Comparing organization-focused and state-focused financing strategies on provider-level reach of a youth substance use treatment model: a mixed-method study.

BACKGROUND: Financial barriers in substance use disorder service systems have limited the widespread adoption-i.e., provider-level reach-of evidence-based practices (EBPs) for youth substance use disorders. Reach is essential to maximizing the population-level impact of EBPs. One promising, but rarely studied, type of implementation strategy for overcoming barriers to EBP reach is financing strategies, which direct financial resources in various ways to support implementation. We evaluated financing strategies for the Adolescent Community Reinforcement Approach (A-CRA) EBP by comparing two US federal grant mechanisms, organization-focused and state-focused grants, on organization-level A-CRA reach outcomes. METHOD: A-CRA implementation took place through organization-focused and state-focused grantee cohorts from 2006 to 2021. We used a quasi-experimental, mixed-method design to compare reach between treatment organizations funded by organization-focused versus state-focused grants (164 organizations, 35 states). Using administrative training records, we calculated reach as the per-organization proportion of trained individuals who received certification in A-CRA clinical delivery and/or supervision by the end of grant funding. We tested differences in certification rate by grant type using multivariable linear regression models that controlled for key covariates (e.g., time), and tested threats to internal validity from our quasi-experimental design through a series of sensitivity analyses. We also drew on interviews and surveys collected from the treatment organizations and (when relevant) interviews with state administrators to identify factors that influenced reach. RESULTS: The overall certification rates were 27 percentage points lower in state-focused versus organization-focused grants (p = .01). Sensitivity analyses suggested these findings were not explained by confounding temporal trends nor by organizational or state characteristics. We did not identify significant quantitative moderators of reach outcomes, but qualitative findings suggested certain facilitating factors were more influential for organization-focused grants (e.g., strategic planning) and certain barrier factors were more impactful for state-focused grants (e.g., states finding it difficult to execute grant activities). DISCUSSION: As the first published comparison of EBP reach outcomes between financing strategies, our findings can help guide state and federal policy related to financing strategies for implementing EBPs that reduce youth substance use. Future work should explore contextual conditions under which different financing strategies can support the widespread implementation of EBPs for substance use disorder treatment.

Comparing two federal financing strategies on penetration and sustainment of the adolescent community reinforcement approach for substance use disorders: protocol for a mixed-method study.

BACKGROUND: Sustained, widespread availability of evidence-based practices (EBPs) is essential to address the public health and societal impacts of adolescent substance use disorders (SUD). There remains a particularly significant need to identify effective financing strategies, which secure and direct financial resources to support the costs associated with EBP implementation and sustainment. This protocol describes a new project comparing two types of U.S. federal grant mechanisms (i.e., a type of financing strategy), which supported the implementation of the Adolescent Community Reinforcement Approach (A-CRA) EBP for SUD, through either organization-focused or state-focused granting of funds. The Exploration-Preparation-Implementation-Sustainment (EPIS) framework will guide our study aims, hypotheses, and selection of measures. METHOD: We will employ a longitudinal, mixed-method (i.e., web surveys, semi-structured interviews, document review, focus groups, administrative data), quasi-experimental design to compare the grant types' outcomes and examine theoretically informed mediators and moderators. Aim 1 will examine the proportion of eligible clinicians certified in A-CRA with adequate fidelity levels (i.e., penetration outcomes) at the end of grant funding. Aim 2 will examine the sustainment of A-CRA up to 5 years post-funding, using a 10-element composite measure of treatment delivery and supervision activities. We will integrate the new data collected from state-focused grant recipients (~85 organizations in 19 states) with previously collected data from organization-focused grant recipients (Hunter et al., Implement Sci 9:104, 2014) (82 organizations in 26 states) for analysis. We will also use sensitivity analyses to characterize the effects of observed and unobserved secular trends in our quasi-experimental design. Finally, aim 3 will use comparative case study methods (integrating diverse quantitative and qualitative measures) to identify and disseminate policy implications about the roles of state- and organization-focused federal grants in efforts to promote adolescent SUD EBP implementation and sustainment. DISCUSSION: The proposed research will have direct, practical implications for behavioral health administrators, policymakers, implementation experts, and the public. It will offer new knowledge that can directly inform financing strategies to support large-scale, sustained EBP delivery in behavioral health-while advancing implementation science through the use of novel methods to study financing strategies and sustainment.

Contingent reinforcement of personal goal activities for adolescents with substance use disorders during post-residential continuing care.

Contingency management (CM) is efficacious in improving outcomes of substance-abusing patients, but CM studies are relatively rare in adolescents. CM approaches can reinforce both abstinence and adherence to treatment-related goal areas. This paper describes 1,739 different activities in 10 goal areas (e.g., education, family/friends, and social/recreational) chosen by 86 adolescents who were participating in a multiple week CM study that reinforced both abstinence and adherence with goal-related activities. The mean activities selected was 20, and the mean completed was 13. Overall, 1,114 or 64% of chosen activities were completed. The clinical feasibility of activity incentive programs for adolescents is discussed.

Smoking cessation 3: multicomponent interventions.

In part 3 of this 3-part review of interventions for tobacco dependence, the authors focus on multicomponent interventions for smoking cessation. Interventions that combine behavioral and pharmacological components have been known to increase abstinence relative to a single type of therapy. Therefore, multicomponent interventions are recommended. The authors present both a brief intervention model and a multiple-session intervention model. These models can be used to create brief intensive, and quitline intervention programs and can be tailored to various types of clinicians and settings. The clinician can choose a multicomponent intervention program that is best suited to the patient's needs and preferences as well as to the clinical setting.

Smoking cessation 2: behavioral treatments.

The authors' purpose of this portion of a 3-part review of interventions for tobacco dependence is to present evidence regarding the efficacy of behavioral treatments for smoking cessation. The present review includes evidence evaluated in the Treating Tobacco Use and Dependence Clinical Practice Guideline (the Guideline) (MC Fiore, WC Bailey, SJ Cohen, et al, 2000) as well as evidence published subsequent to the Guideline. A wide range of effective behavioral treatments for smoking cessation is available. These interventions come in a variety of formats and intensities, can be used by all types of clinicians in a variety of settings, and are appropriate for different types of smokers. The authors have organized recommendations in 2 broad domains that account for much of the variability across behavioral interventions, treatment content, and structure. Finally, the authors discuss key directions for future research.

Smoking cessation 1: pharmacological treatments.

In part 1 of this 3-part review of interventions for tobacco dependence, the authors present evidence regarding the efficacy of pharmacological treatments for smoking cessation. They also present evidence and recommendations included in the U.S. Department of Health and Human Services Treating Tobacco Use and Dependence: Clinical Practice Guideline (the Guideline), evidence from studies published after the Guideline, and recommendations of their own. The authors review nicotine replacement therapies, antidepressants, and other pharmacotherapies, followed by pharmacological treatments for special populations. The evidence indicates that a variety of effective smoking cessation medications are available. First-line medications include nicotine replacement therapies and bupropion. Pharmacotherapy is a vital component of smoking cessation interventions and should be offered to all smokers who want to quit unless contraindicated. There is a need for further research on pharmacotherapies for smoking cessation, and the authors discuss key areas for future research.