Implementing 

Change in 

Substance Abuse 

Treatment 

Programs 

31 TAP 31 

Technical Assistance Publication Series

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment 

www.samhsa.gov 

Implementing Change in Substance 

Abuse Treatment Programs 

Technical Assistance Publication (TAP) Series 

31
 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment 

1 Choke Cherry Road

Rockville, MD 20857 
Acknowledgments 

This publication was produced under the

Knowledge Application Program (KAP), contract number 270-04-7049, a Joint Venture of 

The CDM Group, Inc., and JBS International,

Inc. (JBS), for the Center for Substance

Abuse Treatment (CSAT), Substance Abuse

and Mental Health Services Administration 

(SAMHSA), U.S. Department of Health and

Human Services (HHS). Christina Currier

served as the CSAT Government Project

Officer. 

Disclaimer 

The views, opinions, and content expressed

herein do not necessarily reflect the views,

opinions, or policies of CSAT, SAMHSA, or

HHS. No official support of or endorsement

by CSAT, SAMHSA, or HHS for these opinions or for particular instruments, software,

or resources is intended or should be inferred. 

Public Domain Notice 

All materials appearing in this volume

except those taken directly from copyrighted

sources are in the public domain and may

be reproduced or copied without permission

from SAMHSA/CSAT or the authors. Citation

of the source is appreciated. However, this

publication may not be reproduced or distributed for a fee without specific, written authorization of the Office of Communications, 

SAMHSA, HHS. 

Electronic Access and Copies of 

Publication 

This publication may be downloaded or

ordered at http://www.samhsa.gov/shin. Or, 

please call SAMHSA’s Health Information

Network at 1-877-SAMHSA-7 (1-877-726­

4727) (English and Español). Copies may

also be downloaded from the KAP Web site 

at http://www.kap.samhsa.gov. 

Recommended Citation 

Center for Substance Abuse Treatment. 

Implementing Change in Substance Abuse 

Treatment Programs. Technical Assistance 

Publication Series 31. HHS Publication No. 

(SMA) 09-4377. Rockville, MD: Substance

Abuse and Mental Health Services 

Administration, 2009. 

Originating Office 

Quality Improvement and Workforce

Development Branch, Division of Services

Improvement, Center for Substance Abuse

Treatment, Substance Abuse and Mental 

Health Services Administration, 1 Choke 

Cherry Road, Rockville, MD 20857. 

HHS Publication No. (SMA) 09-4377

Printed 2009 
Contents
 

Chapter 1—Introduction .................................................. 1
 

Challenges of Implementing Change in Substance Abuse Treatment .............. 1
 

Core Concepts Presented in TAP 31 ......................................... 3
 

Models for Implementing Change........................................... 4
 

Principles of Implementing Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
 

Organization of TAP 31 ................................................... 8
 

Chapter 2—Preplanning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
 

What Are the Best Practices/Programs?...................................... 9
 

How Does Your Program Compare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
 

How Do TAU Outcomes Compare With EBP Outcomes? . . . . . . . . . . . . . . . . . . . . . . . 10
 

Is Your Program Ready for Change?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
 

Is Change Realistically Feasible? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
 

Chapter 3—Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
 

Who Should Be at the Planning Table? Selecting the Change Team .............. 19
 

Where Exactly Do You Want To Go? Defining Your Destination . . . . . . . . . . . . . . . . . 20
 

Are You Ready for the Trip? Revisiting the Organizational Assessment........... 21
 

What Are the Change Targets? Setting the Stage ............................. 21
 

What Is Your Route? Mapping the Implementation Plan ....................... 26
 

Chapter 4—Implementation .............................................. 27
 

Are You There Yet? What To Expect Along the Way........................... 27
 

How Do You Navigate Roadblocks? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
 

You’re (Almost) There!................................................... 30
 

Chapter 5—Evaluation................................................... 31
 

Before You Begin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
 

Estimating Cost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
 

Planning the Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
 

Collecting Data......................................................... 42
 

Analyzing Data......................................................... 42
 

Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
 

iii 
Implementing Change in Substance Abuse Treatment Programs 

Chapter 6—Sustainability................................................ 45
 

Sustainability Phases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
 

Where’s the Money? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
 

Appendix A—Bibliography ............................................... 51
 

Appendix B—Implementation Theory Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
 

Appendix C—Evaluation Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
 

Appendix D—Field Reviewers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
 

Appendix E—Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
 

Exhibits
 

2-1 Identifying EBPs Missing From a Hypothetical Program’s

Family-Based Services................................................ 11
 

2-2 Comparing EBPs With a Hypothetical Program’s Practices.................. 12
 

2-3 Sample Change Decision Tree. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
 

3-1 Sample Measure and Indicators ........................................ 21
 

3-2 Change Tracking Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
 

5-1 Pros and Cons of Evaluation Approaches................................. 34
 

5-2 Sample Evaluation Measures .......................................... 39
 

5-3 Comparison of Data Collection Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
 

6-1 Sample Budget Forecast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
 

iv 
Chapter 1—Introduction
 

Technical Assistance Publication (TAP) 31: 

Implementing Change in Substance Abuse 

Treatment Programs offers guidance on how

to integrate evidence-based practices (EBPs)

for substance abuse treatment into clinical 

practice. Informed by the realities of many

substance abuse treatment providers, it

suggests efficient solutions for implementing

change based on proven methods. Through a

practical step-by-step narrative, it explains

how to assess an organization’s capacity

to identify priorities, implement changes,

evaluate progress, and sustain effective

programs over the long run. This TAP

complements the best practices offered to

administrators in the Center for Substance 

Abuse Treatment’s (CSAT’s) Treatment

Improvement Protocols (TIPs) and will be

of use for any treatment program or agency

implementing change or EBPs. The audience

is administrators attempting to integrate

EBPs into their programs. 

Change is a reality for all substance abuse

treatment agencies and organizations.

Rates of substance abuse rise and fall, 

substances of abuse emerge or are rediscovered, science uncovers the mechanisms of 

addictions, and researchers identify effective

interventions. Over the past two decades,

EBPs for substance abuse treatment have 

shifted dramatically from 28-day, 12-Stepbased programs to individualized treatment

that addresses a client’s multiple needs

(Macmaster, Holleran, Chantus, & Kosty,

2005). Providers now implement increasingly

specialized interventions, including

pharmacotherapy, with fewer resources. 

Challenges of Implementing 

Change in Substance Abuse 

Treatment 

For underresourced substance abuse 

treatment organizations, attempts to

integrate EBPs are sometimes performed

piecemeal as resources allow. Compared

with other healthcare sectors, substance 

abuse treatment is particularly slow in

adapting EBPs (Sloboda & Schildhaus,

2002). 

Responding to the dynamic landscape

of substance abuse treatment is often 

complicated by organizational dynamics.

The 2006 National Survey of Substance

Abuse Treatment Services found that 

although the total number of substance

abuse treatment facilities remained virtually

the same between 2002 and 2006, there was 

considerable turnover (Office of Applied

Studies, 2007). Each year, new programs

began and between 10 and 17 percent

of programs closed or stopped providing

substance abuse treatment services 

altogether. Adding to the organizational

upheaval, substance abuse treatment

programs often lack sufficient staff to meet

client needs. For many organizations, staff

turnover is a constant. CSAT (2003) reports

that staff turnover ranges from 19 to

33 percent per year. 

Substance abuse treatment organizations

must adapt to factors imposed by the healthcare system. Changes in managed care and

reimbursement affect the entire substance 

1 
Implementing Change in Substance Abuse Treatment Programs 

abuse treatment system and are keenly felt

at the provider level. Healthcare systems

expand and contract, compelling organizations to adopt new policies and procedures.

Cuts in managed care reimbursement for

substance abuse programs render substance

abuse treatment facilities increasingly

dependent on public funding (Macmaster et

al., 2005, p. 70). New regulations are implemented, revised, and repealed, often imposing

additional administrative burdens. 

Transferring “knowledge to practice” in the real 

world can be viewed as adding even greater 

pressure to do more with less. 

—Simpson, 2002, p.172 

Pressures To Implement Change 

Adding to the organizational and systemwide

strain imposed on them, substance abuse

treatment programs face increasing pressure from funding and regulatory agencies,

insurers, researchers, consumers, and family

members to implement EBPs. For substance

abuse treatment organizations, adopting

EBPs poses unique challenges. For example,

substance abuse treatment programs typically serve diverse populations with complex

problems that do not easily fit criteria for

best programs and practices (Iowa Practice

Improvement Collaborative Project, 2003).

Moreover, most substance abuse treatment 

programs use a credentialed practitioner

model that gives individual practitioners the

freedom to adopt eclectic approaches. Supervision is often administrative, with limited 

feedback on clinical competence, and staff

evaluations are not generally tied to the use

of EBPs. Finally, funding is often based on

reimbursable treatment hours, leaving limited resources for considering and implementing more effective practices (Fixsen, Naoom,

Blase, Friedman, & Wallace, 2005). 

Despite these challenges, many agency

administrators are committed to making

improvements in their service delivery

systems. They know that continuous 

improvement is essential to the long-term

stability of their organization. 

Why Implement EBPs? 

Implementing EBPs can help overcome the

financial and organizational challenges that

make change so difficult. Implementing EBPs 

may: 

●		 Improve client outcomes. EBPs are 

interventions shown to be effective with 

specific client populations. Adopting

practices with a proven record improves

chances of helping people within these

populations recover from the devastating

consequences of substance use disorders. 

●		 Increase access to effective 

treatment. Implementing interventions

and programs with proven effectiveness

gives an organization the greatest chance

of helping the most people. 

●		 Engage staff. Implementing change

involves the entire organization. Involving

staff and key stakeholders in the process

can improve buy-in, enhance motivation,

and ultimately reduce turnover. Improved

client outcomes can encourage staff

members and make them feel better about 

their work. 

●		 Improve operating margins. EBPs 

can reduce treatment costs while 

improving outcomes (Schneider, Peterson,

Vaughn, & Mooss, 2006). More effective

interventions and processes can reduce

relapse and recidivism, requiring fewer

treatment cycles. Proven, targeted

treatments also may enable programs to

eliminate less effective program elements

and increase volume, thereby improving

the bottom line. 

●		 Save time. EBPs can streamline 

treatment, reduce duplication of

services and strategies, and increase

staff productivity. If planned well,

implementation efforts can foster efficient

tracking of clients and outcomes, setting 

2 
Chapter 1—Introduction 

the groundwork for future change and

adjustments. 

●		 Transform organizations from

reactive to responsive. Many

organizations are plagued by crises

that might have been prevented with

thoughtful planning. Through the

process of planning and implementing

change, some organizations develop

the infrastructure to readily identify

and address problems and implement

solutions. 

●		 Provide justification for funding.

Systematic data collection and the

evaluation of outcomes are parts of the

change process. Evaluation provides

valuable information for grant and

accreditation applications and documents

outcomes to sell the program. Evaluation

data also can be used to justify a shift

in funding to practices that have proven 

outcomes. 

Core Concepts Presented in 

TAP 31 

Implementing change in substance abuse

treatment programs is guided by a number

of core concepts. Although precise definitions

differ, the following terms are used throughout TAP 31. 

Evidence-based practice (or best practice). Activity that is based on the best

available research in the context of patient

characteristics, culture, and preferences

(Institute of Medicine, 2001, p. 147). Research

consistently shows that EBPs have positive

outcomes with similar techniques and similar populations (National Implementation

Research Network, 2007). The Substance

Abuse and Mental Health Services Administration’s (SAMHSA’s) National Registry

of Evidence-based Programs and Practices

(NREPP, 2007) defines EBPs as: 

Approaches to prevention or treatment

that are validated by some form of documented scientific evidence. What counts 

as “evidence” varies. Evidence often is 

defined as findings established through

scientific research, such as controlled 

clinical studies, but other methods of 

establishing evidence are considered valid

as well. Evidence-based practice stands in

contrast to approaches that are based on

tradition, convention, belief, or anecdotal 

evidence. 

Distinctions can be made among EBPs, clinical practice guidelines, and clinical pathways.

Generally, EBPs are established through

multiple randomized clinical trials that demonstrate positive outcomes for a particular

intervention or practice in a number of settings. Clinical practice guidelines are based

on current research findings and recommendations by consensus panels composed of

experts in the field. They are general guidelines to help clinicians make better treatment

decisions (Iowa Practice Improvement Collaborative Project, 2003). Likewise, clinical pathways are suggested courses of action based

on specific clinical scenarios. Despite these

differences, EBPs, clinical practice guidelines,

and clinical pathways are all intended to

translate research into practice and improve

the effectiveness of treatment. TAP 31 uses 

EBPs broadly to refer to research-based practices or guidelines intended to improve substance abuse treatment outcomes. 

Evidence-based program (or best program). A set of practices embedded within

the larger service delivery structure and

involving multiple best practices. Evidencebased programs incorporate best practices

while maintaining the goals of the systems

in which the services are delivered (National

Implementation Research Network, 2007).

That is, an evidence-based program uses

many EBPs. 

Diffusion (sometimes called technology

transfer or dissemination). The process by

which results (best practices) are dispersed

to the field. It includes efforts to educate 

or inform, such as trainings, as well as disseminating documents for provider use (such

as TIPs). Diffusion is not implementation; 

3 
Implementing Change in Substance Abuse Treatment Programs 

rather, it is the process through which policymakers, clinicians, administrators, and 

others are made aware of best practices. 

Implementation. The process of putting

best practices in place. It can be a series

of discrete steps, or it can be a single event.

It can be ongoing, or it can have a limited

duration. Implementation usually involves

multiple people, systems, and processes. 

Fidelity. The degree to which the clinician,

substance abuse treatment organization, program, or administrator adheres to established

guidelines, policies, or procedures for best

practices. Generally, higher fidelity results

in better outcomes (Gotham, 2004). In this

TAP, fidelity refers to the degree to which the

EBPs outlined in a TIP are adhered to by the

target audience. 

Reinvention. The process through which a

best practice is modified to fit the individual

program. Reinvention is sometimes necessary, and it can be positive if it demonstrates

improved outcomes. For example, an 8-week

program can be cut to 6 weeks to fit the typical stay in a residential treatment program.

However, reinvention can be negative if it

leads to worse outcomes (Gotham, 2004). 

Purveyor. An individual or group of individuals that initiates and monitors change, such

as an administrator or clinical supervisor or a

group with a specific goal. 

Change agents. Individuals in the organization who promote change by using a shared

value system, institutional memory, or a

particular skill set; individuals who influence

colleagues. 

Organizational change. An alteration in 

the culture, customs, values, practices, or protocols of an organization or agency directed

at improving the organization’s readiness for

change and making the organization more

amenable to implementing EBPs. 

Models for Implementing 

Change1 

No single conceptual model of change can

adequately be applied to all real-world scenarios. However, theories of diffusion, innovation, or organizational change can provide

useful ways to conceptualize the change

process. The process through which research

makes its way into clinical practice has been

well described in the literature. 

Online Resources 

In The Change Book: A Blueprint for Technology 

Transfer, the Addiction Technology Transfer 

Center provides a step-based approach to 

implementation. It is available online at http:// 

www.nattc.org/pdf/The_Change_Book_2nd_ 

Edition.pdf. 

TAP 21-A: Competencies for Substance Abuse 

Treatment Clinical Supervisors provides an 

overview of implementing change in supervisory 

practices. The document is available online 

at http://ncadistore.samhsa.gov/catalog/ 

productDetails.aspx?ProductID=17601. 

Implementation Research: A Synthesis of the 

Literature is available online at http://nirn.fmhi. 

usf.edu/resources/publications/Monograph/ 

index.cfm. 

SAMHSA developed NREPP—a searchable online 

database of mental health and substance abuse 

interventions that have been reviewed and rated 

by independent reviewers. To search NREPP, go 

to http://nrepp.samhsa.gov/index.htm. 

The Network for the Improvement of Addiction 

Treatment (NIATx), a national initiative sponsored 

by the Robert Wood Johnson Foundation’s Paths 

to Recovery program and CSAT’s Strengthening 

Treatment Access and Retention program, offers 

tools and case studies specifically for substance 

abuse and mental health agencies seeking to 

improve outcomes. For more information, go to 

http://www.niatx.net. 

1

Generally, models are replications of processes or systems, and theories are abstract speculations. TAP 31 uses the 

two interchangeably. 

4 
Chapter 1—Introduction 

Once researchers determine that a particular

intervention, or combination of interventions, 

works better than treatment as usual (TAU)

in specific populations, information about

these EBPs must be distributed to the field 

through a variety of venues. Appendix B

provides a list of resource publications for

interested readers. 

