Organizational Factors Influencing Implementation of Evidence-Based Practices for Integrated Treatment in Behavioral Health Agencies

Key Factors for Implementing Supported Employment

State Mental Health Policy: Washington State's Initiative to Disseminate and Implement High-Fidelity ACT Teams

Implementing the Illness Management and Recovery Program in Community Mental Health Settings: Facilitators and Barriers

The impact of criminal justice involvement and clinical characteristics on the cost of public treatment services for adults with serious mental illnesses is unknown. The authors examined differential effects of justice involvement on behavioral health treatment costs by primary psychiatric diagnosis (schizophrenia or bipolar disorder) and also by substance use diagnosis among 25,133 adult clients of Connecticut's public behavioral health system in fiscal years 2006 and 2007. Justice-involved adults with schizophrenia had the highest costs, strongly driven by forensic hospitalizations. Addressing the cross-system burdens of forensic hospitalizations may be a sensible starting point in the effort to reduce costs in both the public behavioral health and justice systems.

In order to address JJ-TRIALS goals of: a) improving behavioral health services for youth with substance use problems; and b) advancing the investigation of implementation efforts in the field of behavioral health, the JJ-TRIALS Workgroup on Evidence-Based Practices (EPA) was first charged with defining quality indicators for practices and programs. We limited that effort to programs, practices, and instruments relevant to the steps in the Behavioral Services Cascade (Screening, Referral and Linkage, Assessment, Prevention and Psychosocial Treatment) for five identified clinical problem areas (Substance use, Mood disorder, ADHD, Trauma exposure, HIV risk). Problem areas were selected as those of moderate prevalence among adolescents in community justice systems with problem substance use. Quality indicators were consistent with the AACAP Practice Parameters Clinical Standard, as reflecting either “rigorous empirical evidence” or “overwhelming clinical consensus” (American Academy of Child and Adolescent Psychiatry, 2013). In a series of directed literature reviews, we catalogued evidence-based programs and instruments addressing these problem areas that had been identified as most strongly supported by existing systematic reviews (e.g., SAMHSA, 2011) and then categorized them into tiers, based on their applicability for JJ-TRIALS efforts (e.g., number of TRIALS problem areas addressed, administration format, delivery setting, inclusion of family collaterals). These reviews identified 18 psychometrically sound screening instruments (3 tiers), 16 sound assessment instruments (4 tiers), 43 EB prevention programs (3 tiers), and 39 EB treatment programs (3 tiers). While the evidence base regarding programs that focus on cross-system linkage (e.g., from screening in a probation setting, with a subsequent referral to a behavioral health provider) is less established, EPA was able to designate three tiers of such programs, defined both by their soundness and their applicability to juvenile justice community settings. As a second set of quality indicators, we considered core content components (that may cut across particular instruments or programs). For assessment, these included eight elements essential for clinical treatment planning for adolescents (e.g., family relationships, readiness for change: American Society of Addiction Medicine, 2013). For treatment programs, these included treatment modalities identified as effectively addressing one or another of the TRIALS problem areas (e.g., CBT; Chorpita, et al., 2011). A final quality indicator for assessment and treatment considered procedural elements (that relate to how an instrument or program is used by a service provider), such as manualization, staff training, and fidelity monitoring (e.g., Brannigan, 2004; Howell & Lipsey, 2012). EPA workgroup products will be incorporated into future JJ-TRIALS training efforts; they will be used to generate menus of high-quality instrument and program options to help juvenile justice partners and the behavioral health agencies with which they collaborate to set implementation goals for participation in JJ-TRIALS.

Leadership in organizations is important in shaping workers' perceptions, responses to organizational change, and acceptance of innovations, such as evidence-based practices. Transformational leadership inspires and motivates followers, whereas transactional leadership is based more on reinforcement and exchanges. Studies have shown that in youth and family service organizations, mental health providers' attitudes toward adopting an evidence-based practice are associated with organizational context and individual provider differences. The purpose of this study was to expand these findings by examining the association between leadership and mental health providers' attitudes toward adopting evidence-based practice. Participants were 303 public-sector mental health service clinicians and case managers from 49 programs who were providing mental health services to children, adolescents, and their families. Data were gathered on providers' characteristics, attitudes toward evidence-based practices, and perceptions of their supervisors' leadership behaviors. Zero-order correlations and multilevel regression analyses were conducted that controlled for effects of service providers' characteristics. Both transformational and transactional leadership were positively associated with providers' having more positive attitudes toward adoption of evidence-based practice, and transformational leadership was negatively associated with providers' perception of difference between the providers' current practice and evidence-based practice. Mental health service organizations may benefit from improving transformational and transactional supervisory leadership skills in preparation for implementing evidence-based practices.

