Abstract
BackgroundMental health policymaking to support the implementation of evidence-based practices (EBPs) largely has been directed toward clinicians. However, implementation is known to be dependent upon a broader ecology of service delivery. Hence, focusing exclusively on individual clinicians as targets of implementation is unlikely to result in sustainable and widespread implementation of EBPs.DiscussionPolicymaking that is informed by the implementation literature requires that policymakers deploy strategies across multiple levels of the ecology of implementation. At the organizational level, policies are needed to resource the added marginal costs of EBPs, and to assist organizational learning by re-engineering continuing education units. At the payor and regulatory levels, policies are needed to creatively utilize contractual mechanisms, develop disease management programs and similar comprehensive care management approaches, carefully utilize provider and organizational profiling, and develop outcomes assessment. At the political level, legislation is required to promote mental health parity, reduce discrimination, and support loan forgiveness programs. Regulations are also needed to enhance consumer and family engagement in an EBP agenda. And at the social level, approaches to combat stigma are needed to ensure that individuals with mental health need access services.SummaryThe implementation literature suggests that a single policy decision, such as mandating a specific EBP, is unlikely to result in sustainable implementation. Policymaking that addresses in an integrated way the ecology of implementation at the levels of provider organizations, governmental regulatory agencies, and their surrounding political and societal milieu is required to successfully and sustainably implement EBPs over the long term.
Highlights
Mental health policymaking to support the implementation of evidence-based practices (EBPs) largely has been directed toward clinicians
Summary: The implementation literature suggests that a single policy decision, such as mandating a specific EBP, is unlikely to result in sustainable implementation
In this article – directed toward policymakers and implementation researchers in public mental health settings – we argue that mandating the use of EBPs by individual clinicians and provider organizations, or narrowly focusing on effecting change within individual organizations, is unlikely to result in their successful and sustainable implementation unless the broader ecology within which these interventions are delivered is supported
Summary
The ecology of implementing EBPs In FY 2005, SAMHSA began funding mental health transformation state incentive grants [20,21]. Several family/consumer fears have been documented in the literature [7], and include concerns that the EBP movement is insufficiently aligned with the recovery model (in which mental health consumers are presumed capable of making considerable progress toward independence [68]), that EBPs may replace other needed services, that there may be a lack of availability of providers able to deliver EBPs, that EBPs may be unduly prescriptive and cause consumers to lose control over their care, and that they may not be sufficiently culturally competent [6,69] Policymakers who confront such issues may benefit from an approach to engaging consumers and families proposed by Birkel and colleagues [70], who suggest that EBP implementation efforts should actively build collaborative relationships at the beginning of the implementation process; should find ways to integrate recovery in the development and deployment of EBPs; should pay special attention to racial/ethnic, geographical, cultural and linguistic diversity in all implementation efforts; and should develop and disseminate resources to support not just the EBP and its advocacy. While none of these approaches directly serve an EBP implementation agenda, they create the contexts for improved access to mental health services, within which an EBP agenda can be supported
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