Implementation Feasibility and Hidden Costs of Statewide Scaling of Evidence-Based Therapies for Children and Adolescents.

OBJECTIVE: State mental health systems are retraining their workforces to deliver services supported by research. Knowledge about evidence-based therapies (EBTs) for child and adolescent disorders is robust, but the feasibility of their statewide scaling has not been examined. The authors reviewed implementation feasibility for 12 commonly used EBTs, defining feasibility for statewide scaling as an EBT having at least one study documenting acceptability, facilitators and barriers, or fidelity; at least one study with a racially and ethnically diverse sample; an entity for training, certification, or licensing; and fiscal data reflecting the costs of implementation. METHODS: The authors reviewed materials for 12 EBTs being scaled in New York State and conducted a literature review with search terms relevant to their implementation. Costs and certification information were supplemented by discussions with treatment developers and implementers. RESULTS: All 12 EBTs had been examined for implementation feasibility, but only three had been examined for statewide scaling. Eleven had been studied in populations reflecting racial-ethnic diversity, but few had sufficient power for subgroup analyses to demonstrate effectiveness with these samples. All had certifying or licensing entities. The per-clinician costs of implementation ranged from $500 to $3,500, with overall ongoing costs ranging from $100 to $6,000. A fiscal analysis of three EBTs revealed hidden costs ranging from $5,000 to $24,000 per clinician, potentially limiting sustainability. CONCLUSIONS: The evidence necessary for embedding EBTs in state systems has notable gaps that may hinder sustainability. Research-funding agencies should prioritize studies that focus on the practical aspects of scaling to assist states as they retrain their workforces.

Evaluation of a Web-Based Training Model for Family Peer Advocates in Children's Mental Health.

OBJECTIVE: The aim of this study was to compare knowledge gains from a new online training program with gains from an existing in-person training program for family peer advocates. METHODS: Data were used from a pre-post study of individuals who enrolled in the Web-based Parent Empowerment Program training; 144 participants completed the training and pre-post tests, and 140 were admitted to the analyses. Knowledge was assessed with 34 questions, 29 of which were common to the online and in-person trainings. Pre-post knowledge scores were available from the in-person training. RESULTS: Statistically significant gains in knowledge were found with both the 34 questions and the 29 questions common to both trainings. Knowledge gains across the two training models did not differ. CONCLUSIONS: Data on knowledge gains from this accessible, affordable online model show promise for training the growing and important workforce of family peer advocates.

Disseminating clinical and fiscal practices across the New York State behavioral healthcare system.

In order to facilitate the adoption of innovative practices in the mental health service system, providers require access to both new information and methodologies, and ongoing training, supervision and consultation. Technical Assistance centers have been proposed as a way to disseminate effective interventions through the provision of resources including information, ongoing training and consultation. The purpose of this study is to describe the New York State Technical Assistance Center's reach across the child public mental health service system and variations in characteristics of training activities, including dosage, content and method of format. Between 2011 and 2015, 460 (92.6%) of all New York State mental health clinics attended a training. The most highly attended events focused on business practices, followed by evidence-based treatments and clinic practices, and trauma-informed care. All were delivered via a webinar format, and were less than one day in duration. The behavioral health service system must be equipped to adapt to changing clinical and business practices in order to provide quality care and remain fiscally viable. New York State's TA center reached the majority of child mental health service providers across the state. Next steps are to closely examine the impact of TA supports upon adoption and sustained use of practices. Implications of these findings and additional future directions are presented.

An Assessment of The New York State Behavioral Health System's Readiness to Transition to Medicaid Managed Care.

New York State has one of the most richly funded Medicaid programs in the United States. In an effort to achieve the triple aim New York State is undergoing a significant redesign of its Medicaid program including transitioning nearly all Medicaid funded behavioral health services into Medicaid managed care. In preparation for this transition, a state funded technical assistance center assessed the behavioral health care system's readiness to undergo this reform across 11 domains. Between September and November, 2014, the TA center electronically distributed a readiness survey to 897 mental health and substance abuse agencies: 313 (n = 269, 33%) organizations completed the assessment. As a whole, the sample felt partially ready to transition; analysis by domain revealed agencies were most ready to interface with managed care providers, and least ready to collect and evaluate outcome data. Significant differences in readiness were found depending by organizational characteristics (number of programs, licensure, and region). In anticipation of large-scale reforms, states would benefit from an initial needs assessment to identify gaps in knowledge and skills, which in turn, can then guide preparatory efforts and provide needed supports to facilitate major changes in service delivery and billing.

