Local Quality Assurance Tool for Family Therapy in Usual Care for Adolescent Substance Use

描述(由申请人提供)：到目前为止，生态家庭疗法(EFT)在治疗青少年物质使用(ASU)方面拥有最大的经验支持基础。在对照试验中，人工EFT模型已被证明一贯优于所有类型的替代治疗。然而， EFT尚未在全国范围内的ASU治疗系统中广泛采用。采用的一个主要障碍是由手动EFT使用的供应商驱动的方法与供应商社区的需求之间的不匹配。EFT有几个品牌，每个品牌都有一套专有的昂贵且高度结构化的培训、监督和保真度控制指南。这些质量保证(QA)程序过于昂贵、僵化且受外部控制，无法满足多样化劳动力的所有需求。这项研究将从经验上提炼出手工化EFT的核心技术，以产生一个非专有的、可免费获得的、心理测量学上有效的EFT QA工具包(保真度工具、培训/实施支持)，该工具包可以在本地与内部资源相结合。该工具包将促进EFT在常规护理或ASU中的高保真交付。开发这一资源的时机恰到好处：《平价医疗法案》和相关政策变化带来了前所未有的机会，通过供应商合同中内置的培训和认证要求，在行为医疗中更多地采用基于证据的方法。因此，行为治疗的有效质量保证程序和措施的需求巨大。遗憾的是，现有的质量保证程序没有包含实施保真度指南：提供哪些具体干预措施，以及如何做好这些干预措施。目前亚利桑那州立大学的治疗系统也是如此，该系统颁布了“最佳做法”，包括客户参与和护理连续性的广泛原则，而不是具体的技术。这项拟议的研究将综合三种EFT模型的核心技术，以构建支持常规护理中EFT保真度的QA工具包。这项研究将对两组记录的会议进行观察保真度分析：(A)来自功能性家庭治疗(FFT)、多维家庭治疗(MDFT)和简短策略性家庭治疗(BSFT)对照试验的300个黄金标准EFT会议；以及(B)来自三项实施研究的300个一线EFT会议，样本在常规环境中进行。新的EFT QA度量将通过使用分别与FFT、MDFT和BSFT相关的经过充分验证的观测保真度度量对这两个会话池进行编码而得到。与父母的衡量标准一样，新的QA工具将评估四个保真度维度：坚持核心EFT技术、全球EFT能力、治疗师家庭联盟和生态重点。EFT QA工具的具体项目将从黄金标准会议(目标1)中综合出来，在一线会议上进行验证(目标2)，并在一线保真度评级和客户结果上进行验证(目标3)。我们 基于使用相同样本收集的试点数据、观测保真度测量和本提案中描述的编码方法，预期在合成核心EFT技术方面取得成功。我们的试点数据显示，代表在数据分析过程中预计出现的四个EFT治疗组成部分的类似项目之间具有很强的相关性：家庭参与、关系重组、家庭重组和家庭技能建设。所有研究分析和QA工具包产品(固定工具和编码手册、EFT技术说明、培训和实施资源)将在协作性工具包开发过程中由专家评审小组审查，该专家评审小组由EFT临床理论和研究、各种儿童障碍的手动治疗模式的核心元素的提炼、EFT保真度-结果研究以及治疗ASU的一线家庭治疗师组成的专家组成。从现有的手册资源开发心理测量学有效的EFT QA工具包将创建一个新的QA资源，可用于评估EFT在行为护理中的广泛实施活动：评估EFT培训结果、基于数据的ASU和相关疾病治疗计划、治疗实践的行政和监管审查以及提供者认证， 仅举几个例子。最重要的是，新的EFT QA工具包可以加速在亚利桑那州立大学的常规护理中采用EFT，因为提供者将倾向于选择一种既高效又以成本效益方式满足监管对质量标准的要求的方法。拟议的工具包将以两种方式提供：(1)向任何有执照的提供者免费提供，以纳入其现有的内部程序，以培训和监测工作人员临床医生；或(2)作为一个更大的质量保证和临床管理系统中的一个治疗模块打包。这项拟议的研究在几个方面具有创新性。它将开发第一个能够为EFT定义通用质量标准的质量保证工具。现有的EFT工具仅为给定的品牌型号定义性能标准，并且在供应商的影响范围之外具有有限的价值。这项研究还将为开发基于验证的保真度衡量标准的核心质量保证工具的经验方法制定路线图；这一创新对其他具有多个手册版本的治疗方法具有广泛的适用性(例如，用于SUD的CBT)，并将推进行为保健的一个重要新研究领域。最后，研究方法将加快确定针对青少年障碍的循证政策质量指标的步伐。目前的努力依赖于多个研究中心的协调努力，以确定基于较长时期的文献审查和共识建立的质量指标。相反，这项研究将使用经验蒸馏方法，并有目的地召集专家小组审查研究数据和产品。

DESCRIPTION (provided by applicant): Ecological family therapy (EFT) has by far the largest base of empirical support for treating adolescent substance use (ASU). Manualized EFT models have proven consistently superior to every type of alternative treatment in controlled trials. Yet, EFT has not been widely adopted within ASU treatment systems nationwide. A primary barrier to adoption is the mismatch between the purveyor-driven methods used by manualized EFTs and the needs of the provider community. There are several EFT brands and each has a proprietary set of expensive and highly structured training, supervision, and fidelity control guidelines. These quality assurance (QA) procedures are too costly, inflexible, and externally controlled to meet all needs of a diverse workforce. This study will empirically distill the core techniques of manualized EFTs to produce a non-proprietary, freely available, psychometrically valid EFT QA toolkit (fidelity tool, training/implementation supports) that can be locally sustaine with intramural resources. This toolkit will promote high-fidelity delivery of EFT in routine care or ASU. The timing is perfect for developing this resource: The Affordable Care Act and related policy changes have ushered in unprecedented opportunities to increase adoption of evidence-based approaches in behavioral healthcare via training and certification requirements built into provider contracts. As a result, valid QA procedures and measures for behavioral treatments are in enormous demand. Unfortunately, existing QA procedures do not contain implementation fidelity guidelines: what specific interventions to deliver, and how to do them well. This is currently true for the ASU treatment system, which has promulgated "best practices" consisting of broad principles of client engagement and continuity-of-care rather than specific techniques. The proposed study will synthesize core techniques from three EFT models to construct a QA toolkit for supporting EFT