Future Directions for the Implementation and

Journal of Clinical Child & Adolescent Psychology

ISSN: 1537-4416 (Print) 1537-4424 (Online) Journal homepage: http://www.tandfonline.com/loi/hcap20

Future Directions for the Implementation and Dissemination of Statewide DevelopmentalBehavioral Pediatric Integrated Health Care T. David Elkin, Dustin E. Sarver, Nina Wong Sarver, John Young & Susan Buttross To cite this article: T. David Elkin, Dustin E. Sarver, Nina Wong Sarver, John Young & Susan Buttross (2016): Future Directions for the Implementation and Dissemination of Statewide Developmental-Behavioral Pediatric Integrated Health Care, Journal of Clinical Child & Adolescent Psychology To link to this article: http://dx.doi.org/10.1080/15374416.2016.1152551

Published online: 21 May 2016.

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Date: 21 May 2016, At: 08:08

Journal of Clinical Child & Adolescent Psychology, 00(00), 1–12, 2016 © 2016 Taylor & Francis Group, LLC ISSN: 1537-4416 print/1537-4424 online DOI: 10.1080/15374416.2016.1152551

Future Directions for the Implementation and Dissemination of Statewide Developmental-Behavioral Pediatric Integrated Health Care T. David Elkin Department of Psychiatry and Human Behavior, University of Mississippi Medical Center

Dustin E. Sarver and Nina Wong Sarver Downloaded by [Dustin Sarver] at 08:08 21 May 2016

Department of Pediatrics, University of Mississippi Medical Center

John Young Department of Psychology, University of Mississippi

Susan Buttross Department of Pediatrics, University of Mississippi Medical Center

The integration of mental health and pediatric health care services has long been a goal for both research and practice. With the advent of federal policies developed to mandate clinical efficiency across the health care spectrum, this issue is becoming more salient. Applied literature on this topic is only recently emerging, however, and there are limited contextual examples to guide program development, research, and refinement. This article presents background information relevant to the development of such a program (the Center for Advancement of Youth). The cultural and organizational contexts for the project are discussed, with particular emphasis on models for cooperation among several institutions of varying size and scope. The implications for the future of tangible research in this area are also discussed, with attention to extending lessons learned to diverse settings motivated to integrate various aspects of health care service provision.

Urgent calls have been made to transform the national pediatric emotional, developmental, and behavioral health care system, particularly in terms of service integration with primary care (e.g., Blanchard, Gurka, & Blackman, 2006; Dougherty & Conway, 2008; Halfon, DuPlessis, & Inkelas, 2007; Smith et al., 2013). The Patient Protection and Affordable Care Act (Department of Health and Human Services, 2012) provided a recent strong catalyst for advancements in terms of integration given its emphasis on expanding and strengthening the role behavioral health plays in the primary care setting. Among the principal changes outlined in the ACA were coverage

Correspondence should be addressed to T. David Elkin, Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216. E-mail: [email protected]

expansion for uninsured populations, increased emphasis on preventative care, and incentives for primary medical care and behavioral health integration. This policy was put forth in an effort to improve patient care and treatment outcomes such that the population as a whole is healthier and services are delivered in the most efficient manner possible at the population level. Although there has been considerable political contention surrounding the cost, moral foundation, and likelihood of success of the ACA, the policy has been enacted into law for several years. As a result, health care policy and administration are rapidly changing, and this shifting landscape for health care provision affords the opportunity for new architectures of service delivery to emerge. The current article provides a description of the development of such a program (the Center for Advancement of Youth [CAY]) and provides

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background on the local environment in which it was established. Given the mandates of ACA, there has accordingly been an increase in scientific interest in defining effective models of health care service integration. This includes research concerning methods, practices, and strategies at the level of providers, patients/consumers, and the systems in which service provision occurs (Ader et al., 2015; Croft & Parish, 2013; Foy, Kelleher, & Laraque, 2010; Kolko et al., 2014; Vickers et al., 2013). Many of these studies have focused on burgeoning methods of screening or physician education programs to facilitate coarse identification of cases eligible for referral to separate mental health services (e.g., Asarnow et al., 2005; J. D. Brown & Wissow, 2012). Notably, though, there is a paucity of data for even these broad models of screening and integration in pediatric populations (Archer et al., 2012; Asarnow, Rozenman, Wiblin, & Zeltzer, 2015; Kuehn, 2011). A recent meta-analysis conducted in this area identified only 31 randomized controlled studies examining integration of behavioral and primary health care in children and adolescents (Asarnow et al., 2015), compared to more than 70 trials examining the same in adults (Woltmann et al., 2012). Further, the vast majority of these studies focused on a specific, narrowly defined dimension of mental health (e.g., depressive symptoms) and examined the effects of service integration unidirectionally in terms of impact on behavioral health only. Despite the narrow focus of extant studies, the relative utility of these approaches on enhancing treatment of identifiable psychiatric symptoms was apparent with moderatesized overall effects (Asarnow et al., 2015). In addition, in a limited subset of studies focused on medical improvements as a function of integrated behavioral care, similar results have been notable (Nansel, Iannotti, & Liu, 2012; Woltmann et al., 2012). Contemporary Models to Health Care Service Integration A synthesis of what is known about integrated service delivery models indicates that the implementation structure routinely differs according to a variety of influences. These include individual practice or agency needs, available resources, target populations and/or settings, and provider characteristics and responsibilities (Wissow et al., 2008). With respect to variation in these and other provider, patient, and system characteristics, primary medical-behavioral health care delivery has been described as falling along a continuum of integration (Ader et al., 2015; Kolko & Perrin, 2014). Broadly speaking, integrated service organizations can be categorized along three dimensional constructs: the degree to which they are coordinated (e.g., phone/webbased consultation with specialist provider; reciprocal referral system between organizations), colocated (e.g., residing at the same facility; nearby offices in the same city), and

