Safety planning intervention and follow-up: A telehealth service model for suicidal individuals in emergency department settings: Study design and protocol.

BACKGROUND: The Safety Planning Intervention with follow-up services (SPI+) is a promising suicide prevention intervention, yet many Emergency Departments (EDs) lack the resources for adequate implementation. Comprehensive strategies addressing structural and organizational barriers are needed to optimize SPI+ implementation and scale-up. This protocol describes a test of one strategy in which ED staff connect at-risk patients to expert clinicians from a Suicide Prevention Consultation Center (SPCC) via telehealth. METHOD: This stepped wedge, cluster-randomized trial compares the effectiveness, implementation, cost, and cost offsets of SPI+ delivered by SPCC clinicians versus ED-based clinicians (enhanced usual care; EUC). Eight EDs will start with EUC and cross over to the SPCC phase. Blocks of two EDs will be randomly assigned to start dates 3 months apart. Approximately 13,320 adults discharged following a suicide-related ED visit will be included; EUC and SPCC samples will comprise patients from before and after SPCC crossover, respectively. Effectiveness data sources are electronic health records, administrative claims, and the National Death Index. Primary effectiveness outcomes are presence of suicidal behavior and number/type of mental healthcare visits and secondary outcomes include number/type of suicide-related acute services 6-months post-discharge. We will use the same data sources to assess cost offsets to gauge SPCC scalability and sustainability. We will examine preliminary implementation outcomes (reach, adoption, fidelity, acceptability, and feasibility) through patient, clinician, and health-system leader interviews and surveys. CONCLUSION: If the SPCC demonstrates clinical effectiveness and health system cost reduction, it may be a scalable model for evidence-based suicide prevention in the ED.

Evaluating the implementation of a community health worker-delivered intervention integrating asthma care in West Philadelphia public schools.

OBJECTIVE: Schools are an important setting because students spend much of their time in school and engage in physical activity during the school day that could exacerbate asthma symptoms. Our objective is to understand the barriers and facilitators to implementing an experimental community health worker-delivered care coordination program for students with asthma within the context of the West Philadelphia Controls Asthma study. METHODS: Surveys (n = 256) and semi-structured interviews (n = 41) were completed with principals, teachers, nurses, and community health workers from 21 public and charter schools in West Philadelphia between January 2019 and September 2021. Survey participants completed the Evidence Based Practice Attitudes Scale, the Implementation Leadership Scale, and Organizational Climate Index. Semi-structured qualitative interview guides were developed, informed by the Consolidated Framework for Implementation Research. RESULTS: Participant responses indicate that they perceived benefits for schools and students related to the community health worker-based care coordination program. Several barriers and facilitators to implementing the program were noted, including challenges associated with incorporating the program into school nurse workflow, environmental triggers in the school environment, and challenges communicating with family members. An important facilitator that was identified was having supportive school administrators and staff who were engaged and saw the benefits of the program. CONCLUSIONS: This work can inform implementation planning for other locales interested in implementing community-based pediatric asthma control programs delivered by community health workers in schools.

Increased Risks for Suicide, Self-Harm, Substance Use, and Psychiatric Disorders in Adults With Inflammatory Bowel Disease: A Nationwide Study in the United States From 2007 to 2017.

In an analysis of over 260 million emergency department visits across the United States from 2007 to 2017, inflammatory bowel disease conferred >10-fold risk for suicide deaths, self-harm, substance use, and psychiatric disorders, though the overall self-harm rates were low (<1% of all-cause inflammatory bowel disease emergency department visits; total 56 suicide deaths).

Treating individuals with suicidal ideation in primary care: Patient-level characteristics associated with follow-up in the Collaborative Care Model.

