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| ID | Type | Description | Link |
|---|---|---|---|
| R01MH119127 | U.S. NIH Grant/Contract | View source |
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| Name | Class |
|---|---|
| University of California, San Diego | OTHER |
| University of Central Florida | OTHER |
| University of Pennsylvania | OTHER |
| National Institute of Mental Health (NIMH) |
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This study will investigate the effects of an organizational implementation strategy called Leadership and Organizational Change for Implementation (LOCI), relative to training and technical assistance only, on fidelity to, and youth service outcomes of, a well-established digital measurement-based care intervention called the Outcomes Questionnaire-Analyst in outpatient community mental health clinics.
Using a cluster randomized, controlled, hybrid type III effectiveness-implementation design, this trial will investigate the effects of LOCI on the fidelity and and clinical outcomes of a digital measurement-based care (MBC) system called the Outcomes Questionnaire Analyst (OQ-A). The trial will enroll up to 22 outpatient mental health clinics that serve youth and randomly assign them using covariate constrained randomization to either LOCI or training and technical assistance only. Within each clinic, up to 2 first level leaders will be recruited (max N of 40 total) and a minimum of 3 clinicians will be recruited per site (60 total). Data on youth outpatients who receive services will be collected in two phases. In each phase, a unique cohort of 360 caregivers of youth who participate in services will be sampled from the participating clinics. Caregivers will report on the service outcomes and experiences of eligible youth who receive services. The total caregiver enrollment for two phases will be 720 (360*2).
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| LOCI (Intervention) | Experimental | In clinics assigned to the LOCI condition, executives and first-level leaders will receive leadership training and coaching to support implementation of the OQ-A system. In addition, leaders and clinicians in this condition will receive training and technical assistance to implement the OQ-A measurement-based care system. |
|
| Training and Technical Assistance only (Control) | Active Comparator | In clinics assigned to the control group, leaders and clinicians will receive training and technical assistance to implement the OQ-A measurement-based care system. In addition, to support enrollment in this condition, leaders in this condition will be offered access to general web-based leadership seminars. |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Leadership for Organization Change and Implementation (LOCI) | Behavioral | LOCI is a multicomponent implementation strategy that engages organizational executives and first-level leaders (i.e., those who administratively supervise clinicians) to build an organizational climate to support the implementation of a focal evidence-based practice (EBP) with fidelity. In this study, the focal EBP is the OQ-A system. LOCI includes two overarching components: (1) monthly organizational strategy meetings between executives and LOCI consultants/trainers to develop and embed policies, procedures, and practices that support implementation of a focal EBP, and (2) training and coaching for first-level leaders, to develop their skills in leading implementation. The aim of these components is to develop an organizational implementation climate in which clinicians' perceive that use of the OQ-A with high fidelity is expected, supported, and rewarded. |
| Measure | Description | Time Frame |
|---|---|---|
| Percentage Fidelity to the OQ-A System Experienced by the Youth (0-100%) | Fidelity to the OQ-A will be measured by using electronic meta-data from the OQ-A system combined with caregiver reported information on the number of sessions the youth attended. For each youth, a fidelity index will be generated that represents the product of two quantities: (a) the youth's completion rate (i.e., number of measures administered relative to the number of sessions attended within the 6-month observation period), and (b) the youth's viewing rate (i.e., the number of feedback reports viewed by the clinician relative to the number of measures administered). Note that this product is equivalent to the ratio of viewed feedback reports to total sessions; it represents an events/trials proportion. MBC fidelity index scores summarize the level of MBC fidelity experienced by each youth (range=0-1). Higher scores indicate the youth experienced greater fidelity to MBC. | 0-6 months after youth's baseline/ entry into treatment |
| Change From Baseline to 6-months in Youth Total Problems Score on the Short Form Assessment for Children (SAC) - Phase I Cohort | The SAC Total Problem Score is a 48-item measure of youth internalizing (e.g., anxious, depressed) and externalizing (e.g., aggressive, noncompliant, overactive) behaviors (range=0-96) completed by caregivers of youth. Total Problem Score was assessed at baseline (youth's entry into treatment) and monthly for 6 months, change from baseline to month 6 is reported. | 0-6 months after youth's baseline/ entry into treatment |
| Change From Baseline to 6-months in Youth Total Problems Score on the Short-form Assessment for Children (SAC) - Phase II Cohort | The SAC Total Problem Score is a 48-item measure of youth internalizing (e.g., anxious, depressed) and externalizing (e.g., aggressive, noncompliant, overactive) behaviors (range=0-96) completed by caregivers of youth. Total Problem Score was assessed at baseline (youth's entry into treatment) and monthly for 6 months, change from baseline to month 6 is reported. | 0-6 months after youth's baseline/ entry into treatment |
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Participants for this project will fall into four groups: 1) clinic executives and upper leaders (i.e., Chief Executive Officer, Executive Directors, program administrators, n=20), 2) clinic first-level leaders (i.e. clinical supervisors, n=20), 3) clinicians serving children with emotional and behavioral disorders (n=120), and 4) caregivers of children with emotional and behavioral disorders who receive outpatient mental health services within participating clinics (n=720). Caregivers will be recruited in two distinct cohorts of 360 each.
