Optimizing Federal Grants to Scale Up Evidence-Based Practices in Health and Social Services: Recommendations from Federal and State Agency Officials

The U.S. federal initiative Healthy People 2030 set national objectives for improving health and well-being in the decade from 2020 to 2030 across a range of health conditions, behaviors, populations, and settings (Office of Disease Prevention Health and Promotion, U.S. Department of Health and Human Services, undated). The initiative set priorities for a wide variety of health-related targets; examples include infant and pregnancy-related deaths, fourth grade reading proficiency, blood pressure control in adults with hypertension, and drug overdose deaths (all ages). Achieving the objectives of Healthy People 2030 can be supported by coordinated federal efforts supporting the large-scale use of evidence-based practices (EBPs), which are practices shown to be effective by research for health care and social service delivery. One of the major selection criteria for the Healthy People 2030 objectives was the availability of EBPs that could improve outcomes through large-scale implementation (National Academies of Sciences Medicine Division, 2020). Investment in EBPs also helps offset the estimated $3.5 trillion that the United States spends annually to address high-priority health problems, while counteracting its historically low (less than 5 percent) national levels of health spending dedicated to public health (National Academies of Sciences Medicine Division, 2020).

That said, the implementation of EBPs is a complex, long-term process that is influenced by characteristics of the EBP, providers, recipients, and context (Crable et al., 2022). Implementing EBPs offers a pathway to high-quality care but also requires knowledge, skills, resources, and effort and, thus, is costly for service delivery organizations (Dopp et al. 2020; Lang and Connell, 2017). The costs of EBP implementation and ongoing delivery are especially formidable barriers when EBPs involve complex behavioral interventions or are delivered by community organizations with limited resources. Because of these costs, availability of adequate funding is one of the factors that most strongly influences the success of EBP implementation efforts (Jaramillo et al., 2019; Stewart et al., 2016).

Researchers in the field of implementation science have begun identifying and testing strategies that support EBP implementation (Bauer and Kirchner, 2020), including financing strategies, which are defined as mechanisms that secure and direct financial resources to cover the costs of EBP implementation (Dopp et al., 2020). Federal grants are a commonly used type of financing strategy on which many service delivery organizations rely to fund EBP implementation (Dopp et al., 2022; Jaramillo et al., 2019). This study presents recommendations identified by federal and state agency officials for improving the design of federal EBP implementation grants and provides real-world examples that illustrate each recommendation. Federal funders can apply these recommendations to optimize existing grant processes or design novel grant mechanisms that maximize support for EBP implementation at scale to create the greatest possible reach for services to help achieve Healthy People 2030 objectives.

Key Recommendations

Through focus groups with federal and state agency officials, we identified seven policy recommendations related to optimizing federal grantmaking to support the large-scale implementation of evidence-based practices (EBPs). These recommendations for federal agency officials are as follows:

• Practice flexibility when considering the evidence and selecting EBPs for grant funding. Overly rigid standards for “sufficient” evidence have constrained EBP selection to date, resulting in bias against practices for marginalized groups or stigmatized health problems.
• Promote equity in grant funding for EBP implementation by supporting low-resourced service delivery organizations to build their capacity for obtaining grant funding and carrying out expected grant activities (e.g., reports, evaluations). At present, there are persistent inequities in the types of organizations that receive federal grants for EBP implementation.
• Support communication and cohesion (e.g., partnerships, relationships) among federal agencies, government entities eligible for federal grants (such as states, territories, and tribal governments), and service delivery organizations throughout grant-related activities to help achieve the grant goals. It is challenging to maintain this type of communication and cohesion among all partners in EBP implementation grants without targeted supports.
• Balance the flexibility to tailor EBPs to local contexts (e.g., provider capacity, client needs) with standards for high EBP fidelity throughout grant implementation and evaluation activities. Navigating tension between flexibility and fidelity is a major challenge in implementation.
• Address the workforce capacity issues at service delivery organizations and government agencies that limit EBP implementation. If grants that fund EBP implementation do not attend to workforce capacity, they are unlikely to produce sustainable changes.
• Lengthen grant award periods to support implementation and sustainment success, such as by allocating funds for planning periods prior to active implementation, time to complete and submit evaluation findings, and continued support (e.g., technical assistance) after grant funding ends. Long-term funding is critical to maintain continuity in EBP implementation.
• Support the integration of indirect EBP activities and direct service delivery into funding systems (e.g., Medicaid) to promote EBP implementation and sustainment beyond federal grants. Given that grant funding eventually ends, it does not offer the same long-term funding stability as when funding systems prioritize covering implementation costs.

