Outer-context determinants in the sustainment phase of a reimbursement-driven implementation of evidence-based practices in children's mental health services

Using Causative Methods to Determine System-Level Factors Driving the Uptake and Use of Evidence-Based Practices in a Public Early Intervention System

Part C Early Intervention (EI) systems are an entry point to services for autistic toddlers and can be leveraged to facilitate access to autism evidence-based practices (EBPs). However, EI systems are complex and limited research has examined how an EI system's infrastructure (i.e. system-level factors) impacts the adoption and implementation of EBPs. To address this gap, 36 EI providers and 9 EI administrators completed a semi-structured interview or focus group about factors impacting the implementation of autism EBPs. Qualitative analysis included a combination of grounded theory and causative coding. Analyses were refined by input from providers, administrators, and family stakeholders in the form of round tables and presentations at the state's interagency coordinating council. Primary themes centered on: (1) the costs associated with independent contracting structures; (2) operational demands; (3) workforce stability; (4) communication consistency; and (5) implementation supports for EBP implementation. Causative coding helped to demonstrate the perceived relationships between these factors and underscored the important role of incentivization structures, collaboration opportunities, and championing in supporting the use of EBPs within a system that primarily uses independent contracting structures. The current study extends previous research by demonstrating how several system-level factors are perceived to play a role in the adoption and implementation of EBPs by independently contracted EI providers. These findings underscore the need for implementation strategies, such as incentivization strategies and social network building, to increase providers' implementation of autism EBPs within EI systems.

Randomized trial of the leadership and organizational change for implementation (LOCI) strategy in substance use treatment clinics

INTRODUCTION

Evidence-based practice (EBP) implementation represents a strategic change that requires alignment of leadership and support throughout organizations. Leadership and Organizational Change for Implementation (LOCI) is a multifaceted implementation strategy that aims to improve implementation leadership and climate within organizations through iterative cycles of leadership and climate assessment and feedback, leadership training and coaching, and strategic planning with upper-level leaders. This study tested the effects of LOCI on transformational and implementation leadership, implementation climate, implementation citizenship behavior, and EBP reach.

METHODS

A multiple cohort, cluster randomized trial tests the effect of LOCI in 60 clinics across nine behavioral health organizations in California and Arizona, USA. The study randomized clinics within organizations to either LOCI or a leadership training webinar control condition in three consecutive cohorts. Repeated web-based surveys of direct service providers (nLOCI = 201, nControl = 179) assessed leadership, implementation climate, and implementation citizenship over time. Multilevel autoregressive modeling was the primary statistical analysis such that providers (level-1) were nested within clinics (level-2). The study predicted between-condition differences at 4-, 8-, and 12-month follow-up assessments. Provider engagement in a fidelity monitoring process assessed reach of motivational interviewing (i.e., number of sessions recorded/submitted for fidelity coding). An independent sample t-test explored between condition differences in motivational interviewing reach.

RESULTS

Results indicated between condition differences at 4 months for implementation leadership, implementation climate, and implementation citizenship behavior such that greater improvements were evidenced in the LOCI condition compared to the control condition. Reach of MI was significantly greater in the LOCI vs control condition such that LOCI providers were significantly more likely to engage in the fidelity monitoring process (chi-square (1, n = 370) = 5.59, p = .018).

CONCLUSIONS

LOCI was developed based on organizational theories of strategic leadership and climate to affect organizational change processes that communicate that innovation implementation is expected, supported, and recognized as a value of the organization. The LOCI implementation strategy resulted in more positive hypothesized outcomes compared to the control condition. Organizational change strategies have utility for implementing health innovations in complex, multilevel contexts and for greater sustainment of facilitative leader behaviors, strategic implementation climate, and improved implementation outcomes.

TRIAL REGISTRATION

This study is registered with Clinicaltrials.gov gov (NCT03042832, 2 February 2017; retrospectively registered).