Issues in Medicaid Policy and System Transformation: Recommendations From the President's Commission

Organizational culture and climate are important determinants of behavioral health service delivery for youth. The Organizational Social Context measure is a well validated assessment of organizational culture and climate that has been developed and extensively used in public sector behavioral health service settings. The degree of concordance between administrators and clinicians in their reports of organizational culture and climate may have implications for research design, inferences, and organizational intervention. However, the extent to which administrators' and clinicians' reports demonstrate concordance is just beginning to garner attention in public behavioral health settings in the United States. We investigated the concordance between 73 administrators (i.e., supervisors, clinical directors, and executive directors) and 247 clinicians in 28 child-serving programs in a public behavioral health system. Findings suggest that administrators, compared to clinicians, reported more positive cultures and climates. Organizational size moderated this relationship such that administrators in small programs (<466 youth clients served annually) provided more congruent reports of culture and climate in contrast to administrators in large programs (≥466 youth clients served annually) who reported more positive cultures and climates than clinicians. We propose a research agenda that examines the effect of concordance between administrators and clinicians on organizational outcomes in public behavioral health service settings.

Making organizations helpful in health care generally means ensuring the delivery of cost-effective approaches to reduce human suffering. Strong leadership can facilitate implementation of innovations and evidence-based health care by fostering an organizational context that is supportive of change, encouraging buy-in from staff, and increasing both implementation fidelity (fidelity to the implementation strategy) and intervention fidelity (fidelity to the clinical intervention). In the current era of health care reform, in which provider accountability for cost-effective intervention is paramount, examining the role of transformational leadership in the implementation process of evidence-based care is critical. Transformational leadership has great potential to support the enactment of changes in health care organizations. In addition, although there has been some criticism, transformational leadership has a great deal of empirical support across settings, cultures, and countries. Despite a growing body of support, there is limited knowledge regarding how organizational culture and climate embedding mechanisms are utilized and how these are a function of or relate to transformational leaders’ influence on followers’ implementation behaviors. Each of the four different studies included in this symposium addresses one or more of these issues related to embedding factors associated with the implementation context. Together, the papers help to advance knowledge about the role of leadership in shaping followers’ attitudes and behaviors about implementation of evidence-based treatment practices in mental health and addiction health service organizations. Each of the four papers relies on unique samples and advanced quantitative and qualitative methods to provide a multifaceted perspective on leadership and implementation, an underresearched area in health care. Together, the papers in this symposium advance implementation science by providing concrete understanding of leadership in real-world health care settings. Implications for methods, theory, and translation of findings into practice are discussed. Leadership and Climates for Implementation of Culturally Responsive and Evidence-Based Practices Presenter: Erick Guerrero; U. of Southern California Presenter: Yinfei Kong; U. of Southern California Presenter: Gina Rosen; U. of Southern California Leadership Intervention to Improve the Implementation of Evidence-Based Health Care Practices Presenter: Howard Padwa; U. of California, Los Angeles Presenter: Lesley Harris; U. of Louisville Organizational Support Moderates the Effect of Leadership on Organizational Citizenship Behavior Presenter: Gregory A. Aarons; U. of California, San Diego Presenter: Mark G. Ehrhart; San Diego State U. Presenter: Elisa Maria Torres; UC San Diego The Effects of Transformational Leadership and Leader-Member Exchange on Attitudes toward Feedback Presenter: Karissa Fenwick; U. of Southern California, School of Social Work Presenter: Kim Brimhall; U. of Southern California

