Introduction

Advances in research, practice, and policy related to behavioral health care have led to greater availability and emphasis on the use of interventions that have proven their effectiveness.1,2 As a result, the interest, development, and implementation of evidence-based practices (EBPs) have grown exponentially.3 Evidence-based practices, programs, interventions, and/or treatments can be defined as activities, frameworks, policies, and/or strategies that have been proven to be effective empirically through rigorous research and take client and practitioner values into consideration.4,5,6,7,8,9 Evidence-based approaches are now used by many health disciplines including medicine, behavioral health, nursing, and psychology.

Since the implementation of the Affordable Care Act, most notably the expansion of mental health and substance use parity that requires insurers to cover mental health and substance use disorders in the same manner as medical illnesses, behavioral health services are in high demand.10,11 In addition, Federal funding organizations such as the Substance Abuse and Mental Health Services Administration, the Centers for Disease Control and Prevention, and the National Institutes of Health now require their grantees to use EBPs as well.10,12 Although there has been an increase in the availability and utilization of EBPs in the last three decades because of the “evidence-based movement” and Federal legislation changing the landscape of behavioral health services, issues still persist with the effective translation of research into practice.5,8,9,10,11 Many behavioral health practitioners and service organizations struggle with successful implementation and integration of EBPs due to a lack of organizational buy-in, insufficient leadership, a lack of knowledge surrounding implementation characteristics, funding, fit of the program, and difficulties with adaptations.13,14,15,16 Due to these challenges, there has been extraordinary growth in the science of implementation over the last two decades.

The field of implementation science (IS) can be defined as methods or activities that promote and support the use of research findings and EBP.1,17,18 Often thought of as an applied science,2 IS seeks to bridge the gap between research and practice by attempting to translate knowledge into practical applications in behavioral health care settings.8 Implementation can be defined as utilizing strategies to identify, select, incorporate, and maintain EBPs as well as systematically change organizational structure, culture, and patterns of practice within settings.19 The challenges associated with implementing EBPs can hinder improvements in the quality and outcomes of behavioral health services.13

Navigating multilayered organizations and communities and their service delivery is an intricate process, often demanding extensive time and resource requirements. Early attempts at EBP dissemination have been met with barriers that may originate from the “top-down” approaches used by researchers to push EBP usage into behavioral health care settings. Research has shown that simply training practitioners in an EBP is not sufficient to ensure success. Accordingly, there is a great need for strategies that build capacity that assists with supporting and implementing innovation in community behavioral health settings.20

Written with behavioral health practitioners and service organizations in mind, the purpose of this commentary is to (1) provide a brief background of IS research and discuss the knowledge to practice gap, (2) provide an introduction to a perspective of implementation practice and its potential application for practitioners, (3) describe ongoing challenges faced by practitioners in applying IS research, and (4) and propose necessary steps in building organizational capacity that enables practitioners to implement the most effective services available.

Implementation Science Research

Due to the growing appreciation and need for a theoretical foundation, the field of IS has seen a massive increase in the development and testing of implementation theory, frameworks, models, and strategies in the last 20 years.21 These multiple IS theories, models, and frameworks support implementation research and provide roadmaps for the difficult processes that are involved with moving EBPs into utilization in the field.22 This scientific foundation has synthesized approaches to identify the critical determinants associated with successful implementation. Work has also progressed to identify not only situational determinants of implementation success such as organizational climate but also relevant implementation strategies, evaluation techniques, and critical measures of implementation success such as fidelity and sustainability.21,22 However, the difficulty now rests on the shoulders of behavioral health researchers and practitioners to select the most appropriate approach to translate EBPs into community settings.

The main objective of these frameworks and models was to assist with the translation of EBPs into the field of practice. Yet, the emphasis remains on research assessing the relevance, breadth, and utility of the models for research rather than on the practical relevance for successfully enabling new programs and interventions. Limited information exists on how to use these models to guide practitioners in the implementation of EBPs. This may be compounded by research that is focused on establishing interval validity within randomized controlled trials (RCTs) at the expense of external validity.23 The complexities of settings and contexts that are critical components to effective implementation may be minimized in highly controlled research settings. This may compromise the usability and usefulness of EBP implementation and its associated IS approaches in real practice settings.23 In addition, what IS researchers and EBP developers choose to research is heavily influenced by what funding is available, which may result in EBPs and IS approaches being developed with static protocols that are highly theoretical, that are often disconnected to the end-user (i.e., practitioners and service organizations), and that do not account for the dynamic nature of behavioral health services.24

