Protocol for the Implementation Mechanisms of Stepping Up (I.M. Stepping Up) Study, a Longitudinal Natural Experiment Examining Implementation Mechanisms to Improve Mental Health and Substance Use Services for Justice-involved Individuals in 950 Stepping Up and Comparison Counties Across the U.S.

Abstract Background. The criminal justice system is the largest provider of mental health services in the U.S. Many jurisdictions are interested in reducing the use of the justice system for mental health problems. The national Stepping Up Initiative works with counties to reduce the number of individuals with mental illness in jails and to improve access to mental health services in the community. The Implementation Mechanisms of Stepping Up (I.M. Stepping Up) Study leverages a large natural experiment created by comparing Stepping Up counties to matched comparison counties over time to examine implementation mechanisms and outcomes. Methods. The study will survey 475 Stepping Up counties and 475 matched comparison counties at three waves: baseline, 18 months, and 36 months. Surveys will be sent to up to four respondents per county including administrators of jail, probation, community mental health services, and community substance use treatment services (3,800 total respondents). Implementation target mechanisms include: (1) use of and capacity for performance monitoring; (2) use and functioning of interagency teams; (3) common goals and mission across agencies; and (4) system integration (i.e., building an integrated system of care rather than adding one program or training). We will examine whether Stepping Up counties show a faster rate of improvement in hypothesized target mechanisms between Wave 1 and subsequent assessments (i.e., Waves 2 and 3) than do comparison counties (primary). We will also examine whether Stepping Up counties show a faster increases in implementation outcomes (number of justice-involved clients receiving behavioral health services, number of behavioral health evidence-based practices and policies [EBPPs] available to justice-involved individuals, and resources for behavioral health EBPP for justice-involved individuals). We will evaluate whether engagement of hypothesized mechanisms explains differences in implementation outcomes. Finally, we will characterize implementation processes and critical incidents using survey responses and qualitative interviews. Discussion. There are few rigorous, prospective studies examining implementation mechanisms and their relationship with behavioral health implementation outcomes in justice and associated community behavioral health settings. There is also limited understanding of implementation mechanisms that occur across systems with multiple goals. This study will elucidate target mechanisms in multi-goal, multi-agency systems.