Many states are experiencing a behavioral health workforce crisis, particularly in the public behavioral health system. An understanding of the factors influencing the workforce shortage is critical for informing public policies to improve workforce retention and access to care. The aim of this study was to assess factors contributing to behavioral health workforce turnover and attrition in Oregon. Semistructured qualitative interviews were conducted with 24 behavioral health providers, administrators, and policy experts with knowledge of Oregon's public behavioral health system. Interviews were transcribed and iteratively coded to reach consensus on emerging themes. Five key themes emerged that negatively affected the interviewees' workplace experience and longevity: low wages, documentation burden, poor physical and administrative infrastructure, lack of career development opportunities, and a chronically traumatic work environment. Large caseloads and patients' high symptom acuity contributed to worker stress. At the organizational and system levels, chronic underfunding and poor administrative infrastructure made frontline providers feel undervalued and unfulfilled, pushing them to leave the public behavioral health setting or behavioral health altogether. Behavioral health providers are negatively affected by systemic underinvestment. Policies to improve workforce shortages should target the effects of inadequate financial and workplace support on the daily work environment.

This study examined turnover rates of teams implementing psychosocial evidence-based practices in public-sector mental health settings. It also explored the relationship between turnover and implementation outcomes in an effort to understand whether practitioner perspectives on turnover are related to implementation outcomes. Team turnover was measured for 42 implementing teams participating in a national demonstration project examining implementation of five evidence-based practices between 2002 and 2005. Regression techniques were used to analyze the effects of team turnover on penetration and fidelity. Qualitative data collected throughout the project were blended with the quantitative data to examine the significance of team turnover to those attempting to implement the practices. High team turnover was common (M+/-SD=81%+/-46%) and did not vary by practice. The 24-month turnover rate was inversely related to fidelity scores at 24 months (N=40, beta=-.005, p=.01). A negative trend was observed for penetration. Further analysis indicated that 71% of teams noted that turnover was a relevant factor in implementation. The behavioral health workforce remains in flux. High turnover most often had a negative impact on implementation, although some teams were able to use strategies to improve implementation through turnover. Implementation models must consider turbulent behavioral health workforce conditions.

The 2003 AMCHA Summit was an initial step. It served to provide a broad outline of the socio-political context and key issues involved in reducing disparities, and it provided some momentum for change. However, much more work remains to be done. The summit clearly demonstrated that the reduction of disparities requires a multi-level approach and multi-disciplinary leaders. As a neutral convener, AMCHA is in a unique position to help advance the debate and lead the field. The membership includes researchers, administrators, clinicians, and policy makers from all levels of the behavioral health system. As noted, a change agenda needs to include efforts at national, state, and local levels involving consumers, providers, purchasers, oversight organizations, and researchers. ACMHA is committed to advancing the field and helping the national effort to reduce disparities. Examples of potential projects include the following: Training: Much has been done to develop effective cultural-competency training modules and to guide states in its implementation. No one should reinvent the wheel at this time. Funding should be targeted to provide incentives to states for dissemination of existing training curricula and the documentation of effectiveness to all providers and administrators. Nationally, the field will benefit from data standards for the collection of and reporting on system disparities. This will facilitate interstate comparisons and provide baseline data for change efforts. Conducting surveys of providers, health plans, and public behavioral health systems on the availability and current uses of data by race and ethnicity is one example of a useful first step in this process of setting data standards. Further research on the nature and causes of disparity is needed. There should be systematic research on factors influencing access, treatment, and outcomes for people of different cultures. Initially, because of the difficulties in deciding on standardized outcome measures, the encounter and claims data will provide the most useful information for analysis. Later, as standardized outcome measures are more widely utilized and the data collected, it may be possible to look for racial and ethnic differences in outcomes. The research agenda needs to be developed with a focus on services and health systems research data. Demonstrations: Demonstration efforts are urgently needed, similar to Connecticut's initiative, that integrate data on disparities with provider reporting, performance contracting, and system-wide interventions. These best practices need to be shared with the field. Coordination: The Summit showed that many are eager to learn from others in this area. As we move from further research to demonstration initiatives, AMCHA can play a role in coordinating these projects, particularly at the state and perhaps local levels. State efforts can benefit from best-practice presentations from other states and by an improved understanding of the nature and scope of the change required at a programmatic and local level. Local efforts need to clearly incorporate the views and perspectives of members of the community and consumers. The 2003 ACMHA Summit provided a foundation and a framework for work to proceed at all levels of the behavioral health delivery system. To accomplish meaningful change, we challenge SAMHSA, and the other federal agencies to provide the leadership to (1) develop common and core-performance measures focused on the reduction of disparities, (2) coordinate the research agenda, and (3) facilitate the use of new information technologies to collect and review these data. This is completely consistent with the vision of federal "leadership by example" that has been outlined by the Institute of Medicine (2003b) for the implementation of the "Crossing the Quality Chasm" report. We need to facilitate the efforts of the states and the federal government to identify and reduce disparities and provide a forum for states to share the results of their efforts, to benchmark their performance, and seek technical assistance. Over the next several years, we also expect that states will expand their efforts to implement evidence-based practices. However, we urge these states to implement existing evidence-based practices cautiously, especially with culturally diverse populations, due to the limited representation of ethnically diverse subjects in the research evidence on current practices. We strongly recommend collecting data on practice-based evidence-where effective interventions are routinely identified from existing practice and shared with the field, particularly those practices that seem effective with minority populations.

