Little is known about high-cost service users in the context of youth outpatient mental health, despite the fact that they account for a large proportion of overall mental healthcare expenditures. A nuanced understanding of these users is critical to develop and implement tailored services, as well as to inform relevant policies. This study aims to characterize high-cost service users by examining demographic factors, diagnoses, and service type use. Administrative service use data were extracted from a large County Department of Behavioral Health Services database. Latent profile analyses suggest a four-profile solution primarily distinguished by youth age and diagnostic complexity. Study findings have implications for defining high-cost service users and key targets for efforts aiming to improve outcomes for these youth.

Little is known about high-cost service users in the context of youth outpatient mental health, despite the fact that they account for a large proportion of overall mental healthcare expenditures. A nuanced understanding of these users is critical to develop and implement tailored services, as well as to inform relevant policies. This study aims to characterize high-cost service users by examining demographic factors, diagnoses, and service type use. Administrative service use data were extracted from a large County Department of Behavioral Health Services database. Latent profile analyses suggest a four-profile solution primarily distinguished by youth age and diagnostic complexity. Study findings have implications for defining high-cost service users and key targets for efforts aiming to improve outcomes for these youth.

Fidelity to intervention protocol is linked to best outcomes for individuals with autism spectrum disorder (ASD; see Boyd & Corley [Autism 5(4):430-441, 2001]; Pellecchia et al. [J Autism Dev Disord 45(9):2917-2927, 2015]); however, fidelity measurement tools that are both accurate and feasible for community use are often not available. In this paper we explore methods for validated simplification of fidelity assessment procedures toward the goal of increased use in clinical practice. Video recordings (n = 36) of therapists working with children with ASD were coded using three variations of fidelity assessment methodology (trial-by-trial, 5-point Likert Scale, and 3-point Likert Scale), and the results were compared for exact agreement, mastery criterion agreement, and overall reliability. The results indicated overall a very high percentage of exact agreement (mean 99.44%, range 94.4-100%) and excellent reliability (mean Krippendorff's alpha [Kα] 1.0) between the trial-by-trial and 5-point Likert Scale across all components; however, the 3-point method may be viewed as being the more feasible strategy within community programs.

The purpose of this study was to examine common and unique factors influencing implementation process for two evidence-based interventions for children with autism spectrum disorder (ASD) in mental health and education service contexts. This study prospectively collected qualitative data from intervention developers and research staff on the implementation process within the context of two separate ASD intervention effectiveness trials. Results reveal common and unique factors influencing implementation in both study contexts. Implementation leadership and provider attitudes and motivation emerge as key influences on implementation across systems. These findings provide promising targets for modular implementation interventions that can be leveraged within growing, large-scale translation efforts in usual care.

Background

Bridging factors are relational ties, formal arrangements, and processes that connect outer system and inner organizational contexts. They may be critical drivers of evidence-based practice (EBP) implementation and sustainment. Yet, the complex interplay between outer and inner contexts is often not considered. Bridging factors were recently defined in the updated Exploration, Preparation, Implementation, Sustainment (EPIS) framework. Further identification and specification of this construct will advance implementation models, measures, and methods. Our goal is to advance bridging factor research by identifying relevant dimensions and exemplifying these dimensions through illustrative case studies.

Methods

We used a multiple case study design. Each case (n = 10) represented different contexts, EBPs, and bridging factor types. Inclusion criteria were the presence of clearly distinguishable outer and inner contexts, identifiable bridging factor, sufficient information to describe how the bridging factor affected implementation, and variation from other cases. We used an iterative qualitative inquiry process to develop and refine a list of dimensions. Case data were entered into a matrix. Dimensions comprised the rows and case details comprised the columns. After a review of all cases, we collectively considered and independently coded each dimension as function or form.

Results

We drew upon the concepts of functions and forms, a distinction originally proposed in the complex health intervention literature. Function dimensions help define the bridging factor and illustrate its purpose as it relates to EBP implementation. Form dimensions describe the specific structures and activities that illustrate why and how the bridging factor has been customized to a local implementation experience. Function dimensions can help researchers and practitioners identify the presence and purpose of bridging factors, whereas form dimensions can help us understand how the bridging factor may be designed or modified to support EBP implementation in a specific context. We propose five function and three form bridging factor dimensions.

Conclusions

Bridging factors are described in many implementation models and studies, but without explicit reference or investigation. Bridging factors are an understudied and critical construct that requires further attention to facilitate implementation research and practice. We present specific recommendations for a bridging factors research agenda.

Classroom Pivotal Response Teaching (CPRT) is a naturalistic behavioral intervention for students with autism spectrum disorder (ASD) that was systematically adapted for teacher use. In this study, the authors evaluate outcomes of a large randomized trial training teachers (n = 126) to use CPRT. Training involved 12 hours of small group sessions and additional 1:1 coaching in each teacher’s classroom. Overall, CPRT fidelity was significantly higher at the end of the training year relative to the observation year (B = 0.24, p =.001) and teachers report using CPRT an average of 47 minutes per day. Moderator analyses indicate that training, teacher, and classroom- and school-level characteristics affected CPRT fidelity. Teachers report high overall satisfaction (M = 4.37, SD = 0.45; 1-5 Likert-type scale) and confidence in their ability to use CPRT with their students (M = 4.2, SD = 0.57). In this study, the authors indicate the acceptability and feasibility of the CPRT training protocol and adds to the limited number of school-based randomized controlled trials (RCTs) evaluating interventions for students with ASD.

