Learning Health Systems and Substance Use Care Cascade Achievement Among Justice-Involved Youth: A Cluster-Randomized Stepped-Wedge Clinical Trial

TL;DR

A learning health systems intervention improved the speed of substance use disorder care for justice-involved youth, especially after the pandemic.

Contribution

This study demonstrates how cross-system learning health systems can enhance care cascade outcomes for justice-involved adolescents.

Findings

The LHS reduced the time between arrest and substance use disorder risk screening.

Youths arrested later in the study had faster treatment initiation and engagement.

The intervention improved care cascade timeliness in a justice-involved population.

Abstract

What is the effect of a learning health systems (LHS) intervention, including the youth legal system and behavioral health care, on substance use or substance use disorder (SU/D) care cascade outcomes among adolescents involved in the youth legal system?

In this cluster-randomized stepped-wedge clinical trial of 5731 youths, a time-to-event analysis indicated the LHS was associated with significantly reduced time between youth arrest and SU/D risk screening. Significant interactions showed reduced times from arrest to treatment initiation and engagement for youths arrested 3.5 to 4.0 years after study start (ie, post COVID-19).

These findings suggest that cross-system LHS may improve timeliness of SU/D risk screening, treatment initiation, and engagement for justice-involved youth.

This cluster-randomized clinical trial examines the impact of a learning health systems intervention on behavioral health care cascade outcomes using administrative records of adolescents involved in the youth legal system.

Adolescents involved in the youth legal system (YLS) rarely use community-based behavioral health services, despite their disproportionate risk for substance use and substance use disorders (SU/D). A care cascade framework quantifies deficits in the process by which 2 systems—YLS and behavioral health care—ensure that youths engage in indicated treatment.

To test effectiveness of a cross-system learning health systems (LHS) intervention on S/UD care cascade outcomes among YLS-involved youth.

This cluster-randomized stepped-wedge clinical trial was designed to improve use of SU/D treatment by youths. Eight counties in a single Midwest state were randomly assigned to 1 of 3 cohorts stepped in from preintervention control to intervention in 9-month intervals. Each county-level LHS team included juvenile probation department and community mental health center representatives. Administrative YLS records were collected from all youths aged 11 to 17 years arrested in participating counties from January 1, 2019, through March 31, 2025, and linked to Medicaid claims data.

LHS interventions were based on principles of continuous quality improvement and data-driven decision-making. Here, LHS principles were innovatively applied among collaborative teams to identify and resolve local gaps in SU/D care cascade achievement.

The main outcome was timeliness of care cascade step achievement after arrest among YLS-involved adolescents. Cascade steps included screening for SU/D risk, identification with need for services, referral for services, initiation of services, and engagement in services.

Cascade step achievement was recorded for 5731 youths with linked YLS and Medicaid records; participants included 3538 males (62%) with a mean (SD) age of 15.4 (1.7) years at the time of arrest. A total of 1010 youths (18%) were Black, 614 (11%) were Hispanic, and 4362 (76%) were White. The LHS was associated with a significant reduction in the number of days between youth first arrest and risk screening (hazard ratio, 1.67; 95% CI, 1.12-2.23); significant interactions showed reductions in time from arrest to service initiation and service engagement for youths arrested later in the study (ie, 3.5-4.0 years after study start through end of study).

This cluster-randomized stepped-wedge clinical trial demonstrated that the LHS improved the timeliness of SU/D care cascade achievement among YLS-involved youth.

ClinicalTrials.gov Identifier: NCT04499079

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