In July 2005, New Mexico placed all publicly funded behavioral health services under the management of one private corporation. This reform emphasized the provision of evidence-based, culturally competent services. Methods. Participant observation and semi-structured interviews with 189 administrators, staff, and providers were carried out in 14 behavioral health safety-net institutions (SNIs) during the transition period. Results. New administrative requirements led to substantial paperwork demands, payment problems, and financial stress within SNIs. Personnel at the SNIs often lacked knowledge about and training in evidence-based practices and culturally competent care, and viewed the costs of delivering such services as prohibitive. Discussion. Policymakers must account for the challenges that SNIs face as the reform continues to unfold. The financial stability of SNIs is of critical importance. Efforts are needed to increase training and development opportunities in evidence-based care and cultural competency; SNIs typically lack resources to pursue these opportunities on their own.

Recent progress in understanding the lifelong effects of early childhood adversities has clarified the need for an organized strategy to identify and intervene with children, adolescents, and families who may be at risk for maladaptive responses. Trauma-informed care (TIC) in child health care operationalizes the biological evidence of toxic stress with the insights of attachment and resilience to enhance health care delivery to mitigate the effects of trauma. The resulting pediatric health care delivery strategy promotes and restores resilience in children and adolescents, partners with families to support relational health, and reduces secondary trauma among pediatric health care clinicians. This policy statement summarizes what policy makers, legislators, and health care organizations need to consider in terms of infrastructure, resources, and financial support to facilitate the integration of TIC principles into all pediatric points of care. The accompanying clinical report describes the elements of TIC in the direct care of children, adolescents, and families and covers the spectrum from prevention to treatment. The recommendations in this statement and the clinical report build on other American Academy of Pediatrics policies that address the needs of special populations (such as children and adolescents in foster or kinship care, in immigrant and refugee families, or in poor or homeless families) and are congruent with American Academy of Pediatrics policies and technical reports concerning the role of pediatric clinicians in the promotion of lifelong health.Over the past 2 decades, basic science has explained how cumulative adverse childhood experiences in the relative absence of safe, stable, nurturing relationships (SSNRs)1 alter neurohormonal stress responses, gene expression, telomere length, brain development, and immunity, enabling researchers to elucidate how the body biologically embeds childhood trauma. Recent studies of toxic stress support assertions that the origins of lifelong health are in early childhood and that chronic stress in childhood strongly predicts adult health status.2,3 In the context of expanding evidence, pediatricians and others involved in community-based early childhood systems need strategies to mitigate the damaging effects of early childhood trauma and to promote resilience in children and families. Trauma-informed care (TIC) offers an organizing principle for pediatric practice that improves awareness of the spectrum of trauma-related symptoms, promotes an emotionally safe environment of care, and provides specific interventions to mitigate the effects of trauma exposure.4,5 This policy statement presents recommendations for policy makers, legislators, and health care organizations for implementation of TIC into pediatric health systems. The accompanying clinical report6 presents best-practice guidance for TIC in the direct care of children and adolescents.TIC is defined by the National Child Traumatic Stress Network as medical care in which all parties involved assess, recognize, and respond to the effects of traumatic stress on children, caregivers, and health care providers. TIC also includes attention to secondary traumatic stress (STS), the emotional strain that results when an individual, whether a health care worker or parent, hears about or witnesses the traumatic experiences, past or present, of children.Every pediatric encounter presents opportunities to promote family resilience and relational health.7 Informed by research in infant mental health and neurodevelopment, early relational health refers to the establishment of foundational relationships during the first 3 years of life that are central to successful physiologic, emotional, and moral development of the young child.8 Relational health, in a more general sense, is applicable to all age groups, is dyadic, and includes the capacity of both the child and caregiver to enter into a safe, secure, nurturing relationship allowing both to thrive.1,9,10 Strong foundational relationships support resilience and buffer stress in children, so they can be considered primary prevention of stress-related disturbance. Trauma-informed practices also support relational health and family resilience as important protective factors for those who have been exposed to persistent adversity or potentially traumatic events (see Fig 1).Human neuroendocrine–immune networks respond to internal and external sensors that identify danger and safety by activating in dangerous circumstances and deactivating when danger has subsided.11 Toxic stress responses occur with prolonged activation of the neuroendocrine–immune system and dysregulation of homeostasis (or allostasis if multiple systems are involved)12 in the absence of buffering by SSNRs. Toxic stress responses can result in lifelong impairments in physical, mental, and relational health.13The concept of toxic stress adds an important physiologic basis to the study of attachment and our understanding of trauma. Trauma is defined as an event, series of events, or circumstances