Continuous Quality Improvement in the Substance Abuse and Mental Health Services Administration's Technology Transfer Center Network: A Process Evaluation.

In healthcare and related fields, there is often a gap between research and practice. Scholars have developed frameworks to support dissemination and implementation of best practices, such as the Interactive Systems Framework for Dissemination and Implementation, which shows how scientific innovations are conveyed to practitioners through tools, training, and technical assistance (TA). Underpinning those aspects of the model are evaluation and continuous quality improvement (CQI). However, a recent meta-analysis suggests that the approaches to and outcomes from CQI in healthcare vary considerably, and that more evaluative work is needed. Therefore, this paper describes an assessment of CQI processes within the Substance Abuse and Mental Health Services Administration's (SAMHSA) Technology Transfer Center (TTC) Network, a large TA/TTC system in the United States comprised of 39 distinct centers. We conducted key informant interviews (n = 71 representing 28 centers in the Network) and three surveys (100% center response rates) focused on CQI, time/effort allocation, and Government Performance and Results Act (GPRA) measures. We used data from each of these study components to provide a robust picture of CQI within a TA/TTC system, identifying Network-specific concepts, concerns about conflation of the GPRA data with CQI, and principles that might be studied more generally.

How do the Substance Abuse and Mental Health Services Administration's Technology Transfer Centers Decide What Evidence-Based Practices to Disseminate and Determine How to Do So? A Cross-Sectional Study of a National Network.

It is important to use evidence-based programs and practices (EBPs) to address major public health issues. However, those who use EBPs in real-world settings often require support in bridging the research-to-practice gap. In the US, one of the largest systems that provides such support is the Substance Abuse and Mental Health Services Administration's (SAMHSA's) Technology Transfer Center (TTC) Network. As part of a large external evaluation of the Network, this study examined how TTCs determine which EBPs to promote and how to promote them. Using semi-structured interviews and pre-testing, we developed a "Determinants of Technology Transfer" survey that was completed by 100% of TTCs in the Network. Because the study period overlapped with the onset of the COVID-19 pandemic, we also conducted a retrospective pre/post-pandemic comparison of determinants. TTCs reported relying on a broad group of factors when selecting EBPs to disseminate and the methods to do so. Stakeholder and target audience input and needs were consistently the most important determinant (both before and during COVID-19), while some other determinants fluctuated around the pandemic (e.g., public health mandates, instructions in the funding opportunity announcements). We discuss implications of the findings for technology transfer and frame the analyses in terms of the Interactive Systems Framework for Dissemination and Implementation.

30 years of youth system of care lessons learned - a qualitative study of Hawai'i's partnership with the Substance Abuse and Mental Health Services Administration.

BACKGROUND: The Hawai'i State Department of Health, Child and Adolescent Mental Health Division (CAMHD) has maintained a longstanding partnership with Substance Abuse and Mental Health Services Administration (SAMHSA) to enhance capacity and quality of community-based mental health services. The current study explored CAMHD's history of SAMHSA system of care (SOC) awards and identified common themes, lessons learned, and recommendations for future funding. METHODS: Employing a two-phase qualitative approach, the study first conducted content analysis on seven final project reports, identifying themes and lessons learned based on SOC values and principles. Subsequently, interviews were conducted with 11 system leaders in grant projects and SOC award projects within the state. All data from project reports and interview transcripts were independently coded and analyzed using rapid qualitative analysis techniques. RESULTS: Content validation and interview coding unveiled two content themes, interagency collaboration and youth and family voice, as areas that required long-term and consistent efforts across multiple projects. In addition, two general process themes, connection and continuity, emerged as essential approaches to system improvement work. The first emphasizes the importance of fostering connections in family, community, and culture, as well as within workforce members and child-serving agencies. The second highlights the importance of nurturing continuity throughout the system, from interagency collaboration to individual treatment. CONCLUSIONS: The study provides deeper understanding of system of care evaluations, offering guidance to enhance and innovate youth mental health systems. The findings suggest that aligning state policies with federal guidelines and implementing longer funding mechanisms may alleviate administrative burdens.

States' investment in recovery support services: An exploratory analysis.

