Site-level evidence-based practice accreditation: A qualitative exploration using institutional theory.

Accreditation is gaining ground in human services as leaders find ways to demonstrate the quality and legitimacy of services. This study examined site-level accreditation for SafeCare®, an evidence-based practice designed to prevent and reduce child maltreatment. We leveraged two waves of qualitative data to explore the perspectives of trainers, organizational and system leaders, and program developers who participated in an initial rollout of a site-level accreditation process for SafeCare. Institutional theory was used to frame accreditation's potential benefits, burden, and impact. Findings highlight specific considerations for the human service environment, including the inherent resource scarcity, interdependence among organizations, and the impact of cost and slow-moving bureaucratic processes.

Implementation determinants and mechanisms for the prevention and treatment of adolescent HIV in sub-Saharan Africa: concept mapping of the NIH Fogarty International Center Adolescent HIV Implementation Science Alliance (AHISA) initiative.

INTRODUCTION: Adolescent HIV prevention and treatment is a high priority for youth healthcare in sub-Saharan Africa. METHODS: This study employed concept mapping to identify factors that impact the implementation of HIV prevention and intervention programs for adolescents in sub-Saharan Africa. Key stakeholders including researchers, policymakers, and non-governmental organization (NGO) personnel constituting membership of the NIH-sponsored Adolescent HIV Prevention and Treatment Implementation Science Alliance responded to the question: "In your experience, what factors have facilitated or hindered implementation of evidence-based HIV prevention or treatment for adolescents in sub-Saharan Africa?" Participants generated statements in response to the focus question, sorted them into thematically relevant groups, and rated each statement on its importance and changeability. RESULTS: Through data analyses and participant feedback, 15 distinct themes were derived. "Workforce/Workflow" and "HIV Stigma and Adolescent Development" were rated highest for importance, and "Threshold Conditions for Treatment" and "Structure of Implementation Efforts" were rated most changeable. CONCLUSIONS: Understanding implementation science determinants and mechanisms can facilitate the uptake of successful implementation and sustainment strategies for the prevention and treatment of HIV in a given context. We placed determinants and mechanisms within the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to provide greater contextual integration with broader theories in implementation science. Implementers across multiple disciplines can use these findings to improve the scale-up of evidence-based practices for adolescent HIV prevention and treatment in sub-Saharan Africa. Implementation approaches that consider the determinants and mechanisms identified in this study and integrated in implementation frameworks will likely have utility for other health conditions and contexts.

An observational study of the impact of COVID-19 and the rapid implementation of telehealth on community mental health center providers.

BACKGROUND: The COVID-19 pandemic has remarkably altered community mental health service delivery through the rapid implementation of telehealth. This study reports provider perspectives on the impact that COVID-19 and the transition to telehealth had on their work and their ability to deliver evidence-based practices (EBPs). METHODS: Providers (n = 93) completed online surveys with quantitative measures and open-ended items exploring their reactions to COVID-19 and to the transition to providing services via telehealth. RESULTS: Perceptions of personal risk and rumination around COVID-19 were low, while telehealth was viewed positively by providers. Three major themes emerged regarding the major impacts of COVID-19 on work: (1) the altered nature of interactions between patient/client and provider due to telehealth implementation, (2) changes in provider expectations regarding productivity, and (3) challenges maintaining work-life balance. In regard to the major impacts of COVID-19 on EBP delivery, three themes emerged: (1) increased difficulty delivering certain therapies via telehealth, (2) potential limitations to session confidentiality, and (3) challenge of engaging children in telehealth. CONCLUSIONS: In the context of the COVID-19 pandemic, community mental health providers continued to engage with clients and deliver EBPs while navigating a number of changes related to the rapid transition to and implementation of telehealth. This study highlights the need for further work on what supports providers need to effectively engage with clients and deliver EBPs via telehealth, and has implications for how telehealth is sustained or de-implemented post-COVID-19.

Advancing the pragmatic measurement of sustainment: a narrative review of measures.

BACKGROUND: Sustainment, an outcome indicating an intervention continues to be implemented over time, has been comparatively less studied than other phases of the implementation process. This may be because of methodological difficulties, funding cycles, and minimal attention to theories and measurement of sustainment. This review synthesizes the literature on sustainment measures, evaluates the qualities of each measure, and highlights the strengths and gaps in existing sustainment measures. Results of the review will inform recommendations for the development of a pragmatic, valid, and reliable measure of sustainment. METHODS: A narrative review of published sustainment outcome and sustainability measures (i.e., factors that influence sustainment) was conducted, including appraising measures in the Society of Implementation Research Collaboration (SIRC) instrument review project (IRP) and the Dissemination and Implementation Grid-Enabled Measures database initiative (GEM-D&I). The narrative review used a snowballing strategy by searching the reference sections of literature reviews and definitions of sustainability and sustainment. Measures used frequently and judged to be comprehensive and/or validated by a team of implementation scientists were extracted for analysis. RESULTS: Eleven measures were evaluated. Three of the included measures were found in the SIRC-IRP, three in the GEM-D&I database, (one measure was in both databases) and six were identified in our additional searches. Thirteen constructs relating to sustainment were coded from selected measures. Measures covered a range of determinants for sustainment (i.e., construct of sustainability) as well as constructs of sustainment as an outcome. Strengths of the measures included, development by expert panels knowledgeable about particular interventions, fields or contexts, and utility in specific scenarios. A number of limitations were found in the measures analyzed including inadequate assessment of psychometric characteristics, being overly intervention or context specific, being lengthy and/or complex, and focusing on outer context factors. CONCLUSION: There is a lack of pragmatic and psychometrically sound measures of sustainment that can be completed by implementation stakeholders within inner context settings (e.g., frontline providers, supervisors).

