How State Administrative Structures Influence Implementation Outcomes for Wraparound Care Coordination

The purpose of this study was to examine how inner-context (organizational) and outer-context (system) variables affect implementation outcomes for wraparound care coordination, an evidence-based strategy for youths with complex behavioral health needs.

This study focused on data from 1,178 providers in 10 states that used one of two state-level administrative structures to implement wraparound care coordination; four states used care management entities (CMEs), and six used community mental health centers (CMHCs). Implementation completeness and duration were assessed with the Stages of Implementation Completion tool, and practice fidelity was assessed with the Coaching Observation Measure for Effective Teams. Multilevel models were used to compare CMEs with CMHCs at the state level in terms of implementation completeness, duration, and fidelity.

Compared with CMHC states, CME states had higher mean fidelity scores among practitioners (0.37 vs. 0.24; t=8.02, df=1,136, p<0.001), completed more implementation activities, and completed most implementation activities faster. Multilevel models found that the duration of the preimplementation phase was positively associated with fidelity (b<0.001, t=3.62, df=10.85, p=0.004) and that the duration of the implementation phase was negatively associated with fidelity (b<-0.001, t=-6.64, df=7.04, p<0.001).

The results reinforce that systems-level strategies such as wraparound care coordination require considerable time to plan and implement and that state-level administrative structures meaningfully influence implementation outcomes and service quality. Taking the time to design hospitable inner and outer contexts is crucial to implementation efficiency, completeness, and quality.