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State and Regional Key Organizational Factors

The information presented in this summary is from the information collected during the 16 IPLT Focus Group Sessions and the 49 Key Informant Interviews. These are themes that emerged related to organizational issues in the delivery of EBPs.

The major themes that emerged in the review of the 16 IPLT focus groups and the 49 key informant interviews included:
State Level:

• At the State Level, the identification of a key point person for each EBP supported by the state is viewed as an important link for the region.  This person helps to address the implementation and sustainability issues at a statewide level and to assist in the coordination of efforts statewide related to the EBP.
• The State established a statewide Practice Improvement Steering Committee (PISC) with representatives from each region.  Greater clarification about the role of this Committee and State as it relates to sustaining the EBPs was seen by the respondents as important, especially in advocating for changes needed to support EBPs over time.  Some of the advocacy areas included: 
• increase awareness of the need to pace the implementation of EBPs to better support regions;
•  address the reality that EBPs are “add ons” to workload for many staff who volunteer to be trained and deliver the EBPs;
• examine ways to adapt EBPs to meet regional needs, especially when one considers rural and urban differences, and regions that operate as a single county versus multi county sites;
• explore different supervision and EBP certification processes to maximize the number of staff and supervisors that can deliver the EBPs and keep up with staff turnover;
• propose ways to support transportation issues for consumers and staff with EBPs that require extensive outreach; and
• promote more graduate programs in social work/psychology/allied health fields to teach EBPs so when students graduate from programs they are ready to engage in the next steps for EBP.
• The state is viewed by the regions as the funding source to support start up of new EBPs and the implementer of the certification requirements and billing procedures for each EBP.  This has been a challenge at times for regions since funding through the grant mechanisms is limited, new billing codes take time to put into place, and certifying who can bill is not always clear. 
• The state structures are also viewed by respondents as a barrier in the implementation of new EBPs due to the strict fidelity requirements that need to be met in order to implement an EBP and the limited number of EBPs approved by the state for initial funding.  Many regions would like to see greater flexibility in the EBPs selected and would like more local choice about what EBPs to implement.  The State helping to establish guidelines for adapting EBPs to local needs was an area that was mentioned often by respondents.
• In terms of sustaining EBPs, the regions look to the state for funding to continue to train workers in the EBPs and initial supervision in the EBPs for workers to be certified.  Delivering the trainings at local sites is a high priority for many regions. The high staff turnover and need for frequent trainings was an area that the respondents look to the State for assistance.  It is a challenge for the regions to keep workers who have been trained and certified to deliver the EBPs.  This is especially a problem for some of the EBPs that require extensive supervision prior to certification.  The train-the-trainer model has worked in regions where there are multiple staff trained in an EBPs but for several regions this approach is costly due to staff size and time away from regular duties for staff members who are trained to be trainers.
• The state audit/quality improvement reporting activities often duplicate work currently being done at the regional level related to fidelity of the EBPs.  Development of common outcome measures at the state level for EBPs is another area that would enhance the ability for regions to determine what EBPs should be sustained as new EBPs emerge. Many respondents recommended that the State engage regions in a discussion about the development of a statewide electronic medical record system.

Regional Level (PIHP):

From the focus groups and key information interviews, the data suggest that the IPLT teams serve the regions as the key organizational structure for the implementation and sustainability of the EBPs in the region. Most IPLT teams reported that they are responsible for monitoring all EBPs in the region, which may total up to 7 or more EBPs.

• The IPLT teams are viewed by the regions as critical to helping to sustain the EBPs.   Some regions have modified the IPLT membership to reflect the local needs of the region (e.g. adding key supervisors from all EBPs, representatives from each mental health center, contract agency representatives).  The IPLT teams in most regions take primary responsibility for
• oversight of all EBPs operating in the region,
• strategic planning activities related to adding additional EBPs, and
• monitoring fidelity to EBPs currently operating in the region. 
• Most of the IPLT teams make recommendations related to EBP implementation and sustainability directly to the administration or leadership of the region.  
• The IPLT teams are operating within each region as the central team to address EBP issues.   The IPLT members feel that the work they do is critical to sustaining the EBPs and that while some of the same people are also on other key organizational committees; this is the only committee where the entire focus is on EBPs.   In several regions, the IPLT teams also provide the ongoing communication about EBPs to all internal and contract agencies in the region.    
• In terms of how meetings are organized, most of the IPLTs include a reporting component to update all members on the status of each EBP and a problem-solving component to address challenges faced in keeping fidelity or implementing the EBPs.   Several of the IPLT teams have sub-committees for each EBP that works on the day to day challenges of implementing/ sustaining the EBPs.  The IPLT teams in many regions are also beginning to focus more on gathering data to assess consumer outcomes related to the implementation of the EBPs. 
• For every IPLT team, one of the challenges has been to try to provide oversight on all of the EBPs that have been implemented since 2005 in the regions.  The IPLT teams highlighted the tension that has emerged for them between trying to balance the reporting out function of the committee with the problem-solving and ongoing sustainability functions of the committee.  Each region has worked to address time constraints on team members and the frequency of IPLT meetings.  The concern is that as EBPs continue to be implemented, the IPLT team may not be able to meet all the responsibilities for oversight of EBPs.
• Several of the IPLT teams mentioned the need to recognize through the reward structure in the organization, staff members who become “champions” for the EBPs.  These staff members often take on additional workload tasks in order to support the EBP growth in the regions and in the state.