Implementation Strategies

We identified the twenty most common implementation strategies in children’s mental health services via a comprehensive review of the literature and nomination from expert colleagues. After Survey 1 results were analyzed, we combined some of these and narrowed the pool of strategies in order to make subsequent surveys feasible. The final list of nine strategies and their definitions are provided below, followed by the original list of twenty strategies.

1. Collaboration with advisory boards and workgroups

An advisory board is made up of representatives of multiple roles (e.g., providers, youth, parents/family members, researchers, policy makers). These boards are formed and tasked with reviewing the EBP implementation approach. They provide suggestions for how to improve the approach, and may do some community organizing activities to help gather input and participation from others.

2. Clinical supervision

Therapists receive ongoing supervision in their agencies. Therapists and supervisors discuss clients and collaboratively problem solve issues that emerge during treatment using the EBP. The clinical supervisor supports the therapist in using the EBP with fidelity (in other words, doing the EBP the way they were trained to do it and with skill). Supervisors do this by providing mentorship and directing the therapist to other sources of support like online trainings and resources.

3. EBP implementation in a novel setting

EBPs are often delivered outside of formal clinical offices. Many youth do not like having appointments with therapists in agency offices, do not have transportation, or do not like talking face-to-face. Some EBPs originally developed to be delivered by a therapist in an office are being modified so they can be delivered via text or smartphone app. Youth receive a similar type of support, content, and strategies as if they would in an office, but are able to communicate by texting or video chat. Another example of delivering an EBP in a different setting would be if the EBP was delivered in schools, churches, drop-in centers or other community setting.

4. Mandate change via agency or state policy

The implementation of EBPs is often the result of mandates from agency leadership or state policy. For instance, a state mental health authority determines that it would be beneficial if more mental health providers used EBPs. Since the mental health authority governs how public mental health money is spent, they write new contracts with the mental health providers to specifically require that the providers are trained in and use a certain percentage of EBPs. They might also require regular quality assurance checks through case reviews or observations to ensure that the EBPs are being used with appropriate clients and with fidelity. Another approach that is within an agency occurs when agency leadership decides they want their providers to use an EBP. They work with their board to write agency policy to use the EBP, and tell providers that therapist use the EBP is a priority.

5. Youth and caregiver peer support providers

Caregiver and youth peers with lived experience in mental health services often provide peer support to others. One example of peer providers or caregivers who themselves are implementing an EBP is when peers are trained in how to use motivational interviewing skills when providing peer support. These skills could be used by peers to help other youths or caregivers identify their desires and actions to improve their life and better prepare the youth to get the most out of therapy. Another example is training caregiver or youth peer support providers in behavior management skills that could help other parents better manage their children’s behavior.

6. Survey youth clients an families about EBP implementation

Input from youth and caregivers about mental health service implementation is sometimes gathered using surveys and questionnaires. For instance, an agency implementing a new EBP might use a feedback survey given to all youth clients and caregivers of youth clients who receive the EBP. The agency would regularly review the information from this survey to identify problems with the EBP implementation activities, make adjustments to how it is delivered, and improve implementation.

7. Clinical training

Training on how to use an EBP includes online or in-person training with lectures, examples, and opportunities to practice the EBP. Trainees may read the treatment manual, have discussions with fellow trainees, watch case example videos, and practice delivering the EBP through role-play while observed by the trainer.

8. Using agency champions to spearhead EBP implementation

Individuals within organizations are often enlisted to champion the implementation efforts among staff within the organization. Prior to implementing a new EBP, individuals within agencies who are passionate about the EBP are identified to support the implementation. These individuals may be “formal” leaders (supervisors) or therapists who are excited and passionate about the EBP. Through collaboration and training, these “champions” help with implementation by providing cheerleading and a positive attitude, ideas for how to move past barriers, role modeling by delivering the EBP first and more. They act as influencers to get others on board with the EBP implementation.

9. Youth/caregiver participation and leadership in EBP implementation planning and evaluation

Youth and caregivers often provide leadership in EBP planning and implementation efforts. An example of youth and caregiver participation in EBP implementation might include several things. A family and youth advisory group or implementation committee could provide regular input on how to best implement the EBP. Caregivers or youth could be hired to be trainers, evaluators, and interviewers. Youth and families may have authority over the design and delivery of certain implementation supports, such as providing testimonials of implementation success.

