On-site Technical Assistance Research Articles

An intensive professional development in family child care: a promising approach

ABSTRACT The quality of early care and education affects a wide range of children’s experiences and developmental outcomes. Family Child Care (FCC) is no exception, and attention to increasing the quality of Family Child Care is needed. The purpose of the current study was to examine an experimental case of intensive Professional Development (PD) in FCC programmes focusing on domain-specific quality (language and literacy) and global quality. Forty-nine FCC providers in two states participated in the study. Thirty-eight FCC providers received intensive PD support, including five three-hour training workshops on early language and literacy, weekly onsite technical assistance, and monthly Community of Practice meetings. Eleven FCC providers served as a comparison group. The Child/Home Environmental Language and Literacy Observation (CHELLO) and Family Child Care Environmental Rating Scale (FCCERS-R) were used to measure the quality of FCC. Results showed significant improvement in the high-intensity PD group on both measures. The study presents a promising model of PD that may be an appropriate approach to embed within Quality Rating and Improvement Systems (QRIS) in early child care and education.

Evaluation of a statewide initiative to reduce expulsion of young children.

This program evaluation study describes 3 years of implementation of Arkansas's BehaviorHelp (BH) system, a statewide expulsion prevention support system for early care and education (ECE). BH coordinates three tiers of supports to ECE professionals, including phone support, on-site technical assistance (TA), and infant and early childhood mental health consultation (IECMHC). We examine differences in characteristics of those served across BH service tiers, describe short-term case outcomes, and explore factors associated with expulsions. BH accepted referrals for 1,195 children in 488 ECE programs. The majority of referrals involved male children over the age of three, and most cases were assigned to the TA tier (68.5%). Cases assigned to receive IECMHC (28.4%) were more likely to involve children in foster care, receiving developmental therapies, and with higher rates of exposure to potentially traumatic events. The expulsion rate among referred children was 2.9%, and reported teacher engagement with the support process was high. Teachers receiving IECMHC services reported significant improvements in children's symptoms of emotional and behavioral problems. Exploratory analyses revealed that risk factors for expulsion included being a male, in foster care, in a lower quality ECE environment, and having a teacher with less training in social-emotional development.

Exploring the Relationship Between Quality Rating and Improvement System Supports and Global Quality in Family Child Care

A Quality Rating and Improvement System (QRIS) is one widespread method to provide a framework for quality improvement in early care and education. However, there is little research examining the relationship between QRIS supports and quality changes in family child care programs. This study aims to examine the associations between supports offered through Delaware’s QRIS and global quality changes in family child care programs. Delaware’s QRIS supports included financial incentives and on-site technical assistance. Data were extracted from the administrative database on 139 family child care programs participating in the QRIS. Repeated measures multivariate analysis of covariance was used to examine the effects of time and Delaware’s QRIS supports. Results showed significant relationships between QRIS supports and the improvement of global quality in family child care programs as measured by the Family Child Care Environment Rating Scale-Revised. Specifically, the amount of on-site technical assistance was significantly associated with changes in the Interaction and Program Structure subscale scores. Additionally, grants received through the QRIS were significantly associated with quality improvements in the home environment. Considering that the amount of technical assistance alone was effective in improving the global quality of family child care programs, professional development strategies that aim to articulate and enhance the technical assistance that is provided to programs would be useful. Further, various types of financial incentives are encouraged to assist family child care programs in improving the structural quality of their environments.

