Framework for Multisector Alignment Research.

CONTEXT: Public health collaboratives are effective platforms to develop interventions for improving population health. Most collaboratives are limited to the public health and health care delivery sectors; however, multisector collaboratives are becoming more recognized as a strategy for combining efforts from medical, public health, social services, and other sectors. PROGRAM: Based on a 4-year multisector collaborative project, we identify concepts for widening the lens to conduct multisector alignment research. The goal of the collaborative was to address the serious care fragmentation and conflicting financing systems for persons with behavioral health disorders. Our work with these 7 sectors provides insight for creating a framework to conduct multisector alignment research for investigating how alignment problems can be identified, investigated, and applied to achieve systems alignment. IMPLEMENTATION: The multisector collaborative was undertaken in Maricopa County, encompassing Phoenix, Arizona, and consisted of more than 50 organizations representing 7 sectors. EVALUATION: We develop a framework for systems alignment consisting of 4 dimensions (alignment problems, alignment mechanisms, alignment solutions, and goal attainment) and a vocabulary for implementing multisector alignment research. We then describe the interplay and reciprocity between the 4 dimensions. DISCUSSION: This framework can be used by multisector collaboratives to help identify strategies, implement programs, and develop metrics to assess impact on population health and equity.

Critical Issues in Leadership Development for Peer Support Specialists.

This paper is a qualitative analysis of perspectives on leadership development among working peer support specialists and highlights the challenges, needs and efficacy these individuals experience in their work settings. Six participants engaged in a 2 h semi-structured focus group. Participants were guided through a series of nine questions regarding their transition to leadership, professional communication and relationships. Seven themes emerged: managing dual relationships; having difficult conversations; push and pull of leadership; taking responsibility for others; taking responsibility for self-care; addressing stigma in the workplace, and, spirituality/a calling to help. These professionals integrate their personal experiences of recovery into their direct care and leadership approaches in the workplace. This blending of recovery concepts and supervision approaches reflect some of the powerful elements that peer recovery specialists are uniquely qualified to lead in the healthcare workforce. These findings provide important implications for leadership development among this growing segment of the healthcare workforce.

How metaphorical framings build and undermine resilience during change: A longitudinal study of metaphors in team-driven planned organizational change.

Change is a constant feature of organizing and one that requires resilience, or the ability to effectively face challenges. Although research demonstrates important findings about resilience during chaotic change like crises, less is known about resilience in mundane situations like planned change. This study explores team-driven planned organizational change, offering insights about how team members metaphorically frame change how their framing fluctuates over time relative to perceptions of team success. Our three theoretical contributions extend theory about metaphors and organizational change, showing how negative framings of change are endemic to teams, regardless of perceived success; generate knowledge about resilience in organizing by showing how metaphors both build and undermine resilience; and extend applied theory about stakeholder participation in bureaucratic organizations.

CORRELATES OF INTERORGANIZATIONAL SERVICE COORDINATION IN COMMUNITY CORRECTIONS.

Because weak interagency coordination between community correctional agencies (e.g., probation and parole) and community-based treatment providers has been identified as a major barrier to the use of evidence-based practices (EBPs) for treating druginvolved offenders, this study sought to examine how key organizational (e.g., leadership, support, staffing) and individual (e.g., burnout, satisfaction) factors influence interagency relationships between these agencies. At each of 20 sites, probation/parole officials (n = 366) and community treatment providers (n = 204) were surveyed about characteristics of their agencies, themselves, and interorganizational relationships with each other. Key organizational and individual correlates of interagency relationships were examined using hierarchical linear models (HLM) analyses, supplemented by interview data. The strongest correlates included Adaptability, Efficacy, and Burnout. Implications for policy and practice are discussed.

Efficacy of a process improvement intervention on delivery of HIV services to offenders: a multisite trial.

