Evidence-based practices (EBPs) continue to proliferate in child and adolescent mental health treatment, many of which are developed under controlled conditions in university clinics and healthcare settings. However, there are many barriers to successful implementation of EBPs in real-world mental health service delivery settings where children and their families are likely to receive care. Notably, intervention evidence is limited by the client populations and settings where the evidence was originally derived (1), often making it necessary to adapt the intervention to fit a particular setting (2, 3). Implementation barriers also exist in the outer setting (e.g., patient needs and resources), and inner setting (e.g., organizational culture, leadership engagement), and relating to individual characteristics and the implementation processes unique to each intervention, intervention level, population and service setting (2).
Desired implementation outcomes are more likely when implementation strategies are selected for and tailored to: 1) specific patient populations 2) care delivery systems and practices, and 3) local barriers and facilitators, often referred to as “determinants of practice” (4, 5). Implementation strategies are single or multiple component approaches aimed at increasing adoption, implementation, and sustainment of EBPs in routine care (6). Currently, there is an established taxonomy of 73 implementation strategies, but minimal guidance exists for how to select, integrate, and adapt these strategies to specific services and contexts (7, 8). Proposed methods put forth by (9) include concept mapping, group model building, conjoint analysis and intervention mapping to fit implementation strategies to identified barriers and facilitators for a new practice in a given setting. Yet, each implementation strategy selection method has limitations, such as requiring advanced methodological consultation, complex modeling that may overwhelm stakeholders, and/or use of proprietary software (9).
Selecting appropriate implementation strategies is a persistent challenge in health, behavioral health, and education, which undermines the quality of implementation (10-12). There are numerous implementation science theories, frameworks, and methods, but implementation practitioners need to improve their literacy to address this issue (12, 13). Some scholars indicate this is creating a research-practice gap in implementation science (i.e., study of methods to promote systematic uptake of evidence-based interventions) that is similar to the one observed in intervention science (i.e., study of treatment interventions to promote patient outcomes), where available research isn’t readily applied in “real world” care systems (14). This may be due to implementation science being driven by traditional research methods that sometimes lack stakeholder collaboration and/or cost or time effectiveness for local systems, organizations, communities, providers and other stakeholders involved in implementation practice (13).
Literature reporting on implementation initiatives, frequently research-practice partnerships focused on “real world” implementation efforts, often describes barriers, facilitators, and implementation outcomes observed by implementation strategies applied (for a few examples, see (15-18). Notable exceptions reflect prospective implementation strategy selection methods that blend research knowledge (e.g., literature review, implementation methods or processes) and field experience from stakeholders and providers close to actual implementation (19, 20). Yet, peer reviewed reports or examples of how to prospectively select and systematically test strategies based on stakeholder knowledge of contextual factors are still scant considering the considerable need for this guidance (4). This study focuses on systematic selection of implementation strategies for a given EBP (measurement-based care) in the most common mental health service delivery setting for children and adolescents (schools) by replicating a pragmatic method that is potentially generalizable to other EBPs and settings (21-24).
Measurement-based care in mental health service delivery
Measurement-based care (MBC) is the routine collection and use of client data throughout treatment, including initial screening and assessment, problem definition and analysis, finalizing treatment objectives and intervention tactics, and monitoring treatment progress collaboratively with the client to inform mid-course treatment plan adjustments (25). MBC is a critical component of an evidence-based practice orientation to mental health treatment (26). There is strong evidence supporting MBC in treatment settings other than schools. For instance, systematic reviews show better and faster goal attainment and symptom reduction with MBC as compared to usual care; effect sizes range from 0.28 to 0.70 (27-29). Larger effect sizes of 0.49 to 0.70 are attributed to MBC with feedback, particularly feedback provided to both the patient and providers, or when clinical support tools are provided (29, 30). Recent Cochrane reviews underscore the importance of including studies where measures are used to adjust the treatment plan (31, 32), indicating that patient outcomes associated with MBC are likely a result of the real time, client-centered, data-driven adjustments made to interventions provided.