REDUCING ANTIPSYCHOTIC PRESCRIBING IN NURSING HOMES: FACILITATORS AND BARRIERS FOR HIGH-IMPACT STATE INITIATIVES

In conjunction with the National Partnership to Improve Dementia Care in Nursing Homes initiated in 2012, states implemented initiatives to reduce antipsychotic use. All achieved substantial reductions, but improvement varied across states. By 2018, several states had achieved reductions of more than 45%, including several of the largest states. These reductions are noteworthy given the challenging nature of behavioral symptoms of dementia, and difficulties encountered historically and internationally in changing strongly-rooted clinical practices. How were these successful interventions achieved in high-performing state initiatives? What were the barriers encountered and facilitators that helped overcome these barriers? What does this experience suggest for sustainability of change? To address these questions, we draw on a mixed-methods study of antipsychotic prescribing in nursing homes incorporating analyses of prescribing data, state policy case studies, and facility case studies. Successful states integrated large-scale educational initiatives with strong regulatory action, often focusing especially on laggard facilities. Texas’ initiative was particularly noteworthy, achieving a 56.5% reduction across its far-flung network of nearly 100,000 residents and 1,200 facilities. Texas used metrics to identify facilities that achieved notable reductions in antipsychotic prescribing, and encouraged them to share their strategies with “late adopters”. The state deployed a designated Quality Monitoring Program (QMP), distinct from the survey process, to provide on-site technical assistance to laggard facilities, and provided education for all levels of staff and assistance in implementing data-driven improvement strategies. Successful state initiatives achieved considerable buy-in on the need to reduce antipsychotic use, a key factor in achieving successful system change.

Comprehensive cancer control planning in the Pacific: the Cancer Council of the Pacific Islands a multi-national regional coalition.

In the early 1990s, a comprehensive cancer control (CCC) approach was developed in the United States (US). In 2003, the US-Affiliated Pacific Islands (USAPI) adopted the CCC approach through a regional coalition, the Cancer Council of the Pacific Islands (CCPI). Using the CCC approach, the CCPI developed jurisdiction-specific cancer coalitions and initiated their respective cancer plans. The evolution of the CCC approach and the history of the CCPI regional coalition are reviewed. The outcomes of the regional approach for cancer control in the USAPI are described to illustrate the possibilities, value-added and innovation of using a CCC strategy in a multi-national coalition based in a resource-limited environment. The CCC approach enabled the CCPI to (1) harmonize cancer control efforts between the six USAPI jurisdictions, (2) represent the USAPI cancer needs as a single voice, and (3) develop a regional cancer control strategy. Outcomes include (1) a regional cancer registry, (2) three sequential regional CCC plans, (3) leveraged resources for the USAPI, (4) enhanced on-site technical assistance and training, (5) improved standards for cancer screening, (6) evidence-based cancer control interventions adapted for the USAPI. The regional CCPI coupled with the CCC approach is an effective engine of change. The CCC strategies enabled navigation of the political, geographic, cultural, and epidemiologic Pacific environment. The regional partners have been able to harmonize cancer control efforts in resource-limited settings. Regional cancer coalitions may be effective in the global arena for cancer control between communities, states, or countries.

Testing implementation support for evidence-based programs in community settings: a replication cluster-randomized trial of Getting To Outcomes\xae

BackgroundCommunity organizations can have difficulty implementing evidence-based prevention programs. More research is needed on implementation support interventions designed to help these organizations implement programs with quality.MethodsPreparing to Run Effective Programs (PREP) is a randomized controlled trial testing Getting To Outcomes (GTO), a 2-year implementation support intervention. It compares 15 Boys and Girls Club sites implementing CHOICE (control group), a five-session evidence-based alcohol and drug prevention program, with 14 similar sites implementing CHOICE supported by GTO (intervention group). PREP replicates a previous GTO study that had the same design, but featured a teen pregnancy prevention program instead. All sites received typical CHOICE training. Fourteen intervention sites received GTO manuals, training, and onsite technical assistance to help practitioners complete implementation best practices specified by GTO (i.e., GTO steps). During the first year, technical assistance providers helped the intervention group adopt, plan, and deliver CHOICE. Then, this group was trained on evaluation and quality improvement steps of GTO using feedback reports summarizing their own data, which yielded revised plans for subsequent implementation of CHOICE. This paper presents results regarding GTO’s impact on CHOICE fidelity (adherence, quality of delivery, dosage) and the proximal outcomes of the youth participants (aged 10–14)—attitudes and intentions regarding cigarettes, alcohol, and marijuana use. Fidelity was assessed at all sites by observer ratings and attendance logs. Proximal outcomes were assessed via survey at baseline, 3, and 6 months.ResultsAfter 1 year, fidelity and proximal outcomes were similar between Intervention and control groups. After 2 years (which included GTO quality improvement activities that took place between years 1 and 2), intervention sites had higher ratings of CHOICE adherence and quality of delivery (dosage remained similar). Proximal outcomes did not differ between groups in either year, although there was universally high endorsement of prosocial responses to those outcomes from the start.ConclusionsFindings suggest that systematic implementation support provided by GTO can help community organizations achieve better fidelity. Findings replicate the implementation results from a previous GTO study using the same design, but with a different evidence-based program and different fidelity measures. Although proximal outcomes did not change, in large part due to ceiling effects, the implementation findings suggest GTO can support a variety of programs.Trial registrationThis project is registered at ClinicalTrials.gov with number NCT02135991. The trial was first registered on May 12, 2014.

