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In this Issue Brief, we provide background on the use of research to inform policy and practice, describe the use of evidence in the context of Massachusetts-wide systems change in children’s behavioral health services, and discuss the key role of intermediaries in facilitating knowledge exchange

Biebel, Kathleen

Debordes-Jackson, Gifty

Leslie, Laurel

Maciolek, Susan

Nicholson, Joanne

English

eScholarship@UMMS

Psychiatry Issue BriefIntermediaries Promote the Use of Research Evidence in Children’s Behavioral Health Systems ChangeKathleen Biebel, Susan Maciolek, Joanne Nicholson, Gifty Debordes-Jackson, & Laurel LeslieVolume 10Issue 42013The use of research to inform policy and practice has received enormous attention in behavioral health over the last decade. Federal agencies and service purchasers are increasingly demanding that interventions and the dollars that fund them be attached to a body of evidence demonstrating effectiveness with regard to desired outcomes. In this Issue Brief, we provide background on the use of research to inform policy and practice, describe the use of evidence in the context of Massachusetts-wide systems change in children’s behavioral health services, and discuss the key role of intermediaries in facilitating knowledge exchange. Research or research evidence is defined as empirical findings derived from systematic analysis of information, guided by purposeful research questions and methods (Asen et al., 2011).Use of Research by Policymakers and PractitionersThere is a small but growing body of literature focused on how policymakers and practitioners interact with researchers around the use of research findings. Earlier, more traditional models of research use suggest a linear, uni-directional approach where a producer, often in an academic setting, conducts and delivers research to a user, usually a policymaker or practitioner (Lavis et al., 2003). More recent models highlight the complexities surrounding the use of research evidence including the bi-directionality of the exchange of research knowledge (Tseng, 2012). Appropriate linkages between research and the users of research are necessary to properly facilitate the use of research in policy and practice. Researchers themselves may not be the best translators of their own work and may lack the communication and leadership skills required to bridge the research to policy and practice gap (Gold, 2009).The Context: The Massachusetts Children’s Behavioral Health System Changes in the Massachusetts children’s behavioral health system over the last decade presented a unique opportunity to examine how research is brought to bear when developing and implementing policy and program change. In 2006, Massachusetts was found in violation of the Federal Early Periodic Screening Diagnosis and Treatment (EPSDT) provisions of the Medicaid Act (Rosie D. v. Romney). A remedy plan was developed to enable eligible children with behavioral health issues to receive appropriate treatment and care in their homes and local communities. Key to the remedy was the incorporation of Wraparound, a family-driven, intensive care coordination process for children involved with public child- and family-serving systems (Burchard et al., 2002; Rossman, 2002). The body of research evidence for Wraparound is growing, with a significant literature base, evaluation data, fidelity measures, and implementation in numerous settings. Investigators examined the use of research evidence (i.e., Wraparound in this case example) as state-level stakeholders prepared for and implemented court-mandated changes in children’s behavioral health services in partnership with community agencies across the state. Investigators conducted a mixed methods study including an extensive review of public documents, an agency survey, and one-on-one and group interviews with key informants. A Publication of the Systems & Psychosocial Advances Research Center (formerly the Center for Mental Health Services Research)A Massachusetts Department of Mental Health Research Center of ExcellenceResearch Evidence in Children’s Behavioral Health Systems ChangeAn intermediary facilitates knowledge exchange and brokers information among stakeholders, providing value-added contributions to decision-making.This is a product of Psychiatry Information in Brief. An electronic copy of this issue brief with full references can be found at http://escholarship.umassmed.edu/pib/vol10/iss4/1Opinions expressed in this brief are those of the author(s) and not necessarily those of the University of Massachusetts Medical School or the Department of Psychiatry.The Role of Intermediaries Intermediaries were critical to translating both the Wraparound model and the Medicaid program context for both state and local stakeholders charged with designing and implementing the Rosie D. remedy. Two distinct types of intermediaries were identified, external intermediaries and internal intermediaries, who completed different types of work, under different conditions, at different stages in the remedy design and implementation. The external intermediary was a policy expert who assisted policymakers in translating the remedy provisions into state Medicaid managed care program standards. This intermediary was based in a local consulting firm, was highly regarded nationally, and had deep experience designing and implementing Medicaid reforms in numerous states. The intermediary was skilled in facilitating the exchange of