Using a Theory-Guided Learning Collaborative Model to Improve Implementation of EBPs in a State Children's Mental Health System: A Pilot Study

Developing the engage for equity institutional multi-sector survey: Assessing academic institutional culture and climate for community-based participatory research (CBPR)

Introduction

Community-engaged research/community-based participatory research/patient-engaged research (CEnR/CBPR/PEnR) are increasingly recognized as important approaches for addressing health equity. However, there is limited support for CEnR/CBPR/PEnR within Academic Health Centers (AHCs). It is important for AHCs to measure and monitor the context, process, and policies in support for CEnR/CBPR/PEnR. The Engage for Equity (E2) team developed the first Institutional Multi-Sector Survey (IMSS) instrument to assess and explore CEnR/CBPR/PEnR-related practices at three AHCs.

Methods

Working with "champion teams" consisting of academic leaders, researchers, and patient/community partners at each AHC, we developed the IMSS to assess the following domains: institutional mission, vision, and values; CEnR/CBPR/PEnR policies/practices; community processes/structures; function of formal community advisory boards; climate/culture for CEnR/CBPR; perceptions of institutional leadership for CEnR/CBPR/PEnR. The survey was piloted to a convenience sample of CEnR/CBPR/PEnR participants at each AHC site.

Results

A sample aggregated across all sites consisting of community (n = 49) and academic (n = 50) participants perceived high levels of advocacy for CEnR/CBPR/PEnR among their AHC research teams. Participants indicated that institutional leadership supported CEnR/CBPR/PEnR in principle, but resources to build CEnR/CBPR/PEnR capacity at their respective institutions were lacking. Differences in responses from community and academic partners are summarized.

Conclusions

While limited by survey length and question adaptation, the findings contribute to identification of institutional barriers and facilitators to CEnR/CBPR/PEnR in AHCs. These findings are critically important to support and improve CEnR/CBPR/PEnR practice in academic institutions and to elevate community partner voices and needs for advancing community and patient partners' research.

Transition Guide Dissemination to Foster Patient-Care Team Conversations: A Childhood Arthritis Rheumatology Research Alliance Transition Learning Collaborative Pilot Implementation Study

OBJECTIVE

Uptake of evidence-informed health care transition processes among pediatric rheumatologists is low despite poor outcomes of transition from pediatric to adult care. We piloted a learning collaborative model to implement transition guides. We dually assessed implementation outcomes and changes in reported patient-care team discussions about transition.

METHODS

This was a type II hybrid effectiveness-implementation pilot study of transition guide dissemination to patients at least 14 years old with rheumatic conditions across nine pediatric rheumatology centers in the Childhood Arthritis Rheumatology Research Alliance Transition Learning Collaborative. We evaluated implementation outcomes (feasibility, adaptations, and fidelity) and the proportion of patients surveyed that reported having discussions with their care team regarding transfer planning.

RESULTS

Six sites were retained through the COVID-19 pandemic (below 70% target). Five out of six sites contributed outcome data (met 80% target) but with substantial heterogeneity in how transition guides were shared (eg, in-person, electronic messages, and posted flyers), and data were collected. The pooled proportion of respondents having discussed transfer planning with their care team was 39% preimplementation (n = 239; 95% confidence interval [CI] 32%-46%) and 55% postimplementation (n = 864; 95% CI 36%-73%). After implementation, there were significant increases in the likelihood of respondents recalling receiving a transition guide (odds ratio [OR] 2.58, 95% CI 1.35-4.92) and discussing transfer planning (OR 2.14, 95% CI 1.30-3.52), adjusted for age and site of care.

CONCLUSION

Transition guide dissemination is a simple intervention associated with increased awareness among young people with rheumatic conditions and discussions with their care team about transition preparation. The learning collaborative model facilitated identification of several dissemination strategies adaptable to site-specific resources.

