Anthony L. Hemmelgarn

THE EFFECTS OF ORGANIZATIONAL CLIMATE AND INTERORGANIZATIONAL COORDINATION ON THE QUALITY AND OUTCOMES OF CHILDREN'S SERVICE SYSTEMS

OBJECTIVE This study examines the effects of organizational characteristics, including organizational climate and interorganizational coordination, on the quality and outcomes of childrens service systems. METHOD A quasi-experimental, longitudinal design was used to assess the effects of increasing interorganizational services coordination in public childrens service agencies. The research team collected both qualitative and quantitative data over a 3-year period describing the services provided to 250 children by 32 public childrens service offices in 24 counties in Tennessee. RESULTS Findings show that organizational climate (including low conflict, cooperation, role clarity, and personalization) is the primary predictor of positive service outcomes (the childrens improved psychosocial functioning) and a significant predictor of service quality. In contrast, interorganizational coordination had a negative effect on service quality and no effect on outcomes. CONCLUSIONS Efforts to improve public childrens service systems should focus on creating positive organizational climates rather than on increasing interorganizational services coordination. This is important because many large-scale efforts to improve childrens service systems have focused on interorganizational coordination with little success and none to date have focused on organizational climate.

Randomized trial of MST and ARC in a two-level evidence-based treatment implementation strategy.

OBJECTIVE A randomized trial assessed the effectiveness of a 2-level strategy for implementing evidence-based mental health treatments for delinquent youth. METHOD A 2 x 2 design encompassing 14 rural Appalachian counties included 2 factors: (a) the random assignment of delinquent youth within each county to a multisystemic therapy (MST) program or usual services and (b) the random assignment of counties to the ARC (for availability, responsiveness, and continuity) organizational intervention for implementing effective community-based mental health services. The design created 4 treatment conditions (MST plus ARC, MST only, ARC only, control). Outcome measures for 615 youth who were 69% male, 91% Caucasian, and aged 9-17 years included the Child Behavior Checklist and out-of-home placements. RESULTS A multilevel, mixed-effects, regression analysis of 6-month treatment outcomes found that youth total problem behavior in the MST plus ARC condition was at a nonclinical level and significantly lower than in other conditions. Total problem behavior was equivalent and at nonclinical levels in all conditions by the 18-month follow-up, but youth in the MST plus ARC condition entered out-of-home placements at a significantly lower rate (16%) than youth in the control condition (34%). CONCLUSIONS Two-level strategies that combine an organizational intervention such as ARC and an evidence-based treatment such as MST are promising approaches to implementing effective community-based mental health services. More research is needed to understand how such strategies can be used effectively in a variety of organizational contexts and with other types of evidence-based treatments.

Emergency Room Culture and the Emotional Support Component of Family-Centered Care

This exploratory study examines the role played by organizational culture in the emphasis that emergency room staff place on the emotional support component of Family-Centered Care. The study combines qualitative and quantitative research methods to study differences among 4 emergency room (ER) cultures. Both methods identify significant differences among ER cultures in the emphasis placed on providing emotional support to families. In addition, the differences in culture parallel differences in organizational climate that affect staff attitudes toward ER work. The findings provide evidence that ER culture is a key factor in determining emergency health care provider practices and attitudes related to Family-Centered Care.

Randomized Trial of the Availability, Responsiveness, and Continuity (ARC) Organizational Intervention With Community-Based Mental Health Programs and Clinicians Serving Youth.

OBJECTIVE Evidence-based Practice (EBP) implementation is likely to be most efficient and effective in organizations with positive social contexts (i.e., organizational culture, climate, and work attitudes of clinicians). The study objective was to test whether an organizational intervention labeled Availability, Responsiveness and Continuity (ARC) could improve the organizational social contexts of community-based mental health programs for youth. METHOD The study randomly assigned 26 community-based mental health programs for youth to ARC or control conditions. The organizational cultures, climates, and work attitudes of clinicians (n = 197) in the programs were assessed with the Organizational Social Context (OSC) measure for mental health services at baseline and following the 18-month ARC intervention. RESULTS Hierarchical linear models (HLM) analyses indicated that organizational culture, climate, and work attitudes were significantly improved in the ARC condition after 18 months. Clinicians in programs assigned to ARC reported less rigid, less centralized and less apathetic organizational cultures, more engaged and functional organizational climates with less role conflict, and work attitudes with improved morale, job satisfaction, and organizational commitment. CONCLUSIONS ARC improved the organizational social contexts of clinicians in community-based mental health programs for youth. Results suggest that organizational intervention strategies can be used to create the types of organizational social contexts that are believed to be necessary for EBP implementation and other service innovations in mental health programs.