Diffusion of Innovations Theories 

Rogers (2003) developed theories to explain

how innovations become reality. After

examining the mechanisms through which

innovations (e.g., best practices) become

standard practices, Rogers identified five

stages in the adoption of new practices: 

1.	 Knowledge of the best practice.

Clinicians and administrators acquire

knowledge through attendance at

conferences and training seminars and

by reading TIPs and journals. 

2.	 Persuasion of its value. A change agent

or purveyor convinces key people of the

importance of changing the approach. 

3.	 Decision to adopt the innovation.

When general agreement is reached, the

decision is made to implement the new

practices. 

4.	 Implementation of the practice. Best 

practices are put into effect. 

5.	 Confirmation to continue or reject 

the process. Postimplementation

assessment leads to embracing (institutionalizing) the practice or rejecting it. 

In Rogers’ (2003) model, individuals play one

of several roles in responding to change: 

●		 Innovators—the risk takers 

●		 Early adapters—leaders 

●		 Early majority—deliberate

decisionmakers 

●		 Late majority—traditionalists, skeptics 

●		 Laggards—those fearful of change,

unaware of trends. 

Although Rogers’ model has been widely

embraced, it imposes limitations on substance 

abuse treatment organizations attempting

to implement best practices. Rogers’ model

assumes that change is linear, following a

natural progression from awareness to adoption (Gotham, 2004). For substance abuse

treatment organizations, changes are rarely

so clear-cut. Information is continually fed

into the process. Old ideas and systems can

be revisited and resurrected. Innovations 

must fit regulatory and financial realities and

the existing organizational culture. Moreover,

Rogers’ model emphasizes the individuals

who make concrete decisions to implement

change. Although individuals may play key

roles in implementing change, organizations and systems also play important roles.

Finally, Rogers’ model fails to account for

education, training, supervision, and competency training required to sustain change. 

Transtheoretical Models 

Transtheoretical models stress the 

importance of the organization’s readiness

to change and the targeted strategies to

improve readiness. These models place

the organization—its culture, structure,

and norms—central to the change process.

Hence, any attempts to implement best

practices must factor in the organizational

context. Transtheoretical models rest on 

two key questions: Is the organization ready

for change? If not, what organizational

changes are needed to prepare it for

change? Prochaska and DiClemente (1983)

adapted the “stages of change” model for

individual change to describe the process of

organizational change. Organizations move

through five stages in the change process: 

1.	 Precontemplation 

2.	 Contemplation 

5 
Implementing Change in Substance Abuse Treatment Programs 

3.	 Preparation 

4.	 Action 

5.	 Maintenance. 

Although organizations consistently complete

each step, change is not necessarily a linear 

process. 

Implementation Models 

Recognition of the distinctions between dissemination and adoption has increased. Dissemination and training sow the seeds for

change. Germination requires thoughtful

planning and sustained effort. The literature

strongly suggests that without specific strategies to implement change, EBPs are unlikely

to find their way into clinical practice (Fixsen

et al., 2005). Fixsen and colleagues maintain that the implementation component is

precisely what has been missing in change

models and in resource allocation. Compared

with the resources allocated for identifying

best practices and disseminating research

results to the field, few resources are provided to show programs how to implement

effective practices. In fact, implementation is

the least researched component of the process

whereby research makes its way into practice

(Gotham, 2004). 

Fixsen and colleagues (2005) maintain that

an implementation model without a clear

plan for change will not work. Basing their

opinion on a review of the literature, they

suggest that successful implementation is

possible only through simultaneous interventions at practitioner, organization, systemof-care, Federal, State, county, and local

levels. Fixsen and others have pointed out

that implementation is not an event but a

mission-oriented process involving multiple

decisions, actions, and corrections. As Phillips

and Allred (2006, p. 172) assert, implementation of best practices is “a form of propagation

... similar to grafting.” 

NIATx (https://www.niatx.net) promotes a

somewhat different implementation model. 

It focuses on organizational change and on

small, manageable change measures that

promote financial sustainability and lead to

tangible results. NIATx has four aims: 

●		 To reduce the wait time between a client’s 

first request for service and the first

treatment session 

●		 To reduce client no-shows 

●		 To increase treatment centers’ admissions 

●		 To increase the treatment continuation 

rate between the first and the fourth 

treatment sessions. 

According to the NIATx model, the essential

ingredients for successful process improvement are: 

●		 Understand and involve the 

customer. The “customer” is defined 

broadly as clients, families and

friends, referral sources, payers, and

the community. Treatment providers

should ask clients about what needs 

improvement and seek their advice on

how to improve services. 

● Fix the key problems. Focusing on

the problems that worry the executive

director helps garner support from the

organization’s leaders and ensure success. 

● Pick a powerful change leader. Those 

in charge of organizational change must

have authority, the respect of their

colleagues, and sufficient time to devote to

the initiative. 

●		 Get ideas from outside the 

organization or field. Other 

organizations or even fields, such as

the hospitality industry, can offer fresh

perspectives. 

●		 Use rapid-cycle testing to establish

effective changes. The idea is to take 

one small change at a time and see how it

works. After making the change, the team

evaluates the results, modifies the change

if necessary, tests it again, and repeats

the process until the change is good

enough to be made permanent. 

6 
Chapter 1—Introduction 

The NIATx improvement model has five

phases: 

●		 Complete a walk-through to understand

customer needs 

●		 Pick a change goal 

●		 Identify a simple data point (or points)

that will help you determine whether you

reached your goal 

●		 Select and rapidly test relevant changes

one at a time 

●		 Sustain the gain. 

For more information, see NIATx’s Resource 

Guide to Process Improvement at https://

www.niatx.net/Content/ContentPage.

aspx?NID=232. 

Principles of Implementing 

Change 

Several principles guide TAP 31. All are

directly analogous to principles of substance

abuse treatment. 

There is no single model for or approach

to implementing a program of organizational change. A preconception about how

change should occur or inflexibility during

the change process is counterproductive if not

fatal to meeting a program’s change goals.

Constant vigilance and in-course corrections

are needed. Corrections should be made in 

consultation with the stakeholders who developed the original change plan. TAP 31 provides logical steps to implementing change.

The document is not intended to be rigidly

prescriptive; rather, it suggests how to go

about the change process, with references to

other resources to fill in the gaps. Programs

will need to modify the process to succeed in

changing or adapting. 

The change program should be individualized to accommodate the specific

needs, goals, culture, and readiness to 

change of an organization. For example, 

a suggested best practice may be to screen

all clients for infectious disease. Limited 

resources may make this impossible. An

alternative would be to screen for HIV and 

hepatitis and refer clients to a clinic offering

screening for other infectious diseases. 

Change is not a linear process. Although

TAP 31 outlines a step-by-step approach,

sometimes it may be necessary to backtrack.

Perhaps early evaluation results reveal that

the new approach is not working. It may be

necessary to revisit the planning phase to

adjust the plan. Or it may become clear at a

later stage that the new program is not sustainable when funding levels decrease, and

adjustments will be necessary. 

Change is ongoing. Change is not a discrete

event. It is a process that requires careful

planning, coordination, cooperation, evaluation, and followup. At least in the first few

years after the implementation of an organizational change plan, continuing care of the

organization’s new accomplishments is critical to their long-term survival. 

The Implementation Headset 

Dissemination and implementation are not the 

same things. Fixsen and colleagues (2005, p. 4) 

coined the phrase “implementation headset” 

to encourage a different kind of thinking about 

implementation. They postulate that, too often, 

researchers, policymakers, administrators, and 

managers assume that distributing information 

about best practices to the field is sufficient. 

Doing more or better research on a program or 

practice itself does not lead to a more successful implementation. Training providers in how to 

use a technique is not the same as incorporating 

proven interventions into clinical practice. Implementation is an entirely different enterprise, 

requiring an entirely different approach. 

The ultimate goal is to create changes

that can be sustained over time. Eventually, the changes will become a regular

feature of the program’s operation through

a process called institutionalization. Institutionalization has occurred when the “new 

practices” introduced have become the 

7 
Implementing Change in Substance Abuse Treatment Programs 

“everyday practices” of the agency. Even after

institutionalization occurs, however, a commitment to continuous quality improvement

ensures the program’s ability to respond to

future changes in the needs of the client

population and community. 

Organization of TAP 31 

The remaining chapters of TAP 31 suggest a

step or stage approach in which one component logically follows another. 

Chapter 2—Preplanning. At this stage,

decisionmakers determine whether best practices are worth implementing. The chapter

suggests practical ways to compare best practices with TAU, evaluate outcomes, and realistically assess whether change is possible or

desirable. 

Chapter 3—Planning. Implementation

requires forethought and planning. This

chapter suggests factors that should be considered in planning for implementation. It

recommends strategies to involve stakeholders, anticipate problems, and align the organization with the impending changes. 

Chapter 4—Implementation. With proper

planning, implementation is a matter of 

following the established course. This chapter

suggests ways to execute plans, monitor

progress, and make adjustments, if 

necessary. 

Chapter 5—Evaluation. Much of the work 

for this step is done in the planning and

implementation stages. Evaluation is the

process of appraising or measuring outcomes,

comparing outcomes with baseline measures,

and determining what, if any, adjustments

need to be made. 

Chapter 6—Sustainability. The best 

programs and practices will be of little use

without a plan to sustain them over time.

This chapter introduces strategies to garner

the financial, political, and systemic support

to make the progress permanent. 

Although there is a logical flow to the steps,

each stage depends on subsequent stages.

Evaluation components should be built into

the planning stage to establish the baseline

and assess what the change process should

address. Sustainability may be a large factor

in deciding whether to move forward with the

change plan and should be considered along

with other factors in the preplanning stage. 

8 
Chapter 2—Preplanning
 

Hypothetical Scenario 

You are an administrator at a small intensive outpatient substance abuse treatment 

program. Twenty percent of the funding for your organization comes from a block grant. 

To qualify for renewed funding, the grantee must demonstrate that activities or projects 

that are funded by monies used for substance abuse and mental health treatment include 

an evidence-based component for family members. Your organization generally follows 

evidence-based practices (EBPs) but does not currently offer comprehensive family 

services. Clients in need of intensive family therapy are referred to a community health 

facility, but there is no coordination of care between your facility and family therapy. You 

are exploring the feasibility of adding an evidence-based family component. 

An organization facing this scenario is in the

preplanning stage of implementing change.

At this juncture, no decision has been made

to commit to change. Rather, the program is

in the exploratory phase in which you ask key

questions: 

●		 What are the current practices? 

●		 How do outcomes from best practices

compare with outcomes from treatment as

usual (TAU)? 

●		 Does the new target practice match client/

community needs? 

●		 Could the new target practice be

realistically accommodated? 

●		 If so, what elements of the program need

to change? 

●		 What data can you collect to establish a

baseline? 

Answers to these questions will decide

whether to move forward with implementing

change and set the stage to address anticipated barriers. 

What Are the Best Practices/ 

Programs? 

The best practices and programs recommended in Treatment Improvement Protocols

are based on research and clinical expertise.

They are interventions that have yielded the

best outcomes in a given population. However, not all recommendations will be possible

or even desirable for your specific situation.

When considering EBPs, evaluate the fit with

your program. Factors to consider are noted

below. 

Populations served. Practices that have 

proved effective with urban adolescents will

not necessarily work for a substance abuse

treatment program for adults in rural or

remote areas. Likewise, EBPs developed for

White women may not be as effective in a

program that serves racially and ethnically

diverse groups. A good fit for your population

is the EBPs that most closely fit your organization’s client base in terms of age, gender,

race, ethnicity, socioeconomic status, education, and co-occurring disorders. 

9 
Implementing Change in Substance Abuse Treatment Programs 

Program type. A specific intervention or

treatment component for an intensive inpatient program may not be a good choice for

another type of setting. Consider whether

research on the intervention was conducted 

for organizations that are similar to yours. 

System of care. EBPs may be based on

research conducted by a State agency, with

partnerships with mental health services,

housing, and child welfare. Practices provided

in an integrated system may not be effective

in your organization. 

Resources. Well-funded organizations can

implement practices that may be beyond the

reach of your program. Scarce funding does

not necessarily mean you cannot move ahead,

but you may need to identify new funding

sources or explore cost-saving relationships

with universities or other organizations. (See

Chapter 6 for more on circumventing costs.)

Also consider whether your staff has the time

and expertise to implement best practices. 

How Does Your Program 

Compare? 

As you consider implementing change, first

look closely at the recommended best practice. Consider whether the recommendation 

is appropriate for your program. As noted,

not all recommendations will be desirable for 

your particular client base, system of care,

or resources. Map out each recommendation

that fits your program and consider it carefully. Include a description of what the recommendation means or examples of how it

would work in clinical practice. As you work

through the implementation process, you will

add detail, identify challenges, and outline

possible solutions. Ultimately, this process

will help you make informed decisions. You

might list each recommended component of

an EBP. Exhibit 2-1 illustrates how closely a

hypothetical program follows best practices

for a family-based intensive outpatient treatment program. 

By looking closely at best practices, you gain

a sense of how your program compares. Perhaps some practices are in accordance with

recommended best practices (e.g., teaching

family members about substance use disorders) but other areas are not (e.g., providing

child care). 

How Do TAU Outcomes Compare 

With EBP Outcomes? 

Before investing resources in changing practices, you should consider whether the proposed changes have the potential for better

outcomes. If, for example, a new intervention

demonstrates a 1-year abstinence rate of 20

percent, and TAU at your organization demonstrates a 1-year abstinence rate of 20 percent, changing current practices is unlikely

to improve results. If, however, your 1-year

abstinence rate is 10 percent, then your program may improve by implementing the new

intervention. 

A vital part of the preplanning stage is to

identify your measurable TAU outcomes and

compare them with outcomes of EBPs. These

comparisons help determine whether to

implement the new approach. Your program

outcomes are the baseline measures for comparing outcomes for the changes you implement. (See Chapter 5 for more on baseline

measures.) Exhibit 2-2 shows a sample of the

measures and data sources for determining 

outcomes. 

Is Your Program Ready for 

Change? 

Evaluating readiness to change requires

objectively examining the factors that help

and impede change, strategizing ways to

build on strengths, and addressing challenges. Depending on the circumstances and

scope of change, this examination can assume

many forms and degrees of intensity. In some

cases, this appraisal can be made by an 

10 
Chapter 2—Preplanning 

Exhibit 2-1 Identifying EBPs Missing From a Hypothetical Program’s Family-Based Services 

Recommended 

Family-Based 

Services* 

EBP Core Components Hypothetical 

Program 

Include family 

members in the 

intake session 

Invite clients to bring family members to intake No 

Conduct family interviews No 

Encourage family participation Minimal 

Ask family members to complete a brief family assessment No 

If a family member makes contact, invite him/her to initial intake No 

Provide culturally 

relevant 

programs and 

education 

Provide interpreters No 

Make education resources available in languages spoken by 

clients and their families 

No 

Allow the client to define “family” to include extended family 

and people who are not biologically related 

Yes 

Incorporate cultural understandings of substance abuse, 

treatment, and recovery 

Varies 

Use clientinitiated 

engagement 

efforts 

Include family participation in treatment plan Varies 

With client permission, contact family and offer invitation to 

participate 

No 

Encourage client to invite family to participate Varies 

Offer incentives Offer incentives for family participation in sessions and for 

completing assignments 

No 

Provide refreshments Yes (family day) 

Provide transportation No 

Provide child care No 

Plan events (e.g., 

picnics, dinners) 

for families 

Schedule family days on weekends or holidays Yes (1 day) 

Combine with educational sessions (e.g., recovery support 

groups, family services, elements of substance use disorders) 

Yes 

Use community 

reinforcement 

training 

interventions 

Teach family members about substance use disorders Yes (2-hour session 

on family day) 

Reinforce that they are not the cause or the cure Yes (see above) 

Communicate in nonjudgmental ways Yes (see above) 

Encourage them to identify and pursue their own interests No 

Encourage drinking of nonalcoholic beverages during social 

occasions 

No 

Manage dangerous situations No 

Discuss treatment with the family members who abuse 

substances 

No 

Create a 

family-friendly 

environment 

Provide flexible program hours No 

Accommodate families in large offices or meeting rooms Yes, but may require 

more space 

Provide safe toys for children No 

Train front-office staff to encourage family members No 

Create a recordkeeping system that provides easy access to 

family-related information for each client 

No 

*Source: Adapted from Center for Substance Abuse Treatment, 2006. 

