Implementing CommonGround in a community mental health center: Lessons in a computerized decision support system.

OBJECTIVE: Although shared decision making (SDM) is a key element of client-centered care, it has not been widely adopted. Accordingly, interventions have been developed to promote SDM. The aim of this study was to explore the implementation process of one SDM intervention, CommonGround, which utilizes peer specialists and a computerized decision support center to promote SDM. METHOD: As part of a larger study, CommonGround was implemented in 4 treatment teams in a community mental health center. The implementation process was examined by conducting semistructured interviews with 12 staff members that were integral to the CommonGround implementation. Responses were analyzed using content analysis. Program fidelity and client program use were also examined. RESULTS: Although key informants identified several client and staff benefits to using CommonGround, including improved treatment engagement and availability of peer specialists, most clients did not use CommonGround consistently throughout the implementation. Key informants and fidelity reports indicated a number of program (e.g., technological difficulties, increased staff burden) and contextual barriers (e.g., poor fit with service structure, decision support center location, low staff investment and high turnover) to the successful implementation of CommonGround. Strategies to maximize the implementation by increasing awareness, buy-in, and utilization are also reported. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: This implementation of CommonGround was limited in its success partly as a result of program and contextual barriers. Future implementations may benefit from incorporating the strategies identified to maximize implementation in order to obtain the full program benefits. (PsycINFO Database Record

Consumer Outcomes After Implementing CommonGround as an Approach to Shared Decision Making.

OBJECTIVE: The authors examined consumer outcomes before and after implementing CommonGround, a computer-based shared decision-making program. METHODS: Consumers with severe mental illness (N=167) were interviewed prior to implementation and 12 and 18 months later to assess changes in active treatment involvement, symptoms, and recovery-related attitudes. Providers also rated consumers on level of treatment involvement. RESULTS: Most consumers used CommonGround at least once (67%), but few used the program regularly. Mixed-effects regression analyses showed improvement in self-reported symptoms and recovery attitudes. Self-reported treatment involvement did not change; however, for a subset of consumers with the same providers over time (N=83), the providers rated consumers as more active in treatment. CONCLUSIONS: This study adds to the growing literature on tools to support shared decision making, showing the potential benefits of CommonGround for improving recovery outcomes. More work is needed to better engage consumers in CommonGround and to test the approach with more rigorous methods.

Enhanced consumer goal achievement through strengths-based group supervision.

PURPOSE: This article seeks to enhance and support consumer-centered care in psychiatric rehabilitation through the use of strengths-based group supervision (SBGS). SOURCES USED: The article is based on social science research findings, 30 years of experience with the model, and the literature on supervision. Relevant findings from research on the model are included. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: SBGS is a promising approach for improving consumer goal achievement and centeredness. It warrants further implementation and research.

The perceptions of supervisory support scale.

The implementation of recovery-oriented and evidence-based practices has become a major challenge for mental health systems and front-line practitioners. This study developed an instrument that would assess the benefits or results that accrue from supervision, including client-centered supervision. The Perceptions of Supervisory Support Scale was administered to 262 case managers. Analyses (including factor analyses and repeated measures analysis of variance) confirmed content validity and reliability. Sub-scales included: (1) emotional support; (2) support for client goal achievement; and (3) professional development support. The scale could guide support for front-line practitioners in delivering client-centered care and could be useful for future research.

Advances in fidelity measurement for mental health services research: four measures.