INTRODUCTION: The Collaborative Care Model (CoCM) is an evidence-based approach which embeds behavioral health providers (BHPs) into primary care. Whether patients with suicidal ideation (SI) are willing to engage in CoCM is unclear. METHODS: Using Patient Health Questionnaire-9 (PHQ-9) administrative data from primary care practices within an urban academic health system, we identified patients with and without SI who were referred to a CoCM BHP. We compared engagement, defined as attendance at ≥1 CoCM visit, across groups. RESULTS: Between 2018 and 2022, 7391 primary care patients were referred to a CoCM BHP. Eight hundred and ninety-two of these patients reported SI on the PHQ-9 (754 on "several days" during the previous 2 weeks and 138 on "more than half or most days"). Across groups, most patients engaged in CoCM. Patients reporting SI on several days engaged at a lower rate (61.4%) than those reporting SI on more than half or most days (65.9%). Both SI groups engaged at a lower rate than the 6499 patients who did not report SI (67.5%). CONCLUSION: Most patients referred to a CoCM BHP engaged in ≥1 visit. Rates were lower for patients with SI, with the lowest rate among those reporting SI on several days.

Advancing research on teams and team effectiveness in implementation science: An application of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework.

Background: Effective teams are essential to high-quality healthcare. However, teams, team-level constructs, and team effectiveness strategies are poorly delineated in implementation science theories, models, and frameworks (TMFs), hindering our understanding of how teams may influence implementation. The Exploration, Preparation, Implementation, Sustainment (EPIS) framework is a flexible and accommodating framework that can facilitate the application of team effectiveness approaches in implementation science. Main Text: We define teams and provide an overview of key constructs in team effectiveness research. We describe ways to conceptualize different types of teams and team constructs relevant to implementation within the EPIS framework. Three case examples illustrate the application of EPIS to implementation studies involving teams. Within each study, we describe the structure of the team and how team constructs influenced implementation processes and outcomes. Conclusions: Integrating teams and team constructs into the EPIS framework demonstrates how TMFs can be applied to advance our understanding of teams and implementation. Implementation strategies that target team effectiveness may improve implementation outcomes in team-based settings. Incorporation of teams into implementation TMFs is necessary to facilitate application of team effectiveness research in implementation science.

Teams and team-level constructs are neglected in implementation theories, models, and frameworks (TMFs). This paper calls attention to the importance of teams in implementation research and practice and provides an overview of team effectiveness research for implementation science. We illustrate how the EPIS framework can be applied to advance our understanding of how teams influence implementation processes and outcomes. We identify future directions for research on teams and implementation, including developing and testing implementation strategies that focus on team effectiveness.

Eliminating Monitor Overuse (EMO) type III effectiveness-deimplementation cluster-randomized trial: Statistical analysis plan.

Background: Deimplementing overused health interventions is essential to maximizing quality and value while minimizing harm, waste, and inefficiencies. Three national guidelines discourage continuous pulse oximetry (SpO2) monitoring in children who are not receiving supplemental oxygen, but the guideline-discordant practice remains prevalent, making it a prime target for deimplementation. This paper details the statistical analysis plan for the Eliminating Monitor Overuse (EMO) SpO2 trial, which compares the effect of two competing deimplementation strategies (unlearning only vs. unlearning plus substitution) on the sustainment of deimplementation of SpO2 monitoring in children with bronchiolitis who are in room air. Methods: The EMO Trial is a hybrid type 3 effectiveness-deimplementation trial with a longitudinal cluster-randomized design, conducted in Pediatric Research in Inpatient Settings Network hospitals. The primary outcome is deimplementation sustainment, analyzed as a longitudinal difference-in-differences comparison between study arms. This analysis will use generalized hierarchical mixed-effects models for longitudinal clustering outcomes. Secondary outcomes include the length of hospital stay and oxygen supplementation duration, modeled using linear mixed-effects regressions. Using the well-established counterfactual approach, we will also perform a mediation analysis of hospital-level mechanistic measures on the association between the deimplementation strategy and the sustainment outcome. Discussion: We anticipate that the EMO Trial will advance the science of deimplementation by providing new insights into the processes, mechanisms, and likelihood of sustained practice change using rigorously designed deimplementation strategies. This pre-specified statistical analysis plan will mitigate reporting bias and support data-driven approaches. Trial registration: ClinicalTrials.gov NCT05132322. Registered on 24 November 2021.

Impact of the collaborative care model on medical spending.

