Financing has been hypothesized as an important driver of the implementation of evidence based practices (EBPs), yet there is little systematic investigation. This article presents a qualitative study of the effects of financial factors on the implementation of EBPs in a large urban publicly-funded mental health system. Our interviews with agency and system leaders identified financial distress in community mental health agencies, leading to concern about implementing complex and expensive EBPs. Stakeholders agreed that the cost of implementation of EBP should be shared between the agencies and the system, but disagreed on the solution.

Background Little work investigates the effect of behavioral health system efforts to increase use of evidence-based practices or how organizational characteristics moderate the effect of these efforts. The objective of this study was to investigate clinician practice change in a system encouraging implementation of evidence-based practices over 5 years and how organizational characteristics moderate this effect. We hypothesized that evidence-based techniques would increase over time, whereas use of non-evidence-based techniques would remain static. Method Using a repeated cross-sectional design, data were collected three times from 2013 to 2017 in Philadelphia’s public behavioral health system. Clinicians from 20 behavioral health outpatient clinics serving youth were surveyed three times over 5 years ( n = 340; overall response rate = 60%). All organizations and clinicians were exposed to system-level support provided by the Evidence-based Practice Innovation Center from 2013 to 2017. Additionally, approximately half of the clinicians participated in city-funded evidence-based practice training initiatives. The main outcome included clinician self-reported use of cognitive-behavioral and psychodynamic techniques measured by the Therapy Procedures Checklist-Family Revised. Results Clinicians were 80% female and averaged 37.52 years of age ( SD = 11.40); there were no significant differences in clinician characteristics across waves (all p s > .05). Controlling for organizational and clinician covariates, average use of CBT techniques increased by 6% from wave 1 ( M = 3.18) to wave 3 ( M = 3.37, p = .021, d = .29), compared to no change in psychodynamic techniques ( p = .570). Each evidence-based practice training initiative in which clinicians participated predicted a 3% increase in CBT use ( p = .019) but no change in psychodynamic technique use ( p = .709). In organizations with more proficient cultures at baseline, clinicians exhibited greater increases in CBT use compared to organizations with less proficient cultures (8% increase vs. 2% decrease, p = .048). Conclusions System implementation of evidence-based practices is associated with modest changes in clinician practice; these effects are moderated by organizational characteristics. Findings identify preliminary targets to improve implementation.

Objectives Community mental health clinics are increasingly utilizing independent contractors to provide clinical services. At the same time, many organizations are participating in initiatives intended to increase implementation of evidence-based practices (EBPs). The primary aim of this study was to understand the associations of utilizing independent contractors with clinician and organizational characteristics associated with implementation of EBPs; as well as to understand the potential impact of using independent contractors on mental health services delivery from the perspective of organizational leadership. Methods Quantitative data were collected from 130 therapists in 23 organizations; qualitative data were collected from executive administrators in 9 of the 16 organizations participating in EBP initiatives sponsored by the City of Philadelphia. Regression with random effects was used to estimate the associations between worker status (i.e., contractor, employee) and clinician attitudes towards EBPs, knowledge of EBPs, and organizational culture and climate. Qualitative inquiry was used to understand the impact of relying on independent contractors on organizational participation in EBP initiatives. Results Independent contractors endorsed less positive attitudes towards EBPs and scored lower on knowledge of EBPs. Interviews revealed four main themes: reasons for using independent contractors, general consequences of independent contractors, specific impact of independent contractors on participation in EBP initiatives, and suggestions for alternatives. Conclusions A growing number of community mental health clinics are relying on independent contractors. There may be consequences of this paradigm shift which deserve exploration.

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