The UCLA/RAND Center, first funded in 1995 by the National Institute of Mental Health, is a joint program of the UCLA Neuropsychiatric Institute and RAND Health in Santa Monica, California that bridges public policy and clinical services research to study mental health and related care for vulnerable populations. Although the center’s projects are, as with any research program, undoubtedly unique, its experiences have raised a number of general research questions, as well as limitations of conventional approaches, in attempting to improve community-based dissemination and implementation in health services.
Several early, innovative randomized studies that center investigators participated in, such as the RAND Health Insurance Experiment (Wells et al. 1989
) and the Medical Outcomes Study (Wells et al. 1996
), took into account general system of care indicators—for example, managed care versus fee-for-service reimbursement systems. This type of research design roughly differentiated incentives facing providers, but did not (nor was intended to) measure implementation in terms of organizational and practice-level changes, how these might have explained differences in outcomes, or the likelihood of sustaining outcomes over time.
A few more recent studies, such as the Health Care for Communities project, have usefully characterized community risk factors for need and unmet need related to alcohol, drug abuse, and mental health conditions (Sturm et al. 1999
; Young et al. 2001
), yet have been less clear in answering the next logical question, namely how to redress unmet needs and identify or develop interventions to improve the quality of local services in particular communities.
Other studies generated within the center, however, have actively developed a range of quality improvement (QI) interventions for highly prevalent mental health conditions in settings accessible to vulnerable populations. It is here where the “gaps” between research and practice have been most evident—and frustrating.
For example, the Partners in Care (Wells et al. 2000
), Youth Partners in Care (Asarnow et al. 2005
), and Project IMPACT (Unützer et al. 2002
) studies have been generally successful in demonstrating the clinical and cost effectiveness of QI interventions for depression treatment in primary care settings for adults, adolescents, and elderly patients, respectively. Yet the interventions reached only a fraction of all eligible patients. Moreover, while establishing effective models of care, the studies have largely been silent on how to assure the sustainability of these relatively complex, multi-modal interventions involving multiple stakeholders or their further adoption in other locales and systems of care.
These and other center studies, such as the Caring for California’s Children Initiative (Zima et al. 2005
), have also included a variety of indicators of organizational capacity for QI obtained through administrator interviews, provider surveys, computerized collection of service data, and other means. While this information has yielded useful insights into implementation issues (Rubenstein et al. 1999; Meredith et al. 1999
), the measures incorporated were typically based more on practical experience than conceptual understanding, and have proved difficult to use in unpacking the implementation and dissemination process, linking those to intervention outcomes, and generalizing findings across studies.
As a consequence, the center’s goals expanded to include an emphasis on dissemination (i.e., the targeted distribution of information on evidence-based health interventions) and implementation (i.e., the adaptation and putting into practice of such interventions over time) within community and healthcare settings (Lomas 1993; Fixsen et al. 2005). A distinctive approach resulting from this new emphasis has been the center’s effort to engage multiple community stakeholders in the design, dissemination, and implementation of health interventions. Termed “community-partnered participatory research” (Jones and Wells 2007
; Wells et al. 2004
), examples of such initiatives include Witness for Wellness—a multi-stakeholder, academic-community partnership aimed at improving health and other outcomes related to depression in minority communities (Bluthenthal et al. 2006
; Stockdale, Patel, et al. 2006
; Jones et al. 2006
; Chung et al. 2006
), Cognitive Behavioral Intervention for Trauma in Schools (or CBITS)—a school-based collaborative project, now extended to a faith-based community health partnership, to provide mental health screening and standardized brief cognitive behavioral therapy treatment for youth exposed to violence (Kataoka et al. 2006
), and the Health Care for Communities (HCC) Partnership Initiative—a collaboration with several community partners to assess organizational capacity and interest in partnering among local agencies around mental health and substance abuse needs (Stockdale, Mendel et al. 2006
As the center has moved toward working more closely with stakeholders in “real world” community settings (e.g., primary care practices, workplaces, community-based organizations, local service organizations), we have recognized the need, as have others (Grimshaw et al. 2004; Shojania and Grimshaw 2005; ICEBeRG 2006), for conceptual models of dissemination, implementation, and sustainability within these contexts in order to help guide and compare results over such varied settings and initiatives.
Beginning in the next section, we present the framework we have developed, illustrated with examples from the Witness for Wellness, CBITS, Partnership Initiative, and other center studies. We view this guiding framework as a necessarily evolving project, as our initial multi-disciplinary integration of social science research meets with ongoing community-based intervention experience and the application of additional concepts over time. The current framework is specifically intended to help answer the following questions that have arisen during our attempts to study and close the research-to-practice gap:
- How best to understand and assess the relevant contextual factors and dynamics affecting the dissemination, implementation, and sustainability of interventions within community and healthcare settings
- How to effectively identify, develop, and evaluate new strategies for tailoring, disseminating, and implementing relatively complex interventions across a variety of healthcare and community stakeholders and contexts
- How to provide useful formative feedback to investigators and other partners to guide the dissemination and implementation of interventions without jeopardizing evaluation objectives
- How to build capacity among academic and other stakeholders both for dissemination and evaluation of interventions in healthcare and community settings
- How to meaningfully generalize findings and pool results across varied dissemination and implementation studies