Overview

 

The gap between research findings and clinical practice has been well documented, but we are learning how to bridge it.

 

Researchers and practitioners have identified numerous barriers to delivering evidence-based treatments in routine care settings. Challenges have been identified at multiple levels, including (but not limited to):

  • Limited alignment with existing policies and practices
  • Organizational and leadership support
  • Limited time and resources for training and implementation
  • Access to competency-based training and support for providers for delivering evidence-based treatments
  • Concerns about fit with therapists’ previous practice and with client needs

In light of these challenges, research on the implementation of EBPs has proliferated in recent years. The field of implementation science has developed into a multidisciplinary discipline with a unique identity and contribution to science and practice.

 

Definitions

Dissemination refers to the distribution of an intervention or innovation to a specific audience. Manuals, presentations, and websites are examples of efforts to disseminate information about interventions.

More recently, there has been greater recognition that the broader context into which an innovation is introduced has a substantial influence on whether they are successfully integrated into routine care. This recognition has led to a shift in focus to implementation, the integration of a new practice within a specific setting or context. Implementation involves the use of strategies to adopt and integrate evidence-based interventions and change practice patterns within specific settings.

Recent Advances

Through research in implementation science, advances have been made in many areas

This website is intended to provide an overview of theory and research that is relevant to efforts to implement EBPs into practice settings. When planning to implement an EBP, identifying programs that have achieved similar goals and learning about the processes they employed can also be extremely helpful for understanding what steps were taken to achieve full or sustained implementation. Therefore, in addition to theory and research, this website presents practical information and guidance for stakeholders in different roles, such as treatment developers, policymakers, administrators, and EBP trainers.

 

Overview

The gap between research findings and clinical practice has been well documented, as have numerous barriers to delivering evidence-based treatments in routine care settings.

These barriers include factors at multiple levels, including but not limited to, limited competency-based training and support for providers for delivering evidence- based treatments, organizational support and cultural factors, and limited alignment with existing policies and practices. There exist a number of practical guides and reviews of implementation science that synthesize implementation theory and research and describe processes to promote effective implementation. Others have focused more specifically on providing practical guidance for training while integrating knowledge from the field of implementation science. These guides all emphasize the importance of taking a multilevel approach and understanding the context into which the intervention is to be implemented. When planning to implement an EBP, identifying programs that have achieved similar goals and learning about the processes they employed can also be extremely helpful for understanding what steps were taken to achieve full or sustained implementation. Finally, processes for adapting interventions when needed to address contextual factors, while preserving the core elements of the interventions, are also being developed and tested.

To understand and address these challenges, research on dissemination and implementation has increased in recent decades, and the field of implementation science has developed into a multidisciplinary discipline with a unique identity and contribution to science and practice. Dissemination refers to the distribution of an intervention or innovation to a specific audience. More recently, recognition that the broader context into which an innovation is introduced has a substantial influence on whether they are successfully integrated into routine care has led to a shift in focus to implementation, the use of strategies to adopt and integrate evidence-based interventions and change practice patterns within specific settings (National Institutes of Health, 2006).

Dissemination and Implementation Theories and Frameworks

Implementation science spans many fields and disciplines, and theories and research in the area of mental health which have informed and been informed by other areas of healthcare. Over 61 frameworks and models of implementation have been published. Different models and frameworks serve different purposes, including identification of determinant factors (explanatory models), process models, and evaluation models.

  • The Exploration, Planning, Implementation and Sustainment (EPIS) framework (Aarons, Hurlburt, & Horwitz, 2011), was developed specifically for research in child service and mental health settings and describes hypothesized influences at four states of implementation.
  • The Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2009) is a consolidation of D&I theories, which includes some constructs that are not emphasized in the EPIS, but which have been empirically associated with key implementation outcomes in mental health settings.
  • Other frameworks, such as the Replicating Effective Programs framework (Kilbourne et al., 2008) provide guidance about steps for successfully transporting an intervention into a new setting.
  • A model that is specific to implementing EBPs into healthcare systems is the National VA Evidence-Based Psychotherapy Dissemination and Implementation Model (Karlin & Cross, 2014). This multi-level model, informed by identified barriers and facilitators in the implementation science literature, guided the national dissemination and implementation of 16 EBPs throughout the VA health care system – the largest dissemination of EBPs in the nation. This model includes interventions and specific strategies at the Policy (requirements for EBP availability), Provider (training and support), Local Systems (infrastructure and buy-in), Patient (clinical implementation strategies), and Accountability (monitoring and evaluation) levels.

Some commonalities exist among these theories and frameworks. For example, most implementation theory and research highlight influences at multiple levels, which can interact with one another, and with the intervention, to influence implementation success. The extent to which new treatments are successfully implemented and sustained can be influenced by the broad sociopolitical context, or outer context, and the inner context of the practice setting itself. Some implementation frameworks and theories also describe the role of characteristics of individuals and characteristics of the intervention.

Some commonalities exist among these theories and frameworks. For example, most implementation theory and research highlight influences at multiple levels, which can interact with one another, and with the intervention, to influence implementation success. The extent to which new treatments are successfully implemented and sustained can be influenced by the broad sociopolitical context, or outer context, and the inner context of the practice setting itself. Some implementation frameworks and theories also describe the role of characteristics of individuals and characteristics of the intervention.

 

Theories and frameworks should be selected based on the goals of the project, the levels at which intervention or assessment are necessary (e.g., organization, provider, etc.) to successfully implement the new practices, and what is needed to inform current and future work. For example, if guidance is needed about steps to implement an EBP, a process model would be useful. If a framework is needed to guide a needs assessment or to identify barriers and facilitators at each level, an explanatory model may be appropriate. Process and explanatory models can be used to complement one another, as well. Further guidance for how to select an implementation framework or model can be found here.

Theories and frameworks should be selected based on the goals of the project, the levels at which intervention or assessment are necessary (e.g., organization, provider, etc.) to successfully implement the new practices, and what is needed to inform current and future work. For example, if guidance is needed about steps to implement an EBP, a process model would be useful. If a framework is needed to guide a needs assessment or to identify barriers and facilitators at each level, an explanatory model may be appropriate. Process and explanatory models can be used to complement one another, as well. Further guidance for how to select an implementation framework or model can be found here.

Implementation typically requires multiple strategies and intervention at multiple levels.

In a recent study, 73 distinct implementation strategies were identified, which can be selected and combined based on a needs assessment that identified barriers and facilitators at each of the above levels. These strategies can be grouped according to six key implementation processes: planning, educating, financing, restructuring, managing quality, and attending to the policy context. Research findings and strategies to intervene at each level in mental health settings were recently reviewed and found that to date, the most research has been done to test theories and implementation strategies at the levels of the inner context and characteristics of the individual.