Federal Funding Recommendations to Scale Up Evidence-Based Practices in Health and Social Services

U .S. federal policy needs to address key priority health and social service needs, ranging from drug overdose and suicide to the human immunodeficiency virus (HIV) and influenza. Implementing high-quality, evidence-based practices (EBPs), supported by the latest and most-rigorous research, is an important way to address these high-priority service needs. Government spending on EBPs can improve population health and well-being, as well as offset billions of dollars' worth of societal harms each year. Therefore, federal officials often want to know: What are the best ways to fund and scale up EBPs?

To answer this question, a RAND research team conducted a series of focus groups with federal and state officials about their experiences with federal grants for EBP implementation in health and social services. The participants represented a variety of state agencies (e.g., child and family services, behavioral health services) from 12 states and federal agencies. All participants had experience with the federally funded implementation of a variety of EBPs.

Recommendations for Improving the Implementation of EBP Grants

Drawing from the focus group discussions, the research team developed recommendations for federal grants supporting large-scale implementation of EBPs in health and social services that address commonly discussed challenges and needs. The team also identified real-world examples that illustrate how federal funders might incorporate the recommendations into grant processes.

Recommendation 1. Practice Flexibility When Considering the Evidence and Selecting EBPs for Grant Funding

Standards of "sufficient" evidence for EBP selection can be rigid, favoring the selection of well-known EBPs. This rigidity embeds bias against practices that are supported by fewer studies or by evidence that is perceived as less rigorous; often, these practices have been developed for marginalized groups and stigmatized health problems (for example, adolescent substance use disorders). Federal agencies should carefully balance the desire for rigorous supporting evidence with the recognition that gaps and inequities exist in the available evidence.

Real-World Example 1: The Evidence-Based Practices and Community-Defined Evidence Practices Grant Program, funded by the California Department of Health Care Services. This grant program emphasizes health equity for racial or ethnic and sexual or gender minority youth, and it includes funding for both evidence-based and community-defined evidence practices.

Recommendation 2. Promote Equity in Grant Funding for EBP Implementation by Supporting Low-Resourced Service Delivery Organizations to Build Their Capacity for Grants

EBP grant funding is not equitably awarded to organizations with low resources, such as those based in rural or predominantly racial or ethnic minority communities, as well as to organizations providing stigmatized services (e.g., harm-reduction services for substance use). It is important to offer capacity-building supports that can help low-resourced service delivery organizations successfully apply for grants to implement EBPs and carry out all the required activities, such as process and outcome evaluations and progress reporting.

Real-World Example 2: The Centering Diverse Healers for Youth Well-Being Grant Program, funded by Public Health—Seattle & King County. The purpose of this grant program is to increase the delivery of youth well-being and mental health programs and practices by a diverse workforce of community-based providers. The funding opportunity offers free technical assistance for applicants and free capacity-building supports for grant recipients while recognizing the needs of low-resourced service delivery organizations.

Recommendation 3. Support Communication and Cohesion Among Federal Agencies, Other Government Agencies, and Service Delivery Organizations Throughout Grant-Related Activities

Strong communication and cohesion among implementation partners is essential to securing and launching an EBP implementation grant. Yet strong partnerships are challenging to build and need to be supported and maintained throughout grant-related activities to help achieve the goals of the grant. Federal funders have an important role in promoting alignment around common goals and activities across implementation partners.

Real-World Example 3: The Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention, created by the Centers for Disease Control and Prevention (CDC). This compendium is a website that allows users to search a list of 271 potential EBPs and provides a one- to two-page summary of each practice. This type of resource can be useful for providing grantees and their partners with a common language and understanding around EBP selection. CDC also offers capacity-building training and technical resources to support later stages of EBP implementation, designed to include a broad range of partners.

Recommendation 4. Balance the Flexibility to Tailor EBPs to Local Contexts with Standards for High EBP Fidelity Throughout Grant Implementation and Evaluation Activities

There is a tension between implementing EBPs with high levels of fidelity (delivering the EBP as designed and tested in research) and tailoring EBP delivery to the implementation context and the needs of providers and service recipients. Supports for implementation and evaluation during federal grants need to be sufficiently flexible to account for a variety of approaches to EBP implementation while still maintaining the EBP’s effectiveness.

