Implementation of the strengths model of case management for people with a traumatic brain injury: a qualitative pre-implementation study.

INTRODUCTION: People who sustain a traumatic brain injury (TBI) may have to live with permanent sequelae such as mental health problems, cognitive impairments, and poor social participation. The strengths-based approach (SBA) of case management has a number of positive impacts such as greater community integration but it has never been implemented for persons with TBI. To support its successful implementation with this population, it is essential to gain understanding of how the key components of the intervention are perceived within the organization applying the approach. OBJECTIVES: Documenting the barriers and facilitators in the implementation of the SBA as perceived by potential adopters. METHODS: A qualitative pre-implementation study was conducted using semi-structured interviews with community workers and managers of the community organization where the SBA is to be implemented. Data were analyzed using a deductive approach based on the Consolidated Framework for Implementation Research (CFIR). RESULTS: The major barriers are associated with the intervention (e.g. adaptability of the intervention) and the external context (e.g. the impact of the pandemic). Perceived facilitators are mainly associated with the internal context (e.g. compatibility with current values). CONCLUSION: The barriers and facilitators identified will inform the research team's actions to maximize the likelihood of successful implementation.

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.

Not Just Mortality and Morbidity but Also Function: Opportunities and Challenges for Occupational Therapy in the World Health Organization's Rehabilitation 2030 Initiative.

The World Health Organization's (WHO's) new focus on rehabilitation offers great opportunities for occupational therapy. Recognizing that the problems in daily function created by the aging of the world's population and the increasing prevalence of chronic health conditions require rehabilitation to be a vital part of health systems, the World Health Organization brought a variety of stakeholders together in 2017 and 2019 to help them develop the Rehabilitation 2030 initiative. Occupational therapy was represented by the World Federation of Occupational Therapists, the American Journal of Occupational Therapy, the Canadian Journal of Occupational Therapy, editorial board members of several occupational therapy journals, and other occupational therapy researchers. A major challenge to meeting the goal of sufficient rehabilitation services to meet global need is the worldwide shortage of occupational therapists. This shortage can be attributed to a paucity of knowledge about occupational therapy as a health care profession, lack of understanding of the occupational therapy scope of practice, the cost of education required to become an occupational therapist, and the need for occupational therapy salaries to offset educational costs. Nonetheless, ongoing success in research and clinical outcomes will increase knowledge of the value of occupational therapy and increase the size of the profession. WHO's focus on function is to be lauded. Yet, occupational therapists must not be content with an emphasis on function. They also need to advocate for contextual changes that eliminate barriers to participation and engagement experienced by people with disability.

Rehabilitation Is a Global Health Priority.

Optimizing functioning at all ages is a major global public health goal. Rehabilitation is unique in its contribution to this public health agenda because of its focus on optimizing function. In this editorial, the editors of leading rehabilitation journals make the case for fully integrating rehabilitation into a nation's health system and strengthening it specifically at the primary care level to increase access and achieve its full potential. Authors submitting papers to rehabilitation journals are encouraged to consider the global health policy implications of their research when they prepare their research reports for publication and to make these implications explicit.

Psychometric properties of the Community Integration Questionnaire: a systematic review of five populations.