To assist federal agencies in applying these recommendations, this study also provides real-world case examples illustrating how funding agencies have put each recommendation into practice.

Focus Group Methods

To understand the perspectives of government officials on federal grant funding for EBP implementation, we held a series of focus groups in October–November 2023 with officials employed at state or federal agencies who were involved in administering grant funding. This section provides a brief summary of the study methods.

We held virtual focus groups via videoconference with state officials (two groups, 12 participants total) and federal officials (again, two groups and 12 participants total). We recruited participants through our professional networks—especially those connected to the research team's ongoing project examining the implementation of a youth substance use treatment through federal grants (described in Dopp et al., 2022, and discussed further below)—and through nominations by potential participants. The participants represented a wide variety of state agencies (e.g., child and family services, behavioral health services) from 12 states and from federal agencies (five agencies both within and outside the U.S. Department of Health and Human Services). All participants had experiences with federally funded implementation of a variety of EBPs.

Each virtual focus group had five to seven participants and lasted 60 minutes. When a focus group was scheduled, the invitation included a one-page research summary that we asked participants to review in advance of the focus group. The summary emphasized that the focus was broadly on funding strategies for EBPs in health and social services, but also presented initial published findings from our ongoing project about youth substance use treatment (Dopp et al., 2023) as a case example that demonstrates how the design of federal grant mechanisms can be associated with the extent of successful EBP implementation during those grants. During each focus group, we presented the content of the research summary to frame the conversation, then asked participants to discuss their perspectives on the implications of the research summary and, more broadly, the barriers and facilitators to optimizing the use of federal grants for EBP implementation. All focus groups were audio-recorded and transcribed.

We followed best practices for qualitative thematic analysis (Braun and Clarke, 2006) to summarize the four focus group transcripts and synthesize the discussion into themes, each of which represented one major policy recommendation. Once thematic analysis was complete, we considered how the recommendations could have practical relevance by searching for real-world examples. By real-world, we mean examples from actual funding contexts that illustrate how federal funders could incorporate the recommendation into grant application, award, and administration processes. We prioritized examples of federal grant mechanisms whenever possible, but, in some cases, the clearest examples were state- or county-level grant initiatives or relevant resources. We selected one example per recommendation.

Policy Recommendations

We identified a total of seven recommendations that federal funders can apply to design federal grants that maximize support for EBP implementation at scale. The focus groups with both state and federal agency officials contributed to every recommendation, with a high level of consensus among participants about barriers, facilitators, and potential solutions. For each recommendation, we present a summary of the discussion along with illustrative quotes from the participants. The real-world examples are presented alongside the recommendations in callout boxes that are numbered to match the recommendations. Table 1 summarizes the policy recommendations and relevant examples.

#	Policy Recommendation	Real-World Examplea
1	Practice flexibility when considering the evidence and selecting EBPs for grant funding.	California Department of Health Care Services, Evidence-Based Practices and Community-Defined Evidence Practices Grant Program, 2022.
2	Promote equity in grant funding for EBP implementation by supporting low-resourced service delivery organizations to build their capacity for grants.	Public Health—Seattle & King County, “Request for Proposals (RFP): Centering Diverse Healers for Youth Well-Being Grant Program,” 2024.
3	Support communication and cohesion among federal agencies, other government agencies, and service delivery organizations throughout grant-related activities.	Centers for Disease Control and Prevention (CDC), Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention: Background, Methods, and Criteria, 2024.
4	Balance the flexibility to tailor EBPs to local contexts with standards for high EBP fidelity throughout grant implementation and evaluation activities.	Substance Abuse and Mental Health Services Administration (SAMHSA), Adapting Evidence-Based Practices for Under-Resourced Populations, PEP22-06-02-004, 2022a.
5	Address the workforce capacity issues that limit EBP implementation.	Health Resources and Services Administration (HRSA), “Funding,” webpage, 2023.
6	Lengthen grant award periods to support implementation and sustainment success.	National Institutes of Health (NIH), “Community Partnerships to Advance Science for Society (ComPASS),” webpage, undated.
7	Support the integration of indirect EBP activities and direct service delivery into funding systems to promote EBP implementation and sustainment beyond federal grants.	Ted Lutterman, Mihran Kazandijian, and Jennifer Urff, Snapshot of State Plans for Using the Community Mental Health Block Grant 10 Percent Set-Aside to Address First Episode Psychosis, Task Order No. HHSS283420002T, August 2018.

