Parent Coaching in Early Intervention for Autism Spectrum Disorder: A Brief Report

Coaching caregivers of young children on the autism spectrum is a critical component of parent-mediated interventions. Little information is available about how providers implement parent coaching for children on the autism spectrum in publicly funded early intervention systems. This study evaluated providers' use of parent coaching in an early intervention system. Twenty-five early intervention sessions were coded for fidelity to established caregiver coaching techniques. We found low use of coaching techniques overall, with significant variability in use of coaching across providers. When providers did coach caregivers, they used only a few coaching strategies (e.g., collaboration and in vivo feedback). Results indicate that targeted training and implementation strategies focused on individual coaching components, instead of coaching more broadly, may be needed to improve the use of individual coaching strategies. A focus on strengthening the use of collaboration and in vivo feedback may be key to improving coaching fidelity overall.

Community Mental Health Clinicians' Perspectives on Telehealth During the COVID-19 Pandemic: Mixed Methods Study.

BACKGROUND: In March 2020, a rapid shift to telehealth occurred in community mental health settings in response to the need for physical distancing to decrease transmission of the virus causing COVID-19. Whereas treatment delivered over telehealth was previously utilized sparingly in community settings, it quickly became the primary mode of treatment delivery for the vast majority of clinicians, many of whom had little time to prepare for this shift and limited to no experience using telehealth. Little is known about community mental health clinicians' experiences using telehealth. Although telehealth may make mental health treatment more accessible for some clients, it may create additional barriers for others given the high rates of poverty among individuals seeking treatment from community mental health centers. OBJECTIVE: We examined community mental health clinicians' perspectives on using telehealth to deliver trauma-focused cognitive behavioral therapy to youth. We sought to better understand the acceptability of using telehealth, as well as barriers and facilitators to usage. METHODS: We surveyed 45 clinicians across 15 community clinics in Philadelphia. Clinicians rated their satisfaction with telehealth using a quantitative scale and shared their perspectives on telehealth in response to open-ended questions. Therapists' responses were coded using an open-coding approach wherein coders generated domains, themes, and subthemes. RESULTS: Clinicians rated telehealth relatively positively on the quantitative survey, expressing overall satisfaction with their current use of telehealth during the pandemic, and endorsing telehealth as a helpful mode of connecting with clients. Responses to open-ended questions fell into five domains. Clinicians noted that (1) telehealth affects the content (ie, what is discussed) and process (ie, how it is discussed) of therapy; (2) telehealth alters engagement, retention, and attendance; (3) technology is a crucial component of utilizing telehealth; (4) training, resources, and support are needed to facilitate telehealth usage; and (5) the barriers, facilitators, and level of acceptability of telehealth differ across individual clinicians and clients. CONCLUSIONS: First, telehealth is likely a better fit for some clients and clinicians than others, and attention should be given to better understanding who is most likely to succeed using this modality. Second, although telehealth increased convenience and accessibility of treatment, clinicians noted that across the board, it was difficult to engage clients (eg, young clients were easily distracted), and further work is needed to identify better telehealth engagement strategies. Third, for many clients, the telehealth modality may actually create an additional barrier to care, as children from families living in poverty may not have the requisite devices or quality broadband connection to make telehealth workable. Better strategies to address disparities in access to and quality of digital technologies are needed to render telehealth an equitable option for all youth seeking mental health services.

Economic Precarity, Financial Strain, and Job-Related Stress Among Philadelphia's Public Mental Health Clinicians.

