BUILDING AN INTEGRATED SYSTEM OF CARE

Organizational Culture

The quality of services provided to families and children is influenced not only by the rigor of a program’s design and its implementation but also by the organizations in which services are embedded. Studies of organizational context have found associations between an organizational culture and climate and participant outcomes (Glisson and Hemmelgarn, 1998). Organizational culture also can result in improved service engagement, reduced staff turnover, and improved child outcomes, independent of the implementation of evidence-based practices (Glisson et al., 2010).

This relationship between organizational culture and program implementation is reciprocal. The implementation of evidence-based practices can adversely impact organizations by adding to the workload of an already overworked labor force or by leading to increased employee turnover as staff are asked to change their practices and adopt new strategies that may restrict their sense of control over the therapeutic process (Glisson et al., 2008; Sheidow et al., 2007; Woltmann et al., 2008). On the other hand, organizations also can benefit from the implementation of evidence-based practices. These benefits include enhanced professional identity, improved client outcomes, and the gratification of contributing to a process of knowledge generation (Aarons and Palinkas, 2007; Palinkas and Aarons, 2009). One statewide study of implementing evidence-based practices found that ongoing fidelity coaching predicted decreased staff burnout and reduced staff turnover (Aarons et al., 2009b).

These benefits aside, the culture of evidence-based practices that stems from an empirically based research perspective and the culture of child abuse and neglect practice may be at odds, engendering a gap that must be bridged if effective implementation is to be achieved (Palinkas et al., 2009). Even something as basic as the reporting of child abuse and neglect may be impacted by organizational context (Ashton, 2007). Thus, for example, an examination of child sexual abuse in the Catholic Church implicates a strong organizational culture as a major factor limiting the institution’s appropriate response to the problem (Keenan, 2011).

While some of the above-mentioned studies assess or deliberately alter organizational context, others examine or cite organizational context as important in the implementation of evidence-based practices (Kolko et al., 2012). Yet while there have been calls for increased attention to organizational context in the dissemination and implementation of evidence-based practices (Chaffin, 2006; Kessler et al., 2005), much research remains to be done on how organizational context in child abuse and neglect settings impacts the implementation process.

Interagency Networks

Although many factors influence the diffusion of evidence-based practices in general, “researchers have consistently found that interpersonal contacts within and between organizations and communities are important influences on the adoption of new behaviors” (Brekke et al., 2007; Palinkas et al., 2005, 2011, p. 8; Rogers, 2003). Based on diffusion of innovations theory (Rogers, 2003) and social learning theory (Bandura, 1986), Valente’s (1995) social network thresholds model calls for identification and matching of champions within peer networks that manage organizational agenda setting, change, and evaluation of change (e.g., data collection, evaluation, and feedback) and use information technology processes consistent with continuous quality improvement strategies (Palinkas et al., 2011).

Studies and meta-analyses have shown that both the influence of trusted others in one’s personal network and access and exposure to external information are important influences on rates of adoption of innovative practices (Palinkas et al., 2011). Across a series of studies, Valente and colleagues found that individuals who were most innovative almost always had the highest exposure to external influences (Valente and Davis, 1999; Valente et al., 2003, 2007). Although external influence played a crucial role in bringing an innovation to an individual’s attention, it was usually the persuasion of trusted others that finally convinced the individual to adopt the innovation (Valente, 1995). Other empirical studies have confirmed the importance and influence of opinion leaders (e.g., Jung et al., 2003). It has also been hypothesized that leaders in dense or centralized groups may have more power than leaders not in such groups (Valente, 2006), although this has not been found in all influence networks (Valente et al., 2007).

Applying this theoretical framework to child abuse and neglect, Palinkas and colleagues (2011) found that the social networks of county-level child welfare, mental health, and juvenile justice system leaders and staff play a significant role in the implementation of evidence-based practices for abused and neglected youth. System leaders develop and maintain networks of information and advice based on roles, responsibilities, geography, and friendship ties. Networks expose leaders to information about evidence-based practices and opportunities to adopt them, and also influence decisions to adopt. In that study, individuals in counties at the same stage of implementation of multidimensional treatment foster care accounted for 83 percent of all network ties. Networks in counties that decided not to implement a specific evidence-based practice had no extracounty ties. Implementation of multidimensional treatment foster care at the 2-year follow-up of a randomized controlled trial funded by the National Institute of Mental Health was associated with the size of the county, urban versus rural counties, and in-degree centrality (i.e., the extent to which others interacted with specific network members).

Successful, large-scale incorporation of evidence-based practices in existing child-serving systems is likely to involve multiple levels of constituents, in part because the new practices affect multiple stakeholders in the funding, planning, coordination, delivery, and receipt of services. Further, the successful implementation of many evidence-based practice models requires substantial interagency linkages.

In their report from the Blueprints programs, Mihalic and colleagues (2004) found these linkages to be a crucial factor in whether the programs had stable funding, a stable referral base, and coordinated case planning activities, especially for youth involved in multiple systems. In addition to interagency coordination, these linkages often include system-level factors that impact the implementing organization’s operation; that relate to federal and state laws and regulations; and that impact larger human resource decisions (e.g., collocation of staff from multiple agencies), access to funding streams, and contracting issues.