^a Each real-world example is detailed in the callout box with the same number as the policy recommendation.

During our analysis, we noted that these recommendations would likely still apply if other entities, such as territories or tribal governments, were involved in the federal EBP implementation grant instead of a state agency (the type of government entity included in our sample). Focus group participants did not specifically discuss those situations, but we opted to use more-inclusive language in the summaries when relevant.

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

Focus group participants discussed the initial process of awarding federal grants for EBP implementation, during which federal agencies determine which programs and practices qualify as EBPs for funding purposes. Participants described how the standards of “sufficient” evidence for EBP selection can be rigid and tended to prioritize programs and practices with large evidence bases that include randomized trials. This rigidity was relevant to funding opportunities that pre-specified which EBPs would be supported, as well as to those in which applicants proposed a program or practice that was then considered during application review. Rigid standards of evidence were observed to favor the selection of well-known EBPs for grant-funding opportunities and applications, embedding bias and stigma when fewer studies and less rigorous evidence were available for program and practice effectiveness with marginalized groups (e.g., culturally responsive interventions) and with health problems that were overlooked or stigmatized (e.g., adolescent health, substance use disorders). For example, focus group participants stated the following:

Participants suggested approaches that federal agencies could use to carefully consider EBP selection standards for grant funding, which balance the desire for rigorous supporting evidence with recognition that gaps and inequities exist in the available evidence. Such approaches included finding ways to identify newer and more-exploratory EBPs, summarizing the evidence supporting those programs and practices, and providing additional resources to concurrently implement and evaluate less-established programs and practices. Participants stated the following:

Example 1: Evidence-Based Practices and Community-Defined Evidence Practices Grant Program

In 2021, the state of California established the Children and Youth Behavioral Health Initiative, which invests state general funds into improving youth behavioral health—i.e., mental health and substance use—services statewide. As part of that initiative, the California Department of Health Care Services is distributing “$429 million in grants to organizations seeking to scale both evidence-based and community-defined evidence practices (EBPs/CDEPs) that improve youth behavioral health” through the Evidence-Based Practices and Community-Defined Evidence Practices Grant Program. Service delivery and community-based organizations are eligible for grants as are tribal governments, statewide and local agencies, and various other partners. Although this is a state-level grant mechanism, the size and scope of the program still provide a useful example for federal grants.

Notably, this grant program explicitly includes both EBPs and CDEPs for funding. The call for proposals defines EBPs as “those with documented, empirical evidence (e.g., randomly controlled trials, peer-reviewed studies, and publications) of effectiveness.” It then defines CDEPs as “community-based [behavioral health] practices that have reached a strong level of support within specific communities.” The grant program especially emphasizes the promotion of health equity for racial or ethnic and sexual or gender minority youth. The department selected six sets of EBP and CDEP categories for scaling through these grants based on a community engagement process that included academic, government, and industry experts, as well as youth and community input.

As of 2024, all rounds of grants have been awarded or are planned to be awarded soon.^a In parallel, the California Department of Public Health Office of Health Equity is funding the California Reducing Disparities Project, which provides evaluation support for 35 pilot CDEP programs to build the evidence base for these practices (and is also related to evaluation considerations under Policy Recommendation 4).

SOURCE: This example features information from California Department of Health Care Services, 2022.

^a Department of Health Care Services, undated.