OBJECTIVES: The collaborative care model integrates mental health care into primary care. In 2017, CMS created new billing codes to reimburse collaborative care. We measured the impact of a program supported by these codes on medical spending. STUDY DESIGN: Quasi-experimental. METHODS: We identified a commercially insured and managed Medicare sample of 825 patients who received collaborative care services in 8 primary care practices. We used propensity score matching to match treated patients to potential controls, resulting in 569 patients per group. We performed a difference-in-differences regression analysis to evaluate the impact of collaborative care on total medical spending, including medical, psychiatric, and pharmaceutical claims. RESULTS: Collaborative care patients' mean total medical cost began to fall after a patient's third month in the program and fell below the mean cost of control patients at month 7. Difference-in-differences regressions indicate a nonsignificant savings in total medical cost of $29.35 per member per month for patients in collaborative care compared with matched controls (95% CI, -$226.52 to $167.82). Treated members incurred $34.11 (95% CI, $31.95-$36.27) higher primary care costs that were directly attributed to collaborative care, $19.91 (95% CI, $4.84-$34.98) higher costs for other mental or behavioral health care, and a nonsignificant reduction of $91.34 (95% CI, -$319.32 to $136.63) in inpatient costs. CONCLUSIONS: Modest spending on collaborative care services to address the behavioral health needs of patients did not increase overall health care costs. This is the first economic study of a collaborative care program supported by the new billing codes.

Moving toward targeted eating disorder care for transgender, non-binary, and gender expansive patients in the United States.

OBJECTIVE: Literature suggests that transgender, non-binary, and/or gender expansive (TNG) people are more likely than cisgender peers to experience eating disorders (EDs) and engage in dangerous weight control behaviors. TNG individuals with EDs are dramatically higher risk for self-harm behaviors, suicidal ideation, and suicidal behaviors than cisgender peers with EDs or TNG peers without EDs, and often engage in ED symptoms/behaviors to alleviate gender dysphoria. Yet, no treatment paradigms have yet been adapted for TNG-specific ED care. This qualitative study aims to identify stakeholder needs from such care to inform future clinical interventions. METHODS: We elicited patient (n = 12) and mental health clinician (n = 9) stakeholder needs and preferences regarding TNG-specific ED care. Semi-structured interview guides informed by the Consolidated Framework for Implementation Research (CFIR) and a behavioral insights framework, EAST, were developed to ensure uniform inclusion and sequencing of topics and allow for valid comparison across interviews. Using a rapid analysis procedure, we produced a descriptive analysis for each group identifying challenges of and opportunities in providing ED care for TNG adults. RESULTS: Stakeholders expressed needs and preferences for TNG-specific treatment including that it be: (1) TNG-affirming, weight-inclusive, trauma-informed, and anti-racist; (2) delivered by an interdisciplinary team, including gender-affirming care clinicians; (3) focused on parsing gender dysphoria from other body image concerns, building distress tolerance, and working toward gender euphoria (rather than body acceptance). DISCUSSION: Future work is needed exploring ED care delivery models that integrate gender-affirming care services with mental health care. Such models may improve TNG access to ED treatment and recovery. PUBLIC SIGNIFICANCE: Transgender, non-binary, and/or gender expansive (TNG) experience disproportionately high rates of eating disorders and have unique barriers to accessing care. In individual interviews, TNG adults with eating disorders and mental health clinicians who provide psychotherapy for eating disorders voiced desire for greater availability of TNG-affirming, weight-inclusive eating disorder care, integrated with other gender-affirming care services. This informs future research developing eating disorder care for TNG individuals.

Generating Actionable Evidence for School-Based Mental Health Service Delivery: Public-Academic Partnership Based Evaluations.

Public-academic partnership-based program evaluations can generate actionable evidence for policymaking, program design and implementation in improving school-based mental health service delivery. The University of Pennsylvania Center for Mental Health and public behavioral health care agencies in Philadelphia in the United States have evaluated Philadelphia's school mental health programs reimbursable through Medicaid billing since 2008. The variety of evaluations include (1) examining acute mental health service use of children receiving school-based mental health care and Medicaid expenditure, (2) examining children's externalizing and internalizing behaviors to measure school mental health providers' performance, and (3) examining effects of different types of school mental health programs on children's behavioral health functioning, school outcomes, and other out-of-school service use. This paper reports key findings of these evaluations, discusses how programs have been refined based on evaluation results, and shares lessons learned for successful public-academic partnership-based evaluations to promote use of actionable evidence.