Recently, new research designs have been proposed for IS, such as hybrid trials25 and user-centered designs,24,26,27 that highlight both program effectiveness and implementation research working together to understand not only effectiveness but also how, why, and in what settings/contexts an EBP or IS approach works.23 However, the sheer number of theories, models, frameworks, and measures may pose an impediment to selecting an IS approach and assisting in EBP implementation. This gap may be further exacerbated due to many theories and frameworks being developed across health disciplines with limited cross-discipline collaboration,21 research findings being potentially contradictory across disciplines,28 and existing frameworks providing limited guidance regarding methods that ensure user needs are being met.24 All of these factors have contributed to a lack of cohesion and transparency among researchers,23 which has led to the issue of a “knowledge to practice” gap.2

Introduction to Implementation Practice

Westerlund and colleagues have noted the recurring question of whether findings and evidence from IS research have sufficiently reached the “world of practice”.2(p. 332) The translation of IS research into practice requires answering the question of how IS research findings can be made relevant for practitioners and service organizations. Implementation practice can be defined as the use of implementation mechanisms and activities informed by research and used by knowledgeable individuals, to facilitate the adoption, implementation, and sustainment of an evidence-based practice, model, or approach. The goal of implementation practice is to solve practical problems to successfully enhance services through practitioners and their organizations to improve outcomes for their clients.

In response to the need for IS at the practice level, the IS discipline has begun to shift toward implementation practice through the development of strategies that build capacity surrounding the implementation of EBPs.29 However, these strategies have largely focused on targeting one specific EBP and often require technical assistance (TA) that is external to the service organization. Using consultative models, EBP purveyors and intermediary organizations may provide TA and training regarding their specific intervention and guide the practitioner through the process of training and implementation.30 Unfortunately, these sources of support may require long-term contracts and funding to be sustainable.

Implementation knowledge is not often provided to practitioners during their formal education. In addition, limited professional development opportunities are available within service organizations to continue practitioner’s education to assist with practice translation.2 The lack of knowledge and skills of behavioral health practitioners related to EBP implementation has consistently emerged from the literature as a barrier to implementing research-supported interventions (i.e., EBPs and IS strategies).31 Universities have recently begun to increase curricula surrounding EBPs, but the evidence for such teaching techniques and their effectiveness is sparse and it is doubtful that solely those efforts will lead to a behavioral health workforce that can facilitate increased and expanded use of EBPs in their practice.31 In addition, general training initiatives or professional development opportunities in IS are heavily focused on engaging academic researchers and have engaged less with other key stakeholders (i.e., practitioners and service organizations) that are essential to the implementation process and its success.32

The next sections will provide an overview of specific challenges behavioral health practitioners and organizations may face when utilizing an EBP that are related to implementation practice. It will also provide recommendations for future research efforts, to be informed by key stakeholders, aimed at developing implementation practice capacity to improve the implementation of EBPs and client outcomes.

Issues for Consideration in Implementation Practice

Challenges to implementation of evidence-based practices

Although the promotion of EBPs in health services represented a critical advancement in behavioral health care, the well-intentioned push towards the use of EBPs often fails to close the gap between the best available research and practice.23,33,34,35 EBPs must be effectively matched to community needs, implemented with fidelity to the standards of the intervention, and integrated within regular practices, so they may be sustained over time to ensure better outcomes for consumers. An organization adopting an EBP without first considering implementation and its associated barriers may not be able to ensure effective outcomes among clients.16,33,36,37 To achieve positive outcomes, EBPs must not simply be implemented but implemented with quality.12,31 However, behavioral health organizations and practitioners face significant challenges to successful implementation. These include the following: (1) being able to access and understand research findings and interpret them for the needs of their clients, agency, and community; (2) being able to identify and select EBPs they can afford; (3) being able to do the actual work of implementing the EBP through staff training, instituting new policies, and negotiating new contracts; and (4) integrating these changes so these efforts can be sustained.