Utility of the Leadership and Organizational Change for Implementation-Systems Level (LOCI-SL) strategy for a statewide substance use treatment implementation effort

INTRODUCTION

Multi-level and cross-context implementation strategies are needed to support health systems, healthcare delivery organizations, and providers to adopt evidence-based practice (EBP) for substance use disorder (SUD) treatment. However, misalignment between state oversight agencies and healthcare organizations about which services to prioritize and which outcomes are reasonable to expect can hinder implementation success and widespread access to high-quality care. This study investigated the utility of the Leadership and Organizational Change for Implementation-System Level (LOCI-SL) strategy for supporting statewide EBP implementation for SUD treatment.

METHODS

Nine community mental health centers (CMHCs) contracted by a state agency participated in a combined motivational-enhancement therapy and cognitive behavioral therapy (MET/CBT) implementation effort. Five of the CMHCs also received the LOCI-SL strategy to obtain ongoing implementation support. We conducted 21 individual interviews and three small group interviews with 30 participants across CMHCs and state health agencies to investigate the utility of LOCI-SL in supporting their EBP implementation efforts. Deductive thematic analysis was guided by the Exploration, Preparation, Implementation, Sustainment Framework.

RESULTS

Five themes described CMHCs' LOCI-SL and broader contextual experiences implementing EBPs: (1) LOCI-SL supported executives in Preparation phase activities that holistically considered organizational needs and capacity to implement and sustain EBPs; (2) LOCI-SL facilitated trust and communication processes across Preparation, Implementation, and Sustainment phases to improve EBP uptake; (3) LOCI-SL increased CMHCs' use of implementation climate strengthening activities throughout the Implementation phase; (4) state contracts did not emphasize quality and thus were not sufficient bridging factors to enforce EBP fidelity during Implementation; and, (5) limited funding and low Medicaid reimbursement rates hindered EBP use throughout the Implementation and Sustainment phases.

CONCLUSIONS

LOCI-SL was viewed as a favorable and useful implementation strategy for supporting statewide adoption of EBPs. However, outer context barriers, including limited financial investments in the treatment system, impeded implementation and sustainment efforts. While previous research suggests that contracts are viable alignment-promoting bridging factors, this study demonstrates the importance of articulating implementation outcome expectations to aid state-contracted organizations in achieving EBP implementation success. This study also highlights the need for multi-level implementation strategies to effectively align implementation expectations between outer- and inner-context entities.

Outer-context determinants on the implementation of school-based interventions for LGBTQ+ adolescents

Background

Schools are critical venues for supporting LGBTQ+ youth well-being. Implementing LGBTQ-supportive practices can decrease experiences of stigmatization, discrimination, and victimization that lead to adverse mental health outcomes like anxiety, depression, and suicidality. However, schools are also subject to a wide range of outer-context pressures that may influence their priorities and implementation of LGBTQ-supportive practices. We assessed the role of emergent outer-context determinants in the context of a 5-year cluster randomized controlled trial to study the implementation of LGBTQ-supportive evidence-informed practices (EIPs) in New Mexico high schools.

Method

Using an iterative coding approach, we analyzed qualitative data from annual interviews with school professionals involved in EIP implementation efforts.

Results

The analysis yielded three categories of outer-context determinants that created challenges and opportunities for implementation: (a) social barriers related to heterocentrism, cisgenderism, and religious conservatism; (b) local, state, and national policy and political discourse; and (c) crisis events.

Conclusions

By exploring the implications of outer-context determinants for the uptake of LGBTQ-supportive practices, we demonstrate that these elements are dynamic-not simply reducible to barriers or facilitators-and that assessing outer-context determinants shaping implementation environments is crucial for addressing LGBTQ health equity.

Revisiting the policy ecology framework for implementation of evidence-based practices in mental health settings

BACKGROUND

Over the past three decades, policy actors and actions have been highly influential in supporting the implementation of evidence-based practices (EBPs) in mental health settings. An early examination of these actions resulted in the Policy Ecology Framework (PEF), which was originally developed as a tactical primer for state and local mental health regulators in the field of child mental health. However, the policy landscape for implementation has evolved significantly since the original PEF was published. An interrogation of the strategies originally proposed in the PEF is necessary to provide an updated menu of strategies to improve our understanding of the mechanisms of policy action and promote system improvement.

