Implementation Of Multiple Evidence-based Practices Research Articles

COVID-19 Infection, Prevention, and Control Considerations in the Obstetric Environment.

Pregnancy increases the risk of severe illness due to coronavirus disease 2019 (COVID-19). Thus, prevention of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission in all obstetrical health care settings requires consistent implementation of multiple evidence-based practices and consideration of local epidemiology, local regulations for COVID-19, and guidance from the Centers for Disease Control and Prevention and Professional Societies. COVID-safe practices should be implemented for patients, visitors/support persons, and health care personnel and include screening, appropriate personal protective equipment, and transmission precautions. Vaccination of all health care personnel, pregnant people, and their support persons remains the best strategy to prevent COVID-19.

Patterns of Child Mental Health Service Utilization Within a Multiple EBP System of Care

The current study (1) characterizes patterns of mental health service utilization over 8 years among youth who received psychotherapy in the context of a community implementation of multiple evidence-based practices (EBPs), and (2) examined youth-, provider- and service-level predictors of service use patterns. Latent profile analyses were performed on 5,663,930 administrative claims data furnished by the county department of mental health. Multinomial logistic regression with Vermunt’s method was used to examine predictors of care patterns. Based on frequency, course, cost, and type of services, three distinct patterns of care were identified: (1) Standard EBP Care (86.3%), (2) Less EBP Care (8.5%), and (3) Repeated/Chronic Care (5.2%). Youth age, ethnicity, primary language, primary diagnosis and secondary diagnosis, provider language and provider type, and caregiver involvement and service setting were significant predictors of utilization patterns. Although the majority of youth received care aligned with common child EBP protocols, a significant portion of youth (13.7%) received no evidence-based care or repeated, costly episodes of care. Findings highlight opportunities to improve and optimize services, particularly for youth who are adolescents or transition-aged, Asian-American/Pacific Islander, Spanish-speaking, or presenting with comorbidities.

Observed Engagement in Community Implemented Evidence-Based Practices for Children and Adolescents: Implications for Practice Delivery

ABSTRACT Objective This observational study characterizes youth and caregiver behaviors that may pose challenges to engagement within a system-driven implementation of multiple evidence-based practices (EBPs). We examined links between Engagement Challenges and therapist EBP implementation outcomes. Method Community therapists (N = 102) provided audio recordings of EBP sessions (N = 666) for youth (N = 267; 71.54%, Latinx; 51.69%, female; M age = 9.85, Range: 1–18). Observers rated the extent to which youth and/or caregivers engaged in the following behaviors: Caregiver and/or Youth Expressed Concerns about interventions, and Youth Disruptive Behaviors. Multilevel modeling was used to identify predictors of observable Engagement Challenges, and examine associations between Engagement Challenges, and therapist-reported ability to deliver planned activities, and observer-rated extensiveness of EBP strategy delivery. Results At least one Engagement Challenge was observed in 43.99% of sessions. Youth Engagement Challenges were not associated with outcomes. Caregiver Expressed Concerns were negatively associated with therapist-reported ability to carry out planned session activities (B = −.21, 95% CI[−.39-(−.02)], p < .05). However, Caregiver Expressed Concerns were positively associated with extensiveness of EBP Content strategy delivery (B = .08, 95% CI[.01-.15], p < .05). Conclusions Results suggest that Youth Engagement Challenges have little observed impact on EBP delivery. In contrast, although therapists perceive that Caregiver Expressed Concerns derail their planned activities, Caregiver Expressed Concerns are associated with more extensive delivery of content about therapeutic interventions. Community therapists’ implementation of EBPs appear unaffected by common youth in-session behavioral challenges, but future research is needed to clarify whether caregivers’ concerns about interventions prompt, or are prompted by, more intensive therapist EBP content instruction.

