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Program Profile: Availability, Responsiveness and Continuity (ARC)

Evidence Rating: Promising - More than one study Promising - More than one study

Date: This profile was posted on September 03, 2019

Program Summary

This program is designed to enhance system effectiveness and organization, to improve client outcomes for child welfare and mental health agencies. The program is rated Promising. There were statistically significant reductions in problem behaviors for youth who were served by agencies that received the intervention, compared with youth who were served by control agencies.

This program’s rating is based on evidence that includes at least one high-quality randomized controlled trial.

Program Description

Program Goals/Target Sites
Availability, Responsiveness and Continuity (ARC) is an intervention for child welfare and mental health agencies designed to enhance system effectiveness and organization, with the goal of improving client outcomes. Clients include youth and their families who may be participating in a variety of services such as pharmacotherapy, individual psychotherapy, family therapy, skills training, and therapeutic groups. ARC is based on the following five priorities that suggest that successful organizational change strategies must be
  1. Mission driven, not rule driven. All service provider behavior and decisions should contribute to improving the well-being of clients.
  2. Results oriented, not process oriented. Performance should be evaluated at all levels (individual service provider, treatment team, program, and organization) and should be scored based on improvements in client well-being.
  3. Improvement directed; not status quo directed. The organization’s top leadership, middle managers, and clinicians should continually seek more effective ways to improve client well-being and avoid complacency with the status quo.
  4. Relationship centered, not individual centered. Mental health services should be supported by a network of service provider relationships, and positive change in client well-being should be supported by a network of relationships (e.g., family, school, community); therefore, poor outcomes should not be attributed to individuals, but rather to failures in the service system.
  5. Participation based, not authority based. There should be active, open, and collaborative participation among clinicians, middle managers, and top administrators to identify and address service barriers (Glisson et al. 2016).
Key Personnel/Program Components
The ARC intervention has two levels: 1) the organizational level, and 2) the inter-organizational domain level. The organizational level includes strategies designed to address the needs of service providers, such as therapists and caseworkers, and involves them in organizational policy decisions that affect service provision. The inter-organizational level includes strategies that encourage collaboration among service providers, organizations, and community stakeholders to address problems, such as delinquency, and support effective service provision. Trained ARC specialists work across both levels to help agencies align their policies and practices with the five priorities of successful organizational change.

ARC includes three stages of change. First, during the collaboration stage, ARC specialists focus on communicating the five priorities to service providers. A multilevel organized action team (OAT) comprising clinicians, middle managers, and top administrators then forms to support and guide collaborative efforts focused on realigning priorities. Second, during the participation stage, ARC specialists encourage teamwork and openness to change. ARC teams are then formed from existing treatment teams and employ ARC tools and processes designed to facilitate participation, information sharing, and support among service providers. Finally, during the innovation stage, the ARC teams identify service barriers (e.g., inappropriate referral procedures, unnecessary red tape, process-oriented evaluative criteria) and work with the OAT to enact practices, protocols, and organizational procedures that reflect the five priorities (Glisson et al. 2016).

Program Theory
The ARC model is based on components from several theories, including general systems theory (Katz and Kahn 1978), diffusion of innovation theory (Rogers 1995), socio-technical models of organization (Rousseau 1977; Trist 1985), classic models of organizational development (Burke 1993; Nadler and Tushman 1977; Porras and Robertson 1992; Tichy 1983), and interorganizational domain development (Gray 1985, 1990; Trist, 1985). Collectively, these theories emphasize that organizations are open systems that rely on external environments (e.g., other organizations, stakeholders, community resources), core technologies, and social processes to maximize organizational performance and effectiveness. Therefore, community-based service systems can improve service delivery by addressing the external contextual deficits and barriers that impede treatment outcomes (Glisson et al. 2016).

Evaluation Outcomes

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Study 1
Total Problem Behavior Scores
Glisson and colleagues (2013) found that the total problem behavior scores of youth who entered care after agencies completed the Availability, Responsiveness, and Continuity (ARC) intervention declined at a faster rate than did the total problem behavior scores of youth in control programs that did not participate in ARC. This difference was statistically significant.

