Weaving Strengths and Vulnerabilities: Implementing Evidence-Based Practices in Core Safety Net Settings

Background and Purpose: Evidence-based practices (EBPs) have not been implemented as much as anticipated despite the prolific amount available.  Patients relegated to core safety net healthcare settings, that have a mission or legal mandate to care for uninsured, underinsured, or members of other vulnerable populations, face even greater obstacles to receiving EBPs that could benefit them than those in settings primarily serving patients with health insurance.

Implementation science, the study of methods to promote the integration of research findings and evidence into practice, is an emerging field shaped by multiple disciplines, including health and mental health care primarily serving patients with insurance, and fields outside of human services, such as sociology and business.  Therefore, less is known about implementation of EBPs in core safety net settings and the relevance of current implementation theories and frameworks to these settings.

The purpose of this project was to examine and elucidate the unique and complex processes and influences affecting implementation of EBPs in core safety net settings.  To accomplish this, administrators and clinical providers were interviewed about their experiences implementing three different evidence-based health and mental health interventions in three core safety net settings. 

Methods: Stratified purposeful sampling was employed to recruit a mix of administrators and clinical providers performing each of various roles in the three different implementations.  Participants were recruited by administrators, or clinicians in managerial positions by word of mouth or flyers.  A total of 18 administrators and 50 clinical providers agreed to participate.  A combination of 16 individual interviews and 13 focus groups (by clinical discipline or role, such as social work or nursing) were conducted.  Semi-structured interview guides focused broadly on challenges and facilitators to implementing the interventions, using open-ended questions.  Interviews and focus groups were audiotaped and transcribed verbatim in two of the implementations, and recorded by a note taker in the third.  Grounded theory, an inductive method of building theory, was used for analysis.  ATLAS.ti qualitative data analysis software was employed. 

Findings: Results in all three implementations revealed challenging and beneficial contextual factors woven together in unique ways that the fabric of their combinations supported the implementations, or possessed vulnerabilities that caused them to falter.  Key findings across all implementations were the significance of the following in successful implementation amidst the formidable challenges of core safety net settings: intervention fit with demographic characteristics, and beliefs and behaviors of patients; intervention compatibility with organization mission; intervention adaptability, quality, and observability; beliefs and behaviors of clinicians; adequate, dedicated clinical staffing; ongoing training and education; structural and cultural organizational assets; and ongoing network and system building.

Conclusion and Implications: Results can contribute to a taxonomy of implementation contextual factors specific to the core safety net setting that can serve as the basis for frameworks and strategies tailored to its unique challenges. This knowledge can inform health and social work policy and practice, ultimately providing core safety net patients with greater opportunity to receive evidence-based treatments.