OBJECTIVES

This paper builds upon the original PEF to address changes in the policy landscape for the implementation of mental health EBPs between 2009 and 2022. We review the current state of policy strategies that support the implementation of EBPs in mental health care and outline key areas for policy-oriented implementation research. Our review identifies policy strategies at federal, state, agency, and organizational levels, and highlights developments in the social context in which EBPs are implemented. Furthermore, our review is organized around some key changes that occurred across each PEF domain that span organizational, agency, political, and social contexts along with subdomains within each area.

DISCUSSION

We present an updated menu of policy strategies to support the implementation of EBPs in mental health settings. This updated menu of strategies considers the broad range of conceptual developments and changes in the policy landscape. These developments have occurred across the organizational, agency, political, and social contexts and are important for policymakers to consider in the context of supporting the implementation of EBPs. The updated PEF expands and enhances the specification of policy levers currently available, and identifies policy targets that are underdeveloped (e.g., de-implementation and sustainment) but are becoming visible opportunities for policy to support system improvement. The updated PEF clarifies current policy efforts within the field of implementation science in health to conceptualize and better operationalize the role of policy in the implementation of EBPs.

Understanding implementation completion of tailored motivational interviewing in multidisciplinary adolescent HIV clinics

Background

Understanding the barriers and facilitators of implementation completion is critical to determining why some implementation efforts fail and some succeed. Such studies provide the foundation for developing further strategies to support implementation completion when scaling up evidence-based practices (EBPs) such as Motivational Interviewing.

Method

This mixed-methods study utilized the Exploration, Preparation, Implementation, and Sustainment framework in an iterative analytic design to compare adolescent HIV clinics that demonstrated either high or low implementation completion in the context of a hybrid Type III trial of tailored motivational interviewing. Ten clinics were assigned to one of three completion categories (high, medium, and low) based on percentage of staff who adhered to three components of implementation strategies. Comparative analysis of staff qualitative interviews compared and contrasted the three high-completion clinics with the three low-completion clinics.

Results

Results suggested several factors that distinguished high-completion clinics compared to low-completion clinics including optimism, problem-solving barriers, leadership, and staff stress and turnover.

Conclusions

Implementation strategies targeting these factors can be added to EBP implementation packages to improve implementation success.

Plain Language Summary

While studies have begun to address adherence to intervention techniques, this is one of the first studies to address organizational adherence to implementation strategies. Youth HIV providers from different disciplines completed interviews about critical factors in both the inner and outer context that can support or hinder an organization's adherence to implementation strategies. Compared to less adherent clinics, more adherent clinics reported more optimism, problem-solving, and leadership strengths and less staff stress and turnover. Implementation strategies addressing these factors could be added to implementation packages to improve implementation success.

A protocol for a multi-site cohort study to evaluate child and adolescent mental health service transformation in England using the i-THRIVE model

The National i-THRIVE Programme seeks to evaluate the impact of the NHS England-funded whole system transformation on child and adolescent mental health services (CAMHS). This article reports on the design for a model of implementation that has been applied in CAMHS across over 70 areas in England using the 'THRIVE' needs-based principles of care. The implementation protocol in which this model, 'i-THRIVE' (implementing-THRIVE), will be used to evaluate the effectiveness of the THRIVE intervention is reported, together with the evaluation protocol for the process of implementation. To evaluate the effectiveness of i-THRIVE to improve care for children and young people's mental health, a cohort study design will be conducted. N = 10 CAMHS sites that adopt the i-THRIVE model from the start of the NHS England-funded CAMHS transformation will be compared to N = 10 'comparator sites' that choose to use different transformation approaches within the same timeframe. Sites will be matched on population size, urbanicity, funding, level of deprivation and expected prevalence of mental health care needs. To evaluate the process of implementation, a mixed-methods approach will be conducted to explore the moderating effects of context, fidelity, dose, pathway structure and reach on clinical and service level outcomes. This study addresses a unique opportunity to inform the ongoing national transformation of CAMHS with evidence about a popular new model for delivering children and young people's mental health care, as well as a new implementation approach to support whole system transformation. If the outcomes reflect benefit from i-THRIVE, this study has the potential to guide significant improvements in CAMHS by providing a more integrated, needs-led service model that increases access and involvement of patients with services and in the care they receive.