A statewide effort to reduce high-dose opioid prescribing through coordinated care organizations

BackgroundOregon's Medicaid program is delivered through 16 Coordinated Care Organizations (CCOs) participating in a statewide performance improvement program to reduce high-dose opioid prescribing. CCOs were allowed flexibility to develop their own dose targets and any policies, trainings, guidelines, and/or materials to meet these targets. In this study, we characterize CCO strategies to reduce high-dose opioid prescribing across the 16 CCOs. MethodsWe reviewed relevant CCO documents and conducted semi-structured interviews with CCO administrators to acquire opioid-related policies, practices, timelines and contextual factors. We applied a systematic coding procedure to develop a comprehensive description of each CCO's strategy. We used administrative data from the state to summarize contextual utilization data for each CCO. ResultsMost CCOs selected a target daily morphine milligram equivalent (MME) dose of 90 mg. Sixteen issued quantity limits related to dose, eight restricted specific drug formulations (short-acting or long-acting), and 11 allowed for time-limited taper plan periods for patients over threshold. Many CCOs also employed provider trainings, feedback reports, and/or onsite technical assistance. Other innovations included incentive measures, electronic health record alerts, and toolkits with materials on local alternative therapy resources and strategies for patient communication. CCOs leveraging collaborations with regional partners appeared to mount a greater intensity of interventions than independently operating CCOs. ConclusionsCCOs developed a diversity of interventions to confront high-risk opioid prescribing within their organization. As healthcare systems mount interventions to reduce risky opioid prescribing, it is critical to carefully describe these activities and examine their impact on process and health outcomes.

Impact of Contextual Factors on Interventions to Reduce Acute Care Transfers II Implementation and Hospital Readmission Rates

ObjectivesIdentify contextual and implementation factors impacting the effectiveness of an organizational-level intervention to reduce preventable hospital readmissions from affiliated skilled nursing facilities (SNFs). DesignObservational study of the implementation of Interventions to Reduce Acute Care Transfers tools in 3 different cohorts. SettingSNFs. ParticipantsSNFs belonging to 1 of 2 corporate entities and a group of independent SNFs that volunteered to participate in a Quality Improvement Organization (QIO) training program. InterventionTwo groups of SNFs received INTERACT II training and technical assistance from corporate staff, and 1 group of SNFs received training from QIO staff. MeasurementsThirty-day acute care hospital readmissions from Medicare fee-for-service claims, contextual factors using the Model for Understanding Success in Quality framework. ResultsAll 3 cohorts were able to deliver the INTERACT training program to their constituent facilities through regional events as well as onsite technical assistance, but the impact on readmission rates varied. Facilities supported by the QIO and corporation A were able to achieve statistically significant reductions in 30-day readmission rates. A review of contextual factors found that although all cohorts were challenged by staff turnover and workload, corporation B facilities struggled with a less mature quality improvement (QI) culture and infrastructure. ConclusionsBoth corporations demonstrated a strong corporate commitment to implementing INTERACT II, but differences in training strategies, QI culture, capacity, and competing pressures may have impacted the effectiveness of the training. Proactively addressing these factors may help long-term care organizations interested in reducing acute care readmission rates increase the likelihood of QI success.

Enhancing capacity among faith-based organizations to implement evidence-based cancer control programs: a community-engaged approach.