11 
Implementing Change in Substance Abuse Treatment Programs 

Exhibit 2-2 Comparing EBPs With a Hypothetical Program’s Practices 

Best Practice 

Outcome Measure Rate 

Psychosocial 

functioning 

baseline 

Independent 

followup of 75% 

of all treatment 

completers using 

self-reports 

through a 

standardized tool 

58% 

demonstrate 

improvement 

in at least one 

domain 

Retention at 

30 days 

Client records 66% 

Retention at 

90 days 

Client records 50% 

Abstinence at 

30 days 

Random urine 

drug screens of all 

clients enrolled 

43% 

Abstinence at 

60 days 

Random urine 

drug screens of all 

clients enrolled 

37% 

Abstinence at 

90 days 

Random urine 

drug screens of all 

clients enrolled 

22% 

Abstinence at 

1 year 

Independent 

followup of at 

least 75% of 

all treatment 

completers using 

self-reports 

20% 

Hypothetical Program 

Outcome Measure Rate 

Psychosocial 

functioning 

baseline 

Not measured N/A 

Retention at 

14 days 

Client records 42% 

Treatment 

completion 

(90-day 

program) 

Client records 22% 

Abstinence at 

30 days 

Self-reports (not 

systematically 

recorded) 

N/A 

Abstinence at 

60 days 

Self-reports (not 

systematically 

recorded) 

N/A 

Abstinence at 

90 days 

Self-reports (not 

systematically 

recorded) 

N/A 

Abstinence at 

1 year 

Self-reports 

of treatment 

completers 

contacted by their 

counselor 

Usually less 

than 40% of 

completers 

informal group (such as the planning team

or another team charged with assessing the

program’s culture). In other cases, more

formal assessments or surveys may require

an outside consultant. 

The literature is rich in information about 

readiness to change, and several tools help

organizations assess it (Knudsen & Roman,

2004; Lehman, Greener, & Simpson, 2002;

Schuh & Leviton, 2006). Based on a survey of

500 staff members and more than 100 treatment units, Lehman and colleagues (2002)

identified important factors in assessing

organizational functioning and readiness for

change: motivation and personality attributes

of program leaders and staff, institutional

resources, and organizational climate. 

Factors identified in the literature are 

described below. 

Environmental stability. Organizations

with consistent management and a basic

structure can more readily adopt best practices (Lehman et al., 2002). Causes for organizational instability may need to be addressed

before any change can take place. High staff

turnover, for example, may require changes

in management. 

Organizational maturity. Schuh and 

Leviton (2006) suggest that organizations go

through stages of organizational capacity,

with more mature agencies more likely to

implement EBPs with fidelity. An organization’s ability to adopt practices depends on 

12 
Chapter 2—Preplanning 

which stage it is in. Five features define an

organization’s maturity: 

●		 Governance—legal status (e.g., nonprofit),

core documents (e.g., mission statement),

oversight board, and so forth 

●		 Financial resources—ability to generate

funds, sustainability, diversity of funding

sources, and the like 

●		 Organizational development—degree of

structure, role differentiation, skills of 

administrative staff, and so on 

●		 Internal operations—administrative

functions, operations, leadership, financial 

systems, management information

systems, and so forth 

●		 Core services—staff skill in providing key

services. 

Nonprofit agencies tend to develop core services first and underemphasize administrative infrastructures and board development

and functioning. When the services offered

are more evolved than the structures that 

support them, dysfunction ensues (Schuh &

Leviton, 2006). Part of your planning process

may be to examine your organization and

consider whether you have an infrastructure

adequate to support your core services. Do

you have enough administrative support,

financial tracking systems, an evolved and

involved board? Change efforts present the

opportunity to strengthen existing infrastructures and align them with the change efforts. 

Policies, procedures, and protocols. What 

policies are related to the possible changes?

For example, if you are considering integrating family-based treatment, which policies

might affect your decision? Do you have

policies that discourage contact with family

members? What procedures might affect the

decision to move forward? If your standard

procedure is to refer people in need of family

therapy to another agency, what implications

will that have for integrating treatment? For

example, incorporating a family component

may require process changes so that staff 

members trained in performing family assessments conduct intakes. 

Organizational fit. Phillips and Allred

(2006) examined the administrators’ decision

process for implementing best practices. They

found that service providers considered not

only empirical evidence but also the practical

merits and how the interventions fit with current practices and systems. Philosophical factors may cause a particular intervention to fit

better than another. For instance, a program

using 12-Step facilitation approaches may

be leery of pharmacological interventions.

These differences do not mean a new intervention should not be implemented. However,

staff may need to be prepared for a change.

Research suggests that clinicians are more

likely to adopt treatments when they understand the evidence base and the potential to

improve client outcomes. 

Adequate resources. Financial resources 

are required to implement most changes.

Organizations struggling financially are

less likely to devote resources necessary

for change (Lehman et al., 2002). Although

many changes may prove profitable in the

long run, change can be costly. It may involve

additional training, staff time dedicated to

planning and implementation, technological enhancements, or the expansion of space.

Consider all possible costs, including but not

limited to consultant costs, trainers, time for 

training, new staff hires, and administrative

costs. Weigh the estimated costs against the

potential for improved outcomes for clients,

improved efficiencies, and associated cost

reductions. To make up for any shortfalls in

costs, consider all potential funding opportunities, including Federal, State, and private

grants and matching funds. (For more on

funding, see Chapter 6.) 

Capacity. Substance abuse treatment organizations often have a limited capacity. An

inpatient treatment center may have 32 beds,

with the capacity for 10 more with modest

renovations. An outpatient facility may be

able to treat 100 clients at any given time. 

13 
Implementing Change in Substance Abuse Treatment Programs 

The Innovative Organization 

Research suggests that certain types of organizations may be more adaptable to change than 

others. Organizations with fewer resources are 

less likely to implement best practices (Rosenheck & Seibyl, 2005). More subtle characteristics 

also predict success. Knudsen and Roman (2004) 

use the term “absorptive capacity” to refer to 

the organization’s “ability ... to access and effectively use information” (p. 51). In general, the 

organization’s engagement with the substance 

abuse treatment field, the number of staff members with advanced degrees, and the degree to 

which innovation is valued positively affect the 

organization’s ability to implement change. For 

more on factors that help or impede the adoption of EBPs, see Chapter 3. 

Capacity refers to the maximum resources

available for operation. It includes: 

●		 Beds or treatment slots 

●		 Available office space 

●		 Hours of operation 

●		 Computer equipment and access 

●		 Educational/training resources 

●		 Available financial resources 

●		 Personnel. 

Consider whether the best practices can be

accommodated with existing resources. In the

hypothetical scenario, including a family component requires additional space to accommodate family sessions, safe spaces for children,

staff to watch children if needed, and changes

in scheduling, among other things. Insufficient resources do not necessarily mean

that the change cannot be implemented. It

means that creative thinking may be needed

to adapt the practice for your facility. For

example, if additional space is unavailable at

your site, a community partner may be able

to accommodate family sessions or days. 

Motivation. External pressures to adopt best 

practices can positively affect an organization’s ability to implement change, as can the

perceived needs for change (Simpson, 2002).

The greater the external or internal pressure for change, the more likely for change to

occur (Lehman et al., 2002). 

External engagement. Based on data from 

the National Treatment Center Study, Knudsen and Roman (2004) suggest that environmental scanning (seeking external sources

of information [e.g., the availability of EBPs;

communication with other, similar organizations] to inform internal decisionmaking)

or the use of such resources as professional

development seminars and publications is an

effective means to positively affect innovation. Likewise, professional growth is a predictor of readiness to change. Organizations

that place a low value on professional growth

or that offer few opportunities for it are associated with low readiness for change (Lehman

et al., 2002). 

Staff attributes. The percentage of master’slevel counselors is positively related to

innovation adoptions. The percentage of

certified/licensed counselors and counselors

in recovery appears to have an indirect

positive influence on the acceptance of

innovative practices (Knudsen & Roman,

2004). Efficacy is positively related to change.

Staff members with low confidence in their 

skill negatively influence readiness for

change. 

The abilities, training, background, and workload of your staff will affect your decision. If

the recommended best practice requires multiple master’s-level staff members, is it feasible to make the necessary hires? How much

time will be involved in training new staff?

While contemplating change, it is important

to assess staff competencies in the areas of

targeted change: 

●		 What specialized trainings do staff

members have? 

●		 What certifications do staff members 

hold? 

●		 Do staff members have experience

working with special populations? If so,

which ones? 

14 
Chapter 2—Preplanning 

●		 Will the changes require hiring or

recruitment? 

●		 How much training of supervisors and

staff will the proposed change require? 

●		 Will the changes affect supervisory

burden? 

Work culture. The work culture can have a 

strong influence on an organization’s adaptability. Staff cohesion, degree of clinical

autonomy, communication styles, and level

of stress affect an organization’s readiness to

change (Lehman et al., 2002; Simpson, 2002).

Organizations that encourage growth, open

communication, and teamwork are likely to

be adaptable to change. Troubled organizations may need to address underlying problems before a change can be successful. 

Staff needs. To be effective, substance abuse 

treatment organizations must give frontline

staff members the resources and support they

need to perform their jobs well. This support

can range from adequate time to complete

their work, to adequate pay to support their

families, to time off to recharge, to resources

(e.g., computer equipment, administrative

support, procedures that simplify rather than

complicate). Potential information sources

include the following: 

●		 Exit interviews. Conduct an exit 

interview with all staff members who 

resign, and track the results. If burnout

is a common cause for departure, consider

ways to lessen the workload, give extra

time off, or promote self-care. If low wages

are a factor, evaluate the competitiveness

of your salaries and benefits. 

● Employee surveys. Provide a 

means for employees to comment on

the organization, management, and

administration. Solicit suggestions for

change. 

● Employer reviews. Conduct 360-degree

reviews. These reviews provide an

ongoing mechanism for staff members to

note what they need to do their jobs well. 

●		 Mechanisms for communication. 

Provide regular forums in which staff

members can identify problems and

express their needs. 

Administration/management. If staff 

turnover is high and morale is low, management may be part of the problem. Supervisors

may lack skills for effective management.

Administrators may be unprepared to make

executive decisions and provide leadership or

vision. A self-assessment can identify changes 

that may improve retention and the overall

functioning of the organization. It may be

useful to revisit (or create) job descriptions,

skill sets, and knowledge requirements for

all leadership positions. Does the leadership have the desired skills, experience, and

knowledge? If not, how can you bring leaders

up to speed? 

Is Your Organization Troubled? 

In some cases, the work culture may be so 

troubled that even the status quo is difficult to 

maintain. Hawkins (2004) noted several characteristics of troubled organizations: 

•	 High level of negativity and passivity 

•	 Dominance by one or two groups 

•	 Poor leadership 

•	 Ineffective problemsolving skills 

•	 Mistaking silence for support 

•	 Strangled communication flow 

•	 Volatile emotions (surface anger) 

•	 Difficulty accepting changes 

•	 Multiple win/lose situations 

•	 High absenteeism rate 

•	 Tendency to blame others or perceive self 

as victim 

•	 Reputation for “eating their young” 

•	 Recruitment or retention difficulty. 

If your organization is troubled, you need to 

build a healthier work culture before change will 

be possible. 

The self-evaluation should not be limited 

to individual qualifications and performance. You should also look at management 

structures: 

15 
Implementing Change in Substance Abuse Treatment Programs 

●		 What are the lines of authority? 

●		 Are there checks and balances in place? 

●		 Do mid-level managers have authority

to address problems as they arise? 

●		 Is there adequate communication between

administrators and managers? 

●		 What is the workload for leadership

positions? Can some responsibilities be

delegated to nonmanagerial staff? 

In substance abuse treatment, it is common 

for counselors to assume leadership positions

with little or no training in effective manage

ment. Technical Assistance Publication 21-A: 

Competencies for Substance Abuse Treatment 

Clinical Supervisors (Center for Substance

Abuse Treatment, 2007) identifies core skill

sets required for clinical supervisors. The

Substance Abuse and Mental Health Services 

Administration’s Addiction Technology and

Transfer Center (http://www.nattc.org/index.

html) offers useful resources to administra

tors and supervisors. 

If your organization is not ready for change,

consider what you can do to improve its abil

ity to implement change. Before you can

implement EBPs, you may need an organizational intervention. Organizational interven

tions require systematic attention to redefine

goals and priorities and improve the organi

zation’s ability to adapt to change (Simpson,

2002). 

To prepare your organization for change, list

the factors that work for and against change

and realistically assess what you can do to

improve readiness. Consider whether mea

sures to improve readiness can be done simultaneously with efforts to implement best

practices or whether a fundamental change

in the organizational culture is needed before

EBPs can be implemented. You may need to

build infrastructures, formalize processes,

and establish specialized job descriptions. 

Client needs. In most organizations, consumer needs drive the demand. Businesses 

change to stay competitive. D’Aunno (2006) 

points out, however, that clients in substance 

­

­

­

­

­

­

abuse treatment are not well positioned to

demand the best care. This makes it even 

more important to use treatment proven to

be effective. EBPs have produced better outcomes in certain populations, but a particular

practice must match clients’ needs. When

identifying what practices and programs

will work best with your clients, consider the

following: 

●		 Substances of abuse (e.g., alcohol,

methamphetamine, multiple drugs) 

●		 Co-occurring mental and medical

disorders 

●		 Gender 

●		 Age 

●		 Race/ethnicity 

●		 Language capacity 

●		 Spiritual/religious beliefs 

●		 Income 

●		 Insurance 

●		 Employment status 

●		 Legal constraints 

●		 Parental status 

●		 Family members 

●		 Sexual orientation 

●		 Mode of entry into treatment 

–	 Self-referred 

–	 Court ordered 

–	 Referrals from mental health 

practitioners
 

–	 Referrals from primary care and

other allied health and human service 

practitioners. 

Consider past, current, and potential client

characteristics. You can review internal 

records, check records from the U.S. Census 

for your community, and investigate other 

information sources to determine the 

demographics of your client base. Perhaps 

your treatment center is in a region that 

16 
Chapter 2—Preplanning 

is 40-percent African American yet only

8 percent of clients completing treatment

are African American. A goal for your

program may be to implement practices

with demonstrated effectiveness for AfricanAmerican clients. At this stage, you may

want to consider what is known about client 

characteristics from the published literature.

For example, a high percentage of people who

abuse alcohol have a mood disorder (Karno

& Longabaugh, 2003). To be effective, your

program may need to have treatments and

systems to address co-occurring depression. 

In addition to compiling information about

your clients, you may wish to identify potential client stakeholders. These could include 

current or past clients, members of advocacy

groups, or representatives from self-help

groups. These individuals not only provide

useful qualitative information but also

increase buy-in from your consumer base. 

Finally, brief surveys of clients, former clients, or community partners may provide

additional insights. Americans with Disabilities Act-compliant Web surveys are available

at nominal cost. For a list of companies offering Web survey services, go to the American

Evaluation Association Web site surveys page

at http://www.eval.org/Resources/surveylinks. 

asp. 

Community partners. Relationships with

other providers, organizations, individuals, or

agencies can be vital in initiating and maintaining change. Your organization may have

relationships with providers to prescribe and

monitor medication, provide more intensive

psychiatric services or family therapy, or help

with occupational or housing needs. Other

organizations with which you can partner

include: 

●		 Social/welfare organizations 

●		 Physicians, dentists, and other medical

professionals 

●		 Employment agencies 

●		 Housing agencies. 

For each relationship, describe its degree of

formality. Is it a contractual relationship or

an informal one? Are there key individuals

with whom your organization does business?

Is there a memorandum of understanding? If

so, is it fully operational? 

It is useful to map different types of services

available in your service community. Perhaps another agency or organization provides

services you need to implement a particular

EBP. Service mapping provides a means to

avoid duplication and identify possible partners and needs. If, for example, you are adding a component to treat people with fetal

alcohol spectrum disorders (FASD), you could

start by identifying the treatment needs of

such individuals and identifying organizations or agencies in the community that can

meet those needs. Perhaps you could link

with an agency that offers vocational training

and a community-based health center with

physicians trained in treating the health consequences of FASD. By mapping services, you

can identify both the needs your program will

meet and how they fit into the service delivery system in your area. 