Using mobile health technology to improve behavioral skill implementation through homework in evidence-based parenting intervention for disruptive behavior disorders in youth: study protocol for intervention development and evaluation.

BACKGROUND: Disruptive behavior disorders (DBDs) (oppositional defiant disorder (ODD) and conduct disorder (CD)) are prevalent, costly, and oftentimes chronic psychiatric disorders of childhood. Evidence-based interventions that focus on assisting parents to utilize effective skills to modify children's problematic behaviors are first-line interventions for the treatment of DBDs. Although efficacious, the effects of these interventions are often attenuated by poor implementation of the skills learned during treatment by parents, often referred to as between-session homework. The multiple family group (MFG) model is an evidence-based, skills-based intervention model for the treatment of DBDs in school-age youth residing in urban, socio-economically disadvantaged communities. While data suggest benefits of MFG on DBD behaviors, similar to other skill-based interventions, the effects of MFG are mitigated by the poor homework implementation, despite considerable efforts to support parents in homework implementation. This paper focuses on the study protocol for the development and preliminary evaluation of a theory-based, smartphone mobile health (mHealth) application (My MFG) to support homework implementation by parents participating in MFG. METHODS/DESIGN: This paper describes a study design proposal that begins with a theoretical model, uses iterative design processes to develop My MFG to support homework implementation in MFG through a series of pilot studies, and a small-scale pilot randomised controlled trial to determine if the intervention can demonstrate change (preliminary efficacy) of My MFG in outpatient mental health settings in socioeconomically disadvantaged communities. DISCUSSION: This preliminary study aims to understand the implementation of mHealth methods to improve the effectiveness of evidence-based interventions in routine outpatient mental health care settings for youth with disruptive behavior and their families. Developing methods to augment the benefits of evidence-based interventions, such as MFG, where homework implementation is an essential mediator of treatment benefits is critical to full adoption/implementation of these intervention in routine practice settings and maximizing benefits for youth with DBDs and their families. TRIAL REGISTRATION: ClinicalTrials.gov NCT01917838.

A model of integrated health care in a poverty-impacted community in New York City: Importance of early detection and addressing potential barriers to intervention implementation.

Disruptive behavior disorders (DBDs) are chronic, impairing, and costly behavioral health conditions that are four times more prevalent among children of color living in impoverished communities as compared to the general population. This disparity is largely due to the increased exposure to stressors related to low socioeconomic status including community violence, unstable housing, under supported schools, substance abuse, and limited support systems. However, despite high rates and greater need, there is a considerably lower rate of mental health service utilization among these youth. Accordingly, the current study aims to describe a unique model of integrated health care for ethnically diverse youth living in a New York City borough. With an emphasis on addressing possible barriers to implementation, integrated models for children have the potential to prevent ongoing mental health problems through early detection and intervention.

Generalizability of the NAMI Family-to-Family Education Program: Evidence From an Efficacy Study.

Previous studies conducted in Maryland of the Family-to-Family (FTF) education program of the National Alliance on Mental Illness (NAMI) found that FTF reduced subjective burden and distress and improved empowerment, mental health knowledge, self-care, and family functioning, establishing it as an evidence-based practice. In the study reported here, the FTF program of NAMI-NYC Metro was evaluated. Participants (N=83) completed assessments at baseline and at completion of FTF. Participants had improved family empowerment, family functioning, engagement in self-care activities, self-perception of mental health knowledge, and emotional acceptance as a form of coping. Scores for emotional support and positive reframing also improved significantly. Displeasure in caring for the family member, a measure of subjective burden, significantly declined. Despite the lack of a control group and the limited sample size, this study further supports the efficacy of FTF with a diverse urban population.

Multilevel predictors of clinic adoption of state-supported trainings in children's services.