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

Participants also expressed concerns that EBP grant funding was not equitably awarded to low-resourced service delivery organizations, such as those based in rural communities or in predominantly racial and ethnic minority communities, as well as organizations providing stigmatized services (e.g., harm reduction services for substance use). They noted that such organizations often do not have sufficient capacity to (1) successfully apply for competitive federal grant opportunities or (2) carry out all the activities expected of grantees (e.g., conduct process and outcome evaluations, complete progress reporting). Regardless of whether funds are awarded directly to service delivery organizations or to government entities, such as state agencies, federal agencies will encounter challenges to achieving equitable reach of the EBP across all relevant organizations and populations. Instead, participants emphasized the importance of offering capacity-building supports that can help low-resourced service delivery organizations successfully apply for and carry out federal grants to implement EBPs. Examples included engaging directly with service delivery organizations to provide funds and support (rather than working through state entities only) and enabling organizations to identify their needs and priorities for EBP-related funding (e.g., for culturally responsive programs and practices). This sentiment is illustrated in the following two quotes from a state official and a federal official:

Example 2: Centering Diverse Healers for Youth Well-Being Grant Program

Public Health—Seattle & King County (Washington state) solicited proposals for the Centering Diverse Healers for Youth Well-Being Grant Program in September 2024. Similar to Example 1, this grant program provides a useful example for federal grants despite being county-level funding. The purpose of this grant program is to increase the provision of youth well-being and mental health programs and practices by a diverse workforce who reflects the backgrounds of the young people receiving services (especially with regard to racial or ethnic and sexual or gender minority status). Funding for the grant program is provided by the county's Best Starts for Kids community-driven initiative for youth health and well-being, as well as the Mental Illness and Drug Dependency Fund countywide sales tax that generates funds for behavioral health services. Nonprofit, community-based, and faith-based organizations are eligible, as well as tribes and tribal organizations, for-profit entities, and public or government agencies. The county prioritizes applicants from “community-led and community-informed organizations that are reflective of and embedded in the communities they serve” and that demonstrate a commitment to social justice. Consistent with Policy Recommendation 1, the request for proposals does not include a restrictive definition of EBPs but, instead, emphasizes the importance of community expertise combined with demonstrated program or practice outcomes. At the time this summary was written, the county anticipated awarding up to five $300,000 grants in November or December 2024.

Although community representation and diversity are the primary priorities of the Centering Diverse Healers for Youth Well-Being Grant Program, the request for proposals from Public Health Seattle & King County also recognizes that applicants from community-led and community-informed organizations are more likely to be low-resourced. The grant program falls under a high-priority investment area to “build community capacity to share resources” and offers several supports focused specifically on capacity-building. First, free technical assistance is available for applicants under this request for proposals “to eliminate linguistic, cultural and other barriers that might prevent organizations from seeking government funding.” Second, once grants are awarded, grantee organizations can receive free capacity-building services through the Best Starts for Kids initiative “to support grantees' program and organizational development, implementation, and sustainability while being rooted in community strengths, needs, and values.” Capacity-building supports focus on a variety of areas, such as administration and governance, program development and evaluation, information technology, legal and human resources, and equity and social justice. Finally, beyond service delivery, funds from the grant program also must be used to increase support for and retention of a diverse provider workforce and offer direct investment in capacity-building that is further intended to decrease provider turnover (also relevant to Policy Recommendation 5).

SOURCE: This example features information from Public Health—Seattle & King County, 2024.

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

Focus group participants described strong communication and cohesion among implementation partners—which can include service delivery organizations, state agencies, and federal agencies—as essential to successfully securing and launching an EBP implementation grant. Participants discussed how strong partnerships are challenging to build and, therefore, need to be supported and maintained throughout grant-related activities to help achieve the goals of the grant. They noted that identifying influential “champions” in each organization who advocate for the use of the EBP is also critical. Of all the recommendations we identified, this one most explicitly drew on discussions of the findings in the research summary: Participants did not view grants awarded to service delivery organizations versus state agencies (the two grant types compared in Dopp et al., 2023) as competing options; rather, they expressed desires for an approach that combines the strengths of both state and organization partners through coordinated funding at both levels. Important elements that participants wanted to leverage included greater buy-in and accountability from funded service delivery organizations and the ability of state agencies to coordinate efforts and resources (including policy changes) statewide:

Participants also identified federal funders as having a role in promoting alignment around common goals and activities across organization and state grantees. However, the logistical challenge of distributing funds to a wide variety of entities in a coordinated fashion was seen as a barrier to the feasibility of this approach. One federal official noted an emphasis on limiting federal regulation and oversight in the policy environment as of 2024, which creates challenges for federal agencies taking on such a coordinating role with various states:

Example 3: Compendium of Evidence-Based Interventions and Best Practices for Human Immunodeficiency Virus Prevention