Therapist Participation in a Learning Collaborative on Trauma-Focused Cognitive Behavioral Therapy: Impact of COVID-related Stressors and Challenges

The rise in mental health problems during the COVID-19 pandemic amplified the need to improve access to evidence-based treatments (EBT) and necessitated changes in treatment delivery and training of mental health providers (MHPs). There is limited information on how the pandemic may have impacted MHPs' participation in training and treatment delivery. This study included 269 MHPs who participated in a Learning Collaborative (LC) focused on an EBT. Qualitative interviews conducted with 15 MHPs who participated in the LC during the pandemic identified facilitators and barriers to training participation and EBT delivery that included social support, technology challenges, and difficulty completing cases following the transition to telehealth. Quantitative results showed that MHPs in the peri-COVID cohorts completed significantly fewer cases and fewer consultation calls compared to those prior to the pandemic. Findings suggest that providing support to train MHPs and promote EBT delivery may be beneficial during times of heightened stress.

A Statewide Randomized Controlled Trial to Compare Three Models for Implementing Parent Child Interaction Therapy

OBJECTIVE

This study (NIMH RO1 MH095750; ClinicalTrials.gov Identifier: NCT02543359) evaluated the effectiveness of three training models to implement a well-established evidence-based treatment, Parent-Child Interaction Therapy (PCIT).

METHOD

Fifty licensed outpatient clinics, including 100 clinicians, 50 supervisors, and 50 administrators were randomized to one of three training conditions: 1) Learning Collaborative (LC), 2) Cascading Model (CM) or 3) Distance Education (DE). Data to assess training and implementation outcomes were collected at 4 time points coinciding with the training period: baseline, 6- (mid), 12- (post), and 24-months (1-year follow-up).

RESULTS

Multi-level hierarchical linear growth modeling was used to examine changes over time in training outcomes. Results indicate that clinicians in CM were more likely to complete training, reported high levels of training satisfaction and better learning experiences compared to the other training conditions. However, supervisors in the LC condition reported greater learning experiences, higher levels of knowledge, understanding of treatment, and satisfaction compared to supervisors in other conditions. Although clinicians and supervisors in the DE condition did not outperform their counterparts on any outcomes, their performance was comparable to both LC and CM in terms of PCIT use, supervisor perceived acceptability, feasibility, system support, and clinician satisfaction.

CONCLUSIONS

Through the use of a randomized controlled design and community implementation, this study contributes to the current understanding of the impact of training design on implementation of PCIT. Results also indicate that although in-person training methods may produce more positive clinician and supervisor outcomes, training is not a one-size-fits-all model, with DE producing comparable results on some variables.

Implementing Trauma-Informed Care Through a Learning Collaborative: A Theory-Driven Analysis of Sustainability

This study investigated the sustainability of a multi-agency 15-month Learning Collaborative (LC) for implementing trauma-informed care in 23 rural Pennsylvania counties. Provider agencies (N = 22) were assessed three years following completion of the LC. Sustained trauma-informed practices were assessed through criteria indicating organizational achievement as a trauma-informed care center. A theoretical model of clinical training was applied to determine the extent to which training- and skill-related factors were associated with sustained trauma-informed care. Three years after the LC, trauma symptom screening rates and staff training improvements were sustained, while staff confidence in delivering trauma-informed care worsened across time. Sustained trauma-informed care was associated with implementation milestone completion and third-party ratings of quality improvement skills during the LC. Building capacity for organizational change through training and skill development during active phases of implementation is important for sustained trauma informed care in behavioral health service.

Implementing Person-Centered Recovery Planning: New England Mental Health Technology Transfer Center Learning Collaborative Evaluation Report

Person-centered recovery planning (PCRP) has been a key aspect in mental health system transformation and delivering quality health care. Despite the mandate to deliver this practice and a growing evidence base, its implementation and understanding of implementation processes in behavioral health settings remain a challenge. New England Mental Health Technology Transfer Center (MHTTC) launched the PCRP in Behavioral Health Learning Collaborative to support agencies' implementation efforts through training and technical assistance. In an effort to explore and understand the internal implementation process changes facilitated by the learning collaborative, the authors conducted qualitative key informant interviews with the participants and the leadership of the PCRP learning collaborative. The interviews revealed the processes that are part of the PCRP implementation efforts, including staff training, changing agency policies and procedures, modifying treatment planning tools, and the structure of the electronic health records. The higher prior organizational investment and readiness for change, building staff's competencies in PCRP, leadership investment, and frontline staff buy-in act as factors that facilitate the implementation of PCRP in behavioral health settings. Our findings inform both the implementation of PCRP in behavioral health settings and future efforts of organizing multi-agency learning collaboratives to support PCRP implementation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43477-023-00078-3.