OBJECTIVES: We tested a modified Network for the Improvement of Addiction Treatment (NIATx) process improvement model to implement improved HIV services (prevention, testing, and linkage to treatment) for offenders under correctional supervision. METHODS: As part of the Criminal Justice Drug Abuse Treatment Studies, Phase 2, the HIV Services and Treatment Implementation in Corrections study conducted 14 cluster-randomized trials in 2011 to 2013 at 9 US sites, where one correctional facility received training in HIV services and coaching in a modified NIATx model and the other received only HIV training. The outcome measure was the odds of successful delivery of an HIV service. RESULTS: The results were significant at the .05 level, and the point estimate for the odds ratio was 2.14. Although overall the results were heterogeneous, the experiments that focused on implementing HIV prevention interventions had a 95% confidence interval that exceeded the no-difference point. CONCLUSIONS: Our results demonstrate that a modified NIATx process improvement model can effectively implement improved rates of delivery of some types of HIV services in correctional environments.

Patterns and Predictors of Sustained Training and Technical Assistance Engagement Among Addiction Treatment and Affiliated Providers.

The current study draws upon data collected over a 4-year period by a regional addiction technology transfer center (ATTC) to better understand the learning patterns and methods of learning engagement among behavioral health professionals. Training participants were found to be predominately female and ethnically diverse, evenly split on attaining a graduate degree, with a third of the participants possessing less than a 4-year college degree. More than one-half reported working in non-health/non-behavioral healthcare settings. Individuals who attended more ATTC events were found to possess less than a master's degree, work in non-behavioral health settings, and identify as Hispanic or other races. In addition, individuals who initially accessed training through an ATTC conference or online asynchronous learning events were found to become engaged learners.

A metaphor analysis of recovering substance abusers' sensemaking of medication-assisted treatment.

In this study, we examined metaphors invoked by people recovering from opioid dependence as they described the challenges and successes of using medication-assisted treatment. Metaphors provide linguistic tools for expressing issues that are confusing, complex, hidden, and difficult to state analytically or literally. Using data from eight focus groups with 68 participants representing four ethnic minority groups, we conducted a grounded analysis to show how recovering substance users communicatively constructed addiction and recovery. The primary medication, methadone, was framed as "liquid handcuffs" that allowed those in recovery to quit "hustling," get "straight," and find "money in their pockets." Nonetheless, methadone also served as a "crutch," leaving them still feeling like "users" with "habits" who "came up dirty" to friends and family. In this analysis, we tease out implications of these metaphors, and how they shed light on sensemaking, agency, and related racial- and class-based structural challenges in substance abuse recovery.

The impact of housing first and peer support on people who are medically vulnerable and homeless.

OBJECTIVE: The purpose of this study was to assess the impact of a local initiative, Project H3, which used housing first, harm reduction, and peer support models to provide housing for 47 homeless people who were medically vulnerable. METHOD: Comparisons of interviews with participants who were housed at the day of their move-in, and 6-months and 12-months after their move-in, were conducted. RESULTS: Ninety-eight percent of the participants remained in housing after 12 months. Individuals who were housed reported significant increases in their access to and utilization of planned health care services and quality of life, and reductions in their involvement in the criminal justice system. CONCLUSION AND IMPLICATIONS FOR PRACTICE: Housing first, harm reduction, and peer support models demonstrate effectiveness in decreasing substance use and improving the quality of life of people who are homeless over time.

Medication-assisted treatment in criminal justice agencies affiliated with the criminal justice-drug abuse treatment studies (CJ-DATS): availability, barriers, and intentions.

Medication-assisted treatment (MAT) is underutilized in the treatment of drug-dependent, criminal justice populations. This study surveyed criminal justice agencies affiliated with the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) to assess use of MAT and factors influencing use of MAT. A convenience sample (N = 50) of criminal justice agency respondents (e.g., jails, prisons, parole/probation, and drug courts) completed a survey on MAT practices and attitudes. Pregnant women and individuals experiencing withdrawal were most likely to receive MAT for opiate dependence in jail or prison, whereas those reentering the community from jail or prison were the least likely to receive MAT. Factors influencing use of MAT included criminal justice preferences for drug-free treatment, limited knowledge of the benefits of MAT, security concerns, regulations prohibiting use of MAT for certain agencies, and lack of qualified medical staff. Differences across agency type in the factors influencing use and perceptions of MAT were also examined. MAT use is largely limited to detoxification and maintenance of pregnant women in criminal justice settings. Use of MAT during the community reentry period is minimal. Addressing inadequate knowledge and negative attitudes about MAT may increase its adoption, but better linkages to community pharmacotherapy during the reentry period might overcome other issues, including security, liability, staffing, and regulatory concerns. The CJ-DATS collaborative MAT implementation study to address inadequate knowledge, attitudes, and linkage will be described.

