Each of the previous five chapters focused on a specific component of EBP implementation, providing detail on how they manifest themselves in social and mental health services that target children and adolescents and their implications for the broader challenge of understanding and facilitating successful implementation of EBPs in any service setting. In Chapter Five, we examined social networks and inter-organizational collaboration and the role they played in the implementation of TFCO in California and Ohio. We then focused on URE as an illustration of both social interactions that facilitate URE and the shared understandings that comprise the organizational culture of URE. This was followed by another illustration of shared understandings, one that comprised the models of and for assessment of the barriers and facilitators of EBP implementation. We then returned to a focus on social relations and shared understandings that operate in the context of research–practice partnerships dedicated to the task of EBP implementation. This was followed by an examination of the exchanges of knowledge, attitudes and practices among implementation partners and the transformations in shared understandings that result from such exchanges.

This chapter summarizes the five components of a model for successful implementation of EBPs in child welfare and child mental health. It also examines the implications of this model in the design and implementation of three implementation ‘facilitators’ or support systems: 1) the development of policies that promote EBP use; 2) the development and use of strategies that facilitate EBP implementation; and 3) the formation and maintenance of partnerships that promote ongoing quality improvement in services delivery.

Evidence-based practices (EBPs) are designed to address specific needs. In many cases, the extent to which these practices successfully address those needs, as evidenced by improved and desired outcomes, determines whether or not they will be sustained. Often, programs will be sustained despite lack of evidence of positive outcomes. In either case, the decision whether or not to adopt a specific program or practice is determined by the availability or supply of services to address a specific need, the demand (that is, number of clients or patients) for that service, and the fit between the practice, the organization responsible for its use, and the patients or clients who are its intended beneficiaries.

In this chapter, we begin with an examination of the need for evidence-based mental health services among youth in general and child-welfare involved youth in particular. We begin with a review of the current state of our understanding of this need among youth in general, focusing on the prevalence of mental and behavioral health problems in this population and the risk of these problems associated with the experience of childhood adversities such as child maltreatment, poverty, racism and discrimination, and involvement in criminal justice systems. We then narrow our focus to youth involved in the child welfare system and examine both the scale and severity of their mental and behavioral health problems and limited access to services to address these problems. The chapter then introduces some of the current evidence-based programs and practices designed to address these problems, focusing on their prevention and treatment, and then concludes with a brief review of the extent to which they are utilized for this purpose.

As we observed in the last chapter, social networks play an important role in the flow of information to and from network members. Much of this information occurs in the form of research evidence that is used to support the choice of an EBP by a service system as well as to provide guidance on how the EBP should be implemented. In this chapter, we examine in closer detail the process of acquiring, evaluating, and applying research evidence in EBP implementation. We draw on the experience of using research evidence to implement TFCO among county-level child welfare, child mental health and juvenile justice systems in California and Ohio and adopting EBPs and other innovative practices in New York State-supported child mental health clinics. The experience of implementation in California and Ohio enables us to examine the extent to which EBP implementation is associated with the source of evidence, how practitioners evaluate the evidence obtained, how they apply it, or ignore it, when deciding whether or not to implement, and whether this use of research evidence (URE) is associated with the implementation stage from engagement to sustainment.

In Chapter Five, the role of social influence networks in implementing EBPs was highlighted. These networks included staff members of one's own organization as well as peers working in other organizations in the same jurisdiction (that is, county) or in other jurisdictions. In the case of the CAL-OH study, the networks also included researchers who developed the EBP (TFCO) and the implementation strategy (CDT) and who assessed the effectiveness of the implementation strategy in scaling up the EBP. However, the specific role of these researchers was not addressed in the CAL-OH study, but rather was viewed implicitly.

In Chapters Six and Seven, two different models of evidence and implementation were introduced: a global model that is external to most settings, scientifically rigorous and generalizable across different settings; and a local model that is internal and originates within an agency or jurisdiction, based on personal experience, and specific to the needs of an organization and the community it serves. Global models typically represent the cultural understandings of researchers, while local models typically represent the shared understandings or cultural systems of practitioners and policymakers. However, there is little understanding of how these two models operate in tandem when researchers and practitioners/policymakers work together to implement an EBP.