The CDC is the United States' national public health agency and part of the U.S. Department of Health and Human Services. The CDC HIV Prevention Research Synthesis project, which reviews and synthesizes research evidence on human immunodeficiency virus (HIV) prevention, was established in 1996 and began publishing a comprehensive compendium of practices in 1999. The purpose of the compendium is to summarize research evidence to inform practice and implementation decisions. As of this writing, the compendium is a website that allows users to search a list of evidence-based and evidence-informed practices by key variables (e.g., population, outcomes, intervention strategies, level of evidence) and provides a one- to two-page summary of each practice; 271 entries are included. The summaries are updated annually via comprehensive literature searches to reflect the current evidence base.

Resources like this compendium can be useful for providing grantees and their partners with a common language and understanding around EBP selection across partners, such as (in the case of HIV prevention) health care clinics and systems, community-based organizations, and state and local health departments. Grant applicants can select practices directly from the compendium for implementation or, if proposing alternatives, describe how those practices meet similar standards of evidence. Furthermore, the information from the brief practice summaries is not sufficient to plan for EBP implementation, so the CDC Capacity Building Provider Network also provides capacity-building training and technical resources to support later stages of implementation.^a Again, the resources are designed for a broad range of partners and could be incorporated into federal EBP implementation grants as planned activities to support cohesion and joint capacity-building among grantees and their partners.

SOURCE: This example features information from Centers for Disease Control and Prevention, 2024.

^a Centers for Disease Control and Prevention, “Capacity Building Assistance,” webpage, undated.

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

Focus group participants described a tension between typical EBP implementation strategies that emphasize high levels of fidelity to delivering the EBP as designed and tested in research—for example, expert training and consultation—versus the benefits of tailoring EBP delivery to the implementation context and the needs of providers and service recipients. These tensions were noted to be evident during grant launch activities and the initiation of active EBP delivery. Furthermore, these tensions were seen as relevant to both how EBPs are delivered and how implementation efforts are evaluated because both activities can involve monitoring fidelity. Participants noted that EBPs are often implemented without strict fidelity to the original model—i.e., as “evidence-informed” rather than “evidence-based” practices—but that such approaches can represent effective tailoring to a given context and should not be treated as inherently deficient compared with high-fidelity implementation. Thus, supports for implementation and evaluation during federal grants need to be sufficiently flexible to account for a wide variety of approaches to EBP implementation while still maintaining the EBP's effectiveness. Participants stated the following:

Example 4: Adapting Evidence-Based Practices for Under-Resourced Populations

SAMHSA is the lead federal agency (within the U.S. Department of Health and Human Services) responsible for the accessibility and quality of behavioral health—i.e., mental health and substance use—services in the United States. The agency has led several initiatives related to evidence-based behavioral health practices, the most recent of which is the Evidence-Based Practices Resource Center (part of the National Mental Health and Substance Use Policy Lab) established in 2018. The center offers an evidence-based resource guide series that provides service organizations,^a providers, policymakers, and information about how to incorporate EBPs into their settings. One such guide, Adapting Evidence-Based Practices for Under-Resourced Populations, directly relates to the recommendation of balancing flexibility with fidelity during the implementation process.^b

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 provides comprehensive information about understanding adaptation and fidelity, research findings to date on adaptation processes and experiences, guidance for adapting EBPs, examples of cultural adaptations to EBPs, and resources for evaluation and quality improvement to assess the impact of adaptations and maximize effectiveness in local implementation contexts over time. The guide includes a recommended seven-step process for planning and executing EBP adaptations that would be beneficial for grantees to follow during their federally funded implementation efforts.

The Evidence-Based Resource Guide Series includes other guides that are relevant to various aspects of the EBP implementation process. For example, Addressing Burnout in the Behavioral Health Workforce Through Organizational Strategies offers evidence-based strategies to minimize burnout that could be useful for addressing Policy Recommendation 5 about workforce capacity issues.^c

SOURCE: This example features information from Substance Abuse and Mental Health Services Administration, 2022a.

^a Abt Global, “SAHMSA Evidence-Based Resource Guide Series,” webpage, undated.

^b Substance Abuse and Mental Health Services Administration, 2022a.

^c Substance Abuse and Mental Health Services Administration, Addressing Burnout in the Behavioral Health Workforce Through Organizational Strategies, PEP22-06-005, 2022b.