Randomized Trial of the Availability, Responsiveness and Continuity (ARC) Organizational Intervention for Improving Youth Outcomes in Community Mental Health Programs

OBJECTIVES The primary objective of the study was to assess whether the Availability, Responsiveness and Continuity (ARC) organizational intervention improved youth outcomes in community based mental health programs. The second objective was to assess whether programs with more improved organizational social contexts following the 18-month ARC intervention had better youth outcomes than programs with less improved social contexts. METHOD Eighteen community mental health programs that serve youth between the ages of 5 and 18 were randomly assigned to ARC or control conditions. Clinicians (n = 154) in the participating programs completed the Organizational Social Context (OSC) measure at baseline and following the 18-month ARC organizational intervention. Caregivers of 393 youth who were served by the 18 programs (9 in ARC and 9 in control) completed the Shortform Assessment for Children (SAC) once a month for six months beginning at intake. RESULTS Hierarchical linear models (HLM) analyses indicated that youth outcomes were significantly better in the programs that completed the 18 month ARC intervention. HLM analyses also showed that youth outcomes were best in the programs with the most improved organizational social contexts following the 18 month ARC intervention. CONCLUSIONS Youth outcomes in community mental health programs can be improved with the ARC organizational intervention and outcomes are best in programs that make the most improvements in organizational social context. The relationships linking ARC, organizational social context, and youth outcomes suggest that service improvement efforts will be more successful if those efforts include strategies to improve the organizational social contexts in which the services are embedded.

The Shortform Assessment for Children: An Assessment and Outcome Measure for Child Welfare and Juvenile Justice

This study describes the design and psychometric characteristics of the Shortform Assessment for Children (SAC). The SAC is an efficient and easy-to-use tool for monitoring the overall mental health and psychosocial functioning of children age 5 to 18 who are served by child welfare and juvenile justice systems. The one-page 48-item instrument was developed with the support of the National Institute of Mental Health to describe internalizing (withdrawn, anxious, depressed) and externalizing (aggressive, antisocial, violent) profiles of children in both home/residential and school/classroom settings. Psychometric data supporting the reliability and validity of the SAC are presented for a sample of 3,790 children served by one state’s child welfare and juvenile justice system.

The Organizational Social Context of Mental Health Medicaid Waiver Programs with Family Support Services: Implications for Research and Practice

Peer family support specialists (FSS) are parents with practical experience in navigating children’s mental health care systems who provide support, advocacy, and guidance to the families of children who need mental health services. Their experience and training differ from those of formally trained mental health clinicians, creating potential conflicts in priorities and values between FSS and clinicians. We hypothesized that these differences could negatively affect the organizational cultures and climates of mental health clinics that employ both FSS and mental health clinicians, and lower the job satisfaction and organizational commitment of FSS. The Organizational Social Context measure was administered on site to 209 FSS and clinicians in 21 mental health programs in New York State. The study compared the organizational-level culture and climate profiles of mental health clinics that employ both FSS and formally trained clinicians to national norms for child mental health clinics, assessed individual-level job satisfaction and organizational commitment as a function of job (FSS vs. clinician) and other individual-level and organizational-level characteristics, and tested whether FSS and clinicians job attitudes were differentially associated with organizational culture and climate. The programs organizational culture and climate profiles were not significantly different from national norms. Individual-level job satisfaction and organizational commitment were unrelated to position (FSS vs. clinician) or other individual-level and organizational-level characteristics except for culture and climate. Both FSS’ and clinicians’ individual-level work attitudes were associated similarly with organizational culture and climate.

The Validity of the Shortform Assessment for Children (SAC)

This study tests the validity of the Shortform Assessment for Children (SAC), a one-page, 48-item measure of a childs overall mental health. Designed as a rapid assessment instrument for child welfare and juvenile justice systems, the SAC measures the broadband constructs of internalizing and externalizing problems using either parents or teachers as respondents. Method: The convergent, divergent, and criterion validity of the SAC (completed by both parents and teachers) was assessed with data gathered on 188 children in two urban child welfare and juvenile justice systems. Results: The validity of the SAC was supported for both parent and teacher respondents. Conclusions: The SACs brevity, validity, and utility (completed by a teacher or parent) provide an efficient and effective assessment tool for child welfare and juvenile justice systems.

Testing for Cross-Situational-Consistency: A Confirmatory Factor Analytic Approach

Numerous procedures have been suggested for investigating behaviors across situations for consistency versus situational specificity. It is proposed here that Confirmatory Factor Analysis (CFA) may provide an useful addition to these procedures. To illustrate the process, a CFA model based on simulated data is presented and tested. The results of this simulation are employed to make recommendations for conducting CFA to test for cross-situational consistency.

An ARC-Informed Family Centered Care Intervention for Children’s Community Based Mental Health Programs

The experience of parents in helping their children access and use mental health services is linked to service outcomes. Parent peer support service, based on the principles of family-centered care, is one model to improve parent experience and engagement in services. Yet, little is known about how best to integrate this service into the existing array of mental health services. Integration is challenged by philosophical differences between family-centered services and traditional children’s treatment services, and is influenced by the organizational social contexts in which these services are embedded. We describe an organizational and frontline team intervention that draws on research in behavior change, technology transfer, and organizational social context for youth with serious emotional disturbance. The two-pronged intervention, called FAMILY (FCC and ARC Model to Improve the Lives of Youth) is guided by the evidence-based Availability, Responsiveness, and Continuity (ARC) organizational intervention, targeted primarily at program and upper management leadership and includes a family-centered care (FCC) intervention, targeted at frontline providers. The approach employs multilevel implementation strategies to promote the uptake, implementation and sustainability of new practices. We include examples of exercises and tools, and highlight implementation challenges and lessons learned in facilitating program and staff level changes in family-centered service delivery.