Mental health intervention research requires clear and accurate specification of treatment conditions in intervention studies. Measures are increasingly available for community-based interventions for persons with serious mental illnesses. Measures must go beyond structural features to assess critical processes in interventions. They must also balance effectiveness, or adequate coverage of active treatment elements, with efficiency, or the degree to which measures may be used cost-effectively. The context of their use is changing with the emergence of new frameworks for implementation research and quality improvement. To illustrate a range of approaches, this article describes four recently developed fidelity measures: Cognitive Therapy for Psychosis Adherence Scale, Strengths Model Fidelity Scale, Illness Management and Recovery Program Fidelity Scale, and Tool for Measurement of ACT. The fidelity measures assess interventions in a range of treatment contexts from dyads to teams. Each measure focuses assessment resources on critical elements. Each has demonstrated coverage of its target intervention and satisfactory psychometric properties and is related to outcomes. Measures have been used for training, quality improvement, or certification. They assess domains and have uses beyond their nominal position in implementation and quality frameworks. This review of recent fidelity measures indicates that process components in community-based interventions can be effectively assessed. Omission of elements assessing potentially critical active treatment components poses risk to both research and practice until there is evidence to demonstrate that they are nonessential. Further development of fidelity measurement theory and approaches should proceed in conjunction with development of theory and methods in implementation science.

Strengths model case management fidelity scores and client outcomes.

OBJECTIVE: The study examined the relationship between fidelity of strengths model case management (SMCM) and client outcomes of psychiatric hospitalization, competitive employment, postsecondary education, and independent living. METHODS: Data were collected over an 18-month period during regularly scheduled fidelity reviews for 14 case management teams representing ten agencies serving an average of 953 clients diagnosed as having a serious mental illness. Time-varying covariate linear growth modeling examined the relationship between fidelity scores and client outcomes. RESULTS: A statistically significant association was found between fidelity scores and psychiatric hospitalization, competitive employment, and postsecondary education. CONCLUSIONS: The study results offer promising evidence that higher SMCM fidelity has a positive effect on clients over an 18-month period, thereby providing an effective complement to current mental health treatment.

A Cross-cultural study of recovery for people with psychiatric disabilities between U.S. and Japan.

The concept of recovery has been expanding overseas with remarkable speed. The Recovery Assessment Scale (RAS) is one of the measures widely used to capture self-perceptions of a sense of recovery for people with psychiatric disabilities. The current study tested measurement invariance of RAS between the US and Japanese samples for people with psychiatric disabilities, which is a precursor of further cross-cultural comparisons without any contamination of systematic cultural bias. A multiple-group confirmatory factor analysis was applied to US (N = 446) and Japanese (N = 214) participants for testing configural, loading, and intercept invariance. The results revealed that RAS items equally captured their associated recovery domains between American and Japanese participants. For two domains, "personal confidence and hope" and "reliance on others," the two groups systematically responded with different patterns. Different cultural environments may have additive influences toward people's response patterns to their recovery across countries.

The experts rate: supervisory behaviors that impact the implementation of evidence-based practices.

The purpose of this study was to identify the critical behaviors of supervisors for the successful implementation of evidence-based practice in adult mental health. Experts who work with supervisors to support implementation in three evidence-based practices were surveyed. The three evidence-based practices included Assertive Community Treatment, Integrated Dual Diagnosis Treatment, and Supported Employment. There was substantial agreement among experts as to the importance of supervisory behaviors in the areas of facilitating team meetings, building and enhancing staff skills, monitoring and using outcomes, and continuous quality improvement activities.

Effect of Wellness Recovery Action Plan (WRAP) participation on psychiatric symptoms, sense of hope, and recovery.

OBJECTIVE: Self-management of psychiatric illness is a central tenet of consumer-directed mental health treatment. While several manualized self-management programs have been developed in recent years, the most widely disseminated is the Wellness Recovery Action Plan (WRAP). This study examined the effects of WRAP participation on psychiatric symptoms, hope, and recovery outcomes for people with severe and persistent mental illness. METHODS: A quasi-experimental study, with an experimental (n=58) and a comparison (n=56) group was conducted. WRAP sessions (8-12 week) were facilitated by one staff person and one peer worker at five community mental health centers in a Midwestern state. The Modified Colorado Symptom Index, the State Hope Scale, and the Recovery Markers Questionnaire (RMQ) were employed at the first and last WRAP sessions, as well as six months following the intervention. Repeated measures analysis of covariance and planned comparisons before and after the intervention were conducted. RESULTS: Findings revealed statistically significant group intervention effects for symptoms and hope, but not for RMQ. Planned comparisons showed statistically significant improvements for the experimental group in psychiatric symptoms and hope after the intervention, while non-significant changes occurred in the comparison group. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The study results offer promising evidence that WRAP participation has a positive effect on psychiatric symptoms and feelings of hopefulness. If recovery is the guiding vision for mental health system reform, the study results provide evidence that WRAP programming may warrant a place in the current array of services offered through the publicly funded mental health system.