Policy Recommendation 5: Address the Workforce Capacity Issues That Limit EBP Implementation

One of the most frequently discussed barriers to EBP delivery—both initial and long-term (i.e., after grant funding ends)—was workforce capacity challenges throughout service systems. Focus group participants noted that turnover is prevalent and widespread in service delivery organizations among the providers who deliver EBPs and their supervisors. Interrelated workforce issues were salient drivers of turnover, including high levels of burnout, staffing shortages, low pay, and negative perceptions of the services (e.g., EBPs) and populations (e.g., adolescents; people with substance use problems, early psychosis, or justice system involvement). Furthermore, turnover was noted to be a challenge at other service system levels, including among state and federal agency staff, for similar reasons. The following quotes exemplify the workforce-related challenges common to implementing EBP grants:

Given the prominence of workforce capacity barriers, participants saw it as important for federal agencies to directly address those barriers as part of grant funding. Most immediately, participants emphasized that resources need to be available for continuous training in EBPs—including protected time for training activities that take time away from billable service delivery—to counteract the effects of turnover. Longer-term, federal grants can also emphasize the importance of efforts toward system-level changes that address underlying drivers of turnover, such as supports to minimize burnout and increased pay for providers. Participants stated that

Example 5: Bureau of Health Workforce Grants

HRSA is the primary federal agency dedicated to increasing the accessibility of health services for vulnerable and underserved populations and is another agency within the U.S. Department of Health and Human Services. A major area of investment for HRSA is the Bureau of Health Workforce, which offers grants for workforce expansion to health service organizations (including schools, health departments), as well as, with a cost share, states and territories. The grants are available across a wide variety of health services, and the bureau also offers 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. In total, the Bureau of Health Workforce budget is more than $2 billion annually.

Federal EBP implementation grants could incorporate elements of HRSA Bureau of Health Workforce grants to address the workforce challenges commonly experienced by grantees. HRSA grant opportunities that have specifically emphasized EBPs are especially relevant. For instance, the Nurse Education, Practice, Quality and Retention Registered Nurse Training Program provided funds to support the development of undergraduate student nurses (including those from underrepresented racial and ethnic minorities) to provide “high quality culturally sensitive care in underserved communities.”^a Similarly, several National Health Service Corps programs provide up to $100,000 in loan repayment assistance for health professionals who “provide evidence-based substance use disorder treatment, assist in recovery, and prevent overdose deaths” in high-need areas. As much as HRSA has prioritized EBPs within workforce development grants, other federal funders could prioritize workforce development in EBP implementation grants.

SOURCE: This example features information from Health Resources and Services Administration, 2023.

^a Health Resources and Services Administration, “Nurse Education, Practice, Quality and Retention (NEPQR)-Registered Nurse Training Program (RNTP),” webpage, undated.

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

Participants noted that it would be beneficial to lengthen grant-funding periods throughout the EBP implementation process, which would increase the feasibility of implementation and support more-thoughtful approaches to decisionmaking and partnership. Examples included extended funding for planning periods prior to active implementation and for completing planned evaluations, plus continued availability of technical assistance and other long-term supports after active grant funding ends. Even prior to funding, having longer time frames to respond to federal requests for proposals was noted as beneficial for planning. Discussions emphasized the long-term and incremental nature of efforts to implement EBPs at scale. Participants described how short-term grant time frames disrupted the continuity of those efforts when planning had to occur quickly or when lapses in funding occurred later. However, they recognized that other government processes (such as changes in federal or state elected administrations) also made it difficult to extend the time frames for implementation efforts while also maintaining continuity.

Example 6: Community Partnerships to Advance Science for Society Grant Program

NIH is the largest public funder of biomedical and behavioral research in the world and is made up of 27 institutes and centers that award research grants and conduct internally funded research focused on specific health areas or topics. In addition, Congress enacted the NIH Common Fund in 2004 to support innovative trans-NIH research programs. NIH Common Fund launched the ComPASS program in 2023 to support research conducting and evaluating community-led health equity structural interventions, which will also inform a new community-led health equity research model for intervention research. NIH awarded $171 million in ComPASS grants to 26 community organizations, as well as a coordinating center, over the next five years; and plans to award Health Equity Research Hubs by end of 2024.