A Note on Fidelity 

Whether you want to implement comprehensive 

programmatic change or add a specific intervention to your program, the goal should be to replicate the best practices and programs as closely 

as possible. Nonetheless, strict adherence to 

EBPs may not be feasible. Whether you choose 

to implement a “near best practice” when an 

exact match is impossible should be determined 

on a case-by-case basis. Be wary, however, of 

drifting from the goal. Based on a review of the 

literature, Fixsen and colleagues (2005) recommend that the practice first be attempted with 

fidelity before innovation is made. Generally, 

adaptations made after a program is implemented with fidelity are more successful than those 

made before the organization has fully implemented the best practice. If it is not feasible to 

implement EBPs with any degree of fidelity, you 

will have to decide whether to move forward. In 

some cases, you may elect to describe incremental steps that are acceptable interim measures. 

17 
 

 

 

 

Implementing Change in Substance Abuse Treatment Programs 

Is Change Realistically Feasible? 

Once you have determined where you are

and where you would like to be, it is time to

assess what will be involved in implementing 

best practices. Based on your assessment of

current practices, determine what would need

to change to get from A (TAU) to B (EBP). 

Consider carefully what will be needed at

each step before you commit to a course of

action. Evaluate the likelihood of accomplishing each step. If, for example, the proposed

change calls for the addition of at least two

staff members and your program is operating at a deficit, it may not be feasible to move

forward. Before abandoning the effort, however, creatively consider options. Remember,

at this stage you are deciding only whether to 

move forward, not necessarily how to move 

forward. 

Look closely at the recommendations. Break

them down into small elements, and consider 

the potential for each: 

●		 Is the recommendation consistent with 

community norms and values? 

●		 Is it relevant to the client population? 

●		 Is it feasible given political realities? 

●		 Can financial resources be accessed? 

●		 Are resources available in the community

(e.g., referral, support services)? 

You may decide to pursue all, some, or none

of the EBPs. Some practices may be impossible to implement, at least at the present.

For example, the research may indicate that

a five-session HIV risk-reduction program

produces better client outcomes than the

standard one-session program. Limited availability of financial and personnel resources

may make a five-session program implausible. You may consider offering three sessions

instead. 

Exhibit 2-3 is a sample decision tree of the

process of deciding to move forward with

implementing change. The choice is not as

clear as yes or no. It may be yes for some components and no for others. Some aspects may

require attention before moving forward. 

Exhibit 2-3 Sample Change Decision Tree 

Is EBP better 

than TAU? 

1. Identify differences 

between TAU and 

EBP. 

No 

No change. 

Yes 

2. Identify what needs to 

change to implement EBP: 

Change intake process. 

Is this 

feasible? 

Yes 

3. Identify resources. 

Are adequate 

resources (staffing/ 

financial/other) available or could they 

be made available to 

implement change? 

Yes 

4. Start planning. 

Go to Chapter 3. 

No 

No change. 

No 

No change. 

18 
Chapter 3—Planning
 

Hypothetical Scenario 

Change is in the air at the small outpatient substance abuse treatment program for 

which you have served as executive director for the past year. You have reviewed 

evidence and decided to move forward with a plan to include in your program a 

component to treat depression. Counseling staff members have vocally opposed the 

plan, reminding you frequently of the last failed attempt to change practices. Their 

concern is that evidence-based practices (EBPs) are developed by researchers with 

very little understanding of real-world clients. What can you do to gain the buy-in 

needed to implement the plan? 

The work you completed for preplanning will

set the stage for the next step: Planning. You

have made the decision to move forward, collected preliminary data, identified specific

needs that may be met by implementing

change, and are now prepared to map out

your plan. This chapter highlights a logical,

step-by-step approach to planning the implementation, although your change process may 

not necessarily follow these steps. 

Who Should Be at the Planning 

Table? Selecting the Change 

Team 

Assembling a planning team is one of the

most important steps you will take in the

journey toward implementing best practices. The team should be selected based 

on skills, knowledge, and social networks

(Sirkin, Keenan, & Jackson, 2005). If your

plan requires financial planning, the person

charged with the operating budget should

be involved. If the changes will affect the

way case managers do their jobs, you should

include case managers who can tell you which

services they provide and what changes will

be needed. If the change has implications

for your relationships with outside providers

or agencies, the team should include people 

who interact with representatives from these

organizations. You might consult staff on

advice for who should be on the team. 

Your team should include stakeholders—the 

people with a vested interest in the outcome

of your efforts. Stakeholders may include

board members, counseling staff, administrative staff, or representatives from advocacy

groups. Consumer involvement may be particularly important—or even required—for

some funding streams. Consumer involvement adds pressure on staff members

who may be opposed to change. Moreover,

research suggests that effective interventions

must be acceptable to clients or potential clients (Gotham, 2004). 

The change team serves a strategic purpose.

Carefully selected team members can ameliorate political fallout. The team should

not consist solely of people who are likely

to support the initiative. Naysayers bring

valid perspectives; they insert reality into

the discussion and identify potential pitfalls.

Moreover, people are less likely to experience

change as stressful, more likely to support

change, and more likely to work toward it

when they are involved in the change process

(Johnson, Brems, Mills, Neal, & Houlihan,

2006). Including people on the change team 

19 
Implementing Change in Substance Abuse Treatment Programs 

is a critical way to establish buy-in up front.

The members of this planning team can

serve as “ambassadors” of the change to their

respective constituencies during the implementation phase (see Chapter 4). 

You can always add members as the process

evolves. As your plan takes shape, you may

need the input from people not represented.

As you encounter potential conflicts, a solution may be to include critics on the team. 

Once the team is identified, establish how it 

will function: 

●		 Establish clear lines of communication 

and a communication plan (e.g., Web

portals, listservs, regular meetings) 

●		 Identify a point of contact for external

stakeholders 

●		 Appoint a lead—the person who will drive

efforts forward 

●		 Clearly define lines of authority—identify

to whom the team reports (e.g., board of

directors, executive director). 

Successful Implementation: 

It’s Not Just a Matter of Chance
 

Despite the obvious differences in goals, products, and clientele, Fortune 500 companies 

can provide models for efficiency, profitability, 

quality, and change management. One model for 

organizational change—DICE—posits four key 

factors for a successful change initiative: 

•	 Duration. It is not how long the change 

process is expected to take but the time between reviews and milestones that matters. 

The most effective milestones focus on bigpicture items—accomplishments and completed action items—rather than day-to-day 

functions. Formal reviews should be distinct 

from maintenance meetings where the project team assesses whether the change has 

the desired effect. 

•	 Integrity. The success of the implementation project depends largely on the abilities, 

cohesiveness, and dedication of the planning 

group. 

•	 Commitment. To be effective, change must 

have the backing of top-level administrators 

and the people who will be affected by the 

changes. 

•	 Effort. Whatever the change, if the level 

of effort is too great or the existing workload too demanding, the implementation is 

less likely to be successful. Ideally, a change 

initiative should not change any one person’s 

workload more than 10 percent. 

Source: Sirkin et al., 2005. 

Where Exactly Do You Want To 

Go? Defining Your Destination 

Before making a specific plan, you should

clearly identify what you hope to accomplish.

If, for example, you are planning to implement EBPs, your goal may be to obtain outcomes comparable with those established for

similar programs using the same practices.

Fidelity is important. If you want outcomes

comparable with those noted in Treatment

Improvement Protocols (TIPs), you need to

institute comparable practices. 

Successful plans have clear goals and established measures for success (milestones). The

goal is the desired destination; the plan is the

route (EBP implemented with fidelity) you

will use to reach your destination. When considering your destination, determine ahead

of time how you will know when you have

reached it. What variables can be measured? 

If you are implementing a specific intervention such as motivational interviewing (MI),

how will you measure success? Examples of

measurable outcomes include the following: 

● Outcome: Staff competency (e.g., ability

to conduct MI) 

Measures: Observations, taped work

samples, certifications, self-reports 

●		 Outcome: Improved client outcomes 

Measures: Improved client retention

rates, higher abstinence rates 

● Outcome: Increased net revenues (from

increased patient fees or new/expanded

contracts with funders) 

Measures: Financial reports. 

It may not be possible to achieve all desired

outcomes. By prioritizing outcomes, you can 

20 
Chapter 3—Planning 

focus on accomplishing the most important

ones first. Once you have prioritized the

outcomes, decide how you will measure success. What is the baseline for each expected

outcome? What is the goal? Include specific

details about each change, the justification

for each change, a list of affected stakeholders, the expected outcomes, and indicators to

evaluate the effects of the change. Exhibit 3-1

gives an example of how to measure outcomes

for one component. This information should

be tracked for each component. 

Exhibit 3-1 Sample Measure and Indicators 

Measure Justification Expected Outcomes Baseline Measures Indicators 

Include 

family in 

initial intake 

Families 

•	Provide 

information 

•	Help engage 

loved ones 

•	Help formulate 

a treatment 

plan 

•	Improved retention 

rates 

•	Increased abstinence 

rates 

•	Improved psychosocial functioning 

•	Retention rates as 

of [date] 

•	Drug/alcohol use as 

of [date] 

•	Employment rates 

as of [date] 

•	Improved retention 

rates (measured weekly) 

•	Improved abstinence 

rates at 3, 6, 9, and 

12 months 

•	Improved employment 

rates at 6 and 12 months 

Are You Ready for the Trip? 

Revisiting the Organizational 

Assessment 

Once you have reached the planning stage,

you have already decided that your organization is ready to implement change. It is

important to bear in mind, however, that

part of your change plan may require interventions to prepare the organization for

change. However effective a practice may be

and however committed individuals may be

to implementing change, not all organizations

are amenable to implementing EBPs. If, for

example, your organization’s culture does not

encourage innovation, part of your planning

process may be to change that culture. 

Revisit the factors you considered in the

preplanning stage (Chapter 2), and include

in your plan steps for addressing problems.

Looking at the hypothetical scenario at the

beginning of this chapter, you might improve

the staff’s receptivity to change by promoting

professional growth. Consider sending staff to 

conferences, distributing TIPs for review

and discussion, circulating relevant journal

articles, or setting aside space for a library.

These activities foster an atmosphere that

values innovation and embraces EBPs. 

For each potential problem, note steps you

can take to address it. If you observed that

your organization lacks adequate administrative infrastructure, include steps in your plan

to remedy this: hire an administrative assistant to assist in day-to-day operations, implement a financial software reporting system,

or differentiate staff responsibilities. 

What Are the Change Targets? 

Setting the Stage 

Change targets do not have to be extensive.

You may want to start with a small pilot

project first. This can be accomplished by

implementing an EBP on a small subset of

your clients first or by implementing one or

two components of a program. 

Building on your preplanning work, you

can now identify the change targets—areas,

programs, structures, or functions that need

to be addressed to make change possible.

Several possibilities are highlighted below,

but there may be many others. The more

forethought you put into this phase, the better prepared you will be to implement change

and the smoother the implementation is

likely to be. Exhibit 3-2 presents an example

of how you track changes needed to implement an EBP. 

21 
Implementing Change in Substance Abuse Treatment Programs 

Exhibit 3-2 Change Tracking Form 

Domain Component Change Needed? 

Y/N 

Administration 

and oversight 

Mission statement 

Oversight board 

Supervisory staff competencies 

Work culture Flexibility 

Support 

Growth opportunities 

Infrastructure 

Policies and 

procedures 

Intake 

Screening and assessment 

Treatment placement 

Treatment planning 

Service recording 

Discharge planning 

Continuity of care 

Incentives 

Staff Staff skills and competencies 

Recruitment 

Training 

Time to attend trainings 

Caseload size/workload 

Productivity 

Reflective supervision, mentoring, or coaching 

Specialized counselor performance appraisal 

Evaluation of service effectiveness and quality assurance 

Strategies to avoid burnout 

Capacity Client capacity (e.g., number of beds in inpatient treatment centers) 

Meeting rooms (e.g., for screening, family therapy) 

Audiovisual technology (e.g., for training) 

Vehicles 

Information 

technology 

Computers/Internet access 

Client tracking 

Information sharing 

Recordkeeping 

Capability to record data needed for outcomes 

Ability to generate and analyze outcome data 

Personnel 

Staff skills competencies 

22 
Exhibit 3-2 Change Tracking Form (continued) 

Domain Component Change Needed? 

Y/N 

Evaluation Resources for evaluation component and recordkeeping 

Evaluation expertise 

Additional measures 

Followup 

Incentives 

Community 

partnerships 

Memoranda of understanding 

Contracts/subcontracts 

Informal understandings 

Communication protocols 

Referrals 

Chapter 3—Planning 

Administration and oversight. Your plans

may require changes at an administrative

level. Perhaps your mission statement needs

to be updated. If, for example, you are including programs for families, you may wish to

revise your mission statement to reflect the

family focus. Determine whether changes

need board approval. 

Staff training. Most change plans require

that staff be trained in new policies, pro

cedures, or treatments. Plans for training

should be specific and include answers to the

following questions: 

●		 Are there internal staff members 

proficient in the EBP? 

●		 Who will conduct the training? 

●		 Do we need to hire an experienced

consultant? 

●		 Do we have the funds to pay for training? 

●		 What is the duration/frequency of the

training? 

●		 How will staff time be made available for 

training? 

●		 What are the training goals? 

●		 How will outcomes be measured? 

●		 How will training be reinforced? 

●		 How/when will new staff be trained? 

­

●		 Are there curricula for training in the

EBP? 

●		 Do supervisory staff members have the

skill to provide training, feedback, and

monitoring? 

Substance abuse treatment organizations

sometimes consider training in a new inter

vention to be the final objective. But the liter

ature increasingly demonstrates that training

staff is not enough. Learning a new skill or

intervention requires practice and reinforce

ment. Implementation rates improve when

staff members are given regular feedback and

reinforcement (Andrzejewski, Kirby, Morral,

& Iguchi, 2001). 

Roadblocks. Anticipating difficulties can

smooth implementation. By identifying factors related to organizational readiness to

change, you have already begun anticipating

roadblocks. Scrutinize the organizational fac

tors that may impede progress. Think care

fully through your goals and action items.

Where are you most likely to encounter prob

lems? They could be internal (staff resistance,

lack of training) or external (legal, regulatory

issues, confidentiality issues). 

Substance abuse treatment centers are bound 

by requirements of external funding organi

zations or regulators that may inadvertently

erect the following roadblocks: 

­

­

­

­

­

­

­

23 
Implementing Change in Substance Abuse Treatment Programs 

● Licensure. Is specific training or

licensure required to conduct the proposed

intervention? If so, what additional 

training/certification is needed for the

clinician and program? 

●		 Accreditation. Does the proposed change 

have implications for your accreditation?

For example, if you add a component that

is likely to attract more clients, will your

treatment center still meet required staff–

client ratios? 

●		 Health, fire, or safety requirements.

Your health or safety inspector may

require certain safety features. Do the

changes have any effect on building

regulations? For example, if you plan to

offer child care, do you need additional

safety measures or a special inspection? 

●		 Coding and verification

requirements. Funding sources may

require that you record data in a certain

way, using specified instruments. Coding

and verification requirements can have

implications for the types of treatment

you provide and the credentials of the

staff members who provide specific

interventions. Consider whether the 

suggested changes have any implications

for coding. Will you bill to new codes? Are

there associated requirements? Are the

people slated to perform the intervention

(e.g., intake) properly credentialed to

do so? 

●		 Confidentiality. If you have an

evaluation component, how will you

collect information and follow up while

meeting confidentiality requirements?

If you are seeking to expand treatment

to include families, what are the 

implications for client confidentiality?

Adding new partners or changing

relationships with existing ones can have

implications for information sharing. 

Funding requirements. The terms of your

grant or award may include requirements

that will affect the change plan. Familiarize

yourself with the terms to ensure compliance. 

Financial considerations. If you are considering adding new components, are there

adequate resources? Will the interventions

qualify for reimbursement, and if so, under

what codes? Are there other possible funding

sources or ways to share costs with community partners? 

Personnel. How will you address internal

resistance to change? McGovern and colleagues (2004) found that clinicians are much

more likely to adopt EBPs if the relevance

of the intervention is made clear to them. 

Therefore, include a plan to demonstrate the

relevance of the proposed intervention or program and how it can improve client outcomes.

Beyond that, ensure that clinicians have adequate time for training. Koch and colleagues

(1998) examined the literature and identified

several strategies to address staff resistance: 

●		 Recognize staff concerns. Staff 

members have legitimate perspectives

and fears. By valuing their expertise,

you can reduce their resistance. Common

fears and ways to allay them include 

– Less time for treatment. Paperwork

and other implementation activities

take time away from staff members’

primary concern—helping people.

Continually remind staff how the

efforts will ultimately help them

better serve their clients. 

–	 Outcomes will be used against staff.

Some staff members may think that

if their outcomes do not improve, the

lack of improvement will be used

against them in reviews. Emphasize

that the evaluation outcomes will 

be used to constructively improve

practices, not to identify poor

performers. 