Design and Implementation of a COVID-19 Case Investigation Program: An Academic-Public Health Partnership, Arizona, 2020.

From May through July 2020, Arizona was a global hotspot for new COVID-19 cases. In response to the surge of cases, local public health departments looked for innovative ways to form external partnerships to address their staffing needs. In collaboration with the Maricopa County Department of Public Health, the Arizona State University Student Outbreak Response Team (SORT) created and implemented a virtual call center to conduct public health case investigations for COVID-19. SORT officially launched a dedicated COVID-19 case investigation program after 3 weeks of program design and training. From June 29 through November 8, 2020, SORT recruited and trained 218 case investigators, completed 5000 case patient interviews, and closed 10 000 cases. Our team also developed process improvements to address disparities in case investigation timeliness. A strong infrastructure designed to accommodate remote case investigations, paired with a large workforce, enabled SORT to provide additional surge capacity for the county's high volume of cases. University-driven multidisciplinary case investigator teams working in partnership with state, tribal, and local public health staff members can be an effective tool for supporting a diverse and growing public health workforce. We discuss the essential design factors involved in building a university program to complement local COVID-19 response efforts, including workflows for case management, volunteer case investigator recruitment and training, secure technology platforms for conducting case investigations remotely, and robust data-tracking procedures for maintaining quality control and timely case reporting.

The employment intervention demonstration program: major findings and policy implications.

This article summarizes the published results of the Employment Intervention Demonstration Program (EIDP), a federally-funded, multi-site study examining the effectiveness of supported employment programs for 1273 unemployed individuals with psychiatric disabilities in the U.S. Findings confirm the effectiveness of supported employment across different models, program locations, and participant populations. The study's results are discussed in the context of public policies designed to encourage return to work for those with a severe mental illness.

Results of a multisite randomized trial of supported employment interventions for individuals with severe mental illness.

CONTEXT: National probability surveys indicate that most individuals with schizophrenia and other severe mental illnesses are not employed. This multisite study tested the effectiveness of supported employment (SE) models combining clinical and vocational rehabilitation services to establish competitive employment. METHODS: We randomly assigned 1273 outpatients with severe mental illness from 7 states in the United States to an experimental SE program or to a comparison or a services-as-usual condition, with follow-up for 24 months. Participants were interviewed semiannually, paid employment was tracked weekly, and vocational and clinical services were measured monthly. Mixed-effects random regression analysis was used to predict the likelihood of competitive employment, working 40 or more hours in a given month, and monthly earnings. RESULTS: Cumulative results during 24 months show that experimental group participants (359/648 [55%]) were more likely than those in the comparison programs (210/625 [34%]) to achieve competitive employment (chi(2) = 61.17; P<.001). Similarly, patients in experimental group programs (330/648 [51%]) were more likely than those in comparison programs (245/625 [39%]) to work 40 or more hours in a given month (chi(2) = 17.66; P<.001). Finally, participants in experimental group programs had significantly higher monthly earnings than those in the comparison programs (mean, US 122 dollars/mo [n=639] vs US 99 dollars/mo [n=622]); t(1259) = -2.04; P<.05). In the multivariate longitudinal analysis, experimental condition subjects were more likely than comparison group subjects to be competitively employed, work 40 or more hours in a given month, and have higher earnings, despite controlling for demographic, clinical, work history, disability beneficiary status, and study site confounders. Moreover, the advantage of experimental over comparison group participants increased during the 24-month study period. CONCLUSION: The SE models tailored by integrating clinical and vocational services were more effective than services as usual or unenhanced services.

Estimated payments to employment service providers for persons with mental illness in the Ticket to Work program.