Adapting psychotherapy in collaborative care for treating opioid use disorder and co-occurring psychiatric conditions in primary care.

INTRODUCTION: Opioid use disorder (OUD) and psychiatric conditions commonly co-occur yet are infrequently treated with evidence-based therapeutic approaches, resulting in poor outcomes. These conditions, separately, present challenges to treatment initiation, retention, and success. These challenges are compounded when individuals have OUD and psychiatric conditions. METHOD: Recognizing the complex needs of these individuals, gaps in care, and the potential for primary care to bridge these gaps, we developed a psychotherapy program that integrates brief, evidence-based psychotherapies for substance use, depression, and anxiety, building on traditional elements of the Collaborative Care Model (CoCM). In this article, we describe this psychotherapy program in a primary care setting as part of a compendium of collaborative services. RESULTS: Patients receive up to 12 sessions of evidence-based psychotherapy and case management based on a structured treatment manual that guides treatment via Motivational Enhancement; Cognitive Behavioral Therapies for depression, anxiety, and/or substance use disorder; and/or Behavioral Activation components. DISCUSSION: Novel, integrated treatments are needed to advance service delivery for individuals with OUD and psychiatric conditions and these programs must be rigorously evaluated. We describe our team's efforts to test our psychotherapy program in a large primary care network as part of an ongoing three-arm randomized controlled trial. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

An Assessment of Faculty Perceptions of Wellness Needs and Strategies to Optimize Engagement With Wellness Resources in Academic Medicine.

OBJECTIVE: Faculty at academic medical institutions are at increased risk for burnout. This study aimed to assess faculty perceptions of wellness needs and identify strategies to optimize engagement with individualized wellness resources. METHODS: Semistructured interviews were conducted with 37 faculty members in one US academic medical center. RESULTS: Participants identified significant barriers to achieving emotional health and wellness goals. Areas where participants identified needing the most support included interpersonal relationships, accountability for wellness goals, career support, financial resources, and mentorship. Most participants were unaware of all wellness resources available at their institution. Participants recommended regular marketing and emphasizing confidentiality of employer-sponsored programs. They also provided feedback on specific dissemination and marketing methods. CONCLUSIONS: This research underscores the need for wellness resources for faculty and the importance of intentional dissemination of these resources to optimize uptake.

Primary care provider confidence in addressing opioid use disorder: A concept analysis.

Primary care providers (PCPs) are well-positioned to provide care for opioid use disorder (OUD), yet very few address OUD regularly. One contributing factor may be PCPs' lack of confidence in their ability to effectively treat OUD. Evidence demonstrates that clinician confidence in home care and hospital settings is associated with improved care delivery and patient outcomes. However, a conceptual definition of PCP confidence in addressing OUD has yet to be established. The aim of this concept analysis is to enhance conceptual understanding of PCP confidence in addressing OUD and inform future measurement strategies. Following Walker and Avant's method of concept analysis, PubMed, PsycINFO, and Google Scholar were searched in October 2021. Manuscripts were included if they referenced confidence in relation to PCPs who provide care to adult patients with OUD. Studies conducted outside the US and not published in English were excluded. The search resulted in 18 studies which were synthesized to conceptualize PCP confidence in addressing OUD. Defining attributes include self-efficacy, experience, and readiness to address OUD. These attributes may be influenced by organizational culture, training, support, and resources. Consequences of PCP confidence addressing OUD may include improved patient outcomes, improved delivery of and access to OUD care, and PCP attitude changes. This concept analysis-which grounds the concept of PCP confidence in addressing OUD in the theoretical and empirical literature-lays the framework for future measurement of the concept. This represents a critical first step towards developing strategies to enhance PCP confidence in addressing OUD.

Identifying Common and Unique Barriers and Facilitators to Implementing Evidence-Based Practices for Suicide Prevention across Primary Care and Specialty Mental Health Settings.