Study 2
Total Problem Behavior Scores
Glisson and colleagues (2016) found youth served by mental health agencies that participated in the ARC intervention experienced statistically significant improvements in their scores of total problem behavior, compared with control group youth at the Phase II follow up (12 months after completion of the ARC intervention). The rate of improvement for ARC scores was 1.6 times the rate of improvement for control group scores.
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Evaluation Methodology

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Study 1
Glisson and colleagues (2013) conducted a randomized controlled trial to evaluate the effectiveness of the Availability, Responsiveness and Continuity (ARC) intervention for reducing problem behaviors for youth. Community based mental health programs were eligible if they employed three or more clinicians who provided mental health services to a target population under 25 years of age. Programs were excluded if they were 24-hour, locked-down facilities; provided only assessment and referral; or if their target population consisted of individuals with severe developmental disabilities or psychosis. Eighteen community mental health programs, serving economically disadvantaged adults, families, and youth in a range of settings across 17 counties in a southeastern state, were identified and agreed to participate in the study. The programs provided individual, group, and family therapy using various treatment models, medication management, and a range of additional services and activities focused on youth and families. Nine programs were randomly assigned to the ARC intervention group, and nine programs were assigned to the control group. The 18-month intervention was delivered between 2009 and 2011.

A total of 402 youth were recruited and agreed to participate in the study. The intervention group consisted of 244 youth, and the control group consisted of 158 youth. The higher number in the ARC condition resulted from the cluster randomization of youth by program and the higher number of youth entering care during the recruitment period for programs randomly assigned to ARC. The overall sample was 60 percent male, 76 percent white, 25 percent black, and 3 percent Hispanic; all youth were between the ages of 5 and 18 (the average age was 12). Family incomes ranged between $0 and $5733, averaging $1492 per month. Youth received services for behavioral or emotional problems that might place them at risk for developing chronic mental health problems. Fifty percent of services targeted chronic and mental health problems, 26 percent of services targeted mental health problems in the juvenile justice system, and 8 percent of services targeted substance abuse problems. Services were provided by 154 participating clinicians who were predominantly white (83 percent) and female (73 percent), had an average age of 32, and 7 years of experience. However, the study authors did not specify if there were any statistically significant differences between the youth in the intervention and control groups at baseline.

The outcome of interest is youths’ problem behavior, assessed using the Shortform Assessment for Children (SAC). SAC measures a youth’s functioning in terms of internalizing behaviors (such as anxiety) and externalizing behaviors (such as aggression). Caregivers completed SAC at intake and at 1-month intervals for 6 months after intake. Caregivers for 393 participating youth completed baseline SAC measures, 352 completed two or more, 247 completed four or more, 206 completed five or more, and 171 completed all six. All available repeated measures for each youth were included in hierarchical liner models (HLM) analyses that estimated each youth’s trend in total problem behavior. The researchers did not conduct subgroup analyses.

Study 2
Glisson and colleagues (2016) conducted a randomized controlled trial to evaluate the effectiveness of a 3-year ARC intervention for reducing problem behaviors for youth. Fourteen outpatient community mental health agencies that serve youth in a major midwestern city were randomly assigned to ARC or control conditions. Programs in the control condition were matched to those in the intervention condition on staff size and budget. The selected agencies reflected characteristics of a national representative sample of mental health agencies that serve youth (Shoenwald et al. 2008). All agencies had one or more units with 15 or more staff who delivered treatment to youth. Agencies were excluded from the study if they had adopted any new treatment programs in the prior year, or if they were part of a federally funded mental health services research network. Participating agencies delivered a variety of mental health services, including pharmacotherapy, individual psychotherapy, family therapy, skills training, and therapeutic groups. Youth were recruited in two study phases of 24 months each. Phase I youth were recruited in the first 24 months of the ARC intervention. Phase II youth were recruited in the final stage (the last 12 months) of the intervention and the 12 months following the completion of the intervention.

The overall sample from both phases included 605 youth (and their caregivers), with 304 youth served by agencies in the ARC intervention and 301 youth served by control agencies that provided treatment as usual. The overall sample was 54 percent male, 65.8 percent white, 25.5 percent black, and the average age was 11.94 years. There were no statistically significant differences between youth served by agencies in the ARC or control conditions in either phase on baseline measures of the outcome variable or demographic variables.