Scaling a Behavioral Health Home Delivery Model to Special Populations

The present project utilized a Learning Collaborative (LC) to disseminate the Behavioral Health Home Plus (BHHP) physical-behavioral health integration model to providers serving two behavioral health populations at risk for adverse health conditions: youth psychiatric residential treatment facilities (five sites) and adult opioid treatment providers (seven sites). Following the positive results of a randomized controlled trial utilizing an LC to implement two behavioral health home models in community mental health provider organizations serving adults with serious mental illness, Community Care Behavioral Health Organization facilitated integration of the models to scale health and wellness supports to additional behavioral health care delivery settings. This paper presents provider results focused on BHHP implementation training, LC implementation, physical health and wellness promotion within sites, and BHHP model sustainment plans. Provider self-reported data indicate that the LC approach is a successful tool for integrating and sustaining BHHP model components in routine care.

Healthier Lives Implementation Research Network for Māori and Pacific community health providers in Aotearoa New Zealand: a study protocol with an observational mixed methods design

BACKGROUND

Despite incremental gains in the Aotearoa New Zealand health sector, Māori and Pacific peoples still experience poorer health outcomes than non-Māori and non-Pacific. Access to the latest research and innovation is critical to improving and addressing health outcomes and health inequities in particular. However, there are numerous challenges to translating research into practice including that there is currently no known a specific infrastructure in Aotearoa New Zealand to facilitate this process. The aim of the project is to develop a network of community providers, researchers and health systems representatives that can help facilitate the implementation of novel and innovative programmes and products that help to meet the health needs of Māori and Pacific communities.

METHODS

This project has three stages, one of which has been completed. In Stage 1, we engaged with key leaders of organisations from various components in the health system through a co-design process to identify parameters and infrastructure of the network. In Stage 2, we propose to construct the network involving approximately 20-30 community providers (and other affiliated researchers and health system representatives) and refine its parameters through an additional co-design process. Additionally, we will use a mixed methods research design using survey and interviews to identify perceived implementation needs, facilitators and barriers to help inform the work in the third stage. In Stage 3, we will support the active implementation of evidence-based programmes with a smaller number of providers (approximately four to eight community providers depending on the complexity of the implementation). Mixed methods research will be conducted to understand facilitators and barriers to implementation processes and outcomes.

DISCUSSION

The proposed network infrastructure is an equity-oriented strategy focused on building capacity through a strength-based approach that can help address inequities over time. Our "proof-of-concept" study will not be able to change inequities in that time period given its relatively small scale and time period, but it should set the foundation for continued equity-oriented work.

Effect of different teaching/learning approaches using virtual patients on student's situational interest and cognitive load: a comparative study

BACKGROUND

Virtual Patients (VPs) have been receiving considerable attention in medical education as an authentic learning and teaching approach. The study aimed to evaluate the effect of using different approaches of conduction of virtual patients (VPs) on students' cognitive load and situational interest.

METHODS

The study is an experimental study. Two different cohorts have participated during the academic year 2019/2020 and 2020/2021. The first cohort (Group 1) was exposed to a lecture followed by an independent VPs session, and the second cohort (Group 2) was exposed to a collaborative VPs session. The situational interest and Cognitive load were compared between the two groups. All sessions are about one topic related to maxillofacial trauma.

RESULTS

Findings showed that there was no significant difference between the median score of the situational interest at repeated time points during the Collaborative VPs (Group 2). However, in group 1, there was a significant difference between the median score of situational interest at repeated time points during independent VPs where the lowest score was found to be at the end of the session. Also, results showed that the collaborative VPs (Group 2) showed a high median score of situational interest than both lecture and independent VPs (Group 1). Furthermore, the study showed that there is no significant difference in the intrinsic cognitive load among the three sessions. However, the extraneous cognitive load was low in collaborative VPs (Group 2) than in both lecture and independent VPs sessions (Group 1).

CONCLUSION

The use of VPs in a collaborative interactive learning activity is more effective than its use as an independent learning activity in enhancing students' situational interest and reducing cognitive load. However, giving independent VPs after the lecture with the same topic is considered a limitation of the study as this can affect the situational interest of the students by filling their gab of knowledge.