INTRODUCTION: Recovery support services (RSS), while not yet precisely defined, nevertheless have a longstanding role in managing chronic illnesses including substance use disorders (SUDs). This exploratory study is the first to identify the amounts of money that states invest from Substance Abuse and Mental Health Services Administration (SAMHSA) Block Grants; SAMHSA discretionary grant and state-appropriated sources; the types of organizations from which RSS are purchased; and the non-financial supports states provide for RSS. METHODS: The study is a mixed method exploratory analysis, based on three data sources: content analysis of all 51 (Washington, D.C. included) Substance Abuse Block Grant (SABG) state applications; in-depth interviews with a purposive sample of ten states and one territory; and a structured electronic survey sent to all SABG recipients. Forty states and 2 territories returned a total of 42 questionnaires from 56 possible states and territories (75%). Thirty-two of the responding states provided complete FY2022 financial data. RESULTS: States reporting financial data spent $412 million from SABG, SAMHSA discretionary grants, and state appropriations for RSS. An estimate based on extrapolating regionally grouped per capita spending averages to non-responding state populations projected $775 million spent from these sources for all states. The study also calculated per capita and SUD prevalent population expenditures from these sources for each state. States purchase services from recovery community organizations and SUD treatment organizations in equal proportions, as well as from statewide recovery support organizations, educational institutions, hospitals, community health centers, and justice system organizations. Purchased services are not uniformly defined, but include community centers, peer staff, housing, and other support services. States provide non-financial support in forms that include technical assistance, community engagement, practice guidelines, and regulatory frameworks. CONCLUSIONS: This first report of states' investments establishes a baseline to serve as a reference point for future analysis of these expenditures, as well as a foundation to which other sources of RSS funding such as Medicaid and other state and federal (e.g. HRSA, CDC, DOJ) dollars may be added. Uniform definitions for RSS will be necessary to support future reporting, accountability, and research. Finally, newly formed peer-based provider organizations need particular attention in order to be sustainable.

Assessing public behavioral health services data: a mixed method analysis.

BACKGROUND: Measuring behavioral health treatment accessibility requires timely, comprehensive and accurate data collection. Existing public sources of data have inconsistent metrics, delayed times to publication and do not measure all factors related to accessibility. This study seeks to capture this additional information and determine its importance for informing accessibility and care coordination. METHODS: The 2018 National Survey for Substance Abuse and Treatment Services (N-SSATS) data were used to identify behavioral health facilities in Indiana and gather baseline information. A telephone survey was administered to facilities with questions parallel to the N-SSATS and additional questions regarding capacity and patient intake. Quantitative analysis includes chi-square tests. A standard qualitative analysis was used for theming answers to open-ended questions. RESULTS: About 20% of behavioral health facilities responded to the study survey, and non-response bias was identified by geographic region. Among respondents, statistically significant differences were found in several questions asked in both the study survey and N-SSATS. Data gathered from the additional questions revealed many facilities to have wait times to intake longer than 2 weeks, inconsistency in intake assessment tools used, limited capacity for walk-ins and numerous requirements for engaging in treatment. CONCLUSION: Despite the low response rate to this study survey, results demonstrate that multiple factors not currently captured in public data sources can influence coordination of care. The questions included in this study survey could serve as a framework for routinely gathering these data and can facilitate efforts for successful coordination of care and clinical decision-making.

Identifying and Reducing Disparities in Mental Health Outcomes Among American Indians and Alaskan Natives Using Public Health, Mental Healthcare and Legal Perspectives.

The purpose of this paper was to investigate disparities in mental healthcare delivery in American Indian/Alaska Native populations from three perspectives: public health, legal policy and mental healthcare and provide evidence-based recommendations toward reducing those disparities. Data on mental health funding to tribes were obtained from the Substance Abuse and Mental Health Services Administration. As a result of analysis of these data, vital statistics and current literature, we propose three recommendations to reduce mental health disparities. First, where possible, increase mental health funding opportunities for federally-recognized tribes. Second, model funding practices on principles of tribal self-determination. Finally, support diverse interventions that are culturally-based and culturally-appropriate.

Ethical Challenges Inherent in the Evaluation of an American Indian/Alaskan Native Circles of Care Project.