OBJECTIVES: This systematic review documents the content and the quality of the psychometric evidence concerning the utilization of the Community Integration Questionnaire for individuals living with a disability other than a traumatic brain injury. DATA SOURCES: Medline, Embase, CINAHL, OTseeker and PsycINFO (searched from inception to June 2019). REVIEW METHODS: Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for conducting and reporting this review. Studies that investigated at least one psychometric property of the Community Integration Questionnaire for individuals living with a disability other than traumatic brain injury were included. Data extraction and critical methodological appraisal of the articles (MacDermid checklist, COnsensus-based Standards for the selection of health Measurement INstruments checklist) were independently performed and validated by the first two authors. RESULTS: Ten studies representing 3000 individuals met the inclusion criteria. Five populations were documented. There are positive and trustable data regarding internal consistency for adults living with multiple sclerosis, spinal cord injury or burns and in mixed samples (α = 0.71-0.84). Construct validity is fairly documented for adults living with multiple sclerosis or aphasia and in mixed samples. Test-retest reliably is acceptable for adults living with multiple sclerosis (intraclass correlation coefficient = 0.91-0.97) as well as responsiveness (area under the receiver operating characteristic curve = 0.81). Other psychometric properties could not be demonstrated sufficiently solid. CONCLUSION: Many psychometric properties of the Community Integration Questionnaire are still poorly evaluated for adults living with a disability other than a traumatic brain injury. However, promising data have been documented in each population included in this review.

Implementation of the Quebec mental health reform (2005-2015).

BACKGROUND: This study evaluates implementation of the Quebec Mental Health (MH) Reform (2005-2015) which aimed to improve accessibility, quality and continuity of care by developing primary care and optimizing integrated service networks. Implementation of MH primary care teams, clinical strategies for consolidating primary care, integration strategies to improve collaboration between primary care and specialized services, and facilitators and barriers related to these measures were examined. METHODS: Eleven Quebec MH service networks provided the study setting. Networks were identified in consultation with 20 key MH decision makers and selected based on variation in services offered, integration strategies, best practices, and geographic criteria. Data collection included: primary documents, structured questionnaires completed by 25 managers from MH primary care teams and 16 respondent-psychiatrists working in shared-care, and semi-structured interviews with 102 network stakeholders involved in the reform. The study employed a mixed method approach, triangulating the three data sources across networks. RESULTS: While implementation was not fully achieved in most networks, the Quebec reform succeeded in improving primary care services with the creation of adult primary care teams, and one-stop services which increased access to care, mainly for clients with common MH disorders. In terms of clinical strategies implemented, the functions provided by respondent-psychiatrists had a greater impact on the MH primary care teams than on general practitioners (GPs) in medical clinics; whereas the implementation of best practices were indirect outcomes of another reform developed simultaneously by the Quebec substance use disorders program. The main integration strategies used for increasing continuity of care and collaboration between primary care and specialized services were those involving fewer formal procedures such as referrals between teams and organizations. The lack of operational mechanisms and protocols governing new services and structures were important barriers to primary care consolidation and service integration, as was the lack of interest and involvement of most GPs in MH. CONCLUSIONS: Successful and sustained healthcare reform requires attention to process and outcomes as well as structural change or service reorganization. Six recommendations for more successful implementation of the Quebec MH Reform are provided, with implications for healthcare reform internationally.

Implementing Housing First Across Sites and Over Time: Later Fidelity and Implementation Evaluation of a Pan-Canadian Multi-site Housing First Program for Homeless People with Mental Illness.

This article examines later fidelity and implementation of a five-site pan-Canadian Housing First research demonstration project. The average fidelity score across five Housing First domains and 10 programs was high in the first year of operation (3.47/4) and higher in the third year of operation (3.62/4). Qualitative interviews (36 key informant interviews and 17 focus groups) revealed that staff expertise, partnerships with other services, and leadership facilitated implementation, while staff turnover, rehousing participants, participant isolation, and limited vocational/educational supports impeded implementation. The findings shed light on important implementation "drivers" at the staff, program, and community levels.

Evaluation of the implementation of the Montreal At Home/Chez Soi project.

