Abstract
BackgroundThe criminal justice system is the largest provider of mental health services in the USA. Many jurisdictions are interested in reducing the use of the justice system for mental health problems. The national Stepping Up Initiative helps agencies within counties work together more effectively to reduce the number of individuals with mental illness in jails and to improve access to mental health services in the community. This study will compare Stepping Up counties to matched comparison counties over time to (1) examine the effectiveness of Stepping Up and (2) test hypothesized implementation mechanisms to inform multi-agency implementation efforts more broadly.MethodsThe study will survey 950 counties at baseline, 18 months, and 36 months in a quasi-experimental design comparing implementation mechanisms and outcomes between 475 Stepping Up counties and 475 matched comparison counties. Surveys will be sent to up to four respondents per county including administrators of jail, probation, community mental health services, and community substance use treatment services (3800 total respondents). We will examine whether Stepping Up counties show faster improvements in implementation outcomes (number of justice-involved clients receiving behavioral health services, number of behavioral health evidence-based practices and policies [EBPPs] available to justice-involved individuals, and resources for behavioral health EBPP for justice-involved individuals) than do matched comparison counties. We will also evaluate whether engagement of hypothesized mechanisms explains differences in implementation outcomes. Implementation target mechanisms include (1) use of and capacity for performance monitoring, (2) use and functioning of interagency teams, (3) common goals and mission across agencies, and (4) system integration (i.e., building an integrated system of care rather than adding one program or training). Finally, we will characterize implementation processes and critical incidents using survey responses and qualitative interviews.DiscussionThere are few rigorous, prospective studies examining implementation mechanisms and their relationship with behavioral health implementation outcomes in justice and associated community behavioral health settings. There is also limited understanding of implementation mechanisms that occur across systems with multiple goals. This study will describe implementation outcomes of Stepping Up and will elucidate target mechanisms that are effective in multi-goal, multi-agency systems.
Highlights
The criminal justice system is the largest provider of mental health services in the USA
This study will describe implementation outcomes of Stepping Up and will elucidate target mechanisms that are effective in multi-goal, multi-agency systems
This paper describes the methods for the first prospective national study evaluating implementation outcomes of efforts to help justice and community behavioral health systems work together better to keep individuals with mental illness out of jail
Summary
County matching and baseline covariate controls increase the rigor for this longitudinal natural experiment, which is described consistent with STROBE guidelines [25] (see Supplemental Materials). Secondary We will conduct a series of analyses examining changes in interagency teams, common goals and missions, and integrated systems of care using scores from respective measures identified above, as mediators of a number of justice-involved individuals receiving services, number of EBPPs available, and number of resources using appropriate baseline measures or months since joining Stepping Up as controls. A priori moderators include months between a county joining Stepping Up and study baseline, levels of implementation outcomes at study baseline, type of agency, organizational culture support for innovations (i.e., score on NCJTP Assess Your Organizational Culture scale [38]), jails with their own behavioral health staff, yes/no presence of legislative reforms, counties in states that have mental health diversion funding, and counties with divisions that provide cross-system trainings. We will compare patterns found in the qualitative data to patterns found in our quantitative data; this side-by-side comparison of patterns can identify sign posts for additional exploration and analyses
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