Implementation of strengths model case management in seven mental health agencies in Canada: Direct-service practitioners' implementation experience.

RATIONALE: Implementation of strengths model case management is increasing internationally. However, few studies have focused on its implementation process, and none have specifically addressed the implementation experience of direct-service practitioners. OBJECTIVE: This paper presents factors that facilitate and impede the successful implementation of the strengths model, with a specific focus on practitioners who deliver the intervention directly to service recipients. METHOD: To address this objective, a qualitative study of seven mental health agencies that implemented the model was conducted, involving a combination of participant observations and qualitative semistructured interviews with case managers, team supervisors, and senior managers. Qualitative data were analyzed using open coding followed by axial coding. Finally, the findings were aligned with an adapted Consolidated Framework for Implementation Research. RESULTS: Implementation of the strengths model involved a significant change in practice for case management practitioners. The results confirm that at the beginning of implementation, the strengths model was perceived as complex and not always adaptable to on-the-ground realities. With time, and with support from management, ongoing training and supervision sessions, and reflection and discussion, practitioners regained feelings of competence and resistance to the model diminished. The use of the model's structured team-based supervision tools was fundamental to supporting the implementation process by enabling an interactive and concrete training approach. CONCLUSIONS: The more an approach leads to changes in daily practice and is perceived as complex, the more concrete support is needed during implementation. This article highlights the importance of attending to a practitioner's sense of personal effectiveness and competence in the adoption of new practices.

The Working Alliance as a Mediator Between Fidelity to Strengths Model Case Management and Client Outcomes.

Objective: The purpose of this study was to examine how the client­case manager working alliance in strengths model case management (SMCM) mediates the relationship between fidelity to the SMCM intervention and clients' quality of life, hope, and community functioning. Methods: In total, 311 people with severe mental illness, served at seven community mental health agencies in Canada, participated in the study. They were new to SMCM and participated in five structured interviews every 4.5 months for 18 months to measure the quality of the client­case manager working alliance and clients' quality of life, hope, and community functioning. The team-level SMCM fidelity scale was administered six times over 3 years. Ordinary least-squares path analysis was used to test simple mediation models. Results: Higher fidelity to SMCM was associated with better client outcomes indirectly through the working alliance. Higher SMCM fidelity predicted a stronger working alliance, which in turn predicted greater improvements in client quality of life (at 9 months and 18 months), hope (at 18 months), and community functioning (at 9 months). Conclusions: The results support the view that SMCM is an effective intervention. When the intervention was implemented as planned, it fostered stronger working alliances between clients and case managers and contributed to greater improvements in the quality of life, hope, and functioning of people with severe mental illness. The findings of this study highlight the value of ongoing monitoring of implementation fidelity to achieve high-fidelity interventions that may lead to positive client outcomes.

Association between fidelity to the strengths model of case management and client outcomes: A quasi-experimental study.

OBJECTIVE: Evidence concerning strengths model of case management (SMCM) remains mixed. This study aimed to test the hypotheses that higher fidelity to SMCM is associated with improved quality of life (QoL), hope, community participation, community functioning, more days of competitive employment and of independent living, and fewer days of hospitalization. METHODS: SMCM was implemented over a 3-year period, at seven sites in the Canadian provinces of Newfoundland and Labrador, Québec, and Ontario. Independent assessors visited 14 teams at the seven sites to evaluate fidelity at baseline and 6, 12, 18, 24, and 36 months later. Participants (N = 311) answered standardized questionnaires at 4.5-month intervals up to 18 months. Fidelity assessments were interpolated so they could be associated with questionnaire responses. Linear mixed-effects models and generalized linear models were estimated. RESULTS: Fidelity increased significantly, with all sites except one achieving or approaching good fidelity within 36 months. Fidelity was not significantly associated with any of the outcome measures, although all estimated directions of relationships were consistent with our hypotheses. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: In a pragmatic study of real-world implementation of the strengths model at seven sites, no statistically significant relationships between fidelity and outcomes were found. Low variation in fidelity across individuals, modest sample size, and limited ability to detect change over 18 months, may have contributed to these null findings. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Implementing the Strengths Model of Case Management: Assessing Practice Three Years After Initial Implementation.

While strengths approaches are important to recovery-oriented practice, implementation can be challenging. This study implemented the strengths model of case management (SMCM) in 11 CM teams and assessed the fidelity of delivery and staff perceptions of the model after 36 months using the SMCM fidelity scale and the Readiness Monitoring Tool. Paired sample t-tests assessed change in fidelity from baseline to 36 months. Adjusted regression analyses compared survey responses of direct and management staff. While fidelity ratings significantly improved across all domains, at 36 months they remained suboptimal in supervision practices and use of model tools. Staff perceptions were generally positive but consistently lower for front-line than management staff. Implementing SMCM into existing case management practice with good fidelity is feasible. However, clear support from management may strengthen staff motivation and delivery. A review of practice later in implementation can flag challenges for sustainability and guide implementation support.

A Qualitative Study of the Working Alliance in the Strengths Model of Case Management with People with Severe Mental Illness.

The purpose of this study was to examine clients' perceptions of the client-case manager working alliance in the context of receiving the Strengths Model of Case Management. Twenty people with severe mental illness, with a SMCM case manager, participated in semi-structured, qualitative interviews. Using first and second cycle coding, data were analyzed thematically. People in the study attributed personal life changes to their relationship with their case manager. They valued their case managers' flexibility and highlighted their work on a wide range of goals of their choosing. Case managers approached the SMCM intervention responsive to their clients' preferences and choices. The working alliance serves as a key element of the SMCM intervention. Clients describe the working alliance as helping to improve their lives. This study supports the implementation of SMCM with people with severe mental illness due to its focus on fostering a strong working alliance.

Validation of the Patient Generated Index for people with severe mental illness.

OBJECTIVE: The Patient Generated Index (PGI) is a personalized quality of life (QOL) measure. This secondary analysis examined its psychometric properties with people with severe mental illness. METHODS: Three hundred and eleven people with severe mental illness participated in structured interviews at baseline, 9 months, and 18 months. RESULTS: The PGI captured a range of self-defined life areas. PGI scores were correlated with measures of QOL, hope, and functioning, indicating concurrent (criterion) validity. The correlation with QOL, with the finding that PGI scores were significantly higher for people who were employed (n = 42) versus unemployed (n = 269) and for people without substance use disorder (n = 269) versus those with substance use disorder (n = 42), is indicative of construct validity. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The results support the suitability of the PGI as an idiographic measure for monitoring personalized QOL of people with severe mental illness. (PsycInfo Database Record (c) 2021 APA, all rights reserved).