collaborative (e.g., multidisciplinary teams; managing care coordinators). These constructs are reflected in the language of the ACA, as well as published descriptions of other service delivery systems models such as the patientcentered medical home (Kilo & Wasson, 2010; Strange et al., 2010). Although fully integrated practices (i.e., those that are measurably high on all three dimensions listed) are considered ideal, it is important to recognize that each model also has its unique advantages and disadvantages (see Ader, 2015, for a thorough discussion). Such organizations are also rare given the barriers to effective communication, coordination, and administration of allied professions. In addition, accessibility of expertise may be limited in many areas, which introduces another barrier to effective integration, particularly in rural areas (elaborated next). Advances in telehealth technology and policy are quickly eroding barriers to access, however, and demonstration of effective service provision via these communication modalities is beginning to emerge (e.g., Comer et al., 2014; Gladstone et al., 2014; Jones et al., 2014; Myers, Stoep, Zhou, McCarty, & Katon, 2015). In addition, methods of evidence-based screening via self-report instruments are becoming more widely disseminated, and many tools identified for this purpose are freely available (Beidas et al., 2015). These can be adapted to integrated environments with consideration of physicians and/or multidisciplinary teams as end users, and used as the foundation for early identification of social, emotional, or behavioral problems (Mash & Hunsley, 2005; Youngstrom, 2013). Such child screening in integrated environments is imperative given that many adult and chronic illness conditions are traced back to childhood, and successful identification may help mitigate negative consequences. Several specific guidelines for this purpose already exist with reference to pediatric settings, including for anxiety (Wren, Bridge, & Birmaher, 2004), attentiondeficit/hyperactivity disorder (R. T. Brown et al., 2001), autism (Filipek et al., 2000), and depression (Zuckerbrot, Cheung, Jensen, Stein, & Laraque, 2007). Indeed, implementing routine screening protocols in colocated practices has been shown to have demonstrable benefits in terms of service efficiency and outcome (Hacker et al., 2015).

CURRENT CHALLENGES TO INTEGRATED SYSTEMS CHANGE Despite nationally recognized calls for reform of pediatric health care systems and burgeoning research on models and procedures, the uptake of these messages have been slow to produce meaningful clinical- or system-level changes (Kelleher & Stevens, 2009). The pace of this change can be attributed to multiple system, organizational, and individual-level barriers facing successful adoption,

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dissemination, and implementation of innovative health care models in practice (Barry & Huskamp, 2011; Herschell et al., 2010). Economic and financial factors are commonly cited as the major impediment to the development, implementation, and sustainability of integrated pediatric primary care programs (Langford, Flynn-Khan, English, Grimm, & Taylor, 2012; Scheirer & Dearing, 2011; Stancin & Perrin, 2014). For example, organizational and administrative leaders routinely attribute the termination of treatment implementation practices to funding difficulties, even when they perceive a cost-benefit of services for the patient (Scheirer & Dearing, 2011). This is a complex, multifaceted problem that may involve differential considerations of various levels of administration, real budgetary constraints, and temporally discounted valuation of future system or patient benefits in comparison to current financial expenditures (e.g., Raineri & Rachlin, 1993; Thaler, 2015). In addition, barriers to change exist in that the most common contemporary models of psychiatric integration have focused primarily on stand-alone assessment through telephone consultation (Aupont et al., 2013) and mental health assessment skills training for pediatricians (Asarnow et al., 2005; J. D. Brown & Wissow, 2012). Although this may promote service accessibility and focused referral in some cases, particularly when facilitated through telehealth models (Jones, 2014; Shore, Brooks, Savin, Mason, & Libby, 2007), these methods are time intensive, costly, problematic with regard to patient surveillance and monitoring, and typically offer limited opportunities for data collection. They also do not typically facilitate institutional integration along dimensions of colocation or collaboration, given that services are segmented and do not necessarily emphasize incentives for reciprocal communication or multidisciplinary planning. As a consequence of this fragmentation, many families thus rely on their primary care providers (Blanchard et al., 2006) or schools (Atkins et al., 2006; Rones & Hoagwood, 2000) for questions or assistance regarding the mental health of their children. These venues may provide useful points of contact but can also contribute to barriers for families who do not understand the intricacies of such systems. Policies are often unclear, and different specialists or fields of service providers operate in largely independent fashion. The ACA (Department of Health and Human Services, 2012) contains language to this effect, as well as federal mandates to increase health care efficiency by facilitating greater service integration amongst public institutions (i.e., the “no wrong door” approach to care coordination). Unfortunately, this policy has thus far done little to diminish the fragmented nature of health care services provision (Barry & Huskamp, 2011), and providers across disciplines may be slow to adopt new approaches or integrated models formed on this basis. As a result, families continue to encounter redundant or unnecessary services, inefficient service delivery, extended delays until initial