 

The original list of twenty strategies, rated by participants in Survey 1:

Implementation Strategy	Definition	Example(s)
1. Training therapists in an EBP	Plan for and conduct training in the EBP.	Training on how to use an EBP might include online or in-person training with lectures, examples, and opportunities to practice the EBP. Trainees may read the treatment manual, have discussions with fellow trainees, watch case example videos, and practice delivering the EBP through role-play while observed by the trainer.
2. Provide therapists with clinical supervision	Provide therapists with ongoing supervision on the EBP.	Therapists receive ongoing supervision in their agencies. Therapists and supervisors discuss clients and collaboratively problem solve issues that emerge during treatment using the EBP. The clinical supervisor supports the therapist in using the EBP with fidelity (in other words, doing the EBP the way they were trained to do it and with skill). Supervisors do this by providing mentorship and directing the therapist to other sources of support like online trainings and resources.
3. Youth and caregiver peer support providers	Training peers and parents to support or deliver an EBP.	One example of training a peer provider or caregiver in an EBP is training in motivational interviewing skills. These skills could be used by peers to help other youths or caregivers identify their desires and actions to improve their life and better prepare the youth to get the most out of therapy. Another example is training caregiver or youth peer support providers in behavior management skills that could help other parents better manage their children’s behavior.
4. Quality assurance	Develop and organize systems and procedures that monitor clinical processes and/or outcomes. The goal is to be sure that EBP quality stays high and problems can be identified and addressed early.	Quality assurance involves regularly reviewing steps to be continuously assess EBP quality. For instance, quality assurance indicators might include the percentage of clients who are receiving an EBP, the percentage of therapists in a state who are trained to deliver EBPs, or the availability of EBPs across a state or region. Client charts could be reviewed to determine if EBPs are being delivered with fidelity.
5. EBP implementation in a novel setting or format (e.g. school, drop-in and access centers, smartphone apps, texting)	Adapting or adjusting the EBP so it can be delivered in a place other than a mental health clinic. Other places include schools, churches, community centers, access centers, or through video, phone, or phone apps.	Many youth do not like having appointments with therapists in agency offices, do not have transportation, or do not like talking face-to-face. Some EBPs originally developed to be delivered by a therapist in an office are being modified so they can be delivered via text or smartphone app. Youth receive a similar type of support, content, and strategies as if they would in an office, but are able to communicate by texting or video chat. Another example of delivering an EBP in a different setting would be if the EBP was delivered in schools, churches, drop-in centers or other community setting.
6. Internet-accessible  EBP training, fidelity guidelines, and other support tools	Electronically distribute or provide online access to educational materials (including guidelines, manuals, and toolkits) about how to perform the EBP with fidelity.	Websites can provide descriptions about the EBP, instructional manuals, toolkits such as handouts and exercises to use. Websites can include videos providing instructions and modeling of the EBP, and checklists to ensure that all parts of the therapy are delivered. Therapists, supervisors, and others can visit these websites to gain additional training and support in clinical delivery of the EBP.
7. Computer decision support	Computer applications to track client changes (e.g. clinical dashboarding), guide clinical decision making, and maintain fidelity to an EBP.	In computer support systems, therapists can collect measures from their clients to track symptom change over time. They can download information sheets to remind them how to do elements of the EBP with fidelity, or read about how an EBP should be structured and in what order sessions are supposed to be delivered. For instance, a therapist may have a client with anxiety. The client is asked to fill out a short anxiety measure every session. The therapist and client may work on facing situations that make the client anxious. The computer decision support system will help the therapist note whether the client’s anxiety is getting better, worse, or staying the same. If the client does not improve, the system may suggest how to improve exposure or alternative techniques.
8. Consultation & coaching	Provide ongoing consultation with one or more experts in the strategies used to support implementing the EBP.	Someone who is learning to use an EBP may receive support from an expert in the EBP or in strategies to support the EBP. The expert may provide coaching or consultation in using the EBP and provide help with challenges that might occur.
9. Therapist incentives	Incentivize the adoption and implementation of the EBP with extra pay or other rewards.	A mental health agency that wants to build its group of EBP- trained therapists can offer a cash incentive to those who become certified. The clinic could also pay therapists who use an EBP at a higher per-person rate than other therapists at the agency. Another example incentive would be to promote therapists who learn EBPs.
10. Improving implementation climate and readiness to implement an EBP	Improve how the agency expects, supports, and rewards EBP delivery.	To effectively begin using new EBPs in an agency, it helps to have a good implementation climate and culture including: having supervisors who know the EBP and can support therapists as they use it, leadership skills, members’ commitment to implement the EBP, and a shared belief in the capacity to implement the EBP. Improving implementation climate could be done by training leaders to use more effective leadership skills in supporting the EBP, implementing new computer systems to improve the tracking of EBP use, or using strategies to motivate the workforce to be enthusiastic and supportive of the EBP.
11. Develop academic partnerships	Partner with a university or academic unit for the purposes of shared training on an EBP, and bringing research skills to the implementation of the EBP.	A state mental health organization or an individual agency may partner with a University. Example goals could be for the University partner to provide EBP training and/or support to evaluate EBP implementation success (e.g., EBP fidelity).