Comprehensive electronic decision support systems.

This Open Forum describes a vision of comprehensive electronic decision support systems that could provide information and supports to both clients and clinicians in order to facilitate shared decision making and encourage collaborative management of illness and wellness. The authors argue that these systems have the potential to improve mental health care by enhancing and connecting the three elements of evidence-based medicine: client preferences, research evidence, and clinician skills.

Pathways to recovery (PTR): impact of peer-led group participation on mental health recovery outcomes.

OBJECTIVE: This study examined the positive effects on recovery outcomes for people with severe and persistent mental illness using peer-led groups based on Pathways to Recovery: A Strengths Recovery Self-Help Workbook (PTR). PTR translates the evidence-supported practice of the Strengths Model into a self-help approach, allowing users to identify and pursue life goals based on personal and environmental strengths. METHODS: A single-group pretest-posttest research design was applied. Forty-seven members in 6 consumer-run organizations in one Midwestern state participated in a PTR peer-led group, completing a baseline survey before the group and again at the completion of the 12-week sessions. The Rosenberg Self-Esteem Scale, the General Self-Efficacy Scale, Multidimensional Scale of Perceived Social Support, the Spirituality Index of Well-Being, and the Modified Colorado Symptom Index were employed as recovery outcomes. Paired Hotelling's T-square test was conducted to examine the mean differences of recovery outcomes between the baseline and the completion of the group. RESULTS: Findings revealed statistically significant improvements for PTR participants in self-esteem, self-efficacy, social support, spiritual well-being, and psychiatric symptoms. CONCLUSIONS: This initial research is promising for establishing PTR as an important tool for facilitating recovery using a peer-led group format. The provision of peer-led service has been emphasized as critical to integrating consumers' perspectives in recovery-based mental health services. Given the current federal funding stream for peer services, continued research into PTR and other peer-led services becomes more important.

Outcomes of an illness self-management group using wellness recovery action planning.

OBJECTIVE: The aim of this preliminary study was to examine the impact of participation in an illness self-management recovery program (Wellness Recovery Action Planning-WRAP) on the ability of individuals with severe mental illnesses to achieve key recovery related outcomes. METHODS: A total of 30 participants from three mental health centers were followed immediately before and after engaging in a 12-week WRAP program. RESULTS: Three paired sample t-tests were conducted to determine the effectiveness of WRAP on hope, recovery orientation, and level of symptoms. A significant positive time effect was found for hope and recovery orientation. Participants showed improvement in symptoms, but the change was slightly below statistical significance. CONCLUSIONS: These preliminary results offer promising evidence that the use of WRAP has a positive effect on self-reported hope and recovery-related attitudes, thereby providing an effective complement to current mental health treatment.

Developing a framework to support shared decision making for youth mental health medication treatment.

Medical shared decision making has demonstrated success in increasing collaboration between clients and practitioners for various health decisions. As the importance of a shared decision making approach becomes increasingly valued in the adult mental health arena, transfer of these ideals to youth and families of youth in the mental health system is a logical next step. A review of the literature and preliminary, formative feedback from families and staff at a Midwestern urban community mental health center guided the development of a framework for youth shared decision making. The framework includes three functional areas (1) setting the stage for youth shared decision making, (2) facilitating youth shared decision making, and (3) supporting youth shared decision making. While still in the formative stages, the value of a specific framework for a youth model in support of moving from a client-practitioner value system to a systematic, intentional process is evident.

Evidence-based practice implementation in Kansas.

Over the last 8 years, Kansas has been successful in the implementation of evidence-based practices. This paper describes the strategies used at multiple levels of the mental health system including: state policy, provider agency management, fidelity and outcome monitoring, supervisor training and support, and practitioner training. The challenges going forth are described.