Evidence-based interventions (EBIs) to promote cancer control among Latinos have proliferated in recent years, though adoption and implementation of these interventions by faith-based organizations (FBOs) is limited. Capacity building may be one strategy to promote implementation. In this qualitative study, 18 community key informants were interviewed to (a) understand existing capacity for health programming among Catholic parishes, (b) characterize parishes' resource gaps and capacity-building needs implementing cancer control EBIs, and (c) elucidate strategies for delivering capacity-building assistance to parishes to facilitate implementation of EBIs. Semi-structured qualitative interviews were conducted. Key informants concurred about the capacity of Catholic parishes to deliver health programs, and described attributes of parishes that make them strong partners in health promotion initiatives, including a mission to address physical and mental health, outreach to marginalized groups, altruism among members, and existing engagement in health programming. However, resource gaps and capacity building needs were also identified. Specific recommendations participants made about how existing resources might be leveraged to address challenges include to: establish parish wellness committees; provide "hands-on" learning opportunities for parishioners to gain program planning skills; offer continuous, tailored, on-site technical assistance; facilitate relationships between parishes and community resources; and provide financial support for parishes. Leveraging parishes' existing resources and addressing their implementation needs may improve adoption of cancer control EBIs.

Meaningful Use in Chronic Care: Improved Diabetes Outcomes Using a Primary Care Extension Center Model.

The effect of practice facilitation that provides onsite quality improvement (QI) and electronic health record (EHR) coaching on chronic care outcomes is unclear. This study evaluates the effectiveness of such a program-similar to an agricultural extension center model-that provides these services. Through the Health Information Technology for Economic and Clinical Health (HITECH) portion of the American Recovery and Reinvestment Act, the North Carolina Area Health Education Centers program became the Regional Extension Center for Health Information Technology (REC) for North Carolina. The REC program provides onsite technical assistance to help small primary care practices achieve meaningful use of certified EHRs. While pursuing meaningful use functionality, practices were also offered complementary onsite advice regarding QI issues. We followed the first 50 primary care practices that utilized both EHR and QI advice targeting diabetes care. The achievement of meaningful use of certified EHRs and performance of QI with onsite practice facilitation showed an absolute improvement of 19% in the proportion of patients who achieved excellent diabetes control (hemoglobin A1c < 7%) compared to baseline. In addition, the percentages of patients with poorly controlled diabetes (hemoglobin A1c > 9%) fell steeply in these practices. No control group was available for comparison. Practice facilitation that provided EHR and QI coaching support showed important improvements in diabetes outcomes in practices that achieved meaningful use of their EHR systems. This approach holds promise as a way to help small primary care practices achieve excellent patient outcomes.

A Technical Assistance Framework to Facilitate the Delivery of Integrated Behavioral Health Services in Federally Qualified Health Centers (FQHCs)

An implementation approach, featuring direct, onsite technical assistance is described, and findings from a pilot study assessing the capability of Federally Qualified Health Centers to provide integrated behavioral health services are presented. Investigators used the Behavioral Health Integration in Medical Care (BHIMC) index to measure integration at baseline and follow-up at four FQHCs in New Jersey. Results indicate that the average baseline capability score of 1.95 increased to 2.44 at follow-up, almost one-half point on the five-point BHIMC index. This pilot project demonstrates that co-occurring capability can be assessed, and system-wide technical assistance can be delivered to assist FQHCs in integrating behavioral health services. Future research should test technical assistance as an implementation strategy to promote the integration of medical care and behavioral health treatment on a wider scale.

A novel test of the GTO implementation support intervention in low resource settings: Year 1 findings and challenges

Implementation research is expanding because Evidence-Based Programs (EBPs) are not adopted in many medical domains. However, rigorous implementation research is needed in nonclinical, community-based settings, which often have low capacity that undermines implementation quality and outcomes. This presentation describes Enhancing Quality Interventions Promoting Healthy Sexuality, a 5-year, cluster Hybrid Implementation RCT (Type II) testing how well a community-based setting (Boys & Girls Clubs, BGCs) conducts an EBP called Making Proud Choices (MPC) that aims to prevent teen pregnancy and sexually transmitted infections, with and without an implementation support intervention called Getting To Outcomes (GTO). GTO is a 10-step model of program operation grounded in implementation theory and an intervention of written tools, training and bi-weekly onsite technical assistance.

