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1.  Adolescent Outpatient Treatment and Continuing Care: Main Findings from a Randomized Clinical Trial* 
Drug and alcohol dependence  2010;110(1-2):44-54.
This study evaluated the effectiveness and cost-effectiveness of two types of outpatient treatment with and without Assertive Continuing Care (ACC) for 320 adolescents with substance use disorders. Study participants were randomly assigned to one of four conditions: (a) Chestnut’s Bloomington Outpatient Treatment (CBOP) without ACC; (b) CBOP with ACC; (c) Motivational Enhancement Therapy/Cognitive Behavior Therapy-7 session model (MET/CBT7) without ACC; and (d) MET/CBT7 with ACC. All study conditions attained high rates of participant engagement and retention. Follow-up interviews were completed with over 90% of the adolescents at three, six, nine, and twelve months after treatment admission. There was a significant time by condition effect over 12 months, with CBOP having a slight advantage for average percentage of days abstinent. Unlike previous findings that ACC provided incremental effectiveness following residential treatment, there were no statistically significant findings with regard to the incremental effectiveness of ACC following outpatient treatment. Analysis of the costs of each intervention combined with its outcomes revealed that the most cost-effective condition was MET/CBT7 without ACC.
doi:10.1016/j.drugalcdep.2010.02.003
PMCID: PMC2885472  PMID: 20219293
substance abuse; adolescent outpatient treatment; continuing care; outcomes
2.  Training and retaining staff to competently deliver an evidence-based practice: The role of staff attributes and perceptions of organizational functioning 
Within the context of an initiative to implement evidence-based practices (EBPs) for adolescents with substance use disorders, this study examined the extent to which staff factors measured at an initial EBP training workshop were predictive of EBP-competence and turnover status of staff (N=121) measured 6, 9, and 12 months post-training. By the final assessment point, 52.3% of staff transitioned to the Employed/EBP-Competent category, 26.6% transitioned to the Not Employed/Not EBP-Competent category, 4.6% transitioned to the Not Employed/EBP-Competent category, and 16.5% had not transitioned out of the initial category. Multilevel multinomial regression analysis identified several measures that were significant predictors of staff transitions to the Not Employed/Not EBP-Competent category (e.g., program needs, job satisfaction, burnout) and transitions to the Employed/EBP-Competent category (e.g., months in position, pressures for change, influence). Findings have implications for the development and testing of strategies to train and retain staff to deliver EBPs in practice settings.
doi:10.1016/j.jsat.2011.10.016
PMCID: PMC3268826  PMID: 22112507
Adolescent; treatment; training; implementation; turnover; fidelity; competence
3.  Treatment staff turnover in organizations implementing evidence-based practices: Turnover rates and their association with client outcomes 
High staff turnover has been described as a problem for the substance use disorder treatment field. This assertion is based primarily on the assumption that staff turnover adversely impacts treatment delivery and effectiveness. This assumption, however, has not been empirically tested. In this study, we computed annualized rates of turnover for treatment staff (n=249) participating in an evidence-based practice implementation initiative and examined the association between organizational-level rates of staff turnover and client-level outcomes. Annualized rates of staff turnover were 31% for clinicians and 19% for clinical supervisors. Additionally, multilevel analyses did not reveal the expected relationship between staff turnover and poorer client-level outcomes. Rather, organizational-level rates of staff turnover were found to have a significant positive association with two measures of treatment effectiveness: less involvement in illegal activity and lower social risk. Possible explanations for these findings are discussed.
doi:10.1016/j.jsat.2011.10.015
PMCID: PMC3268938  PMID: 22154040
substance abuse counselors; clinical supervisors; turnover; retention; workforce
4.  Adolescent Community Reinforcement Approach (A-CRA) Outcomes Differ among Emerging Adults and Adolescents 
One-fifth of all public treatment admissions are emerging adults, and few studies have considered whether treatments are developmentally appropriate. This study compares outcomes between substance use-disordered adolescents and emerging adults that received the Adolescent Community Reinforcement Approach (A-CRA). Propensity score matching was used to create a weighted comparison group of adolescents (n=151) that had similar demographic characteristics, clinical severity, and treatment retention as the group of emerging adults (n=152). We examined age differences in abstinence and other psychosocial outcomes at the last available follow up. Emerging adults and adolescents both reduced their substance use at follow-up. However, emerging adults were less likely to be abstinent and in remission, and had more days of alcohol use when compared to adolescents. This study’s findings are consistent with prior work on emerging adults. Additional research should examine features of interventions that are most effective in addressing the developmental needs of emerging adults.
doi:10.1016/j.jsat.2011.06.003
PMCID: PMC3205255  PMID: 21831564
Emerging Adults; Adolescents; Drug Abuse Treatment; Propensity Score Matching
5.  The impact of pay-for-performance on therapists’ intentions to deliver high quality treatment 
This paper examined the extent to which assignment to a pay-for-performance (P4P) experimental condition impacted therapists’ intentions to deliver high quality treatment and the extent to which therapists’ intentions could be explained by the theory of planned behavior. Data were collected from 95 therapists who agreed to participate in a P4P experiment related to their implementation of an evidence-based treatment (EBT) for adolescents with substance use problems. Relative to those in the control condition, therapists in the P4P condition reported significantly greater intentions to achieve monthly competence (B = 1.41, p < .001) and deliver a targeted threshold level of treatment to clients (B = 1.31, p < .001). Additionally, therapists’ intentions could be partially explained by the theory of planned behavior. Meta-analyses have found intentions to be one of the best predictors of behavior, thus these findings provide initial support for using P4P approaches as a method of increasing the quality of substance use treatment.