– Violation of consumer confidentiality.

Involve staff in identifying safeguards

to protect confidentiality. 

–	 Lack of value. Many staff members

will have had experiences in which 

24 
Chapter 3—Planning 

they were required to take extra steps

or change practices without being

told the outcomes, either positive or

negative. Results should be reported

to staff promptly. Data collection

efforts should be delayed until an

accurate and timely system is in place

to generate reports for staff. 

●		 Educate and discuss. The change and

how it will improve clients’ lives must be

clear to staff. Allow for open discussions

of the proposed change. Consider staff

feedback in planning and implementation. 

● Obtain management support. Visible 

support from decisionmakers is crucial.

Change efforts can easily fall by the

wayside without management support. 

● Walk the walk. If you are implementing

new practices, you should demonstrate

them. All members of the change team are

mentors and should act accordingly. 

● Start small. In some programs, it may

be best to start with a pilot project or to

pilot test before final implementation.

These results can be used to inform the 

implementation plan. 

● Start with volunteers. Volunteers 

should understand that the effort 

will require time away from other

responsibilities. 

● Provide incentives. Base performance

on adherence to best practices. Offer

bonuses or rewards for those who partake

in the change plan or obtain desired 

outcomes. 

● Reduce burden on staff. Wherever 

possible, choose the path that imposes the

smallest burden on staff. In designing a

new intake form, for example, you may be

able to eliminate collecting information

that will not be measured or is not 

otherwise required or useful. Remember

the practical applications of what you

implement, and seek staff members’

expertise on how the changes are likely to

affect them. 

Risk Management in EBPs 

Panzano and Roth (2006) evaluated the 

decisionmaking process of 78 projects involving 

decisions to adopt 1 of 4 evidence-based mental 

health practices. They found that the propensity 

to adopt a best practice depended not so 

much on the inherent risk-taking traits of the 

decisionmakers, but rather on the perceived 

risks of adopting the practice. Implementation 

was negatively related to the perceived risk, 

positively related to the expected capacity 

to manage risk, and positively related to an 

organization’s past propensity to take risks. 

●		 Provide timely and useful feedback.

When evaluation results are available, 

share them with staff. 

●		 Use the results of evaluation to 

improve services or to show how

services have improved. Most staff 

members are motivated to help people. If

a new intervention is working, share that.

If it is not, explain where improvements

are needed. 

●		 Monitor for signs of staff resistance.

Well-laid plans have gone awry because

of staff resistance or sabotage, not always

manifested in the form of open reluctance.

There could be quiet refusal to perform

new functions or follow new procedures.

Do not assume that no news is good news.

Monitor activities to ensure compliance;

if it is lacking, find out why. Encourage

dialog so that staff members can voice

their concerns openly. 

Lessons Learned 

•	It’s not just about the intervention. Changing 

services and practices requires more than 

intervention-specific knowledge. Service 

providers may need to learn information 

management technologies, assessment tools, 

client tracking, and so forth. 

•	It’s not just about evidence. Technologies 

are adopted into systems and organizations. 

Evidence of outcomes must be balanced with 

political and financial realities. 

Source: Phillips & Allred, 2006. 

25 
Implementing Change in Substance Abuse Treatment Programs 

●		 Solicit feedback at regular intervals.

Get feedback on the change plan. Be

prepared to listen, reflect, and adjust the

plan. 

Cost. Cost can be prohibitive, especially for

substance abuse treatment facilities operating at a deficit. As you work through your

plan, identify ways to cut costs. Could you use 

volunteers for certain functions? Could you

partner with other agencies, organizations, or

research institutions? What are the potential

benefits versus the costs? Could other components be cut to accommodate changes? 

What Is Your Route? Mapping the 

Implementation Plan 

You have already done a lot of the work. Formalizing the implementation plan is now a

matter of assembling the pieces, establishing

timelines, and identifying milestones. 

Review the work you have done so far. You

have prioritized expected outcomes, assessed

your organization’s readiness for change,

identified change targets, and noted potential

roadblocks. Now is the time to strategize: 

●		 If your organizational self-assessment

has identified issues that will negatively

influence change, determine what can be

done at each level to improve readiness

for change. 

●		 Identify ways to maximize the positive

elements. For example, in staff meetings

highlight new efficiencies that free

staff members to take advantage of

professional growth.
 

●		 For each change target, identify specific

strategies to accomplish your goals and

designate people charged with carrying

them out. If, for example, you need to

modify the mission statement to address

the commitment to serving families,

specify steps for drafting a mission

statement and submitting it to the board

for approval. 

●		 Determine a timeline for change. Set

measurable milestones, such as hiring a

new intake staff member or completing

training in a certain intervention. Be

sure to build in components to measure 

success. 

●		 Assign responsibilities for implementing

the specific strategies. Identify people to

oversee specific areas. Clearly state who

will monitor progress. 

●		 Establish a communication plan (e.g.,

weekly meetings, message board). 

●		 If training is required, determine training

format, schedule, and attendees. Specify

expected outcomes for training and a

plan to measure success. For example,

suppose you decide to increase your staff

members’ proficiency with MI to improve

client retention. You will want to measure 

the degree to which staff MI skills have

increased with the training and any

changes in client retention. 

●		 Build in an evaluation component. What

are your baseline measures? When, how,

and by whom will data be collected? How

will they be stored and analyzed? 

●		 Make fidelity measures core to your plan.

How will you measure the degree to

which implemented practices match best

practices? Who will monitor the practices?

How and when will you determine

whether modifications are required? 

●		 Identify a plan to sustain newly

implemented best practices. 

●		 Make sure your action plan is multitiered

and addresses multiple layers (e.g.,

administrative—time for oversight,

reporting mechanisms for external

stakeholders). 

●		 Identify resources needed, including

funding, personnel, administrative

support, technology, and consultants (e.g.,

evaluators, trainers). 

Now it’s time to implement your plan! 

26 
Chapter 4—Implementation
 

Hypothetical Scenario 

As the administrator for an intensive outpatient treatment facility, you recently 

launched a change initiative to include occupational training as a treatment component. You lined up supporters and formed a change team. The initial enthusiasm has 

waned somewhat, as your staff complains of the extra work involved and questions 

why the change was necessary in the first place. What can you do to motivate staff 

and address complaints before they grow into problems? 

You have developed a plan, set action items,

identified potential roadblocks, established

timelines, and determined communication 

strategies. Members of your implementation

team know their responsibilities, deadlines,

and milestones. Now it is time to put the

pieces in motion. 

Are You There Yet? What To 

Expect Along the Way 

Change is stressful, even in the best circumstances. For substance abuse treatment clinicians who deal with tense situations every

day, the added stress of changes that affect

their jobs can be detrimental. By offering

staff members opportunities to engage in the

change process, to join the dialog, and to offer

their expertise, you stand not only to gain

valuable insights, but also to minimize stress.

In a study of the relationship between stress

and change in substance abuse treatment

and mental health agencies, Johnson and

colleagues (2006) found that staff members’

level of self-reported stress during change

processes declined as their perceived control

and input into the process increased. 

As you install the change plan, it may seem

awkward at first. Expect protests, confusion,

and disharmony. This initial stage is temporary. As Fixsen and colleagues (2005) note, 

Compelling forces of fear of change,

inertia, and investment in the status quo

combine with the inherently difficult and

complex work of implementing something

new. And, all of this occurs at a time when 

the program is struggling to begin and

when confidence in the decision to adopt

the program is being tested. (p. 16) 

Simple strategies can help along the way.

Some are noted below. 

Make realistic goals. Bars that are set too 

high can negatively affect morale and set up

lose/lose situations. Make sure milestones

are realistic. For example, instead of striving

for an 80-percent completion rate of a newly

implemented intake form, set the bar at 20

percent, then 40 percent, and so forth. Small

successes motivate continued success. 

Celebrate baby steps. Make accomplishments public. Send congratulatory e-mails.

Make announcements at staff meetings.

Invite staff for a celebratory cake. It may

also be effective to provide case studies,

highlighting the human aspect of the new

practice or program. For example, tell the

staff about a thank-you note from a patient

who was helped by the new family counseling

component you’re implementing. 

27 
Implementing Change in Substance Abuse Treatment Programs 

Strategies for an Effective Implementation 

Relevant. The change must have obvious application. As you introduce your change plan, make sure you 

explain how the innovation fits with your mission and goals and clients’ needs. 

Timely. Make sure you explain why change is needed now. 

Clear. Use plain language in explaining the change and the change process. Avoid using elaborate conceptual models or other visual aids that require a legend or advanced degree to understand. 

Credible. Cite sources. Circulate Treatment Improvement Protocols (TIPs). Show evidence that the new 

practice or program works. 

Multifaceted. Your change plan involves multiple systems and people. Allow for different styles, speeds, 

and ways of learning. Create multiple venues for learning, messages for different stakeholder groups, 

and communication formats. 

Continuous. Change is a long-term process requiring continual reinforcement. Acknowledge accomplishments, however small. Make your message clear and consistent. 

Bidirectional. Allow for regular communication between your implementation team and the people it 

affects. 

Source: Addiction Technology Transfer Center, 2004. 

Keep your eye on the prize. Continually

remind program staff and other stakeholders

of why you are changing practices. Provide

reminders of how the changes will improve

lives. Stay in contact with all stakeholders

and staff. Provide updates and reassurances.

Create an open dialog. Allow staff members

to voice concerns openly. 

Evaluate and reevaluate. Measure your

progress and make modifications as needed.

Adhere to your data collection and analysis

plan. Observe preliminary results, and modify practices as needed. Working out the bugs,

streamlining new procedures, and making

modifications to better your organization are

typical of any change process. 

Monitor progress. Hold people accountable for deadlines and milestones. Schedule 

regular meetings to assess progress and

troubleshoot challenges. Do not assume that

all is going according to plan or that no news

is good news. Success often includes making

modifications to the strategy until the criterion for success is met. 

Stay faithful to fidelity. The point of

change efforts is to replicate best practices as

closely as possible. Clear, consistent guidance

may avoid drifting from the program you

want to implement. 

Factor in personalities. Just as clients in 

substance abuse treatment do not respond

equally to different treatment approaches,

staff members are likely to need different

kinds of interventions to convince them to 

change. Wyszewianski and Green (2000)

outline four basic types of counselors and propose strategies for convincing them to change

practices: 

● Seekers are engaged in the field. They

read journals, subscribe to listservs,

and access electronic repositories of

information. They readily adopt a new

practice when research supports its use.

Seekers are likely to embrace changes

when they critically evaluate the evidence

themselves. For this group, distributing

original research findings, outcomes, or

other data will likely convince them of the

need for change. 

● Receptive clinicians are likely to

change practices when information

comes from credible sources. Unlike 

seekers, they rely on expert opinions

that are based on scientific findings. This

group will use TIPs or other consensus

documents. It may be important to

remove obstacles to implementing new

practices and procedures and offer

continued support. 

28 
Chapter 4—Implementation 

● Traditionalists rely mostly on

authoritative sources for deciding to

change practices. However, they focus

less on evidence and more on experience,

skill, and the authority of the people

advocating change. Traditionalists are

likely to accept recommendations from

sources they consider clinically valid (e.g.,

people with clinical experience). To win

traditionalists’ support for the change

plan, it is important to remove obstacles

and offer supportive mechanisms.

Traditionalists are likely to respond

to rewards, penalties, and real-time

reinforcement. 

● Pragmatists want the bottom line. They

are unlikely to be receptive to practices

that disrupt treatment or otherwise

interfere with treatment as usual. 

For pragmatists, removing obstacles

and creating a smooth transition are

crucial. They are likely to require strong

incentives to change (e.g., performance

review based on incorporation of change)

and strong incentives to overcome

barriers. 

How Do You Navigate 

Roadblocks? 

Change plans can fail at the implementation

stage often because of unforeseen factors.

Some factors may mean an end to the change

plan. Funding may be cut, eliminating financial resources. Policies that mandated the 

change may be revoked. Other unforeseen

events may require adjustments. Research

may determine that a new treatment

approach is more effective than the proposed

approach. If a key staff member resigns, who

can fill his or her role? If support from key

stakeholders is withdrawn, what can be done 

to regain their support? This section highlights problems that sometimes occur during

the change process and suggests possible

solutions. 

The organizational memory. As most 

administrators or managers know, one of the

biggest challenges in changing course is past 

experiences with attempts to change. Veteran

staff members may recall details of the disaster that befell the organization when person 

X attempted to change Y. Staff members 

who “remember when” are voicing legitimate

fears. History can repeat itself, but it does

not have to. Ask the staff members who recall 

previous events to share their insights. What

went wrong the last time? What can be done

differently? In a way this is much like doing

relapse prevention with patients, encouraging 

them to learn from past efforts. Encourage

a climate of active participation and shared

decisionmaking. 

Low participation/interest. Perhaps you

are creating a new program and the interest

or response is not what you expected. You

have made family counseling available, but

only a few clients have used it. Or perhaps

staff members have not engaged in planned

trainings. When participation is not what it

should be, the first step is to figure out why. 

Are clients unaware of the services? Are 

counselors not offering them? Are sessions at

inconvenient times? 

Inadequate resources. A frequent challenge in implementing change plans is a

lack of human and financial resources. If 

you have done your homework, you have

already identified the necessary resources

and found ways to make them available. But

unforeseen circumstances occur. Perhaps you

have underestimated the time needed for the 

implementation team to tend to the change

process. You may need to adjust timelines to

allow for a slower pace or supply rewards for

the extra work required. 

Role confusion. As you embark on new

processes and programs, standard operating

procedures are no longer standard. Routines

are disrupted. The work no longer flows. As

people struggle to find their way through the

change, it is important to check in frequently.

For example, perhaps you charged someone

to administer a new assessment tool but 

failed to specify how the activity should

be billed or who should enter the data in 

the system or how the results will affect 

29 
Implementing Change in Substance Abuse Treatment Programs 

treatment planning. Regular meetings will

identify and remedy planning oversights. 

Resistance. A certain amount of resistance 

to change is to be expected. Change disrupts

everyday life. It pushes people out of their

comfort zones and requires them to adapt

to practices, learn new skills, and live with

uncertainty. Resistance can generally be confronted by encouraging open discussions of

the change process and addressing concerns

directly. 

You’re (Almost) There! 

Full operation has occurred when the programs and practices are completely integrated, when the “changes” are now standard

operating procedures, and when you have

reached your goals. Once you have implemented your plan, you are almost there. The

evaluation component (Chapter 5) will help

you identify where your program is working

and where it is not. Midcourse adjustments

are likely to be necessary. 

30 
Chapter 5—Evaluation
 

Hypothetical Scenario 

You are a clinical supervisor in a small inpatient treatment center for women. Recently, 

you applied for a grant that would enable children younger than age 10 to reside at 

the treatment facility with their mothers. Grant administrators have informed you 

that your award is contingent on establishing a plan to evaluate the evidence-based 

practices (EBPs) that you will use. At a minimum, your evaluation must demonstrate 

outcomes in abstinence at specified intervals. In addition, children must be evaluated 

based on predetermined developmental measures and psychosocial functioning. Data 

at 1 year posttreatment are required for at least 60 percent of participants. 

It is common for funding and regulatory

agencies to require substance abuse treatment providers to demonstrate results. Even

without such an imperative, evaluation is

key to any implementation effort. Without

it, there is no way of knowing the effect of

the changes or how closely you are following

EBPs (fidelity). Evaluation is a built-in navigation system. It will alert you when you are

off course and offer reassuring evidence when

you are on target. It gives you “numbers to

sell” to funding agencies, boards of directors, community partners, and skeptical staff

members. Finally, evaluation results can provide the underpinning for sustainability (see

Chapter 6). 

This chapter is only a starting point for

planning the evaluation. Excellent guides

to program evaluation are available online.

Appendix C provides a list of additional 

resources. 

Before You Begin 

Evaluations of new programs or practices

serve two purposes: (1) to determine how

closely your new programs and practices

match best practices and (2) to measure the

effect of the change on one or more elements 

of your program: clients, staff, processes,

procedures, costs, or other factors. Most

substance abuse treatment organizations

operate on limited budgets, and defining a

clear reason for the change is important to

contain costs and focus resources on the most 

important factors. Your evaluation may be to 

measure: 

●		 How closely the program or practice is

being implemented as planned 

●		 How closely the program or practice

matches best practices or programs 

●		 Whether you are meeting your objectives

for change 

●		 The degree to which outcomes compare

with treatment as usual (TAU) (before

implementation) and/or the outcomes of

similar organizations (e.g., other inpatient

programs for mothers with young

children) 

●		 The effect of the intervention on 

predetermined measures (e.g., client

outcomes, abstinence) 

●		 The costs of a program or practice 

●		 The efficiency of the program or practice 

31 
Implementing Change in Substance Abuse Treatment Programs 

●		 The effectiveness of specific implementation strategies (e.g., training, mentoring). 