Inclusion criteria for all groups of participants are intentionally broad in line with the pragmatic nature of the trial.
Inclusion Criteria for Clinics
Inclusion Criteria for Executives and Upper Leaders
1. Identified as Chief Executive Officer, Executive Director, or high-level administrator at an enrolled clinic
Inclusion Criteria for first-level leaders
1. Identified as a clinical supervisor or clinical work-group supervisor/ leader at an enrolled clinic
Inclusion Criteria for Clinicians
Inclusion Criteria for Caregivers of Youth Who Receive Services at Participating Clinics
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| Name | Affiliation | Role |
|---|---|---|
| Nate Williams, PhD | Boise State University | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| University of California, San Diego | San Diego | California | 92093 | United States | ||
| University of Central Florida |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 41656239 | Derived | Williams NJ, Choy-Brown M, Vega N, Aarons GA, Ehrhart MG, Marcus SC. Testing normalization process theory in a randomized trial of mental health clinics implementing digital measurement-based care. Implement Sci. 2026 Feb 9;21(1):16. doi: 10.1186/s13012-026-01485-4. | |
| 39797386 | Derived | Williams NJ, Gomes AE, Vega NR, Esp S, Choy-Brown M, Beidas RS. A multilevel framework for recruitment and retention in implementation trials: An illustrative example. Clin Trials. 2025 Jun;22(3):325-341. doi: 10.1177/17407745241307948. Epub 2025 Jan 10. |
| Label | URL |
|---|---|
| Information about Leadership for Organizational Change for Implementation (LOCI). | View source |
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Data were only collected from caregivers of youth who received services at participating clinics. Caregivers reported on youth's mental health service experiences and outcomes. Consequently, started and completed numbers shown below only reflect caregivers of eligible youth who participated in services (i.e., number of caregivers enrolled). Youths were not enrolled.
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| ID | Title | Description |
|---|---|---|
| FG000 | LOCI (Intervention) | In clinics assigned to the LOCI condition, executives and first-level leaders will receive leadership training and coaching to support implementation of the OQ-A system. In addition, leaders and clinicians in this condition will receive training and technical assistance to implement the OQ-A measurement-based care system. Leadership for Organization Change and Implementation (LOCI) is a multicomponent implementation strategy that engages organizational executives and first-level leaders (i.e., those who administratively supervise clinicians) to build an organizational climate to support the implementation of a focal evidence-based practice (EBP) with fidelity. In this study, the focal EBP is the OQ-A system. LOCI includes two overarching components: (1) monthly organizational strategy meetings between executives and LOCI consultants/trainers to develop and embed policies, procedures, and practices that support implementation of a focal EBP, and (2) training and coaching for first-level leaders, to develop their skills in leading implementation. The aim of these components is to develop an organizational implementation climate in which clinicians' perceive that use of the OQ-A with high fidelity is expected, supported, and rewarded. Training and Technical Assistance: All leaders and clinicians in participating clinics will receive standardized OQ-A training and technical assistance provided by the OQ-A purveyor organization. |
| FG001 | Training and Technical Assistance Only (Control) | In clinics assigned to the control group, leaders and clinicians will receive training and technical assistance to implement the OQ-A measurement-based care system. In addition, to support enrollment in this condition, leaders in this condition will be offered access to general web-based leadership seminars. Training and Technical Assistance Only: All leaders and clinicians in participating clinics will receive standardized OQ-A training and technical assistance provided by the OQ-A purveyor organization. This includes an initial, 6-hr, in-person OQ-A training; two, live, virtual, 1-hr booster trainings, offered 3 and 5 months after the initial training; and, year-round technical assistance from the OQ-A purveyor organization. Technical assistance includes virtual training sessions, online library of training videos, and customer care representative for technical support. In addition, to encourage participation in the study, a set of four 1-hr, web-based general leadership seminars will be offered to leaders in the control condition. These will cover topics ranging from effective leadership, to giving effective feedback. |
| Title | Milestones | Reasons Not Completed | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Phase I |
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| ||||||||||||||||||
| Phase II |
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The data presented below reflects characteristics of youth as reported by their enrolled caregivers. With the exception of the family variables noted below, data on caregivers was not reported. Required fields for age, race, and sex refer to caregivers and therefore have values of 0 because this data was not reported. Please also note that the baseline characteristics shown below are reported separately for Phase I and Phase II of the trial because each phase was enrolled as a separate cohort.
