Measurement Training and Feedback System for Implementation of family-based services for adolescent substance use: protocol for a cluster randomized trial of two implementation strategies.

BACKGROUND: This article describes a study protocol for testing the Measurement Training and Feedback System for Implementation (MTFS-I) and comparing two implementation strategies for MTFS-I delivery. MTFS-I is a web-based treatment quality improvement system designed to increase the delivery of evidence-based interventions for behavioral health problems in routine care settings. This version of MTFS-I focuses on family-based services (FBS) for adolescent substance use. FBS, comprising both family participation in treatment and family therapy technique use, have achieved the strongest evidence base for adolescent substance use and are a prime candidate for upgrading treatment quality in outpatient care. For FBS to fulfill their potential for widespread dissemination, FBS implementation must be bolstered by effective quality procedures that support sustainable delivery in usual care. METHODS/DESIGN: Adapted from measurement feedback systems for client outcomes, MTFS-I contains three synergistic components: (a) weekly reporter training modules to instruct therapists in reliable post-session self-reporting on FBS utilization; (b) weekly mock session videos of FBS interventions (5-8 min) for supportive training in, and practice coding of, high-quality FBS; and (c) monthly feedback reports to therapists and supervisors displaying aggregated data on therapist-reported FBS use. MTFS-I is hosted online and requires approximately 20 min per week to complete. The study will experimentally compare two well-established implementation strategies designed to foster ongoing MTFS-I usage: Core Training, consisting of two 3-h training sessions focused on FBS site mapping, selecting FBS improvement goals, and sustaining MTFS-I, followed by routine remote technical assistance; and Core + Facilitation, which boosts Core Training sessions with collaborative phone-based clinical consultation and on-site facilitation meetings for 1 year to promote FBS goal achievement. The study design is a cluster randomized trial testing Core Training versus Core + Facilitation in ten substance use treatment clinics. Study aims will compare conditions on MTFS-I uptake, FBS delivery (based on therapist-report and observational data), and 1-year client outcomes. DISCUSSION: Study contributions to implementation science and considerations of MTFS-I sustainability are discussed. TRIAL REGISTRATION: ClinicalTrials.gov NCT03342872 . Registered 10 November 2017.

A randomized trial to identify accurate and cost-effective fidelity measurement methods for cognitive-behavioral therapy: project FACTS study protocol.

BACKGROUND: This randomized trial will compare three methods of assessing fidelity to cognitive-behavioral therapy (CBT) for youth to identify the most accurate and cost-effective method. The three methods include self-report (i.e., therapist completes a self-report measure on the CBT interventions used in session while circumventing some of the typical barriers to self-report), chart-stimulated recall (i.e., therapist reports on the CBT interventions used in session via an interview with a trained rater, and with the chart to assist him/her) and behavioral rehearsal (i.e., therapist demonstrates the CBT interventions used in session via a role-play with a trained rater). Direct observation will be used as the gold-standard comparison for each of the three methods. METHODS/DESIGN: This trial will recruit 135 therapists in approximately 12 community agencies in the City of Philadelphia. Therapists will be randomized to one of the three conditions. Each therapist will provide data from three unique sessions, for a total of 405 sessions. All sessions will be audio-recorded and coded using the Therapy Process Observational Coding System for Child Psychotherapy-Revised Strategies scale. This will enable comparison of each measurement approach to direct observation of therapist session behavior to determine which most accurately assesses fidelity. Cost data associated with each method will be gathered. To gather stakeholder perspectives of each measurement method, we will use purposive sampling to recruit 12 therapists from each condition (total of 36 therapists) and 12 supervisors to participate in semi-structured qualitative interviews. DISCUSSION: Results will provide needed information on how to accurately and cost-effectively measure therapist fidelity to CBT for youth, as well as important information about stakeholder perspectives with regard to each measurement method. Findings will inform fidelity measurement practices in future implementation studies as well as in clinical practice. TRIAL REGISTRATION: NCT02820623 , June 3rd, 2016.

Association of housing first implementation and key outcomes among homeless persons with problematic substance use.

OBJECTIVES: Housing First is a supportive housing model for persons with histories of chronic homelessness that emphasizes client-centered services, provides immediate housing, and does not require treatment for mental illness or substance abuse as a condition of participation. Previous studies of Housing First have found reduced governmental costs and improved personal well-being among participants. However, variations in real-world program implementation require better understanding of the relationship between implementation and outcomes. This study investigated the effects of Housing First implementation on housing and substance use outcomes. METHODS: Study participants were 358 individuals with histories of chronic homelessness and problematic substance use. Clients were housed in nine scatter-site Housing First programs in New York City. Program fidelity was judged across a set of core Housing First components. Client interviews at baseline and 12 months were used to assess substance use. RESULTS: Clients in programs with greater fidelity to consumer participation components of Housing First were more likely to be retained in housing and were less likely to report using stimulants or opiates at follow-up. CONCLUSIONS: Consistently implemented Housing First principles related to consumer participation were associated with superior housing and substance use outcomes among chronically homeless individuals with a history of substance use problems. The study findings suggest that program implementation is central to understanding the potential of Housing First to help clients achieve positive housing and substance use outcomes.

Adolescent and caregiver reports of ADHD symptoms among inner-city youth: agreement, perceived need for treatment, and behavioral correlates.