Associations among tiered quality rating and improvement system supports and quality improvement

This descriptive study investigated the associations between change in quality and quality improvement supports among center-based programs and family child care homes within Miami-Dade County, Florida's tiered quality rating and improvement system (TQRIS), Quality Counts. The TQRIS supports included grants and financial awards for materials and equipment, educational scholarships for staff, and on-site technical assistance to raise quality. Data were extracted from a TQRIS information management system on 412 programs (342 center-based programs and 70 family child care homes) participating in the TQRIS from 2008 to 2013. Results indicated that across both types of care (centers and homes), quality increased over time. Duration, or amount of time in the TQRIS, was significantly related to quality change. Scholarship amounts received were also significantly related to quality change for centers. Interactions between dosage and supports suggested that some supports were associated with quality change for programs that were in the TQRIS for a shorter duration. The consistent findings regarding duration in the TQRIS and scholarships suggest the importance of supporting programs and their staff. Policy implications related to building TQRISs are discussed.

QA Meets PI

A modified learning collaborative that included in-person educational sessions, on-site technical assistance and additional web-based learning sessions and training modules. Participants: 17 nursing homes in 4 states participated in the demonstration project. The homes represented a wide range of experience with quality improvement and represented a range of characteristics including: ownership, urban and rural settings, Five Star ratings, and services offered.

Improving Educational Programs for Students with Autism in Rural Schools: A Preliminary Program Description of the Montana Autism Education Project

The Montana Autism Education Project (MAEP), that started in 2010, aimed to: (a) increase teacher knowledge of Evidence-Based Practices (EBPs), (b) provide on-site technical assistance and peer-to-peer collaboration, (c) develop sustainable support for teachers across Montana, and (d) develop inter-agency collaboration between the project and various stakeholders. Preliminary evaluation focused on three categories: (a) consultant visits, (b) trainings, and (c) video training via Internet technology. Analysis of data suggests that MAEP helped improve teachers' ability to implement quality educational programs for students with autism spectrum disorders (ASD), especially in rural areas and in schools located on or near Indian reservations. Future directions for statewide efforts are highlighted.

An intervention to improve program implementation: findings from a two-year cluster randomized trial of Assets-Getting To Outcomes.

BackgroundStudies have shown that communities have not always been able to implement evidence-based prevention programs with quality and achieve outcomes demonstrated by prevention science. Implementation support interventions are needed to bridge this gap between science and practice. The purpose of this article is to present two-year outcomes from an evaluation of the Assets Getting To Outcomes (AGTO) intervention in 12 Maine communities engaged in promoting Developmental Assets, a positive youth development approach to prevention. AGTO is an implementation support intervention that consists of: a manual of text and tools; face-to-face training, and onsite technical assistance, focused on activities shown to be associated with obtaining positive results across any prevention program.MethodsThis study uses a nested and cross-sectional, cluster randomized controlled design. Participants were coalition members and program staff from 12 communities in Maine. Each coalition nominated up to five prevention programs to participate. At random, six coalitions and their respective 30 programs received the two-year AGTO intervention and the other six maintained routine operations. The study assessed prevention practitioner capacity (efficacy and behaviors), practitioner exposure to and use of AGTO, practitioner perceptions of AGTO, and prevention program performance. Capacity of coalition members and performance of their programs were compared between the two groups across the baseline, one-, and two-year time points.ResultsWe found no significant differences between AGTO and control group’s prevention capacity. However, within the AGTO group, significant differences were found between those with greater exposure to and use of AGTO. Programs that received the highest number of technical assistance hours showed the most program improvement.ConclusionsThis study is the first of its kind to show that use of an implementation support intervention-AGTO -yielded improvements in practitioner capacity and consequently in program performance on a large sample of practitioners and programs using a randomized controlled design.ClinicalTrials.gov identifierNCT00780338

Evaluating the Impact of Getting to Outcomes–Underage Drinking on Prevention Capacity and Alcohol Merchant Attitudes and Selling Behaviors