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| ID | Title | Description |
|---|---|---|
| BG000 | LOCI (Intervention) | The Leadership for Organization Change and Implementation (LOCI) strategy is a multicomponent implementation strategy that engages organizational executives and first-level leaders (i.e., those who administratively supervise clinicians) to build an organizational climate to support the implementation of a focal evidence-based practice (EBP) with fidelity. In this study, the focal EBP is the OQ-A system. LOCI includes two overarching components: (1) monthly organizational strategy meetings between executives and LOCI consultants/trainers to develop and embed policies, procedures, and practices that support implementation of a focal EBP, and (2) training and coaching for first-level leaders, to develop their skills in leading implementation. The aim of these components is to develop an organizational implementation climate in which clinicians' perceive that use of the OQ-A with high fidelity is expected, supported, and rewarded. |
| Units | Counts |
|---|---|
| Participants |
|
| Title | Description | Population Description | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Denominator Units Selected | Denominators | Classes |
|---|---|---|---|---|---|---|---|---|---|
| Age, Categorical | Data not collected from caregivers for this baseline measure |
| Type | Title | Description | Population Description | Reporting Status | Anticipated Posting Date | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Time Frame | Units Analyzed | Denominator Units Selected | Arm/Group Information | Denominators | Classes | Analyses |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Primary | Percentage Fidelity to the OQ-A System Experienced by the Youth (0-100%) | Fidelity to the OQ-A will be measured by using electronic meta-data from the OQ-A system combined with caregiver reported information on the number of sessions the youth attended. For each youth, a fidelity index will be generated that represents the product of two quantities: (a) the youth's completion rate (i.e., number of measures administered relative to the number of sessions attended within the 6-month observation period), and (b) the youth's viewing rate (i.e., the number of feedback reports viewed by the clinician relative to the number of measures administered). Note that this product is equivalent to the ratio of viewed feedback reports to total sessions; it represents an events/trials proportion. MBC fidelity index scores summarize the level of MBC fidelity experienced by each youth (range=0-1). Higher scores indicate the youth experienced greater fidelity to MBC. | Youths from the Phase I Cohort were included in this analysis. | Posted | Mean | Standard Error | percentage fidelity achieved | 0-6 months after youth's baseline/ entry into treatment |
|
Adverse event data were not collected for caregivers, who were the ones formally enrolled in the study.
Because adverse event data were not collected for caregiver participants, the numbers at risk in each category below equal zero.