OBJECTIVE: This study investigated adolescent and caregiver reports of ADHD symptoms in a sample of clinically referred inner-city adolescents. METHOD: Participants (N = 168) included youth ages 12-18 (54% male, 98% ethnic minority) and their caregivers who each completed diagnostic interviews of ADHD symptoms and assessments of perceived need for ADHD treatment and correlated behavior problems. RESULTS: Informants showed poor agreement on DSM-IV diagnostic categories and also dimensional scales, Inattention/Disorganization (I/D) and Hyperactivity/Impulsivity (H/I). Both caregiver and adolescent reports of I/D symptoms, but not H/I symptoms, were related to perceived need for ADHD treatment. Caregiver reports were linked to behavioral correlates typically associated with ADHD: I/D symptoms correlated with planning/organization and socioemotional deficits, and H/I symptoms correlated with externalizing and behavior regulation deficits. In contrast, adolescent reports of I/D were related to internalizing and externalizing problems, and their reports of H/I correlated with externalizing only. Few gender effects were found. CONCLUSION: Study results underscore the developmental salience of I/D symptoms and have implications for ADHD diagnosis and treatment planning for adolescents.

Predictors of employment in substance-using male and female welfare recipients.

This study examined predictors of employment among substance-using men and women enrolled in welfare-to-work programs. Participants were 394 welfare applicants assigned to either coordinated care management or usual care for treatment services and job training and followed up for 1 year to track employment outcomes. Common barriers to work were assessed at baseline in four key domains: disabilities, situational barriers, labor capital, and motivation. Results indicated substantial gender differences in the number and profile of work barriers. Among men, work experience and job motivation were the only significant predictors of employment; among women, multiple factors from each barrier domain predicted job acquisition even when controlling for all other significant predictors. Findings suggest that welfare-to-work programs should emphasize job training and job seeking during the early stages of welfare interventions for men and for many women.

Does coordinated care management improve employment for substance-using welfare recipients?

OBJECTIVE: This study tested whether coordinated care management, a continuity of care intervention for substance-use disorders, improved employment among men and women on public assistance compared with usual welfare management. METHOD: Participants were 421 welfare applicants identified via substance-use-disorder screening and assigned via a computerized allocation program to coordinated care management (CCM; n = 232) or referral and monitoring practices in usual care (UC; n = 189). Substance use, treatment attendance, job training and search activities, and employment outcomes were assessed for 1 year after baseline. RESULTS: Men were more likely to be working than women overall. Among women, CCM clients increased their employment over time, whereas UC clients remained stable at very low employment levels. There were no treatment effects on employment for men. Also among women only, greater substance-use-disorder treatment attendance and abstinence in the first 6 months of CCM predicted higher rates of later employment. Job training activities were low and did not differ by condition between either gender. CONCLUSIONS: Findings are consistent with previous research supporting the effectiveness of case management for improving abstinence, which leads to employment gains, among substance-using women on public assistance. In contrast, various mandated elements of welfare-to-work programs for substance users-treatment attendance, case management, job training-did not improve employment rates for men. Implications of study results for designing effective welfare-to-work interventions in a post-welfare-reform era are discussed.

A practical clinical trial of coordinated care management to treat substance use disorders among public assistance beneficiaries.

This study tested whether coordinated care management (CCM), a continuity of care intervention for substance use disorders (SUD), improved rates of abstinence when compared with usual welfare management for substance-using single adults and adults with dependent children applying for public assistance. The study was designed as a practical clinical trial and was implemented in partnership with a large city welfare agency. Participants were 421 welfare applicants identified via SUD screening and assigned via an unbiased computerized allocation program to a site that provided either CCM (n = 232) or usual care (UC; n = 189). Outcomes were assessed for 1 year postbaseline with self-reports and biological measures of substance use. As hypothesized, for participants not enrolled in methadone maintenance programs (n = 313), CCM clients received significantly more services than did UC clients. Nonmethadone CCM also showed significantly higher abstinence rates (odds ratio = 1.75; 95% confidence interval = 1.12, 2.76; d = 0.31) that emerged early in treatment and were sustained throughout follow-up. In contrast, no treatment services or outcome effects were found for methadone maintenance clients (n = 108). Findings suggest that CCM is promising as a wraparound to SUD treatment for welfare recipients.

Characteristics of individuals screening positive for substance use in a welfare setting: implications for welfare and substance-use disorders treatment systems.

OBJECTIVE: This study examined barriers to employability, motivation to abstain from substances and to work, and involvement in multiple service systems among male and female welfare applicants with alcohol- and drug-use problems. METHOD: A representative sample (N= 1,431) of all persons applying for public assistance who screened positive for substance involvement over a 2-year period in a large urban county were recruited in welfare offices. Legal, education, general health, mental health, employment, housing, and child welfare barriers to employability were assessed, as were readiness to abstain from substance use and readiness to work. RESULTS: Only 1 in 20 participants reported no barrier other than substance use, whereas 70% reported at least two other barriers and 40% reported three or more. Moreover, 70% of participants experienced at least one additional barrier classified as "severe" and 30% experienced two or more. The number and type of barriers differed by gender. Latent class analysis revealed four main barriers-plus-readiness profiles among participants: (1) multiple barriers, (2) work experienced, (3) criminal justice, and (4) unstable housing. CONCLUSIONS: Findings suggest that comprehensive coordination among social service systems is needed to address the complex problems of low-income Americans with substance-use disorders. Classifying applicants based on barriers and readiness is a promising approach to developing innovative welfare programs to serve the diverse needs of men and women with substance-related problems.