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Specifying cross-system collaboration strategies for implementation: a multi-site qualitative study with child welfare and behavioral health organizations.

  • Bunger, Alicia C1
  • Chuang, Emmeline2
  • Girth, Amanda M3
  • Lancaster, Kathryn E4
  • Smith, Rebecca5
  • Phillips, Rebecca J6
  • Martin, Jared7
  • Gadel, Fawn8
  • Willauer, Tina9
  • Himmeger, Marla J8
  • Millisor, Jennifer8
  • McClellan, Jen8
  • Powell, Byron J10, 11, 12
  • Saldana, Lisa13
  • Aarons, Gregory A14
  • 1 Division of General Internal Medicine, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, OH, USA. [email protected].
  • 2 School of Social Welfare, University of California Berkeley, Berkeley, CA, USA.
  • 3 John Glenn College of Public Affairs, The Ohio State University, Columbus, OH, USA.
  • 4 School of Medicine, Wake Forest University, Winston-Salem, NC, USA.
  • 5 Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
  • 6 Social Science Division, Western Oregon University, Monmouth, OR, USA.
  • 7 Center for Vulnerable Populations, Department of Medicine, University of California, San Francisco, CA, USA.
  • 8 Public Children Services Association of Ohio, Columbus, OH, USA.
  • 9 Children and Family Futures, Irvine, CA, USA.
  • 10 Center for Mental Health Services Research, Brown School, Washington University in St. Louis, St. Louis, MO, USA.
  • 11 Center for Dissemination & Implementation, Institute for Public Health, Washington University in St. Louis, St. Louis, MO, USA.
  • 12 Division of Infectious Diseases, John T. Milliken Department of Medicine, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA.
  • 13 Lighthouse Institute, Chestnut Health Systems, Eugene, OR, USA.
  • 14 Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA.
Published Article
Implementation Science
Springer (Biomed Central Ltd.)
Publication Date
Feb 12, 2024
DOI: 10.1186/s13012-024-01335-1
PMID: 38347639


Cross-system interventions that integrate health, behavioral health, and social services can improve client outcomes and expand community impact. Successful implementation of these interventions depends on the extent to which service partners can align frontline services and organizational operations. However, collaboration strategies linking multiple implementation contexts have received limited empirical attention. This study identifies, describes, and specifies multi-level collaboration strategies used during the implementation of Ohio Sobriety Treatment and Reducing Trauma (Ohio START), a cross-system intervention that integrates services across two systems (child welfare and evidence-based behavioral health services) for families that are affected by co-occurring child maltreatment and parental substance use disorders. In phase 1, we used a multi-site qualitative design with 17 counties that implemented Ohio START. Qualitative data were gathered from 104 staff from child welfare agencies, behavioral health treatment organizations, and regional behavioral health boards involved in implementation via 48 small group interviews about collaborative approaches to implementation. To examine cross-system collaboration strategies, qualitative data were analyzed using an iterative template approach and content analysis. In phase 2, a 16-member expert panel met to validate and specify the cross-system collaboration strategies identified in the interviews. The panel was comprised of key child welfare and behavioral health partners and scholars. In phase 1, we identified seven cross-system collaboration strategies used for implementation. Three strategies were used to staff the program: (1) contract for expertise, (2) provide joint supervision, and (3) co-locate staff. Two strategies were used to promote service access: (4) referral protocols and (5) expedited access agreements. Two strategies were used to align case plans: (6) shared decision-making meetings, and (7) sharing data. In phase 2, expert panelists specified operational details of the cross-system collaboration strategies, and explained the processes by which strategies were perceived to improve implementation and service system outcomes. We identified a range of cross-system collaboration strategies that show promise for improving staffing, service access, and case planning. Leaders, supervisors, and frontline staff used these strategies during all phases of implementation. These findings lay the foundation for future experimental and quasi-experimental studies that test the effectiveness of cross-system collaboration strategies. © 2024. The Author(s).

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