OBJECTIVE: Efforts to improve mental health treatment delivery come at a time of rising inequality and cuts or insufficient increases to mental health funding. Public mental health clinicians face increased demands, experience economic stress, and treat underresourced patients disproportionately burdened by trauma. The authors sought to understand clinicians' current economic and psychological conditions and the relationship of these conditions to the delivery of an evidence-based intervention (EBI) designed to treat posttraumatic stress disorder among youths. METHODS: In July 2020, 49 public mental health clinicians from 16 Philadelphia clinics who were trained in an EBI, trauma-focused cognitive-behavioral therapy (TF-CBT), were surveyed by e-mail. Respondents reported on their economic precarity, financial strain, burnout, secondary traumatic stress (i.e., the stress response associated with caring for people exposed to trauma), and TF-CBT use. Associations between clinicians' job-related stressors and their use of TF-CBT were examined with mixed models. Content coding was used to organize clinicians' open-ended responses to questions regarding financial strain related to the COVID-19 pandemic. RESULTS: Clinicians' economic precarity, financial strain, and job-related stress were high; 37% of clinicians were independent contractors, 44% of whom wanted a salaried position. Of 37 clinicians with education debt, 38% reported owing ≥$100,000. In the past year, 29% of clinicians reported lack of personal mental health care because of cost, and 22% met the cutoff for experiencing secondary traumatic stress symptoms. Education debt was negatively associated with use of TF-CBT (p<0.001). CONCLUSIONS: The stress of providing care in underresourced clinical settings may interfere with efforts to integrate scientific evidence into mental health care.

Implementing nudges to promote utilization of low tidal volume ventilation (INPUT): a stepped-wedge, hybrid type III trial of strategies to improve evidence-based mechanical ventilation management.

BACKGROUND: Behavioral economic insights have yielded strategies to overcome implementation barriers. For example, default strategies and accountable justification strategies have improved adherence to best practices in clinical settings. Embedding such strategies in the electronic health record (EHR) holds promise for simple and scalable approaches to facilitating implementation. A proven-effective but under-utilized treatment for patients who undergo mechanical ventilation involves prescribing low tidal volumes, which protects the lungs from injury. We will evaluate EHR-based implementation strategies grounded in behavioral economic theory to improve evidence-based management of mechanical ventilation. METHODS: The Implementing Nudges to Promote Utilization of low Tidal volume ventilation (INPUT) study is a pragmatic, stepped-wedge, hybrid type III effectiveness implementation trial of three strategies to improve adherence to low tidal volume ventilation. The strategies target clinicians who enter electronic orders and respiratory therapists who manage the mechanical ventilator, two key stakeholder groups. INPUT has five study arms: usual care, a default strategy within the mechanical ventilation order, an accountable justification strategy within the mechanical ventilation order, and each of the order strategies combined with an accountable justification strategy within flowsheet documentation. We will create six matched pairs of twelve intensive care units (ICUs) in five hospitals in one large health system to balance patient volume and baseline adherence to low tidal volume ventilation. We will randomly assign ICUs within each matched pair to one of the order panels, and each pair to one of six wedges, which will determine date of adoption of the order panel strategy. All ICUs will adopt the flowsheet documentation strategy 6 months afterwards. The primary outcome will be fidelity to low tidal volume ventilation. The secondary effectiveness outcomes will include in-hospital mortality, duration of mechanical ventilation, ICU and hospital length of stay, and occurrence of potential adverse events. DISCUSSION: This stepped-wedge, hybrid type III trial will provide evidence regarding the role of EHR-based behavioral economic strategies to improve adherence to evidence-based practices among patients who undergo mechanical ventilation in ICUs, thereby advancing the field of implementation science, as well as testing the effectiveness of low tidal volume ventilation among broad patient populations. TRIAL REGISTRATION: ClinicalTrials.gov , NCT04663802 . Registered 11 December 2020.

Realizing the Promise of Learning Organizations to Transform Mental Health Care: Telepsychiatry Care As an Exemplar.

To address the global mental health crisis exacerbated by the COVID-19 pandemic, an urgent need has emerged to transform the accessibility, efficiency, and quality of mental health care. The next suite of efforts to transform mental health care must foster the implementation of "learning organizations," that is, organizations that continuously improve patient-centered care through ongoing data collection. The concept of learning organizations is highly regarded, but the key features of such organizations, particularly those providing mental health care, are less well defined. Using telepsychiatry care as an example, the authors of this Open Forum concretely describe the key building blocks for operationalizing a learning organization in mental health care to set a research agenda for services transformation.