Other factors are likely to influence the purpose and scope of your evaluation. As noted

in the hypothetical scenario at the beginning

of this chapter, funding sources often require

an evaluation component. Factors to consider

in deciding the purpose of your evaluation are

noted below: 

●		 Cost. Determine how you will pay for

the evaluation. Do you have funds set

aside for evaluation? Will additional 

funds be available if needed? Is there a 

set-aside in current funding streams or

grant opportunities for the evaluation

component? 

● Existing information. Identify ready

sources of data. Tapping existing

information may cut costs. Identify the

data you routinely collect (e.g., admission

and discharge interviews, family

interviews), and consider whether existing 

forms and data entry or storage processes

will be useful in the evaluation effort. Are 

there data in other reports you routinely

submit (e.g., annual reports to a funding

or accreditation body) that will be useful

in your evaluation? 

●		 Funding, licensure, or accreditation

requirements. Funding, licensure,

and accreditation agencies may dictate

the parameters of the evaluation (e.g.,

the use of an outside evaluator, specific

instruments at specified intervals). Be

specific when noting requirements for

data collection, analysis, and reporting. 

●		 Expertise. Consider staff members’ 

experience or expertise (e.g., statistical

evaluation, information technology, focus

groups, data collection, coding, analysis).

Look to community partners, boards of

directors, and your volunteer base for

skills that may prove valuable. 

●		 Management information system

(MIS). Identify program data that are

routinely collected by a statewide MIS

or a managed care company-based MIS. 

This effort will ensure that data collection 

is not duplicated. It may be possible to

develop or enhance a program-level MIS

that supplies data required by thirdparty payers and governmental bodies

to collect change-specific information.

If your organization does not have the

resources to develop a sophisticated

system, you should be able to automate

collecting at least a minimum amount of

client information through commercially

available software. 

●		 Resources. Identify resources available

for the evaluation. Do staff members 

with evaluation experience have time

available? Are people available to perform

quality checks and data collection? Do you

have computer equipment that you can

use to store data? Do you have statistical

software packages? 

● Past experience. Note whether your

organization has conducted evaluations in

the past. If so, were they successful? What

were the lessons learned? What was the 

cost? Can components of past evaluations

be used in the current evaluation? Can 

you use data from past evaluations for

comparison? 

Select the Evaluation Team 

Deciding whom to include on the evaluation

is a practical and strategic decision. At a

practical level, you will want to include staff

members with research and evaluation skills. 

You will also want staff members, clinical 

supervisors, and other personnel with an

understanding of (1) how the program works,

(2) the change you are implementing, (3) the

types of information that will be useful,

(4) the ways in which the evaluation can be

easily integrated into the current program,

and (5) how the results may be used for

future program improvement. 

Your choices should be strategic. By incorporating input from stakeholders, you enhance

the credibility of the evaluation and make the

process transparent. Taking the hypothetical 

32 
 

scenario at the beginning of this chapter as

an example, you might consider consulting: 

●		 The project officer or representative of the

funding agency 

●		 Representatives from the State child

welfare department 

●		 Counseling and supervisory staff

members 

●		 Experts in child welfare 

●		 Former clients and their family members 

●		 Members of the board of directors 

●		 Community representatives 

●		 Representatives from associations 

●		 Representatives from school systems or

daycare facilities 

●		 Representatives from housing authorities 

●		 Representatives from the court system 

●		 Maternal/child health groups. 

For most organizations, evaluation team

members should be limited to those with a 

vital interest. Input from too many stakeholders may slow the evaluation by trying to

address everyone’s interest, but input from

an appropriate few will build credibility

where you need it most. 

Identify the Evaluator 

Whereas the evaluation itself will be a team 

effort involving many stakeholders and staff

members, someone should oversee the effort. 

You may decide to hire an outside evaluator, such as an independent consultant, a

research institute, a research university, or a

nonprofit or professional research firm. You

may ask other programs about their experiences with evaluators and the associated 

costs (Hosley, 2005). Even if you select an

external evaluator, you may need in-house

expertise for an ongoing evaluation. 

If you decide to hire an evaluator, keep your

team involved to ensure that the evaluator 

understands the goals of your program and

your evaluation. You must inform the evaluator of any requirements for data collection

specified by funding sources and identify

potential data sources. 

Chapter 5—Evaluation 

Guidelines for a Successful Evaluation 

Invest in planning. As precisely as possible, identify what you would like to discover, and use this 

information to guide your evaluation. 

Integrate the evaluation into the program. Program managers often view evaluation as something “tacked on” to please funders or regulatory 

agencies. The evaluation should be integrated 

into the change plan from the very beginning, 

and the evaluation results should continually 

support the process. 

Participate in the evaluation to show program 

staff that it is important. An evaluation needs 

the support and active participation of the program administrator. Even if an outside evaluator 

is hired to conduct the evaluation, the administrator should be a full partner in the evaluation 

process. 

Involve as many program staff members as 

much as possible and as early as possible. Staff 

members will have questions and issues that 

the evaluation can address and can contribute 

their expertise to ensure that the evaluation 

questions, design, and methodology are appropriate for the program’s participants. Early 

involvement of staff members will increase their 

willingness to participate in data collection and 

other evaluation-related tasks. 

Be realistic about the burden on you and your 

staff. Evaluations take time and work. Even if 

your evaluation calls for an outside evaluator to 

do most of the data collection and analysis, it 

takes time for the evaluator to access records, 

administer questionnaires, or conduct interviews. 

Agencies and evaluators often underestimate 

how much additional effort this involves. 

Be aware of the ethical and cultural issues. 

When you evaluate a program that provides services, always consider your responsibilities to the 

clients. Evaluation instruments and methods of 

data collection should be culturally sensitive. 

Source: Administration for Children and Families, 

2003. 

33 
Implementing Change in Substance Abuse Treatment Programs 

For programs with in-house expertise,

performing the evaluation without outside help may cut costs. Be wary, however,

because the person charged with your evaluation should have relevant, recent expertise. A

caveat: it could be a serious strategic mistake

to use internal resources (or find the cheapest

external evaluator) to minimize costs. That

approach may leave an agency with a poorly

executed, useless evaluation. Another option

is to select a combination approach in which

you hire an evaluator to create the design,

verify data integrity, and perform statistical

analysis while your staff collects and enters

data. Exhibit 5-1 summarizes the pros and

cons of each approach. 

Exhibit 5-1 Pros and Cons of Evaluation Approaches 

Approach Pros Cons 

External 

evaluators 

•	May see more clearly how the program functions, what can be improved, and barriers to change 

•	Inspire faith in funders for outcomes 

identified by impartial third parties 

•	Have technical expertise to design 

and conduct evaluation 

•	Generally are more expensive than 

internal or combined evaluation 

•	May lead to conflicts if perceived 

negatively 

•	May lack an understanding of the 

nuances of the program 

Internal 

evaluators 

•	Generally are less expensive 

•	Promote maximum involvement and 

participation of program staff and 

contribute to building staff expertise 

for future evaluation efforts 

•	Allow for close monitoring and immediate adjustments 

•	Can be taxing on staff 

•	May lack sufficient knowledge of 

evaluation design, data collection, and 

analysis 

•	May not be viewed as objective by 

funders and others 

Combinations •	Provide cost efficiency (may maximize the benefit while minimizing 

cost) 

•	Can be inefficient if communication and 

cooperation are not sound 

Source: Adapted from the Corporation for National and Community Service, n.d. 

Hire an Evaluator 

If you decide to hire an evaluator, your choice

can make the difference between a solid evaluation that impresses funding agencies and a

costly evaluation that calls your program into

question. The Program Manager’s Guide to 

Evaluation (Administration for Children

and Families, 2003) provides six steps for

selecting an evaluator. 

Step 1. Draft a job description. This 

should list the services or products to be provided by the evaluator. It should describe the

evaluation activities to be performed and the

timelines for completing them. 

Step 2. Identify sources for evaluators.

Potential sources include the following: 

● Other organizations. Other 

organizations may have experiences with

evaluators. Ask them relevant questions.

Was the work completed on time and on

budget? Did the evaluator collaborate

with staff? Did he or she produce a

credible report? Did the evaluator attend

staff and board meetings as needed? 

●		 Evaluation divisions of State or local 

agencies. Some evaluation divisions offer 

their services at no cost. 

34 
Chapter 5—Evaluation 

●		 Local colleges and universities.

Specific departments or university-based

research centers are possible sources. 

● Technical assistance providers. Some 

Federal grant programs include a national 

or local technical assistance provider. If

your agency is participating in this kind

of grant program, help in identifying and

selecting an evaluator is an appropriate

technical assistance request. 

●		 Research institutes and consulting 

firms. Many experienced evaluators are

part of research institutes and consulting

firms. They are sometimes listed in

the Yellow Pages under “Research” or

“Marketing Research.” Your State human

services department may have a list of

firms that have bid on recent contracts for 

evaluations of State programs. 

●		 National advocacy groups and local

foundations. Some groups have the

staff and resources to conduct (or help

conduct) evaluations. Individuals from

these groups usually have a substantive

understanding of substance abuse

treatment systems and a clear sense of

the issues that will be important. 

●		 Professional associations. Examples

include the American Evaluation 

Association, American Sociological

Association, and the Society for Research

on Child Development. 

Sample Ad 

Professional Evaluator Wanted 

Seasoned evaluator sought for a residential substance abuse treatment program for women. The 

evaluator will: 

•	 Develop an evaluation plan based on grant 

and program requirements 

•	 Select standardized instruments (if available) 

•	 Train project staff	 

•	 Design and administer surveys	 

•	 Design data collection instruments 

•	 Develop a database 

•	 Code, enter, and clean data 

•	 Conduct interviews and focus groups 

•	 Provide regular progress reports 

•	 Attend project staff meetings and other 

administrative meetings 

•	 Write an evaluation report 

•	 Present findings at local and national meetings 

and conferences.

Candidates should have expertise in relevant qualitative and quantitative data analysis tools (e.g., SPSS). 

Familiarity with confidentiality regulations is required. Candidates must have expertise in culturally appropriate tools. Also required is experience with substance abuse treatment program evaluations and Federal 

grantee reporting requirements. 

Step 3. Advertise and solicit applications. Potential sources include the following: 

●		 The local newspaper 

●		 Job boards or newspapers of local colleges

or universities 

●		 Agency or association newsletters or Web

sites 

●		 Local and national meetings 

●		 Professional journals 

●		 Listservs. 

Advertise as widely as your budget allows,

using multiple advertising sources and allowing as much time as possible between posting

the position and reviewing applications. 

Step 4. Select an applicant. In reviewing

applicants, you should include the following

considerations: 

35 
Implementing Change in Substance Abuse Treatment Programs 

●		 Experience conducting similar evaluations 

at comparable costs 

●		 Familiarity with your funding or regulatory agency’s reporting requirements

(e.g., Government Performance and

Results Act) 

●		 Experience working with substance

abuse treatment programs 

●		 Experience evaluating programs that

work with minority or other special

populations 

●		 The type of evaluation plan proposed 

●		 The candidate’s report-writing competence as demonstrated by samples of

recent written evaluations. 

After you have narrowed your selection to

two or three candidates, you are ready to

determine whether you and the evaluator are

compatible. As you do with other job applicants, you must check references from other

programs that worked with the candidate. 

Step 5. Negotiate costs. It is common for 

an evaluator to propose a higher cost than

you had planned. In this case, your choices

are to look for a cheaper evaluator, identify

other funding sources, or negotiate with the

evaluator. In the last case, you may persuade

the evaluator to donate a portion of the costs

as in-kind services or to give you a prorated

cost. Some universities can lower costs by

engaging graduate students to conduct some

evaluation activities under the direction of a 

professor. Alternatively, a researcher may be

willing to contribute his or her services 

in exchange for data about participants and

programs. If you choose this option, be sure

to adhere to all State and Federal confidentiality requirements. (Go to the Substance

Abuse and Mental Health Services Administration’s Web site for information on 

42 Code of Federal Regulations and Health

Insurance Portability and Accountability

Act requirements [http://www.hipaa.samhsa.

gov].) 

Many program managers and staff believe that 

it is unethical to use program or agency financial 

resources for an evaluation, because available 

funds should be spent on serving participants. 

However, it is more accurate to view money 

spent on evaluation as an investment in your 

program and in your participants, rather than 

as a diversion of funds available for participants. 

Evaluation is essential if you want to know 

whether your program is benefiting participants. 

—Administration for Children and Families, 2003 

Step 6. Create a contract. A contract spells

out terms, prevents confusion, and protects

your organization should your evaluator fail

to live up to his or her responsibilities. Your

contract should specify the following: 

●		 Ownership. Specify that the agency

owns and controls the data, and note 

the procedures required for releasing

information to external sources. 

●		 Responsibilities for evaluation 

tasks. Specify who is responsible for

specific evaluation activities. Be sure

that the individuals specified are

qualified or will be sufficiently trained.

For example, if you hire a firm to conduct

the evaluation, specify the level of staff

required for certain activities. Junior

staff members should not design the

evaluation, but they might conduct

interviews or focus groups. 

●		 Expectations. Spell out how your

organization expects to be involved in

the evaluation and, conversely, how

the evaluators will be involved in your

program. Specify whether the evaluators

are expected to attend board or staff

meetings. Indicate that you expect to

be consulted on decisions about data 

collection instruments and who will 

perform specific evaluation tasks. Spell

out the level of contact between the 

evaluator and the program. 

●		 Deadlines. Make the timeline part of

the contract. Specify milestones and

deliverables. 

●		 Reports. Document the reports you

expect, when, and in what format. If 

36 
Chapter 5—Evaluation 

there is a final report, be specific about

the expected scope and content and the

process for reviewing drafts. 

● Publications. Prevent difficulties 

later by establishing the process

for determining authorship for any

publications based on evaluation results.

Outline procedures (e.g., who will write,

who will contribute, who must approve).

Be sure to incorporate any grant

requirements. 

When Problems Arise 

•	 Original design is inadequate. The evaluation may outgrow its plan. In some cases staff can pick 

up the work. If not, discuss add-ons to the existing contract. Sometimes, a new contract may be 

warranted. 

•	 Evaluator departs or terminates the contract. You will likely need to hire a new evaluator. 

•	 Evaluator fails to meet contract obligations. If attempts to negotiate a solution are unsuccessful, 

public agencies should turn the case over to their procurement office. Private agencies should seek 

legal counsel. 

•	 Evaluator lacks expertise in specific areas. Focus groups or interviews with community members 

may ensure that evaluation questions and activities are appropriate for communities served. 

•	 You question findings. If the evaluator’s conclusions are not what you expected, consult with the 

evaluator to ensure that the instruments used were appropriate and implemented properly. However, 

remember that the point of an evaluation is to obtain objective measures. It may be simply that your 

program or practices are not working as expected. Obtain specific information. For what groups are 

the interventions working? For what groups are they not working? 

Estimating Cost 

For most substance abuse treatment programs, cost is a primary concern. In The 

Program Manager’s Guide to Evaluation

(Administration for Children and Families,

2003), the authors equate evaluation to building a house: 

If you spend a small amount of money,

you can build the foundation for

the house. Additional money will be

required to frame the house and still

more money will be needed to put on

the roof. To finish the inside of the 

house so that it is inhabitable will 

require even more money.
 

General guidelines for cost are as follows: 

●		 Minimal cost evaluations. For little 

money, you can obtain basic data on

the number of clients being served,

services being provided, and demographic

information about the people you

serve. In some cases, you can acquire

information on client satisfaction with 

services or staff’s satisfaction with 

training. Generally, minimal spending

will not show you how successful your

implementation plan was in terms of

fidelity measures or outcomes. 

●		 Moderate cost evaluations. A modest 

increase in the evaluation budget will

enable you to assess changes in client

outcomes. Depending on resources or

availability of control groups (including

historical control groups), you can ascribe

changes in outcome specifically to an

intervention. You can collect indepth

information about aspects of program

intervention through interviews or focus 

groups. 

● Highest cost evaluations. If you have

sufficient resources, you can evaluate

long-term outcomes—such as abstinence

at 2 years or children’s psychosocial

functioning at 5 years after the treatment

episode. The expenses are associated

with tracking clients after they complete

the program to get an adequate response

rate (more than 75 percent) to make

conclusions from followup data credible. 