Barriers to evidence-based practice implementation: results of a qualitative study.

This study reports on a qualitative study of barriers to EBP implementation in one state that sought to implement supported employment and integrated dual diagnosis treatment. The study found that the most significant obstacles emanated from the behavior of supervisors, front-line staff and other professionals in the agency. A lack of synergy profoundly impeded implementation.

Individualization and quality improvement: two new scales to complement measurement of program fidelity.

Fidelity scales have been widely used to assess program adherence to the principles of an evidence-based practice, but they do not measure important aspects of quality of care. Pragmatic scales measuring clinical quality of services are needed to complement fidelity scales measuring structural aspects of program implementation. As part of the instrumentation developed for the National Implementing Evidence-Based Practices Project, we piloted a new instrument with two 5-item quality scales, Individualization (a client-level quality scale) and Quality Improvement (an organizational-level quality scale). Pairs of independent fidelity assessors conducted fidelity reviews in 49 sites in 8 states at baseline and at four subsequent 6-month intervals over a 2-year follow-up period. The assessors followed a standardized protocol to administer these quality scales during daylong site visits; during these same visits they assessed programs on fidelity to the evidence-based practice that the site was seeking to implement. Assessors achieved acceptable interrater reliability for both Individualization and Quality Improvement. Principal components factor analysis confirmed the 2-scale structure. The two scales were modestly correlated with each other and with the evidence-based practice fidelity scales. Over the first year, Individualization and Quality Improvement improved, but showed little or no improvement during the last year of follow-up. The two newly developed scales showed adequate psychometric properties in this preliminary study, but further research is needed to assess their validity and utility in routine clinical practice.

The State Health Authority Yardstick (SHAY).

State mental health authorities have a leadership role in implementing evidence-based practices (EBPs), but few instruments are available to assess the impact of this role. We describe the development of the State Mental Health Authority Yardstick (SHAY), a behaviorally anchored instrument designed to assess state-level facilitating conditions associated with successful implementation of EBPs in community mental health centers. The SHAY assesses the SMHA role in seven domains: Planning, Financing, Training, Leadership, Policies and Regulations, Quality Improvement, and Stakeholders. Preliminary evidence from the National Evidence-Based Practices Project partially supports the construct and criterion-oriented validity of this instrument for rating state-level activities supporting or blocking the implementation of evidence-based practices.

Key factors for implementing supported employment.

OBJECTIVE: This study examined strategies and barriers for implementing supported employment in routine mental health services. METHODS: Qualitative and fidelity data from a two-year period (2002-2004) were examined for nine sites participating in the National Evidence-Based Practices Project. RESULTS: At baseline, none of the sites were providing high-fidelity supported employment. However, by the two-year follow-up, eight of the nine sites successfully implemented high-fidelity programs. Three factors, leadership, mastery, and attitudes, were identified as strongly influencing the implementation (both positively and negatively) across the nine sites. CONCLUSIONS: The findings indicate the need for strong leadership on both the administrative and program levels, an in-depth understanding of the nature and level of training and consultation needed for program leaders and employment specialists, and the value of hiring staff with clinical or business skills. The study also demonstrated that employing staff who doubt and challenge the evidence-based model slows down the implementation process, suggesting the critical role of hiring staff who believe in recovery and supported employment principles.

A two-year longitudinal study of the Kansas consumers as providers training program.

OBJECTIVE: This study reports student outcomes for the Kansas Consumers as Providers (CAP) training program. Graduates provide mental health services to other consumers in the community. CAP is a semester-long class plus a 104-hour internship in a social service agency. METHODS: This paper reports on the results of a two-year quantitative, longitudinal study of people with psychiatric disabilities who completed the program. RESULTS: Graduates had statistically significant pre-post differences in employment and post-secondary education enrollment at all three follow-up points. CONCLUSION: Results suggest that CAP graduates can and do provide valuable mental health services to other consumers.