Recovery Management Checkup Scalability and Sustainability Hybrid Experiment

This project is a hybrid type 2 design for three key reasons based on the hybrid design literature. First, while RMC has proven efficacy, its delivery by community-based recovery staff represents a new context where prior assumptions may not hold. Our study design will enable us to compare the feasibility and scalability of delivering RMC with staff in a research setting to staff in a range of community settings. Second, our prior research and studies on recovery-oriented service settings offer insights into determinants affecting implementation outcomes. Third, guided by this knowledge and the literature we have identified the implementation phases at which these barriers are likely most salient and selected a package of discrete implementation strategies to address them. We will use a multiple case study design, which is well suited for understanding how specific strategies used to support RMC Adopters impact implementation outcomes. The study is guided by the Exploration, Preparation, Implementation, and Sustainment (EPIS) model, which groups implementation determinants into intervention, inner and outer context, and bridging factors (elements connecting inner and outer contexts). The project provides an Implementation Research Logic Model mapping implementation determinants, selected strategies, theorized mechanisms of action, and proposed outcomes.

AIMS 1. EVALUATE THE EQUIVALENCE OF RMC PROVIDED BY COMMUNITY ORGANIZATIONS AND RESEARCH TEAMS IN TERMS OF:

1a) days of any SUD treatment (primary outcome); and

1. b) structural equation modeling (SEM) invariance of effects on SUD intervention dose (medication, other SUD treatment, mutual-help group, overdose prevention), public health outcomes (substance use, SUD symptoms, overdose, risk behaviors), and public safety outcomes (types of drug-related, property and interpersonal/violent crime and days of illegal activity). AIM1: OVERVIEW OF EQUIVALENCE COMPONENT DESIGN. Using data obtained from Cook County Coroner's Office and the Chicago Police Department, we identified 4 discrete community areas of Chicago with the highest risk of substance-related fatalities and arrest and recruited one or more RMC Adopters from each area to implement and sustain RMC. We will recruit approximately 150 people from each area who have been arrested and report weekly use of alcohol, stimulants, or opioids in the prior 90 days. The Cook County Sheriff's Department has approved our use of their first appearance court (aka pre-bond) processing area as the primary recruitment location. Jail staff will refer individuals whose home zip code/community is in one of the four target areas to on-site research staff for initial screening and consent to contact; individuals who consent will be contacted for study enrollment by research staff following their release after court (Illinois is a cashless bail state some most are released). Eligible clients who complete study consent and enrollment with research staff (at the research office) will be randomly assigned at to receive RMC for 9 months either from Linkage Mangers (LM) who are located and supervised at the community-based RMC Adopter agency or by research staff at Chestnut's research office. Through the implementation strategy described below, LMs and their supervisors at the RMC Adopter agencies will be provided with strategies aimed at supporting equivalent knowledge, skills, and performance with that of research-supervised RMC staff. Both groups will have access to the same AI-based tools for continued role playing and skill practice. Research interviewers will assess clients at enrollment and quarterly for 12 months. Data will include standardized surveys using the JCOIN core and additional local measures; AI-based linkage meeting ratings; and treatment, arrest and death records. The primary hypothesis for Aim 1 is that there will be no statistical (p<.05) or clinical (Cohen's |d|<.3) differences between groups receiving RMC from either the RMC Adopters sites or Chestnut research site in terms of the cumulative days of SUD treatment over 12 months. The study will also examine mean and path invariance in an established structural equation model (SEM) of the relationship between RMC (by setting), Justice System Involvement (n of arrests, days in jail, on probation/parole, and meeting with probation officer), SUD intervention[s] received (days of medication, SUD treatment modality, days of mutual-help group participation, overdose prevention), public health outcomes (substance use, symptoms, overdose, risk behaviors, recovery environment) and public safety outcomes (types of drug-, property- and interpersonal/violence-related crimes, days of illegal activity). AIM 2. ASSESS THE IMPACT OF MULTI-COMPONENT FACILITATION-BASED STRATEGIES IN SUPPORTING RMC INTEGRATION ACROSS PRE-IMPLEMENTATION, IMPLEMENTATION, AND SUSTAINMENT PHASES, INCLUDING 3 ANALYTICAL SUB-AIMS TO IDENTIFY:
2. a) how pre-implementation and implementation-phase strategies impacted the final site intervention fidelity score (main implementation outcome);

2b) the impact of pre-implementation- and implementation-phase duration and proportion of activities completed on RMC Adopter's ability and time to reach competency; and 2c) organizational-level determinants of achieving and maintaining RMC sustainment.

AIM 2: IMPLEMENTATION COMPONENT DESIGN. We will use a multiple case study design to evaluate the impact of a multi-component external facilitation strategy supporting RMC integration within community organizations across distinct implementation phases. Guided by EPIS, this study will focus on the last three phases (i.e., preparation, implementation, and sustainment) as operationalized through the Stages of Implementation Completion (SIC) measure (see "Other Implementation Measures" under "Aim 2 Approach" section), having already engaged community organizations interested in implementing RMC. It is important to note that the implementation stages are not typically progressed through linearly and the SIC accounts for the overlapping nature of these phases. We will employ a mixed-methods design, analyzing quantitative and qualitative data with input from community partners and our Community Board. We will use a mixed-methods, multiple-case study analysis processes, with each case representing an RMC Adopter. The analysis will examine relationships between strategies and implementation outcomes, using replication logic to identify similar or distinct outcomes and generalize findings across populations. Pattern matching will compare predicted mechanisms with observed processes, exploring mismatches and analyzing strategy-context interactions. Quantitative and qualitative data will be integrated to explain how strategies drive outcomes.