The outcome of interest, youths’ total problem behavior score was assessed using the Shortform Assessment for Children (SAC). HLM analyses were used to estimate each youth’s trend in total problem behavior scores. The researchers did not conduct subgroup analyses.
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There is no cost information available for this program.
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Evidence-Base (Studies Reviewed)

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These sources were used in the development of the program profile:

Study 1
Glisson, Charles, Anthony Hemmelgarn, Philip Green, and Nathaniel J. Williams. 2013. “Randomized Trial of the Availability, Responsiveness and Continuity (ARC) Organizational Intervention for Improving Youth Outcomes in Community Mental Health Programs.” Journal of the American Academy of Child and Adolescent Psychiatry 52(5):493–500.

Study 2
Glisson, Charles, Nathaniel J. Williams, Anthony Hemmelgarn, Enola Proctor, and Philip Green. 2016. “Aligning Organizational Priorities with ARC to Improve Youth Mental Health Service Outcomes.” Journal of Consulting and Clinical Psychology 84(8):713–25.
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Additional References

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These sources were used in the development of the program profile:

Burke, W.W. 1994. Organization Development (Second Edition). Reading, Mass.: Addison-Wesley.

Glisson, Charles, and Sonja Schoenwald. 2005. “The ARC Organizational and Community Intervention Strategy for Implementing Evidence-Based Children’s Mental Health Treatments.” Mental Health Services Research 7(4):243–59.

Glisson, Charles, Sonja K. Schoenwald, Anthony Hemmelgarn, Philip Green, Denzel Dukes, Kevin S. Armstrong, and Jason E. Chapman. 2010. “Randomized Trial of MST and ARC in a Two-Level Evidence-Based Treatment Implementation Strategy.” Journal of Consulting and Clinical Psychology 78(4):537–50. (This study was reviewed but did not meet criteria for inclusion in the overall program rating.)

Gray, B. 1990. “Building Interorganizational Alliances: Planned Change in a Global Environment.” Research in Organizational Change and Development 4:101–40.

Katz, D., and R.L. Kahn. 1978. The Social Psychology Organizations (Second Edition). New York: Wiley.

Nadler, D.A., and M. L. Tushman.1977. “A Diagnostic Model for Organizational Behavior.” In J.R. Hackman, E.E. Lawler III, and L.W. Porter (eds.). Perspectives on Behavior in Organizations. New York: McGraw-Hill, 85–98.

Porras, J.I., and P.J. Robertson. 1992. “Organizational Development: Theory, Practice, and Research.” In M. D. Dunnette and L. M. Hough (eds.). Handbook of Industrial and Organizational Psychology (Second Edition, Volume 3). Palo Alto, Calif.: Consulting Psychologists Press, Inc., 719–822.

Rogers, E.M. 1995. Diffusion of Innovations. New York: Free Press.

Schoenwald, Sonja K., Jason E. Chapman, Kelly Kelleher, Kimberly E. Hoagwood, John Landsverk, Jack Stevens, Charles Glisson, Jenifer Rolls-Reutz, and the Research Network on Youth Mental Health. 2008. “A Survey of the Infrastructure for Children’s Mental Health Services: Implications for the Implementation of Empirically Supported Treatments (ESTs).” Administration and Policy in Mental Health and Mental Health Services Research 35: 84–97.

Trist, E. 1985. “Intervention Strategies for Interorganizational Domains.” In R. Tannenbaum, N. Margulies, and F. Massarik (eds.). Human Systems Development. San Francisco, Calif.: Jossey-Bass.
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Program Snapshot

Age: 5 - 18

Gender: Both

Race/Ethnicity: Black, Hispanic, White

Geography: Rural, Suburban, Urban

Setting (Delivery): Inpatient/Outpatient

Program Type: Cognitive Behavioral Treatment, Family Therapy, Group Therapy, Individual Therapy, Vocational/Job Training

Current Program Status: Active

Listed by Other Directories: Model Programs Guide

Charles Glisson
Chancellor’s Professor Emeritus
University of Tennessee
1540 Agawela Avenue
Knoxville TN 37919-8317
Phone: 865.525.4007