Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) to Improve Collaboration in School Mental Health: Protocol for a Mixed Methods Hybrid Effectiveness-Implementation Study

Background Public schools in the United States are the main providers of mental health services to children but are often ill equipped to provide quality mental health care, especially in low-income urban communities. Schools often rely on partnerships with community organizations to provide mental health services to students. However, collaboration and communication challenges often hinder implementation of evidence-based mental health strategies. Interventions informed by team science, such as Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), have the potential to improve treatment implementation and collaboration within schools. Objective The objective of this study is to improve communication and collaboration strategies among mental health and school staff by adapting an evidence-based team science intervention for school settings. We present a protocol for a hybrid effectiveness-implementation study to adapt TeamSTEPPS using stakeholder feedback, develop a tailored implementation plan, and pilot the adapted content in eight schools. Methods Study participants will be recruited from public and charter schools and agencies overseeing school mental health services in the local metro area. We will characterize current services by conducting a needs assessment including stakeholder interviews, observations, and review of administrative data. Thereafter, we will establish an advisory board to understand challenges and develop possible solutions to guide additional TeamSTEPPS adaptations along with a complementary implementation plan. In aim 3, we will implement the adapted TeamSTEPPS plus tailored implementation strategies in eight schools using a pre-post design. The primary outcome measures include the feasibility and acceptability of the adapted TeamSTEPPS. In addition, self-report measures of interprofessional collaboration and teamwork will be collected from 80 participating mental health and school personnel. School observations will be conducted prior to and at three time points following the intervention along with stakeholder interviews. The analysis plan includes qualitative, quantitative, and mixed methods analysis of feasibility and acceptability, school observations, stakeholder interviews, and administrative data of behavioral health and school outcomes for students receiving mental health services. Results Recruitment for the study has begun. Goals for aim 1 are expected to be completed in Spring 2021. Conclusions This study utilizes team science to improve interprofessional collaboration among school and mental health staff and contributes broadly to the team science literature by developing and specifying implementation strategies to promote sustainability. Results from this study will provide knowledge about whether interventions to improve school culture and climate can ready both mental health and school systems for implementation of evidence-based mental health practices. Trial Registration ClinicalTrials.gov NCT04440228; https://clinicaltrials.gov/ct2/show/NCT04440228 International Registered Report Identifier (IRRID) DERR1-10.2196/26567


DESCRIPTION (provided by applicant):
Children obtain more mental health services through schools than through any other public system or agency. School-based mental health care often is provided by community mental health clinicians contracted to deliver school-based services. A ratelimiting step to the team's success in providing effective, evidence-based care is that the mission and work of the mental health teams, whose focus is on behavioral health service delivery, is not always consistent with the educational mission and needs of under-resourced schools. Participants will be drawn from school-based teams in Philadelphia's community mental health network and public schools. Existing methods to enhance the adoption, implementation, and sustainability of evidence-based practices have not addressed the challenges that this common model of collocated services poses, such as disparate goals and lack of coordination and collaboration. Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) has been widely disseminated in health care settings and provides a promising strategy for addressing communication and climate in school mental health teams. Philadelphia provides an ideal context in which to explore the impact of TeamSTEPPS on inter-organizational processes because Philadelphia relies heavily on mental health agencies to provide services in schools. Most students are low income minority children, allowing us to simultaneously address multiple AHRQ priority populations. We propose to take a participatory approach to collaboratively identify solutions to challenges in collocated school-based mental health services based upon the feedback of stakeholders using TeamSTEPPS to support mental health team-school collaboration. Consistent with AHRQ priorities to minimize adverse events, maximize recovery and support 360° person-centered team-based care, we propose the following aims. First, in Aim 1 we will capture key stakeholder perspectives about challenges in collocated school mental health services through formative work to inform collaborative planning and capacity building activities in Aim 2. Then, in Aim 2 we will identify inter-organizational challenges and required components of TeamSTEPPS to adapt. We will establish an advisory board and adapt TeamSTEPPS. The product of Aim 2 will be an adapted TeamSTEPPS, directed toward both school mental health and school-employed personnel, and specific, tailored implementation strategies to improve services in schools in conjunction with 1 R18 HS026862-01A1 3 HSQR WOLK, C TeamSTEPPS. Finally, we will explore the feasibility, acceptability, and utility of TeamSTEPPS and the strategies generated in Aim 2 on inter-professional collaboration, teamwork, and student outcomes in eight schools.

PUBLIC HEALTH RELEVANCE:
The present study has the potential to impact public health by improving the quality of mental health services received by children in schools. The research activities will improve our understanding of the complex problems that may occur when mental health services are collocated in schools and examine possible solutions. Intervention and implementation strategies to support this type of work will be important going forward given that s c hool dis tric ts are inc reas ingly relying on c ontrac ted m ental health providers and c olloc ation is a c om m on m odel in other settings (e.g., primary care).

CRITIQUES:
The written critiques of individual reviewers are provided in essentially unedited form below. These critiques were prepared prior to the meeting and may not have been revised afterwards. The "Resume and Summary of Discussion" above summarizes the final opinions of the committee.