An Observational Study of the Impact of COVID-19 and the Transition to Telehealth on Community Mental Health Center Providers.

BACKGROUND: The COVID-19 pandemic has swiftly and remarkably altered community mental health service delivery and evidence-based practice (EBP) implementation. This study reports provider perspectives on the impact that COVID-19 had on their work and EBP implementation. METHODS: Providers (n = 93) completed online surveys with quantitative measures and open-ended items targeting their responses and/or reactions to COVID-19, and to the transition to providing services via telehealth. RESULTS: Perceptions of personal risk and rumination around COVID-19 were low, while telehealth was viewed positively by providers. Three major themes emerged regarding the major impacts of COVID-19 on work: 1) the altered nature of interactions between patient/client and provider, 2) changes in provider expectations regarding productivity, and 3) challenges maintaining work-life balance. In regard to the major impacts of COVID-19 on EBP implementation, three themes emerged: 1) increased difficulty delivering certain therapies via telehealth, 2) potential limitations to session confidentiality, and 3) challenge of engaging children in telehealth. CONCLUSIONS: In the context of the COVID-19 pandemic, community mental health providers continued to engage with clients and implement EBPs while navigating a number of changes related to the transition to telehealth. This study highlights the need for further work on what supports providers need to effectively engage with clients and deliver EBPs via telehealth and has implications for how telehealth is sustained or de-implemented in response to COVID-19.

Turning Back to Treatment: The Effect of Attendance and Symptom Outcomes on Subsequent Service Use.

This study explored whether post-treatment symptom severity moderated the association between session attendance during an initial treatment episode and subsequent mental health service use. Data on attendance, symptom severity, and service use were gathered from an effectiveness trial testing a modular treatment for youth anxiety, depression, disruptive behavior, and traumatic stress. Multilevel logistic regression analyses showed a significant interaction between attendance and post-treatment symptom severity on subsequent service use, such that attendance significantly predicted subsequent service use when post-treatment symptom severity was in the normal range. Implications regarding the influence of treatment engagement on future help-seeking are discussed.

Leader-member exchange and organizational climate effects on clinician turnover intentions.

PURPOSE: Clinician turnover in mental health settings impacts service quality, including availability and delivery of evidence-based practices. Leadership is associated with organizational climate, team functioning and clinician turnover intentions (TI). This study examines leader-member exchange (LMX), reflecting the relationship between a supervisor and each supervisee, using mean team LMX, dispersion of individual clinician ratings compared to team members (i.e. relative LMX) and team level variability (i.e. LMX differentiation), in relation to organizational climate and clinician TI. DESIGN/METHODOLOGY/APPROACH: Survey data were collected from 363 clinicians, nested in children's mental health agency workgroups, providing county-contracted outpatient services to youth and families. A moderated mediation path analysis examined cross-level associations of leader-member exchange with organizational climate and turnover intentions. FINDINGS: Lower relative LMX and greater LMX differentiation were associated with higher clinician TI. Higher team-level demoralizing climate also predicted higher TI. These findings indicate that poorer LMX and more variability in LMX at the team level are related to clinician TI. ORIGINALITY/VALUE: This study describes both team- and clinician-level factors on clinician TI. Few studies have examined LMX in mental health, and fewer still have examined relative LMX and LMX differentiation associations with organizational climate and TI. These findings highlight the importance of leader-follower relationships and organizational climate and their associations with clinician TIs. Mental health service systems and organizations can address these issues through fostering more positive supervisor-supervisee relationships.

Identifying strategies to promote team science in dissemination and implementation research.

INTRODUCTION: Scientific endeavors are increasingly carried out by teams of scientists. While there is growing literature on factors associated with effective science teams, little is known about processes that facilitate the success of dissemination and implementation (D&I) teams studying the uptake of healthcare innovations. This study aimed to identify strategies used by D&I scientists to promote team science. METHODS: Using a nominal group technique, a sample of 27 D&I scholars responded to the question, "What strategies have you or others used to promote team science?" Participants were asked to individually respond and then discuss within a small group to determine the group's top three strategies. Through a facilitated consensus discussion with the full sample, a rank-ordered list of three strategies was determined. RESULTS: A total of 126 individual responses (M = 9; SD = 4.88) were submitted. Through small group discussion, six groups ranked their top three strategies to promote team science. The final ranked list of strategies determined by the full sample included: (1) developing and maintaining clear expectations, (2) promoting and modeling effective communication, and (3) establishing shared goals and a mission of the work to be accomplished. CONCLUSIONS: Because of its goal of translating knowledge to practice, D&I research necessitates the use of team science. The top strategies are in line with those found to be effective for teams in other fields and hold promise for improving D&I team cohesion and innovation, which may ultimately accelerate the translation of health innovations and the improvement of care quality and outcomes.