Support From Intermediary Organizations for Evidence-Based Practices in Behavioral Health Care

Intermediary and purveyor organizations (IPOs) support dissemination and implementation of evidence-based behavioral health best practices (EBPs) (1, 2). Purveyor organizations support implementation of one or two specific EBPs, whereas intermediary organizations offer support across a range of EBPs (1). Intermediary organizations also support the development of organizational capacity to implement EBPs (1). IPOs provide this support by offering consultations, training, tools, and tailored technical assistance throughout the implementation process, informed by EBP and implementation science (1, 2). Increasingly, federal and state governments partner with and support IPOs to disseminate and support the implementation of EBP (1). A recent Open Forum described the inputs, activities, and outcomes for IPOs (3). The Center for Practice Innovations (CPI) is a state-funded intermediary organization that was established in 2007 to promote widespread use of EBPs developed for adults diagnosed as having serious mental illness throughout New York State. In this Open Forum, we use CPI as a case example to describe how state-funded intermediary organizations can enhance the implementation and sustainment of EBP.

Relationship and Communication With State Agencies

Intermediaries working within specific systems are well positioned to influence outside partners (the “outer setting”), which may include hospital systems, school districts, or states (4). Long-standing relationships and regular communication with critical staff in the outer setting provide opportunities for intermediaries to collaborate with the outer setting to support implementation and to respond and adapt to changes in the system. For CPI, the outer setting includes state agencies that oversee the public behavioral health care system by setting policy, providing organizational guidance, and overseeing not only continued licensure of behavioral health care organizations but also policies, regulations, and fiscal incentives that support EBP. These agencies—the New York State Offices of Mental Health (OMH) and of Addiction Services and Supports—provide insight into the current service system and guide CPI’s training and implementation supports to improve the system of care.

As an intermediary, CPI works closely with state partners to develop clear expectations, incentives, and standards of care for organizations. Given this relationship, CPI is often invited to help shape new initiatives and policies that can benefit organizations. For example, OMH collaborated with CPI to improve care for obsessive-compulsive disorder (OCD) based on New York State Medicaid data in 2019, which indicated the underdiagnosis and undertreatment of OCD in children and adults (5). This initiative has provided more than 100 consultations to providers (N=96) and state agencies (N=12) and piloted an OCD screening project that resulted in 386 people being screened for OCD. OMH also invited CPI and other partners to develop a statewide training initiative to improve engagement of and outcomes for people receiving rehabilitation program services. CPI will co-create and provide relevant training and implementation supports as part of that initiative. Currently, 120 organizations across New York State (more than 700 practitioners) are benefiting from training and support. Further, CPI is working closely with OMH to establish the Care Management Institute, for which CPI will provide comprehensive training and implementation support, including competency development and enhancement, to care managers across the state.

CPI has also become a trusted conduit for reporting barriers observed across EBP in practice settings. CPI learns about barriers through regular technical assistance activities with providers, supervisors, or clinical leadership, and through data that CPI collect to monitor and support implementation. CPI conveys these barriers with recommendations to agencies via e-mail and regular meetings, and CPI strategizes with agencies to remove barriers and further incentivize quality care implementation. For example, the initial rollout of a new program model allowed some programs to offer intensive EBPs at a higher reimbursement rate only if they were colocated within a clinic. CPI learned that all programs provided intensive services; however, programs that could not bill for the higher rate were struggling financially and at risk of closing. CPI made OMH aware of this barrier and OMH removed the clinic requirement, which then allowed all programs to benefit from the higher rate and supported broader implementation of these evidence-based services.