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visits, and visits that fail to provide appropriate clinical assessment (Soares, Baum, & Frick, 2015). The end result is that the contexts in which youth most frequently present for help (i.e., in primary care settings) with their mental health concerns are disconnected, uncoordinated, and ultimately inaccessible for many families. This contributes to exacerbation of both physical and mental health issues (Chan, Zhan, & Homer, 2002; Merikangas et al., 2011; Prince et al., 2007; Reilly & Kelly, 2011; Simon, VonKorff, & Barlow, 1995) as well as higher utilization costs due to greater complexity of cases and longer treatment duration (Gurney, McPheeters, & Davis, 2006; T. L. Johnson et al., 2015). A final barrier to service integration is accessibility of expertise in specific areas of clinical practice. This is often inherent in rural areas, particularly Southern states that are among the most rural areas in the nation. For instance, the numbers of psychologists and behavioral health providers per capita in Alabama, Louisiana, and Mississippi are much lower than the rest of the country (Ellis, Konrad, Thomas, & Morrissey, 2009; Miller, Petterson, Burke, Phillips, & Green, 2014). Likewise, access to behavioral specialists in the medical profession (psychiatrists and developmentalbehavioral pediatricians) is comparatively scarce in these areas, which contributes to unmet mental health needs (Thomas, Ellis, Konrad, Holzer, & Morrissey, 2009). Geographic disparity in the professional workforce takes on additional importance in the context of the shortage of medical and mental health professionals available to meet the high prevalence rates of youth behavioral health problems. In particular, children and families seeking to present to mental health professionals specifically will likely encounter barriers, including limitations in terms of availability and distance from their homes (Costello, He, Sampson, Kessler, & Merikangas, 2014).

LOCAL CONTEXT AND PROCESS DEVELOPMENT Mississippi, the geographical context for the innovative service delivery program to be described, exemplifies the barriers just described. The state is primarily composed of rural communities, many of which are extremely low income. According to the most recent census data, 22.7% of Mississippi’s citizens live in poverty, which is approximately 50% higher than the national average of 15.4% (U.S. Census Bureau, 2015). As is often the case in economically disadvantaged areas, the state also suffers a dearth of available medical services, particularly in its rural locations. The University of Mississippi Medical Center (UMMC) in Jackson comprises the state’s only academic medical center and children’s hospital, and thus serves as a centralized provider to a wide catchment area. Children and families present from all 82 counties and frequently have mental health concerns; however, it is rarely these specific

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conditions that lead them to travel long distances to access services, and the base rate of psychiatric symptoms across hospital programs is unknown. An epidemiological perspective would suggest that this frequency is substantial (Centers for Disease Control and Prevention, 2013; Costello, Mustillo, Erklani, Keeler, & Angold, 2003; Kessler et al., 2012), although limited communication between providers and programs within UMMC yields barriers to study. Similar to silos of health care evident in national trends, programs at UMMC lack consistent integration or a programmatic focus on holistic health. Establishing a more multidimensional process for integrated care in this system was made difficult for a number of reasons. As with many large health care facilities, there are numerous moving parts with limited connection between departments. The system also lacked sufficient resources to coordinate all mental health practitioners providing care. Developmental-behavioral health services were historically housed in the Department of Pediatrics, under the Division of Child Development, where developmental pediatricians, psychologists and behavioral interventionists practiced in a typical multi-disciplinary setting. Separate from that was the Division of Child Psychiatry, housed in the Department of Psychiatry with child psychiatrists, psychologists and behavioral therapists. Historically, the two operated in separate silos and with little communication between the departments, often resulting in duplication of services. This manner of practice engendered confusion of primary care providers and often led them to question which group was appropriate to consult. Furthermore, some providers simply consulted with both, leading to a waste of time and resources. In the era of the ACA and its increasing emphasis on health care integration and efficiency, it became apparent that this process of fragmented, nonsystematic services was untenable. Discussions of how to improve procedures began to occur among UMMC administrators in both mental health and medicine, with a particular emphasis on what resources would be necessary to facilitate changes. The solution that was ultimately developed was to bring pediatric medical and psychological services together under a single administrative umbrella to allow seamless assessment at any point of entry into the child/adolescent health care system. In turn, this integrated, multidisciplinary entity could perpetuate systematic referral to other services as necessary. The initial conceptualization of this model, along with previous demonstrations of the complexity of establishing systems of care (e.g., Bickman, 1996; Weisz, Han, & Valeri, 1997), provided insight into the monumental nature of such a task. Although there were numerous issues and anticipated barriers, the overarching concerns evident in the first attempt to detail plans for integration could be framed in terms of the two following specific challenges. The first involved financing of new administrative structures and methods of clinical interaction. Decades of