OBJECTIVE: We identified common and unique barriers and facilitators of evidence-based suicide prevention practices across primary care practices with integrated behavioral health services and specialty mental health settings to identify generalizable strategies for enhancing future implementation efforts. METHOD: Twenty-six clinicians and practice leaders from behavioral health (n = 2 programs) and primary care (n = 4 clinics) settings participated. Participation included a semi-structured qualitative interview on barriers and facilitators to implementing evidence-based suicide prevention practices. Within that interview, clinicians participated in a chart-stimulated recall exercise to gather additional information about decision making regarding suicide screening. Interview guides and qualitative coding were informed by leading frameworks in implementation science and behavioral science, and an integrated approach to interpreting qualitative results was used. RESULTS: There were a number of similar themes associated with implementation of suicide prevention practices across settings and clinician types, such as the benefits of inter-professional collaboration and uncertainties about managing suicidality once risk was disclosed. Clinicians also highlighted barriers unique to their settings. For primary care settings, time constraints and competing demands were consistently described as barriers. For specialty mental health settings, difficulties coordinating care with schools and other providers in the community made implementation of suicide prevention practices challenging. CONCLUSION: Findings can inform the development and testing of implementation strategies that are generalizable across primary care and specialty mental health settings, as well as those tailored for unique site needs, to enhance use of evidence-based suicide prevention practices in settings where individuals at risk for suicide are especially likely to present.HIGHLIGHTSWe examined barriers and facilitators to suicide prevention across health settings.Common and unique barriers and facilitators across health-care settings emerged.Findings can enhance suicide prevention implementation across health-care settings.

Equitable implementation of S.A.F.E. Firearm: A multi-method pilot study.

Attention to health equity is critical in the implementation of firearm safety efforts. We present our operationalization of equity-oriented recommendations in preparation for launch of a hybrid effectiveness-implementation trial focused on firearm safety promotion in pediatric primary care as a universal suicide prevention strategy. In Step 1 of our process, pre-trial engagement with clinican partners and literature review alerted us that delivery of a firearm safety program may vary by patients' medical complexity, race, and ethnicity. In Step 2, we selected the Health Equity Implementation Framework to inform our understanding of contextual determinants (i.e., barriers and facilitators). In Step 3, we leveraged an implementation pilot across 5 pediatric primary care clinics in 2 health system sites to study signals of inequities. Eligible well-child visits for 694 patients and 47 clinicians were included. Our results suggested that medical complexity was not associated with program delivery. We did see potential signals of inequities by race and ethnicity but must interpret with caution. Though we did not initially plan to examine differences by sex assigned at birth, we discovered that clinicians may be more likely to deliver the program to parents of male than female patients. Seven qualitative interviews with clinicians provided additional context. In Step 4, we interrogated equity considerations (e.g., why and how do these inequities exist). In Step 5, we will develop a plan to probe potential inequities related to race, ethnicity, and sex in the fully powered trial. Our process highlights that prospective, rigorous, exploratory work is vital for equity-informed implementation trials.

Sustainable deimplementation of continuous pulse oximetry monitoring in children hospitalized with bronchiolitis: study protocol for the Eliminating Monitor Overuse (EMO) type III effectiveness-deimplementation cluster-randomized trial.