Mental Health Reform: Design and Implementation of a System to Optimize Outcomes for Veterans and Their Families

The social, health, and economic burden of mental health problems in the veteran community is heavy. Internationally, the array of services and support available to veterans and their families are extensive but vary in quality, are often disconnected, complex to navigate, and lack clear coordination. This paper describes a conceptual framework to guide the design and implementation of a system of services and supports to optimize the mental health and wellbeing of all veterans and their families. The framework recognizes the diversity of veterans across intersecting identities that uniquely shape experiences of posttraumatic mental health and wellbeing. It brings together several strands of research: the values and principles that should underpin the system; the needs of diverse veterans and their families; challenges in the current services and supports; evidence-based interventions; and principles of effective implementation. Central to the future system design is a next generation stepped model of care that organizes best and next practice interventions in a coherent system, matches service provision to level of need and addresses access and navigation. Practical guidance on implementation provides an aspirational and flexible structure for system evolution, and a template for all stakeholders-individuals, groups, agencies and organizations-to effect system change.

Therapists' Perceived Competence in Trauma-Focused Cognitive Behavioral Therapy and Client Outcomes: Findings From a Community-Based Learning Collaborative

This study examined therapists' perceived competence in Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and its association with youth treatment outcomes (posttraumatic stress and depression). Participants included 99 community therapists enrolled in a TF-CBT-focused Learning Collaborative (LC), along with one of their randomly selected TF-CBT training cases. Analyzed data included: 1) caregiver/youth-reported posttraumatic stress and depressive symptoms, pre- and post-treatment, and 2) therapist-perceived competence with TF-CBT components across treatment delivery. Youth- and caregiver-reports indicated large, significant pre- to post-treatment decreases in youth posttraumatic stress (ds = 1.10-1.30, ps < .001) and depressive symptoms (d = 1.01, p < .001). Higher therapist-perceived competence with TF-CBT predicted positive treatment responses for posttraumatic stress (ds = 0.38-0.39, ps = .03) and depression (d = 0.25), though only the former association was significant (ps = .03 vs. p = .15). Findings highlight the need to monitor and improve therapists' competencies to enhance clinical outcomes for trauma-exposed youth and suggest that LCs may be an effective training/implementation model to help achieve those critical goals.

Student outcomes of an international learning collaborative to develop patient safety and quality competencies in nursing

Background

Patient harm is a global crisis fueling negative outcomes for patients around the world. Working together in an international learning collaborative fostered learning with, from and about each other to develop evidence-based strategies for developing quality and safety competencies in nursing.

Aims

To report student outcomes from an international learning collaborative focused on patient safety using the Quality and Safety Education for Nurses competency framework.

Methods

A global consortium of nursing faculty created an international learning collaborative and designed educational strategies for an online pre-workshop and a 10-day in-person experience for 21 undergraduate and graduate nursing students from six countries. A retrospective pre-test post-test survey measured participants' confidence levels of patient safety competence using the health professional education in patient safety survey and content analysis of daily reflective writings.

Results

Statistical analysis revealed student confidence levels improved across all eight areas of safe practice comparing-pre and post-education (significance, alpha of P < 0.05). Two overarching themes, reactions to shared learning experiences and shared areas of learning and development, reflected Quality and Safety Education for Nurses competencies and a new cultural understanding.

Conclusions

The international learning collaborative demonstrated that cross-border learning opportunities can foster global development of quality and safety outcome goals.

The ParentingWell Learning Collaborative Feasibility Study: Training Adult Mental Health Service Practitioners in a Family-Focused Practice Approach

This study investigates the feasibility and impact of the ParentingWell Learning Collaborative (PWLC) model in supporting mental health practitioners in implementing the family-focused ParentingWell practice approach with adults with mental illness. An exploratory design and qualitative methods were employed. Practitioners (n = 29) participated in in-person orientation, training and debriefing sessions; virtual coaching sessions; and via an interactive online hub. Researchers obtained data on participant engagement and satisfaction, and participants' reports of use, helpfulness, intention to use and impact. Participants were engaged in and highly satisfied with the PWLC. They deployed PWLC skills, tools and resources with parents. Evidence of impact was provided at the personal, practice and organizational levels. This study provides preliminary support for the feasibility and impact of the PWLC. Clear specification of a theoretically-based training model for practitioners is an essential step in adapting, implementing and testing interventions in new contexts .

