< Previous50 PERSPECTIVES VOLUME 44, NUMBER 2 USING IMPLEMENTATION SCIENCE TO ADVANCE SPECIALIZED MENTAL HEALTH PROBATION APPROACHES BY TONYA B. VAN DEINSE, GARY S. CUDDEBACK, MARILYN GHEZZI, ERIKA L. CRABLE, KAREN BUCK, MAGGIE BREWER, SONYA BROWN, NICOLE SULLIVAN IT’S NOT JUST IT’S51 AMERICAN PROBATION AND PAROLE ASSOCIATION DEVELOPMENT OF THE EVIDENCE SUPPORTING SPECIALTY MENTAL HEALTH PROBATION The focus on the mental health needs of individuals in the criminal justice system, particularly among adults on probation, has been accelerated by a number of developments over the last two decades. In 2002, in its report on the Criminal Justice/Mental Health Consensus Project, the Council of State Governments (CSG) outlined a number of actionable policy statements and recommendations for addressing the mental health needs of justice-involved individuals. CSG’s specific recommendations for community supervision included: (1) impose modified supervision conditions, (2) give more attention to psychosocial needs, (3) ensure greater continuity of federal and state benefits to enable treatment engagement, (4) assign individuals with mental illnesses to designated mental health officers, (5) reduce caseload sizes for specialty mental health caseloads, and (6) develop guidelines for managing supervision compliance (CSG, 2002). In 2003, the American Probation and Parole Association (APPA), advanced CSG’s recommendations by adopting a resolution calling for programs, policies, and legislation that would improve the community supervision response to mental illness. APPA also recommended that Congress, the Department of Justice, and the Department of Health and Human Services partner with states and jurisdictions to increase access to funding to meet the goals of the resolution. Concurrent with CSG and APPA efforts, research focused on individuals with serious mental illnesses in the criminal justice system and interventions at the interface of the mental health and criminal justice systems also accelerated. In 2006, Skeem and colleagues conducted a national survey to assess the variation in specialty mental health probation (SMHP) approaches across the U.S. and codified a prototypical model of SMHP composed of five key elements: (1) caseloads composed exclusively of adults with mental illnesses; (2) small caseloads (i.e., less than 50 individuals); (3) sustained mental health training for officers; (4) a problem-solving supervision orientation; 52 PERSPECTIVES VOLUME 44, NUMBER 2 and (5) collaboration with internal and external resources to link individuals with supports (Skeem, Emke-Francis, & Eno Louden, 2006). In identifying these five elements as prototypical model components, they aimed to reduce the variability in SMHP models and to focus on specific SMHP features that were reproducible in research. Subsequent to publication of that survey, additional studies have examined the effectiveness of the prototypical model to determine the strength of the evidence for this specialty probation approach (Manchak, Skeem, Kennealy, & Eno Louden, 2014; Skeem, Manchak, & Montoya, 2017; Wolff et al., 2014). Many studies have focused on understanding SMHP’s effectiveness, but those in the criminal justice research field have paid less attention to factors affecting the implementation of SMHP. In fact, there is a dearth of published, peer-reviewed research and grey literature (e.g., agency reports) examining SMHP model implementation (Manchak et al., 2014; Van Deinse, Bunger, Burgin, Wilson, & Cuddeback, 2019). This gap in the literature is problematic, given the complexity of SMHP models (i.e., multiple interrelated components), their interdisciplinary approach (e.g., behavioral health and criminal justice), and their reliance on the existence of and interactions with an external resource environment, including mental health services (Van Deinse et al., 2019). This lack of focus on implementation leaves probation agencies without a roadmap for implementing complex interventions, such as SMHP, which require probation officers and agencies to expand their role and scope of practice beyond public safety and to establish an infrastructure to sustain SMHP model fidelity beyond initial implementation. Many studies have focused on understanding SMHP’s effectiveness, but those in the criminal justice research field have paid less attention to factors affecting the implementation of SMHP. 53 AMERICAN PROBATION AND PAROLE ASSOCIATION IMPLEMENTATION SCIENCE AND COMMUNITY CORRECTIONS Twenty years ago, Gendreau, Goggin and Smith (1999) posited 32 principles of program implementation across four dis- tinct categories: (1) organizational factors, (2) program factors, (3) change agents, and (4) staffing activities. Although these