BACKGROUND: Homelessness and mental disorders constitute a major problem in Canada. The purpose of the At Home/Chez Soi pilot project was to house and provide supports to marginalised groups. Policymakers are in a better position to nurture new, complex interventions if they know which key factors hinder or enable their implementation. This paper evaluates the implementation process for the Montreal site of this project. METHODS: We collected data from 62 individuals, through individual interviews, focus groups, questionnaires, observations and documentation. The implementation process was analysed using a conceptual framework with five constructs: Intervention Characteristics (IC), Context of Implementation (CI), Implementation Process (IP), Organizational Characteristics (OC) and Strategies of Implementation (SI). RESULTS: The most serious obstacle to the project came from the CI construct, i.e., lack of support from provincial authorities and key local resources in the homelessness field. The second was within the OC construct. The chief hindrances were numerous structures, divergent values among stakeholders, frequent turnover of personnel and team leaders; lacking staff supervision and miscommunication. The third is related to IC: the complex, unyielding nature of the project undermined its chances of success. The greatest challenges from IP were the pressure to perform, along with stress caused by planning, deadlines and tension between teams. Conversely, SI construct conditions (e.g., effective governing structures, comprehensive training initiatives and toolkits) were generally very positive even with problems in power sharing and local leadership. For the four other constructs, the following proved useful: evidence of the project's scope and quality, great needs of services consolidation, generous financing and status as a research pilot project, enthusiasm and commitment toward the project, substantially improved services, and overall user satisfaction. CONCLUSION: This study demonstrated the difficulty of implementing a complex project in the healthcare system. While the project faced many barriers, minimal conditions were also achieved. At the end of the study period, major tensions between organizations and teams were significantly reduced, supporting its full implementation. However, in late 2013, the project was unsustainable, calling into question the relevance of achieving a significant number of positive conditions in each area of the framework.

Implementation of a strengths-based approach in a traumatic brain injury community service; perspectives of community workers.

Background The strengths-based approach (SBA) was initially developed for people living with mental health issues but may represent a promising support option for community participation of people living with a traumatic brain injury (TBI). A community-based organisation working with people living with TBI is in the process of adapting this approach to implement it in their organisation. No studies explored an SBA implementation with this population. This study explores the implementation of key components of the SBA in a community-based organisation dedicated to people living with TBI. Methods A qualitative descriptive design using semi-structured interviews (n = 10) with community workers, before and during implementation, was used. Transcripts were analysed inductively and deductively. Deductive coding was informed by the SBA fidelity scale. Results Group supervision and mobilisation of personal strengths are key SBA components that were reported as being integrated within practice. These changes led to improved team communication and cohesiveness in and across services, more structured interventions, and greater engagement of clients. No changes were reported regarding the mobilisation of environmental strengths and the provision of individual supervision. Conclusion The implementation of the SBA had positive impacts on the community-based organisation. This suggests that it is valuable to implement an adaptation of the SBA for people living with TBI.

The effectiveness of an online short-format Recovery College model: a co-learning model to support mental health.

BACKGROUND: Our societies are facing mental health challenges, which have been compounded by the Covid-19. This event led people to isolate themselves and to stop seeking the help they needed. In response to this situation, the Health and Recovery Learning Center, applying the Recovery College (RC) model, modified its training program to a shorter online format. This study examines the effectiveness of a single RC training course delivered in a shortened online format to a diverse population at risk of mental health deterioration in the context of Covid-19. METHODS: This quasi-experimental study used a one-group pretest-posttest design with repeated measures. Three hundred and fifteen (n = 315) learners agreed to take part in the study and completed questionnaires on wellbeing, anxiety, resilience, self-management, empowerment and stigmatizing attitudes and behaviors. RESULTS: Analyses of variance using a linear mixed models revealed that attending a RC training course had, over time, a statistically significant effect on wellbeing (p = 0.004), anxiety (p < 0.001), self-esteem/self-efficacy (p = 0.005), disclosure/help-seeking (p < 0.001) and a slight effect on resilience (p = 0.019) and optimism/control over the future (p = 0.01). CONCLUSIONS: This study is the first to measure participation in a single online short-format RC training course, with a diversity of learners and a large sample. These results support the hypothesis that an online short-format training course can reduce psychological distress and increase self-efficacy and help-seeking. TRIAL REGISTRATION: This study was previously approved by two certified ethics committees: Comité d'éthique de la recherche du CIUSSS EMTL, which acted as the committee responsible for the multicenter study, reference number MP-12-2021-2421, and Comité d'éthique avec les êtres humains de l'UQTR, reference number CER-20-270-07.01.