Confronting Stressors in the Therapy Room: Emergent Life Events in a Multiple Evidence-Based Practice Implementation Context

ABSTRACT Life stressors, or emergent life events, have the potential to interfere with child and family therapy processes and have been cited as barriers to implementing evidence-based practices (EBPs) for child mental health in community settings. The purpose of this study is to characterize the discussion of emergent life events in therapy sessions and examine its association with therapist delivery of EBP strategies, all within the context of system-driven implementation of multiple EBPs. Data were drawn from 680 audio-recorded psychotherapy sessions in which an EBP was delivered to 274 youth receiving care from 103 community therapists in 14 mental health agencies. Emergent life events were mentioned in 143 sessions (21.0%), with 77 sessions (11.3%) containing a mild intensity emergent life event and 66 sessions (9.7%) containing an emergent life event of at least moderate intensity (moderate to severe). Multi-level analyses found that session/EBP-, child-, therapist-, and agency-related factors were associated with the reporting of emergent life events in session. In addition, the reporting of an emergent life event of at least moderate intensity (moderate to severe) was associated with less extensive observed delivery of EBP strategies within the same session, whereas the reporting of an emergent life event of mild intensity was not significantly associated with the extensiveness of EBP strategy delivery. Emergent life events can influence the delivery of EBP strategies in community mental health services.

A Mixed-Method Analysis on the Impacts of a System-Driven Implementation of Multiple Child Evidence-Based Practices on Community Mental Health Providers.

Initiatives to scale up evidence-based practices (EBPs) in routine care are likely to have myriad impacts on community providers, but these impacts have not yet been examined in depth. This is especially true within the context of simultaneous implementation of multiple evidence-based practices. The aim of this study was to characterize the multifaceted impacts on community mental health therapists within a system-driven implementation of multiple EBPs for youth and families. Semistructured interview and survey data were gathered from 60 therapists at 11 agencies contracted with the Los Angeles County Department of Mental Health to deliver EBPs within the Prevention and Early Intervention initiative. Therapists' accounts of impacts varied, and were either predominately negative, predominantly positive, or mixed-valence. Mixed-methods analyses using Kruskal-Wallis tests showed therapist valence groups varied on mean levels of self-reported burnout on surveys. Themes from qualitative data revealed several favorable (e.g., increased EBP knowledge, structure) and unfavorable (e.g., distress, feeling constrained by EBPs) impacts of county-contracted EBP implementation. These findings inform the development and implementation of future system-driven EBP initiatives that consider therapist perspective to optimize positive impacts and minimize negative impacts on therapists.

Service use by youth with autism within a system-driven implementation of evidence-based practices in children's mental health services.

Public mental health systems play an important role in caring for youth with autism spectrum disorder. Like other dually diagnosed populations, youth with autism spectrum disorder may receive services in the context of evidence-based practice implementation efforts within public mental health systems. Little is known about service use patterns within the context of system-driven implementations efforts for this population. This case-control study examined mental health service patterns of 2537 youth with autism spectrum disorder compared to 2537 matched peers receiving care in the Los Angeles County Department of Mental Health, the largest public mental health department in the United States, within the context of a system-driven implementation of multiple evidence-based practices. Although not the primary target of this implementation effort, youth with autism spectrum disorder were served when they met criteria for the services based on their presenting mental health symptoms. Comparative analyses using administrative claims data were conducted to examine differences in mental health utilization patterns and clinical characteristics. Findings revealed significant differences in the volume and duration of mental health services as well as differences in the service type and evidence-based practice delivered between youth with and without autism spectrum disorder. Results provide direction targeting implementation efforts for youth with autism spectrum disorder within a public mental health system care reform.

Caregiver Attendance as a Quality Indicator in the Implementation of Multiple Evidence-Based Practices for Children

Objective: This study investigated a quality indicator for children’s mental health, caregiver attendance in youth psychotherapy sessions, within a system-driven implementation of multiple evidence-based practices (EBPs) in children’s community mental health services. Method: Administrative claims from nine fiscal years were analyzed to characterize and predict caregiver attendance. Data included characteristics of therapists (n = 8,626), youth clients (n = 134,368), sessions (e.g., individual, family), and the EBP delivered. Clients were primarily Latinx (63%), male (54%) and mean age was 11; they presented with a range of mental health problems. Three-level mixed models were conducted to examine the association between therapist, youth, service, EBP characteristics and caregiver attendance. Results: Caregivers attended, on average, 46.0% of sessions per client for the full sample and 59.6% of sessions for clients who were clinically indicated, based on age and presenting problem, to receive caregiver-focused treatment. Following initial EBP implementation, the proportion of caregiver attendance in sessions increased over time. Caregivers attended a higher proportion of youth psychotherapy sessions when clients were younger, had an externalizing disorder, were non-Hispanic White, and were male. Further, higher proportions of caregiver attendance occurred when services were delivered in a clinic setting (compared with school and other settings), by bilingual therapists, and the EBP prescribed caregiver attendance in all sessions. Conclusions: Overall, the patterns of caregiver attendance appear consistent with evidence-informed practice parameters of client presenting problem and age. Yet, several improvement targets emerged such as client racial/ethnic background and service setting. Potential reasons for these disparities are discussed.

