***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background The many r and omized trials of the collaborative care model for improving depression in primary care have not described the implementation and maintenance of this model . This paper reports how and the degree to which collaborative care process changes were implemented and maintained for the 75 primary care clinics participating in the DIAMOND Initiative ( Depression Improvement Across Minnesota – Offering a New Direction ) . Methods Each clinic was trained to implement seven components of the model and participated in ongoing evaluation and facilitation activities . For this study , assessment of clinical process implementation was accomplished via completion of surveys by the physician leader and clinic manager of each clinic site at three points in time . The physician leader of each clinic completed a survey measure of the presence of various practice systems prior to and one and two years after implementation . Clinic managers also completed a survey of organizational readiness and the strategies used for implementation . Results Survey response rates were 96 % to 100 % . The systems survey confirmed a very high degree of implementation ( with large variation ) of DIAMOND depression practice systems ( mean of 24.4 ± 14.6 % ) present at baseline , 57.0 ± 21.0 % at one year ( P = < 0.0001 ) , and 55.9 ± 21.3 % at two years . There was a similarly large increase ( and variation ) in the use of various quality improvement strategies for depression ( mean of 29.6 ± 28.1 % at baseline , 75.1 ± 22.3 % at one year ( P = < 0.0001 ) , and 74.6 ± 23.0 % at two years . Conclusions This study demonstrates that under the right circumstances , primary care clinics that are prepared to implement evidence -based care can do so if financial barriers are reduced , effective training and facilitation are provided , and the new design introduces the specific mental models , new care processes , and workers and expertise that are needed . Implementation was associated with a marked increase in the number of improvement strategies used , but actual care and outcomes data are needed to associate these changes with patient outcomes and patient-reported care OBJECTIVE A r and omized trial assessed the effectiveness of a 2-level strategy for implementing evidence -based mental health treatments for delinquent youth . METHOD A 2 x 2 design encompassing 14 rural Appalachian counties included 2 factors : ( a ) the r and om assignment of delinquent youth within each county to a multisystemic therapy ( MST ) program or usual services and ( b ) the r and om assignment of counties to the ARC ( for availability , responsiveness , and continuity ) organizational intervention for implementing effective community-based mental health services . The design created 4 treatment conditions ( MST plus ARC , MST only , ARC only , control ) . Outcome measures for 615 youth who were 69 % male , 91 % Caucasian , and aged 9 - 17 years included the Child Behavior Checklist and out-of-home placements .  RESULTS A multilevel , mixed-effects , regression analysis of 6-month treatment outcomes found that youth total problem behavior in the MST plus ARC condition was at a non clinical level and significantly lower than in other conditions . Total problem behavior was equivalent and at non clinical levels in all conditions by the 18-month follow-up , but youth in the MST plus ARC condition entered out-of-home placements at a significantly lower rate ( 16 % ) than youth in the control condition ( 34 % ) . CONCLUSIONS Two-level strategies that combine an organizational intervention such as ARC and an evidence -based treatment such as MST are promising approaches to implementing effective community-based mental health services . More research is needed to underst and how such strategies can be used effectively in a variety of organizational context s and with other types of evidence -based treatments OBJECTIVES We evaluated an education , distribution , and fitting program for increasing age-appropriate and correct child restraint use . METHODS We performed a cluster r and omized trial involving 28 early childhood education centers in low socioeconomic status areas in Sydney , Australia . The main outcome was optimal restraint use defined as age-appropriate restraints , installed into the vehicle correctly and used correctly . RESULTS One service withdrew after r and omization , so data are presented for 689 child passengers , aged 3 to 5 years , from 27 centers . More children attending intervention centers were optimally restrained ( 43 % vs 31 % ; P = .01 ; allowing for clustering ) . More 3-year-olds were using forward-facing seats rather than booster seats , more 4- to 5-year-olds were using booster seats instead of seat belts alone , and there were fewer errors in use at intervention centers . Among non-English-speaking families , more children attending intervention centers were optimally restrained ( 43 % vs 17 % ; P = .002 ; allowing for clustering ) . CONCLUSIONS The program increased use of age-appropriate restraints and correct use of restraints , which translates to improved crash injury protection . Multifaceted education , seat distribution , and fitting