Specifying cross-system collaboration strategies for implementation: a multi-site qualitative study with child welfare and behavioral health organizations.

BACKGROUND: Cross-system interventions that integrate health, behavioral health, and social services can improve client outcomes and expand community impact. Successful implementation of these interventions depends on the extent to which service partners can align frontline services and organizational operations. However, collaboration strategies linking multiple implementation contexts have received limited empirical attention. This study identifies, describes, and specifies multi-level collaboration strategies used during the implementation of Ohio Sobriety Treatment and Reducing Trauma (Ohio START), a cross-system intervention that integrates services across two systems (child welfare and evidence-based behavioral health services) for families that are affected by co-occurring child maltreatment and parental substance use disorders. METHODS: In phase 1, we used a multi-site qualitative design with 17 counties that implemented Ohio START. Qualitative data were gathered from 104 staff from child welfare agencies, behavioral health treatment organizations, and regional behavioral health boards involved in implementation via 48 small group interviews about collaborative approaches to implementation. To examine cross-system collaboration strategies, qualitative data were analyzed using an iterative template approach and content analysis. In phase 2, a 16-member expert panel met to validate and specify the cross-system collaboration strategies identified in the interviews. The panel was comprised of key child welfare and behavioral health partners and scholars. RESULTS: In phase 1, we identified seven cross-system collaboration strategies used for implementation. Three strategies were used to staff the program: (1) contract for expertise, (2) provide joint supervision, and (3) co-locate staff. Two strategies were used to promote service access: (4) referral protocols and (5) expedited access agreements. Two strategies were used to align case plans: (6) shared decision-making meetings, and (7) sharing data. In phase 2, expert panelists specified operational details of the cross-system collaboration strategies, and explained the processes by which strategies were perceived to improve implementation and service system outcomes. CONCLUSIONS: We identified a range of cross-system collaboration strategies that show promise for improving staffing, service access, and case planning. Leaders, supervisors, and frontline staff used these strategies during all phases of implementation. These findings lay the foundation for future experimental and quasi-experimental studies that test the effectiveness of cross-system collaboration strategies.

The Sobriety Treatment and Recovery Teams program for families with parental substance use: Comparison of child welfare outcomes through 12 months post-intervention.

BACKGROUND: The 2018 Family First Prevention Services Act (FFPSA) shifted child welfare funding to interventions proven effective in preserving families with parental substance use and child welfare involvement. The Sobriety Treatment and Recovery Teams (START) program serves this population with FFPSA aligned goals. OBJECTIVE: This study was the first to test the sustained effects of START from the initial CPS report through 12-months post-intervention. PARTICIPANTS AND SETTING: Children (n = 784) receiving START services in four sites were compared to 784 children receiving child welfare treatment as usual (TAU). METHODS: Using child welfare administrative data, children in START were matched to children in TAU using propensity score matching. Outcomes were tested during the intervention period, and at six- and 12-months post-intervention using comparative statistics and multilevel logistic regression. RESULTS: The odds of START children being placed in out-of-home care (OOHC) during the intervention period were half those of children in TAU (20.3% vs. 35.2%, p < .001, OR = 0.47, 95% CI [0.37, 0.59]). When placed in OOHC, START children were more likely to be reunified with their parents (p = .042, OR = 1.44, 95% CI [0.99, 1.62]). At 12-months post-intervention, 68.5% of START and 56.0% of TAU-served children remained free from both OOHC placement and child abuse and neglect (after multilevel clustering adjustment: p < .001, OR = 1.85, 95% CI [1.41, 2.43]). CONCLUSION: The primary impact of START was significantly reduced rates of OOHC placement, with results sustained through 12-months post-intervention and after accounting for family clusters and site differences.

Comparative outcomes for Black children served by the Sobriety Treatment and Recovery Teams program for families with parental substance abuse and child maltreatment.