Implementing a Learning Collaborative for Population-Based Physical and Behavioral Health Integration

Behavioral health home models are increasingly being utilized to provide physical-behavioral health integration for individuals with mental illness. The Behavioral Health Home Plus model (BHHP) is a phased approach designed to instill a culture of wellness, provide wellness coaching, and offer care coordination for individuals with serious mental illness. The present study utilized a 12-month Learning Collaborative to implement scaling of BHHP in two cohorts totaling 24 community mental health provider organizations in Pennsylvania to include population-wide screening and intervention for tobacco use and hypertension. Providers reported increases in screening rates and wellness goals related to tobacco use and hypertension, as well as reductions in tobacco use and blood pressure readings among participating individuals. Evidence presented indicates that a Learning Collaborative of community mental health providers is a feasible quality improvement approach to scale integration of physical and behavioral health care for individuals with serious mental illness.

Applying the Exploration, Preparation, Implementation, Sustainment (EPIS) Framework to Safe Surgery 2020 Implementation in Tanzania's Lake Zone

BACKGROUND

Access to safe, high-quality surgical care in sub-Saharan Africa is a critical gap. Interventions to improve surgical quality have been developed, but research on their implementation is still at a nascent stage. We retrospectively applied the Exploration, Preparation, Implementation, Sustainment framework to characterize the implementation of Safe Surgery 2020, a multicomponent intervention to improve surgical quality.

METHODS

We used a longitudinal, qualitative research design to examine Safe Surgery 2020 in 10 health facilities in Tanzania's Lake Zone. We used documentation analysis with confirmatory key informant interviews (n = 6) to describe the exploration and preparation phases. We conducted interviews with health facility leaders and surgical team members at 1, 6, and 12 months (n = 101) post initiation to characterize the implementation phase. Data were analyzed using the constant comparison method.

RESULTS

In the exploration phase, research, expert consultation, and scoping activities revealed the need for a multicomponent intervention to improve surgical quality. In the preparation phase, onsite visits identified priorities and barriers to implementation to adapt the intervention components and curriculum. In the active implementation phase, 4 themes related to the inner organizational context-vision for safe surgery, existing surgical practices, leadership support, and resilience-and 3 themes related to the intervention-innovation-value fit, holistic approach, and buy-in-facilitated or hindered implementation. Interviewees perceived improvements in teamwork and communication and intra- and inter-facility learning, and their need to deliver safe surgery evolved during the implementation period.

CONCLUSIONS

Examining implementation through the exploration, preparation, implementation, and sustainment phases offers insights into the implementation of interventions to improve surgical quality and promote sustainability.

When Do Therapists Stop Using Evidence-Based Practices? Findings from a Mixed Method Study on System-Driven Implementation of Multiple EBPs for Children

Therapist discontinuation of delivering an evidence-based practice (EBP) is a critical outcome in the community implementation of EBPs. This mixed methods study examined factors associated with therapist discontinuation within a large reimbursement-driven implementation of multiple EBPs in public children's mental health services. The study integrated quantitative survey data from 748 therapists across 65 agencies, and qualitative interviews from a subset of 79 therapists across 14 agencies. Therapists adopted, on average, 2.41 EBPs (SD = 1.05, range = 1-5), and nearly half (n = 355, 47.5%) reported discontinuing at least one EBP. Multi-level models were used to predict the binary outcome of discontinuation, and qualitative analyses were used to expand upon quantitative findings. Quantitative models revealed that therapist factors, including fewer direct service hours per week, a greater number of EBPs adopted, higher emotional exhaustion, and more negative attitudes toward EBPs in general were associated with discontinuation. In addition, EBP-specific factors including more negative perceptions of the particular EBP and lower self-efficacy for delivering the specific EBP predicted discontinuation. Themes from interview responses highlighted the importance of fit of the EBP with the agency's client base, as well as therapist perceptions of adequate EBP training supports, and the alignment of an EBP with therapists' professional goals. Together, the findings suggest the need for strategic sustainment planning interventions that target EBP fit (i.e., fit between adopted EBPs and agency target population, fit between EBP and therapist preferences and career goals) and support therapist self-efficacy in delivering EBPs.

