In the past few years several major reports highlighted the gap between our knowledge of effective treatments and services currently being received by consumers. These reports agree that we know much about interventions that are effective but make little use of them to help achieve important behavioral health outcomes for children families and adults nationally. This theme is repeated in reports by the Surgeon General (United States Department of Health and Human Services 1999; 2001) the National Institute of Mental Health [NIMH] National Advisory Mental Health Council Workgroup on Child and Adolescent Mental Health Intervention Development and Deployment (2001) Bernfeld Farrington & Leschied (2001) Institute of Medicine (2001) and the Presidents New Freedom Commission on Mental Health (2003). The authors call for applied research to better understand service delivery processes and contextual factors to improve the efficiency and effectiveness of program implementation at local state and national levels. Our understanding of how to develop and evaluate evidence-based intervention programs has been furthered by on-going efforts to research and refine programs and practices to define "evidence bases" and to designate and catalogue "evidence-based programs or practices". However the factors involved in successful implementation of these programs are not as well understood. Current views of implementation are based on the scholarly foundations prepared by Pressman & Wildavskys (1973) study of policy implementation Havelock & Havelocks (1973) classic curriculum for training change agents and Rogers (1983; 1995) series of analyses of factors influencing decisions to choose a given innovation. These foundations were tested and further informed by the experience base generated by pioneering attempts to implement Fairweather Lodges and National Follow-Through education models among others. Petersilia (1990) concluded that "The ideas embodied in innovative social programs are not self-executing." Instead what is needed is an "implementation perspective on innovation--an approach that views postadoption events as crucial and focuses on the actions of those who convert it into practice as the key to success or failure". (excerpt)

Implementation research: a synthesis of the literature.

A Preliminary Theory of Interorganizational Network Effectiveness: A Comparative Study of Four Community Mental Health Systems

• A conceptual model for the development of communitybased treatment programs for the chronically disabled psychiatric patient was developed, and the results of a controlled study and follow-up are reported A community-treatment program that was based on the conceptual model was compared with conventional treatment (ie, progressive short-term hospitalization plus aftercare) The results have shown that use of the community program for 14 months greatly reduced the need to hospitalize patients and enhanced the community tenure and adjustment of the experimental patients When the special programming was discontinued, many of the gains that were attained deteriorated, and use of the hospital rose sharply The results suggest that community programming should be comprehensive and ongoing

Alternative to Mental Hospital Treatment: I. Conceptual Model, Treatment Program, and Clinical Evaluation

Because economic evaluations of health care services are being published with increasing frequency it is important to (a) evaluate them rigorously and (b) compare the net benefit of the application of one technology with that of others. Four "levels of evidence" that rate economic evaluations on the basis of their methodologic rigour are proposed. They are based on the quality of the methods used to estimate clinical effectiveness, quality of life and costs. With the use of the magnitude of the incremental net benefit of a technology, therapies can also be classified into five "grades of recommendation." A grade A technology is both more effective and cheaper than the existing one, whereas a grade E technology is less or equally effective and more costly. Those of grades B through D are more effective and more costly. A grade B technology costs less than $20,000 per quality-adjusted life-year (QALY), a grade C one $20,000 to $100,000/QALY and a grade D one more than $100,000/QALY. Many issues other than cost effectiveness, such as ethical and political considerations, affect the implementation of a new technology. However, it is hoped that these guidelines will provide a framework with which to interpret economic evaluations and to identify additional information that will be useful in making sound decisions on the adoption and utilization of health care services.

How attractive does a new technology have to be to warrant adoption and utilization? Tentative guidelines for using clinical and economic evaluations

The thesis of this paper is that the most important and interesting aspects of community life are by their very nature paradoxical; and that our task as researchers, scholars, and professionals should be to “unpack” and influence contemporary resolutions of paradox. Within this general theme I will argue that in order to do so we will need to be more a social movement than a profession, regain our sense of urgency, and avoid the tendency to become “one-sided.” I will suggest that the paradoxical issue which demands our attention in the foreseeable future is a conflict between “rights” and “needs” models for viewing people in trouble.

In Praise of Paradox: A Social Policy of Empowerment over Prevention

• A cost-benefit analysis should be seen not as a mechanism for deciding mechanically on the allocation of funds and resources among programs but as a structure for weighing advantages and disadvantages (that is, for organizing knowledge). Considering all the forms of benefits and costs that we were able to derive in monetary terms, the experimental program provided both additional benefits and additional costs as compared with the conventional treatment. However, the added benefits, some $1,200 per patient per year, are nearly $400 more per patient per year than the added costs. A number of the forms of benefits and costs that we have measured in quantitative but nonmonetary terms show additional advantages of the community-based experimental program. The generalizability of a single experiment is limited, but the methodologies developed may be useful if their proper role is appreciated.

Alternative to Mental Hospital Treatment: II. Economic Benefit-Cost Analysis

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Alternatives to Mental Hospital Treatment

• Much concern has been expressed over the possible burden placed on family and community members by programs that emphasize community treatment of severely disturbed patients. In this study, the social costs of an experimental in-community program were compared with those of a traditional approach using short-term hospitalization plus aftercare. Six objective and one subjective measures of the burden placed on the family members of patients in both groups were obtained. Community burden was assessed through police records of frequency of patient arrests, number of suicidal gestures that required medical attention, and frequency of emergency room use. All measures showed that the total in-community program resulted in no more burden on the family or community than the traditional approach. The large amount of support provided to patients, families, and community members in the experimental approach is emphasized in explaining these results.

Mary Ann Test

Papers

Alternative to Mental Hospital Treatment: I. Conceptual Model, Treatment Program, and Clinical Evaluation

Alternative to Mental Hospital Treatment: II. Economic Benefit-Cost Analysis

Alternatives to Mental Hospital Treatment

Alternative to mental hospital treatment. III. Social cost

The Strengths Model: Case Management With People Suffering From Severe and Persistent Mental Illness