12. Youth and caregiver participation and leadership in EBP implementation planning and evaluation	Authentically engage youth clients and their families in decision making. This includes decisions about what EBP to implement, planning for how to implement the EBP, implementation of the EBP, and activities to evaluate and sustain EBP implementation.	An example of youth and caregiver participation in EBP implementation might include several things. A family and youth advisory group or implementation committee could provide regular input on how to best implement the EBP. Caregivers or youth could be hired to be trainers, evaluators, and interviewers. Youth and families may have authority over the design and delivery of certain implementation supports, such as providing testimonials of implementation success. (Note: “Peer support providers” is asked about elsewhere and different than this item,” youth and caregiver participation”.)
13. Motivate and problem-solve with youth clients to increase fidelity to the EBP	Develop strategies with youth clients to encourage their participation in treatment, and problem- solve around fidelity to the EBP practices and skills being delivered by the therapist.	EBPs can be implemented with greater fidelity when there is a good fit with clients’ enthusiasm. In this example, EBPs could be supplemented with intentional efforts to build client’s support for the EBP. This could be done in several ways, such as describing to the client in youth-friendly terms the benefits of the EBP, providing examples of other youth’s EBP experiences, and encouraging client’s involvement in problem-solving around personal EBP challenges. For instance, certain EBPs for anxiety work best when clients repeatedly practice doing things that increase feelings of anxiety. This can be emotionally difficult for clients and therapists are often hesitant to ask their clients to engage in the exposure practice, because of increased client anxiety. It may help youth engage in this exposure practice to first describe the benefits and provide video testimonials of how it helped.
14. Mandate use of EBPs via agency leadership or agency policy	Agency leadership states that using the EBP is a priority for the agency.	Leadership at an agency decides to use an EBP. They work with their board to write agency policy to use the EBP, and tell providers that therapist use the EBP is a priority. Use of the EBP is included as an element for evaluation of staff reviews. Note: This item is about agency-initiated policies and mandates. State-initiated policies and mandates are asked about elsewhere.
15. Survey youth clients and their families about the EBP implementation	Develop surveys to obtain youth client and family feedback on the implementation effort.	An agency implementing a new EBP uses a feedback survey given to all youth clients and caregivers of youth clients who receive the EBP. The agency regularly reviews the information from this survey to identify problems with the EBP implementation activities, make adjustments to how it is delivered, and improve implementation.
16. Prepare youth clients to be active participants in the EBP	Prepare youth clients to be active in the EBP, and to ask questions about the EBP, its evidence, and whether there are other available EBPs that could be a better fit for them.	A training is developed to help engage youth clients so they better understand the important aspects of their care, and are encouraged to be active participants in the EBP delivery by asking questions of providers. They are given ideas about good topics to ask about, including the evidence behind their treatment, and what types of treatments may be available that are evidence-based.
17. Collaboration with advisory boards and workgroups	Create and engage a formal group of multiple kinds of stakeholders to provide input and advice on EBP implementation efforts and to elicit recommendations for improvements.	An advisory board made up of representatives of multiple roles (e.g., providers, youth, parents/family members, researchers, policy makers) is formed and tasked with reviewing the EBP implementation approach. They provide suggestions for how to improve the approach, and may do some community organizing activities to help gather input and participation from others.
18. Use agency “champions” to spearhead EBP implementation	Identify and prepare individuals within an agency to support, market, and drive implementation of an EBP.	Prior to implementing a new EBP, individuals within agencies who are passionate about the EBP are identified to support the implementation. These individuals may be “formal” leaders (supervisors) or therapists who are excited and passionate about the EBP. Through collaboration and training, these “champions” help with implementation by providing cheerleading and a positive attitude, ideas for how to move past barriers, role modeling by delivering the EBP first and more. They act as influencers to get others on board with the EBP implementation.
19. Mandate change via state contracts with public mental health agencies to implement EBPs	State mental health authorities or managed healthcare organizations (MCOs) write contracts with public mental health providers to implementation of EBPs.	A state mental health authority determines that it would be beneficial if more mental health providers used EBPs. Since the mental health authority governs how public mental health money is spent, they write new contracts with the mental health providers to specifically require that the providers are trained in and use a certain percentage of EBPs. They might also require regular quality assurance checks through case reviews or observations to ensure that the EBPs are being used with appropriate clients and with fidelity. Note: Within-agency policy changes and mandates are asked about elsewhere, this item pertains only to state-level policies and contract changes.
20. Conduct a strengths and needs assessment	Assess various aspects of an agency to determine its degree of readiness, barriers, and strengths that can be used in the EBP implementation effort.	An agency might conduct a formal assessment of their strengths and needs and/or what they have in place to implement the EBP (staff needed, appropriate clients for the EBP, resources needed). They would then work to improve areas where the organization is not ready. Certain barriers such as staff knowledge or motivation could be identified and addressed.