title: Independent Contractors in Public Mental Health Clinics: Implications for Use of Evidence-Based Practices.
abstract: Community mental health clinics are increasingly utilizing independent contractors to provide clinical services. At the same time, many organizations are participating in initiatives intended to increase implementation of evidence-based practices (EBPs). The primary aim of this study was to understand the associations of utilizing independent contractors with clinician knowledge and attitudes toward EBPs and organizational culture and climate. The study also sought to understand the potential impact of using independent contractors on mental health services delivery from the perspective of organizational leadership.
  
  
  
  Quantitative data were collected from 130 therapists in 23 organizations; qualitative data were collected from executive administrators in nine of the 16 organizations participating in EBP initiatives sponsored by the City of Philadelphia. Regression with random effects was used to estimate the associations between worker status (contractor or employee) and clinician attitudes toward EBPs, knowledge of EBPs, and organizational culture and climate. Qualitative inquiry was used to understand the impact of reliance on independent contractors on organizational participation in EBP initiatives.
  
  
  
  Independent contractors endorsed less positive attitudes toward EBPs and scored lower on knowledge of EBPs. Interviews revealed four main themes: reasons for using independent contractors, general consequences of using independent contractors, specific impact of independent contractors on participation in EBP initiatives, and suggestions for alternatives.
  
  
  