experienced by a person as physically or emotionally harmful that can have long-lasting adverse effects on the person’s functioning and well-being (emotional, physical, or spiritual).14 Attachment theory describes the deep and enduring relationship between a child and adult caregiver that ideally provides a secure base from which the child can develop and explore the world.15Resilience is the dynamic process of adaptation to or despite significant adversity by using protective factors and learned skills to manage stressful circumstances.16 Resilience may allow a person to experience tolerable rather than toxic stress in response to adversity. Some characteristics of resilient children include strong executive functions (self-control of attention and impulses) and a strong personal identity, often related to a cultural or faith tradition.17 However, most important to both resilience and relational health is the capacity for young children to form at least one stable, caring, and supportive relationship.9,18Almost half of American children, or 34 million younger than 18 years, have faced at least one potentially traumatic early childhood experience.19 More than 1 in 7 adults report exposure during childhood to 4 or more adverse childhood experiences such as abuse, neglect, or other household adversity,20 including intimate partner violence or parental incarceration. Certain populations are at higher risk for trauma exposure, both physical and emotional. In surveys, poverty or financial stress is the most commonly reported childhood adversity, second only to loss of a parent.21,22 Exposure to divorce, child maltreatment, sexual abuse, intimate partner violence, bullying, parental mental illness, parental substance use problems, and community violence are also common.21 Specific populations at high risk for trauma include children and adolescents who identify as LGBTQ, have developmental or behavioral problems,23–25 are in foster or kinship care, are incarcerated, are living in deep poverty, or are immigrants. Potentially traumatic environmental and community-level conditions include economic stress, school or community violence, adverse experiences during and after immigration, natural disasters, pandemics, and mass-casualty events such as shootings or bombings.Racism is a common cross-cutting risk factor. Racial, ethnic, or religious bigotry magnifies the risk inherent to other special populations.26 Experiences ranging from hate crimes, police profiling, bullying, or microaggressions to covert discrimination are traumatic events and may be internalized as trauma by those who are victims, indirectly or directly, of the events.27,28 Historical trauma refers to the collective, transgenerational emotional and psychological injury of specific ethnic, racial, or cultural groups and their descendants who have experienced major events of oppression such as genocide, forced displacement, or slavery.29,30 Originally applied to children of the Holocaust, the concept is now applied to American Indian and Alaskan native people, African American people, Mexican American people, Japanese American people, and other groups of people who have experienced mass trauma.30 Investigators link historical “soul wounding” to current health and behavioral disorders including substance use disorder, domestic violence, and suicide, particularly in Indigenous communities.29,31 Children separated from families during immigration and/or detained in group facilities overseen by the Office of Refugee Resettlement are a recent special population at severe risk for long-term sequelae resulting from forced family separation.32,33In November 2019, the Centers for Disease Control and Prevention reviewed the emerging literature linking early childhood adversity with adult illnesses20,34 and analyzed survey data from 25 states over 2 years.3,35 Researchers concluded that reducing exposure to early childhood trauma and mitigating posttrauma effects would generally and significantly reduce adult morbidity and mortality. Using logistic regression modeling, they estimated potential reductions in incidence from low for obesity (1.7%) to high for heavy drinking, chronic obstructive pulmonary disease, and depression (23.9%, 27.0%, and 44.1%, respectively). Recommendations included creating healthy communities, supporting SSNRs, and developing programs that apply primary (reducing exposure to childhood adversity) and secondary prevention (mitigating the effects of exposure) on the basis of principles of TIC.The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) presents a list of trauma-related disorders ranging from mild (adjustment disorder) to severe (posttraumatic stress disorder [PTSD]).36 Two additional categories, reactive attachment disorder and disinhibited social engagement disorder, are specific to young children (please see the DSM-5 for complete diagnostic criteria). This nosology can be expanded to describe other presentations common in pediatric health care settings: developmental trauma disorder (DTD), pediatric medical traumatic stress (PMTS), and STS, the last being most relevant for health care workers, family members, and caregivers.The diagnosis of PTSD, as outlined in the current DSM-5, does not adequately describe the variable presentations of trauma manifestations in children across developmental stages.37 Children with complex trauma histories often exhibit heterogeneous developmental symptoms as well as difficulties with intimate relationships and with regulation of attention and impulse control.38 DTD is a proposed new diagnostic category that incorporates these differences and attempts to better describe the disturbances that occur in multiple developmental domains.39 The omission of DTD in the DSM-5 has been controversial,40 and the search for a better nosology of trauma, including DTD, is ongoing.41PMTS refers to the distress that patients and family members experience during hospitalization for a perceived life-threatening diagnosis or while living with or caring for individuals with life-altering chronic conditions.42 PMTS is underrecognized and rarely addressed despite its high prevalence.43,44 Up