fidelity in routine care. The study will conduct observational fidelity analyses on two pools of recorded sessions: (a) 300 gold-standard EFT sessions from controlled trials of Functional Family Therapy (FFT), Multidimensional Family Therapy (MDFT), and Brief Strategic Family Therapy (BSFT); and (b) 300 front-line EFT sessions from three implementation studies with ASU samples conducted in in routine settings. A new EFT QA measure will be derived from coding these two session pools using well-validated observational fidelity measures associated with FFT, MDFT, and BSFT respectively. As is true for the parent measures, the new QA tool will assess four fidelity dimensions: adherence to core EFT techniques, global EFT competence, therapist-family alliance, and ecological foci. Specific items for the EFT QA tool will be synthesized from gold- standard sessions (Aim 1), verified on front-line sessions (Aim 2), and validated on front-line fidelity ratings and client outcomes (Aim 3). We anticipate success in synthesizing core EFT techniques based on pilot data collected using the same samples, observational fidelity measures, and coding methods described in this proposal. Our pilot data reveal strong correlations among similar items representing four EFT treatment components projected to emerge during data analysis: family engagement, relational reframing, family restructuring, and family skill building. All study analyses and QA toolkit products (fideliy tool and coding manual, description of EFT techniques, training and implementation resources) will be vetted during a collaborative toolkit development process by an Expert Review Panel containing experts in EFT clinical theory and research, distillation of the core elements of manualized treatment models for various childhood disorders, and EFT fidelity-outcome research, along with front-line family therapists who treat ASU. Developing a psychometrically valid EFT QA toolkit from existing manualized resources would create a new QA resource that could be used to assess a wide spectrum of EFT implementation activities in behavioral care: evaluation of EFT training outcomes, data-based treatment planning for ASU and related disorders, administrative and regulatory review of treatment practices, and provider certification, to name a few. Most importantly, the new EFT QA toolkit could accelerate the adoption of EFT in routine care for ASU because providers will be inclined to select an approach that is both highly effective and meets regulatory demands for quality standards in a cost-efficient manner. The proposed toolkit will be available in two ways: (1) Cost-free to any licensed provider for incorporation into their existing intramural procedures for training and monitoring staff clinician; or (2) Packaged as one treatment module within a larger QA and clinical management system. The proposed study is innovative in several ways. It would develop the first QA tool capable of defining universal quality standards for EFT. Existing EFT tools define performance standards only for the given brand- name model and have limited value outside the purveyor's sphere of influence. The study will also produce a roadmap for developing empirical methods for distilling core QA tools based on validated fidelity measures; this innovation has broad applicability to other treatment approaches with multiple manualized versions (e.g., CBT for SUD) and will advance a vital new research area for behavioral healthcare. Finally, study methods will accelerate the pace of identifying quality indicators of EBPs for youth disorders. Current efforts rely on coordinated efforts from multiple research centers to identify quality metrics based on extended periods of literature review and consensus building. In contrast, this study will use empirical distillation methods and vet study data and products with a purposively convened expert panel.