implementation principles were based on observations from a single research team’s experiences, Gendreau et al.’s ap- proach was one of the first applications of an implementation science approach described within the criminal justice lit- erature. Since then, the nascent field of implementation science has grown across numerous disciplines including medicine, mental health services, and child welfare, and has enhanced our understanding of how evidence-based practices are adopt- ed (Chambers, Feero, & Khoury, 2016; Glasgow et al., 2012; Landsverk, Brown, Reutz, Palinkas, & Horwitz, 2011; Proctor et al., 2009). For example, in 2002, the national Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) initiative focused on developing implementation strategies to enhance interventions addressing drug abuse in justice-involved individuals (Ducharme, Chandler, & Wiley, 2013; Friedmann et al., 2012; Welsh et al., 2016a; Welsh et al., 2016b). CJ-DATS demonstrated the utility of implementation science frameworks and implementa- tion strategies and the relevance of these methods for enhancing the implementa- tion of interventions in diverse community corrections settings. SPECIALTY MENTAL HEALTH PROBATION AND IMPLEMENTATION SCIENCE: A CASE EXAMPLE In 2012, the North Carolina Governor’s Crime Commission awarded a research grant to the North Carolina Department of Public Safety (NCDPS) and the University of North Carolina at Chapel Hill (UNC-CH) to pilot test a prototypical model of SMHP in one rural and one urban county. NCDPS and UNC-CH were later awarded a three-year grant from the Bureau of Justice Assistance to expand the pilot into six additional counties. The following section of this article describes four ways NCDPS and UNC-CH used an implementation science approach during the two-county pilot study (2012-2014) and the six-county expansion project (2015-2019) to assess the evidence base for SMHP, examine SMHP implementation, develop reproducible implementation strategies, and use study results to plan for dissemination and sustainability. DEVELOP AN ACADEMIC PARTNERSHIP Implementation science research recommends formal relationships between agencies and academic institutions in order to share skills, integrate research perspectives, and conduct evaluations (Powell et al., 2015). The academic 54 PERSPECTIVES VOLUME 44, NUMBER 2 partnership between NCDPS and the UNC-CH began in 2009 when a research team from UNC-CH worked with NCDPS on a project related to the community corrections workforce, caseload size, and specialized caseloads. In 2011, following reports of serious crimes involving probationers with serious mental illnesses, the NCDPS reached out to the UNC-CH team to assist with the development and implementation of special programming for individuals with serious mental illnesses. The UNC-CH team developed a series of mental health training modules for all officers across the state and developed, implemented, and evaluated SMHP in the two-county and subsequent six-county pilot studies mentioned above. This ongoing partnership has created opportunities for rigorous research methods (e.g., randomized controlled trials) and the development and testing of implementation strategies to plan for statewide dissemination of SMHP. IMPLEMENT HYBRID EFFECTIVENESS- IMPLEMENTATION STUDIES Hybrid or blended research designs simultaneously focus on the effectiveness of an intervention and its implementation. This dual focus allows for rapid generation of useful knowledge about an intervention and the development of effective implementation strategies, both of which can facilitate quicker uptake of the intervention (Curran et al., 2012). The UNC-CH research team chose this hybrid research design to be able to rigorously assess the evidence of SMHP while examining its implementation under real- world conditions. The effectiveness arm of the study used a randomized controlled trial in which individuals on probation who agreed to participate in the study were randomly assigned to a standard caseload or a SMHP caseload. The implementation arm was a simultaneous process evaluation (Curran et al., 2012) which examined factors impacting the implementation of SMHP (e.g., barriers and facilitators; see Van Deinse et al., 2019), developed strategies to enhance the uptake of core components of the model, and examined inter-organizational relationships between SMHP officers and resource providers. Due to the lessons learned from the hybrid effectiveness-implementation study during the two-county pilot, NCDPS and the UNC-CH research team were able to rapidly expand the model into the six additional counties. ASSESS THE LOCAL CONTEXT AND DETERMINE READINESS FOR IMPLEMENTATION Given the complexity and interdisciplinary