcomes: two measures of fidelity (i.e., session exposure, procedure exposure) and two measures of penetration (i.e., absolute client penetration, absolute staff penetration).,Adjusting for client substance use at intake, as well as several client characteristics (e.g., age, race, criminal justice involvement), client substance use at follow-up was significantly lower for treatment organizations that had higher procedure exposure (B = − 1.227, standard error [SE] = 0.583, 95% confidence interval = − 2.370, 0.252; p < .05). None of the other three implementation outcome measures were found to predict improvements in client outcomes.,The current study provides support for procedure exposure as an organizational-level EBMI for A-CRA. Thus, future efforts focused on implementing A-CRA could be improved by measuring and monitoring the extent to which A-CRA procedures are being delivered to clients. Additionally, given the dearth of studies that have examined the relationship between organizational-level measures of implementation and client outcomes, this article provides a prototype for future research to identify EBMIs for other behavioral treatments.

BACKGROUND: Millions of people who need treatment for substance use disorders (SUD) do not receive it. Evidence-based practices for treating SUD exist, and some are appropriate for delivery outside of specialty care settings. Primary care is an opportune setting in which to deliver SUD treatment because many individuals see their primary care providers at least once a year. Further, the Patient Protection and Affordable Care Act (PPACA) increases coverage for SUD treatment and is increasing the number of individuals seeking primary care services. In this article, we present the protocol for a study testing the effects of an organizational readiness and service delivery intervention on increasing the uptake of SUD treatment in primary care and on patient outcomes. METHODS/DESIGN: In a randomized controlled trial, we test the combined effects of an organizational readiness intervention consisting of implementation tools and activities and an integrated collaborative care service delivery intervention based on the Chronic Care Model on service system (patient-centered care, utilization of substance use disorder treatment, utilization of health care services and adoption and sustainability of evidence-based practices) and patient (substance use, consequences of use, health and mental health, and satisfaction with care) outcomes. We also use a repeated measures design to test organizational changes throughout the study, such as acceptability, appropriateness and feasibility of the practices to providers, and provider intention to adopt the practices. We use provider focus groups, provider and patient surveys, and administrative data to measure outcomes. DISCUSSION: The present study responds to critical gaps in health care services for people with substance use disorders, including the need for greater access to SUD treatment and greater uptake of evidence-based practices in primary care. We designed a multi-level study that combines implementation tools to increase organizational readiness to adopt and sustain evidence-based practices (EBPs) and tests the effectiveness of a service delivery intervention on service system and patient outcomes related to SUD services.

One barrier to widespread public access to empirically supported treatments (ESTs) is the limited availability and high cost of professionals trained to deliver them. Our earlier work from 2 clinical trials demonstrated that front-line addiction counselors could be trained to deliver a manualized, group-based cognitive behavioral therapy (GCBT) for depression, a prototypic example of an EST, with a high level of adherence and competence. This follow-up article provides specific recommendations for the selection and initial training of counselors, and for the structure and process of their ongoing clinical supervision. We highlight unique challenges in working with counselors unaccustomed to traditional clinical supervision. The recommendations are based on comprehensive feedback derived from clinician notes taken throughout the clinical trials, a focus group with counselors conducted 1 year following implementation, and interviews with key organization executives and administrators.

Group motivational interviewing (MI) interventions that target youth at-risk for alcohol and other drug (AOD) use may prevent future negative consequences. Youth in a teen court setting [n = 193; 67% male, 45% Hispanic; mean age 16.6 (SD = 1.05)] were randomized to receive either a group MI intervention, Free Talk, or usual care (UC). We examined client acceptance, and intervention feasibility and conducted a preliminary outcome evaluation. Free Talk teens reported higher quality and satisfaction ratings, and MI integrity scores were higher for Free Talk groups. AOD use and delinquency decreased for both groups at 3 months, and 12-month recidivism rates were lower but not significantly different for the Free Talk group compared to UC. Results contribute to emerging literature on MI in a group setting. A longer term follow-up is warranted.

Few integrated substance use and depression treatments have been developed for delivery in outpatient substance abuse treatment settings. To meet the call for more "transportable" interventions, we conducted a pilot study to test a group cognitive–behavioral therapy (CBT) for depression and substance use that was designed for delivery by outpatient substance abuse treatment counselors. Seventy-three outpatient clients were randomized to usual care enhanced with group CBT or usual care alone and assessed at three time points (baseline and 3 and 6 months postbaseline). Our results demonstrated that the treatment was acceptable and feasible for delivery by substance abuse treatment staff despite challenges with recruiting clients. Both depressive symptoms and substance use were reduced by the intervention but were not significantly different from the control group. These results suggest that further research is warranted to enhance the effectiveness of treatment for co-occurring disorders in these settings.

This study evaluates the effectiveness of motivational enhancement therapy/cognitive behavioral therapy–5 (MET/CBT-5) when delivered in community practice settings relative to standard community-based adolescent treatment. A quasi-experimental strategy was used to adjust for pretreatment differences between the MET/CBT-5 sample (n = 2,293) and those who received standard care (n = 458). Results suggest that youth who received MET/CBT-5 fared better than comparable youth in the control group on five of six 12-month outcomes. A low follow-up rate (54%) in the MET/CBT-5 sample raised concerns about nonresponse bias in the treatment effect estimates. Sensitivity analyses suggest that although modest differences in outcomes between the MET/CBT-5 nonrespondents and respondents would yield no significant differences between the two groups on two of the six outcomes, very large differences in outcomes between responders and nonresponders would be required for youth receiving MET/CBT-5 to have fared better had they received standard outpatient care.

Prevention support systems (PSSs) are designed to help communities implement evidence-based practices (EBPs). Little is known about the factors that influence their adoption. In this article, the authors examined adoption of a PSS for substance abuse prevention called Getting To Outcomes (GTO) among staff in two community coalitions with varying levels of exposure to it over a 2-year period. A multistage regression model was used to determine the relative predictive power of organizational, innovation-related, and practitioner characteristics on adoption. Findings indicate that GTO adoption occurred through increased exposure, especially via staff training. Perceptions of the system's complexity moderated this effect. Individuals with high GTO exposure were less likely to adopt it if they perceived it as complex. Other organizational, innovation-related, and practitioner characteristics did not predict adoption. Results from this study are useful for understanding the factors associated with PSS adoption and suggest ways to increase their use in typical delivery settings.

The brief summarizes seven policy recommendations to optimize federal spending on large-scale implementation of evidence-based practices in health and social services, identified through focus groups with officials, and real-world examples of each.