Table 7 Summary of key barriers and facilitators to A-CRA provider-level reach outcomes from qualitative interviews

Innovation

Lack of fit with population (B)

Some providers noted A-CRA was not culturally appropriate for their population, often due to disparities in access to resources (e.g., low-income or minoritized racial/ethnic groups). Others noted fit problems due to the clinical population, such as not working as well with for youth in residential care or with severe mental health problems.

Participants from state-focused grants reported more frequent and serious barriers around fit of A-CRA with their client population compared to participants from organization-focused grantees. This suggested there was a greater likelihood of fit issues when implementing treatment organizations were encouraged to implement by state agencies rather than making the decision to implement themselves, which may have decreased certification rates under state-focused grants.

Exemplar quote for contribution: “One of the difficulties with A-CRA … is that there is a big component of getting kids involved in more pro-social activities. There’s a lot of barriers to that culturally and otherwise and financially for folks…. so there aren’t a lot of resources for things for young people to do, especially in the after school hours, or the money to do a whole lot.” (SF, P)

Inner context

Strategic planning (F)

Treatment organizations described engaging in strategic planning to promote adoption and use of A-CRA, with an emphasis on fully successful implementation and preparing for sustainment after the SAMHSA funding ended.

Engagement in strategic planning to promote adoption and use of A-CRA was uniquely describe by organization-focused grantees as a facilitator; state-focused grantees described minimal strategic planning. This may have been a natural extension of the strategic planning process that went into organization-focused grantees applying for and securing their grants through a competitive application process.

Exemplar quote for contribution: “Part of planning was also to work with state legislature, [Department of Children and Families], and Court Services Division to let them know about [A-CRA] and seek longer-term state-based funding for these services. We have also done some work with [Department of Social Service]… to advocate for this model as being paid for in full.” (OF, P)

Outer context

State leadership support (F/B)

Having state agency staff dedicated to working with treatment organizations on A-CRA helped facilitate project administration, encouraged buy-in at the organizational level, and helped move providers through the

certification process, whereas participants in other states noted their state agency did not encourage use of A-CRA and the model was not marketed well in those states.

State leadership support was only relevant under state-focused grants. Some respondents described state substance use agency administrators as helpful in guiding the implementation process, which encouraged organizational buy-in; however, state administrators also encountered challenges to fulfilling their role, with the specific challenges varying from state to state (e.g., limited support from state

leaders, decision-making power lying with local authorities, turnover of state agency staff). These challenges helped explain why state-focused grant activities were challenging to execute and resulted in lower average certification rates, despite the strengths of some state agency leadership.

Exemplar quote for contribution: “We kept in really good contact with the people from the state … I remember the guy who was from the state department that I talked to about [A-CRA], we talked to each other at least, I would say every other week, at a minimum. So from the state department all the way down, I think everyone involved in the [state-focused grant] program was pretty supportive.” (SF, P)

Community beliefs about substance use (B)

Substance use issues were seen as a less serious problem in some communities—including among caregivers, partner organizations, and providers—decreasing youth referrals and engagement.

Such attitudes (community beliefs about substance use, adolescents not a priority group) were uniquely described by participants from the more recent state-focused grants. Some participants attributed changing attitudes to increased legalization of cannabis in the USA. Such trends may indeed have been occurring in US society, although we did not find strong evidence that they influenced A-CRA reach rates (e.g., the grant end date covariate in the models did not have a significant effect for any outcome). This finding may also reflect differences in the type of organization that implemented A-CRA through organization-focused versus state-focused grants, similar to the “lack of fit with population” code above.

Adolescents not a priority group (B)

In some communities, adolescents were not viewed as a priority treatment group. Thus, state and federal funding was focused on adult populations instead of youth, limiting resources available for youth treatments like A-CRA.

Exemplar quote for contribution: “There’s been tremendous reduction in referrals to substance use treatment. And most of those, that reduction, is really due to the decline of children and teenagers, families requesting treatment for marijuana. I mean, it’s really significant. It’s a dramatic drop.” (SF, A)

Bridging factors

State funding (F)

The money states provided to treatment organizations in state-focused grants was integral to funding training, certification, supervision, and the resources needed to fully understand and deliver A-CRA with clients.

These activities (state-led training activities and comprehensive funding for A-CRA) were identified as major facilitators for state-focused grants, because they allowed for statewide coordination of activities. Despite the facilitators not leading to higher certification rates, they provided insight into the potential that SAMHSA and state agencies saw in pursuing state-focused grants as a financing strategy.

However, it was also the case that organization-focused grants provided similar benefits as state-focused grants (i.e., training and comprehensive funding) through a more direct mechanism, albeit only to individual organizations.

State-led Training Activities (F)

The partnership between states and Chestnut Health Systems to provide initial A-CRA training was viewed as informative to providers and state administrators, and helped them implement the model.

Exemplar quote for contribution: “One of the most important things that [state agency] can provide is accessibility to training and evidence-based models of treatment. My [organization] is a nonprofit. We serve an underserved community. When SAMHSA, through the states, is able to offer us access to training, consultation, and support, that’s an important resource.” (SF, P)

Bridging factors, continued

Intensive support for organization-focused grants (F)

Many participants found the support provided by SAMHSA organization-focused grants to be of good quality.

Organization-focused grantees’ experiences differed in that they worked with SAMHSA directly, a collaboration often described as helpful but also as intensive and overwhelming. Combined with these organizations tending to exhibit more strategic planning and better fit between A-CRA and their climates and communities, the direct relationship with SAMHSA created by organization-focused grants could have lent greater support for increasing certification rates than state agencies were able to provide. These organizations did report more burden due to assessment and reporting requirements of the organization-focused grants, but those factors were not closely related to the A-CRA certification process—consistent with the higher certification rates under organization-focused grants.

Assessment tool was cumbersome (B)

The GAIN (Global Assessment of Individual Needs), an assessment SAMHSA required organization-focused grantees to collect and report, was frequently seen as overly complex and burdensome.

Too much reporting/paperwork (B)

Reporting and paperwork related to administration of federal grants were seen as a barrier to using organization-focused grants

Exemplar quotes for contribution:

“I think SAMHSA provided a lot of good training with the [A-CRA provider organizations] involved… I felt like there was a lot of support. It helped us get through what we needed to do.” (OF, P)

“It was a very intensive-labor process, and it was monitored closely by SAMHSA … you would not be able to sustain that level of involvement per client. You would have to cut down on all the reporting.” (OF, P)