37 
Implementing Change in Substance Abuse Treatment Programs 

Despite the expense, long-term outcome

information can reveal whether initial 

outcomes are maintained over time. 

Although it is generally true that as you

increase your budget you gain more information, indiscriminately collecting data can be

a waste of resources. Carefully consider each

piece of information you plan to collect. What

does it tell you? Is this information helpful

for your organization’s mission? Decide what

you need to know per funding requirements,

accreditation, and so forth and what information is not essential now but may be useful in

the future (e.g., information that might help

with fundraising). Your plan will start with

items that satisfy the first requirement and

will add items to meet the second requirement as resources allow. 

Strategies for Trimming Evaluation Costs 

•	Prioritize evaluation questions. Distinguish 

between essential and optional items. 

•	Search for inexpensive ways to gather information (e.g., as added items at points at which 

information is already gathered). 

•	Share costs with other agencies/organizations. 

•	Use staff or volunteers whenever possible. 

Source: Hosley, 2005. 

Planning the Evaluation 

Whether you are doing your evaluation with

an internal or external evaluator, planning

the evaluation is vital. Careful planning can

prevent future problems, such as discovering

that you have not collected data consistently

or realizing that you missed an opportunity to

collect important information. Every evaluation is unique to the particular program and

system in which it operates. It is critical to

collect only the data you need for the evaluation—such as how closely your program

adheres to best practices (fidelity) or how

best practices are improving client outcomes.

The assessment burden (i.e., the number of

instruments and questions you ask of participants) has a great influence on the cost of the

evaluation and, perhaps more important, the 

willingness of participants to cooperate. Be

parsimonious in data collection. 

Step 1. Selecting the Type of Evaluation 

There are two basic types of evaluations: process evaluations and outcome evaluations. 

Process evaluations demonstrate how a 

program functions, how different parts relate

to one another, and how well the pieces

fit together. This information determines

whether a program’s overall functioning has

improved as a result of the changes. Process

evaluations can elucidate unquestioned practices, such as who makes decisions and how 

new staff members are trained. Types of process evaluations are explained below: 

●		 Fidelity evaluations measure how 

closely the intervention or component

matches EBPs. A fidelity evaluation

of motivational interviewing (MI), for

example, could include observation of

counseling sessions. The observer could

record how closely the clinician followed

best practices. 

●		 Cost-benefit evaluations provide information on the relative costs and benefits 

of a particular implementation. Costbenefit analysis can include measures

of overall costs (e.g., the administrative

burden of a particular program or intervention), or it can provide information

on costs saved by reducing recidivism

through a deterrent program. The Drug

Abuse Treatment Cost Analysis Program

(DATCAP) is a collection instrument and

interview guide for use in a variety of

settings. DATCAP can be used for economic evaluations of addiction treatment 

through the sharing of proprietary instruments, working papers, and published

research. Resources are available at 

http://www.DATCAP.com. 

● Program evaluations are generally

broader than outcome evaluations (see

below) or fidelity evaluations. Program

evaluations attempt to appraise the 

38 
whole program—how well does the

program adhere to its mission? How well

does it address the needs of consumers? 

Information for a program evaluation can

be gleaned from other types of evaluation,

such as outcomes evaluation or costbenefit evaluation. 

Outcome evaluations provide information

on the effect the changes have on the individual, program, or community. This type

of evaluation is tailored to specific factors

identified for change (e.g., increase client

retention). It provides information about the

program’s or intervention’s success compared

with TAU. Outcome evaluations measure 

short-term change (improved retention in

treatment) or long-term change (decreased

criminal activity). 

Step 2. Deciding What To Measure and 

How To Measure It 

A first step in your evaluation is to decide

what, exactly, you want to measure. What

are the goals of the evaluation? Are you interested in outcomes, such as retention rates 

and abstinence rates? Do you want to know 

Chapter 5—Evaluation 

how closely your program follows best practices? Evaluations can measure the following: 

●		 Client satisfaction 

●		 Outcomes of specific interventions 

●		 Effectiveness of training in achieving

desired outcomes (e.g., skill enhancement,

staff retention, staff satisfaction) 

●		 Degree to which the program or practice

matches EBPs 

●		 Program efficiency 

●		 Costs of program or intervention. 

For every piece of information, you should

identify how you will measure outcomes.

Exhibit 5-2 gives examples of measures for

the program described in the hypothetical

scenario at the beginning of the chapter. For

most substance abuse treatment organizations, costs will be a primary concern. Data

that are independent of patient self-reports

increase the costs of the evaluation. Generally, self-report measures are acceptable as

long as data are collected in the manner that

ensures their reliability and validity (e.g.,

independent followup interviews). 

Exhibit 5-2 Sample Evaluation Measures 

Outcome Measure Inpatient (0–6 months) Outpatient (7–12 months) 

Abstinence Substance-free urine 

sample 

Random urine drug testing Random urine drug testing 

Housing Stable housing defined as 

lease, ownership, or indefinite residence with family 

member/friend in drugfree accommodation 

N/A Followup visit 

Confirmation through lease, title, 

or letter from family/friend 

Employment 3 months of employment 

for at least 30 hours per 

week 

Self-reports at intake Confirmation with employer or 

pay stubs 

Self-reports of days worked, type 

of work, and net income 

Criminal 

justice 

involvement 

Arrests with charges to 

new crimes 

Probation/parole violations 

Criminal record at intake Self-reports and court, probation, 

or parole officer reports 

Child 

psychosocial 

functioning 

Assessment at intake Periodic assessments 

Staff, family, and teacher 

observations 

Periodic assessments 

Staff, family, and teacher 

observations 

39 
Implementing Change in Substance Abuse Treatment Programs 

Step 3. Setting the Baseline 

Most types of evaluations require a baseline

for comparison. Baseline measures provide a

snapshot of conditions and outcomes of TAU.

Data may be collected on a range of factors: 

●		 Outcomes 

–	 Urine drug test results 

–	 Psychosocial functioning as measured

from either self-reports or thirdparty reports (e.g., family members,

probation officers) 

–	 Days abstinent 

–	 Retention rates 

–	 Psychosocial functioning (e.g.,

employment, satisfaction scales) 

–	 Recidivism (arrests, incarceration) 

●		 Client demographics (e.g., gender, race,

ethnicity) 

●		 Numbers treated 

●		 Duration of treatment 

●		 Costs of treatment 

●		 Referrals 

●		 Number of counseling sessions 

●		 Types of interventions 

●		 Client–counselor ratios. 

Your current data collection processes may

not capture enough data to establish a

baseline. For example, if the EBP measures

abstinence at 90 days through random urine

drug screens, you may not have comparable

data. Perhaps you rely on self-reports. Or

perhaps you do not track this information.

To establish a baseline, you must implement

random urine drug testing and record those

results in a systematic, retrievable manner 

before you make changes to your treatment

program. Otherwise, you will not know with

certainty how well the changes are working.

Exhibit 5-3 compares the advantages and 

disadvantages of different methods for collecting data. 

Step 4. Selecting Data Collection Points 

As you develop your evaluation plan, consider appropriate points at which to collect

data. These points could be at intake and at

specified times before and after intake. Data

collection points are also time intervals after

a specific event, such as a training episode

or an employee evaluation. In some cases,

funders may require that data be collected

at specified points as illustrated in the hypothetical scenario at the start of the chapter.

For example, you may be required to record

outcomes at specified intervals. Or you may

want to replicate the treatment guidelines for

the new EBP you are implementing to better 

compare outcomes. 

Step 5. Measuring Fidelity 

Although best practices cannot always be replicated in the real world, measuring fidelity is

vital to the evaluation. Without it, you have

no way of knowing how closely you are following best practices or whether changes in outcomes are attributable to the new programs

or practices or to other factors. 

In a review of fidelity measures, Mowbray

and colleagues (2003) provide an overview of

fidelity criteria in mental health, education,

and other human services and outline the 

steps involved in establishing fidelity criteria: 

●		 Identify key components of the

intervention or program. These 

elements, strategies, or processes define

the best practice. For example, the best

practice for a family-focused intervention

might include 5 sessions of family

therapy, at least 2 sessions of individual

therapy for each family member, and 10

followup family sessions. Key components

would be each type of session (family and

individual), sessions during and after

treatment, and the number of each. 

40 
Chapter 5—Evaluation 

Exhibit 5-3 Comparison of Data Collection Methods 

Method Advantages Disadvantages Examples 

Questionnaires, 

surveys 

Can be collected 

anonymously 

Are inexpensive 

Provide broad reach 

Can bias client’s responses 

Provide no followup 

May require sampling expert 

Questionnaires on client/ 

family/staff experiences 

Staff perceptions of needs/ 

problems/attitudes 

Client satisfaction surveys 

Surveys of community partners 

and community perceptions of 

program 

Interviews Provide depth of 

information 

Can engage/educate 

clients/stakeholders 

Are time consuming 

Are difficult to analyze 

Are costly 

Allow for interviewer bias 

Are questionable unless 

standardized, validated tools 

are used 

Posttreatment interview 

Staff interviews to assess 

perceptions 

Interviews with partner groups 

Documentation 

reviews 

Provide comprehensive 

and historical 

information 

Can be conducted 

without interruption 

of processes 

Evaluate information 

available 

Can be unbiased 

Are time consuming 

May record incomplete 

information 

Require clear parameters 

Can limit scope and quality of 

what has been recorded 

Chart reviews 

Review of intake information 

Observational 

studies 

Provide real-time 

information 

Are flexible 

Are difficult to interpret 

Can have observer bias 

May alter behaviors in presence of observer 

Can be expensive 

Observational evaluation of 

counseling techniques 

Focus groups Allow for guided 

discussion 

Can be easy way to 

gather information/ 

impressions 

Can quickly gather 

breadth of information 

Are difficult to analyze 

Require experienced 

facilitator 

Are logistically challenging 

Allow for peer influence 

Focus groups of patients 

Focus groups of stakeholders 

to identify perception/ 

experience 

Case studies Are in depth 

Illustrate success/ 

problems/limitations 

Support the power of 

personal narrative 

Are time consuming 

Are subjective 

Offer few data for analysis 

Case records 

SourceS: Centers for Disease Control and Prevention, 2005; McNamara, 2007; W. K. Kellogg Foundation, 1998. 

41 
Implementing Change in Substance Abuse Treatment Programs 

Don’t worry about what type of evaluation 

you need or are doing—worry about what you 

need to know to make the program decisions 

you need to make, and worry about how you 

can accurately collect and understand that 

information. 

—McNamara, 2007 

●		 Define measurable indicators for 

each component. In some cases, 

the indicator will be easy to define. A

treatment session occurred or did not 

occur. In other cases, the indicator 

will not be so clear-cut. For specific

techniques (e.g., MI), the indicators may

not be obvious and may require subjective

observation. 

●		 Collect the data measuring the

indicators. Data collection for fidelity

measures might include the number of

sessions a client attends or the amount of 

time spent in treatment sessions. 

●		 Examine the reliability and

validity of the fidelity criteria. To 

be worthwhile, fidelity measures should

consistently and accurately measure

indicators. Mowbray and colleagues

(2003) identify common measures for

assessing the validity and reliability

of the fidelity criteria. For example,

observations of a counselor’s use of a 

particular technique might yield two very

different interpretations, suggesting that

the evaluation criteria need to be more 

objective (inter-test reliability). 

Collecting Data 

Your evaluation will be only as good as your

data. Without clear, consistent data collection procedures and thorough quality checks,

the evaluation will be useless. Questions to 

consider when deciding how data will be collected include the following: 

●		 Who will collect the data? Are staff 

members responsible? If so, are they

trained in data collection techniques? Do

they have adequate time? 

●		 Will data collection use validated, reliable 

tools (strongly recommended when

available) or a tool of your own invention

(making outcomes less comparable with

the EBP)? 

●		 How will you ensure that data are

collected consistently and in formats that

minimize errors? 

●		 Will data be compiled from outside

sources (e.g., the courts)? If so, are the

data collection points compatible with

measures collected internally (e.g., at the

same intervals, using the same methods)? 

●		 How will data be stored? Will backup

systems ensure data are not lost? Is

the system secure? Does it conform to

confidentiality requirements? 

●		 Who is responsible for quality assurance?

Have you developed a system to verify

that data are collected, recorded, and 

stored appropriately? How often will

quality assurance checks be performed? 

Analyzing Data 

Data analysis is the examination of the

information gathered. It can be as simple as

calculating percentages based on answers to

questions or as complex as identifying relationships between events or outcomes. There

are two basic types of analysis: 

●		 Quantitative data analysis. Gives 

measurements as percentages,

significance, or probabilities. It assigns

numbers to information, quantifying

results. Quantitative data can be derived 

from surveys, demographics on client

outcomes, or costs. Generally, performing

quantitative data analysis requires a

background in statistical analysis. 

●		 Qualitative data analysis. Provides 

more contextual information and can 

be a valuable tool in explaining why

elements work or do not. It can help you

understand how closely your program

follows EBPs. For example, if you have 

42 
Chapter 5—Evaluation 

adopted MI, results of observations and

interviews could demonstrate where 

counselors are falling short. Qualitative

data analysis can describe processes,

highlight key relationships, and give the

overall picture in which the program

exists or the practices occur. Qualitative

data can be derived from interviews, 

open-ended surveys, focus groups, or

observations. 

Regardless of type of data analysis, important

considerations include the following: 

●		 How will the data be analyzed (e.g.,

statistical method)? 

●		 Who will analyze the data? Are they

qualified to do so? 

●		 What measures have you taken to

minimize bias? For example, if you ask

clinicians to rate their clients’ functioning,

are standardized criteria used by all

clinicians? 

Results that are not what you had hoped

are not necessarily a sign of a failed implementation effort. They mean only that you

may need to revise your strategy. Are you

adhering to best practices? Are counselors

consistent in how they deliver services? Are

the parts of the plan working together? For

areas that fall short, use your implementation team to identify problems and possible

solutions. Perhaps trainings are insufficient 

or counselors need more feedback on their 

performance. 

Reporting 

Evaluation results should be shared openly

and often and with consideration of the 

audience (W. K. Kellogg Foundation, 1998).

Highlight positive effects, but make sure

your results are presented in a credible way

for your audience. For the implementation

team, you should show how the evaluation

results compare with the goals and implementation plan. Demonstrate where you are

meeting targets and where you are falling

behind. Communicate findings to all staff

members, accentuating the positive effects

and soliciting feedback on why results may

not be what you had hoped. For funding and

accreditation agencies, your results must

include discussion of the methodology and

limitations and the names of professional

evaluators. Note any corrective actions taken

as a result of the evaluation and processes

you have implemented to ensure the validity

of the results. 

Ultimately, the evaluation will serve as a

cornerstone to justify the changes to staff,

funders, and stakeholders. If you have conducted a credible evaluation with demonstrated outcomes, you are well on your way

to the next chapter—sustainability. 

43 

Chapter 6—Sustainability
 

Hypothetical Scenario 1 

You have implemented your change plans, and the results are good. Client retention 6 

months after implementation has improved 20 percent! You celebrate your success and 

congratulate staff, only to discover that staff members are unhappy with the changes. 

More clients are staying in treatment, and new admissions have not decreased. Overburdened by the increased client load, some staff members ask to return to the way 

things were before the changes. Your plan, although successful, also achieved unintended consequences. What to do now? 

Change efforts—no matter how effective—are

not likely to survive without a plan to sustain

them. By carefully developing the implementation plan and evaluating new programs

and practices, you are well on your way to

implementing long-term change. However,

full implementation—the point at which

best practices or programs become “practice

as usual”—can take as long as 2 to 4 years

(Fixsen, Naoom, Blase, Friedman, & Wallace,

2005). Even then, best practices are not selfmaintaining. Changes in staffing, treatment

priorities, reimbursement systems, and funding or accrediting requirements require an

ongoing effort to ensure practices are in line

with research. 

Sustainability Phases 

Sustainability can be understood as a longterm process involving three overlapping

phases (Jerald, 2005): 

●		 Maintenance—the immediate aftermath 

of the implementation 

●		 Extension—survival after the change has

proved successful 

●		 Adaptation—long-term survival. 

Jerald (2005) notes that, although these

phases apply to discrete periods, the strategies to ensure sustainability should be instigated as soon as the change efforts begin.

This chapter suggests ways to nurture the

changes for each stage and suggests strategies for long-term financial survival. 