to 80% of ill or injured children and their families may have traumatic stress reactions after a life-threatening illness, injury, or procedure.45 In some surveys, up to 20% of parents of children admitted to a PICU develop PTSD within a few months.45 The suffering of family members and caregivers is often not addressed because of existing structural and reimbursement obstacles for multigenerational care.Although research on PMTS (and on pediatric postintensive care syndrome)46,47 is ongoing, researchers in 1 study found that approximately 10% of children developed PTSD 3 to 5 months after major surgery, and 28% developed posttraumatic stress symptoms (PTSS) resulting in functional disability by parent report.48 PTSS can also occur after a severe injury or diagnosis of an illness such as cancer. In another family study, more than 10% of children had persistent functional impairment from PTSS at 6 weeks and 1 year after a potentially life-threatening injury or diagnosis, and 15% of mothers and 8% of fathers met criteria for PTSD at 1 year.49As described earlier, STS may occur in parents, other family members, and health care workers such as physicians, nurses, other hospital staff, first responders, and therapists. STS may have many of the same long-term effects on health that affect children exposed to trauma.50 Some health care workers may also develop disabling posttrauma symptoms that can interfere with quality of life both at work and home. Health care workers may have their own trauma histories that contribute to their reactions when exposed to the suffering of others. Nonclinical staff may also experience STS triggered by their own trauma histories, especially if the health care facility is located in an area with high adversity and nonclinical staff live in the vicinity.Preliminary evidence exists of a synergistic effect among STS, depression, and burnout in affected health care workers.51 STS in combination with burnout has been associated with a significant increase in the frequency of medical errors.52,53 Depression, anxiety, and suicide are greater risks for physicians than for the general population. In the United States, the rate of suicide among female physicians is 130% higher than among women who are not physicians; the rate for male physicians is 40% higher than for men who are not physicians.51 Burnout includes a spectrum of pathologic conditions that develop in the context of occupational stress and is almost twice as prevalent among physicians. The risk among nurses for burnout, depression, and STS is even higher. More than half of nurses reported suboptimal mental or physical health,54 approximately 35% reported a high degree of emotional exhaustion,55 and 18% reported depression in national surveys. Reports of posttraumatic stress among health care workers related to the coronavirus disease 2019 pandemic prompted worldwide concern for increased awareness and trauma-informed support for the mental health of all involved.56Core principles that can be helpful for policy development, outlined by the National Council on Behavioral Health (2019)57 are outlined in the following sections. Implementation of TIC at a practice level is described in detail in the accompanying clinical report.6The health care organization, workspace, and every encounter should be characterized by compassion, cultural humility, equity, collaboration, and safety for families and employees. An emotionally safe workplace includes acknowledgment of and particular attention to racial and gender discrimination, including implicit bias both in rendering care and workplace human relations. A review of health care settings from the viewpoints of patients, families, and staff can uncover practices, processes, or details in the environment that are potentially traumatizing.Hospital and health system leadership can annually review policies and procedures to ensure a safe work environment and setting to provide TIC, to reduce STS and burnout, and to promote sensitivity to the needs of trauma survivors.58 The alignment of financial and human capital resources to support an optimal health environment in all levels and locations of care is extremely important. Surveys designed to assess system readiness for implementation are available and can be adapted for pediatric health care settings.Surveillance and standardized screening to assess staff and patients for trauma exposure, symptoms, and strengths are important components of trauma-informed pediatric care. Universal screening, when implemented within the larger context of trauma-informed approaches and endorsed and supported by administrative leadership, reduces stigma and allows standardized responses such as time off or referral to an employee assistance program. Families and youth may be queried at the point of care, such as at the time of hospital admission. Formal screening should always be for the benefit of children and adolescents, avoid retraumatization, and identify protective as well as risk factors.59 More specific information about screening is included in the accompanying clinical report.6Involvement of families and youth in the development of TIC policies and practices, particularly regarding cultural, historical, and gender issues, is essential to building an environment of support and mutuality.14 Both formal and informal structures, such as Family Advisory Councils and family-centered rounds,60 create a cultural expectation of collaboration and enable the health care team to understand the strengths and vulnerabilities of individual families and of the populations served. When appropriate, tribal elders, traditional healers, and other faith community leaders can be included in developing individual care plans or institutional quality-improvement efforts. A whole-person, whole-family, whole-community perspective promotes improved awareness of how cultural backgrounds affect the perception of trauma, safety, and privacy.61,62TIC, from a public health perspective, includes primary, secondary, and tertiary prevention strategies. Primary prevention is a comprehensive approach that addresses social determinants of health (such as structural