The application of implementation science to community mental health

Behavioral health disorders account for the largest proportion of the global burden of diseases, measured by years lived with disability1. This burden could be greatly diminished if individuals and populations had access to programs and services with established effectiveness – so-called evidence-based practices (EBPs). Implementation science has been defined as the study of "methods and strategies to promote the uptake of interventions that have proven effective into routine practice, with the aim of improving population health"2. Implementation science does not focus on developing new behavioral health interventions and proving their effectiveness. Rather, a successful implementation science trial teaches how to increase the use of EBPs in a care system. The successful application of implementation science to community mental health is thus central to the challenge of addressing the devastating impact of behavioral health disorders in the global community. Here we outline the role of implementation science in the future of community mental health. What do community mental health leaders need to understand about implementation science? It is important to note that, in contrast to quality improvement programs, which address a specific problem within a specific health care system, implemen­tation science aims to produce generalizable knowledge that would be applicable across different systems. Also, implementation science reaches beyond dissemination, which is more focused on the spread of information. Implementation science almost always involves multiple stake­holders, including patients, providers, supervisors, agency leads and payors. Inattention to multiple levels of stakeholders may cause an effort to fail, because durable change is often complicated and multiple factors contribute to the status quo. Implementation science relies on the use of theories, models and frameworks3 to guide: a) the step-by-step planning and execution of EBP implementation, from pre-implementation to sustainability; b) the identification of barriers and facilitators to implementing EBPs; and c) the evaluation of implementation, to know if efforts have produced change at the organization, provider or patient levels4. Finally, implementation science provides direction on how to select from an array of implementation strategies5 (e.g., audit and feedback, educational outreach, e-learning, inter-professional education, managerial supervision), based on their effectiveness6, and adapt them to the local setting. Specialized organizations, called intermediary and purveyor organizations (IPOs), support the spread of EBPs in community mental health. A purveyor organization focuses on one specific practice, whereas an intermediary organization supports the development and implementation of multiple best practices, along with infrastructure to sustain them7. IPOs cultivate partnerships and link academic researchers, treatment developers, implementation specialists, service system authorities, behavioral health agency administrators, service providers, service recipients and other community stakeholders. One example of a government-funded IPO in the US is the Center for Practice Innovations (CPI) at Columbia Psychiatry and the New York State Psychiatric Institute. CPI is supported by the New York State Office of Mental Health to promote the widespread use of recovery-oriented EBPs for adults with serious mental illness, through scalable training and implementation support to over 41,000 behavioral health clinicians statewide. Core initiatives of CPI include assertive community treatment (ACT), supported employment/education via individual placement and support (IPS), treatment of co-occurring mental health and substance use disorders, coordinated specialty care for first-episode psychosis (called OnTrackNY), and suicide prevention. The work of these CPI initiatives is guided by an implementation science-informed practice change model that considers inner (i.e., program-practice fit, leadership investment, organizational culture, time and resources available for practice implementation) and outer setting of the organization, program or clinic (i.e., policy, regulatory and financial environment of practice change)8, 9. CPI recognizes that training is not enough to change practitioners' daily actions and achieve high quality implementation of the desired EBP. It thus offers empirically driven support to supervisors, managers and practitioners focused upon their im­plementation efforts. As clinicians at an organization engage in online training, we conduct formative evaluation to plan for post-training implementation support. Barriers identified during this process are mapped to corresponding strategies and vetted by key stakeholders. Selected strategies will inform the implementation plan and determine mode of implementation support delivery. This may include interactive webinars, an online resource library with practical tools (e.g., manuals and fidelity checklists), consultations, and learning collaboratives during which program staff share successes and receive consultation from peers and experts on their implementation challenges. These learning collaboratives frequently use performance indicators and fidelity self-assessments to help guide programs through continuous quality improvement projects. This data allows programs to identify challenges in implementation, and work with CPI staff to address these challenges. Summative evaluation in our initiatives helps us to understand the impact of implementation strategies and clinician- and patient-level outcomes. For example, in our IPS initiative, between 45% and 55% of individuals receiving IPS services in New York State are employed competitively each month. This compares very favorably with national benchmarks established by the developers of IPS. In OnTrackNY, among young adults with a schizophrenia-spectrum diagnosis, engagement in work and school increases from 41% in the 3 months prior to enrollment to 70% by the second quarter of enrollment, a rate which is largely sustained over the course of treatment. This systematic, implementation science-informed approach is now also being applied to a new initiative to increase clinician competency in guideline-concordant care for adults and children with obsessive-compulsive disorder, an undertreated illness identified as an important cause of global health-related disability. Community mental health plays a crucial role in the global pursuit of reducing the burden of behavioral health disorders, by increasing access to programs and services that have established effectiveness. As a field, implementation science produces tools and knowledge of great relevance to this effort. Community mental health leaders need to understand if and how these tools may be locally applied. IPOs can play a role in the future of community mental health as translators of the science and natural laboratories for understanding and evaluating if applying implementation science products and tools can help reduce the gaps in behavioral health care.