enhanced legislation effects , and the effect size was larger in non-English-speaking families PURPOSE The aim of this paper is to identify initial barriers influencing implementation of supported employment ( SE ) . SE , according to the individual placement and support ( IPS ) approach , has been recognised as an evidence -based method to help people with severe mental illness to find regular employment . DESIGN / METHODOLOGY /APPROACH A systematic implementation evaluation of the first r and omised controlled SE ( IPS ) trial in Sweden was conducted in August 2008 and August 2009 . Data were collected on a regular basis from SE employment specialists , process heads , clients and representatives from mental health care units and vocational services ( social insurance and public employment offices ) using interviews , non-participant observations and document analysis . FINDINGS SE employment specialists reported that existing regulations for social insurance and employment regulations presented major obstacles to implementation . Difficulties were reported in cooperation with h and ling officers at the vocational services . Scepticism towards persons with mental illness was common and employers expected to receive subsidies if they hired a person with mental illness . SE participants expressed fear of losing their social benefits . ORIGINALITY/VALUE The results illuminate a collision between an innovative evidence -based practice and the existing systems for social benefits and work rehabilitation PURPOSE The objective of this study was to eluci date the effect of facilitation on practice outcomes in the 2-year patient-centered medical home ( PCMH ) National Demonstration Project ( NDP ) intervention , and to describe practice s ’ experience in implementing different components of the NDP model of the PCMH . METHODS Thirty-six family practice s were r and omized to a  facilitated intervention group or a self-directed intervention group . We measured 3 practice -level outcomes : ( 1 ) the proportion of 39 components of the NDP model that practice s implemented , ( 2 ) the aggregate patient rating of the practice s ’ PCMH attributes , and ( 3 ) the practice s ’ ability to make and sustain change , which we term adaptive reserve . We used a repeated- measures analysis of variance to test the intervention effects . RESULTS By the end of the 2 years of the NDP , practice s in both facilitated and self-directed groups had at least 70 % of the NDP model components in place . Implementation was relatively harder if the model component affected multiple roles and processes , required coordination across work units , necessitated additional re sources and expertise , or challenged the traditional model of primary care . Electronic visits , group visits , team-based care , wellness promotion , and proactive population management presented the greatest challenges . Controlling for baseline differences and practice size , facilitated practice s had greater increases in adaptive reserve ( group difference by time , P = .005 ) and the proportion of NDP model components  implemented ( group difference by time , P=.02 ) ; the latter increased from 42 % to 72 % in the facilitated group and from 54 % to 70 % in the self-directed group . Patient ratings of the practice s ’ PCMH attributes did not differ between groups and , in fact , diminished in both of them . CONCLUSIONS Highly motivated practice s can implement many components of the PCMH in 2 years , but apparently at a cost of diminishing the patient ’s experience of care . Intense facilitation increases the number of components implemented and improves practice s ’ adaptive reserve . Longer follow-up is needed to assess the sustained and evolving effects of moving independent practice s toward OBJECTIVE People with psychiatric impairments ( primarily schizophrenia or a mood disorder ) are the largest and fastest-growing group of Social Security Disability Insurance ( SSDI ) beneficiaries . The authors investigated whether evidence -based supported employment and mental health treatments can improve vocational and mental health recovery for this population . METHOD Using a r and omized controlled trial design , the authors tested a multifaceted intervention : team-based supported employment , systematic medication management , and other behavioral health services , along with elimination of barriers by providing complete health insurance coverage ( with no out-of-pocket expenses ) and suspending disability review s. The control group received usual services .  