Where is "policy" in dissemination and implementation science? Recommendations to advance theories, models, and frameworks: EPIS as a case example

BACKGROUND

Implementation science aims to accelerate the public health impact of evidence-based interventions. However, implementation science has had too little focus on the role of health policy - and its inseparable politics, polity structures, and policymakers - in the implementation and sustainment of evidence-based healthcare. Policies can serve as determinants, implementation strategies, the evidence-based "thing" to be implemented, or another variable in the causal pathway to healthcare access, quality, and patient outcomes. Research describing the roles of policy in dissemination and implementation (D&I) efforts is needed to resolve persistent knowledge gaps about policymakers' evidence use, how evidence-based policies are implemented and sustained, and methods to de-implement policies that are ineffective or cause harm. Few D&I theories, models, or frameworks (TMF) explicitly guide researchers in conceptualizing where, how, and when policy should be empirically investigated. We conducted and reflected on the results of a scoping review to identify gaps of existing Exploration, Preparation, Implementation, and Sustainment (EPIS) framework-guided policy D&I studies. We argue that rather than creating new TMF, researchers should optimize existing TMF to examine policy's role in D&I. We describe six recommendations to help researchers optimize existing D&I TMF. Recommendations are applied to EPIS, as one example for advancing TMF for policy D&I.

RECOMMENDATIONS

(1) Specify dimensions of a policy's function (policy goals, type, contexts, capital exchanged). (2) Specify dimensions of a policy's form (origin, structure, dynamism, outcomes). (3) Identify and define the nonlinear phases of policy D&I across outer and inner contexts. (4) Describe the temporal roles that stakeholders play in policy D&I over time. (5) Consider policy-relevant outer and inner context adaptations. (6) Identify and describe bridging factors necessary for policy D&I success.

CONCLUSION

Researchers should use TMF to meaningfully conceptualize policy's role in D&I efforts to accelerate the public health impact of evidence-based policies or practices and de-implement ineffective and harmful policies. Applying these six recommendations to existing D&I TMF advances existing theoretical knowledge, especially EPIS application, rather than introducing new models. Using these recommendations will sensitize researchers to help them investigate the multifaceted roles policy can play within a causal pathway leading to D&I success.

Assessing the sustainability capacity of evidence-based programs in community and health settings

Background

Within many public health settings, there remain large challenges to sustaining evidence-based practices. The Program Sustainability Assessment Tool has been developed and validated to measure sustainability capacity of public health, social service, and educational programs. This paper describes how this tool was utilized between January 2014 and January 2019. We describe characteristics of programs that are associated with increased capacity for sustainability and ultimately describe the utility of the PSAT in sustainability research and practice.

Methods

The PSAT is comprised of 8 subscales, measuring sustainability capacity in eight distinct conceptual domains. Each subscale is made up of five items, all assessed on a 7-point Likert scale. Data were obtained from persons who used the PSAT on the online website (https://sustaintool.org/), from 2014 to 2019. In addition to the PSAT scale, participants were asked about four program-level characteristics. The resulting dataset includes 5,706 individual assessments reporting on 2,892 programs.

Results

The mean overall PSAT score was 4.73, with the lowest and highest scoring subscales being funding stability and program adaptation, respectively. Internal consistency for each subscale was excellent (average Cronbach's alpha = 0.90, ranging from 0.85 to 0.94). Confirmatory factor analysis highlighted good to excellent fit of the PSAT measurement model (eight distinct conceptual domains) to the observed data, with a comparative fit index of 0.902, root mean square error of approximation equal to 0.054, and standardized root mean square residual of 0.054. Overall sustainability capacity was significantly related to program size (F = 25.6; p < 0.001). Specifically, smaller programs (with staff sizes of ten or below) consistently reported lower program sustainability capacity. Capacity was not associated with program age and did not vary significantly by program level.