information among a small number of stakeholders representing plaintiffs and defendants working together intensively, over a concentrated period of time. This group produced complex documents (i.e., Medicaid program standards aligned across seven remedy components) that served as the foundation for the systems change initiative. As someone external to the state system, the intermediary brought knowledge and experience from other states’ reforms as well as the skills to support the group in exchanging and using knowledge from a range of sources. The internal intermediaries advised practitioners at community agencies using Wraparound in their work with children and families. These intermediaries were staff of the Medicaid Program’s Managed Care Entities (MCEs), which hold and manage contracts with the community agencies. They provided real-time consultation at agency site visits and statewide meetings about how to adhere to Wraparound best practice within the Medicaid program. These intermediaries brought their internal knowledge of Massachusetts Medicaid and, over time, developed proficiency in Wraparound best practice. This work has been ongoing for over three years. Using Intermediaries The decision to engage an external intermediary or develop internal intermediary capacity should be informed by the nature of the work and the conditions under which it must be accomplished. In this study, the work of intensive, time-limited policy-making and long-term system-wide practice change required different types of intermediaries. •	 The external intermediary brought knowledge and skills not available within the stakeholder organizations. The one-time nature of the work and aggressive timeline made developing these assets internally impractical. •	 Internal intermediaries were developed over time in order to build the organizational capacity needed to sustain the practice change. MCE-based intermediaries received training in Wraparound to complement their pre-existing expertise in Medicaid requirements. Characteristics of Intermediaries Stakeholders identified certain personal qualities and characteristics of intermediaries as important to building their relationships and facilitating the work. •	 Trust. Trust was based on the intermediary’s reputation, existing relationships or networks, and the reliability of the information they shared. •	 Neutrality and transparency. The external intermediary was valued for the ability to remain impartial – not representing any one position (e.g., plaintiff or defendant). Although the internal intermediaries were not neutral regarding their MCE role, they were transparent about how they were translating the research evidence in the context of the Medicaid program. •	 Collegiality and enthusiasm. Ease of working together, enthusiasm for the work and commitment to the collaborative knowledge exchange process facilitated evidence-informed decision-making. This was particularly important given time and resource parameters established in the remedy plan.Preliminary findings from this study highlight the important role of intermediaries along with characteristics and strategies that may be related to the promotion of research evidence use in policy and practice decision-making. Further model development and testing will allow for more specific, evidence-based recommendations in the future.Investigators: Joanne Nicholson, PhD (Dartmouth); Laurel K. Leslie, MD, MPH (Tufts); Susan Maciolek, MPP (Policy & Management Consultant); Kathleen Biebel, PhD (UMMS); & Gifty Debordes-Jackson, MA (UMMS)  Funder: The William T Grant Foundation  Time Period: July 2010 to June 2013  Contact: Joanne.Nicholson@Dartmouth.eduReferencesAsen, R., Gurke, D., Connors, P., Solomon, R., & Gumm, E. (2011). “The research says:” Definitions and uses of a key policy term in federal law and local school board deliberations. Argumentation and Advocacy, 47, 195-213.Burchard, J. D., Bruns, E. J., & Burchard, S. N. (2002). The Wraparound approach. In B. J. Burns & K. Hoagwood (Eds.), Community treatment for youth: Evidence-based interventions for severe emotional and behavioral disorders (1st ed., pp. 69–90). New York, NY: Oxford University Press, Inc.Gold, M. (2009).  Pathways to the use of health services research in policy.  Health Services Research, 44(4), 1111-1136.Lavis, J. N., Robertson, D., Woodside, J. M., Mcleod, C. B., & Abelson, J. (2003). How can research organizations more effectively transfer research knowledge to decision makers? Milbank Quarterly, 81(2), 221–248.Rossman, S. (2002). Services integration: Strengthening offenders and families, while promoting community health and safety. From Prison to Home: The Effect of Incarceration and Reentry on Children, Families, and Communities. The Urban Institute. Retrieved from http://www.urban.org/publications/410625.htmlTseng, V. (2012). Social policy report: The uses of research in policy and practice (Vol. 26). Society for Research in Child Development.Intermediaries Promote the Use of Research Evidence in Children’s Behavioral Health Systems Change - Biebel, Maciolek, Nicholson, Debordes-Jackson, & Leslie

Intermediaries Promote the Use of Research Evidence in Children\u27s Behavioral Health Systems Change [English and Spanish versions]

https://escholarship.umassmed.edu/cgi/viewcontent.cgi?article=1081&amp;context=pib

Intermediaries Promote the Use of Research Evidence in Children\u27s Behavioral Health Systems Change [English and Spanish versions]

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