This article provides first-person accounts of ethical issues inherent in an evaluation of the Native American Indian Center of Central Ohio (NAICCO) Circles of Care project. Circles of Care is a three-year, infrastructure development program funded through the Substance Abuse and Mental Health Services Administration (SAMHSA) which is part of the federal Department of Health and Human Services (DHHS). The grant program is for American Indian and Alaskan Native (AI/AN) tribes and urban Indian communities and includes a strong emphasis on community engagement and community ownership. The Native American Indian Center of Central Ohio received a Circles of Care grant in the fifth cohort of the program. The first author (Project Evaluator) presents views that typically represent a western approach to evaluation, while the second author (Project Director) presents a Native perspective. Ethical issues are defined as well as the authors' efforts to address these concerns.

SSI/SSDI Outreach, Access, and Recovery (SOAR): Disability Application Outcomes Among Homeless Adults.

OBJECTIVE: The SSI/SSDI Outreach, Access, and Recovery (SOAR) program has been shown to increase access to Supplemental Security Income and Social Security Disability Insurance benefits among homeless adults. However, little empirical data exist on how or for whom SOAR achieves successful application outcomes. This study investigated applicant and application characteristics associated with disability application outcomes among homeless adults. METHODS: Secondary data on 6,361 SOAR-assisted applications were obtained. Multilevel models investigated between-applicant differences in application processing time and decision as a function of applicant and application characteristics. RESULTS: Older age and living in an institution were associated with greater odds of application approval. Female gender and receipt of public assistance were associated with longer processing time and lower odds of approval. Except for quality review, SOAR critical components were associated with greater odds of approval. CONCLUSIONS: Women and adults receiving public assistance appear disadvantaged in the SOAR application process. SOAR critical components promote successful disability application outcomes.

Screening, Brief Intervention and Referral to Treatment: implications of SAMHSA's SBIRT initiative for substance abuse policy and practice.

AIMS: This paper describes the major findings and public health implications of a cross-site evaluation of a national Screening, Brief Intervention and Referral to Treatment (SBIRT) demonstration program funded by the US Substance Abuse and Mental Health Services Administration (SAMHSA). METHODS: Eleven multi-site programs in two cohorts of SAMHSA grant recipients were each funded for 5 years to promote the adoption and sustained implementation of SBIRT. The SBIRT cross-site evaluation used a multi-method evaluation design to provide comprehensive information on the processes, outcomes and costs of SBIRT as implemented in a variety of medical and community settings. FINDINGS: SBIRT programs in the two evaluated SAMHSA cohorts screened more than 1 million patients/clients. SBIRT implementation was facilitated by committed leadership and the use of substance use specialists, rather than medical generalists, to deliver services. Although the quasi-experimental nature of the outcome evaluation does not permit causal inferences, pre-post differences were clinically meaningful and statistically significant for almost every measure of substance use. Greater intervention intensity was associated with larger decreases in substance use. Both brief intervention and brief treatment were associated with positive outcomes, but brief intervention was more cost-effective for most substances. Sixty-nine (67%) of the original performance sites adapted and redesigned SBIRT service delivery after initial grant funding ended. Four factors influenced SBIRT sustainability: presence of program champions, availability of funding, systemic change and effective management of SBIRT provider challenges. CONCLUSIONS: The US Substance Abuse and Mental Health Services Administration's Screening, Brief Intervention and Referral to Treatment (SBIRT) demonstration program was adapted successfully to the needs of early identification efforts for hazardous use of alcohol and illicit drugs. SBIRT is an innovative way to integrate the management of substance use disorders into primary care and general medicine. Screening, Brief Intervention and Referral to Treatment implementation was associated with improvements in treatment system equity, efficiency and economy.

Health insurance, alcohol and tobacco use among pregnant and non-pregnant women of reproductive age.