Real-World Example 4: Adapting Evidence-Based Practices for Under-Resourced Populations Resource Guide, created by the Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA and other federal funders could incorporate elements of the adaptation resource guide into grant opportunities to support thoughtful approaches to fidelity and adaptation. The guide includes a recommended seven-step process for planning and executing EBP adaptations that would benefit grantees.

Recommendation 5. Address the Workforce Capacity Issues at Service Delivery Organizations and Government Agencies That Limit EBP Implementation

Workforce capacity throughout service systems presents a challenge to both initial and long-term delivery (i.e., after grant funding ends). Turnover is prevalent and widespread in health and social service delivery organizations and is linked to high levels of burnout, staffing shortages, low pay, and negative perceptions of the services (e.g., EBPs) and populations. Similar challenges affect the workforce at other service-system levels, including among state and federal agency staff. It is important for federal agencies to directly address workforce challenges as part of grant funding, such as developing staff retention incentives, continuous training in EBPs, and system-level changes that address underlying drivers of turnover.

Real-World Example 5: Bureau of Health Workforce Grants, funded by the Health Resources and Services Administration (HRSA). HRSA workforce grants are available across a wide variety of health services, as well as loan, scholarship, and loan repayment programs to support health-related professional education. Funding mechanisms target training activities (e.g., didactic education, supervised experiential learning), incentives to provide health services to vulnerable and underserved communities, or both.

Recommendation 6. Lengthen Grant Award Periods to Support Implementation and Sustainment Success

Implementing EBPs at scale is a long-term effort. Prior to funding, longer periods to respond to federal requests for proposals allows for more-deliberate planning. Funded projects would benefit from planning periods prior to active implementation, time to complete and submit evaluation findings, and continued support (e.g., technical assistance) after the initial implementation activities are completed. By contrast, short-term grant time frames can cause rushed planning and disrupt implementation.

Real-World Example 6: Community Partnerships to Advance Science for Society (ComPASS) Grant Program, funded by the National Institutes of Health (NIH). NIH ComPASS grants were designed to span the full implementation process over a ten-year period of funding. Furthermore, these grants support research conducting and evaluating community-led health equity structural interventions, and they are awarded to and led by community-based organizations.

Recommendation 7. Support the Integration of Indirect EBP Activities and Direct Service Delivery into Funding Systems to Promote EBP Implementation and Sustainment Beyond Federal Grants

Continued funding is vital to sustain EBPs long term at service delivery organizations after initial EBP implementation grants end. Typical funding systems, such as Medicaid and other forms of insurance, often fall short in covering the full range of EBP-related costs, including direct service delivery costs and indirect costs of implementation and sustainment supports. Strengthened federal and state supports are needed to better integrate coverage for EBP costs into available reimbursement, which could supplement federal funds during implementation and support sustainment after the grants end.

Real-World Example 7: Mental Health Block Grant Set-Aside for First-Episode Psychosis, funded by SAMHSA. By law, states and territories must use 10 percent of their annual block grant funds for mental health services that support people with serious mental illness, especially EBPs for first-episode psychosis. This set-aside in the block grant illustrates how funding systems can be modified to support EBP implementation and sustainment costs. When designing EBP implementation grants, federal funders can support grantees in identifying or developing a variety of relevant funding sources (of which block grant funds are one possible example) and assessing the role of each in EBP implementation and sustainment.

Conclusion

Through focus groups with federal and state agency officials, the research team identified recommendations for policies that optimize federal grants to support large-scale EBP implementation in health and social services. Combining elements of existing grant mechanisms (such as the real-world examples) in flexible ways might be ideal for achieving desired outcomes. These recommendations offer a foundation for developing comprehensive guidance on designing federal grant mechanisms with high-quality, sustainable EBP implementation in mind.

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Topics

• Evidence Based Health Practice
• Health Care Costs
• Social Services and Welfare