A mixed methods study was conducted to examine the implementation process of 26 urban school-based mental health clinics that took part in a training and implementation support program for an evidence-based school trauma intervention. Implementation process was observed using the Stages of Implementation Completion (SIC) measure. Qualitative interviews were conducted with clinic leaders in order to gain insight into clinic processes related to the SIC. Results showed that almost all of the clinics engaged in some activities related to pre-implementation (engagement, feasibility, and readiness), but only 31% of the sites formally started delivering the program to youth. Completing more pre-implementation activities, particularly those related to readiness, predicted program start-up. Qualitative analysis comparing those that implemented the program to those that did not revealed critical differences in decision-making processes, leadership strategies, and the presence of local champions for the program. This study documented the patterns of clinic behavior that occurs as part of large-scale training efforts, suggests some unique challenges that occur in schools, and highlights the importance of engaging in particular implementation activities (i.e., readiness planning, stakeholder consensus and planning meetings) as part of program start-up. Findings indicate that pre-implementation and readiness-related consultation should be employed as part of broad-scale implementation and training efforts.

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Background Sustainment is a desirable outcome of implementation, but its precise definition remains unclear, contributing to the difficulty of identifying a generalized rate of sustainment. Several studies and reviews on the topic differ on both definition and levels of analysis. Furthermore, methodological limitations might have influenced the results, including the unknown quality with which some interventions were delivered. The Universal Stages of Implementation Completion (UniSIC) is a standardized measurement tool that tracks the implementation process and milestone completion across a wide range of real-world implementations—this provides a unique opportunity to identify a generalized rate of sustainment. Methods UniSIC data was captured from the SIC website on 27 September 2020 and included data from all sites (n = 1778) that had been tracked to date. Data were restricted to sites that achieved competency in program delivery, and thus had a newly adopted program worthy of sustainment. Dates and indicator variables of implementation activities were combined to form two alternate definitions of sustainment: sustained (start-up) was achieved if sites continued to deliver services 2 years past their program start-up date; sustained (competent) was achieved if sites continued to deliver services 2 years past their competence and/or certification date. Of sites eligible for inclusion based on these definitions (N = 208), descriptive analyses were conducted to determine a rate of sustainment for all programs that successfully started a program. These definitions were also applied to a combined sample for a general rate of sustainment among all sites. Rates of competency among both a sample of sites that started up and a combined sample were also identified. Results The rate of competence was 58.5% and the rate of sustained (start-up) was 37.1%, while the rate of sustained (competent) was 25.1%. The rates of competence and sustainment among the combined samples were far lower: 15.6% for competence, 6.8% for sustained (start-up), and 4.4% for sustained (competent). Conclusions These identified rates of sustainment are accurate initial estimates of sustainment of community-based practices, or in general. Future research on rates of sustainment should carefully define measures of sustainment and be transparent about the real-world conditions on which analyses are centered.

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Limited evidence-based practices exist to address the unique treatment needs of families involved in the child welfare system with parental substance abuse. Specifically, parental opioid and methamphetamine abuse have increased over the last decade, with associated increases of families reported to the child welfare system. The Families Actively Improving Relationships (FAIR) program was developed to address the complexities of these families. Evidence-based strategies to address the interrelated needs of parents—including substance abuse and mental health treatment, parent skills training, and supportive case management to improve access to ancillary needs—are integrated in an intensive community outpatient program. This study examined the clinical effectiveness of FAIR when delivered in a Medicaid billable outpatient clinic. Parents (n = 99) were randomized either to the immediate FAIR condition or to the Waitlist (WL) condition, using a dynamic wait-listed design, with all parents provided the opportunity to eventually receive FAIR. Outcomes show statistically and clinically significant reductions in parental opioid and methamphetamine use, mental health symptoms, and parenting risk, and improvements in stability in parents receiving FAIR. Providing services to families who require travel in excess of 20 miles for sessions has challenging implications for program costs under a Medicaid structure. Study outcomes highlight the need for policies to support funding of intensive family-based programs.