Examining Determinants of Implementation for Cornerstone, an Intervention for Transition Age Youth with Mental Health Challenges

Background & Purpose: Transition-age youth (TAY) have elevated rates of mental health challenges as compared to other age groups. Yet, they are unlikely to receive developmentally-appropriate services in part because few mental health interventions have been created specifically for TAY and even fewer have been found to be effective. Cornerstone is a theoretically-guided, multi-component intervention that has shown promise for addressing the mental health and developmental needs of TAY. Cornerstone provides case management, mentoring, community-based in-vivo practice, and practical skill development to improve the transition to independence among TAY with mental health challenges. Using the Consolidated Framework for Implementation Research (CFIR), this study examined determinants of implementation of the Cornerstone intervention with the goal of creating a manual to guide real-world implementation as well as future effectiveness trials.

Methods: Within a Hybrid Type 2 trial, investigators developed a semi-structured interview protocol using implementation strategy domains as a framework. Face-to-face interviews were conducted with clinic staff (n= 8) and state-level leadership (n= 3), and research staff (n = 1) on determinants of implementation for Cornerstone, such as planning, training, and supervision. Using grounded theory with sensitizing concepts, multiple coders analyzed the data using constant comparison. Following initial comparison, a code book was created and used to guide the analysis of all interviews. Iterative discussions occurred over six months until saturation was met and reliability achieved. The themes that emerged comprise the results below.

Results: Participants reported acceptability and feasibility for the Cornerstone intervention and its components. Outer setting themes converged around the external policy context, with respondents discussing the implications of Medicaid reform such as value-based payment and the importance of tracking non-billable tasks of mentors and clinicians. For example, one clinician stated, “What we do at Cornerstone requires more time than what we do at the clinic. You know, InVivo for example, the time that I spend traveling with the clients...would that be able to be compensated?” Process themes pointed to important areas of planning: integration of mentors within the clinic, regular team check-ins, increased use of technology, and supervision emphasizing evidence-based practices that are part of the model (Critical Time Intervention, Trauma-Focused CBT). For example, one agency supervisor stated, “I think what was most helpful to get the staff really thinking was me using the language from the models...Somebody would come in and start talking about a case and I’d say okay, hold on a second. What phase of treatment are they in?”.

Conclusions and Implications: These results suggest key areas of support and planning strategies practitioners, supervisors, agency leadership, and policy makers may need when implementing Cornerstone. Next steps of this research including combining these results with user-centered design approaches to develop a Cornerstone Implementation Manual for both scale-up and further testing of this intervention. The implementation manual may serve as a model for other mental health interventions for TAY conducted in real-world agency settings.