OBJECTIVE: The Ticket to Work and Work Incentives Improvement Act of 1999 removes work disincentives and promotes access to vocational services for people with disabilities. This study calculated the amount of payments that would have been made to employment service providers if study participants had been enrolled in the Ticket program. METHODS: Data were from 450 Social Security Disability Insurance beneficiaries with psychiatric disabilities enrolled in a multisite study of supported employment. Earnings over two years were used to calculate provider payments under two reimbursement formulas used in the Ticket program. RESULTS: Only a quarter of service recipients (26 percent) reached earnings levels that would have triggered provider payments under the first reimbursement formula. Only 4 percent would have completed their trial work period and left the rolls, generating payments under the second formula. CONCLUSIONS: The current provider payment systems of the Ticket to Work program do not reflect the reality of rehabilitation for individuals with severe mental illness. Reforms should take into account outcomes of return-to-work services for this population.

Using distance education to promote the transfer of motivational interviewing skills among behavioral health professionals.

This study evaluated the effectiveness of distance education for training behavioral health professionals. Five live video workshops that covered key elements of Motivational Interviewing (MI) were delivered. The programs occurred a month apart, each 3 hours long. The programs used compressed video, transmitting the video signal through telephone lines. The audience was staff at substance abuse treatment organizations throughout the state of Arizona. Participants completed assessments regarding their training experiences, knowledge and self-efficacy in MI, and their satisfaction with the training, prior to, during, and subsequent to the workshops. Participation in the five workshops varied; the first workshop had the largest attendance of 351, the fourth the lowest of 92; 145 participants attended all five workshops. Participants expressed moderate levels of satisfaction with most aspects of the training, although some expressed frustration with interrupted audio or video signals during the programs. The handouts and videotaped examples of MI were identified as the more helpful aspects of the training. Participants reported statistically significant improvements in their self-perceived knowledge and skills. They demonstrated a statistically significant but clinically insignificant increase in knowledge. A small group of participants provided audiotapes of actual counseling sessions. These participants demonstrated minimal improvement in skills across the study that were not statistically significant. These results are discussed in terms of their implications for future research in the use of distance education as a technology transfer tool in the addiction treatment profession.

Factors associated with the health service utilization of unsheltered, chronically homeless adults.

Individuals who are chronically homeless have significantly higher rates of morbidity at significantly younger ages because they experience homelessness, physical and mental health impairments, and substance use disorders. The health status and health service utilization of 260 unsheltered, chronically homeless individuals in a large southwestern, metropolitan community are reported. The behavioral model for vulnerable populations was used to conceptualize the factors associated with hospital, mental health, and substance abuse service utilization among the sample. Health insurance coverage was positively associated with the use of all health services. Other factors were also observed to exert differential relationships to health service utilization.

Predicting substance-abuse treatment providers' communication with clients about medication assisted treatment: a test of the theories of reasoned action and planned behavior.

The purpose of this investigation is to determine if the theory of reasoned action (TRA) and theory of planned behavior (TPB) can retrospectively predict whether substance-abuse treatment providers encourage their clients to use medicated-assisted treatment (MAT) as part of their treatment plan. Two-hundred and ten substance-abuse treatment providers completed a survey measuring attitudes, subjective norms, perceived behavioral control, intentions, and behavior. Results indicate that substance-abuse treatment providers have very positive attitudes, neutral subjective norms, somewhat positive perceived behavioral control, somewhat positive intentions toward recommending MAT as part of their clients' treatment plan, and were somewhat likely to engage in the actual behavior. Further, the data fit both the TRA and TPB, but with the TPB model having better fit and predictive power for this target audience and behavior. The theoretical and practical implications for the developing messages for substance-abuse treatment providers and other health-care professionals who provide treatment to patients with substance use disorders are discussed.

A cluster randomized trial of an organizational process improvement intervention for improving the assessment and case planning of offenders: a Study Protocol.