INTRODUCTION: An urgent need exists for child welfare and substance use disorder (SUD) interventions that safely preserve Black families, engage parents in treatment services, and improve child and parent outcomes. The Title IV-E Prevention Services Clearinghouse rated The Sobriety Treatment and Recovery Teams (START) as a promising practice for families with parental substance use and child maltreatment. This study is the first to test the effects of START on Black families. METHODS: This study compared child welfare and parent outcomes for 894 children and their 567 primary parents in three groups: Black children served by START, Black children served in treatment as usual (TAU), and White children served in START. This was a quasi-experimental study using a propensity score matched dataset of START-served children to TAU children. Comparisons included placement in state custody and repeat child abuse or neglect (CA/N) during the intervention period, and at 12 months post-intervention. Generalized linear models accounted for the effects of clustering and unbalanced covariates on outcomes. RESULTS: In this study, 51.8% of children were neonates or infants at the CPS report. At 12-months post-intervention, 80.6% of Black children served by START, but only 56.0% of Black children in TAU, remained free of both placement in state custody and CA/N (p < .001, OR = 3.27, 95% CI [2.14, 4.98]); these effects held after controlling for family clusters. Black and White families in START received equal SUD treatment and community-based services. For START-served families, parental use of opioids (p = .005, OR = 3.52, 95% CI [1.46, 8.48]) and mental health issues (p = .002, OR = 1.90, 95% CI [1.27, 2.86]), rather than race, predicted child placement in state custody. Parent mental health issues or opioid use doubled or quadrupled, respectively, the odds of failing to achieve early recovery by case closure. CONCLUSIONS: START is a potent intervention, co-implemented with SUD treatment providers, that kept Black children safely with their families through the intervention and 12-months post-intervention periods. Scaling up effective programs, like START, that align with the goals of the Family First Prevention Services Act might reduce racial disparities and improve child welfare and SUD treatment outcomes.

Medication-Assisted Treatment Improves Child Permanency Outcomes for Opioid-Using Families in the Child Welfare System.

Parents who use opioids and are involved in the child welfare system are less likely to retain custody of their children than parents who use other drugs. No previous studies have described medication-assisted treatment (MAT) utilization and child permanency outcomes for this population. The Sobriety Treatment and Recovery Team (START) model is a child welfare-based intervention focused on families with co-occurring substance use and child abuse / neglect issues. This study examined the prevalence and correlates of MAT utilization among parents in the START program with a history of opioid use, and compared child outcomes for families who received MAT services to those who did not. Of the 596 individuals with a history of opioid use in the START program, 55 (9.2%) received MAT. Receipt of MAT services did not differ by gender, age, county of residence, or drug use, though individuals who identified as White were more likely to participate in MAT. In a multiple logistic regression model, additional months of MAT increased the odds of parents retaining custody of their children. To address barriers to MAT, results-focused educational interventions may be needed for the child welfare workforce, as well as programs to improve collaboration and decision-making between the child welfare workforce, court personnel, and drug addiction treatment providers.

Sobriety Treatment and Recovery Teams: Implementation Fidelity and Related Outcomes.

BACKGROUND: Although integrated programs between child welfare and substance abuse treatment are recommended for families with co-occurring child maltreatment and substance use disorders, implementing integrated service delivery strategies with fidelity is a challenging process. OBJECTIVE: This study of the first five years of the Sobriety Treatment and Recovery Team (START) program examines implementation fidelity using a model proposed by Carroll et al. (2007). The study describes the process of strengthening moderators of implementation fidelity, trends in adherence to START service delivery standards, and trends in parent and child outcomes. METHODS: Qualitative and quantitative measures were used to prospectively study three START sites serving 341 families with 550 parents and 717 children. RESULTS: To achieve implementation fidelity to service delivery standards required a pre-service year and two full years of operation, persistent leadership, and facilitative actions that challenged the existing paradigm. Over four years of service delivery, the time from the child protective services report to completion of five drug treatment sessions was reduced by an average of 75 days. This trend was associated with an increase in parent retention, parental sobriety, and parent retention of child custody. Conclusions/Importance: Understanding the implementation processes necessary to establish complex integrated programs may support realistic allocation of resources. Although implementation fidelity is a moderator of program outcome, complex inter-agency interventions may benefit from innovative measures of fidelity that promote improvement without extensive cost and data collection burden. The implementation framework applied in this study was useful in examining implementation processes, fidelity, and related outcomes.

Sobriety Treatment and Recovery Teams in Rural Appalachia: Implementation and Outcomes.

The Sobriety Treatment and Recovery Teams (START) model is designed for families with co-occurring substance use and child maltreatment. This study describes the implementation and outcomes of START in a rural Appalachian county with high rates of poverty, non-medical prescription drug use, and child maltreatment. Despite a severely limited addiction treatment infrastructure at baseline, children served by START were less likely to experience recurrence of child abuse or neglect within 6 months or re-enter foster care at 12 months compared with a matched control group.