Discussion

The PSAT maintained its excellent reliability when tested with a large and diverse sample over time. Initial criterion validity was explored through the assessment of program characteristics, including program type and program size. The data collected reinforces the ability of the PSAT to assess sustainability capacity for a wide variety of public health and social programs.

Implementation of Evidence-Based Practices within Treatment-As-Usual and Evidence-Based Practice Initiatives

Publicly funded initiatives are underway to improve implementation of evidence-based practices (EBP) in youth mental health services. However, we know little about the success of these initiatives or about EBP implementation independent of such initiatives. We examined EBP implementation in a treatment as usual (TAU) state and in six states with publicly funded EBP initiatives (EBPIs). In Study 1, we examined providers' use of practices derived from the evidence base (PDEB) and their predictors among 780 providers in a TAU state. In Study 2, we conducted a systematic review of implementation strategies, outcomes, and predictors of EBP use in six state funded EBPIs. Study 1 suggests TAU providers use PDEB alongside practices without consistent research support; provider racial/ethnic minority status, learning theory orientation, and manual use predict greater PDEB use. Study 2 indicates EBPIs employ multiple recommended implementation strategies with variable outcomes across studies and measurement approaches. Predictors of EBP use in EBPIs also varied, though training, setting, and youth age were consistent predictors across studies. While sample differences and inconsistent measurement across studies made direct comparisons somewhat tenuous, rates of PDEB use in the TAU sample appeared similar to those in publicly funded EBPIs. However, two states reported comparisons with TAU samples and found higher EBP implementation under EBPI. Different predictors impacted EBP use in TAU versus EBPIs. Our findings highlight the need for improved evaluation of EBPIs including clear reporting standards for outcomes and more consistent, standardized measurement of EBP use in order to better understand and improve EBPIs.

Barriers to Clinician Implementation of Parent-Child Interaction Therapy (PCIT) in New Zealand and Australia: What Role for Time-Out?

BACKGROUND

Parent-Child Interaction Therapy (PCIT) is an effective parent training approach for a commonly occurring and disabling condition, namely conduct problems in young children. Yet, despite ongoing efforts to train clinicians in PCIT, the intervention is not widely available in New Zealand and Australia.

METHODS

We undertook a cross-sectional online survey of clinicians in New Zealand and Australia who had completed at least the 40-h initial PCIT training, to understand the barriers they encountered in their implementation efforts, and the extent to which attitudes toward time-out influenced implementation. The overall response rate was 47.5% (NZ: 60%; Australia: 31.4%).

RESULTS

Responses suggested that participants generally viewed PCIT as both acceptable and effective. Australian participants reported seeing significantly more clients for PCIT per week than those in NZ (Medians 0 and 2, respectively; χ2(1) = 14.08, p < 0.001) and tended to view PCIT as more effective in treating disruptive and oppositional behaviour (95% CI: -0.70, -0.13, p = 0.005). Participants currently seeing PCIT clients described it as more enjoyable to implement than those not using PCIT (95% CI: -0.85, -0.10, p = 0.01). Thirty-eight percent of participants indicated that they adapt or tailor the standardised protocol, primarily by adding in content relating to emotion regulation, and removing content relating to time-out. Participants generally felt that they had fewer skills, less knowledge, and less confidence relating to the Parent-Directed Interaction phase of PCIT (which involves time-out), compared with the Child-Directed Interaction phase.

CONCLUSION

While we had hypothesised that time-out represented an intra-intervention component that detracted from implementation success, results suggested that clinician concern over the use of time-out was present but not prominent. Rather, the lack of access to suitable equipment (i.e., one-way mirror and ear-piece) and difficulties associated with clients attending clinic-based sessions were barriers most commonly reported by clinicians. We suggest that future research might consider whether and how PCIT might be "re-implemented" by already-trained clinicians, moving beyond simply training more clinicians in the approach.