Background

Effective implementation of evidence-based practices (EBPs) remains a significant challenge. Numerous existing models and frameworks identify key factors and processes to facilitate implementation. However, there is a need to better understand how individual models and frameworks are applied in research projects, how they can support the implementation process, and how they might advance implementation science. This systematic review examines and describes the research application of a widely used implementation framework, the Exploration, Preparation, Implementation, Sustainment (EPIS) framework.

Methods

A systematic literature review was performed to identify and evaluate the use of the EPIS framework in implementation efforts. Citation searches in PubMed, Scopus, PsycINFO, ERIC, Web of Science, Social Sciences Index, and Google Scholar databases were undertaken. Data extraction included the objective, language, country, setting, sector, EBP, study design, methodology, level(s) of data collection, unit(s) of analysis, use of EPIS (i.e., purpose), implementation factors and processes, EPIS stages, implementation strategy, implementation outcomes, and overall depth of EPIS use (rated on a 1-5 scale).

Results

In total, 762 full-text articles were screened by four reviewers, resulting in inclusion of 67 articles, representing 49 unique research projects. All included projects were conducted in public sector settings. The majority of projects (73%) investigated the implementation of a specific EBP. The majority of projects (90%) examined inner context factors, 57% examined outer context factors, 37% examined innovation factors, and 31% bridging factors (i.e., factors that cross or link the outer system and inner organizational context). On average, projects measured EPIS factors across two of the EPIS phases (M = 2.02), with the most frequent phase being Implementation (73%). On average, the overall depth of EPIS inclusion was moderate (2.8 out of 5).

Conclusion

This systematic review enumerated multiple settings and ways the EPIS framework has been applied in implementation research projects, and summarized promising characteristics and strengths of the framework, illustrated with examples. Recommendations for future use include more precise operationalization of factors, increased depth and breadth of application, development of aligned measures, and broadening of user networks. Additional resources supporting the operationalization of EPIS are available.

Naturalistic developmental behavioral interventions include an explicit focus on coaching parents to use therapy techniques in daily routines and are considered best practice for young children with autism. Unfortunately, these approaches are not widely used in community settings, possibly due to the clinical expertise and training required. This article presents the work of the Bond, Regulate, Interact, Develop, Guide, Engage (BRIDGE Collaborative), a multidisciplinary group of service providers (including speech-language pathologists), parents, funding agency representatives, and researchers dedicated to improving the lives of young children with autism spectrum disorder and their families. The group selected and adapted a parent coaching naturalistic developmental behavioral intervention specifically for use with toddlers and their families for community implementation. Lessons learned from the implementation process include the importance of therapist background knowledge, the complexity of working with parents of young children, and needed supports for those working closely with parents, including specific engagement strategies and the incorporation of reflective practice.

Background

Sustainment, an outcome indicating an intervention continues to be implemented over time, has been comparatively less studied than other phases of the implementation process. This may be because of methodological difficulties, funding cycles, and minimal attention to theories and measurement of sustainment. This review synthesizes the literature on sustainment measures, evaluates the qualities of each measure, and highlights the strengths and gaps in existing sustainment measures. Results of the review will inform recommendations for the development of a pragmatic, valid, and reliable measure of sustainment.

Methods

A narrative review of published sustainment outcome and sustainability measures (i.e., factors that influence sustainment) was conducted, including appraising measures in the Society of Implementation Research Collaboration (SIRC) instrument review project (IRP) and the Dissemination and Implementation Grid-Enabled Measures database initiative (GEM-D&I). The narrative review used a snowballing strategy by searching the reference sections of literature reviews and definitions of sustainability and sustainment. Measures used frequently and judged to be comprehensive and/or validated by a team of implementation scientists were extracted for analysis.

Results

Eleven measures were evaluated. Three of the included measures were found in the SIRC-IRP, three in the GEM-D&I database, (one measure was in both databases) and six were identified in our additional searches. Thirteen constructs relating to sustainment were coded from selected measures. Measures covered a range of determinants for sustainment (i.e., construct of sustainability) as well as constructs of sustainment as an outcome. Strengths of the measures included, development by expert panels knowledgeable about particular interventions, fields or contexts, and utility in specific scenarios. A number of limitations were found in the measures analyzed including inadequate assessment of psychometric characteristics, being overly intervention or context specific, being lengthy and/or complex, and focusing on outer context factors.

Conclusion

There is a lack of pragmatic and psychometrically sound measures of sustainment that can be completed by implementation stakeholders within inner context settings (e.g., frontline providers, supervisors).

Classroom pivotal response teaching (CPRT) is an evidence-based practice (EBP) adapted for classroom use. A recent effectiveness trial of CPRT involved training 98 special education classrooms in Southern California. The Exploration, Planning, Implementation, and Sustainment (EPIS) conceptual framework illustrates the impact of inner- and outer-context factors on implementation outcomes. This article evaluates how teacher factors (including attitudes toward EBP) and organizational factors (implementation climate and district support) influence training outcomes (fidelity of intervention, report of use, sustainment, and satisfaction). Teachers’ ratings of training quality were related to higher fidelity during their follow-up year, β =.34, t(78) = 2.97, p <.004, and rating of intervention ease of use was related to higher daily CPRT use. Teacher ratings on the appeal scale of the attitudes measure were associated with individual sustainment, β =.35, t(55) = 2.76, p <.01. Leader involvement at recruitment meetings, β =.35, t(48) = 2.58, p =.01, and provision of CPRT training space, β =.44, t(48) = 2.73, p <.01, were significantly related to school sustainment. Teachers’ overall attitudes toward the intervention were significantly related to satisfaction with CPRT training, β =.41, t(80) = 3.96, p <.01. This study makes important preliminary contributions to understanding the impact of inner-context implementation determinants of a classroom-based EBP for students with autism spectrum disorder.