Center for Mental Health Quality & Accountability

Implementation Issues
Implementation Issues


Implementation issues, such as stakeholder concerns and infrastructure development, are common across all practices and settings. Other issues, such as cultural competence and patient-centered care are more setting-specific. Here you will find discussions on these issues, as well as a list of references to articles and materials that cover a wide range of issues pertaining to EBP implementation.


Factors Constraining EBP Implementation: (Ganju, 2003, p. 126)

  • Evidence-based practices may not be reimbursed by Medicaid or other health insurance

  • Clinicians and providers may not have been trained to deliver EBPs

  • Relative advantages of EBPs may not be clear to stakeholders

  • Innovative services may be perceived as a threat to the existing organizational structure and hierarchy

  • Regulations and policies may not support EBPs

  • Rapid staff turnover

  • New funding for training and transitioning service delivery procedures may not be available

  • Mental health systems may lack ability to provide incentives for innovative practices


Cultural Competence

A culturally competent mental health delivery system is one that is sensitive and responsive to the needs and differences among varying ethnic, cultural, and belief groups in its community of care. A panel of experts released a Consensus Statement on Evidence-Based Programs and Cultural Competence that reveals:

  • We do not know the effectiveness of many services that are delivered because they have not been researched.

  • Little research related to evidence-based programs has been conducted with diverse populations.

  • Where studies have been done that include different racial, ethnic, or cultural groups, small sample sizes have prevented any conclusions regarding the effectiveness of evidence-based programs for these populations.

  • In communities where evidence-based programs depend on the availability of an adequate infrastructure (e.g., financial and human resources), strategies to promote community organization and readiness, implementation and knowledge transfer strategies, fidelity measurement procedures, support from stakeholders is imperative so that partnerships are developed with specific racial, ethnic, and cultural communities, allowing them to participate fully in the design, implementation, and evaluation of promoting best practice models.

  • Further research is required to understand what adaptations and modifications need to occur to improve the implementation of best practice models in diverse communities.

  • There is evidence that there are services and programs that are ineffective for the problems they are intended to address, and that persons belonging to specific racial, ethnic, and cultural groups may be disproportionately affected.



EBP Stakeholders

Stakeholders have concerns about the costs, goals, and impacts of evidence-based practices (Ganju, 2003, p. 128-129)

  • Administrators and funders may consider that the cost of changing service delivery is too expensive an investment.

  • Advocates may consider that the goals of some evidence-based practices may not directly promote recovery.

  • Families and consumers may be concerned that evidence-based practices will be considered the only beneficial ones, and that this will limit the availability of services that families and consumers think are beneficial.



Patient-Centered Care

A renewed emphasis is increasingly being placed on patient-centered care. This will greatly influence the development and implementation of evidence-based practices. The 2001 Institute of Medicine Report predicts that patient-centered care will be a core characteristic of effective service delivery. In fact, patient preference will be an element of control exerted by people as they make health care decisions.


In health care encounters patients will grow to expect that:

  • Care will be individualized

  • Care will be provided in various forms (e.g., via face-to-face meetings, telephone calls, and the internet)

  • The patient will be in control

  • The patient will have access to their medical records

  • Evidence-based care will be provided

  • Patients will be safe in the health care system

  • Care will be proactive

  • Care will be coordinated



Strategies Employed to Implement Evidence-Based Practices

The concept of evidence-based practices is generally received enthusiastically because of hopes for improved quality and outcomes of services, the opportunity to strengthen the interface between research and practice, and because EBPs require accountability.


Several research projects, including the Center for Mental Health Quality and Accountability's Survey of the 50 States' Adult and Child Mental Health Directors, the MacArthur Foundation's qualitative study of the Dartmouth Toolkit Project, and other research seek to pinpoint factors that facilitate or inhibit the adoption of EBPs, implementation with fidelity, and sustaining the practices through time while linking back to performance measurement and quality improvement.


Implementation issues arise as EBPs are implemented in the mental health service system; including misalignment between the system and organizational infrastructures, policies and procedures, and the availability of resources necessary to support this new type of practice. The information provided in the following sections present the most current thoughts on strategies concerning the implementation of EBPs.



Key Factors in Developing Infrastructure

The resources below provide a background on lessons learned and present ideas on how to move forward with developing an infrastructure to implement and sustain the use of evidence-based practices:

  • Jeanne Rivard of the NASMHPD Research Institute's CMHQA developed a presentation entitled, "EBP Implementation and Dissemination Strategies: Learning from Multiple Sources"

  • Reports regarding state mental health efforts to support and facilitate EBP implementation are based on a series of site visits sponsored by the MacArthur Foundation which document activities occurring in states involved in SAMHSA's National EBP Demonstration Project. The NRI's Center for Mental Health Quality and Accountability conducted site visits and developed the individual state reports, which will be available soon.


Consensus Building

Arriving at consensus among all stakeholder groups is a great challenge for leaders of EBP implementation teams. Below are several documents that offer universally-applicable strategies on building consensus:



Budgeting and Planning

The NASMHPD Research Institute recently commissioned Anthony Broskowski, Ph.D., and Bill Barton of Pareto Solutions, and Christina Thompson, Ph.D., of the Heart of the Matter Consulting, Inc. to prepare a Planning and Budgeting Model for the implementation of Supported Employment. While this report is specific to one particular EBP, its structure and approach provide an adaptable model for the budgeting and planning of other evidence-based practices.



Please note that any of the NRI resources mentioned above can be requested from NRI via



References on EBP Implementation Issues