BACKGROUND: Methods of sustaining the deimplementation of overused medical practices (i.e., practices not supported by evidence) are understudied. In pediatric hospital medicine, continuous pulse oximetry monitoring of children with the common viral respiratory illness bronchiolitis is recommended only under specific circumstances. Three national guidelines discourage its use for children who are not receiving supplemental oxygen, but guideline-discordant practice (i.e., overuse) remains prevalent. A 6-hospital pilot of educational outreach with audit and feedback resulted in immediate reductions in overuse; however, the best strategies to optimize sustainment of deimplementation success are unknown. METHODS: The Eliminating Monitor Overuse (EMO) trial will compare two deimplementation strategies in a hybrid type III effectiveness-deimplementation trial. This longitudinal cluster-randomized design will be conducted in Pediatric Research in Inpatient Settings (PRIS) Network hospitals and will include baseline measurement, active deimplementation, and sustainment phases. After a baseline measurement period, 16-19 hospitals will be randomized to a deimplementation strategy that targets unlearning (educational outreach with audit and feedback), and the other 16-19 will be randomized to a strategy that targets unlearning and substitution (adding an EHR-integrated clinical pathway decision support tool). The primary outcome is the sustainment of deimplementation in bronchiolitis patients who are not receiving any supplemental oxygen, analyzed as a longitudinal difference-in-differences comparison of overuse rates across study arms. Secondary outcomes include equity of deimplementation and the fidelity to, and cost of, each deimplementation strategy. To understand how the deimplementation strategies work, we will test hypothesized mechanisms of routinization (clinicians developing new routines supporting practice change) and institutionalization (embedding of practice change into existing organizational systems). DISCUSSION: The EMO trial will advance the science of deimplementation by providing new insights into the processes, mechanisms, costs, and likelihood of sustained practice change using rigorously designed deimplementation strategies. The trial will also advance care for a high-incidence, costly pediatric lung disease. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05132322 . Registered on November 10, 2021.

Leveraging behavioral economics and implementation science to engage patients at risk for suicide in mental health treatment: a pilot study protocol.

BACKGROUND: Primary care is an ideal setting to connect individuals at risk for suicide to follow-up care; however, only half of the patients referred from the primary care attend an initial mental health visit. We aim to develop acceptable, feasible, low-cost, and effective new strategies to increase treatment initiation among at-risk individuals identified in primary care. METHODS: We will conduct a multi-phase, mixed-methods study. First, we will conduct a chart review study by using administrative data, including medical records, to identify characteristics of primary care patients at risk for suicide who do or do not attend an initial mental health visit following a referral. Second, we will conduct a mixed methods study by using direct observations and qualitative interviews with key stakeholders (N = 65) to understand barriers and facilitators to mental health service initiation among at-risk individuals. Stakeholders will include patients with suicidal ideation referred from primary care who do and do not attend a first mental health visit, primary care and behavioral health providers, and individuals involved in the referral process. We also will collect preliminary self-report and behavioral data regarding potential mechanisms of behavior change (i.e., self-regulation and social support) from patients. Third, we will leverage these findings, relevant frameworks, and the extant literature to conduct a multi-arm, non-randomized feasibility trial. During this trial, we will rapidly prototype and test strategies to support attendance at initial mental health visits. Strategies will be developed with subject matter experts (N = 10) and iteratively pilot tested (~5 patients per strategy) and refined. Research will be completed in the Penn Integrated Care Program (PIC), which includes fourteen primary care clinics in Philadelphia that provide infrastructure for electronic referrals, patient communication, and data access. DISCUSSION: We will leverage frameworks and methods from behavioral economics and implementation science to develop strategies to increase mental health treatment initiation among individuals at risk for suicide identified in primary care. This project will lead to an evaluation of these strategies in a fully powered randomized trial and contribute to improvements in access to and engagement in mental health services for individuals at risk for suicide. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05021224.

Metrics to evaluate implementation scientists in the USA: what matters most?

BACKGROUND: Implementation science has grown rapidly as a discipline over the past two decades. An examination of how publication patterns and other scholarly activities of implementation scientists are weighted in the tenure and promotion process is needed given the unique and applied focus of the field. METHODS: We surveyed implementation scientists (mostly from the USA) to understand their perspectives on the following matters: (1) factors weighted in tenure and promotion for implementation scientists, (2) how important these factors are for success as an implementation scientist, (3) how impact is defined for implementation scientists, (4) top journals in implementation science, and (5) how these journals are perceived with regard to their prestige. We calculated univariate descriptive statistics for all quantitative data, and we used Wilcoxon signed-rank tests to compare the participants' ratings of various factors. We analyzed open-ended qualitative responses using content analysis. RESULTS: One hundred thirty-two implementation scientists completed the survey (response rate = 28.9%). Four factors were rated as more important for tenure and promotion decisions: number of publications, quality of publication outlets, success in obtaining external funding, and record of excellence in teaching. Six factors were rated as more important for overall success as an implementation scientist: presentations at professional meetings, involvement in professional service, impact of the implementation scientist's scholarship on the local community and/or state, impact of the implementation scientist's scholarship on the research community, the number and quality of the implementation scientist's community partnerships, and the implementation scientist's ability to disseminate their work to non-research audiences. Participants most frequently defined and described impact as changing practice and/or policy. This expert cohort identified Implementation Science as the top journal in the field. CONCLUSIONS: Overall, there was a significant mismatch between the factors experts identified as being important to academic success (e.g., tenure and promotion) and the factors needed to be a successful implementation scientist. Findings have important implications for capacity building, although they are largely reflective of the promotion and tenure process in the USA.