racism, poverty, and violence) that are often root causes of community trauma.63 Promotion of relational health and other resilience factors (such as strong executive function and self-efficacy) may be considered primary prevention.64 Following the fourth edition of Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, promotion of early childhood relational health is a core purpose of both pediatric primary care and early childhood education.65The National Child Traumatic Stress Network includes the promotion of child and family resilience, enhancement of protective factors, awareness of parent or caregiver trauma, and involvement of families in program development and evaluation as secondary prevention.66 Trauma-informed therapies (eg, trauma-focused cognitive behavioral therapy) for symptomatic children and youth are considered tertiary prevention. These therapies are especially important for high-risk populations as identified earlier.67–70 Attachment-based dyadic therapies, such as parent–child interaction therapy, may serve to prevent development of persistent traumatic stress symptoms in high-risk families71 and may be considered both secondary and tertiary prevention.Recruitment and pre-employment practices may help discern the capacity for empathy among prospective employees.72 Training and education of all administrators, clinicians, and staff, both clinical and nonclinical, can promote the appreciation of the lifelong effects of trauma on child and adolescent development and family resilience and the implementation of trauma-aware practices. Continuous quality-improvement programs translate new knowledge and skills about childhood trauma into supervision, training, and patient care.Prevention of STS requires specific training of all staff to raise awareness, promote resilience, and explore the interaction among STS, burnout, depression, substance use, and professional quality of life. Supportive supervision and peer mentoring offer opportunities for all employees to reflect on their own trauma histories and to promote compassion, nonjudgmental attitudes and collaboration.73Trauma-informed health care systems establish and support collaborative, interdisciplinary relationships among community and public health agencies that serve children and adolescents to coordinate care for children, adolescents, and families exposed to trauma. Schools,74 juvenile justice programs,75 mental health professionals,76 home visiting services, child welfare systems,76 and foster care agencies77 are natural partners for pediatric health organizations in promoting community resilience. Many have established TIC programs. Community early intervention programs can help prevent and mitigate adversity and often have the advantage of caring for young children in their natural environment as home visitors.78–80Federal agencies such as the Centers for Disease Control and Prevention can continue and expand research to improve understanding of the developmental effects of trauma and the efficacy of specific interventions for historically resilient populations. Urgently needed are successful strategies to interrupt the intergenerational transfer of family violence. Strategies are also crucial to blunt the impact of historical trauma in communities of color and in American Indian and Alaskan native populations in the United States.30 It is particularly important to identify the origins of and successfully mitigate community violence, including racism, misogyny, and religious, ethnic, and cultural bias.State-level resources can be directed to implementation, dissemination, and evaluation of trauma-informed community programs, such as interagency and multigenerational strategies for opioid dependency. One example of a state interagency, multigenerational treatment program is Ohio START (Sobriety, Treatment and Reducing Trauma).81 States could develop a communication infrastructure to facilitate data sharing, improve interdisciplinary/interagency cooperation, and engage community partners including foundations and academic institutions.Federal guidelines can require that state Medicaid programs ensure comprehensive coverage for all children and adolescents and pregnant mothers without regard for legal or immigration status and mandate that coverage include mental health and substance use disorder services. Financing that increases access to high-quality, comprehensive, coordinated, culturally competent health care for high-risk populations is a high priority. Federal and state regulations can require all insurers, including Medicaid and private health insurers, to include coverage for TIC elements, including surveillance, screening, diagnosis, counseling, case management, follow-up, community collaboration, mental health care, and home visiting.In large health systems, leadership can align its mission and financing with the core elements of trauma-informed systems.82 Supporting TIC includes payment for trauma-informed, integrated mental health services, care coordination, rigorous case management, and seamless referral networks for intensive treatment. Prevention of secondary trauma, including care of affected health care workers, should be built into the mission of the health system.Academic health centers train and educate the next generation of physicians, nurses, and ancillary health personnel and can promote the transformation to TIC in all health settings through education, research, and advocacy. Children’s hospitals and health systems can model mental health integration83 and trauma-informed practices throughout all service lines.84 Because children’s hospitals embrace population health management and community advocacy, they may serve as the anchor institution collaborating with community agencies to address social adversity at the neighborhood level while promoting TIC services.85 Together with community pediatric care systems, academic health centers and children’s hospitals can integrate core elements of education into workforce training for health care workers and community partners such as first responders, child welfare workers, teachers, and juvenile justice personnel.86,87Deborah L. Shropshire, MD, FAAP

