Contributions to the literature
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Implementation-oriented policy research is scarce. The current paper uses data from a longstanding federal effort to track implementation of evidence-based treatments (EBTs) in US states to evaluate the influence of outer setting factors on EBT investment, support, and adoption.
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The study found “unmodifiable” factors (e.g., per capita income, controlling political party) predicted funding support for EBTs, while “modifiable” factors (e.g., collaboration, investment in research) predicted presence of EBT-supportive state policies.
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The study also found that different types of outer setting factors were associated with adoption of adult EBTs versus child EBTs.
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The paper expands knowledge of the role of the outer setting in implementation and provides insights into how best to focus state-level efforts to promote EBT.
Background
Existing knowledge base
Current aims
Methods
Measures and data sources
Item | Source |
---|---|
Provision of specific EBTs (yes/no) | |
Multisystemic therapy | Uniform Reporting System |
Therapeutic foster care | Uniform Reporting System |
Functional family therapy | Uniform Reporting System |
Supported employment | Uniform Reporting System |
Supported housing | Uniform Reporting System |
Assertive community treatment | Uniform Reporting System |
State characteristics | |
Geographic region (South, West, Midwest, Northeast) | US Census Bureau |
Number of adults and children | US Census Bureau |
Per capita income | US Department of Commerce |
Amount of budget surplus or deficit | Harvard Dataverse |
Controlling political party | Harvard Dataverse |
Medicaid expansion status (yes/no) | Kaiser Family Foundation |
Controlled per capita expenditures of the SMHA (in millions) | State Profiles Survey |
SMHA directly operates community-based mental health programs or funds county or city mental health authorities which, in turn, fund local provider agencies to provide care (yes/no) | State Profiles Survey |
SMHA located within another state agency (yes/no) | State Profiles Survey |
SMHA director sit as a member of the Governor’s cabinet (yes/no) | State Profiles Survey |
Research is located within the SMHA (yes/no) | State Profiles Survey |
Research is located outside of the SMHA (yes/no) | State Profiles Survey |
SMHA promotes consumer/survivor participation in resource allocations at the SMHA level (yes/no) | State Profiles Survey |
SMHA has initiatives underway to work with other state government agencies to coordinate, reduce, or eliminate barriers between delivery systems and funding streams to the provision of appropriate mental health services (yes/no) | State Profiles Survey |
Representatives from other state government agencies participate as members of SMHA’s mental health planning Council/Group (yes/no) | State Profiles Survey |
Information functions located inside of SMHA (yes/no) | State Profiles Survey |
Information functions located outside of SMHA (yes/no) | State Profiles Survey |
SMHA is involved in activities to downsize, reconfigure, close and/or consolidate one or more State mental hospitals (yes/no) | State Profiles Survey |
Policy supports to promote EBT adoption | |
Modification of information systems and data reports is used to promote the adoption of EBPs (yes/no) | State Profiles Survey |
Monitoring of fidelity is used to promote the adoption of EBPs (yes/no) | State Profiles Survey |
SMHA implemented or is it implementing a statewide client outcome monitoring system (yes/no) | State Profiles Survey |
SMHA conduct research/evaluations on client change in functioning (yes/no) | State Profiles Survey |
Internal staff are used to provide on-going training to providers related to evidence-based practices (yes/no) | State Profiles Survey |
Expert consultants used to provide on-going training to providers related to evidence-based practices (yes/no) | State Profiles Survey |
Collaboration with universities used to provide on-going training to providers related to evidence-based practices (yes/no) | State Profiles Survey |
Establishment of research/training institute(s) is used to provide on-going training to providers related the evidence-based services (yes/no) | State Profiles Survey |
Awareness/training is used to promote the adoption of EBPs (yes/no) | State Profiles Survey |
Financial incentives are used to promote the adoption of EBPs (yes/no) | State Profiles Survey |
Specific budget requests are used to promote the adoption of EBPs (yes/no) | State Profiles Survey |
SMHA funds a research center/institute (yes/no) | State Profiles Survey |
Fiscal supports to EBT adoption | |
Incorporation in contracts is used to promote the adoption of EBPs (yes/no) | State Profiles Survey |
SMHA integrated/linked/matched its client datasets with client datasets from any other agencies (yes/no) | State Profiles Survey |
SMHA have initiatives underway to work with other state government agencies to coordinate, reduce, or eliminate barriers between delivery systems and funding streams to the provision of appropriate mental health services (yes/no) | State Profiles Survey |