Although ComPASS grants are for research, several elements make them a relevant model for grants that support federal EBP implementation. First, NIH awards the grants to community-based organizations that lead the design and implementation of interventions to be evaluated with their research partners, which is similar to how many EBP implementation grants are structured. Second, these grants were designed to span the full implementation process over a ten-year period of funding.^a The projects involve three phases: (1) planning, development and partnership (years 1–2); (2) implementation (years 3–8); and (3) assessment, dissemination, and sustainability (years 9–10). Administrative review and approval is required to transition into the second phase and begin active implementation. Given these two features, ComPASS grants offer a model for how to structure federal grant support that coordinates implementation and evaluation activities throughout the implementation process. Although only some funded ComPASS projects focus on an identified EBP, all projects have the potential to develop and generate evidence for EBPs that meet community needs while balancing adaption and fidelity in the evaluations (also reflecting Policy Recommendations 1 and 5).

SOURCE: This example features information from NIH, undated.

^a NIH Common Fund, “Community Partnerships to Advance Science for Society (ComPASS) Program: Community-Led, Health Equity Structural Intervention Initiative (OT2),” September 12, 2022.

Policy 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

Focus group participants frequently raised the importance of continued funding to sustain EBPs long term at service delivery organizations after initial EBP implementation grants end. They emphasized that typical funding systems (e.g., Medicaid and other forms of insurance) tend to be inadequate for covering the full range of EBP-related costs, which include direct service delivery costs and indirect costs of ongoing implementation and sustainment supports (e.g., regular provider trainings, ongoing supervision and quality assurance, outreach and marketing, collaboration with external partners). Participants discussed how federal and state supports are needed to better integrate coverage for EBP costs into available reimbursement, which could help supplement the impact of federal funds during active implementation, as well as support sustainment after the grant has ended. This could include finding ways for typical reimbursement sources for direct services to offer increased rates for EBPs, as well as state agencies supplementing the available reimbursement sources to cover indirect EBP costs. Furthermore, service delivery organizations were noted to sometimes have limited experience or capacity for obtaining external funding, so more-general capacity-building and supports for external funding may be necessary alongside EBP-specific efforts. Participants stated the following:

In addition, participants commented that

Example 7: Mental Health Block Grant Set-Aside for First-Episode Psychosis

The SAMHSA Community Mental Health Services Block Grant illustrates how funding systems can be modified to support EBP implementation and sustainment costs. This block grant was established in 1992 to provide U.S. states and territories with annual funding for a variety of behavioral health services with a focus on vulnerable and high-risk populations. By law, states have been required to use a portion of their funds from the Mental Health Block Grant to fund “evidence-based programs that address the needs of individuals with early [serious mental illness], including psychotic disorders”; the percentage was initially 5 percent when it was established in 2014, then it was raised to 10 percent in 2016. SAMHSA especially emphasizes funding services for first-episode psychosis, such as Coordinated Specialty Care, as an early intervention strategy to reduce societal impacts of psychosis.^a These set-aside funds totaled $81.5 million in fiscal year 2022–2023 and supported evidence-based treatment programs for first-episode psychosis in all 50 states, Washington D.C., and Puerto Rico.

Given that states and territories have broad discretion with these block grant funds, evaluations of the set-aside for first-episode psychosis have demonstrated considerable variation in how the funds were used,^b as well as greater impacts in policy contexts that allowed for a wide variety of funding options. When designing EBP implementation grants, federal funders can support grantees in identifying or developing a variety of relevant funding sources and assessing the role of each funding source in sustainment. The set-aside for first-episode psychosis represents a substantial investment in specific EBPs, but the Community Mental Health Block Grant also includes a general 5-percent administrative set-aside for the development of state/territory mental health systems, which SAMHSA described as being used “with other funding sources” for EBP implementation. In each case, federal funders can help grantees determine the strategic value of various funding sources to their EBP implementation and sustainment goals.

SOURCE: This example features information from Lutterman, Kazandijian, and Urff, 2018.

^a Substance Abuse and Mental Health Services Administration, “Guidance for Revision of the FY2016–2017 Block Grant Application for the New 10 Percent Set-Aside,” February 8, 2016.

