Getting Research Into Practice: A Guide to Implementation Strategies
Shining a light on integrated care to promote mastery and unlock human potential.
Research laboratories produce thousands of promising health treatments and interventions each year. But a recurring problem plagues the healthcare field: most of this scientific evidence never makes it into actual practice. Some research estimates that fewer than half of evidence-based interventions make it into standard care—those that do arrive only after 17 years, on average, without support from implementation strategies. Clinics don’t adopt new protocols, doctors stick with familiar methods, and patients never benefit from the latest findings.
Dr. Gracelyn Cruden, an implementation scientist with Chestnut Health Systems, recently addressed this challenge in a presentation titled: “Implementation Strategies: Approaches for Getting Evidence into Practice.” The presentation was delivered to participants in the C-DIAS Fellowship in Addiction Implementation Science, a structured professional development experience designed to strengthen the capacity of early- and mid-career professionals to apply rigorous implementation science methods to improve access to high-quality addiction treatment. The Fellowship enables participants to maintain full-time roles at their home institutions while engaging in two years of curated learning, mentoring, and peer cohort collaboration.
Dr. Cruden’s presentation outlined the current state of implementation strategies, how healthcare organizations can use them effectively, and areas for further research.
What Are Implementation Strategies?
An implementation strategy is an intervention designed to increase the adoption, high-quality implementation, and long-term use of scientific evidence in practice. The goal is not to develop new clinical interventions that foster healthy outcomes, but to ensure that evidence-based interventions and guidelines actually get used.
The ERIC Taxonomy classifies 73 distinct strategies into nine broad categories, including engaging consumers, utilizing financial incentives, adapting and tailoring interventions to context, and supporting clinicians.
Other taxonomies exist, classifying strategies by what they target:
Dissemination strategies focus on awareness and intention. They help people learn about new interventions and understand why they matter.
Implementation Process strategies address planning and integration activities. They help organizations prepare systems and workflows to accommodate new practices. The implementation is often characterized into pre-implementation (or exploration and preparation), active implementation, and sustainment. Different strategies may be needed across each implementation phase.
Integration strategies tackle factors that prevent people from using evidence-based interventions, such as competing demands or organizational leaders’ attitudes towards evidence-based interventions and change.
Capacity-building strategies target motivation and self-efficacy. They help implementers feel confident and capable of making changes.
Scale-up strategies have a goal of bringing an evidence-based intervention being implemented at smaller scales or lower levels, such as a school, to a larger scale or level, such as a school district or state-wide school system. Thus, they address broader systemic factors like policy, leadership, and often require multi-level coordination. Policy and leadership can also play important roles in a single-level implementation.
It’s important to distinguish implementation strategies and health interventions from what researchers call “adjunctive interventions.” Implementation strategies target the people delivering care, the delivery systems, or those who shape the context in which care is delivered (e.g., policymakers). Adjunctive interventions target the intended recipients of evidence-based interventions to increase their motivation or capacity to use a health intervention.
Specifying Strategies
For an implementation strategy to work reliably and for the evidence base to grow about which strategies work best in a given context for a given intervention, it must be clearly specified. Dr. Cruden outlined several essential elements, drawing from the Implementation Outcomes Framework:
Actor: Who delivers the strategy?
Action: What specific steps are involved?
Action Target: What mechanism or barrier is being addressed?
Temporality: When in the implementation process is the strategy used?
Dose: How much of the intervention is delivered?
Implementation Outcomes: What results are expected? Note: these are distinct from service and patient outcomes. They include outcomes such as the perceived appropriateness or acceptability of an intervention, its reach into the intended population, delivering the intervention as intended (fidelity), and sustainability.
Justification: What theoretical or empirical reasoning supports this approach?
Without these specifications, strategies become what Dr. Cruden calls non-reproducible “magic.” They might work once in one setting, but other organizations and researchers can’t replicate the success because the critical details weren’t documented.
Selecting Strategies Aligned to the Setting
Choosing which implementation strategies to use should include intentional methods. Implementation Science is still learning which methods work best for given contexts and interventions. The two most commonly used are Implementation Mapping and Concept Mapping. Even more common is a multi-step process that involves conducting an assessment of factors that help or hinder implementation, a researcher-driven, non-systematic “best guess” of which implementation strategies may address those factors, and then potentially modifying the strategies for the implementation context (e.g., clinic).
Other approaches include:
Group Model Building: Teams use semi-structured scripts to build consensus and commitment to implementation plans through participatory processes and systems thinking.
Human-Centered Design: A four-stage process (such as is outlined in the Discover, Design, Build, Test framework from Implementation Science) that refines strategies through repeated testing with end users and usability improvements.
Conjoint Analysis: A method that reveals the specific trade-offs implementers are willing to make and how much they value characteristics of implementation strategies.