doi:10.1016/j.jsat.2011.01.012
PMCID: PMC3110635  PMID: 21315539
adolescents; intentions; pay-for-performance; substance use treatment
6.  A Large-scale Dissemination and Implementation Model for Evidence-based Treatment and Continuing Care 
Multiple evidence-based treatments for adolescents with substance use disorders are available; however, the diffusion of these treatments in practice remains minimal. A dissemination and implementation model incorporating research-based training components for simultaneous implementation across 33 dispersed sites and over 200 clinical staff is described. Key elements for the diffusion of the Adolescent Community Reinforcement Approach and Assertive Continuing Care were: (a) three years of funding to support local implementation; (b) comprehensive training, including a 3.5 day workshop, bi-weekly coaching calls, and ongoing performance feedback facilitated by a web tool; (c) a clinician certification process; (d) a supervisor certification process to promote long-term sustainability; and (e) random fidelity reviews after certification. Process data are summarized for 167 clinicians and 64 supervisors.
doi:10.1111/j.1468-2850.2011.01236.x
PMCID: PMC3086782  PMID: 21547241
technology transfer; clinical training; substance abuse treatment; adolescent; A-CRA; ACC
7.  MONITORING FIDELITY IN THE ADOLESCENT COMMUNITY REINFORCEMENT APPROACH (A-CRA): THE TRAINING PROCESS FOR A-CRA RATERS 
Ensuring evidence-based treatments are delivered with a high degree of fidelity is an important aspect of transporting these practices to community-based treatment providers. Just as training is critical for clinicians who plan to deliver the Adolescent Community Reinforcement Approach (A-CRA), a process of training and vetting individuals who assess sessions for fidelity also is critical. This article describes the training process for session raters who assess fidelity of A-CRA during the clinician training and certification process. A-CRA is currently being implemented in 32 independent community-based agencies as part of a large initiative funded by the Center for Substance Abuse Treatment.
PMCID: PMC3083030  PMID: 21533009
training; treatment fidelity; adolescent; treatment; A-CRA
8.  Exposure to Adolescent Community Reinforcement Approach (A-CRA) treatment procedures as a mediator of the relationship between adolescent substance abuse treatment retention and outcome 
Data from 399 adolescents, who participated in one of four randomly controlled trials of the A-CRA intervention, were used to examine the extent to which exposure to Adolescent Community Reinforcement Approach (A-CRA) procedures mediated the relationship between treatment retention and outcomes. Although zero-order correlations indicated that retention in treatment was a significant predictor of AOD use (r = -.18, p < .001), this relationship was reduced to non-significance (p = .39) when exposure to A-CRA procedures was included in the model. Overall, the final model evidenced a very good fit (RMSEA=.00; NFI = .99; CFI = 1.00), and explained 29% and 43% of the variance in adolescents’ post-treatment AOD use and AOD-related problems, respectively. Additionally, CHAID analysis was used to derive a target level of A-CRA exposure, which was found to be significantly related to being in recovery at follow-up. The current findings are useful, as little research to date has identified significant mediators of the relationship between retention and treatment outcomes or identified target thresholds of treatment exposure.
doi:10.1016/j.jsat.2008.06.007
PMCID: PMC2675944  PMID: 18715742
adolescent; treatment; exposure; fidelity; substance use
9.  The Reinforcing Therapist Performance (RTP) experiment: Study protocol for a cluster randomized trial 
Background
Rewarding provider performance has been recommended by the Institute of Medicine as an approach to improve the quality of treatment, yet little empirical research currently exists that has examined the effectiveness and cost-effectiveness of such approaches. The aim of this study is to test the effectiveness and cost-effectiveness of providing monetary incentives directly to therapists as a method to improve substance abuse treatment service delivery and subsequent client treatment outcomes.
Design
Using a cluster randomized design, substance abuse treatment therapists from across 29 sites were assigned by site to either an implementation as usual (IAU) or pay-for-performance (P4P) condition.
Participants
Substance abuse treatment therapists participating in a large dissemination and implementation initiative funded by the Center for Substance Abuse Treatment.
Intervention
Therapists in both conditions received comprehensive training and ongoing monitoring, coaching, and feedback. However, those in the P4P condition also were given the opportunity to earn monetary incentives for achieving two sets of measurable behaviors related to quality implementation of the treatment.
Outcomes
Effectiveness outcomes will focus on the impact of the monetary incentives to increase the proportion of adolescents who receive a targeted threshold level of treatment, months that therapists demonstrate monthly competency, and adolescents who are in recovery following treatment. Similarly, cost-effectiveness outcomes will focus on cost per adolescent receiving targeted threshold level of treatment, cost per month of demonstrated competence, and cost per adolescent in recovery.
Trial Registration
Trial Registration Number: NCT01016704
doi:10.1186/1748-5908-5-5
PMCID: PMC2824685  PMID: 20205824

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