As noted in the last chapter, there are numerous theories, models and frameworks used in implementation science to understand the features of an intervention, an organization and its external environment believed to be associated with implementation outcomes, and to identify strategies designed to facilitate successful implementation (Nilsen, 2015). With all of these theories, models and frameworks to guide the selection of strategies for implementation, why is there a need for yet another theory, model or framework? The answer to this question lies in the emphasis that this model places on the transactions that occur in both social relations and cultural systems and the roles they play in implementation.

In this chapter, we introduce four major studies where the four pillars of implementation science were applied to identify barriers and facilitators to EBP implementation, evaluate strategies designed to overcome barriers and maximize facilitators, and employ innovative methods for examining the process and outcomes of EBP implementation. The lessons learned from each of these studies serve to build upon existing implementation theories, models and frameworks to highlight the roles of social networks, use of research evidence (URE), local models of implementation and evidence, research–practice–policy partnerships (RPPP), and cultural exchanges among implementation stakeholders in implementation processes and outcomes.

The social context of EBP implementation

Social interactions among various stakeholders have been a prominent feature of existing implementation theories, models and frameworks. For instance, Rogers (2003) highlights the role of social networks and the importance of the social system in his diffusion of innovations theory. Greenhalgh and colleagues (2004) hypothesize that organizations that are well connected to other comparable organizations in networks are more susceptible to the network impact in terms of adopting innovations, and that the role of inter-organizational support becomes more important when the implementation of an innovation is more complex.

As we observed in the last chapter, the evidence used to support an EBP can come from a variety of sources. One often thinks of EBPs as being supported by rigorous scientific methods using data that is more often than not collected from populations and communities that are external to the community considering implementation. An agency in the United Kingdom considering the adoption and implementation of multisystemic therapy (MST) (Henggeler et al, 1998), for instance, may be asked to place their faith in the evidence-base of this EBP that was generated from a randomized controlled trial (RCT) conducted in the United States or Australia. To the degree that MST works in the U.K. in much the same manner that it does in the United States, the EBP and the evidence base for the EBP can be viewed as being global in nature. Global evidence is external (that is, originates outside of an agency or jurisdiction), scientifically rigorous (for example, RCTs), and generalizable or transferable from one setting to another. Global evidence is the foundation for EBP.

In the last chapter, however, we also identified other sources of ‘evidence’ used in the evaluation of whether or not to implement a particular EBP. This evidence relies heavily on characteristics of the local context in which the implementation occurs (that is, the supply of resources to support evidence use and the EBP itself, and the demand for the EBP and supporting evidence), as well as clinical experience of those responsible for implementing the EBP. These forms of evidence are considered to be local in nature.

Conceptual models of evidence use in policy and practice acknowledge that the URE to make or support decisions is often a collective and interactive endeavor rather than an activity performed by any one individual decision maker (Traynor et al, 2014; Edelstein, 2016). This collective endeavor involves the utilization of social capital (Spillane et al, 2001; Honig and Coburn, 2008), social networks (Foster-Fishman et al, 2001; Valente et al, 2015), a common language (Kothari et al, 2011), and the exchange of knowledge or information between researchers and practitioners and within networks of practitioners (Lomas, 2000; Mitton et al, 2007; Nutley et al, 2007).

As illustrated by the three case studies presented in the last chapter, the extent of collaboration between researchers and practitioners is often dependent upon the willingness and ability to exchange information and values through their interactions. This exchange is consistent with a conceptual model of evidence use in which decision makers are human information processors who interact with the evidence, interpret its meaning, and hence determine whether and how they will permit the evidence to influence them (Kennedy, 1984).

Implementation science is one of a number of “sciences” to have emerged in the past few decades to tackle one of the most important problems associated with the delivery of health and social services in our time, that is, the 17-year gap between the identification of a priority for service delivery that promises better outcomes at less cost, and the routine use of that service. People in need of such services generally cannot afford to wait that long to receive them. Even then, we devote so much time, energy and resources to developing these services and then creating an evidence base using costly randomized controlled trials, only to have the routine use of these services more the exception than the rule. The problem often lies in a failure to understand and address the potential barriers to the implementation and sustainment of these evidence-based services and policies, known in this book as evidence-based practices or EBPs.