Policy and Practice Innovations to Improve Prescribing of Psychoactive Medications for Children

Psychoactive medications are the most expensive and fastest-growing class of pharmaceutical agents for children. The cost, side effects, and unprecedented growth rate at which these drugs are prescribed have raised alarms from health care clinicians, patient advocates, and agencies about the appropriateness of how these drugs are distributed to parents and their children. This article examines current prescribing of three classes of psychoactive drugs-stimulants, antidepressants, and antipsychotics-and efforts to improve pediatric prescribing of these agents. Federal policy efforts to curb questionable prescribing of psychoactive medications to children have focused particularly on oversight of antipsychotic use among foster care children. The article reviews system-level interventions, including delivery system enhancements, which increase availability of alternatives to medication treatments, employ electronic medical record reminders, and increase cross-sector care coordination; clinician prescribing enhancements, which disseminate best-practice guidelines, create quality and learning collaboratives, and offer "second opinion" psychiatric consultations; and prescriber monitoring programs, which include retrospective review and prospective monitoring of physicians' prescribing to identify patterns suggestive of inappropriate prescribing. Potential interventions to deter inappropriate pediatric prescribing are briefly described, such as transparency in drug prices and incentives among insurers, public agencies, and pharmacy benefit managers; value-based purchasing, specifically value-based payment for medications; and preventive interventions, such as parent training.

Race and Equity in Statewide Implementation Programs: An Application of the Policy Ecology of Implementation Framework

Although the literature is growing regarding large-scale, system-wide implementation programs, the broader political and social contexts, including race and ethnicity, are frequently ignored. Using the Policy Ecology of Implementation framework (Raghavan et al., Implement Sci 3:26, 2008), Minnesota's CEMIG is examined to investigate the role of social and political contexts in the implementation process and the barriers they create. Data from 22 interview transcripts from DHS administrators, agency grant managers, university educators, advocacy group representatives, and mental health board members, along with more than 1000 grant documents were qualitatively analyzed using content analysis to reveal three themes concerning how the participants experienced program implementation: invisibility, isolation, and inequity. Findings demonstrate the participants perceived that the grant program perpetuated inequities by neglecting to promote the program, advocate for clinicians of color, and coordinate isolated policy ecology systems. Strategies for future large-scale, system-wide mental health program implementation are provided.

Understanding quality improvement collaboratives through an implementation science lens

Quality improvement collaboratives (QICs) have long been used to facilitate group learning and implementation of evidence-based interventions (EBIs) in healthcare. However, few studies systematically describe implementation strategies linked to QIC success. To address this gap, we evaluated a QIC on colorectal cancer (CRC) screening in Federally Qualified Health Centers (FQHCs) by aligning standardized implementation strategies with collaborative activities and measuring implementation and effectiveness outcomes. In 2018, the American Cancer Society and North Carolina Community Health Center Association provided funding, in-person/virtual training, facilitation, and audit and feedback with the goal of building FQHC capacity to enact selected implementation strategies. The QIC evaluation plan included a pre-test/post-test single group design and mixed methods data collection. We assessed: 1) adoption, 2) engagement, 3) implementation of QI tools and CRC screening EBIs, and 4) changes in CRC screening rates. A post-collaborative focus group captured participants' perceptions of implementation strategies. Twenty-three percent of North Carolina FQHCs (9/40) participated in the collaborative. Health Center engagement was high although individual participation decreased over time. Teams completed all four QIC tools: aim statements, process maps, gap and root cause analysis, and Plan-Do-Study-Act cycles. FQHCs increased their uptake of evidence-based CRC screening interventions and rates increased 8.0% between 2017 and 2018. Focus group findings provided insights into participants' opinions regarding the feasibility and appropriateness of the implementation strategies and how they influenced outcomes. Results support the collaborative's positive impact on FQHC capacity to implement QI tools and EBIs to improve CRC screening rates.

Preaching to the Choir? Predictors of Engagement in a Community-Based Learning Collaborative

This study examined predictors of engagement among 283 professionals from 34 agencies participating in three community-based learning collaboratives (CBLCs) on trauma-focused cognitive-behavioral therapy (TF-CBT). Only 50.2% of participants completed the CBLC, primarily due to not attending consultation calls or completing training cases. While higher engagement was associated with being trauma-informed and using more of the TF-CBT components prior to the CBLC, most predictors were not significant, perhaps due to ceiling effects. Positive attitudes and high organizational support were not sufficient to ensure engagement. Future research using longitudinal measurement of a wider range of predictors is needed.