Planning a multi-site, complex intervention for homeless people with mental illness: the relationships between the national team and local sites in Canada's At Home/Chez Soi project.

This research focused on the relationships between a national team and five project sites across Canada in planning a complex, community intervention for homeless people with mental illness called At Home/Chez Soi, which is based on the Housing First model. The research addressed two questions: (a) what are the challenges in planning? and (b) what factors that helped or hindered moving project planning forward? Using qualitative methods, 149 national, provincial, and local stakeholders participated in key informant or focus group interviews. We found that planning entails not only intervention and research tasks, but also relational processes that occur within an ecology of time, local context, and values. More specifically, the relationships between the national team and the project sites can be conceptualized as a collaborative process in which national and local partners bring different agendas to the planning process and must therefore listen to, negotiate, discuss, and compromise with one another. A collaborative process that involves power-sharing and having project coordinators at each site helped to bridge the differences between these two stakeholder groups, to find common ground, and to accomplish planning tasks within a compressed time frame. While local context and culture pushed towards unique adaptations of Housing First, the principles of the Housing First model provided a foundation for a common approach across sites and interventions. The implications of the findings for future planning and research of multi-site, complex, community interventions are noted.

Learner Experience of an Online Co-Learning Model to Support Mental Health during the COVID-19 Pandemic: A Qualitative Study.

The COVID-19 pandemic has had a negative impact on the mental health of the population such as increased levels of anxiety, psychological distress, isolation, etc. Access to mental health services has been limited due to the "overflow" of demands. The Recovery College (RC) model, an education-based approach, has addressed this challenge and provided online well-being and mental health courses to at-risk populations. The RC model proposes a co-learning space in an adult education program where learners from diverse backgrounds collectively learn and empower themselves to better address psychological well-being and mental health issues. The aim of this study was to document the experience of learners who participated in online RC courses during the COVID-19 pandemic and the perceived impact of these courses on their mental health. A qualitative interpretative descriptive study design was employed, and Miles and Huberman's stepwise content analysis method was used to mine the data for themes. Fourteen structured online interviews were conducted with a sample representative of the diversity of learners. Five categories of themes emerged: (1) updating and validating your mental health knowledge, (2) taking care of yourself and your mental health, (3) improving and modifying your behaviors and practices, (4) changing how you look at yourself and others, and (5) interacting and connecting with others. Results suggest that online RC courses can be an effective strategy for supporting individual self-regulation and empowerment, breaking social isolation, and reducing the effects of stress in times of social confinement measures and limited access to care.

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.

Assessing Changes in Anxiety, Empowerment, Stigma and Wellbeing in Participants Attending an Online-Based Recovery College in Quebec During the Covid-19 Pandemic: A Pre-Experimental Study.

Objectives: The present study aims to evaluate the effect of an online Recovery College (RC) program implemented in Quebec (Canada) during the COVID-19 pandemic. From October 2020 to June 2021, 27 training groups were conducted with a total of 362 attendees. Methods: Outcome was evaluated using a single group repeated measure design, assessing participants prior the training (T0), after the training (T1) and at follow up (T2). 107 learners of the Quebec RC program attended three two-hour sessions agreed to participate to the research. Results: Overall findings show at T1 a small but statistically significant reduction of anxiety and increase in empowerment, and below threshold reduction of stigmatizing attitudes and increase of wellbeing. Conversely, the medium-term changes at follow up were non-significant for all the outcome dimension except for anxiety. Conclusion: Findings suggest that the RC online program can be considered as a potential effective strategy to support self-regulation and empowerment of individuals and to reduce anxiety in the context of crisis for the general population.

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).

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).