Factors Associated With Caregiver Attendance in Implementation of Multiple Evidence-Based Practices in Youth Mental Health Services.

The implementation of evidence-based practices (EBPs) in community mental health settings for youths has consistently yielded weakened effects compared with controlled trials. There is a need to feasibly measure the quality of large-scale implementation efforts to inform improvement targets. This study used therapist-reported caregiver attendance in treatment sessions as a quality indicator in the community implementation of EBPs. Data were collected from therapists practicing in agencies contracted to provide publicly funded children's mental health services following a system-driven implementation of multiple EBPs. Community therapists (N=101) provided information about youth clients (N=267) and psychotherapy sessions (N=685). Multivariable binomial logistic regressions were conducted to examine associations between caregiver attendance and therapist factors (e.g., licensure status, education), youth factors (e.g., gender, age), and the type of EBP delivered. Caregiver attendance occurred in 42% of sessions. The following factors were associated with increased odds of caregiver attendance: younger client age, male sex of client, externalizing presenting problem, and delivery of an EBP that prescribes caregiver attendance at all sessions. Caregiver attendance at sessions targeting trauma or externalizing disorders appeared to explain the differences between boys and girls in levels of caregiver engagement. Overall, the patterns of actual caregiver attendance appeared consistent with empirically informed practice parameters for involvement of caregivers in treatment. Still, the rates of caregiver attendance in externalizing-focused sessions were suboptimal, and the gender difference in these rates-which clearly disfavored girls-suggests targeted areas for quality improvement. Potential reasons for these quality gaps are discussed.

Community Therapist Reports of Client Engagement Challenges During the Implementation of Multiple EBPs in Children’s Mental Health

ABSTRACTThis study investigated therapist reports of client engagement challenges in delivering evidence-based practices (EBPs), within the context of a large-scale implementation of multiple practices in children’s mental health services. Data were drawn from an online survey of 668 therapists (88% female, 35.0% Non-Hispanic White). The majority of therapists (75.4%) endorsed at least one client engagement challenge during their implementation of an EBP with an identified client over the previous two months. Two types of EBP client engagement challenges with distinct correlates but similar overall frequencies could be readily differentiated – Expressed Client Concerns and Limited Client Engagement in therapy activities. Limited Client Engagement were more commonly reported for clients with externalizing problems and by therapists with higher emotional exhaustion and negative perceptions of the specific EBP being delivered, whereas Hispanic/Latino therapists were less likely to report Limited Client Engagement. In contrast, Expressed Client Concerns were more commonly reported by therapists with positive general attitudes towards EBPs, and among therapists delivering a parent training EBP. Limited Client Engagement but not Expressed Concerns were linked with therapists’ self-reported ability to carry out the EBP with the target client. Findings suggest that client engagement challenges are frequent during the delivery of EBPs, but may impact implementation differently based on whether they relate to challenges in engaging clients in therapy activities versus addressing concerns raised by clients

Predictors of burnout among community therapists in the sustainment phase of a system-driven implementation of multiple evidence-based practices in children’s mental health.