specialty providers developing practice parameters in silos meant that rapid changes would require significant resources to institute and reinforce. Put differently, it was realized early on that program integration would be more akin to new program development than reformulation and would need to be funded as such. This challenge was ultimately met by cooperation with Mississippi’s Division of Medicaid, who had a vested interest in improving efficiency and effectiveness of child and adolescent services. Approximately half of youth seen at UMMC are covered by Medicaid or CHIP programs, and thus any improvements to their services resulted in improvements to Medicaid’s operating costs, efficiency, and treatment outcomes. Initial startup funding of $3 million was provided to establish CAY (which operates under the direction of the first and last authors) at UMMC. The purpose of these funds was to develop an innovative system of integrated health care that would address youths’ medical and emotional-behavioral needs in a parsimonious fashion.1 Once funding was secured the second challenge to effective, efficient service integration became more salient. Namely, who was going to provide outpatient mental health services for youth identified as needing them? UMMC’s current system did not have the capacity to deliver the volume of services to meet the demand. Additionally, there was a need for a formal process that would route patients to needed resources after their evaluation. Thus, another innovative solution became necessary to solve this capacity problem, which prompted consideration of contracting a private partner for outpatient treatment. This process was informed by both methods for integrated care and public/private partnership (Chorpita & Mueller, 2008; Stancin & Perrin, 2015) and was viewed as the first step to establishing a sustainable model focused on integrated care and ensuring that every family accessing the system would get to exactly the right place in order to treat their needs. The agency selected as the most viable source of providing a sufficient volume of outpatient treatment was Mississippi Children’s Home Services (MCHS). This nonprofit, private organization has a 100-plus-year history of providing social and emotional services and supports to Mississippi’s children and families. It began as an adoption facility and expanded to include a wide array of services along a stepped continuum of care, from long-term psychiatric residential treatment to school-based counseling. Many of the agency’s services were already supported by Medicaid, and they had years of experience working on funded innovation projects in that context (e.g., Young, Plotner, Damon, & Hight, 2008). Their long history of service provision in the state also meant that they had 1

A forthcoming article will discuss the process of cooperation between the administrators, providers, and public payer system that led to this allocation of funds, but further detail is beyond the scope of the current article.

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relationships with many communities, as well as physical office space in numerous locations. Collectively, the cooperation of CAY and MCHS (as funded through Medicaid) was formally termed the Mississippi Children’s Collaborative. The goals of this Collaborative, qualitative description of its initial progress, and implications for future directions in statewide behavioral health care service provision are detailed next. Throughout this description the reader is encouraged to keep in mind that this is a work in progress and was designed to be deliberately (and quickly) flexible such that the system was rapidly responsive to feedback from all sources. It was also conceived of with attention to developing a general process that could be used to create similar programs in other places. All elements of the system have been constructed to foster program evaluation for these purposes, the data from which are intended to be sources of future study. Goal 1: Establish and Enhance Efficient, Multidisciplinary Care The first goal of the Children’s Collaboration was to improve interdepartmental cooperation and restructure the system of care within the hospital. This was informed by many sources, including the mandates of the ACA (Department of Health and Human Services, 2012), recent national trends toward medical home models (e.g., Stewart et al., 2010), professional pediatrics’ call for basic mental health screening as a standard part of practice (American Academy of Pediatrics, 2010; Asarnow et al., 2015), and local need established by aggregated data from clinical practice and program evaluation (e.g., Daleiden & Chorpita, 2005). The initiative to integrate care necessarily required multidisciplinary cooperation in establishing clinical and administrative procedures. The first and last authors (a psychologist and developmentalbehavioral pediatrician, respectively) worked to develop a developmental-behavioral triage system as the cornerstone of clinical practice for the Collaborative network. These assessments are provided by dyadic teams consisting of a developmental pediatrician (MD) and either a psychologist (PhD) or master’s-level behavioral specialist. This model is effectively an extreme version of interdisciplinary colocation (Stancin & Perrin, 2014). It is designed to contribute to efficiency, engagement, and less burden on families, as well as the opportunity for providers to quickly develop a multidisciplinary case conceptualization and service plan. This streamlined process thus affords much more rapidity of response than the previous external method of psychological/psychiatric consultation. It also allows referrals for additional coordinated services to happen immediately, thus increasing the likelihood that families will follow through with recommendations and will encounter fewer barriers. At this point in the Collaborative’s development, some general trends can be noted. Approximately 5% of cases