OBJECTIVE: Characteristics associated with participation in training in evidence-informed business and clinical practices by 346 outpatient mental health clinics licensed to treat youths in New York State were examined. METHODS: Clinic characteristics extracted from state administrative data were used as proxies for variables that have been linked with adoption of innovation (extraorganizational factors, agency factors, clinic provider-level profiles, and clinic client-level profiles). Multiple logistic regression models were used to assess the independent effects of theoretical variables on the clinics' participation in state-supported business and clinical trainings between September 2011 and August 2013 and on the intensity of participation (low or high). Interaction effects between clinic characteristics and outcomes were explored. RESULTS: Clinic characteristics were predictive of any participation in trainings but were less useful in predicting intensity of participation. Clinics affiliated with larger (adjusted odds ratio [AOR]=.65, p<.01), more efficient agencies (AOR=.62, p<.05) and clinics that outsourced more clinical services (AOR=.60, p<.001) had lower odds of participating in any business-practice trainings. Participation in business trainings was associated with interaction effects between agency affiliation (hospital or community) and clinical staff capacity. Clinics with more full-time-equivalent clinical staff (AOR=1.52, p<.01) and a higher proportion of clients under age 18 (AOR=1.90, p<.001) had higher odds of participating in any clinical trainings. Participating clinics with larger proportions of youth clients had greater odds of being high adopters of clinical trainings (odds ratio=1.54, p<.01). CONCLUSIONS: Clinic characteristics associated with uptake of business and clinical training could be used to target state technical assistance efforts.

Adoption of clinical and business trainings by child mental health clinics in New York State.

OBJECTIVE: This study prospectively examined the naturalistic adoption of clinical and business evidence-informed training by all 346 outpatient mental health clinics licensed to treat children, adolescents, and their families in New York State. METHODS: The study used attendance data (September 2011-August 2013) from the Clinic Technical Assistance Center, a training, consultation, and educational center funded by the state Office of Mental Health, to classify the clinics' adoption of 33 trainings. Adoption behavior was classified by number, type, and intensity of trainings. The clinics were classified into four adopter groups reflecting the highest training intensity in which they participated (low, medium, and high adopters and "super-adopters"). RESULTS: A total of 268 clinics adopted trainings (median=5); business and clinical trainings were about equally accessed (82% versus 78%). Participation was highest for hour-long Webinars (96%) followed by learning collaboratives, which take six to 18 months to complete (34%). Most (73%-94%) adopters of business learning collaboratives and all adopters of clinical learning collaboratives had previously sampled a Webinar, although maintaining participation in learning collaboratives was a challenge. The adopter groups captured meaningful adopter profiles: 41% of clinics were low adopters that selected fewer trainings and participated only in Webinars, and 34% were high or super-adopters that accessed more trainings and participated in at least one learning collaborative. CONCLUSIONS: More nuanced definitions of adoption behavior can improve the understanding of clinic adoption of training and hence promote the development of efficient rollout strategies by state systems.

Scaling up evidence-based practices for children and families in New York State: toward evidence-based policies on implementation for state mental health systems.

Dissemination of innovations is widely considered the sine qua non for system improvement. At least two dozen states are rolling out evidence-based mental health practices targeted at children and families using trainings, consultations, webinars, and learning collaboratives to improve quality and outcomes. In New York State (NYS) a group of researchers, policymakers, providers, and family support specialists have worked in partnership since 2002 to redesign and evaluate the children's mental health system. Five system strategies driven by empirically based practices and organized within a state-supported infrastructure have been used in the child and family service system with more than 2,000 providers: (a) business practices, (b) use of health information technologies in quality improvement, (c) specific clinical interventions targeted at common childhood disorders, (d) parent activation, and (e) quality indicator development. The NYS system has provided a laboratory for naturalistic experiments. We describe these initiatives, key findings and challenges, lessons learned for scaling, and implications for creating evidence-based implementation policies in state systems.

Beyond context to the skyline: thinking in 3D.

Sweeping and profound structural, regulatory, and fiscal changes are rapidly reshaping the contours of health and mental health practice. The community-based practice contexts described in the excellent review by Garland and colleagues are being fundamentally altered with different business models, regional networks, accountability standards, and incentive structures. If community-based mental health services are to remain viable, the two-dimensional and flat research and practice paradigm has to be replaced with three-dimensional thinking. Failure to take seriously the changes that are happening to the larger healthcare context and respond actively through significant system redesign will lead to the demise of specialty mental health services.

Best practices: wellness self-management: an adaptation of the illness management and recovery program in New York State.

Wellness Self-Management (WSM) is a recovery-oriented, curriculum-based practice designed to help adults with serious mental health problems make informed decisions and take action to manage symptoms and improve their quality of life. WSM is an adaptation of the illness management and recovery program, a nationally recognized best practice. WSM uses comprehensive personal workbooks for group facilitators and consumers and employs a structured and easy-to-implement group facilitation framework. Currently, more than 100 adult mental health agencies are implementing WSM in New York State. The authors describe the development and key features of WSM and an initiative to promote widespread adoption and sustainability.