nature of SMHP, readiness for implementation depends on multilevel factors (officers, agency, community). The implementation science literature recommends conducting local 55 AMERICAN PROBATION AND PAROLE ASSOCIATION assessments to identify factors that will impact successful implementation, including individual and organizational readiness for implementation, leadership support, agency capacity and expertise, stakeholder attitudes, available resources, and other strengths that can be leveraged to support implementation (Powell et al., 2015). To assess the local context and readiness for implementation, NCDPS and UNC-CH have used a number of approaches for assessing officer, agency, and community characteristics to learn more about the needs, resources, and potential challenges impacting SMHP implementation. On an officer level, NCDPS used a two-part assessment of officer characteristics for individuals interested in becoming SMHP officers. The first part of the process involved administering the Dual Role Relationship Inventory-Revised (Skeem, Eno Louden, Polaschek, & Camp, 2007) to a sample of individuals on prospective SMHP officers’ caseloads and to their chief officer. NCDPS used these data to determine the fit of the candidate for the role of SMHP officer. The second part of the officer assessment was an examination of officers’ case planning notes and documentation to assess for thoroughness in case planning and the use of supervision tools (such as structured worksheets), as well as their follow- through on action steps related to mental health and substance use services. At the agency level, NCDPS and the UNC-CH team administered the Organizational Readiness for Implementing Change scale (ORIC; Shea, Jacobs, Esserman, Bruce, & Weiner, 2014) and the Implementation Leadership Scale (ILS; Aarons, Ehrhart, & Farahnak, 2014) to assess key organizational and leadership factors that impact successful implementation of interventions. The ORIC measures an agency’s change commitment and change efficacy and the ILS examines key characteristics of leaders and their readiness to support the implementation of interventions, such as being proactive, knowledgeable, supportive, and perseverant. The UNC- CH team administered these surveys to all officers in the six-county expansion project to assess needs across counties prior to initial SMHP implementation and to troubleshoot any problematic trends (e.g., low levels of reported knowledge of SMHP in a particular county). At the community level, the UNC-CH team conducted a number of interviews with key stakeholders involved with initial implementation of the two-county pilot to understand factors that were promoting and/or inhibiting implementation. Results from this analysis were used to identify needs and inform subsequent strategies for implementation (Van Deinse, et al., 2019).56 PERSPECTIVES VOLUME 44, NUMBER 2 To plan the assessment activities described here, agencies and research partners should consider selecting an implementation framework. Frameworks and theories in implementation science are used to guide how research is translated to practice, to understand what factors impact implementation, and to guide the development of evaluations of implementation (Nilsen, 2015). For instance, for our assessment of implementation challenges and facilitators during the two-county study, the UNC-CH research team selected the consolidated framework for implementation research (CFIR; Damschroder et al., 2009), which consists of five domains that influence successful intervention implementation (see Van Deinse et al., 2019 for a description of how CFIR was applied to SMHP). The CFIR framework (Figure 1) was used to understand the barriers and facilitators associated with implementing SMHP and was selected because it is a widely used framework that provides online resources (cfirguide.org) available to researchers and practitioners. CFIR is just one of the available frameworks, and those interested in using a framework to guide their implementation of SMHP should review articles by Nilsen (2015) and Tabak and colleagues (Tabak, Khoong, Chambers, & Brownson, 2012). SCALE-UP IMPLEMENTATION WITH A PHASED APPROACH The implementation literature recommends an iterative approach to 57 AMERICAN PROBATION AND PAROLE ASSOCIATION implementing models rather than a full- scale roll out of a new intervention (Powell et al., 2015). As described above, North Carolina’s SMHP implementation began with the small, two-county pilot study that tested the model’s effectiveness using a randomized controlled trial while also assessing the implementation context and building strategies to enhance the adoption of model components. During the pilot phase, the UNC-CH team developed