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seen for dyadic intake are determined to need no further services. Assistance is ubiquitously provided to the 95% of families that require additional behavioral and/or medical care from an external source such that they understand the reasons for referral, process of engaging another provider, and the utility of sharing information gathered during their dyadic assessment with their pediatrician. Measurably, 100% of families referred have made appointments for follow-up within 48 hr, with most behavioral health appointments being arranged before departing the clinic. Evidence for the importance of care coordination in promoting follow-through is accumulating rapidly (Silverstein et al., 2015; Turchi et al., 2014), and it is emphasized as a central aspect of the Collaborative’s system development. In addition, measurement of concrete behaviors related to this construct are tracked through program evaluation efforts, including engagement, treatment adherence, early dropout rate, and appointment efficiency. Although many of these variables require longitudinal and/or deferred measurement, the process also incorporates proximal measures based on methods of factory analytics (e.g., Huson & Nanda, 1995; Miltenberg, 1989) at the initial assessment (i.e., wait times, length of appointment, time spent completing measurements, etc.). Each aspect of concrete data collected can serve as a decision-making tool for immediate system/process improvement, as well as later covariates for clinical service evaluation and formal scientific research. Goal 2: Community-Based Care With the Fewest Possible Barriers to Accessibility The goal of seamless integration between services required a strong partnership between UMMC and MCHS, which in turn required initial commitment from both institutions’ leadership and formal contracts to launch. Beyond launch, this arrangement also necessitated system-wide collaboration and communication in order to function. One method of sustaining interagency communication was to establish several oversight committees empowered to make decisions that affect the Collaborative as a whole. These committees include an external advisory board that comprises the first and last author of this article, the director of the Mississippi Division of Medicaid, community health care providers (e.g., pediatricians, psychologists), and community leaders who are unaffiliated with health care per se. Similarly, an internal advisory board at UMMC was created for additional accountability and consists of administrative leaders across different departments (including pediatrics, psychiatry, legal, fiscal, and hospital-level administration). These advisory boards meet quarterly to establish and review policies as informed by relevant stakeholders throughout the system. In addition, separate committees with equal membership from UMMC and MCHS were established to review clinical procedures and research/program evaluation. Both are focused on making real-time use of observations in

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suggesting revisions of policies and procedures to the internal and external advisory boards pursuant the goal of truly integrated, efficient health care service provision. The clinically focused committee (Clinical Council; led by the third author) meets monthly to promote integrated care and address patient-related interagency operations. Members of the Council include directors of operations/ program development, care coordinators, and staff from both UMMC and MCHS. The Council focuses on establishing and enhancing daily operations that directly influence patient care, with an emphasis on effective communication between sites. For example, in the earliest stages of the Collaborative’s clinical services, this committee determined that referrals for outpatient services made via fax or phone were not working as intended. This led to inefficiency and confusion, and precipitated wasted time attempting to get clinically relevant information from one agency to another. As a consequence, the committee strongly advocated that this system be made electronic and automatic such that any individual flagged for outpatient treatment referral in UMMC/CAY’s medical record would immediately become visible in MCHS’s software. The technical process necessary for this to occur was much more difficult than initially imagined, particularly considering the burden of communication between disparate records softwares (Epic at UMMC and Evolv at MCHS), need to maintain HIPAA-compliance, and issues related to consent upon initial assessment. The collective resources of the group were able to address these issues, however, and Collaborative startup funds were available to pay for solutions to technological barriers. The end result was an instantaneous, seamless system of referral and review that now enables much faster appointment times for children and families served. In addition, the clinical committee provides oversight and guidance to ensure that available services are evidence-based. This group is responsible for not only identifying standards and providing practice guidelines related to patient care but also monitoring trends in treatment outcomes, engagement, and satisfaction to inform service delivery. The research committee serves a similar function as the clinical committee but focuses more on aggregated data to inform policy decisions at an administrative or procedural level. Formal methods of program evaluation are implemented in routine processes to ensure adherence to the Collaborative’s procedural guidelines. This includes several reports that are conducted monthly or quarterly (e.g., treatment outcome for all current and recently discharged cases in a 3-month period), as well as nominated topics. This process of nomination can be from any member of the Collaborative system and can focus on clinical, administrative, or procedural issues. In effect, this creates an opendoor policy for system improvement based on the observation of all members of the network by leveraging capabilities for research from the Collaborative’s academic contingent. Although somewhat uncommon in the context

