States are key to implementing evidence-based practices, but state mental health authorities should note that each of the practices requires different skill sets and involves different stakeholders. Thus implementing many evidence-based practices at once may not yield economies of scale.

Objective This study evaluates a large demonstration project of collaborative care in community health centers by examining the role of clinic site on measures of the implementation process and on clinical outcomes that are not accounted for by characteristics of the patients served. Methods This quasi-experimental study examines data on the treatment of 2821 patients over three years at six organizations that implemented collaborative depression care. Outcome data included two quality indicators (receipt of early follow-up or appropriate pharmacotherapy) and depression improvement (50% reduction in PHQ-9 score or PHQ-9 score ≤ 5). Results Multivariate logistic regression models revealed significant differences across clinics in the probability of receiving early follow-up (.34 to .88) or appropriate pharmacotherapy (.27 to .69); or experiencing improvement (.36 to .84) after adjustment for patient characteristics. Similarly, Cox proportional hazards models revealed that time to improvement differed significantly across clinics (p ≤ 0.0001) after adjusting for patient characteristics. Conclusions Across all sites, a plurality of patients achieved meaningful improvement in depression and in many sites improvement occurred rapidly. Despite receiving similar training and resources, organizations exhibited substantial variability in their ability to enact change in clinical care systems, as evidenced by both quality indicators and outcomes. Although we cannot conclude that performance on quality indicators caused improved outcomes, those sites that performed better had better outcomes, differences that were not attributable to patient characteristics.

States are key to implementing evidence-based practices, but state mental health authorities should note that each of the practices requires different skill sets and involves different stakeholders. Thus implementing many evidence-based practices at once may not yield economies of scale.

The evidence-based practice demonstration for services to adults with serious mental illness has ended its pilot stage. This paper presents the approaches states employed to combine traditional policy levers with more strategic/institutional efforts (e.g., leadership) to facilitate implementation of these practices. Two rounds of site visits were completed and extensive interview data collected. The data were analyzed to find trends that were consistent across states and across practices. Two themes emerged for understanding implementation of evidence-based practices: the support and influence of the state mental health authority matters and so does the structure of the mental health systems.

Despite receiving similar training and resources, organizations exhibited substantial variability in enacting change in clinical care systems, as evidenced by both quality indicators and outcomes. Sites that performed better on quality indicators had better outcomes, and the differences were not attributable to patients' characteristics.