Co-Occurring Evidence-Based Practice: Integrated Dual Disorder Treatment Fidelity at Baseline, Full Implementation, and with Practice Alteration

Background and Purpose: Almost 8 million Americans have a co-occurring mental illness and substance use disorder.  Co-occurring disorders (COD) are associated with worse outcomes in incarceration, homelessness, hospitalization, unemployment, and health concerns compared to single disorders.  Integrated Dual Disorder Treatment (IDDT), a team Evidence-Based Practice (EBP) with a toolkit and fidelity scale designed by SAMHSA is associated with improvements in outcomes.  IDDT can take years to implement.  Additional EBPs and team leader turnover effect fidelity.  Studies to date on IDDT fidelity have been limited to 6 teams over a period of 5 years, and systematic changes to the IDDT team of adding peers has not been studied.  Key research questions include the variability of IDDT fidelity at baseline and subsequent reviews, change in fidelity over time across teams, and within teams over time, and the difference in fidelity for IDDT teams that included peers, and those that did not, were evaluated.

Methods:  A descriptive and binomial analysis of a secondary data set including the full population of IDDT fidelity reviews from 2006-2012 in one state was completed.  Predictor variables including rural teams, also practicing ACT, and year of review, and outcome variable, total fidelity, were used.  Hierarchical linear models with reviews (122) at level 1 and teams (68) at level two evaluated growth trajectory over time between and within teams.  Data on peers on IDDT teams, a major practice alteration, was collected retrospectively from team leaders for each year of analysis, with a 27% response rate. 

Results: At first fidelity review (68), 45.6% of teams were in rural counties, and 77.9% were also practicing ACT.  Mean baseline review total fidelity (M=3.38, SD=.71) was significantly related to year of review (F(6, 57) =5.34, p<.001) in the ANOVA analysis, with later reviews having higher fidelity.  Teams that were not practicing ACT had significantly higher fidelity (t(62) =2.33, p=.023).  Second fidelity reviews (40) had higher fidelity (M=3.76, SD=.67), and third reviews (13) higher fidelity still (M=3.92, SD=.63).  Teams that did not have a second or third review did not have significantly higher outcomes than teams that did, so results could be extrapolated to the whole population.  There was positive growth in fidelity within teams over time (=3.73, SE=.17, t(65) =21.53, p<.001) and teams that were not also practicing ACT had significantly higher baseline fidelity and slope.  Of the 20 teams that reported peer variables at their most recent fidelity review, 3 had no peer, 9 a part-time peer, and 8 a full-time peer.  Full-time peer status was significantly associated with higher fidelity (F(2, 17) =5.88, p<.05).

Conclusions and Implications: In this large sample over a long window of time, IDDT takes time to implement at improved fidelity, and improves within teams over occurrences.  The practice alteration of adding peers is associated with higher fidelity, which has implications for team composition, implementation, and policy.  Results confirm previous smaller studies of IDDT fidelity, and make possible advanced multi-level modeling to examine growth within and between teams, adding to the research on EBPs for COD.