Issue Brief #35

November 21, 2014

Bridging Research and Practice
The Role of Implementation Science in Improving Children's Mental Health Services

Over the past two decades, much progress has been made in developing effective children’s health and mental health programs. There are now more than 210 evidence-based practices (EBPs) for youth -- programs demonstrated by research to successfully treat a variety of mental health and substance abuse concerns.[1]  Use of EBPs also results in significant cost-savings over time, even accounting for higher upfront implementation costs.[2]

 Despite these benefits, bringing EBPs to everyday mental health practitioners in a way they can use with children and families is a challenge. The availability of EBPs in community-based mental health settings remains limited. As many as 80% of children who need mental health treatment do not receive any treatment,[3] and those that do rarely receive EBPs. 

Implementation of an EBP is a complex, challenging process that typically takes several years. Significant barriers to implementation exist in community-based mental health settings including inadequate funding, competing organizational priorities, inadequate support from agency leadership, policies that don’t support EBPs, limited collaboration across systems, and staff turnover.[4] The field of implementation science provides a number of strategies to address these challenges.[5]

Implementation Science:  Bridging Research and Practice

Implementation science is the study of how to bridge the research-to-practice gap by developing and evaluating strategies for successfully implementing and sustaining innovations, including EBPs, in community settings. Federal agencies, including the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Institutes of Health, and the Veteran’s Administration, along with many state agencies that administer children’s mental health services, have recently recognized the importance of implementation science for improving health care services. Historically it has taken an average of 17 years for research innovations to be integrated into practice.[6]  Implementation science aims to accelerate this process.

Intermediary organizations such as the Child Health and Development Institute (CHDI) are increasingly called upon to put implementation science into practice by collaborating with funders, state- and community-based agencies, and treatment developers to ensure efficient and successful implementation of EBPs. In addition to the traditional format of didactic training, which produces limited practice change and uptake alone,[7] EBP implementation requires intensive coaching, fidelity monitoring, and adequate supervision. Implementation must also extend beyond clinicians to address the practices of supervisors, agency leaders, non-clinical staff, and external partners. Implementation typically involves organizational assessments, consultation on staff selection, agency policy review, data collection and reporting, quality assurance, adaptations to the EBP, examining how the EBP fits into the agency’s culture and array of services, and long-term sustainability planning.

Dissemination of EBPs in Connecticut:  the “Learning Collaborative” Approach

Connecticut was among the first states to apply implementation science to its efforts to improve children’s mental health services. In 2007, CHDI partnered with the Department of Children and Families (DCF) to adapt the Breakthrough Series Collaborative model to disseminate EBPs in Connecticut using “learning collaboratives.” The Breakthrough Series Collaborative model was originally developed by the Institute for Healthcare Improvement to spread innovations in health, and was subsequently adopted by SAMHSA’s National Child Traumatic Stress Network to disseminate mental health EBPs nationally. Learning collaboratives are one example of a well-defined dissemination model grounded in implementation science.

DCF selected CHDI as the intermediary organization to coordinate the dissemination of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) using learning collaboratives in 2007. Through a combination of state and federal funding,[8] CHDI, DCF, and more recently the Court Support Services Division (CSSD) have partnered to disseminate TF-CBT to thirty community agencies across the state. CHDI has trained more than 600 clinicians, staff members in the child welfare and juvenile justice systems, and family partners. As a result, more than 4,500 children in Connecticut have received TF-CBT, and those completing treatment demonstrate excellent clinical outcomes. All agencies have sustained TF-CBT programs up to six years following implementation.CHDI’s 2011 IMPACT report,Statewide Implementation of Best Practices: The Connecticut TF-CBT Learning Collaborative, describesTF-CBT as a successful case example of statewide EBP dissemination.

CHDI also has assisted in using learning collaboratives to disseminate other EBPs in Connecticut including Child FIRST, an early childhood mental health intervention, and the Child and Family Traumatic Stress Intervention (CFTSI) model developed at the Yale Child Study Center. We are working with a developer of the Modular Approach to Therapy for Children: Anxiety, Depression, Trauma and Conduct Problems (MATCH-ADTC) at Harvard University to do the same over the next three years.

Next Steps:  

Connecticut has established itself as a national leader in bringing EBPs and other children’s mental health practice innovations to the state. Despite this significant investment, much more needs to be done to reach the thousands of Connecticut families and children still without access to high quality treatment. Implementation science offers the best approach for expanding access to EBPs in Connecticut.

The State’s Children’s Behavioral Health Plan, prepared by CHDI in partnership with DCF and submitted to the Connecticut General Assembly in October 2014, recognizes the important role of EBPs in improving children’s mental health services over the next five years. The Plan specifically addresses expanding investment in EBPS in the areas of early intervention, prevention and outpatient services and calls for Connecticut to “scale up its nationally recognized trauma support and evidence-based services … to prevent system involvement and reduce escalation of need.”  

Recommendations for how Connecticut can support the use of EBPs in children’s mental health include the following:

• Base EBP dissemination efforts on current implementation science and include ongoing consultation, coaching and technical assistance, the use of data and quality improvement approaches, a focus on organizational change, and sustainability planning;
• Align public and private reimbursement policies to support the cost of implementation and sustainability of EBPs, particularly in light of research showing they result in future cost savings;
• Provide state resources for ongoing financial and technical support for agencies to implement and sustain EBPs, including blending funding across multiple state agencies;
• Conduct a comparative analysis of the cost effectiveness of various EBPs to assist with identifying which to scale up, similar to the approach taken by Washington State;
• Actively engage other child serving systems (e.g., child welfare, juvenile justice, education, and health care) in EBP dissemination efforts so that all providers who are in a position to refer children and families for behavioral health services are fully aware of the opportunity for these interventions to more effectively meet the needs of those they serve.

For more information, visit www.chdi.org/EBPs  or contact Jason Lang (jalang@uchc.edu).