Enhancing the effectiveness of measurement-based care for youth by identifying key fidelity indicators

PROJECT SUMMARY Measurement-based care (MBC) is considered an evidence-based practice. However, low MBC fidelity (the extent to which MBC practices are delivered) in community mental health centers (CMHCs) undermines effectiveness. To optimize MBC effectiveness, theory-informed fidelity research is needed to identify influential MBC practice(s) that engage target mechanisms and predict youth clinical outcomes. The proposed project will achieve this goal via three primary aims: (1) Define and evaluate the entire continuum of MBC fidelity domains; (2) Assess the impact of MBC fidelity on target mechanisms and youth clinical outcomes; and (3) Evaluate the utility of pragmatic MBC fidelity indicators (i.e., self-report and digital usage data). This project will utilize existing data from the Community Study of Outcome Monitoring for Emotional Disorders in Teens (COMET), a randomized effectiveness trial comparing two MBC conditions [MBC+TAU (treatment as usual) and MBC+EBT (Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents, UP-A)] to TAU. COMET allows rigorous assessment of the entire continuum of MBC practice domains, client-level mechanisms of MBC, and youth clinical outcomes. The COMET sample includes 82 clinicians and 177 youth treated in CMHCs in Florida and Connecticut. To achieve study aims, a multi-method (digital MBC system usage data, self-report, observer-report) and multi-informant (clinician, observer) measurement approach will be used to rigorously assemble and evaluate the entire continuum of MBC fidelity practice domains. Item Response Theory (IRT) measurement models will evaluate dimensionality, reliability, validity, and item fit for all MBC fidelity indicators. Additional models will target MBC-specific data features (for individual fidelity indicators and overall fidelity scores), including variability and reliability across sessions, youth, clinicians, clinics, and data sources. We will then evaluate the impact of MBC fidelity (scores and indicators) on target mechanisms (youth/caregiver alliance, youth/caregiver engagement, and UP-A mechanisms) and youth clinical outcomes (youth, caregiver, independent-evaluator ratings of symptoms, improvement, and global functioning). Finally, a subset of pragmatic fidelity indicators (i.e., digital usage data, self-report) will be evaluated as proxy measures of MBC fidelity. Our long-term goal, consistent with NIMH Strategic Goal 4, is to optimize MBC effectiveness and thus improve youth clinical outcomes. Next, we will create implementation strategies to improve MBC fidelity and test them through a Type 1 Effectiveness Implementation Hybrid funded by an NIMH R34. This R01 is a critical building block in our effort to realize the promise and optimize the effectiveness of MBC.