Sarah L. Kopelovich, Rachel M. Brian, Akansha Vaswani-Bye, Lydia Chwastiak, Chris McCain, Victoria Shepard, Wenqi Zhang, Mackenzie Tennison, Sarah Fikre, and Maria Monroe-DeVita
University of Washington affiliated authors are displayed in bold.
Published: January 2024
Sara J. Becker, Tim Janssen, Tim Souza, Bryan Hartzler, Carla J. Rash, Kira DiClemente-Bosco & Bryan R. Garner
University of Washington affiliated authors are displayed in bold.
Published: December 2025
Contingency management (CM), a behavioral treatment that incentivizes patients for attaining treatment goals, is a highly effective adjunct to medication for opioid use disorder. However, CM is rarely offered in opioid treatment programs in the United States. In a prior pilot trial, the implementation strategy (didactic workshop + feedback + consultation) delivered by the Addiction Technology Transfer Centers (ATTC strategy) promoted CM adoption more effectively than didactic training, but the speed and duration of implementation were sub-optimal. This 28-site type 3 hybrid trial tested the comparative effectiveness of the ATTC strategy versus an Enhanced-ATTC (E-ATTC) strategy that contained two theory-driven techniques targeting implementation climate to improve acceleration and sustainment, respectively: a provider-focused incentivization strategy and a team-focused facilitation strategy. We hypothesized that the E-ATTC strategy would be associated with superior implementation and patient outcomes.
Twenty-eight opioid treatment programs, 186 providers, and 592 patients were cluster-randomized to receive either the ATTC or E-ATTC strategy. Providers logged their CM sessions in an online CM Tracker and submitted audio-recorded CM sessions, and patients completed surveys about their opioid use at three timepoints. Intention-to-treat analyses examined impacts of the two multi-level strategies on implementation outcomes (CM Exposure, CM Competence, CM Sustainment) and patient outcomes (Opioid Abstinence, Opioid Related Problems).
The pattern of results was identical across unadjusted, propensity score-adjusted, and covariate-adjusted general linear mixed models, though significance varied slightly. Relative to providers receiving the ATTC strategy, those receiving the E-ATTC strategy had significantly higher odds of CM Exposure (covariate adjusted OR = 3.21, p < 0.05) and of attaining the Excellent CM Competence benchmark (propensity-adjusted OR = 4.07, p < 0.05). Patients at the E-ATTC sites had significantly greater likelihood of Opioid Abstinence over time (OR = 2.04, p < 0.05). There were no significant conditional differences in CM Sustainment, though data were measured at the program-level, which limited power to detect differences.
The theory-driven E-ATTC strategy, which targeted implementation climate via facilitation and incentivization, had superior implementation and patient outcomes relative to the ATTC strategy. Results of this study can help inform ongoing CM implementation efforts across the United States.
**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**
Hannah E. Frank, Laura Evans, Gary Phillips, R Phillip Dellinger, Jessyca Goldstein, Lori Harmon, David Portelli, Nima Sarani, Christa Schorr, Kathleen M. Terry, Sean R. Townsend, & Mitchell M. Levy
University of Washington affiliated authors are displayed in bold.
Published:September 2023
Sepsis is the leading cause of intensive care unit (ICU) admission and ICU death. In recognition of the burden of sepsis, the Surviving Sepsis Campaign (SSC) and the Institute for Healthcare Improvement developed sepsis “bundles” (goals to accomplish over a specific time period) to facilitate SSC guideline implementation in clinical practice. Using the SSC 3-h bundle as a base, the Centers for Medicare and Medicaid Services developed a 3-h sepsis bundle that has become the national standard for early management of sepsis. Emerging observational data, from an analysis conducted for the AIMS grant application, suggest there may be additional mortality benefit from even earlier implementation of the 3-h bundle, i.e., the 1-h bundle.
The primary aims of this randomized controlled trial are to: (1) examine the effect on clinical outcomes of Emergency Department initiation of the elements of the 3-h bundle within the traditional 3 h versus initiating within 1 h of sepsis recognition and (2) examine the extent to which a rigorous implementation strategy will improve implementation and compliance with both the 1-h bundle and the 3-h bundle. This study will be entirely conducted in the Emergency Department at 18 sites. A secondary aim is to identify clinical sepsis phenotypes and their impact on treatment outcomes.
This cluster-randomized trial, employing implementation science methodology, is timely and important to the field. The hybrid effectiveness-implementation design is likely to have an impact on clinical practice in sepsis management by providing a rigorous evaluation of the 1- and 3-h bundles.
**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**
Julia C. Dombrowski, Scott Halliday, Judith I. Tsui, Deepa Rao, Kenneth Sherr, Meena S. Ramchandani, Ramona Emerson, Mark Fleming, Teagan Wood & Lydia Chwastiak
University of Washington affiliated authors are displayed in bold.