  A growing number of community mental health clinics rely on independent contractors. There may be consequences of this shift that deserve exploration.
authors.affiliation: Dr. Beidas, Dr. Stewart, Dr. Benjamin, Ms. Adams, Dr. Hadley, and Dr. Mandell are with the Department of Psychiatry and Dr. Barg is with the Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia (e-mail: rbeidas@upenn.edu ). Dr. Marcus is with the School of Social Policy and Practice, University of Pennsylvania, Philadelphia. Dr. Evans and Dr. Hurford are with the Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia. Dr. Jackson, Dr. Neimark, Ms. Erney, and Dr. Rubin are with Community Behavioral Health, Philadelphia.
authors.forename: Rinad S
authors.initials: RS
authors.lastname: Beidas
authors.affiliation: Dr. Beidas, Dr. Stewart, Dr. Benjamin, Ms. Adams, Dr. Hadley, and Dr. Mandell are with the Department of Psychiatry and Dr. Barg is with the Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia (e-mail: rbeidas@upenn.edu ). Dr. Marcus is with the School of Social Policy and Practice, University of Pennsylvania, Philadelphia. Dr. Evans and Dr. Hurford are with the Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia. Dr. Jackson, Dr. Neimark, Ms. Erney, and Dr. Rubin are with Community Behavioral Health, Philadelphia.
authors.forename: Rebecca E
authors.initials: RE
authors.lastname: Stewart
authors.affiliation: Dr. Beidas, Dr. Stewart, Dr. Benjamin, Ms. Adams, Dr. Hadley, and Dr. Mandell are with the Department of Psychiatry and Dr. Barg is with the Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia (e-mail: rbeidas@upenn.edu ). Dr. Marcus is with the School of Social Policy and Practice, University of Pennsylvania, Philadelphia. Dr. Evans and Dr. Hurford are with the Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia. Dr. Jackson, Dr. Neimark, Ms. Erney, and Dr. Rubin are with Community Behavioral Health, Philadelphia.
authors.forename: Courtney
authors.initials: C
authors.lastname: Benjamin Wolk
authors.affiliation: Dr. Beidas, Dr. Stewart, Dr. Benjamin, Ms. Adams, Dr. Hadley, and Dr. Mandell are with the Department of Psychiatry and Dr. Barg is with the Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia (e-mail: rbeidas@upenn.edu ). Dr. Marcus is with the School of Social Policy and Practice, University of Pennsylvania, Philadelphia. Dr. Evans and Dr. Hurford are with the Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia. Dr. Jackson, Dr. Neimark, Ms. Erney, and Dr. Rubin are with Community Behavioral Health, Philadelphia.
authors.forename: Danielle R
authors.initials: DR
authors.lastname: Adams
authors.affiliation: Dr. Beidas, Dr. Stewart, Dr. Benjamin, Ms. Adams, Dr. Hadley, and Dr. Mandell are with the Department of Psychiatry and Dr. Barg is with the Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia (e-mail: rbeidas@upenn.edu ). Dr. Marcus is with the School of Social Policy and Practice, University of Pennsylvania, Philadelphia. Dr. Evans and Dr. Hurford are with the Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia. Dr. Jackson, Dr. Neimark, Ms. Erney, and Dr. Rubin are with Community Behavioral Health, Philadelphia.
authors.forename: Steven C
authors.initials: SC
authors.lastname: Marcus
authors.affiliation: Dr. Beidas, Dr. Stewart, Dr. Benjamin, Ms. Adams, Dr. Hadley, and Dr. Mandell are with the Department of Psychiatry and Dr. Barg is with the Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia (e-mail: rbeidas@upenn.edu ). Dr. Marcus is with the School of Social Policy and Practice, University of Pennsylvania, Philadelphia. Dr. Evans and Dr. Hurford are with the Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia. Dr. Jackson, Dr. Neimark, Ms. Erney, and Dr. Rubin are with Community Behavioral Health, Philadelphia.
authors.forename: Arthur C
authors.initials: AC
authors.lastname: Evans
authors.affiliation: Dr. Beidas, Dr. Stewart, Dr. Benjamin, Ms. Adams, Dr. Hadley, and Dr. Mandell are with the Department of Psychiatry and Dr. Barg is with the Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia (e-mail: rbeidas@upenn.edu ). Dr. Marcus is with the School of Social Policy and Practice, University of Pennsylvania, Philadelphia. Dr. Evans and Dr. Hurford are with the Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia. Dr. Jackson, Dr. Neimark, Ms. Erney, and Dr. Rubin are with Community Behavioral Health, Philadelphia.
authors.forename: Kamilah
authors.initials: K
authors.lastname: Jackson
authors.affiliation: Dr. Beidas, Dr. Stewart, Dr. Benjamin, Ms. Adams, Dr. Hadley, and Dr. Mandell are with the Department of Psychiatry and Dr. Barg is with the Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia (e-mail: rbeidas@upenn.edu ). Dr. Marcus is with the School of Social Policy and Practice, University of Pennsylvania, Philadelphia. Dr. Evans and Dr. Hurford are with the Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia. Dr. Jackson, Dr. Neimark, Ms. Erney, and Dr. Rubin are with Community Behavioral Health, Philadelphia.
authors.forename: Geoffrey
authors.initials: G
authors.lastname: Neimark
authors.affiliation: Dr. Beidas, Dr. Stewart, Dr. Benjamin, Ms. Adams, Dr. Hadley, and Dr. Mandell are with the Department of Psychiatry and Dr. Barg is with the Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia (e-mail: rbeidas@upenn.edu ). Dr. Marcus is with the School of Social Policy and Practice, University of Pennsylvania, Philadelphia. Dr. Evans and Dr. Hurford are with the Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia. Dr. Jackson, Dr. Neimark, Ms. Erney, and Dr. Rubin are with Community Behavioral Health, Philadelphia.
authors.forename: Matthew O
authors.initials: MO
authors.lastname: Hurford
authors.affiliation: Dr. Beidas, Dr. Stewart, Dr. Benjamin, Ms. Adams, Dr. Hadley, and Dr. Mandell are with the Department of Psychiatry and Dr. Barg is with the Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia (e-mail: rbeidas@upenn.edu ). Dr. Marcus is with the School of Social Policy and Practice, University of Pennsylvania, Philadelphia. Dr. Evans and Dr. Hurford are with the Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia. Dr. Jackson, Dr. Neimark, Ms. Erney, and Dr. Rubin are with Community Behavioral Health, Philadelphia.
authors.forename: Joan
authors.initials: J
authors.lastname: Erney
authors.affiliation: Dr. Beidas, Dr. Stewart, Dr. Benjamin, Ms. Adams, Dr. Hadley, and Dr. Mandell are with the Department of Psychiatry and Dr. Barg is with the Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia (e-mail: rbeidas@upenn.edu ). Dr. Marcus is with the School of Social Policy and Practice, University of Pennsylvania, Philadelphia. Dr. Evans and Dr. Hurford are with the Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia. Dr. Jackson, Dr. Neimark, Ms. Erney, and Dr. Rubin are with Community Behavioral Health, Philadelphia.
authors.forename: Ronnie
authors.initials: R
authors.lastname: Rubin
authors.affiliation: Dr. Beidas, Dr. Stewart, Dr. Benjamin, Ms. Adams, Dr. Hadley, and Dr. Mandell are with the Department of Psychiatry and Dr. Barg is with the Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia (e-mail: rbeidas@upenn.edu ). Dr. Marcus is with the School of Social Policy and Practice, University of Pennsylvania, Philadelphia. Dr. Evans and Dr. Hurford are with the Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia. Dr. Jackson, Dr. Neimark, Ms. Erney, and Dr. Rubin are with Community Behavioral Health, Philadelphia.
authors.forename: Trevor R
authors.initials: TR
authors.lastname: Hadley
authors.affiliation: Dr. Beidas, Dr. Stewart, Dr. Benjamin, Ms. Adams, Dr. Hadley, and Dr. Mandell are with the Department of Psychiatry and Dr. Barg is with the Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia (e-mail: rbeidas@upenn.edu ). Dr. Marcus is with the School of Social Policy and Practice, University of Pennsylvania, Philadelphia. Dr. Evans and Dr. Hurford are with the Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia. Dr. Jackson, Dr. Neimark, Ms. Erney, and Dr. Rubin are with Community Behavioral Health, Philadelphia.
authors.forename: Frances K
authors.initials: FK
authors.lastname: Barg
authors.affiliation: Dr. Beidas, Dr. Stewart, Dr. Benjamin, Ms. Adams, Dr. Hadley, and Dr. Mandell are with the Department of Psychiatry and Dr. Barg is with the Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia (e-mail: rbeidas@upenn.edu ). Dr. Marcus is with the School of Social Policy and Practice, University of Pennsylvania, Philadelphia. Dr. Evans and Dr. Hurford are with the Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia. Dr. Jackson, Dr. Neimark, Ms. Erney, and Dr. Rubin are with Community Behavioral Health, Philadelphia.
authors.forename: David S
authors.initials: DS
authors.lastname: Mandell
mesh_terms: D001291:Attitude of Health Personnel; D003156:Community Mental Health Services / Q000706:statistics & numerical data*; D055317:Evidence-Based Practice / Q000706:statistics & numerical data*; D007722:Health Knowledge, Attitudes, Practice; D006282:Health Personnel / Q000706:statistics & numerical data*; D006801:Humans; D015143:Philadelphia; D055818:Public-Private Sector Partnerships / Q000706:statistics & numerical data*