Despite the promise of MBC to improve mental health service quality, use of MBC in practice is minimal. Fewer than 20% of providers report collecting progress measures at least monthly (33, 34). However, when providers use clinical judgment alone without a structured assessment process, they are much less accurate in predicting progress and risk, providing services that are neither individualized to patient concerns nor responsive to progress (35-37).
School mental health treatment services
Schools are the most common site for providing children’s mental health treatment, particularly for children and families who face barriers to accessing care in traditional clinic settings (21-24). However, the extent to which school mental health (SMH) treatment services are grounded in EBPs is largely unknown (38, 39). Applying implementation science methods to advance EBP implementation in schools is particularly advantageous for youth and families. Schools reduce barriers of access to mental health services often encountered in clinic- or hospital-based settings, meaning that EBPs implemented in schools have potentially broad reach (40, 41) because traditionally, virtually all children physically attend school. Also, school-based implementation of EBPs allows for adaptation to local culture and contexts that is scalable across communities and states (42, 43). Yet, knowledge and application of implementation science frameworks, methods and measures in school settings is in its infancy (44). Arguably, MBC could be a particularly useful tool for school-based providers working with children/adolescents in the fast pace of the current climate in schools and communities which is ever more present with the COVID-19 pandemic and increased attunement to social injustices and inequities. Given the dynamic nature of education, behavioral health, and child and family development right now, regularly checking in about current functioning with progress measures and being able to flexibly tailor treatment to clients’ changing needs may be more important now than ever (45, 46).
Implementation considerations in schools
Selection and adaptation of implementation strategies must be tailored to the school context for any likelihood of EBP implementation success. Schools are a highly-unique setting for implementing evidence-based mental health treatment services. Indeed, implementing new practices in educational settings requires careful attention to school organizational factors such as principal leadership, education policies at state and federal levels, a heterogenous mental health workforce, requirements and constraints related to professional development and ongoing coaching, and logistics as basic as the school calendar (47). Other studies point to the importance of flexible treatment delivery and intentional family engagement efforts to facilitate EBP implementation and improve student outcomes (48).
MBC implementation in schools
Although scientifically-rigorous applications of MBC in SMH are new, an individualized approach to monitoring student progress and outcomes has been emphasized and studied in schools for decades (49, 50). There are some published demonstrations of standardized, patient-reported outcome measures being implemented in school mental health systems (51, 52), as well as examples of psychosocial progress monitoring in schools as part of high quality, comprehensive school mental health systems (53). Moreover, MBC is consistent with schools’ emphasis on Response to Intervention (i.e., using student progress data to prevent and remediate academic and behavioral difficulties; (54) and accountability requests for SMH service providers to demonstrate outcomes (55). Recent studies have highlighted case examples of an MBC approach in SMH, from assessment tool selection to measurement processes and the role of feedback to the student and family (55, 56). Yet, there still remains a substantial gap in the literature regarding implementation strategies best suited to MBC implementation in school mental health treatment services, particularly in the context of how often children, adolescents and families receive care on school grounds.
The current study identifies feasible and important implementation strategies to increase provider use of MBC in SMH. This work builds on an initial list of 70+ implementation strategies that have been codified for general use (8, 57), and a recent extension to identify and define top strategies relevant to and important for implementing evidence-based practices in school settings – the School Implementation Strategies, Translating ERIC Resources (SISTER) Project (Cook et al., 2019; Lyon et al., 2019). We focused specifically on strategies for measurement-based care in schools and adopted methods used in prior implementation strategy selection research. We focused on importance and feasibility ratings for implementation as well as operational definitions for practical application in context (8, 57-59) to ensure that the strategies address real-world practice implementation challenges. Our objective was to identify the most important and feasible implementation strategies for MBC as rated by provider and research stakeholders involved in the provision of school mental health treatment services.