Tracking Changes Over Time
Implementation doesn’t follow a fixed script; organizations may need to modify strategies as circumstances change. These modifications must be documented. Adaptations can include adding or removing implementation strategies or modifying specification components such as dosage.
The FRAME-IS framework helps teams plan for modifications and track what was modified (such as content, context, or training), why it was modified (organizational pressures, political factors, or other reasons), and whether the change was planned or made reactively.
The Longitudinal Implementation Tracking System (LISTS) specifies strategy names and definitions, as well as monitor modifications, additions, and discontinuations over time. A publicly-accessible website is being developed for implementers and researchers to use instead of developing their own tracking systems.
Implementation and research teams should also track implementer “dosage,” defined as the time the implementation team spends on the project. (This is distinct from the dosage of the implementation strategy that implementers receive, as specified above.) This measurement helps gauge progress toward the ultimate goal: implementation that runs independently without constant support from researchers.
What Actually Works?
The effectiveness of implementation strategies varies considerably. A meta-analysis showed that using local opinion leaders produces a median absolute improvement of 12% in rates of intervention adoption. By contrast, educational outreach and meetings result in only a 6% improvement in provider behavior and clinical outcomes, on average. Regardless, these are practically small effects.
Research also shows that certain strategies are frequently bundled together. For example, “Audit and provide feedback” is often combined with “External facilitation” in intervention packages. These strategies are complicated in and of themselves, yet often face challenges in specification and thus replication.
Pre-implementation strategies are critical for implementation start-up and achieving competency (i.e., delivering an evidence-based intervention as intended). The Stages of Implementation Completion® framework and measure of the implementation process have identified implementation strategies that are commonly used across evidence-based interventions and implementation settings. Completing more of these common activities in a timely manner, particularly during pre-implementation, is important for a successful implementation effort.
What We Still Don’t Know
Dr. Cruden identified several critical questions that remain unanswered:
How should implementation strategy selection methods be matched to implementation contexts? Different settings have different constraints and resources, but guidance on matching methods to contexts, and how service and client outcomes are subsequently improved as a result of “better” matching, remains limited.
What do implementation strategies actually cost? Organizations need cost data to make informed decisions, but comprehensive cost analyses of implementation strategies, not just interventions, are rare.
How can the field move away from non-reproducible “magic”? Strategies need to be manualized (including the processes to deliver them) and specified clearly enough that other settings and researchers can reproduce them with scientific reliability.
How much specification is too much? There’s a tension between providing enough detail for reproducibility and creating overly complex protocols that are difficult to follow. The field hasn’t yet determined where to draw that line.
Which implementation strategies are complementary and thus should be bundled?
Which implementation strategies are most effective for pre-implementation? Most implementation strategies are developed and tested for the active implementation phase. More evidence is needed for strategies that support evidence-based intervention adoption and preparation to implement.
Moving Forward
Healthcare organizations, community programs, and public health agencies all face the same fundamental problem: good evidence sitting unused. Implementation strategies offer a systematic approach to solving it.
The value of implementation science lies in its ability to bridge the “know-do” gap: the area between what we know through research and what we achieve in practice. By shifting the focus from “if a solution works” to “how it can work in complex, real-world settings,” implementation science ensures that our greatest innovations reach the people and communities who need them most.
Free, Online Toolkit for Partnering with Communities in Substance Use Research
Chestnut Health Systems has released the final chapters of its free, online Community-Based Participatory Research (CBPR) toolkit, created to help researchers build meaningful partnerships through Community Boards of people with lived experience with substance use. This resource is informed by years of collaboration with individuals from the HEAL Connections Lived Experience Panel, the JEAP Initiative Community Boards, the CHEARR Community Boards, and the PATH Community Board.
Catalyst Poll
Chestnut Health Systems’ Lighthouse Institute is recruiting Emerging Adults (18-26 years old) facing challenges related to substance use, along with their parents, for a paid research study seeking feedback for a new recovery program called Launch. Participating families will receive Launch services at no cost, be compensated for virtual research visits, and there is no waitlist! Call or Text Alice Dawson today (541-251-8507) or fill out the form on the Launch Website for more information.
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About Chestnut Health Systems’ Lighthouse Institute
Chestnut Health Systems’™ Lighthouse Institute was established in 1986. Our mission is to help practitioners improve the quality of their services through research, training, and publishing. Serving health and human service organizations through offices in Chicago and Bloomington/Normal, Illinois, and Eugene, Oregon, Lighthouse Institute staff conduct applied research, program evaluation, training, and consultation.
Lighthouse Institute publishes books, monographs, curricula, and manuals on various issues of behavioral health, education, and program management. Institute staff have backgrounds and expertise in addictions, business, education, management information systems, psychology, public health, rehabilitation, research methods, statistics, and social work. For more, visit https://www.chestnut.org/lighthouse-institute/