Infrastructure

Intermediaries that support multiple EBPs can pool their resources to develop a specialized infrastructure to support workforce development and evaluation, which may be less costly to the funder (e.g., state agencies). For example, OMH funds CPI’s infrastructure and several specific EBPs (6). CPI’s infrastructure includes a robust learning management system, dedicated content development team, core group of data analysts, and a unit that oversees the continuing education credits for multiple disciplines. This infrastructure allows CPI to rapidly develop and disseminate high-quality learning and implementation supports, thus reaching large numbers of providers across New York State. As of March 31, 2023, nearly 70,000 unique learners had completed at least one training; a cumulative total of 647,227 online training modules were completed across initiatives. This infrastructure also enables CPI to provide OMH with regular reports, including EBP fidelity through time, attendance or completion of training and technical assistance events, learner change in knowledge and confidence, practice change, and outcomes for service recipients. CPI provides these reports at several levels—organization, region, organization type, and system-wide. These reports inform multiple OMH priorities and help to shape strategies to support implementation of EBPs (e.g., the performance of an organization across EBP, strengths and barriers in particular regions, specific organization types, and systems issues that may benefit from additional policy or guidance). Licensing staff use training data to highlight programs that have reached exemplary goals and to follow up with programs where staff still need to complete required training. Evaluation information identifies knowledge, confidence, and practice gaps that OMH can prioritize for further support. Performance indicator data highlight fidelity trends and point to areas where OMH can provide additional support, guidance, or incentives.

Organizations also benefit from the infrastructure of an intermediary, which can become a single resource for many organizations’ training and implementation needs. Organizations that develop trust in an intermediary to provide high-quality training and support and to respond to their requests are more willing to engage with that intermediary to implement the next EBP. Organizations can direct their staff to a single online system to register for training and support, which simplifies the learner experience while creating a track record of that learner’s participation. This allows supervisors to better assign and track training.

Tailored Training and Technical Assistance

Intermediaries are also well positioned to provide customized training and technical assistance for specific organizational needs. Organizations’ specific cultures and resources, including infrastructure, mission alignment, and physical space, comprise the inner setting characteristics that influence implementation (4). As an intermediary, CPI customizes specific implementation efforts to meet a particular organization’s needs, including additional training and support around procedures and skills applicable to implementation across EBP and cross-cutting core competencies that are not EBP specific. Additionally, organizations sometimes need support for several EBPs they are expected to implement. As an intermediary supporting these multiple practices and collaborating with state partners, CPI helps organizations prioritize which changes to make first and to identify synergies among the different EBPs. This flexibility is essential for successful implementation; others have noted that offering organizations several EBP and cross-cutting competencies allows them to adopt practices that match their strengths, culture, and resources (3).

Offering Multiple Evidence-Based Practices to Optimize Outcomes

Intermediaries that support multiple practices can combine their resources to optimize the impact of various EBPs by delivering them together to address specific needs. For example, employment and education are important to many individuals served by assertive community treatment (ACT) and coordinated specialty care for first-episode psychosis (OnTrackNY) teams. The supported employment initiative implementation specialists train and mentor the employment specialists who work with the ACT and OnTrackNY initiatives. A study including 779 OnTrackNY participants demonstrated increased school and work participation rates over time (7). Similarly, the integrated treatment initiative supports substance use specialists on these same teams. Anecdotally, staff report that these cross-collaborations improve job satisfaction, which is consistent with the literature (8). Specifically, in a study including 315 mental health professionals, stronger team support and collaboration were significant predictors of job satisfaction (8).

Communities of Practice

Intermediaries with multiple staff in similar positions across EBPs can help staff feel supported in their work and create opportunities to develop cross-cutting tools to meet system needs. For example, implementation specialists regularly meet to share experiences, brainstorm implementation challenges, and review new research findings and tools that support their work. Cross-initiative communities of practice also emerge from their shared challenges. For example, ACT and OnTrackNY initiative data identified a problem with transition planning. In response, a cross-initiative community of practice, including OMH, developed transition planning guidance for their respective teams. To date, 1,851 staff from ACT teams have accessed these resources.

Conclusions

State-funded intermediary organizations are well positioned to support provider organizations as they navigate the implementation of EBP and then strive to sustain multiple EBPs within their settings. The benefits of state-funded intermediaries include the ability to collaborate with state entities to address barriers to and incentivize best practices, the resources to develop a robust infrastructure to support EBP, and the capacity to support organizations beyond an individual EBP (e.g., developing an internal quality-improvement process, supporting cross-cutting competencies, helping organizations to identify synergies across EBPs and prioritize which to implement first). These benefits align well with recommendations to increase the implementation of EBP in public systems (9). Intermediary organizations also benefit internally from communities of practice and having a range of EBPs that, based on data or need, can be adapted for implementation in other initiatives. Although we recognize that some states and other large funders are better positioned to support an intermediary organization, we invite these systems to consider supporting intermediary organizations to maximize EBP implementation and sustainment.