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| ID | Title | Description | Deaths (Affected) | Deaths (At Risk) | Serious Events (Affected) | Serious Events (At Risk) | Other Events (Affected) | Other Events (At Risk) |
|---|---|---|---|---|---|---|---|---|
| EG000 | LOCI (Intervention) | The Leadership for Organization Change and Implementation (LOCI) strategy is a multicomponent implementation strategy that engages organizational executives and first-level leaders (i.e., those who administratively supervise clinicians) to build an organizational climate to support the implementation of a focal evidence-based practice (EBP) with fidelity. In this study, the focal EBP is the OQ-A system. LOCI includes two overarching components: (1) monthly organizational strategy meetings between executives and LOCI consultants/trainers to develop and embed policies, procedures, and practices that support implementation of a focal EBP, and (2) training and coaching for first-level leaders, to develop their skills in leading implementation. The aim of these components is to develop an organizational implementation climate in which clinicians' perceive that use of the OQ-A with high fidelity is expected, supported, and rewarded. |
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| Title | Organization | Phone | Extension | |
|---|---|---|---|---|
| Dr. Nathaniel Williams | Boise State University | 2084263145 | natewilliams@boisestate.edu |
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| Type | Includes Protocol | Includes SAP | Includes ICF | Document Label | Document Date | Document Uploaded Date | Document File Name |
|---|---|---|---|---|---|---|---|
| Prot_SAP | Yes | Yes | No | Study Protocol and Statistical Analysis Plan | Dec 21, 2023 | Jan 31, 2024 | Prot_SAP_000.pdf |
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| ID | Term |
|---|---|
| D001526 | Behavioral Symptoms |
| ID | Term |
|---|---|
| D001519 | Behavior |
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| ID | Term |
|---|---|
| D007857 | Leadership |
| ID | Term |
|---|---|
| D010559 | Personnel Management |
| D009934 | Organization and Administration |
| D006298 | Health Services Administration |
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| NIH |
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Clinicians and caregivers of youth were naïve to condition; however, masking of clinic leaders was not possible due to the nature of the LOCI strategy (which entails leadership training and consultation).
|
| Training and Technical Assistance Only | Behavioral | All leaders and clinicians in participating clinics will receive standardized OQ-A training and technical assistance provided by the OQ-A purveyor organization. This includes an initial, 6-hr, in-person OQ-A training; two, live, virtual, 1-hr booster trainings, offered 3 and 5 months after the initial training; and, year-round technical assistance from the OQ-A purveyor organization. Technical assistance includes virtual training sessions, online library of training videos, and customer care representative for technical support. In addition, to encourage participation in the study, a set of four 1-hr, web-based general leadership seminars will be offered to leaders in the control condition. These will cover topics ranging from effective leadership, to giving effective feedback. |
|
| Orlando |
| Florida |
| 32816 |
| United States |
| Boise State University | Boise | Idaho | 83725 | United States |
| University of Pennsylvania | Philadelphia | Pennsylvania | 19104 | United States |
| 38549122 | Derived | Williams NJ, Ehrhart MG, Aarons GA, Esp S, Sklar M, Carandang K, Vega NR, Brookman-Frazee L, Marcus SC. Improving measurement-based care implementation in youth mental health through organizational leadership and climate: a mechanistic analysis within a randomized trial. Implement Sci. 2024 Mar 28;19(1):29. doi: 10.1186/s13012-024-01356-w. |
| 38070868 | Derived | Williams NJ, Marcus SC, Ehrhart MG, Sklar M, Esp SM, Carandang K, Vega N, Gomes AE, Brookman-Frazee L, Aarons GA. Randomized Trial of an Organizational Implementation Strategy to Improve Measurement-Based Care Fidelity and Youth Outcomes in Community Mental Health. J Am Acad Child Adolesc Psychiatry. 2024 Oct;63(10):991-1004. doi: 10.1016/j.jaac.2023.11.010. Epub 2023 Dec 7. |
| 37024945 | Derived | Choy-Brown M, Williams NJ, Ramirez N, Esp S. Psychometric evaluation of a pragmatic measure of clinical supervision as an implementation strategy. Implement Sci Commun. 2023 Apr 6;4(1):39. doi: 10.1186/s43058-023-00419-1. |
| Information about the digital measurement-based care system, OQ-A. | View source |
| NOT COMPLETED |
|
|