Burnout among community mental health (CMH) therapists has been associated with poorer therapist health, high agency turnover, poorer client outcomes, and compromised quality of care. Recent mandates to learn and implement multiple evidence-based practices (EBPs) within CMH settings are intended to improve the quality of community care, yet there is mixed evidence concerning the impacts on workforce burnout. The current study sought to identify correlates of therapist emotional exhaustion, a key aspect of burnout, during the sustainment phase of a system-driven implementation of multiple EBPs in children's mental health services. We hypothesized that high workload and unfavorable organizational climate would relate to therapist emotional exhaustion, but that positive experiences with EBPs adopted would relate to lower exhaustion. Although agency-level indices of organizational climate were unrelated to exhaustion, a multilevel model revealed that therapists' weekly work hours, caseload, and number of EBPs delivered were associated with increased emotional exhaustion. Additionally, activities associated with the EBP implementation efforts (e.g., hours spent in EBP-related activities, supervision or consultation, or outcome monitoring), were not associated with emotional exhaustion. Therapists' knowledge and confidence delivering EBPs and their positive perceptions of EBPs were protective against emotional exhaustion, but these perceptions did not buffer the risks associated with heavy workload. Findings point to implementation strategies to prevent burnout and associated turnover that compromise the returns on investments in EBP implementation.

Using Survival Analysis to Understand Patterns of Sustainment within a System-Driven Implementation of Multiple Evidence-Based Practices for Children's Mental Health Services.

Evidence-based practice (EBP) implementation requires substantial resources in workforce training; yet, failure to achieve long-term sustainment can result in poor return on investment. There is limited research on EBP sustainment in mental health services long after implementation. This study examined therapists’ continued vs. discontinued practice delivery based on administrative claims for reimbursement for six EBPs [Cognitive Behavioral Interventions for Trauma in Schools (CBITS), Child–Parent Psychotherapy, Managing and Adapting Practices (MAP), Seeking Safety (SS), Trauma-Focused Cognitive Behavior Therapy (TF-CBT), and Positive Parenting Program] adopted in a system-driven implementation effort in public mental health services for children. Our goal was to identify agency and therapist factors associated with a sustained EBP delivery. Survival analysis (i.e., Kaplan–Meier survival functions, log-rank tests, and Cox regressions) was used to analyze 19 fiscal quarters (i.e., approximately 57 months) of claims data from the Prevention and Early Intervention Transformation within the Los Angeles County Department of Mental Health. These data comprised 2,322,389 claims made by 6,873 therapists across 88 agencies. Survival time was represented by the time elapsed from therapists’ first to final claims for each practice and for any of the six EBPs. Results indicate that therapists continued to deliver at least one EBP for a mean survival time of 21.73 months (median = 18.70). When compared to a survival curve of the five other EBPs, CBITS, SS, and TP demonstrated a higher risk of delivery discontinuation, whereas MAP and TF-CBT demonstrated a lower risk of delivery discontinuation. A multivariate Cox regression model revealed that agency (centralization and service setting) and therapist (demographics, discipline, and case-mix characteristics) characteristics were significantly associated with risk of delivery discontinuation for any of the six EBPs. This study illustrates a novel application of survival analysis to administrative claims data in system-driven implementation of multiple EBPs. Findings reveal variability in the long-term continuation of therapist-level delivery of EBPs and highlight the importance of both agency and workforce characteristics in the sustained delivery of EBPs. Findings direct the field to potential targets of sustainment interventions (e.g., strategic assignment of therapists to EBP training and strategic selection of EBPs by agencies).

Agency responses to a system-driven implementation of multiple evidence-based practices in children\u2019s mental health services

BackgroundLarge mental health systems are increasingly using fiscal policies to encourage the implementation of multiple evidence-based practices (EBPs). Although many implementation strategies have been identified, little is known about the types and impacts of strategies that are used by organizations within implementation as usual. This study examined organizational-level responses to a fiscally-driven, rapid, and large scale EBP implementation in children’s mental health within the Los Angeles County Department of Mental Health.MethodsQualitative methods using the principles of grounded theory were used to characterize the responses of 83 community-based agencies to the implementation effort using documentation from site visits conducted 2 years post reform.ResultsFindings indicated that agencies perceived the rapid system-driven implementation to have both positive and negative organizational impacts. Identified challenges were primarily related to system implementation requirements rather than to characteristics of specific EBPs. Agencies employed a variety of implementation strategies in response to the system-driven implementation, with agency size associated with implementation strategies used. Moderate- and large-sized agencies were more likely than small agencies to have employed systematic strategies at multiple levels (i.e., organization, therapist, client) to support implementation.ConclusionsThese findings are among the first to characterize organizational variability in response to system-driven implementation and suggest ways that implementation interventions might be tailored by organizational characteristics.