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Taking Issue   |    
The Missing Link Between Science and Service
Kenneth Minkoff, M.D.; Christie A. Cline, M.D., M.B.A.
Psychiatric Services 2003; doi: 10.1176/appi.ps.54.3.275
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"Science to service," the effort to implement evidence-based practices (EBPs), has become a defining slogan for the recently reorganized Substance Abuse and Mental Health Services Administration (SAMHSA). Considerable resources are being dedicated to studying the implementation of EBPs and technology transfer. Yet, as our understanding of EBPs grows, it is becoming apparent that our ability to broadly implement such practices is lagging sadly behind.

How can EBPs be widely and routinely disseminated in systems with scarce resources? How can we move beyond the impact of special funding or program-level demonstration projects? These are fundamental questions to be addressed at the federal, state, county, and local levels.

Often, EBP implementation strategies focus on improving communication between researchers and clinicians. But that is not where the answer lies. Implementation of EBPs is fundamentally a systems management function. Success depends on the application of sound management and administrative practices—for example, strategic planning, management science, and quality improvement—to build and organize systems capable of adopting innovative technologies. These practices are commonplace in most thriving industries and are carefully studied so that information on successful strategies can be routinely disseminated.

Current systems research in behavioral health does not address systems management and may create an illusion that systems features are being investigated when they are not. The ACCESS demonstration project concluded that interventions designed to improve systems integration did not result in better client outcomes. This powerful assertion might lead to the belief that developing systems of care and doing integrated system planning to promote implementation of EBPs would not be a good investment, when, in fact, such investment is likely to be essential. It is not that the ACCESS researchers were wrong, only that they defined systems integration as a composite of interagency referral patterns, information sharing, and funding relationships. This construct bears little relationship to the multiple strategically linked management decisions and functions that result in truly integrated service delivery.

SAMHSA, as can be seen in its recent report to Congress on co-occurring disorders, is increasingly recognizing the importance of investigating "in vivo" systems management for EBP implementation. If we are to achieve broader implementation, we need to look beyond the current state of systems research and focus on studying the management of real-world systems and how those systems are conceptualized, designed, developed, and supported.

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