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.

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.

Supporting shared decision making beyond consumer-prescriber interactions: Initial development of the CommonGround fidelity scale.

Shared decision-making has become a central tenet of recovery-oriented, person-centered mental health care, yet the practice is not always transferred to the routine psychiatric visit. Supporting the practice at the system level, beyond the interactions of consumers and medication prescribers, is needed for successful adoption of shared decision-making. CommonGround is a systemic approach, intended to be part of a larger integration of shared decision-making tools and practices at the system level. We discuss the organizational components that CommonGround uses to facilitate shared decision-making, and we present a fidelity scale to assess how well the system is being implemented.

Barriers to supported education implementation: implications for administrators and policy makers.

The economic impact of a lack of educational achievement for individuals with psychiatric disabilities is profound. Current poor economic conditions exacerbate the effects of low educational levels. This article presents the current educational barriers faced by individuals with psychiatric disabilities and introduces one potential solution: supported education. Supported education is an emerging best practice which holds promise for helping individuals with psychiatric disabilities in their pursuit of educational goals. However, additional barriers stand in the way of widespread supported education implementation. Recommendations are included for policymakers and community mental health centers to help increase the penetration of this much-needed service.

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.

Case managers' perceptions of consumer work readiness and association with pursuit of employment.

OBJECTIVE The purpose of this study was to determine whether case managers' perceptions of consumers' work readiness-in the areas of the individual consumer's hygiene, social skills, medication adherence, psychiatric symptoms, and substance use-influence pursuit of employment. METHODS A cross-sectional survey study design was used to assess the role of staff perceptions in consumers' pursuit of employment. A hierarchical generalized linear model with a logit link function was used to analyze data from 1,556 consumers nested within data for 113 case manager caseloads. RESULTS Case managers' perception of work readiness was significantly associated with pursuit of employment. CONCLUSIONS The clients of case managers with less stringent criteria for pursuing employment were more likely to take positive steps toward employment.

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.