System-Level Influences on the Sustainability of a Cognitive Therapy Program in a Community Behavioral Health Network
Abstract
Objective:
Methods:
Results:
Conclusions:
Methods
Setting and Context
Data Sources
Analysis
Results
Influence and examplesa | Interactions |
---|---|
Collaboration and communication | Facilitated program adaptation and evolution, planning and support, and evaluation |
DBHIDS administrator: Having someone on our staff [who] is dedicated to ensuring the coordination and collaboration of agencies, Penn, and DBHIDS has played a huge role in [the initiative’s] being successful]. | |
Penn administrator: The agencies really learn from each other. . . . [T]hey come early and stay late and are . . . chatting with each other about potential problems or questions. . . . And we find that the more senior agencies, like the ones that went through it more in the beginning, really have a lot of great tips and suggestions for the newer agencies because they’ve been through it, and they’ve kind of been in their shoes. I think that’s a great way to keep them connected and feeling like they’re part of a group as opposed to isolated agencies just doing CT work. | |
Agency administrator: We’ve had these arranged meetings between DBHIDS and administrators here, and of course the folks from Penn, to make sure we are doing things that make sense and making course corrections when necessary. | |
Alignment with sociopolitical influences and system priorities | Facilitated program adaptation and evolution; facilitated by intervention fit and flexibility, perceived benefit, and collaboration |
DBHIDS administrator: The [politics and] advocacies and community-based pressure to improve and enhance services for children certainly played a part in wanting to extend the Beck Initiative to [school settings and] other child providers. [Also] the mayor’s initiative around ending homelessness. . . . [T]hat wasn’t . . . initially a stated goal for the city in terms of behavioral health priority. So very quickly it became a priority in [the] behavioral health system in accord with the mayor’s initiative. So there’s another opportunity where political and “critical” need aligned with the opportunity to use the Beck Initiative. | |
DBHIDS administrator: Over time, the focus of the network has changed, and . . . it’s been important to be flexible and to go with those needs within the network and sort of [be] there as partners. I’m afraid that if we had stayed in that adult outpatient box, I don’t think [the BI] would still be where it is today. Maybe it would be, but not [at] such a broad level. It would have been more of an afterthought. I think for it to truly be an example for future and current evidence-based practices, . . . it’s been pivotal that it’s able to reach so many different levels of care and so many different diagnostic areas. There are other evidence-based practices that we are currently implementing or looking to implement that are not as broad as CT, and the question about sustaining them over time in the network has been brought up. They are more short term, like, “What are we going to do once the contract [for training] ends?” | |
Intervention flexibility | Facilitated alignment with sociopolitical influences, system needs, and program evolution; interacted with planning and technical support |
BI training consultant: The types of issues [we addressed] were issues where there had been work done with cognitive therapy to address those issues. Everything from anger and bipolar disorder and . . . significant anxiety. Certainly there was some depression, psychosis—and these were all areas where people had done work to develop [CT], so we were really just talking about how to apply interventions and conceptualize around those issues and across multiple issues as well. | |
Agency administrator: [The new BI program] followed the [initial] training, and about a year later we started that group [for a specific population]. [The BI training consultant] brought the material to us. She brought the concepts and reintroduced the group at the [agency name], and we were able to mold and shape the group to fit our specific program, and it’s been pretty successful ever since. | |
Program adaptation and evolution | Facilitated perceived benefit; facilitated by evaluation and perceived benefit, sociopolitical influences, intervention fit, and flexibility |
Penn training consultant: We have . . . a pretty fluid process where we were asking for lots of feedback from primarily the therapists during the training—lots of feedback about how is this fitting for you. How does this apply with somebody that you would work with . . . so . . . a lot of the adaptation happens in the training because it is a very bidirectional thing. It’s very conversation guided. I think that the therapists often initially looked surprised that [we] were asking. I think it’s not a typical experience for them in training, but [it’s] then ultimately received really well. Feedback that we receive . . . is that they really appreciate that we want to make sure that it is a fit for all of the realities of where they are. | |
Agency administrator: The Beck folks were very flexible. It’s terribly important to take this model and see how we can adapt it [here]. We first try to do the model as true as we can, but as time [goes] on to see how we can make it work so we can use it more effectively, more often here. | |