BACKGROUND: Understanding the relationship between health insurance coverage and tobacco and alcohol use among reproductive age women can provide important insight into the role of access to care in preventing tobacco and alcohol use among pregnant women and women planning to become pregnant. METHODS: We examined the association between health insurance coverage and both past month alcohol use and past month tobacco use in a nationally representative sample of women age 12-44 years old, by pregnancy status. The women (n=97,788) were participants in the National Survey of Drug Use and Health (NSDUH) in 2010-2013. Logistic regression models assessed the association between health insurance (insured versus uninsured), past month tobacco and alcohol use, and whether this was modified by pregnancy status. RESULTS: Pregnancy status significantly moderated the relationship between health insurance and tobacco use (p-value≤0.01) and alcohol use (p-value≤0.01). Among pregnant women, being insured was associated with lower odds of alcohol use (adjusted odds ratio [AOR]=0.47; 95% confidence interval [CI]=0.27-0.82), but not associated with tobacco use (AOR=1.14; 95% CI=0.73-1.76). Among non-pregnant women, being insured was associated with lower odds of tobacco use (AOR=0.67; 95% CI=0.63-0.72), but higher odds of alcohol use (AOR=1.23; 95% CI=1.15-1.32). CONCLUSION: Access to health care, via health insurance coverage is a promising method to help reduce alcohol use during pregnancy. However, despite health insurance coverage, tobacco use persists during pregnancy, suggesting missed opportunities for prevention during prenatal visits.

Cost of Screening, Brief Intervention, and Referral to Treatment in Health Care Settings.

AIMS: This study analyzed service unit and annual costs of substance abuse screening, brief intervention, and referral to treatment (SBIRT) programs implemented in emergency department (ED), inpatient, and outpatient medical settings in three U.S. states and one tribal organization. METHODS: Unit costs and annual costs were estimated from the perspective of service providers. Data for unit costs came from 26 performance sites, and data for annual costs came from 10 programs. A bottom-up approach was used to derive unit costs and included labor, space, and materials used in each SBIRT activity. Activities included direct SBIRT services and activities that support direct service delivery. Labor time spent in each activity was collected by trained observers using a time-and-motion approach. A top-down approach used cost questionnaires completed by program administrators to calculate annual costs and included labor, space, contracted services, overhead, training, travel, equipment, and supplies and materials. Costs were estimated in 2012 U.S. dollars. RESULTS: Average unit costs for prescreening, screening, brief intervention, brief treatment, and referral to treatment were $0.61, $6.59, $10.48, $22.63, and $12.06 in ED; $0.86, $6.33, $9.07, $27.61, and $8.03 in inpatient; and $0.84, $3.98, $7.81, $27.94, and $9.23 in outpatient settings, respectively; over half of the costs were attributable to support activities. Across all settings, the average cost to provide SBIRT per positive screen, for 1year, was about $400. CONCLUSIONS: Support activities comprise a large proportion of costs. Health administrators can use the results to budget and compare how much sites are reimbursed for SBIRT to how much services actually cost.

Substance Abuse and Mental Health Services Administration (SAMHSA) Behavioral Health Disaster Response App.

The Substance Abuse and Mental Health Services Administration (SAMHSA) in the Department of Health and Human Services offers extensive disaster behavior health resources to assist disaster survivors in preparing for, responding to, and recovering from natural and manmade disasters. One of SAMHSA's most innovative resources is the SAMHSA Behavioral Health Disaster Response App (SAMHSA Disaster App). The SAMHSA Disaster App prepares behavioral health responders for any type of traumatic event by allowing them to access disaster-related materials and other key resources right on their phone, at the touch of a button. The SAMHSA Disaster App is available on iPhone, Android, and BlackBerry devices.

Substance abuse and mental health visits among adolescents presenting to US emergency departments.

OBJECTIVES: The objectives of the study were to identify factors associated with adolescent emergency department (ED) visits for substance abuse, including those complicated by mental health (dual diagnosis), and to analyze their effect on ED length of stay (LOS) and disposition. METHODS: We performed a secondary analysis of ED visits by adolescents (age, 11-24) using the National Hospital Ambulatory Medical Care Survey (1997-2010) to identify visits for mental health, substance use, and dual diagnosis. Univariate and multivariate statistics were used to analyze demographic and visit-level factors, factors associated with substance use and dual diagnosis visits, as well as the effects of substance use and mental health conditions on ED LOS and disposition. RESULTS: Substance use and mental health accounted for 2.1% and 4.3% of all adolescent visits, respectively, with 20.9% (95% confidence interval [CI], 18.3%-23.5%) of substance abuse visits complicated by mental health. The factors significantly associated with substance use include the following: male sex, urban location, West region, ambulance arrival, night and weekend shift, anxiety disorders, mood disorders, and psychotic disorders. Additional LOS was 89.77 minutes for mental health, 71.33 minutes for substance use, and 139.97 minutes for dual diagnosis visits, as compared with visits where these conditions were not present. Both mental health and substance use were associated with admission/transfer as compared with other dispositions as follows: mental health odds ratio (OR), 5.93 (95% CI, 5.14-6.84); illicit drug use OR, 3.56 (95% CI 2.72-4.64); and dual diagnosis OR, 6.86 (95% CI, 4.67-10.09). CONCLUSIONS: Substance abuse and dual diagnosis are common among adolescent ED visits and are strongly associated with increased use of prehospital resources, ED LOS, and need for hospitalization.