Most evidence-based practice implementation studies that focus on interorganizational collaboration fail to consider the wider context within which collaboration occurs, including such factors as the involvement of external stakeholders, sociopolitical processes, and the roles of relationships and leadership (Horwath and Morrison, 2007). Increasingly, this context is characterized by government mandates and fiscal realities that require collaboration in the form of integrative multidisciplinary practice in the delivery of children’s services (Ehrle et al., 2004; Hogan and Murphey, 2002). In a sociopolitical climate in which organizations face increasing budget restrictions and are challenged to do more with less, collaboration across agencies and organizations appears to be critical for successful implementation of evidence-based practices. In turn, an understanding of effective collaboration appears to be at the core of many evidence-based practices developed to improve outcomes in child-serving systems (Prince and Austin, 2005).

An extensive literature exists on the nature of interagency collaboration for the delivery of health and human services in general and child welfare services in particular. Although many consider such collaboration to be essential to the delivery of a complex array of services (Jones et al., 2004; Lippitt and van Til, 1981; Stroul and Friedman, 1986), others have questioned its usefulness on both theoretical (Scott, 1985) and empirical (Glisson and Hemmelgarn, 1998; Longoria, 2005) grounds. Several studies have pointed to improved access to services and improved outcomes associated with interagency collaboration (Bai et al., 2009; Cottrell et al., 2000; Hurlburt et al., 2004). However, Glisson and Hemmelgarn (1998) found that efforts to coordinate the services of public child-serving agencies in Tennessee were negatively associated with the quality of services provided. And Chuang and Wells (2010) found that while interagency sharing of administrative data increased the odds of youth receiving inpatient behavioral health services, having a single agency accountable for youth care increased the odds of receiving both inpatient and outpatient services.

In part, this inconsistency in findings may be attributable to differences in the definition and operationalization of key terms. For instance, some researchers have distinguished among collaboration, cooperation, coordination, and networking, whereas others have used these terms interchangeably (Grace et al., 2012; Hodges et al., 1999). Others view interagency collaboration as an aspect of organizational culture, defined as “the way things are done in an organization” (Glisson, 2007, p. 739).

Specific factors that have been found to contribute to successful interagency collaboration for child welfare and other agencies include shared goals, a high level of trust, mutual responsibility, open lines of communication, and strong leadership (Johnson et al., 2003; Weinberg et al., 2009). Barriers to effective collaboration include deeply ingrained mistrust and continued lack of other agencies’ values, goals, and perspectives; different organizational priorities; confusion over how services should be funded and who has jurisdiction over participants; and difficulty in tracking cases across organizations (Conger and Ross, 2006; Green et al., 2008; Sedlak et al., 2006).

The Bottom Line

Treatment and prevention programs generally are delivered by public agencies or community-based organizations. The operating culture within these entities has an impact on the quality of services and the extent to which evidence-based practices will be implemented and sustained over time. Research suggests that a degree of reciprocity exists between service models and their host agencies. In some instances, the rigor and quality of these innovations may alter the standards of practice throughout an agency, thereby improving the overall service delivery process and enhancing participant outcomes. In other cases, organizations that provide little incentive for staff to adopt new ideas or reduce the dosage or duration of evidence-based models to accommodate an agency’s limited resources contribute to poor implementation and reduced impacts. Maximizing the impact of evidence-based models and proven approaches will require more explicit attention to the organizational strengths and weaknesses of the agencies in which such models and approaches are embedded and how these factors impact service implementation.

Equally important is developing a research base that can inform the process of building a collaborative culture and a set of working relationships across the institutions and community-based agencies that constitute the child maltreatment response system. Because child abuse and neglect is a complex, multifaceted problem with myriad causes, promising treatment and prevention strategies lie within a variety of disciplines and multiple institutions. Additional research is needed to understand how these multiple institutional resources can be integrated in ways that reinforce the impact of these individual strategies in the most efficient and cost-effective manner.

Finding: Maximizing the impact of evidence-based models and proven approaches will require more explicit attention to the organizational strengths and weaknesses of the agencies in which such models and approaches are embedded and how these factors impact service implementation.

Finding: Multiple high-quality interventions and strategies must be sustained to address child abuse and neglect—a complex problem with diverse causal pathways, manifestations, and affected populations. An effective response to the problem would be facilitated by a more explicit focus on building an infrastructure that can support the most promising interventions as they emerge and link them in ways that maximize their collective impact.

Finding: Because child abuse and neglect are complex, multifaceted problems with myriad causes, a variety of disciplines and multiple institutions support treatment and prevention programs. Additional research is needed to understand how these multiple institutional resources can be integrated in ways that reinforce the impact of individual strategies in the most efficient and cost-effective manner.

Finding: Limited research has been conducted on the impact of infrastructure reforms on program implementation and participant outcomes. More research is needed to determine how best to direct efforts aimed at enhancing the knowledge and skills of the workforce, strengthening organizational capacity to support evidence-based practices, and reducing barriers to service access through better interagency coordination.