Practitioners may have difficulty accessing and interpreting the research literature regarding EBPs for their service populations. Synthesizing the research literature surrounding EBPs is difficult and may not be as an intuitive process for practitioners as was originally intended by EBP developers and researchers.10 Systematic reviews, meta-analyses, and literature reviews tend to predominantly include RCTs. This, coupled with research methodology and EBPs not being topics where clinicians are well-versed,10 may result in valuable information being omitted from consideration when seeking information about a specific EBP.28

Practitioners may also have difficulties in matching EBPs that are often developed with very narrow and specific populations, with their more diverse clientele. Those they serve may suffer from multiple, complex issues bridging mental and physical health concerns, historic disparities and discrimination, poverty, mobility, and education. A topic that has caused tension in the research community is the discussion of fidelity and adaption. While many argue that adaptations are necessary to meet the needs of a specific setting, others postulate that an EBP that has been adapted may compromise the core elements of the program and be less effective when compared to the original program.8,37,38,39 Although fidelity has become the “gold standard” for successful program implementation,40 it may not take into consideration how a program fits within a context. In addition, organizational characteristics such as readiness for change, climate, staffing, leadership, and funding can significantly impact the adoption, implementation, and sustainability of EBPs.8,41 Sustainability may require long-term commitments to facilitate change, including the support of new policies, procedures, and infrastructure enhancements. Supporting implementation and sustainability may require new partnerships and collaborations, sufficient funding, and ongoing problem-solving.42,43 Figure 1 illustrates the core challenges of translating implementation science into implementation practice.

Figure 1
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Core Challenges of Translating Implementation Science into Implementation Practice

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Implementation practice capacity

A significant amount of IS research is often conducted with limited collaboration or input from key stakeholders (i.e., clients, practitioners, and service organizations).32 This may result in an implementation strategy that does not take real-world barriers into consideration, that may be used incorrectly, and/or that is unable to be replicated.22,44 In order to develop tangible, applicable, and sustainable strategies for capacity building among practitioners and service organizations in implementation practice, it is essential that the strategies are created and tested in collaboration with the key stakeholders intended for its use.

Given these challenges and the lack of opportunity for formal training related to EBPs and IS, strategies are needed to build practice level capacity in service organizations for identifying, adopting, implementing, and sustaining EBPs. To influence professional practice, practitioners and service organizations must know how to (1) choose between competing theories, frameworks, models, and strategies of implementation;45 (2) must be able to determine which issues are most central to consider for their agency;33 (3) assess fit for their population;8 (4) acquire and/or allocated resources;36 (5) determine which approach(es) have the highest potential to produce successful implementation in their unique service setting;36 and (6) marshal resources to ensure continuation and continuity of the supports necessary for sustainability.42

This capacity must address the organization’s ability to adjust and account for changes at systems levels, within Federal and state regulations and licensing and funding requirements; at organizational levels, including considering the organization of programs, the structure of the organization, and its relation to other practitioners; and within the consumer community—by building tolerance, trust, and acknowledging the expectations of consumers (see Figure 1).45

Albers and colleagues conducted a systematic integrative review examining what implementation strategies are used by implementation support practitioners (ISP) (e.g., purveyors or intermediary organizations) to assist service organizations in practice settings. Findings suggest ISPs need to have a certain set of skills and knowledge to assist service organizations in the utilization of EBPs.31 However, there was limited discussion on the internal capacities needed on behalf of the service organizations themselves. There is a need to provide professional development to build capacity of current practitioners and service organizations to utilize EBPs and carry out activities associated with implementation practice. The mixed results of IS research conducted in various settings highlight the need for targeted exploration of implementation practice and capacity building in community-based and social service behavioral health care settings.22,29

To create a foundation for gaining insight regarding implementation capacity from key stakeholders, it is important to consult the research literature based on the science and practice of implementation. Although much of the information may be rooted in theory and research as opposed to practice, the IS literature provides a solid foundation of information that has allowed for the initial development and framing of the essential areas of implementation competencies that may account for successful implementation practice. Ten critical implementation areas related to practice that have been deemed essential by research for successful adoption, implementation, and sustainability of EBPs have been identified: (1) addressing fit and adaption; (2) funding and resources; (3) establishing implementation/organizational readiness; (4) addressing organizational culture/climate and buy-in; (5) providing leadership; (6) providing education, training, and coaching; (7) navigating external policies; (8) establishing communication and collaboration networks; (9) navigating the use of data to inform and monitoring/evaluating intervention(s); and (10) ensuring sustainability.28,33,36,46,47,48,49,50 Table 1 provides a brief overview of each implementation practice capacity and items for stakeholder consideration.

