Comparison of Assertive Community Treatment Fidelity Assessment Methods: Reliability and Validity.

Assertive community treatment is known for improving consumer outcomes, but is difficult to implement. On-site fidelity measurement can help ensure model adherence, but is costly in large systems. This study compared reliability and validity of three methods of fidelity assessment (on-site, phone-administered, and expert-scored self-report) using a stratified random sample of 32 mental health intensive case management teams from the Department of Veterans Affairs. Overall, phone, and to a lesser extent, expert-scored self-report fidelity assessments compared favorably to on-site methods in inter-rater reliability and concurrent validity. If used appropriately, these alternative protocols hold promise in monitoring large-scale program fidelity with limited resources.

Consumer and relationship factors associated with shared decision making in mental health consultations.

OBJECTIVE: This study explored the association between shared decision making and consumers' illness management skills and consumer-provider relationships. METHODS: Medication management appointments for 79 consumers were audio recorded. Independent coders rated overall shared decision making, minimum level of shared decision making, and consumer-provider agreement for 63 clients whose visit included a treatment decision. Mental health diagnoses, medication adherence, patient activation, illness management, working alliance, and length of consumer-provider relationships were also assessed. Correlation analyses were used to determine relationships among measures. RESULTS: Overall shared decision making was not associated with any variables. Minimum levels of shared decision making were associated with higher scores on the bond subscale of the Working Alliance Inventory, indicating a higher degree of liking and trust, and with better medication adherence. Agreement was associated with shorter consumer-provider relationships. CONCLUSIONS: Consumer-provider relationships and shared decision making might have a more nuanced association than originally thought.

"I'm not abusing or anything": patient-physician communication about opioid treatment in chronic pain.

OBJECTIVE: To characterize clinical communication about opioids through direct analysis of clinic visits and in-depth interviews with patients. METHODS: This was a pilot study of 30 patients with chronic pain, who were audio-recorded in their primary care visits and interviewed after the visit about their pain care and relationship with their physicians. Emergent thematic analysis guided data interpretation. RESULTS: Uncertainties about opioid treatment for chronic pain, particularly addiction and misuse, play an important role in communicating about pain treatment. Three patterns of responding to uncertainty emerged in conversations between patients and physicians: reassurance, avoiding opioids, and gathering additional information. Results are interpreted within the framework of Problematic Integration theory. CONCLUSION: Although it is well-established that opioid treatment for chronic pain poses numerous uncertainties, little is known about how patients and their physicians navigate these uncertainties. This study illuminates ways in which patients and physicians face uncertainty communicatively and collaboratively. PRACTICE IMPLICATIONS: Acknowledging and confronting the uncertainties inherent in chronic opioid treatment are critical communication skills for patients taking opioids and their physicians. Many of the communication behaviors documented in this study may serve as a model for training patients and physicians to communicate effectively about opioids.

Workplace social networks and their relationship with job outcomes and other employment characteristics for people with severe mental illness.

Clients with severe mental illness (SMI) often struggle in their efforts to maintain employment. One cause of early job terminations is interpersonal difficulties in the workplace. This study explored workplace social networks and their relationship with job outcomes and other employment characteristics for people with SMI. Results indicated that clients generally had positive experiences with both supervisors and coworkers. Contrary to our hypothesis, employment model was not associated with better workplace network characteristics. Also contrary to our hypothesis, clients employed in group placements did not differ in workplace network characteristics from those in competitive employment settings. Workplace network characteristics were robustly correlated with job satisfaction, but not strongly related to hourly wages or overall job tenure. Job tenure at the time of the workplace network assessment did show a few modest negative correlations with supervisor and coworker support, indicating declining perceived social network support with increasing job tenure. Study limitations and future directions for research using this methodology are discussed.