Paid employment was the primary outcome measure , and overall mental health and quality of life were secondary outcome measures . RESULTS Overall , 2,059 SSDI beneficiaries with schizophrenia , bipolar disorder , or depression in 23 cities participated in the 2-year intervention . The teams implemented the intervention package with acceptable fidelity . The intervention group experienced more paid employment ( 60.3 % compared with 40.2 % ) and reported better mental health and quality of life than the control group . CONCLUSIONS Implementation of the complex intervention in routine mental health treatment setting s was feasible , and the intervention was effective in assisting individuals disabled by schizophrenia or depression to return to work and improve their mental health and quality of life Integrating Mental Health Services for Mothers of Children With Autism Autism is one of the most common childhood mental health conditions , affecting one child per 88 children . Although up to 40 % of mothers of children with autism report clinical ly significant depressive symptoms , there has been little attention to the mental health needs of parents . Because most autism services for young children rely on active parental engagement to deliver recommended therapies , maternal functioning directly affects the intensity and quality of therapy that children with autism receive . Developing feasible and acceptable strategies to support the mental health of mothers who care for children with autism has the potential to optimize both maternal and child functioning . In 2009 , as part of a clinical trial supported by the Combating Autism Act , our groupbegan to offer abrief , manualized cognitive-behavioral intervention— problem-solving education — to mothers of children with new autism diagnoses and whowere receiving early-intervention services authorized under Part C of the Individuals With Disabilities Education Act .  Problem-solving education is an adaptation of an evidence -based depression treatment known as problemsolving therapy and is tailored to mothers of young children . It aims to strengthen an individual ’s problemsolving skills as a strategy to prevent depression and improve parental involvement in intensive autism-specific therapy . Experience supports the program ’s feasibility and provides a model to engage an at-risk group of parents in mental health services in a novel , home-based setting . Problem-solving education was integrated into the existing service delivery model of early intervention , which has a national infrastructure for replication and dissemination . Early intervention provides a flexible , individualized array of therapeutic services based on a child ’s needs and a family ’s goals . Family support is an explicit but not fully realized aim of early intervention . Authorizing legislation allows parents as well as children to receive services . Mothers ( N537 ) involved in this program received six individual problem-solving education sessions ( 30–45 minutes ) delivered biweekly at home as a supplement to early-intervention services . During each workbook-based session , mothers focused on one problem and worked through a series of problem-solving steps that included defining the problem , identifying a short-term achievable goal , brainstorming multiple solutions , evaluating their pros and cons , choosing the best solution , and developing an action plan . The most common problems that mothers selected to address were related to child rearing , followed by time management . Time spent providing problemsolving education was billed and reimbursed in the same way as other family support services . This flexibility in the early-intervention service delivery model supports opportunities for integrating  parental mental health services into a nonstigmatizing setting . To support future replication and dissemination , we trained multidisciplinary early-intervention staff , many of whom did not have clinical mental health training , to deliver problem-solving education .  Eighteen early-intervention staff completed a st and ardized training curriculum that included one day of didactics , followed by five practice sessions . All early-intervention staff achieved reliability within eight weeks . Fidelity was assessed in 34 r and omly selected problemsolving sessions that were audiotaped and scored with a st and ardized form and predetermined criteria . All sessions were judged to be of excellent quality . A major challenge confronted at the outset of the program was the belief that mothers of young children with a new diagnosis of autism would be too busy or overwhelmed to participate . The demographic characteristics of women who received problem-solving education suggested that the program successfully engaged mothers at risk of major depression . Of the 37 mothers who received problem-solving education , 75 % had incomes,200 % of federal poverty level and were from racial-ethnic minority groups ( 54 % ) . Almost a quarter ( 24 % ) of the mothers were born outside of the United States . Although mothers were not selected on the basis of depression risk , 35 % reported they had received a depression diagnosis in their lifetime and 68%had current symptoms . Seventy-five percent of mothers completed the full six sessions , supporting the program ’s acceptability . Satisfaction with the program and continued use of the skills learned in the program were evaluated at the nine-month followup assessment . Satisfaction was high ; participants reported using the problemsolving skills , such as thinking through pros and cons of solutions , and behavioral activation strategies almost weekly . Our experience supports the feasibility and acceptability of integrating parental 
    Output:
    
Conclusions This is the first study to our knowledge to use a systematic review process to identify empirically observed external context factors documented to impact implementation .