The task of changing the behavior of individual practitioners and service organizations for the sake of EBP implementation has drawn upon a number of theoretical traditions associated with an array of disciplines, including rural sociology, cultural anthropology, social work, organizational psychology, management science, public health, and social psychology. The model introduced in this book draws from transactional theory as represented in the work of anthropologist Frederick Bailey. However, while Bailey focused on transactions as a source of political gain and competitive struggle, the model advanced in this book sees social change as a bidirectional process in which both parties in a transaction exchange one thing in order to receive something else. In this instance, the social change is successful implementation observed in research conducted in child welfare and child mental health by the author in the past decade. The argument advanced in this book is that in order to change the behavior of the individual practitioners and organizations in these systems of care, or in any health and social service system for that matter, researchers and EBP developers must be willing and able to change themselves. Further, that change manifests itself through a series of transactions in knowledge, attitudes and practices that occur through social relationships between researchers, practitioners and policymakers, and the emergence of a set of shared understandings or common “culture of implementation” linking all participants in this endeavor.

Evidence provided by single studies, systematic reviews, and government statistics suggests that mental health problems affect up to one-quarter of all youths worldwide at any one point in time and about one-third across their lifetimes (Merikangas, 2009). Half of all lifetime cases of mental health problems begin before age 14 and 75 percent by age 24 years (Kessler et al, 2005) if not sooner (Kim-Cohen et al, 2003). These problems include depression, anxiety, traumatic stress, conduct disorders, and substance abuse. Youth involved in child welfare systems are at even higher risk, with as many as 50 percent having behavioral and mental health problems (Burns et al, 2004).

In this chapter, we examine in detail the role of social networks in implementation process and outcomes. Beginning with a review of the importance of such networks in current implementation theories, models and frameworks, we focus on the Exploration, Preparation, Implementation and Sustainment (EPIS) framework developed by Aarons and colleagues (2011), and the Consolidated Framework for Implementation Research (CFIR) developed by Damschroder and colleagues (2009). The chapter then summarizes research on the influence of social networks and inter-organizational collaborations in implementing Treatment Foster Care Oregon (TFCO) (Chamberlain et al, 2007), an EBP designed to meet the behavioral health needs of youth in foster care, in California and Ohio. This research also demonstrates how community development teams, a continuous quality improvement strategy developed by the California Institute of Mental Health, can be used to build and sustain such networks.

Interpersonal contacts and implementation

Interpersonal contacts within and between organizations and communities are among the most important influences on the adoption of new behaviors. Interpersonal relations were given a prominent role in diffusion theory in explaining how new ideas and cultural practices expand within and between communities (Green et al, 2009). The importance of interpersonal contact and the social networks that provide such contacts in the diffusion of new ideas and practices has been repeatedly demonstrated by empirical research, including the pioneering study of Ryan and Gross (1943), which emphasized the importance of social factors in understanding farmers’ adoption of new patterns of behavior. Rogers (2003) also emphasized the importance of social networks for both the diffusion and adoption of innovations. These contacts may influence the behavior of individual providers or the behavior of entire organizations.

As noted in the last chapter, despite the existence of numerous EBPs for prevention and treatment of mental and behavioral health problems in youth, fewer than one in five youth in need of such EBPs actually receive them. Given that one in every three to five youth are in need of such services at some point in their lives, the disconnect between supply of EBPs and demand for them is concerning. Identifying the barriers to successful EBP implementation and sustainment and application of evidence-based strategies to overcome these barriers are the aims of implementation science.

In this chapter, we examine common barr iers to EBP implementation found in most systems of care that help to explain why EBP implementation has enjoyed limited success in child welfare and child mental health to date. We then introduce the four pillars underlying implementation science; 1) theories, models and frameworks that identify and explain the associations between potential predictors and outcomes of implementation efforts; 2) discrete and multifaceted strategies for achieving positive implementation outcomes; 3) measures for assessing implementation process and outcomes; and 4) innovative methods for implementation science such as mixed methods, hybrid and alternative experimental designs, and systems science methods.