of clinical care (let alone multi-institutional, multidisciplinary, integrated care), this approach to research and quality improvement was derived from a community-based participatory research framework (e.g., Wells, Miranda, Bruce, Alegria, & Wallerstein, 2004) and attempts to engender global strategies of multidirectional communication to improve the system as a whole. Finally, Medicaid funding authorities also review patient care and fiscal reports quarterly. This is viewed as critical not only for resource management but also from the perspective of system sustainability. If this integrated method of medical-behavioral service delivery is to become a model for future program development in different geographical, cultural, and fiscal contexts, then it must be conceived, designed, implemented, and refined with attention to costs (given the primacy of fiscal resources in determining program adoption and longevity). Further, previous, wide-scale research in integrated systems of care has produced limited evidence for effectiveness in comparison to services administered as usual, albeit at measurably higher cost (e.g., Bickman, Lambert, Andrade, & Penaloza, 2000). The need to carefully, appropriately, objectively examine tangible costs and specific clinical practices from onset was thus salient when this project began and was informed by previous criticisms of research methods and program development strategies in this area (e.g., Weisz et al., 1997). These economic data were also viewed as important in terms of their potential contribution to the field, given the relative paucity of representation in research literature (particularly randomized trials funded by research grants). Although some individual “branded” therapeutic approaches advance data concerning cost effectiveness (most notably Multisystemic Therapy; e.g., Henggeler, 2011; Sheidow et al., 2004; Wagner, Borduin, Sawyer, & Dopp, 2014), a focus on administrative costs necessary to establish largescale evidence-based service programs is largely absent from the broader community mental health literature.

Goal 3: Evidence-Based Services in Private Provider Network The Children’s Collaborative was intentionally formed as a private provider network for many reasons, not least of which were issues of capacity and scale. A large hospitalbased network does not typically have mobile mental health teams or infrastructure at numerous locations, whereas a private provider network has the flexibility to more easily establish such services. Alternatively, a private provider group rarely has access to the most contemporary science concerning clinical strategies and outcomes, particularly in comparison to an academic medical center with researchfocused personnel. A formal model for collaboration and cooperation between organizations, however, allows specialized resources from each institution to be pooled and a high

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standard of systematic evidence-based service provision throughout the system to be realized. In the case of the Collaborative, there was a need for services to be manualized but also adaptable to complex, comorbid cases with a high potential for multiple social stressors and/or resource deficiencies. Fortunately, contemporary science provided reference to a well-understood approach that has been thoroughly studied in the widely disseminated MacArthur Foundation Child Systems and Treatment Enhancement Projects (e.g., Chorpita et al., 2013; Schoenwald, Kelleher, Weisz, & the Research Network on Youth Mental Health, 2008; Weisz et al., 2012). Concisely, this broad-scale effectiveness trial indicated that it was possible to train community clinicians in flexible evidence-based services such that their clients exhibited significantly better treatment outcomes in comparison to treatment as usual. This approach involved formal, intensive training on modular manualized treatment (i.e., the Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems; Chorpita & Weisz, 2009). Thus, a method of standardizing treatment that had demonstrable effectiveness in an applied setting appeared ideal for the Collaborative’s clinical and administrative needs. As a consequence, all outpatient clinicians at MCHS were certified through PracticeWise (www.practicewise. com), the commercial entity founded on concepts just outlined, and supported by data from the MacArthur Research Network on Youth Mental Health (www.macfound.org/net works/research-network-on-youth-mental-health-care/). PracticeWise provides structured training for novitiate therapists and supervisors, as well as access to a diverse array of web-based tools for clinical supervision and consultation to facilitate delivery of evidence-based techniques. This system, collectively referred to as the Managing and Adapting Practice system (MAP), provides a flexible method for integrating evidence-based services into multiple contexts (e.g., Bruns et al., 2014; Southam-Gerow et al., 2014). Training includes an intensive, in-person course as well as longer term follow-up consultation and official certification, all of which are consistent with the most common strategies to disseminate evidence-based behavioral treatments (McHugh & Barlow, 2010). Last, the MAP system provided a way to evaluate treatment fidelity and associated implementation outcomes (i.e., client receipt, enactment, and patient outcomes). Much of this tracking is accomplished through the use of a clinical dashboard, which is a central tool in guiding case formulation, treatment techniques utilized, and client progress (Chorpita and Daleiden, 2009; Chorpita, Bernstein, Daleiden, & the Research Network on Youth Mental Health, 2008). In addition to formal certification as MAP therapists, another initiative of the Collaborative advisory committees was to facilitate ongoing training and consultation for evidence-based clinical services. This included providing