Study protocol: cluster randomized trial of consultation strategies for the sustainment of mental health interventions in under-resourced urban schools: rationale, design, and methods.

BACKGROUND: The school is a key setting for the provision of mental health services to children, particularly those underserved through traditional service delivery systems. School-wide Positive Behavioral Interventions and Supports (PBIS) is a tiered approach to service delivery based on the public health model that schools use to implement universal (Tier 1) supports to improve school climate and safety. As our prior research has demonstrated, PBIS is a useful vehicle for implementing mental and behavioral health evidence-based practices (EBPs) at Tier 2 for children with, or at risk for, mental health disorders. Very little research has been conducted regarding the use of mental health EBPs at Tier 2 or how to sustain implementation in schools. METHODS/DESIGN: The main aim of the study is to compare fidelity, penetration, cost-effectiveness, and student outcomes of Tier 2 mental health interventions across 2 sustainment approaches for school implementers in 12 K-8 schools. The study uses a 2-arm, cluster randomized controlled trial design. The two arms are: (a) Preparing for Sustainment (PS)-a consultation strategy implemented by school district coaches who receive support from external consultants, and (b) Sustainment as Usual (SAU)-a consultation strategy implemented by school district coaches alone. Participants will be 60 implementers and 360 students at risk for externalizing and anxiety disorders. The interventions implemented by school personnel are: Coping Power Program (CPP) for externalizing disorders, CBT for Anxiety Treatment in Schools (CATS) for anxiety disorders, and Check-in/Check-out (CICO) for externalizing and internalizing disorders. The Interactive Systems Framework (ISF) for Dissemination and Implementation guides the training and support procedures for implementers. DISCUSSION: We expect that this study will result in a feasible, effective, and cost-effective strategy for sustaining mental health EBPs that is embedded within a multi-tiered system of support. Results from this study conducted in a large urban school district would likely generalize to other large, urban districts and have an impact on population-level child mental health. Trial registration ClinicalTrials.gov identifier number NCT04869657. Registered May 3, 2021.

Implementing evidence-based practices in nonspecialty mental health settings.

OBJECTIVE: Mental health services are often implemented in settings in which mental health is not the primary mission. Schools, primary care clinics, criminal justice and child welfare institutions, and senior centers have been increasingly adding mental health care to their compendium of services owing to the high rates of mental health needs in these settings. Despite numerous challenges to implementing mental health practices in settings where mental health care has not traditionally been a part of the service model, the demand for mental health services in these settings is growing. Implementation science offers a lens through which to understand unique challenges and potential solutions to implementing mental health services in these settings, with the ultimate goal of ensuring the implementation of evidence-based services. METHOD AND RESULTS: In this conceptual article, we discuss common overarching barriers to implementing evidence-based mental health interventions in nonspecialty mental health settings, such as workforce challenges, competing priorities, and financial considerations. Then, using examples from schools and primary care, we elucidate unique contextual considerations and implementation challenges in these settings. Finally, we articulate a research agenda for advancing implementation of evidence-based practices in nonspecialty mental health including highlighting promising implementation strategies (e.g., task shifting, adaptation) and the most relevant implementation outcomes to assess in these contexts (e.g., appropriateness, feasibility). CONCLUSIONS: Given that nonspecialty mental health settings deliver a large proportion of mental health care to traditionally underserved populations, there are important public health implications to advancing research in this area and ensuring implemented services are evidence-based. (PsycInfo Database Record (c) 2022 APA, all rights reserved).