Published: April 2023
The collaborative care management (CoCM) model is an evidence-based intervention for integrating behavioral health care into nonpsychiatric settings. CoCM has been extensively studied in primary care clinics, but implementation in nonconventional clinics, such as those tailored to provide care for high-need, complex patients, has not been well described.
We adapted CoCM for a low-barrier HIV clinic that provides walk-in medical care for a patient population with high levels of mental illness, substance use, and housing instability. The Exploration, Preparation, Implementation, and Sustainment model guided implementation activities and support through the phases of implementing CoCM. The Framework for Reporting Adaptations and Modifications to Evidence-Based Interventions guided our documentation of adaptations to process-of-care elements and structural elements of CoCM. We used a multicomponent strategy to implement the adapted CoCM model. In this article, we describe our experience through the first 6 months of implementation.
The key contextual factors necessitating adaptation of the CoCM model were the clinic team structure, lack of scheduled appointments, high complexity of the patient population, and time constraints with competing priorities for patient care, all of which required substantial flexibility in the model. The process-of-care elements were adapted to improve the fit of the intervention with the context, but the core structural elements of CoCM were maintained.
The CoCM model can be adapted for a setting that requires more flexibility than the usual primary care clinic while maintaining the core elements of the intervention.
**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**
Jonathan Purtle, Nicole A. Stadnick, Megan Wynecoop, Eric J. Bruns, Margaret E. Crane, & Gregory Aarons
University of Washington affiliated authors are displayed in bold.
Published: March 2023
Insufficient funding is frequently identified as a critical barrier to the implementation and sustainment of evidence-based practices (EBPs). Thus, increasing access to funding is recognized as an implementation strategy. Policies that create earmarked taxes—defined as taxes for which revenue can only be spent on specific activities—are an increasingly common mental health financing strategy that could improve the reach of EBPs. This project’s specific aims are to (1) identify all jurisdictions in the USA that have implemented earmarked taxes for mental health and catalogue information about tax design; (2) characterize experiences implementing earmarked taxes among local (e.g., county, city) mental health agency leaders and other government and community organization officials and assess their perceptions of the acceptability and feasibility of different types of policy implementation strategies; and (3) develop a framework to guide effect earmarked tax designs, inform the selection of implementation strategies, and disseminate the framework to policy audiences.
The project uses the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to inform data collection about the determinants and processes of tax implementation and Leeman’s typology of implementation strategies to examine the acceptability and feasibility strategies which could support earmarked tax policy implementation. A legal mapping will be conducted to achieve aim 1. To achieve aim 2, a survey will be conducted of 300 local mental health agency leaders and other government and community organization officials involved with the implementation of earmarked taxes for mental health. The survey will be followed by approximately 50 interviews with these officials. To achieve aim 3, quantitative and qualitative data will be integrated through a systematic framework development and dissemination process.
This exploratory policy implementation process study will build the evidence base for outer-context implementation determinants and strategies by focusing on policies that earmarked taxes for mental health services.
**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**
Deborah J. Bowen, Ann M. Nguyen, Cynthia LeRouge, Erin LePoire, & Tao Sheng Kwan-Gett
University of Washington affiliated authors are displayed in bold.
Published: September 2021
As healthcare systems progress toward initiatives that increase patient engagement, stakeholder hopes are that shared decision making (SDM) will become routine practice. Yet, there is limited empirical evidence to guide such SDM program implementations, particularly in obstetric practices. The first stage of any project implementation is the "initiation stage", in which project leaders define a project's purpose and stakeholders and structures are put in place to support the new initiative.
Our study's objective was to identify factors affecting the initiation stage of an SDM program implementation project for TOLAC, trial of labor after Cesarean. We conducted a multiple-case study of an SDM program implementation in three obstetric settings in Washington State. The research design and analysis were guided by implementation science frameworks and project management literature. Data sources included interviews with key informants from the State, SDM tool vendors, and three project sites, as well as implementation documents.
The study results provide insight into how the identified project implementation factors provide an essential foundation for informing project planning, execution, and reflection/evaluation. In this study, the State's decision aid certification program pressured the project sites to shape the project purpose and engage stakeholders that would meet immediate project requirements (specifically, state requirements).
The study reveals that external demands may not be in perfect alignment with the internal necessities required for an SDM program's long-term viability and sustainability. Findings may be used by implementers and researchers to model and strategize the early stages of SDM program implementation projects, particularly in the obstetric setting.