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resources for rehearsal and refinement of PracticeWise modular content, training clinical case conceptualization, and establishing a system of evidence-based assessment. Prior to service rollout, the Collaborative made the conscious decision to invest resources in a half day of therapist time each week being dedicated to these activities. This typically includes a clinical consultation group (led by the fourth author) to discuss any and all aspects of practice from an evidentiary perspective. Role-play activities and group discussion of which techniques are most difficult to conduct in context are emphasized. In addition, interactive didactic trainings on models of evidence-based services (e.g., Chorpita, Daleiden, & Weisz, 2005a, 2005b; Mash & Hunsley, 2005) are common, as are presentations designed to disseminate research findings on topics nominated by clinicians. The Collaborative also structured clinical services to rely heavily on a system of standardized measurement using evidence-based assessment strategies. These include psychometrically sound instruments assessing symptoms from a caretaker, youth, clinician, and teacher perspective, most of which are freely available. In addition, all clinicians receive training and support for implementation of structured clinical interviews at intake (i.e., the Child Interview for Psychiatric Syndromes; Weller, Weller, Fristad, Rooney, & Schecter, 2000). The presence of weekly clinical meetings with a researcher also affords the ability for clinicians to ask questions about measurement of symptoms not covered in the standard battery and thus track outcomes in a potentially limitless number of domains. Although spatial constraints preclude a detailed listing of all instruments utilized in this context,2 the take-home point is that heavy investment of resources and reciprocal exchange between clinicians and researchers enables a thorough, evidentiary approach to services from initial assessment to discharge (Lyon et al., 2011). This is consistent with the goals of disseminating science to practice environments (see Southam-Gerow & Dorsey, 2014, for the introduction to a special issue of this journal on this topic) and the accumulating findings concerning optimal methods of training (Beidas & Kendall, 2010; Rakovshik & McManus, 2010) and sustainability of practices implemented in applied environments (Bond et al., 2014).

Goal 4: Economic Sustainability Another key goal of the Collaborative as it continues to develop is economic sustainability. Funding from and cooperation with the Division of Medicaid have established a unique context for program development, in that Collaborative organizations are free from the burden of Please contact the first author for a comprehensive list of instrumentation if interested. 2

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startup costs. They are thus strongly incentivized to engage in Collaborative efforts, given increased patient volume and the opportunity to extend and/or refine their current service offerings. The value of this context for startup cannot be overstated, as it ameliorates one of the most commonly cited reasons that most attempts to disseminate evidence-based services in applied contexts fail (i.e., initial fiscal expenditures). This innovative approach is unlikely to be replicated across all other settings, however, given the relatively complex nature of tasks involved and already limited funds for existing medical/mental health care services. In addition, startup funding does nothing to ensure successful perpetuation of services in the long-term, which can only be realized if shown to be cost effective. As previously outlined, there are several other resource expenditures beyond the innovative startup model that could be difficult for the typical system to access due to reasons of cost and/or accessibility. Connection to established systems of care, development of technological solutions to clinical or administrative problems, and university-grade consultants all require connections and money, both of which may be in short supply in many service organizations. As a consequence, the Collaborative is working to quantify costs associated with all elements of program design and ongoing service implementation, with the intention to understand which aspects are most easily scalable in other settings. Eventual computation of costs of services rendered will be from the perspective of the ratio between funds expended and treatment outcome. Funds expended will include a careful accounting not only of direct service reimbursement but of all other resources necessary to facilitate ongoing evidence-based service in applied settings. To the degree significant improvement is notable in comparison to treatment as usual, it will be possible to assign econometric value to the investment of resources in training, assessment, and program evaluation. For the program to be successfully maintained and/or proliferated in other venues, this value must be demonstrably higher than a similar analysis of treatment as usual. It should be noted that these analyses are being designed and conducted by specialized economic health care consultants, whose costs are also figured into the model. In addition, UMMC/CAY’s connection to Mississippi’s Division of Medicaid has enabled numerous advantages for ensuring sustainability, including access to their large data sets on health care utilization trends in the state. This has precipitated awareness of areas that they have identified as inefficient and/or ineffective, which has stimulated tremendous generation of ideas and studies to improve procedures. The organization of the Collaborative as deliberately flexible and responsive to these issues effectively creates a realtime innovation lab to conduct small-scale tests of solutions to identifiable system problems. The potential for successful demonstrations to save money in the future is enormous, particularly when solutions can be examined as short pilot

studies with very low costs prior to attempting system-wide implementation. Working as part of a coordinated, colocated, connected network with Medicaid as one of the members has also fostered discussion of innovations in terms of service reimbursement. For example, it was noted that overall medical expenditures for Medicaid-covered children diagnosed with attention-deficit/hyperactivity disorder were higher across all categories when compared to their peers (with or without other psychiatric conditions). A review of procedures indicated that the process of requesting authorization for comprehensive evaluation of ADHD symptoms was languid and complex. This may have contributed to the observed trend of most providers obviating assessment in favor of skipping immediately to treatment (principally rendered through stimulant medication; Visser et al., 2015). Discussions of the potential cost savings on treatment through appropriate assessment beforehand (assuming removal of false-positive cases), has led to the potential to revise the process for testing in the system. This is but one salient example of economic benefit from close coordination among payers, administrators, and clinicians, and it is meant to engender awareness of the possibilities of these relationships in the context of integrated care. Finally, economic sustainability requires the ability to scale solutions as necessary, including facilitations of a wider number and type of partnerships. It is intended that the startup phase of the Collaborative establish processes through which additional provider organizations can be brought into the group, including those with specialized, scarce, or otherwise high-demand expertise. For example, in Mississippi this includes neuropsychological assessment, specialists in autism spectrum disorders, and health psychologists emphasizing prevention/treatment of obesity. This openinnovation framework would allow individual or institutional membership, including at the level of third-party payers. To the degree that these connections are productive, it will be possible to more rapidly and thoroughly diffuse effective policies and procedures throughout multiple systems.