Evaluation and perceived benefit | Facilitated program adaptation and interaction; planning and support (financial); facilitated by communication and collaboration; program adaptation and evolution; planning and support (technical) |
BI training consultant: [Clients at the agency] . . . made some improvements. I think some people were really impressed with some of the improvements that they saw. Others I think it was only smaller gains, but in general I think people felt positive about what was happening. | |
DBHIDS administrator: From our standpoint the first measure of success would be in number of clinicians—number and diversity and the capacity building—[so] that we’re able to say, “we’re in this many agencies, we have this many clinicians, and they’re all on these levels of care.” The next chain of outcomes that we don’t have is . . . the critical outcomes with individuals. | |
DBHIDS administrator: It’s more anecdotal than I’d like, but [agency-level data are] from a mixture of sources and information. Some [come] from provider meetings that we have and some . . . from what was credentialing and what is now the Network Improvement and Accountability Collaborative reviews. | |
DBHIDS administrator: It would be very nice, for example, to see how many patients are actually being treated . . . and [it] also would be interesting to know what impact it has on the patient in terms of improvement. We have attempted to get some sense of that through giving BDIs, but there have been some administration problems in terms of that, so at this moment we don’t have really good data in terms of the patients. | |
Penn administrator: We keep running into problems in terms of getting statistical analyses [on DBHIDS client databases], and it has been a stumbling block for us. For a number of years we’ve been wanting more analyses, and it seems that they are understaffed and overextended. | |
DBHIDS administrator: I think we are learning a lot; I just think we need to be more systematic about documenting [what we learn] and then packaging it in such a way that it can be useful to other initiatives that we’re doing in the system. But I do think that we are learning a lot. I think that our provider world is benefiting from the training. I think that we are having an impact, but again I think we need to be able to document that. | |
Planning and support: technical assistance | Resulted from collaboration and communication, program adaptation, and evolution; affected by planning and financial support, evaluation, and perceived benefit |
DBHIDS administrator: What has helped . . . is that Penn has been going out and visiting each of the agencies every 6 to 8 weeks, sitting at the internal group, bringing some CT material, and just being there to keep the focus. | |
DBHIDS administrator: The majority of the issues that I see really have to do with how we handle the uncertainty of, that is, assuring the sustainability going forward, how we’re going to structure these things, how far out [we can] plan in terms of training, how we’re going to deal with issues of attrition and loss of capacity. | |
Agency administrator: Whenever we vocalize that someone feels stuck with a certain issue, [DBHIDS administrator and Penn personnel] have been really helpful in trying to put something together for us. | |
DBHIDS administrator: [Sometimes] I don’t know what we would have done without [the Web-based training]. It’s a really good way for people to get up to speed on the basics of CT to the point that they can join the internal group and be mentored [by previously trained clinicians]. | |
Planning and support: financial support | Affected by sociopolitical influences, evaluation and perceived benefit, and program adaptation and evolution |
DBHIDS administrator: As a department we’re unique in a city this size to have the county authority and funding and [be] the policy-setting entity also in control of the Medicaid funding. . . . We have a mission and can also ensure that the funding streams are available to support it. | |
DBHIDS administrator: There might be populations [for] the initiatives that we want to [reach] that we think will take several years . . . because it’s difficult to make those kinds of decisions [when funding decisions can be made only on a year-to-year basis]. . . . I think that’s one of the reasons why we had to take things in a more stepwise fashion . . . based on the finances. |
Influence | System administrators (N=3) | Penn administrators (N=4) | Training consultants (N=8) | Clinic administrators (N=9) | Total stakeholders who endorsed (N=24) |
---|---|---|---|---|---|
Collaboration and communication | 3 | 4 | 7 | 6 | 20 |
Alignment with sociopolitical influences and system priorities | 3 | 3 | 4 | 4 | 14 |
Intervention flexibility | 3 | 4 | 6 | 4 | 17 |
Program adaptation and evolution | 2 | 2 | 7 | 6 | 17 |
Evaluation and perceived benefit | 3 | 4 | 3 | 7 | 17 |
Planning and support | |||||
Technical assistance | 3 | 4 | 8 | 7 | 22 |
Financial support | 3 | 4 | 2 | 6 | 15 |
Collaboration and Communication
Sociopolitical Influences and Alignment With System and Agency Priorities
Intervention Fit and Flexibility
Program Adaptation and Evolution
Evaluation and Perceived Benefit
Planning and Support for Sustainability
Ongoing technical support and consultation.
Financial support.
Discussion
Conclusions
Acknowledgments
Footnotes
References
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Authors
Funding Information
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