| BG001 | Training and Technical Assistance Only (Control) | All leaders and clinicians in participating clinics will receive standardized OQ-A training and technical assistance provided by the OQ-A purveyor organization. This includes an initial, 6-hr, in-person OQ-A training; two, live, virtual, 1-hr booster trainings, offered 3 and 5 months after the initial training; and, year-round technical assistance from the OQ-A purveyor organization. Technical assistance includes virtual training sessions, online library of training videos, and customer care representative for technical support. In addition, to encourage participation in the study, a set of four 1-hr, web-based general leadership seminars will be offered to leaders in the control condition. These will cover topics ranging from effective leadership, to giving effective feedback. |
| BG002 | Total | Total of all reporting groups |
| Count of Participants |
| Participants |
|
| Sex/Gender, Customized | Data not collected from caregivers for this baseline measure | Count of Participants | Participants |
|
| Race/Ethnicity, Customized | Data not collected from caregivers for this baseline measure | Count of Participants | Participants |
|
| Phase I: Youth Short-form Assessment for Children (SAC) Total Problem Score | The SAC Total Problem Score is a 48-item measure of youth internalizing (e.g., anxious, depressed) and externalizing (e.g., aggressive, noncompliant, overactive) behaviors (range=0-96). It has extensive evidence of score reliability and validity in clinical and non-clinical samples as well as sensitivity to change in randomized trials. Higher scores indicate more problems. The clinical cut score is 26. | Data for Phase I only | Mean | Standard Deviation | units on a scale |
|
| Phase I: Youth received prior mental health treatment | Data for Phase I only | Count of Participants | Participants |
|
| Phase I: Family Income | Data for Phase I only | Count of Participants | Participants |
|
| Phase I: Parent Highest Education Level | Data for Phase I only | Count of Participants | Participants |
|
| Phase I: Youth age | Data for Phase I only | Mean | Standard Deviation | years |
|
| Phase I: Youth sex | Data for Phase I only | Count of Participants | Participants |
|
| Phase I: Youth Race | Data for Phase I only | Count of Participants | Participants |
|
| Phase I: Youth Hispanic/ Latinx Ethnicity | Date for Phase I only | Count of Participants | Participants |
|
| Phase II: Youth Short-form Assessment for Children (SAC) Total Problem Score | The SAC Total Problem Score is a 48-item measure of youth internalizing and externalizing behaviors (range=0-96). It has extensive evidence of score reliability and validity in clinical and non-clinical samples as well as sensitivity to change in randomized trials. Higher scores indicate more problems. The clinical cut score is 26. | Data for Phase II only | Mean | Standard Deviation | units on a scale |
|
| Phase II: Youth received prior mental health treatment | Data for Phase II only | Count of Participants | Participants |
|
| Phase II: Family income | Data for Phase II only | Count of Participants | Participants |
|
| Phase II: Parent Highest Education Level | Data for Phase II only | Count of Participants | Participants |
|
| Phase II: Youth age | Data for Phase II only | Mean | Standard Deviation | years |
|
| Phase II: Youth sex | Data for Phase II only | Count of Participants | Participants |
|
| Phase II: Youth race | Data for Phase II only | Count of Participants | Participants |
|
| Phase II: Youth Hispanic/ Latinx Ethnicity | Data for Phase II only | Count of Participants | Participants |
|
| Description |
|---|
| OG000 | LOCI (Intervention) | The Leadership for Organization Change and Implementation (LOCI) strategy is a multicomponent implementation strategy that engages organizational executives and first-level leaders (i.e., those who administratively supervise clinicians) to build an organizational climate to support the implementation of a focal evidence-based practice (EBP) with fidelity. In this study, the focal EBP is the OQ-A system. LOCI includes two overarching components: (1) monthly organizational strategy meetings between executives and LOCI consultants/trainers to develop and embed policies, procedures, and practices that support implementation of a focal EBP, and (2) training and coaching for first-level leaders, to develop their skills in leading implementation. The aim of these components is to develop an organizational implementation climate in which clinicians' perceive that use of the OQ-A with high fidelity is expected, supported, and rewarded. |