^b Marcela Horvitz-Lennon, Joshua Breslau, Deborah Scharf, Madeline Doyle, Nupur Nanda, Daniela Kusuke, Justin W. Timbie, and Virginia Kotzias, Case Study: Early Assessment of the Mental Health Block Grant Set-Aside Program for Addressing First Episode Psychosis and Other Early Serious Mental Illness, September 29, 2015; Lutterman, Kazandijian, and Urff, 2018.

Conclusions

Through focus groups with federal and state agency officials, we identified recommendations for policies that optimize federal grants to support large-scale EBP implementation in health and social services in line with Healthy People 2030 objectives. As illustrated in our real-world examples, existing federal grant mechanisms (and related funding mechanisms) have strengths and limitations with respect to these recommendations that can be tailored to match the characteristics of the EBP, providers, recipients, and external contexts involved in implementation. Combining elements of existing grant mechanisms—such as those highlighted in real-world examples—in flexible ways might be ideal for achieving the desired outcomes.

Ultimately, it will be helpful to build these recommendations into comprehensive guidance on how to design federal grant mechanisms with high-quality implementation and long-term sustainment in mind. A useful starting place could be a report from Results for America, which is a U.S. nonprofit focused on evidence-based policymaking; this study details a variety of strategies and activities that government grant programs have used to prioritize evidence of effectiveness in funding decisions—in other words, grant funding for EBPs (Results for America, undated). The overarching strategies are to define and identify evidence, prioritize EBPs in grant design, use outcomes-based grant management, and engage in evidence-building activities. The first two strategies most directly relate to Policy Recommendation 1 (by offering options to flexibly consider the evidence when selecting EBPs for grant funding), and the latter two most directly relate to Policy Recommendation 4 (by offering options to flexibly consider fidelity and outcomes within the grant context). The strategies from the study could benefit from expansion to include activities related to the other five recommendations—for example, to address Policy Recommendation 2 (promote equitable funding for low-resource organizations), Policy Recommendation 3 (support communication and cohesion), or Policy Recommendation 5 (address workforce capacity issues).

Despite the promise of the recommendations that we identified, many gaps remain in the scientific evidence that is available to inform strategies for federally funded EBP implementation. Researchers should expand partnerships with policymakers and agency officials, service delivery organizations, and communities to prioritize how to best continue studying the design and outcomes of federal grants and other financing strategies. Dopp et al. (2020) offers a detailed research agenda on financing strategies that was informed by a scoping review of relevant literature. It will also be useful to conduct hybrid implementation-effectiveness studies that produce evidence on both service recipient and implementation process outcomes (Curran et al., 2022). Finally, there is great potential for studying how to best maintain alignment in goals and activities between federal funders and service delivery organizations; communities; and state, territory, and tribal government entities throughout the implementation process (Aarons, Ehrhart, et al., 2014).

The findings from this study should be considered in light of three research limitations. First, the focus group discussions may have skewed toward issues that are relevant to implementing youth substance use EBPs, because the research summary used as the discussion prompt focused on one such EBP and the state agency officials were all involved in grants implementing the same EBP. That said, focus group participants readily discussed the implementation of other types of EBPs. Second, the focus group guide centered on federal funding, which limited our understanding of the extent to which these recommendations might apply to other contexts, such as state-level funding for EBP implementation. However, our real-world examples suggest that many of the recommendations have broader applicability than federal funding. Finally, the focus groups represented a small sample of government officials, and important perspectives may have been absent. For example, participants did not discuss tribal or territorial implementation contexts.

In future work, we will focus on EBP sustainment outcomes following the end of federal grant funding (see Dopp et al., 2022). Broad-scale implementation is a necessary precondition for achieving equity and sustainability in EBP implementation efforts at scale—but will only be sufficient when followed by long-term sustainment (Aarons, Green, et al., 2014). Focus group participants anticipated this topic by directly linking the success of grant activities to EBP sustainment, particularly in Policy Recommendation 6 (lengthening grant award periods) and Policy Recommendation 7 (integration of EBPs into funding systems). We also plan to gather input from service delivery organizations because they are directly affected by policy decisions regarding federal grant mechanisms. Finally, we are conducting case study analyses that compare how states developed and maintained infrastructure for EBP delivery through federal grants to help identify state-level policy recommendations. Overall, we will seek to continue generating practical guidance that can inform how federal agencies invest in the implementation of EBPs at scale to address society's most pressing health problems.