Impact of learning health systems on cross-system collaboration between youth legal and community mental health systems: a type II hybrid effectiveness-implementation trial

Background: Youth involved in the legal system have disproportionately higher rates of problematic substance use than non-involved youth. Identifying and connecting legal-involved youth to substance use intervention is critical and relies on the connection between legal and behavioral health agencies, which may be facilitated by learning health systems (LHS). We analyzed the impact of an LHS intervention on youth legal and behavioral health personnel ratings of their cross-system collaboration. We also examined organizational climate toward evidence-based practice (EBP) over and above the LHS intervention.

Methods: Data were derived from a type II hybrid effectiveness trial implementing an LHS intervention with youth legal and community mental health centers (CMHCs) in eight Indiana counties. Using a stepped wedge design, counties were randomly assigned to one of three cohorts and stepped in at nine-month intervals. Counties were in the treatment phase for 18 months, after which they were in the maintenance phase. Youth legal system and CMHC personnel completed five waves of data collection (n=307 total respondents, ranging from 108-178 per wave). Cross-system collaboration was measured via the Cultural Exchange Inventory, organizational EBP climate via the Implementation Climate Scale and Implementation Citizenship Behavior Scale, and intervention via a dummy-coded indicator variable. We conducted linear mixed models to examine: 1) the treatment indicator, and 2) the treatment indicator and organizational EBP climate variables on cross-system collaboration.

Results: The treatment indicator was not significantly associated with cross-system collaboration. When including the organizational EBP climate variables, the treatment indicator significantly predicted cross-system collaboration. Compared to the control phase, treatment (B=0.41, standard error [SE]=0.20) and maintenance (B=0.60, SE=0.29) phases were associated with greater cross-system collaboration output.

Conclusions: The analysis may have been underpowered to detect an effect; third variables may have explained variance in cross-system collaboration, and, thus, the inclusion of important covariates may have reduced residual errors and increased the estimation precision. The LHS intervention may have affected cross-system collaboration perception and offers a promising avenue of research to determine how systems work together to improve legal-involved-youth substance use outcomes. Future research is needed to replicate results among a larger sample and examine youth-level outcomes.

Trial registration: Clinicaltrials.gov identifier: NCT04499079. Registered 30 July 2020. https://clinicaltrials.gov/study/NCT04499079 .