Underage drinking is a significant problem facing US communities. Several environmental alcohol prevention (EAP) strategies (laws, regulations, responsible beverage service training and practices) successfully address underage drinking. Communities, however, face challenges carrying out these EAP strategies effectively. This small-scale, 3-year, randomized controlled trial assessed whether providing prevention coalitions with Getting To Outcomes-Underage Drinking (GTO-UD), a tool kit and implementation support intervention, helped improve implementation of two common EAP strategies, responsible beverage service training (RBS) and compliance checks. Three coalitions in South Carolina and their RBS and compliance check programs received the 16-month GTO-UD intervention, including the GTO-UD manual, training, and onsite technical assistance, while another three in South Carolina maintained routine operations. The measures, collected at baseline and after the intervention, were a structured interview assessing how well coalitions carried out their work and a survey of merchant attitudes and practices in the six counties served by the participating coalitions. Over time, the quality of some RBS and compliance check activities improved more in GTO-UD coalitions than in the control sites. No changes in merchant practices or attitudes significantly differed between the GTO-UD and control groups, although merchants in the GTO-UD counties did significantly improve on refusing sales to minors while control merchants did not.

Scaling Up an Early Reading Program: Relationships Among Teacher Support, Fidelity of Implementation, and Student Performance Across Different Sites and Years

Successful implementation of evidence-based educational practices at scale is of great importance but has presented significant challenges. In this article, the authors address the following questions: How does the level of on-site technical assistance affect student outcomes? Do teachers’ fidelity of treatment implementation and their perceptions of school climate mediate effects on student performance? Using a randomized control trial at scale, the authors examine Kindergarten Peer Assisted Learning Strategies, which previously has been shown to be effective in increasing student reading achievement. Analyzing data from 2 years and three sites, the analyses show that the level of on-site technical support has significant effects on reading achievement gains, are robust across multiple sites, and are mediated by fidelity of implementation within teachers’ classrooms.

Does providing technical assistance for toxics use reduction really work? A program evaluation utilizing toxics use reduction act data to measure pollution prevention performance

The 1989 Massachusetts Toxics Use Reduction Act (TURA) instituted a preventive approach to chemical pollution and wastes: reducing toxic chemicals at the source through prevention planning, public reporting of chemical input, and fees for chemical use. The act also created the Massachusetts Office of Technical Assistance for Toxics Use Reduction (OTA), a voluntary program, to make onsite visits to companies that request assistance. OTA staff review the use of toxic chemicals at the facility, and make recommendations for either using substitutes, or using the chemicals more efficiently. Because TURA requires covered companies (large quantity toxics users) to report chemical input (what they use), output (resulting chemical waste), and a production index, it is possible to measure trends in toxics use relative to production, and waste byproduct per pound of chemical use input. These are uniquely precise measurements of a company's ability to accomplish the form of pollution prevention known as toxics use reduction. From 1993 to 2002, companies used approximately 500 million pounds (227 million kg) less toxic chemicals than they were expected to use, based on past performance. Those companies that received onsite technical assistance visits from OTA made substantially greater improvements in TUR performance than those not visited, and as compared to their own performance after being visited. They reduced an average of 9.4% more toxics use after being visited than before, and the difference was statistically significant. More companies in the visited group made progress than companies not visited, and had greater reductions than those not visited by nearly all measures. The results of two additional studies supported these findings of program effectiveness. One study examined companies that dropped out of the system, and found that those that were visited employed toxics use reduction to achieve below-threshold use amounts more frequently than those that were not visited. The other study, an independent research project using econometric methods to determine the causative relevance of provided assistance, found OTA's service to be an explanatory factor associated with significant toxics use and byproduct reductions.

Free Technical Assistance to Small Wastewater Treatment Facilities 25 Years of Success

Free Technical Assistance to Small Wastewater Treatment Facilities 25 Years of SuccessSection 104(g)(1) of the Clean Water Act authorizes funding for the Wastewater Treatment Plant Operator Onsite Technical Assistance Training Program (Program). The Program was implemented in 1982 and has been funded every year to improve compliance at small, publicly owned wastewater treatment plants with a discharge of less than 18.9 million liters per day (ML/d) (5 million gallons per day...Author(s)Gajindar SinghRussell MartinKeith KroegerSourceProceedings of the Water Environment FederationSubjectSession 20: Performance of Small Community InfrastructureDocument typeConference PaperPublisherWater Environment FederationPrint publication date Jan, 2008ISSN1938-6478SICI1938-6478(20080101)2008:16L.1423;1-DOI10.2175/193864708788735178Volume / Issue2008 / 16Content sourceWEFTECFirst / last page(s)1423 - 1436Copyright2008Word count191