Predicting Evidence-Based Treatment Sustainment

Results from a Longitudinal Study of the Adolescent-Community Reinforcement Approach

Published in: Implementation Science, Volume 12, Number 1 (2017), page 75. doi: 10.1186/s13012-017-0606-8

by Sarah B. Hunter, Bing Han, Mary Ellen Slaughter, Susan H. Godley, Bryan R. Garner

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Research Question

  1. What factors contribute to the continued use of Adolescent-Community Reinforcement Approach (A-CRA) at community-based organizations after the loss of federal implementation funding?


Implementation support models are increasingly being used to enhance the delivery of evidence-based treatments (EBTs) in routine care settings. Little is known about the extent to which these models lead to continued EBT use after implementation support ends. Moreover, few empirical studies longitudinally examine the hypothesized factors associated with long-term psychosocial EBT use (i.e., sustainment). In an effort to address this gap, the current study examined sustainment of an EBT called the Adolescent-Community Reinforcement Approach (A-CRA) following the end of implementation support.


Between 2006 and 2010, the Substance Abuse and Mental Health Services Administration awarded 3 years of A-CRA implementation support to 82 community-based organizations around the USA. The extent to which A-CRA was sustained following grant end and the hypothesized factors associated with EBT sustainment were collected using both retrospective and prospective data. We examined the extent to which 10 core treatment elements of A-CRA were sustained and the associations between the extent of A-CRA sustainment and hypothesized factors using a pattern-mixture longitudinal modeling approach.


Staff from 76 organizations participated in data collection for a 92.86% response rate. On average, about half of the 10 core treatment elements were sustained following the loss of implementation support. Factors that appeared most important to A-CRA sustainment included characteristics that were related to the outer setting (communication, funding, and partnerships), inner setting (political support, organizational capacity, and supervisor turnover rate), implementation support period (number of clinicians and supervisors certified and employed at support end and number of youth served), and staff perceptions of the intervention (implementation difficulty, relative advantage, and perceived success).


Even with multiple years of implementation support, community-based organizations face challenges in sustaining EBT delivery over time. Consistent with implementation theories, multiple factors appear related with EBT sustainment, including the degree of implementation during the initial support period, as well as adequate funding, infrastructure support, and staff support following the end of funding.

Key Findings

  • Community-based organizations frequently sustained a portion of the ten core elements of A-CRA after losing implementation support.
  • An organization's performance and capacity at the end of the grant strongly predicted how well the organization could sustain A-CRA.
  • Important external factors include stability of funding and support for the treatment, both politically and among the community.
  • Internal organization factors include sufficient supervisor staffing, organizational capacity, and clinical staff perceptions about A-CRA.

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