A Longitudinal Study of State Strategies and Policies to Accelerate Evidence-Based Practices in the Context of Systems Transformation.

OBJECTIVE: To profile state agency efforts to promote implementation of three evidence-based practices (EBPs): screening and brief intervention (SBIRT), psychosocial interventions, and medication-assisted treatment (MAT). DATA SOURCES/STUDY SETTING: Primary data collected from representatives of 50 states and the District of Columbia's Single State Authorities from 2007 to 2009. STUDY DESIGN/DATA COLLECTION: The study used mixed methods, in-depth, semistructured interviews and quantitative surveys. Interviews assessed state and provider strategies to accelerate implementation of EBPs. PRINCIPAL FINDINGS: Statewide implementation of psychosocial interventions and MAT increased significantly over 3 years. In the first two assessments, states that contracted directly with providers were more likely to link use of EBPs to reimbursement, and states with indirect contract, through counties and other entities, increased recommendations, and some requirements for provision of specific EBPs. The number of states using legislation as a policy lever to promote EBPs was unchanged. CONCLUSIONS: Health care reform and implementation of parity in coverage increases access to treatment for alcohol and drug use. Science-based substance abuse treatment will become even more crucial as payers seek consistent quality of care. This study provides baseline data on service delivery, contracting, and financing as state agencies and treatment providers prepare for implementation of the Affordable Care Act.

Sustained, new, never, and discontinued tobacco cessation services adopters.

This study examined longitudinal adoption patterns of tobacco cessation (TC) counseling and TC pharmacotherapy in substance use disorder treatment programs and baseline predictors (program characteristics and program culture) of these patterns 12-months later. Telephone survey data were collected in 2010 from 685 randomly sampled program administrators working in geographically representative treatment programs across the U.S. Regarding TC counseling, about 41% of programs never adopt, 33% sustain, and 27% change adoption patterns. Concerning TC pharmacotherapy, about 62% of programs never adopt, 19% sustain, and 18% change adoption patterns. The three most consistent predictors of counseling adoption patterns are TC reimbursement, TC financial resource availability, and smoking culture. For TC pharmacotherapy adoption patterns, the most consistent predictors include profit status, TC reimbursement, level of care, TC financial resource availability, and smoking culture. Findings provide insights into program characteristics and program culture as both potential barriers and facilitators of longitudinal TCS adoption.

Examining the sustainment of the Adolescent-Community Reinforcement Approach in community addiction treatment settings: protocol for a longitudinal mixed method study.

BACKGROUND: Although evidence-based treatments are considered the gold standard for clinical practice, it is widely recognized that evidence-based treatment implementation in real world practice settings has been limited. To address this gap, the federal government provided three years of funding, training and technical assistance to 84 community-based treatment programs to deliver an evidence-based treatment called the Adolescent-Community Reinforcement Approach (A-CRA). Little is known about whether such efforts lead to long-term A-CRA sustainment after the initial funding ends. METHODS/DESIGN: We will use a longitudinal mixed method data analytic approach to characterize sustainment over time and to examine the factors associated with the extent to which A-CRA is sustained. We will use implementation data collected during the funding period (e.g., organizational functioning, staff certification rates and penetration) and supplement it with additional data collected during the proposed project period regarding implementation quality and the hypothesized predictors of sustainment (i.e., inner and outer contextual variables) collected over three waves from 2013 to 2015 representing program sustainment up to five years post-initial funding. DISCUSSION: Gaining a better understanding of the factors that influence the evidence-based treatment sustainment may lead to more effective dissemination strategies and ultimately improve the quality of care being delivered in community-based addiction treatment settings.