How Health Care Workers Wield Influence Through Twitter Hashtags: Retrospective Cross-sectional Study of the Gun Violence and COVID-19 Public Health Crises.

BACKGROUND: Twitter has emerged as a novel way for physicians to share ideas and advocate for policy change. #ThisIsOurLane (firearm injury) and #GetUsPPE (COVID-19) are examples of nationwide health care-led Twitter campaigns that went viral. Health care-initiated Twitter hashtags regarding major public health topics have gained national attention, but their content has not been systematically examined. OBJECTIVE: We hypothesized that Twitter discourse on two epidemics (firearm injury and COVID-19) would differ between tweets with health care-initiated hashtags (#ThisIsOurLane and #GetUsPPE) versus those with non-health care-initiated hashtags (#GunViolence and #COVID19). METHODS: Using natural language processing, we compared content, affect, and authorship of a random 1% of tweets using #ThisIsOurLane (Nov 2018-Oct 2019) and #GetUsPPE (March-May 2020), compared to #GunViolence and #COVID19 tweets, respectively. We extracted the relative frequency of single words and phrases and created two sets of features: (1) an open-vocabulary feature set to create 50 data-driven-determined word clusters to evaluate the content of tweets; and (2) a closed-vocabulary feature for psycholinguistic categorization among case and comparator tweets. In accordance with conventional linguistic analysis, we used a P<.001, after adjusting for multiple comparisons using the Bonferroni correction, to identify potentially meaningful correlations between language features and outcomes. RESULTS: In total, 67% (n=4828) of #ThisIsOurLane tweets and 36.6% (n=7907) of #GetUsPPE tweets were authored by health care professionals, compared to 16% (n=1152) of #GunViolence and 9.8% (n=2117) of #COVID19 tweets. Tweets using #ThisIsOurLane and #GetUsPPE were more likely to contain health care-specific language; more language denoting positive emotions, affiliation, and group identity; and more action-oriented content compared to tweets with #GunViolence or #COVID19, respectively. CONCLUSIONS: Tweets with health care-led hashtags expressed more positivity and more action-oriented language than the comparison hashtags. As social media is increasingly used for news discourse, public education, and grassroots organizing, the public health community can take advantage of social media's broad reach to amplify truthful, actionable messages around public health issues.

A rapid pre-implementation evaluation to inform a family engagement navigator program during COVID-19.

BACKGROUND: Innovative models of family engagement and support are needed in the intensive care unit (ICU) during times of restricted visitation such as the COVID-19 pandemic. Limited understanding of the factors affecting the uptake and outcomes of different family support models hinders the implementation of best practices. We aimed to conduct a rapid pre-implementation evaluation of stakeholder-perceived facilitators and barriers to design implementation strategies to support a novel program using medical students to facilitate family-centered care in the ICU. METHODS: We conducted a 2-step process. In step 1, we gathered contextual data via interview-style open-ended questions sent to clinicians and navigator stakeholders via email. We used electronic data collection due to the physical distancing requirements, the need to prioritize brief data collection for respondent burden, and the need for rapid knowledge gain. A codebook based on the Consolidated Framework for Implementation Research (CFIR), an integrated framework from the field of implementation science, was used to analyze the findings. In step 2, a pilot of the intervention was implemented with 3 navigators over 2 weeks. Implementation strategies were developed to target barriers identified by the pre-implementation evaluation. RESULTS: Fourteen (70%) of the identified stakeholders responded to the survey. Ten constructs encompassing all five CFIR domains were present in responses as implementation influencers, with the Intervention domain most frequently represented. Through these results and operational feedback from navigators during the pilot period, stakeholders selected multiple implementation strategies: audit and provide feedback, develop educational materials, conduct ongoing training, promote adaptability, assess and redesign workflow, identify and prepare champions, and engage community resources. CONCLUSIONS: We demonstrated how a conceptually based pre-implementation program evaluation can be used to rapidly inform optimal implementation strategies. We report key factors to inform design and implementation strategies for a novel ICU family engagement navigator program that may be useful to others wishing to adopt similar programs.