Despite the development of numerous evidence-based practices (EBPs), disseminating and implementing them in practice is a well-documented challenge. Indeed, a blue ribbon panel on health services research recently highlighted the need for research to identify the most effective ways to deliver high-quality treatment. One approach recommended by the Institute of Medicine (IOM) to improve the quality of health care is to reward provider performance (i.e., pay-for-performance).
The specific aims of the proposed study are to evaluate the effectiveness and cost-effectiveness of reinforcing therapists as a method to improve implementation of EBPs. A Center for Substance Abuse Treatment (CSAT) initiative called Assertive Adolescent and Family Treatment (AAFT;RFA TI-06-007) provides a unique opportunity to braid NIH research dollars and over $30 million of SAMHSA funding to address these aims. CSAT is providing each AAFT grantee with approximately $300,000 per year (for three years), as well as a comprehensive training and technical assistance model to facilitate the implementation of the Adolescent Community Reinforcement Approach (A-CRA;Godley et al., 2001). Ninety therapists from 32 AAFT grantees, who will provide treatment to approximately 3,000 adolescents, will receive the same comprehensive training and technical assistance in A-CRA. In the proposed experiment, therapists will be randomly assigned by site to be in either the control or in the reinforcement group. Therapists in the latter group will receive monetary incentives for (a) each of their adolescent clients who receive an empirically derived target level of A-CRA (i.e., 12 or more A-CRA procedures over eight or more A-CRA sessions);and (b) each month that a randomly selected session recording is rated at or above the competence level required for A-CRA certification. Urn randomization and propensity score adjustments will be used to control for differences in both therapist-level and client-level variables. Effectiveness analyses will focus on the extent to which the reinforcement approach increases the likelihood that (a) adolescents receive the target level of A-CRA treatment;(b) therapists demonstrate monthly competence;and (c) adolescents are in recovery (no alcohol or other drug use, abuse, or dependence symptoms while living in the community) 12 months after intake. Cost analyses will focus on whether the increased costs of therapist incentives can be offset by improvements in these three outcomes.
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