Factors Associated With School Nurses' Self-Efficacy in Provision of Asthma Care and Performance of Asthma Management Behaviors

Asthma is a chronic disease affecting nearly 6 million children in the United States and accounts for nearly 14 million missed school days. School nurses' performance of asthma management behaviors (AMBs) may reduce exacerbations, thereby decreasing emergency visits and hospitalizations and increasing attendance at school. Self-efficacy can have a positive effect on AMBs. More research is needed on the interplay between environmental factors in school nurses' work setting, self-efficacy in providing asthma care (hereafter "self-efficacy in asthma care"), and performance of AMBs. This study used a descriptive cross-sectional online survey design with practicing registered school nurses in Pennsylvania (N = 231). Data analysis included descriptive statistics, correlation tests, and multiple regression. In separate models, self-efficacy in asthma care and student-nurse ratio were significantly associated with performance of AMBs. Schools and school nurses need stronger efforts to strengthen self-efficacy in asthma care, with the goal of increasing nurses' performance of AMBs.

Implementation of the hub and spoke model for opioid use disorders in California: Rationale, design and anticipated impact

As part of the State Targeted Response to the opioid epidemic, California has adopted the Hub and Spoke model to expand access to medications for opioid use disorder, particularly buprenorphine, throughout the state. By aligning opioid treatment programs as hubs with primary care, office-based practitioners, and other health care settings as spokes, a broader treatment model can reach more people with opioid use disorder, improve access to medications for opioid use disorders, and decrease overdose deaths. Expanding access requires expanding knowledge and intensive implementation support of new practices. This paper describes the rationale, specific activities and anticipated impact of the implementation plan in California's Hub and Spoke system. Training and technical assistance are designed to: increase the number and capacity of waivered prescribers; enhance skills of prescribers and multidisciplinary teams; and create systems change. Activities include buprenorphine waiver trainings and provider support, a practice facilitator program, Project ECHO sessions, webinars, clinical skills trainings, and regional learning collaboratives. This overview highlights the steps California is taking to build treatment capacity to address the opioid epidemic.

Building community-clinical linkages to increase older adult physical activity: The PT-REFER trial protocol and participant baseline characteristics

Background

Physical activity is important for maintaining older adult health, but a majority of older adults are not meeting recommended physical activity levels. This paper describes the protocol and participant baseline characteristics for a trial (named "PT-REFER") to test an intervention focused on developing community-clinical linkages to increase older adult referrals from physical therapy clinics to an evidence-based group exercise program (Enhance®Fitness) (EF) offered by YMCA associations.

Methods

We designed a two-arm cluster-randomized controlled trial with YMCA associations. We conducted formative research with YMCA staff and physical therapists to inform intervention format and content. The primary outcome is the number of new participants enrolled in EF over the course of 30 months. We also collect process information on cost and implementation though structured surveys and semi-structured qualitative interviews.

Results

The PT-REFER intervention creates a learning collaborative for YMCA associations, which are tasked with implementing a number of capacity- and partnership-building activities over the course of seven months, and participating in monthly group technical assistance calls. We recruited 20 YMCA associations from 13 states. At baseline, the average number of EF sites per association was 3.9 and the monthly average number of new EF participants was 3.7.

Conclusions

This study will test an approach to increasing the capacity of YMCAs for conducting outreach to physical therapy clinics, and evaluate the factors that may influence its implementation. As a result, it has the potential to contribute to our understanding of how to develop viable and sustainable community-clinical linkages for older adult health.

Self-Regulation Approach to Training Child and Family Practitioners

Evidence-based psychotherapies or programs (EBPs) exist for most mental health disorders that occur in childhood; however, the majority of children with a mental health disorder do not receive such treatments. This research-practice gap has been attributed to a range of factors that complicate the delivery of EBPs in everyday practice. While most suggestions to bridge this gap have focused on how to develop EBPs that will have a better fit for the clinical settings in which they will ultimately be deployed, a useful adjunct is to enhance practitioners' capacity to flexibly deliver EBPs to manage these factors. We propose that the extent to which a practitioner is able to change their own behaviour in response to cues and information about the current needs of their clients, and do so while maintaining the integrity of an EBP, may be a function of practitioners' self-regulatory capacity. In this conceptual paper, we describe a model of self-regulation that can be applied to child and family practitioners. We argue that practitioners with greater self-regulatory capacity are more likely to take up EBPs, sustain their use of them and have superior outcomes with clients. We draw on our experience in disseminating a system of parenting support to illustrate how practitioners' self-regulatory capacity can be enhanced while simultaneously receiving training in an EBP. Advantages and disadvantages of a self-regulatory approach to training are discussed and directions for future research are offered.