Strengths
• This is a revised application that aims at adapting TeamSTEPPS to support mental health teamschool collaboration. The study aims at remediating the challenge posed by the lack of shared vision and mission of behavioral mental health service delivery in school and its educational mission. This diversion in mission forms the rate-limiting step in providing evidence-based mental health. The investigators preliminary work with school-based mental health teams in Philadelphia suggested lack of integration and alignment of mental health services with the educational mission, agenda and priorities. • This study addresses a significant challenge which is offering effective metal health services in school. Multiple previous models have been attempted but apparently failed (based on personal communication to the investigators). The current proposal will adapt a model that have demonstrated utility in other settings. • The investigative team is very experienced in this proposed model and have completed preliminary work within school and this application built on their previous experience which identified major challenges as communication and role definition. • Study's first aim is to capture key stakeholder perspectives about challenges in implementing mental health services in school and conduct a needs assessment with 15 key informants to understand why previous models of school-based mental health services have not improved child outcomes including inter-organizational challenges. • Aim 2 will focus on identification of inter-organizational challenges and required components of TeamSTEPPS to adapt, which will be accomplished through the advisory board consultative process. Stakeholders will include school mental health and school-employed personnel. • Aim 3 will involve an implementation feasibility, acceptability and utility of the optimized TeamSTEPPS, Weaknesses • Reportedly multiple evidence based models have failed to enhance mental health care within the school system. References to that failure is based on personal communication only. It 1 R18 HS026862-01A1 4 HSQR WOLK, C was unclear why the previous experiences have failed and what pitfalls the present proposal needs to address to avoid similar outcome. While this will be the goal of one study aim, it would have been helpful to have working hypotheses about the reasons for failure based on preliminary discussions with key informants from those experiences.

Significance: Strengths
• This study addresses a significant problem which is providing effective mental health services in school. • Providing mental health service within the school is an important goal and could be particularly impacting for children from low income and disadvantaged household. • The proposed model is designed to address two identified challenges for a successful integration of such services. More organic integration of mental health services within the educational goals and organizational structure is proposed to overcome some of the identified challenges. • If successful, this study may provide a successful model replicable in similar setting nationwide.

Weaknesses
• Limited evidence is presented to justify that the presented model will address the barriers to a better implementation of mental health services in school.

Investigators: Strengths
• Team with multiple expertise include implementation science, team science, school mental health research, and the relevant analytic approaches. He is a senior scientist who will consult on team science, Ming Xie highly experienced data analyst working with Medicaid and other health claims data.

Weaknesses
• PI relatively junior investigator • Still too many investigators

Innovation: Strengths
• This study is moderately innovative in terms of refining and adapting an already known intervention to a new setting and in examining broader contextual organizational processes and stakeholder involvements in school setting. • Use of nomenclature emphasizing student or children instead of patients Weaknesses • None noted.

Approach: Strengths
• Preliminary work indicated TeamSTEPPS was feasible and acceptable to implement.
• Identified leadership as an important facilitator.
• Identified barriers included staff turnover, lack of resources, and challenges in the school-mental health team relationship • Using the Consolidated Framework for Implementation Research (CFIR) Implementation Model as an overarching framework. • The approach has 3 aims: An interview with stakeholders to understand why previous model failed, the formation of an advisory board to develop an adapted model to apply to the school and then a feasibility and acceptability trials. • Assessment of outcome will include collaboration and teamwork (via self-report and observation), and of students' behavioral and educational outcomes. • TeamSTEPPS has been adapted to multiple health care setting • Aims 1 will include 3 main activities: An interview with key stake holders regarding previous failed experiences, an observation of 5 successful MH teams and 5 underperforming MH team and team work will be assesses using the Oxford Non-Technical Skills (NOTECHS) scale, the third activity is to examine students' behavioral health and school outcomes, by analyzing Medicaid claims data. • Widely representative group of stakeholders including school mental health providers (including clinicians and paraprofessionals), teachers, school and agency leaders/supervisors, parents of youth receiving school-based mental health services, and stakeholders from .
• Aim 3 will test the feasibility and acceptability on inter-professional collaboration, teamwork, and student outcomes in eight schools. • Scales to assess TeamSTEPPS outcomes are well validated.

Weaknesses
• There is no review of national experience with school-based mental health care.
• Time-line (5 years) seems too excessive, for example an entire year is allowed for the advisory group to formulate the adapted model. • The integration of the data gathered from aim 1 and how it will help to adapt the proposed model was not clear as the role of the Medicaid claim data. • The advisory board in aim 2 has an a priori primary focus which is stated as to understand challenges, including but not limited to the problem of limited coordination and collaboration between mental health providers and school personnel, and identify possible solutions and further TeamSTEPPS adaptations. If these issues have been identified a priori, it was unclear whether the insight derived from aim 1 will address these issues and how data derived from aim 1 will inform aim 2. • The process of aim 2 in terms of themes is not very well specified and open ended.
• Administrative data is collected during 1 st year and apparently the year after the intervention, however the table of the study timeline is confusing and does not reflect this schedule. • No assessment of parents' opinion of outcome.
• Instrument used to assess study outcome of interprofessional collaboration is still not well validated. • The link between failure of previous mental health service models and the proposed model as a remedial model is not clear and not supported by the data presented. • The interview assessing the feasibility and acceptability of TeamSTEPPS has not been developed yet. • Evaluation of the potential dissemination of the model to other schools seems premature if the model's utility has not been proven yet. • Nebulous calculation of sample size needed.