FUTURE DIRECTIONS The Children’s Collaborative initiative is still in its infancy and can be considered something of a disruptive innovation (Christensen, 2013). If this model of integrated behavioral and medical care is to be successful, there are several important considerations for the future. First and foremost will be the ability of the disparate membership to acquire meaningful clinical, administrative, and fiscal data useful for research. At a program evaluation level this has been incorporated as a specific part of planning from onset, and provisions have also been made to ensure close connection to academic resources for more formal, peer-reviewed products. In a practical sense, however, the utility of data

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collection will be defined by the Collaborative’s ability to facilitate real-time (or at least proximal) changes on the basis of information gathered. In some ways this may be difficult given that the typical function of administrators and/or academics is not to make short-term decisions on the basis of limited information, or to shift processes without reference to a specific time line. To truly innovate and efficiently extract the maximum learning potential from the Collaborative, however, its members will need to develop this set of skills. Further, the future of the model as a potential blueprint for other facilities seeking to provide integrated services depends on a strongly theoretical, cogent approach to organizational innovation and adaptation. In the context of the ACA and medical professional organizations’ calls for additional emphasis on behavioral health, it is likely that the future of the Collaborative is replete with opportunities to contribute to formative guidelines. Thus, the steering committees, administrators, and research consultants have made data collection and model explication a priority for all future efforts. In particular, data concerning costs and the benefits of resources expended are viewed as of primary importance. In light of the often replicated finding in public mental health that a small percentage of individuals consume a disproportionate amount of resources, yet achieve no discernible benefit (e.g., T. L. Johnson et al., 2015), we believe that these data will be among the most useful contributions to this area in the next 5 to 10 years. Implicit in the forgoing discussion of model codification and adaptation is an emphasis on continual systemic evolution. To a large degree, the ability to continually innovate and evolve is the model of choice, in that it guards against insular thinking that has the potential to cultivate the development of administrative or practice silos (Christensen & Raynor, 2013; Rogers, 2003). To loosely borrow a phrase from author Steven S. Johnson (2011, p. 174), “Chance favors the connected mind.” Thus, the future directions of statewide collaboratives involve greater integration of not only clinical service expertise but also experts from economics, business, management, marketing, and innovation research. Connection, and connectivity, among diverse academic disciplines will facilitate a strong advance from health care as it stands now to a more optimal organization in the future. Part of this connection also involves development of methods that may seem somewhat antithetical or objectionable to many in the profession of clinical psychology. The superordinate importance of fiscal analyses, for example, is perhaps so uncommon in the field of clinical research because academic advancement and recognition do not have contingencies related to practical application. To ignore an increasingly large amount of data that suggest these issues are of central importance to determining how the products of scientific research are ultimately used, however, is similarly antithetical to the principles of science. To enable the best

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possible chance for dissemination and accurate implementation, researchers would do well to attend to end users’ contingencies rather than their own (Beveridge et al., 2015; Weisz, Chu, & Polo, 2004). These end users include system administrators seeking to develop methods of evaluating their workforce, organizational performance, and business processes. The Collaborative is highly oriented to these problems and has developed several tools for aggregated reporting. One example examines individual clinician performance across their caseload, using psychometrically sound measurements as the basis to understand client outcomes. Information from these analyses can be viewed at a number of different levels, including by therapist and by broad category of diagnosis treated by that therapist (e.g., anxiety, depression, behavioral disturbance, etc.). Although formative at this stage, the intended use of this information in the future includes clinical logistics. For example, if a given therapist is noted to have stronger outcomes for anxiety treatment than for other diagnostic types, and his or her clients have better outcome for anxiety than other therapists in the same office, then this realization could be useful to differentially assign anxiety cases to that therapist (among other possible outcomes, including suggesting additional training). The Collaborative continues to expand methods of evaluation around these ideas, and we hope it will use the results for publication in the future. The final point to highlight in terms of the Collaborative’s future endeavors surrounds methods of dissemination. Traditionally, this might entail academic papers or books and grant submissions, most of which are demonstrably effective at reaching only other academics. The intention of the Collaborative, however, is to draw on as many methods of diffusion, dissemination, and communication as possible to facilitate additional extrapolation within an architecture of open innovation. This includes resources from other social sciences, as just outlined, but also direct connection and collaboration with other organizations with a desire to integrate care. It is this direct connection with people, who make decisions in diverse organizational contexts, and exchange of ideas that may have the most potential to truly integrate behavioral and medical services in the future. FUNDING This project was funded in part by a contract with the Mississippi Division of Medicaid through a grant from CMS.

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