Statewide implementation of child trauma-focused practices using the community-based learning collaborative model

A significant number of youth in the United States experience traumatic events that substantially increase the risk of physical and behavioral health problems across the life span. This public health concern warrants concerted efforts to promote trauma-informed, evidence-based practices that facilitate recovery. Although youth-focused trauma-specific treatments exist, determining effective ways to disseminate and implement these services-so that they are available, accessible, and sustainable-poses an ongoing challenge. This paper describes a comprehensive model for such implementation, the community-based learning collaborative (CBLC), developed as part of Project BEST, a four-phase statewide initiative to promote trauma-focused practices. The CBLC augments the learning collaborative model by including clinical and nonclinical (i.e., broker) professionals from multiple service organizations within a targeted community. CBLCs aim to build capacity for sustained implementation of trauma-focused practices by promoting interprofessional collaboration among those involved in the coordination and provision of these services. This paper describes the iterative development of the CBLC by examining participant completion data across the three completed phases of Project BEST (N = 13 CBLCs; 1,190 participants). Additionally, data from Project BEST's third phase (N = 6 CBLCs; 639 participants) were used to evaluate changes in the frequency of specific practices, pre- to post-CBLC, and post-CBLC perceived utility of CBLC components. High participant completion rates, significant increases in reported trauma-focused practices, and positive ratings of the CBLC's utility provisionally support the feasibility and efficacy of the model's final iteration. Implications for implementation and CBLC improvements are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Proposing a Mechanistic Model of Clinician Training and Consultation

To make evidence-based treatments deliverable, effective, and scalable in community settings, it is critical to develop a workforce that can deliver evidence-based treatments as designed with skill. However, the science and practice of clinician training and consultation lags behind other areas of implementation science. In this paper, we present the Longitudinal Education for Advancing Practice (LEAP) model designed to help span this gap. The LEAP model is a mechanistic model of clinician training and consultation that details how training inputs, training and consultation strategies, and mechanisms of learning influence training outcomes. We first describe the LEAP model and then discuss how key implications of the model can be used to develop effective training and consultation strategies.

Synchronizing Watches: The Challenge of Aligning Implementation Science and Public Systems

This special issue of Administration and Policy in Mental Health explores the complexities of the outer system context in implementation science research. In this commentary, we highlight areas of asynchrony between implementation science research and policy realities of public systems. Timing is a critical factor for many aspects of system-level implementation including when and how evidence-based practice initiatives are launched, short and inconsistent timeframes for funding and support, need for early indicators of success and demonstrating return on investment. Greater consideration for the timing that drives change in public systems will strengthen efforts to implement and sustain EBPs in community settings.

Use of Research Evidence and Implementation of Evidence-Based Practices in Youth-Serving Systems

Although the effectiveness of interventions for prevention and treatment of mental health and behavioral problems in abused and neglected youth is demonstrated through the accumulation of evidence through rigorous and systematic research, it is uncertain whether use of research evidence (URE) by child-serving systems leaders increases the likelihood of evidence- based practice (EBP) implementation and sustainment. Information on URE was collected from 151 directors and senior administrators of child welfare, mental health and juvenile justice systems in 40 California and 11 Ohio counties participating in an RCT of the use of community development teams (CDTs) to scale up implementation of Treatment Foster Care Oregon over a 3 year period (2010-12). Separate multivariate models were used to assess independent effects of evidence acquisition (input), evaluation (process), application (output), and URE in general (SIEU Total) on two measures of EBP implementation, highest stage reached and proportion of activities completed at pre-implementation, implementation and sustainment phases. Stage of implementation and proportion of activities completed in the implementation and sustainment phases were independently associated with acquisition of evidence and URE in general. Participation in CDTs was significantly associated with URE in general and acquisition of research evidence in particular. Implementation of EBPs for treatment of abused and neglected youth does appear to be associated with use of research evidence, especially during the later phases.