two implementation strategies: (1) clinical case consultation for SMHP officers, and (2) officer-stakeholder engagement. Clinical case consultation aimed to enhance SMHP officers’ capacity (i.e., knowledge and skills) to work with individuals with mental illnesses through monthly consultation sessions with a licensed clinical social worker. Officer- stakeholder engagement activities focused on building SMHP officers’ resource networks (i.e., reliable connections to local behavioral health services providers) and consisted of introductory network events, developing points of contact at different agencies, and creating opportunities for case staffing. Building on the successes of the two- county pilot study, NCDPS and UNC- CH were granted additional funding to disseminate SMHP into six additional counties. In order to select the new counties, NCDPS assessed the capacity of potential counties, checking for the number of vacancies in leadership and officer positions, and balanced the selection of urban and rural settings. After county selection, NCDPS and UNC-CH then used the implementation strategies (clinical case consultation and officer- stakeholder engagement) developed during the pilot phase to rapidly implement SMHP. Currently, the UNC-CH research team and NCDPS are planning to implement SMHP in seven new counties, with future plans to implement the model statewide. CONCLUDING REMARKS This article describes how implementation science methods and frameworks were used to inform and study the implementation of SMHP in one state. The methods described here are not a representative or exhaustive list of the ways in which implementation science can be integrated into community corrections in general or for SMHP specifically. Agencies and research partners interested in integrating implementation science methods into their practices should consider reviewing these two articles available from the journal Implementation Science source journal that publishes articles on implementation science methods: (1) “An Introduction to Implementation Science for the Non-Specialist” (Bauer, Damschroder, 58 PERSPECTIVES VOLUME 44, NUMBER 2 Hagedorn, Smith, & Kilbourne (2015); and (2) “A Refined Compilation of Implementation Strategies: Results from the Expert Recommendations for Implementation Change (ERIC) Project” (Powell et al., 2015), which includes useful ancillary materials. Although many resources reference health care settings, the methods described therein are broadly applicable to intervention implementation in other sectors such as community corrections. REFERENCES Aarons, G. A., Ehrhart, M. G., & Farahnak, L. R. (2014). 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Administration and Policy in Mental Health and Mental Health Services Research, 43(1), 105-121. DOI:0.1007/ s10488-014-0623-8 Welsh, W. N., Prendergast, M., Knight, K., Knudsen, H., Monico, L., Gray, J., ... & Shafer, M. S. (2016). Correlates of interorganizational service coordination in community corrections. Criminal Justice and Behavior, 43(4), 483-505. DOI: 10.1177/0093854815607306 Wolff, N., Epperson, M., Shi, J., Huening, J., Schumann, B. E., & Sullivan, I. R. (2014). Mental health specialized probation caseloads: Are they effective? International Journal of Law and Psychiatry, 37, 464–472. doi: 10.1016/j.ijlp.2014.02.019 ABOUT THE AUTHORS TONYA B. VAN DEINSE, Ph.D., is a clinical associate professor at the University of North Carolina at Chapel Hill School of Social Work and is the corresponding author on this manuscript. Email: tbv@email. unc.edu; phone (919) 962-6428. GARY S. CUDDEBACK, Ph.D., is a professor at the University of North Carolina at Chapel Hill School of Social Work and a research fellow at the Cecil G. Sheps Center for Health Services Research. MARILYN GHEZZI, MSW, LCSW, is a clinical associate professor at the University of North Carolina at Chapel Hill School of Social Work. ERIKA L. CRABLE, MA, is a research fellow at the Evans Center for Implementation and Improvement Sciences, Boston University School of Medicine, Boston, MA, USA and PhD candidate in the Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA. KAREN BUCK is the Evidence-based Practice Administrator, North Carolina Department of Public Safety, Division of Adult Correction and Juvenile Justice, Raleigh, NC. MAGGIE BREWER is Deputy Director, North Carolina Department of Public Safety, Division of Adult Correction and Juvenile Justice, Raleigh, NC. SONYA BROWN is the Social Work Practice Administrator, North Carolina Department of Public Safety, Division of Adult Correction and Juvenile Justice, Raleigh, NC. NICOLE SULLIVAN is the Director of Reentry Programs and Services, North Carolina Department of Public Safety, Raleigh, NC.Next >