Public-Academic Partnerships: Evidence-Based Implementation: The Role of Sustained Community-Based Practice and Research Partnerships

Relationship building between researchers and providers began in the fall of 2008, and the meeting was held in the fall of 2011. Seven community-based primary care and mental health sites were identified as potential study participants by leaders from two regional community-based practice networks (Colorado Access in Aurora, Colorado, and Washtenaw Community Health Organization in Ann Arbor, Michigan). Participating sites were similar to other community-based mental health and primary care sites from the same region.

To encourage participation in the parent study, researchers met with providers before the start of the study (spring 2007) to obtain their input on implementing the CCM. All sites volunteered to take part in the study, in part because they felt that the CCM should be applied to bipolar disorder, because unmet need for bipolar disorder treatment is costly to their practices. When the study was funded in 2008, all sites participated in the planning process, which included the meeting described in this column. Because community providers had been involved from the beginning, they joined the study knowing that their input was valued, sharing a common understanding and supporting the partnership to implement the CCM.

The meeting content and structure were based on the Replicating Effective Programs framework (5). The framework includes four phases: preconditions (identifying need and a suitable evidence-based practice), preimplementation (community input and packaging the evidence-based practice), implementation (package dissemination, training, technical assistance, and evaluation), and maintenance and evolution (sustainability). [A table summarizing components of the four phases is available online as a data supplement to this column.] Some of these components have been used in other implementation frameworks (2,4) but they have not heretofore been operationalized in combination.

The first day of the meeting included an overview of the study, CCM, and Replicating Effective Programs, followed by group discussions. On the second day, partners separated into focus groups composed of administrators, providers, researchers, and federal representatives that discussed adaptations to the CCM. Partners reconvened in the large group and discussed augmentations to Replicating Effective Programs in light of the recommended adaptations to the CCM. Participants provided informed consent in accordance with local institutional review board requirements.

Fifty-three individuals participated in six focus groups. Results from the group discussions were categorized into two main themes: creating organizational and financial incentives (for the CCM and for Replicating Effective Programs) and promoting implementation and sustainability. Providers and researchers generated roughly equal numbers of suggestions, and both groups were generally consistent in their support of these suggestions. At the end of the meeting, partners desired to continue their relationship beyond the implementation phase.

Three core principles made this researcher-community partnership particularly strong: a practice-based research agenda, inclusion of multiple levels of personnel from the health care organizations, and enhancement of an already established implementation framework to collaboratively sustain an evidence-based practice for bipolar disorder. Together, these inform a road map for ROCC through practical feedback not only on the CCM but also on the expansion of the Replicating Effective Programs-Facilitation framework.

Overall, meeting participants suggested practical strategies for improving the implementation of evidence-based practices and the implementation strategy itself. Many of the recommended changes to the CCM reflect a more public health-oriented practice model proposed in other implementation frameworks (3). Moreover, key enhancements to the Replicating Effective Programs-Facilitation framework reflect established community-based strategies in mental health services research, notably engaging multiple stakeholders and identifying organizational and contextual factors that facilitate or impede implementation (4). Although the original CDC Research-to-Practice framework was successfully used to implement psychosocial evidence-based practices for HIV prevention (5), in many cases funding was tied to intervention adoption and completion. In contrast, evidence-based practices delivered in health service systems, such as the CCM, often face organizational and financial barriers to implementation at multiple levels and across different stakeholders (4). Thus the process for eliciting community-based input was vital to the development of the enhanced framework to address these key issues and to increase the probability of successful implementation of evidence-based practices for mental disorders in real-world practice.

All participants agreed on key organizational and financial incentives, notably facilitation and alignment of the CCM with reimbursement strategies. Nevertheless, providers and researchers differed in how the framework components should be applied, such as technical assistance beyond implementing the CCM and opportunities to blend the CCM with other treatment modalities. Acting on these suggestions may lead to win-win situations, especially if it produces effective combinations of treatment models that help consumers. Therefore, careful consideration of the community providers' priorities, focus on the evidence-based practice's components, and dialogue between partners and researchers (4) can enhance the balance between fidelity to the evidence-based practice and flexibility.

Replicating Effective Programs-Facilitation is potentially applicable to a wide range of evidence-based practices for community health care settings. All partners agreed on the recommendations to expand the framework to include more formal facilitation, alignment of the goals of the CCM with those of changing clinic program priorities, and linking core components of the CCM to reimbursement models. The resulting framework includes guidance on organizational and financial incentives that are aligned with providers' needs and goals, notably through the establishment of program facilitators. Overall, we demonstrated the effectiveness of a research-community provider partnership in which stakeholders had active roles in not only enhancing the intervention but also expanding the implementation framework. Such partnerships could facilitate the use of other evidence-based practices across real-world treatment settings.

The authors thank the National Institute of Mental Health for support of this program (grants R01 MH 79994 and R01 MH 74509) and the U.S. Department of Veterans Affairs (VA) Health Services Research and Development Program (HSRD 07-115). They also acknowledge the support of the University of Michigan Comprehensive Depression Center (Director's Innovation Fund). They acknowledge support and input from the ROCC core coinvestigators, consultants, consumers, and site leaders. The views expressed are those of the authors and do not necessarily represent the views of the VA. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the CDC.

The authors report no competing interests.