Table 1 Implementation Practice Capacities: Definitions
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Next steps in building organizational capacity

For community-based practitioners and their organizations, these implementation practice areas define competencies that may be required for the successful process of adopting, implementing, and sustaining EBPs. From a practice standpoint, what remains is the need to identify the importance and presence of these areas from the stakeholder’s perspective and how these areas are or should be made explicit in the organization. In addition, research must determine which of these areas compose a critical baseline capacity within the organization internally and which may be best addressed through external consultation and TA. While TA efforts can assist in building capacity, research has shown that to fully benefit from TA, general capacity must be present within the organization to maximize program effectiveness.28

Practitioners and/or their service organizations must determine the discrepancies between capacities they need, the capacities they have, and the ideal process to bridge this gap. It is critical for future research to identify and develop methods and tools to measure the areas of implementation practice capacity so they may be operationalized and replicated as well as prospectively identified to enable targeted capacity building efforts. While work on assessing organizational capacity has begun (e.g., State Implementation and Scaling-Up of Evidence-based Practices)51, it could benefit from further development. The uptake of an evidence-based program or policy, the size of the organization and its relationship to funders and other agencies, and local government and the community will all influence these considerations.

Among the implementation practice areas described in Table 1, it may be hypothesized that some areas could be readily addressed through strengthening existing internal capacity. It may be expected behavioral health and social service agencies have the structure for education and training experiences for accreditation purposes and for professional licensure and certification. Educating and training for EBPs may be handled internally or through established educational and training partnerships.15,33,36 Likewise, building and maintaining communication and collaboration within and across the agency and its partners may be part of an internal capacity.33 Quality circles and continuous quality improvement (i.e., monitoring and/or evaluation) efforts logically reside within the agency.52 The identification and selection of potential capacity building strategies, however, may be hypothesized to most efficiently be accomplished through external consultation and TA. For example, practitioners may not have the time or resources to identify and compare potential new EBPs as they become available.

Other competencies, such as establishing implementation readiness, may be built through a consultative process where the unique components of a proposed EBP are considered in light of organizational needs and positioning. Researchers as well as EBP developers play a crucial role in the translational of research to practice, and it is essential that these purveyors work collaboratively with the target population to maximize the usefulness and sustainability of the intended product.28

Implications for Behavioral Health

Historically, research and its corresponding initiatives (e.g., RCTs, EBPs, and/or trainings) have been conducted and/or developed in the absence of the primary stakeholders: the consumers and practitioners and their service organizations. Because of this, certain methods or strategies related to improving the implementation process may be proven to be less efficient and effective than they were originally intended.53 Therefore, the science and practice of implementation needs to be developed and defined in collaboration with primary stakeholders (i.e., service organizations and their frontline staff) instead of in their absence. The development of implementation practice areas, competencies, and strategies is a critical first step.

Due to the current gaps in the literature, there is an additional need to acquire behavioral health organization and practitioner perceptions of the implementation process and to confirm what implementation practice areas are deemed essential within their specific settings. It is suggested that future research explore service organizations’ perceptions of implementation capacity building and what skills and resources they think are necessary to successfully adopt, implement, and sustain EBPs.

Conceptual and operational clarity surrounding IS frameworks, models, and strategies is also required to optimize their effectiveness in behavioral health care service settings. These efforts will serve to inform future research and practice efforts attempting to build general/baseline capacity. Incorporating stakeholders’ feedback into the creation of a training initiative aimed at building implementation practice capacity may result in a tailored framework and training techniques, greater buy-in within the organizations, and increased efficacy in the operationalization of capacity building strategies and interpretation of data evaluating a training initiative.54

The field of IS has provided the foundation and general explanation of what needs to be accomplished for effective services to be in place. The next step is doing that work (implementation practice) and prospectively assessing what needs to take place within the service organization regarding EBP implementation for it to succeed and be sustainable. Simply adopting an EBP may not be sufficient to address the needs of clients, the expertise of practitioners, and the requirements of the service organization. Organizations must often restructure the way they do business to enable them to identify, choose, implement, and support evidence-based services. Agencies must have continuity and consistency in their business and clinical practices, and this may contribute to an over reliance on passive compliance and reliance on the status quo in service delivery. The critical nature of IS is the recognition that implementing new programs requires a significant investment of resources to continually improve outcomes for consumers. This must be accomplished through a process that maximizes opportunities for service organizations and practitioners to take advantage of new interventions. This can only be accomplished through collaboration with service organizations and practitioners and giving them the resources, knowledge, and skills necessary to successfully utilize EBPs with their unique clients and communities.