BackgroundSubstance abuse agencies have been slow to adopt and implement evidence-based practices (EBPs), due in part to poor provider morale and organizational climates that are not conducive to successful learning and integration of these practices. Person-organization fit theory suggests that alignment, or fit, between provider- and agency-level characteristics regarding the implementation of EBPs may influence provider morale and organizational learning climate and, thus, implementation success. The current study hypothesized that discrepancies, or lack of fit, between provider- and agency-level contextual factors would negatively predict provider morale and organizational learning climate, outcomes shown to be associated with successful EBP implementation.MethodsDirect service providers (n = 120) from four substance abuse treatment agencies responded to a survey involving provider morale, organizational learning climate, agency expectations for EBP use, agency resources for EBP use, and provider attitudes towards EBP use. Difference scores between combinations of provider- and agency-level factors were computed to model provider-agency fit. Quadratic regression analyses were conducted to more adequately and comprehensively model the level of the dependent variables across the entire “fit continuum”.ResultsDiscrepancies, or misfit, between agency expectations and provider attitudes and between agency resources and provider attitudes were associated with poorer provider morale and weaker organizational learning climate. For all hypotheses, the curvilinear model of provider-agency discrepancies significantly predicted provider morale and organizational learning climate, indicating that both directions of misfit (provider factors more favorable than agency factors, and vice-versa) were detrimental to morale and climate. However, outcomes were most negative when providers viewed EBPs favorably, but perceived that agency expectations and resources were less supportive of EBP use.ConclusionsThe current research benefits from a strong theoretical framework, consistent findings, and significant practical implications for substance abuse treatment agencies. Comprehensive attempts to strengthen outcomes related to EBP implementation must consider both provider- and agency-level characteristics regarding EBP use. Organizational efforts to more closely align provider attitudes and agency priorities will likely constitute a key strategy in fostering the implementation of EBPs in substance abuse treatment organizations.