**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**
Aaron R. Lyon, Michael D. Pullmann, Shannon Dorsey, Carol Levin, Larissa M. Gaias, Stephanie K. Brewer, Madeline Larson, Catherine M. Corbin, Chayna Davis, Ian Muse, Mahima Joshi, Rosemary Reyes, Nathaniel J. Jungbluth, Rachel Barrett, David Hong, Michael D. Gomez & Clayton R. Cook
University of Washington affiliated authors are displayed in bold.
Published: January 2021
More than two-thirds of youth experience trauma during childhood, and up to 1 in 5 of these youth develops posttraumatic stress symptoms that significantly impair their functioning. Although trauma-focused cognitive behavior therapy (TF-CBT) has a strong evidence base, it is rarely adopted, delivered with adequate fidelity, or evaluated in the most common setting where youth access mental health services—schools. Given that individual behavior change is ultimately required for successful implementation, even when organizational factors are firmly in place, focusing on individual-level processes represents a potentially parsimonious approach. Beliefs and Attitudes for Successful Implementation in Schools (BASIS) is a pragmatic, motivationally focused multifaceted strategy that augments training and consultation and is designed to target precise mechanisms of behavior change to produce enhanced implementation and youth clinical outcomes. This study protocol describes a hybrid type 2 effectiveness-implementation trial designed to concurrently evaluate the main effects, mediators, and moderators of both the BASIS implementation strategy on implementation outcomes and TF-CBT on youth mental health outcomes.
Using a cluster randomized controlled design, this trial will assign school-based mental health (SMH) clinicians and schools to one of three study arms: (a) enhanced treatment-as-usual (TAU), (b) attention control plus TF-CBT, or (c) BASIS+TF-CBT. With a proposed sample of 120 SMH clinicians who will each recruit 4–6 youth with a history of trauma (480 children), this project will gather data across 12 different time points to address two project aims. Aim 1 will evaluate, relative to an enhanced TAU condition, the effects of TF-CBT on identified mechanisms of change, youth mental health outcomes, and intervention costs and cost-effectiveness. Aim 2 will compare the effects of BASIS against an attention control plus TF-CBT condition on theoretical mechanisms of clinician behavior change and implementation outcomes, as well as examine costs and cost-effectiveness.
This study will generate critical knowledge about the effectiveness and cost-effectiveness of BASIS—a pragmatic, theory-driven, and generalizable implementation strategy designed to enhance motivation—to increase the yield of evidence-based practice training and consultation, as well as the effectiveness of TF-CBT in a novel service setting.
ClinicalTrials.gov registration number NCT04451161. Registered on June 30, 2020.
**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**
Andrea K. Graham, Emily G. Lattie, Byron J. Powell, Aaron R. Lyon, Justin D. Smith, Stephen M. Schueller, Nicole A. Stadnick, C. Hendricks Brown, & David C. Mohr
University of Washington affiliated authors are displayed in bold.
Published: November 2020
Amy Drahota, Rosemary D. Meza, Tatiana E. Bustos, Aksheya Sridhar, Jonathan I. Martinez, Brigitte Brikho, Aubyn C. Stahmer, Gregory A. Aarons
University of Washington affiliated authors are displayed in bold.
Published: September 2020
Eric J. Bruns, Elizabeth M. Parker, Spencer Hensley, Michael D. Pullmann, Philip H. Benjamin, Aaron R. Lyon & Kimberly E. Hoagwood
University of Washington affiliated authors are displayed in bold.
Published: November 2019
Despite consistent recognition of their influence, empirical study of how outer setting factors (e.g., policies, financing, stakeholder relationships) influence public systems’ investment in and adoption of evidence-based treatment (EBT) is limited. This study examined associations among unmodifiable (e.g., demographic, economic, political, structural factors) and modifiable (e.g., allocation of resources, social processes, policies, and regulations) outer setting factors and adoption of behavioral health EBT by US states.
Multilevel models examined relationships between state characteristics, an array of funding and policy variables, and state adoption of behavioral health EBTs for adults and children across years 2002–2012, using data from the National Association for State Mental Health Program Directors Research Institute and other sources.
Several unmodifiable state factors, including per capita income, controlling political party, and Medicaid expansion, predicted level of state fiscal investments in EBT. By contrast, modifiable factors, such as interagency collaboration and investment in research centers, were more predictive of state policies supportive of EBT. Interestingly, level of adult EBT adoption was associated with state fiscal supports for EBT, while child EBT adoption was predicted more by supportive policies. State per capita debt and direct state operation of services (versus contracting for services) predicted both child and adult EBT adoption.
State-level EBT adoption and associated implementation support is associated with an interpretable array of policy, financing, and oversight factors. Such information expands our knowledge base of the role of the outer setting in implementation and may provide insight into how best to focus efforts to promote EBT for behavioral health disorders.
**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**