Clarity and consistency in government-funded implementation strategies associated with greater evidence-based...

Policymakers need research-informed guidance on leveraging national government funding to promote evidence-based practice (EBP) implementation, however empirical studies of policy financing strategies in implementation science remain limited. Major investments are already being made. Starting in 2012, the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) funded state substance use service agencies to implement EBPs for youth substance use. We examined 19 states funded to implement the Adolescent Community Reinforcement Approach (A-CRA), an exemplar EBP selected by most states. Using the Exploration, Preparation, Implementation, Sustainment (EPIS) Framework, we sought to explain state-level variation in A-CRA reach (defined as the proportion of A-CRA certified providers) and to identify policy implications for improving EBP financing strategies.

We conducted an explanatory sequential mixed-method (QUAN→QUAL) comparative case study, treating each state as a case. States were categorized as achieving high, medium, and low reach during their grant periods using A-CRA certification records and state demographic data. We then synthesized available data (i.e., interviews with 33 state agency administrators, grant administrative records, other documents describing A-CRA implementation) to summarize grant activities completed and their quality, and factors potentially influencing reach in each state. Finally, we compared and contrasted state cases to identify policy implications through pattern matching techniques.

We characterized the 19 states' reach levels as high (n = 7), medium (n = 5), and low (n = 7) and identified an average of 5 grant-related activities completed per state; the most common being A-CRA training to treatment organizations. Six states were case anomalies (e.g., low quantity and quality of activities, while achieving high reach). Most notably, we found that high-reach states had more specific, intentional, and explicit A-CRA implementation requirements for treatment organizations than did low- and medium-reach states. States were also more successful in achieving A-CRA reach when they reported proactively addressing implementation barriers (e.g., provider turnover, state leadership buy-in and support).

Our mixed-method comparative case study advances policy-focused implementation research related to EBP financing strategies, demonstrating how examination of large-scale real-world funding initiatives can produce generalizable lessons. Our findings have implications for how future funding initiatives can facilitate EBP delivery to maximize reach.