| OG001 | Training and Technical Assistance Only (Control) | All leaders and clinicians in participating clinics will receive standardized OQ-A training and technical assistance provided by the OQ-A purveyor organization. This includes an initial, 6-hr, in-person OQ-A training; two, live, virtual, 1-hr booster trainings, offered 3 and 5 months after the initial training; and, year-round technical assistance from the OQ-A purveyor organization. Technical assistance includes virtual training sessions, online library of training videos, and customer care representative for technical support. In addition, to encourage participation in the study, a set of four 1-hr, web-based general leadership seminars will be offered to leaders in the control condition. These will cover topics ranging from effective leadership, to giving effective feedback. |
|
|
|
| Primary | Change From Baseline to 6-months in Youth Total Problems Score on the Short Form Assessment for Children (SAC) - Phase I Cohort | The SAC Total Problem Score is a 48-item measure of youth internalizing (e.g., anxious, depressed) and externalizing (e.g., aggressive, noncompliant, overactive) behaviors (range=0-96) completed by caregivers of youth. Total Problem Score was assessed at baseline (youth's entry into treatment) and monthly for 6 months, change from baseline to month 6 is reported. | Analysis includes youths from Phase I cohort. | Posted | Mean | Standard Error | units on a scale | 0-6 months after youth's baseline/ entry into treatment |
|
|
|
|
| Primary | Percentage Fidelity to the OQ-A System Experienced by the Youth (0-100%) | Fidelity to the OQ-A will be measured by using electronic meta-data from the OQ-A system combined with caregiver reported information on the number of sessions the youth attended. For each youth, a fidelity index will be generated that represents the product of two quantities: (a) the youth's completion rate (i.e., number of measures administered relative to the number of sessions attended within the 6-month observation period), and (b) the youth's viewing rate (i.e., the number of feedback reports viewed by the clinician relative to the number of measures administered). Note that this product is equivalent to the ratio of viewed feedback reports to total sessions; it represents an events/trials proportion. MBC fidelity index scores summarize the level of MBC fidelity experienced by each youth (range=0-1). Higher scores indicate the youth experienced greater fidelity to MBC. | Analyses based on an intent-to-treat approach. Note that one clinic was identified as an extreme outlier and consequently was excluded from analyses. | Posted | Mean | Standard Error | percentage fidelity achieved | 0-6 months after youth's baseline/ entry into treatment |
|
|
|
|
| Primary | Change From Baseline to 6-months in Youth Total Problems Score on the Short-form Assessment for Children (SAC) - Phase II Cohort | The SAC Total Problem Score is a 48-item measure of youth internalizing (e.g., anxious, depressed) and externalizing (e.g., aggressive, noncompliant, overactive) behaviors (range=0-96) completed by caregivers of youth. Total Problem Score was assessed at baseline (youth's entry into treatment) and monthly for 6 months, change from baseline to month 6 is reported. | One clinic was excluded from analyses because it was an extreme outlier. | Posted | Mean | Standard Error | units on a scale | 0-6 months after youth's baseline/ entry into treatment |
|
|
|
|
| 0 |
| 0 |
| 0 |
| 0 |
| 0 |
| 0 |
| EG001 | Training and Technical Assistance Only (Control) | All leaders and clinicians in participating clinics will receive standardized OQ-A training and technical assistance provided by the OQ-A purveyor organization. This includes an initial, 6-hr, in-person OQ-A training; two, live, virtual, 1-hr booster trainings, offered 3 and 5 months after the initial training; and, year-round technical assistance from the OQ-A purveyor organization. Technical assistance includes virtual training sessions, online library of training videos, and customer care representative for technical support. In addition, to encourage participation in the study, a set of four 1-hr, web-based general leadership seminars will be offered to leaders in the control condition. These will cover topics ranging from effective leadership, to giving effective feedback. | 0 | 0 | 0 | 0 | 0 | 0 |
Not provided
Not provided
| Black or African American |
|
| Pacific Islander or Hawaiian Native |
|
| Prefer to self-describe |
|
| Prefer not to disclose |
|
| More than one race (Multiracial) |
|
| White |
|
| Unknown or not reported |
|
| $35,536 to $51,500 |
|
| More than $51,500 |
|
| Unknown or not reported |
|
| Bachelor's degree |
|
| Graduate degree |
|
| Unknown or not reported |
|
| Prefer not to disclose |
|
| $35,536 to $51,500 |
|
| More than $51,500 |
|
| Unknown |
|
| Bachelor's degree |
|
| Graduate degree |
|
| Unknown |
|
| Prefer not to disclose |
|
| Black or African American |
|
| Pacific Islander or Hawaiian Native |
|
| Prefer not to disclose |
|
| Prefer to self-describe |
|
| Multiracial |
|
| White |
|