Internal staff used to provide on-going training to providers related to evidence-based practices (yes/no) | State Profiles Survey |
Provider-to-provider training used to provide on-going training to providers related to evidence-based practices (yes/no) | State Profiles Survey |
SMHA worked with academia in curriculum development to reflect evidence-based practices, promising practices, or value-based practices (yes/no) | State Profiles Survey |
State characteristics
EBT adoption
State fiscal supports to promote EBT adoption
State policy supports to promote EBT adoption
Years examined
Sample
Data analysis
Results
Associations between state characteristics and EBT fiscal and policy supports
State characteristics and policy supports to promote EBT adoption
Outcome 1: Fiscal supports to promote EBT adoption | Outcome 2: Policy supports to promote EBT adoption | Outcome 3: EBT availability | ||||
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Parameter | Unstandardized coef a | SE | Unstandardized coef a | SE | Unstandardized coefb | SE |
Political party in control | 0.260^ | 0.141 | 0.248 | 0.177 | − 0.148 | 0.191 |
Budget surplus (z score) | − 0.088 | 0.096 | 0.123 | 0.146 | − 0.750*** | 0.204 |
Per capita income (z score) | 0.433^ | 0.253 | 0.307 | 0.225 | − 0.036 | 0.236 |
Region | ||||||
South | − 0.00039 | 0.271 | 0.211 | 0.288 | 0.501 | 0.449 |
West | − 0.594 | 0.336 | − 0.513 | 0.343 | 0.355 | 0.560 |
Midwest | − 0.126 | 0.334 | − 0.140 | 0.370 | − 0.937* | 0.340 |
Northeast | 0.721 | 0.357 | 0.443 | 0.433 | 0.081 | 0.601 |
2013 Medicaid expansion | 0.950* | 0.372 | − 0.109 | 0.432 | 0.445 | 0.655 |
SMHA funds county (single or multicounty) or city mental health authorities which, in turn, fund local provider agencies or directly provide mental health services | ||||||
Directly operates community-based programs | − 0.241 | 0.507 | 0.049 | 0.666 | 1.037* | 0.526 |
Funds county or city MH authorities | − 0.039 | 0.434 | 0.047 | 0.421 | 0.139 | 0.465 |
Directly funds, but does not operate community-based agencies | Ref | Ref | Ref | |||
SMHA is located within another state agency (ref = SMHA is an independent department/agency) | − 0.511 | 0.427 | − 0.743^ | 0.434 | − 0.060 | 0.690 |
SMHA Director sits as a member of the Governor’s cabinet (ref = no) | 0.025 | 0.355 | 0.177 | 0.408 | − 0.474 | 0.426 |
Research located within the SMHA (ref = no) | 0.822* | 0.372 | 0.870* | 0.357 | 0.228 | 0.484 |
Research located outside the SMHA (ref = no) | 0.906** | 0.342 | 0.855* | 0.389 | 0.338 | 0.619 |
SMHA promotes consumer/survivor participation in resource allocations at the SMHA level (ref = no) | 0.185 | 0.392 | 0.095 | 0.470 | 0.151 | 0.099 |
SMHA has initiatives underway to work with other state government agencies to coordinate, reduce, or eliminate barriers between delivery systems and funding streams to the provision of appropriate mental health services (ref = no) | 0.515* | 0.246 | 2.836*** | 0.317 | 0.359 | 0.430 |
Representatives from other state government agencies participate as members of your SMHA’s mental health planning Council/Group (ref = no) | 0.953 | 0.600 | 1.739** | 0.532 | 0.112 | 0.466 |
Information management functions located within SMHA (ref = no) | − 0.168 | 0.299 | − 0.187 | 0.421 | No data available | |
Information management functions located outside SMHA (ref = no) | − 0.470 | 0.622 | − 0.853 | 0.579 | No data available | |
SMHA currently involved in activities to downsize, reconfigure, close and/or consolidate one or more state mental hospitals (ref = no) | − 0.033 | 0.228 | 0.416 | 0.301 | − 0.028 | 0.387 |
Per capita expenditures (z score) | − 0.054 | 0.183 | 0.209 | 0.193 | − 0.055 | 0.180 |
Controlled per capita expenditures for SMHA (z score) | 0.038 | 0.325 | 0.256 | 0.258 | − 0.071 | 0.215 |
Per capita mental health expenditures (z score) | 0.274 | 0.196 | 0.277 | 0.259 | 0.097 | 0.271 |
Count of number of available child EBTs | 0.238^ | 0.138 | 0.521** | 0.185 | ||
Count of number of available adult EBTs | 0.286* | 0.115 | 0.103 | 0.181 | ||
Count of number of available EBTs (child and adult) | 0.204* | 0.081 | 0.242* | 0.119 |
State characteristics and fiscal supports to promote EBT adoption
Associations between state characteristics and availability of EBTs
State characteristics and the availability of EBTs
Fiscal supports and specific EBT availability
Outcome | Fiscal supports to promote EBT adoption | Policy supports to promote EBT adoption | ||||
---|---|---|---|---|---|---|
OR | 95% CI | SE | OR | 95% CI | SE | |
Child EBTs | ||||||
Therapeutic foster carea | 1.091 | (0.954, 1.248) | 0.068 | 1.018 | (0.905, 1.145) | 0.060 |
Multisystemic therapyb | 1.056 | (0.937, 1.190) | 0.061 | 1.138* | (1.010, 1.282) | 0.061 |
Functional family therapyb | 1.132* | (1.003, 1.277) | 0.061 | 1.176** | (1.068, 1.296) | 0.049 |
Adult EBTs | ||||||
Supported housingb | 0.864^ | (0.734, 1.017) | 0.082 | 0.977 | (0.868, 1.101) | 0.060 |
Supported employmentb | 1.304*** | (1.148, 1.480) | 0.064 | 1.059 | (0.966, 1.162) | 0.047 |
Assertive community treatmentb | 1.107 | (0.958, 1.280) | 0.073 | 0.992 | (0.893, 1.102) | 0.053 |
Unstandardized coef | SE | Unstandardized coef | SE | |||
EBT Adoption Indexc | 0.079 | 0.083 | 0.066 | 0.076 |