Sustaining Evidence-Based Practices in Behavioral Health Settings: One State's Experience

Background and Purpose: States are investing public dollars to train behavioral health workers in the delivery of core evidence-based practices. By training the workforce to deliver evidence-based practices with fidelity, States hope to improve outcomes for consumers of behavioral health services.  Understanding the organizational factors that contribute to sustaining these evidence-based practices in public behavioral health settings once the implementation phase has ended is critical and a major focus of this study.

This study examined one state’s efforts to implement and sustain evidence-based practices over time. The study explored organizational factors at the regional and local levels as it related to sustaining evidence-based practices 3 years post implementation. In addition, the study conducted fidelity assessments of two of the evidence-based practices implemented to determine drift from the original model and whether these practices were still in place. The study involved multi-methods to capture the lessons learned as it relates to sustaining practices and improving consumer outcomes.

Methods: The study involved four phases (conducting telephone interviews with key informants throughout the State at the regional and local levels; conducting focus group sessions with members of the Improving Practices Leadership teams at each region in the State; a statewide survey of behavioral health staff focusing on organizational factors related to sustaining evidence-based practices; and completing fidelity assessments of two evidence-based practices).  At total of 49 key informants participated in the telephone interviews, 16 focus groups of the Improving Practices Leadership teams were held, and 139 surveys were completed.  The key informant interviews and the focus group sessions were audio-taped and transcribed.  Content themes were identified and codes assigned using NVivo software.  Inter-rater reliability was assessed using multiple coders and team conferencing.  Descriptive statistics, ANOVAS, and t-tests were used to interpret the findings from the statewide survey using SPSS software. Fidelity assessments of two evidence-based practices were completed using multiple informants.

Results:  The results demonstrated that all regions in the state were sustaining the evidence-based practices with fidelity post implementation.  The organizational factors that contributed to sustainability of these practices included:  low staff turnover, consumer demand for the evidence-based practice, availability of ongoing training, knowledgeable oversight of staff/clinicians delivering the evidence-based practices, leadership that promotes a culture of evidence-based practice, dedicated champions of the evidence-based practices and funding to support these practices. While the practices were sustained, the penetration rates were low.  Consumer outcome information for those who received an evidence-based practice was also limited.

Conclusions and Implications:  The key implication from this study of one state’s implementation of evidence-based practices and sustainability is that to be successful in sustaining evidence-based practices, administrators need to invest up-front in the training and on-going supervision of workers in the evidence-based practice and keep a commitment at all levels of the organization (administrative, supervisory, clinical and consumer) to the evidence-based practices post implementation. It was clear that multiple organizational factors contributed to the sustainability of these practices.  Further study of the organizational factors to better understand how sustainability improves outcomes is needed.