Maintenance Phase 

Change plans—however successful—often

have unanticipated consequences. No amount

of planning can foresee how changes in one

area will affect other program components.

Strategies for monitoring your progress and

making necessary adjustments are noted

below. 

Provide reinforcement. The literature 

on organizational change consistently

demonstrates the importance of consistent

and clear reinforcement of the new practices

(Dansereau & Dees, 2002; Fixsen et al.,

2005; Silversin & Kornacki, 2003; Torrey et

al., 2002). Reinforcement can come in many

forms: continual reminders in staff meetings,

evaluations that reward implementations,

ongoing training and coaching, or supervisory oversight. Dansereau and Dees 

45 
Implementing Change in Substance Abuse Treatment Programs 

(2002) evaluated training programs for

implementing cognitive mapping. They found

that the key to successful and sustained

implementation is to focus less on the “rules”

of the intervention and more on providing

specialized feedback. They recommend

practice sessions to help counselors integrate

intellectual understanding with the actual

performance of the intervention and ongoing

coaching that provides one-on-one feedback.

In practice, such reinforcement can be

challenging to fit into an already-taxed

work schedule. If these practice sessions

are implemented, the schedules for the

individuals involved should be reduced to 

accommodate the added burden. 

Monitor fidelity. Over time, some practitioners retreat to old patterns and behaviors,

making it important to continually monitor

how closely the programs and practices follow best practices. In their review of the literature, Fixsen and colleagues (2005) found

that positive outcomes are more likely to

continue when fidelity is high. The distinction

needs to be made, however, between “drift” 

and “reinvention” (sometimes referred to as

innovation). Drift refers to the tendency to

move away from best practices as time goes

on. The pull of treatment as usual (TAU) may

cause clinicians to return to familiar treatment approaches. Programs may retreat from

the practices that have proved to be effective.

Conversely, reinvention refers to positive

adaptations that improve outcomes or that

make evidence-based practices (EBPs) possible. For example, a substance abuse treatment agency may find that recommended

daily counseling sessions are too costly to 

sustain but that comparable outcomes are

acquired through sessions held three times a

week. 

Monitor outcomes. As the change effort

unfolds, do not wait for the final evaluation to 

examine the results. Although the full benefit

of the changes may take time, preliminary

results can identify areas in need of change or

attention. 

Look out for unintended consequences.

As noted in hypothetical scenario 1, change

sometimes has unintended consequences. A

new policy may have repercussions you had

not considered. For example, you may have a

new policy requiring drug testing, but you did

not establish processes for collecting and processing samples. Or perhaps you have added

a family component but find that staff members are overburdened with the emotional 

repercussions from their clients. 

Monitor how change has affected revenues and expenses. Have you improved

your outcomes slightly while increasing

your costs significantly without a commensurate increase in revenues from your new

or improved services? Keep your eye on the

bottom line. New funding revenues may be

needed, or you may need to scale back your

program. (See Where’s the Money? on page

49.) 

Train new staff. Not all new staff will enter 

your program with the same understanding of best practices. Include training in best

practices at orientation, and explain why you

adhere to best practices. 

46 
Chapter 6—Sustainability 

Hypothetical Scenario 2 

You are the director of a program that provides residential treatment for mothers and 

their children. Two years ago, you started a groundbreaking program that included 

treatment for co-occurring disorders with specialized attention to trauma, parenting 

classes, and other components tailored to the population you serve. The program was 

considered one of the best in the country—a model program that others sought to 

replicate. Staff is now familiar with the interventions and practices and executes them 

routinely. Surprisingly, however, the gains you made in years 1 and 2 hold steady in year 

3 and drop dramatically in year 4. What happened? 

As you explore the causes, you note that since your program first began, staff turnover has been high. New staff members have not been trained and coached on the 

interventions to the same degree. Moreover, since your program began, the number 

of clients abusing several drugs has increased and several clients have begun abusing 

methamphetamine. Funding cuts have forced you to reduce treatment to a maximum 

of 3 months. A community-based nonprofit that you had partnered with to help program graduates find jobs has closed. The only occupational services provided now are 

through the overtaxed county employment office. What to do now? 

Extension Phase 

Treatment Improvement Protocols (TIPs)

describe best practices at a particular time.

As new research becomes available, substance abuse patterns shift, client demographics change, funding streams expand and

contract, and best practices can become outdated. Without specific, ongoing mechanisms

to ensure long-term survival, today’s EBPs

may not be considered best practices in the

future. To stay up to date, your program must

implement mechanisms such as the following

to ensure that program components remain 

current: 

●		 Continue to monitor outcomes and other 

consequences of the implementation, and

make adjustments as they are indicated. 

●		 Be prepared to make changes. Reconvene

your implementation team if major

changes are indicated, and begin the

planning process anew. 

●		 Develop staff skills. Recruit staff

with experience in the best practice

or program. Continue to include best

practices in new staff orientation,

and provide ongoing training for all

staff members. Initiate a mentoring

program that allows less experienced

staff members to benefit from seasoned 

counselors. Incorporate best practices into

employee reviews, and provide rewards

for adherence. 

●		 Stay abreast of developments and

research. As new TIPs are issued, review 

their recommendations. Be prepared to

revise and update as research suggests

improved practices. 

●		 Keep your finger on the pulse of your

client base. Identify changes in client

demographics, and anticipate needs in the

communities you serve. 

47 
Implementing Change in Substance Abuse Treatment Programs 

Hypothetical Scenario 3 

Once considered a model program, your organization now faces the possibility of 

closing its doors. Practices that worked well 10 years ago are not working as well now. 

Your clientele is getting younger; the number of female clients is increasing; and many 

clients abuse methamphetamine. TAU no longer works—potential clients are looking for 

programs that offer specialized programs, that treat co-occurring mental disorders, and 

that offer extended continuing care. What went wrong? 

Adaptation Phase 

The adaptation phase is more than the survival of the best practices; it is the long-term

survival of the organization itself. Unless

you have a clear sense of your organization’s

values, mission, and goals, your organization can easily flounder in the face of changes

and challenges. This section suggests steps

you can take to build an organization that

thrives. 

Sustaining success over the long term requires 

a fierce, very intentional kind of “opportunism.” 

That isn’t just a platitude: The research on organizational change has confirmed again and again 

that the organizations most successful at sustaining improvement over long periods of time 

learn to enact new, “next generation” improvements even as they work to maintain practices 

that are already working.

 —Jerald, 2005 

Create a vision. Sustaining change for the

long run requires a clear vision of where your

organization is headed beyond the implementation stage. Define your goals for the long

term. Rewrite your mission statement to promote the use of EBPs. Understand the niche 

that your program fills. Consider gaps in

current delivery systems, and develop ideas

for how your program might position itself to

bridge them. 

Garner support. Publicize your implementation of best practices and improved

outcomes in every source available to you 

(e.g., organization newsletter, Web site, local

media, presentations at conferences, local/

national associations, advocacy groups).

Develop relationships with universities and

other research institutions. Stay active in

professional associations, and make your

presence known to advocacy groups. 

Encourage advocacy. Cultivate relationships with people who support your program

and are in positions to speak for you. Torrey

and colleagues (2002) suggest maintaining

long-term involvement with clients and their

families. These consumers often have a personal interest in ensuring that the best possible care is available. The authors also suggest

that fostering relationships with advocacy

organizations, universities, and professional

organizations may provide valuable reinforcement to programs. 

Stay adaptable. Programs that work now

may be less effective in the future. Set up a

system for periodic review of current practices and exploration of new programs and

practices. Be prepared to change course

as improved treatment options become

available. 

Monitor trends. Stay abreast of trends in

the field. Subscribe to journals, attend conferences, and encourage staff members to

stay current in their field. Be familiar with

trends in your community, and be prepared to

address changing demographics of abuse. 

48 
Chapter 6—Sustainability 

Hypothetical Scenario 4 

You have completed an evaluation of a program to integrate treatment for cooccurring mental disorders into your long-term outpatient substance abuse treatment 

program. The results are positive. At 1 year, clients show higher rates of employment, 

improved psychosocial functioning, higher abstinence rates, and fewer arrests compared with TAU. Despite the promising outcomes, the grant that funds the additional 

components runs out in 6 months, and you cannot reapply. If funding sources are not 

identified, you will be forced to dismantle services. What to do now? 

Where’s the Money? 

The best-laid plans require money. Even with

a thoughtful vision, precise change plans,

and a commitment to organizational change,

your best thinking is not likely to take you

far without a plan for sustained financial 

support. 

Long-range financial planning is an imprecise

exercise. Funding sources can be unpredictable, changing frequently. The same logic

that applies to effective personal financial

planning applies here. Diversify funding

sources. Overreliance on one funding stream

can be disastrous when the funding ends. 

Perhaps the new or improved service can

be self-sustaining through increased revenue (e.g., an increased fee for the service or

additional patients attracted because of the

change). Positive outcomes achieved under

one funding stream can be used to acquire

additional funding. By providing services

with proven effectiveness, you will be better positioned to compete for other funding 

sources. 

Cost-Cutting Strategies 

•	Solicit in-kind support. Solicit nonmonetary contributions for goods and services you would otherwise 

purchase (e.g., donations of computer equipment, plumbing services from local businesses). 

•	Share resources/staff. Consider sharing resources with other organizations in your community (e.g., 

staff, vehicles, computer equipment, combined trainings). 

•	Hand the services off to another organization or agency. Keep program components running by allowing another organization to assume responsibility for them. 

•	Tap into personnel resources that are shared or in training. Recruit people in other organizations who 

can be shared at low or no cost (e.g., clerical staff). Take advantage of volunteers, internships, and 

college work-study programs. 

•	Develop a fee-for-service structure. Consider requiring clients to pay for services. Sliding-fee scales 

impose minimal burdens on those with limited resources while providing a steady (if limited) financial 

stream. 

•	Budget efficiently. Examine your current budget. Are funds used efficiently? Do they fit with your 

organization’s priorities? Are there programs or services that do not demonstrate good outcomes? 

Is there duplication in services? 

Source: Robert Wood Johnson Foundation, n.d. 

Draft a detailed account of all elements of the 

new program or practice and the resources

(personnel, equipment, space, etc.) needed to

sustain all aspects of your program, including

ongoing evaluation. Include in your equation 

49 
Implementing Change in Substance Abuse Treatment Programs 

the costs of monitoring, mentoring, and

training. Consider your overall budget, your

projected revenues, and the total expected

expenditures (see Exhibit 6-1). 

Exhibit 6-1 Sample Budget Forecast 

Expenditures Year 1 Year 2 Year 3 Year 4 Year 5 

Computer equipment $2,500 $500 $500 $500 $1,200 

Space/insurance $12,000 $12,500 $13,000 $13,500 $14,000 

Vehicles $12,000 $1,000 $1,000 $1,000 $1,000 

Staff $289,000 $312,000 $325,000 $350,000 $375,000 

Training $10,000 $8,000 $5,000 $5,000 $5,000 

Evaluator $12,000 $6,000 $6,000 $6,000 $6,000 

Total costs $337,500 $340,000 $350,500 $376,000 $402,200 

Income Year 1 Year 2 Year 3 Year 4 Year 5 

Federal funds $250,000 $250,000 $250,000 0 0 

State grant funds $50,000 $50,000 $50,000 $50,000 $50,000 

Potential matching funds $125,000 $125,000 $125,000 0 0 

Fees for service $40,000 $40,000 $40,000 $40,000 $40,000 

Total funds $465,000 $465,000 $465,000 $90,000 $90,000 

Surplus/Deficit +$127,500 +$125,000 +$114,500 -$286,000 -$312,200 

Think creatively when considering possible

financial resources. Funding can come from

traditional sources (grants, Federal support),

as well as from unexpected places (third parties, planned giving arrangements). Venues

for financial inflow are noted below: 

●		 Federal grants 

●		 State legislature appropriations or grants 

●		 City council/government appropriations or 

grants 

●		 County appropriations or grants 

●		 Client fees 

●		 Third-party funding (organizations

or businesses with a track record of 

supporting substance abuse treatment or

with a vested interest in treatment) 

●		 Fundraisers 

●		 Endowments or planned giving. 

50 
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58 
Appendix C—Evaluation Resources 

American Evaluation Association 

http://www.eval.org 

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Prevention 

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Community Tool Box, University

of Kansas 

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Georgetown University Center for

Child and Human Development

http://gucchd.georgetown.edu 

Harvard Family Research Project

http://www.gse.harvard.edu/hfrp 

Innovation Network 

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Network for the Improvement of 

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https://www.niatx.net/Home/Home.

aspx?CategorySelected=HOME 

Robert Wood Johnson Foundation 

Community Toolbox

http://www.rwjf.org/grantees/howtotools/

communitytoolbox.jsp 

Sierra Health Foundation 

http://www.sierrahealth.org 

University of Wisconsin Cooperative 

Extension 

●		 Evaluation Resources 

http://www.uwex.edu/ces/pdande 

●		 Logic Model Course

http://www1.uwex.edu/ces/lmcourse 

W. K. Kellogg Foundation

http://www.wkkf.org 

59 

Appendix D—Field Reviewers
 

Catherine S. Chichester, M.S.N., RN, CS 

Executive Director 

Co-Occurring Collaborative of Southern

Maine 

Portland, Maine 

Ann Davis, M.Ed., LCAS, CCS 

Director of Administrative Services 

Walter B. Jones Alcohol and Drug Abuse

Treatment Center 

Greenville, North Carolina 

Dedric L. Doolin, M.P.A.
 

Deputy Director

Area Substance Abuse Council, Inc.
 

Cedar Rapids, Iowa
 

Kevin Doyle, Ed.D., LPC, LSATP

Vice President for Enhancement
 

Vanguard Services Unlimited

Alexandria, Virginia
 

Steve Gallon, Ph.D.
 

Director
 

Northwest Frontier Addiction Technology

Transfer Center 

Salem, Oregon 

Karen Garrett, M.A., CAP, CAPP, CMPH 

Senior Director of Quality Improvement

and Training

River Region Human Services, Inc.

Jacksonville, Florida 

Catherine A. Kendrick, M.Ed. 

School-Based Therapist

Jefferson Center for Mental Health 

Lakewood, Colorado 

Paul D. Nagy, M.S., LPC, LCAS, CCS

Program Director

Duke Addiction Program

Department of Psychiatry

Duke University

Durham, North Carolina 

Patrick Reilly, Ph.D.

Santa Rosa Veterans Clinic 

Santa Rosa, California 

Jeffrey Savoy, LCSW, CASAC

Vice President, Director of Clinical Support

Services 

Odyssey House

New York, New York 

Gerard Schmidt, M.A., LPC, MAC 

Vice President and Chief Development Officer

Valley Healthcare System

Morgantown, West Virginia 

Kathyleen Tomlin, M.S., LPC, CADCII

Clinical Services Manager

Department of Addiction Medicine

Portland, Oregon 

Michael Towey, M.P.A., CDP, CPP

Faculty

Tacoma Community College

Tacoma, Washington 

Kerry W. Wicks, LAC

Clinical Director 

North Dakota State Hospital, Behavioral

Health Services 

Jamestown, North Dakota 

Edie Wooldridge, CADCII

Community Justice Manager

Day Reporting Center

Multnomah County Department of

Community Justice

Portland, Oregon 

Diana Yazzie Devine, M.B.A., LCSAC, CSAC 

President, CEO 

Native American Connections 

Phoenix, Arizona 

61 

 

 

 

 

 

 

 

 

Appendix E—Acknowledgments
 

Numerous people contributed to the development of this TAP, including TAP Field

Reviewers (see Appendix D). 

This publication was produced under the

Knowledge Application Program (KAP), a

Joint Venture of The CDM Group, Inc., and

JBS International, Inc. (JBS), for the Substance Abuse and Mental Health Services 

Administration, Center for Substance Abuse 

Treatment. 

Lynne MacArthur, M.A., A.M.L.S., served as 

the JBS KAP Executive Project Co-Director, 

and Barbara Fink, RN, M.P.H., served as the 

JBS KAP Managing Project Co-Director. Other 

JBS KAP personnel included Candace Baker, 

M.S.W., CSAC, MAC, Deputy Director for Product Development; Thomas R. Jackson, M.S.W., 

Expert Content Director; Deborah Steinbach, 

M.A., Senior Writer; Wendy Caron, Editorial Quality Assurance Manager; and Frances 

Nebesky, M.A., Quality Assurance Editor. 

63 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

10

15

20

25

30

Other Technical Assistance Publications (TAPs) include: 

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HHS Publication No. (SMA) 09-4377

Substance Abuse and Mental Health Services Administration

Printed 2009