BACKGROUND: The Organizational Process Improvement Intervention (OPII), conducted by the NIDA-funded Criminal Justice Drug Abuse Treatment Studies consortium of nine research centers, examined an organizational intervention to improve the processes used in correctional settings to assess substance abusing offenders, develop case plans, transfer this information to community-based treatment agencies, and monitor the services provided by these community based treatment agencies. METHODS/DESIGN: A multi-site cluster randomized design was used to evaluate an inter-agency organizational process improvement intervention among dyads of correctional agencies and community based treatment agencies. Linked correctional and community based agencies were clustered among nine (9) research centers and randomly assigned to an early or delayed intervention condition. Participants included administrators, managers, and line staff from the participating agencies; some participants served on interagency change teams while other participants performed agency tasks related to offender services. A manualized organizational intervention that includes the use of external organizational coaches was applied to create and support interagency change teams that proceeded through a four-step process over a planned intervention period of 12 months. The primary outcome of the process improvement intervention was to improve processes associated with the assessment, case planning, service referral and service provision processes within the linked organizations. DISCUSSION: Providing substance abuse offenders with coordinated treatment and access to community-based services is critical to reducing offender recidivism. Results from this study protocol will provide new and critical information on strategies and processes that improve the assessment and case planning for such offenders as they transition between correctional and community based systems and settings. Further, this study extends current knowledge of and methods for, the study of evidence-based practice adoption and implementation.

Effects of co-occurring disorders on employment outcomes in a multisite randomized study of supported employment for people with severe mental illness.

Effects of co-occurring disorders on work outcomes were explored among individuals with severe mental illness who were participating in a multisite randomized study of supported employment. At seven sites, 1,273 people were randomly assigned to an experimental supported employment program or a control condition and followed for 2 years. Multivariate regression analysis examined work outcomes including earnings, hours worked, and competitive employment, as well as whether psychiatric disability was disclosed to coworkers and supervisors. Individuals with any comorbidity had lower earnings and were less likely to work competitively. Those with physical comorbidities had lower earnings, worked fewer hours, and were less likely to work competitively. Disclosure was more likely among those with both cognitive and physical comorbidities, as well as those with learning disabilities. Competitive employment was less likely among those with intellectual disability, visual impairment, and human immunodeficiency virus/acquired immuno-deficiency syndrome. The experimental condition was positively related to all outcomes except disclosure. The results suggest that, with some exceptions, comorbidities affect employment outcomes, requiring tailored services and supports to promote vocational success.

Clinical factors associated with employment among people with severe mental illness: findings from the employment intervention demonstration program.

Research has shown that supported employment programs are effective in helping psychiatric outpatients achieve vocational outcomes, yet not all program participants are able to realize their employment goals. This study used 24 months of longitudinal data from a multisite study of supported employment interventions to examine the relationship of patient clinical factors to employment outcomes. Multivariate random regression analysis indicated that, even when controlling for an extensive series of demographic, study condition (experimental versus control), and work history covariates, clinical factors were associated with individuals' ability to achieve competitive jobs and to work 40 or more hours per month. Poor self-rated functioning, negative psychiatric symptoms, and recent hospitalizations were most consistently associated with failure to achieve these employment outcomes. These findings suggest ways that providers can tailor supported employment programs to achieve success with a diverse array of clinical subpopulations.

An analysis of post-booking jail diversion programming for persons with co-occurring disorders.

For persons with co-occurring disorders, interaction with criminal justice systems is a frequent occurrence. As a result, a variety of diversionary programs have been developed nationwide. In this study, a total of 248 individuals with co-occurring disorders of serious mental illness and substance use disorders who had been arrested and booked on misdemeanor charges participated in a post-booking jail diversion program in two urban communities. A quasi-experimental design was used with individuals assigned to diversion or non-diversion status based upon the decision processes of the mental health-criminal justice systems. The effectiveness of the jail diversion program was evaluated from a variety of sources, including structured interviews, behavioral health service utilization patterns, and criminal justice recidivism patterns. Analyses revealed general main effects for time on many of the outcome variables, with few main effects or interaction effects detected on the basis of diversion status (diverted versus non-diverted). Across all measures assessing mental health and substance abuse, study participants displayed improvements over time, irrespective of their diversion status or program location. Participants generally displayed no significant changes in their rates of accessibility to, or frequency of use of, the various mental health, substance abuse, and other services, and few changes for diversion status were detected with regard to service utilization. Although a number of indicators of criminality and violence were reduced over time, these reductions were statistically insignificant, with changes for diversionary status or time identified at follow-up. These results are discussed in light of their implications for jail diversion programming and future research in this area.