Implementing Person-Centered Recovery Planning: New England Mental Health Technology Transfer Center Learning Collaborative Evaluation Report.

Person-centered recovery planning (PCRP) has been a key aspect in mental health system transformation and delivering quality health care. Despite the mandate to deliver this practice and a growing evidence base, its implementation and understanding of implementation processes in behavioral health settings remain a challenge. New England Mental Health Technology Transfer Center (MHTTC) launched the PCRP in Behavioral Health Learning Collaborative to support agencies' implementation efforts through training and technical assistance. In an effort to explore and understand the internal implementation process changes facilitated by the learning collaborative, the authors conducted qualitative key informant interviews with the participants and the leadership of the PCRP learning collaborative. The interviews revealed the processes that are part of the PCRP implementation efforts, including staff training, changing agency policies and procedures, modifying treatment planning tools, and the structure of the electronic health records. The higher prior organizational investment and readiness for change, building staff's competencies in PCRP, leadership investment, and frontline staff buy-in act as factors that facilitate the implementation of PCRP in behavioral health settings. Our findings inform both the implementation of PCRP in behavioral health settings and future efforts of organizing multi-agency learning collaboratives to support PCRP implementation. Supplementary Information: The online version contains supplementary material available at 10.1007/s43477-023-00078-3.

Developing a Tool to Measure Person-Centered Care in Service Planning.

Background: Delivering person-centered care is a key component of health care reform. Despite widespread endorsement, medical and behavioral health settings struggle to specify and measure person-centered care objectively. This study presents the validity and reliability of the Person-Centered Care Planning Assessment Measure (PCCP-AM), an objective measure of the extent to which service planning is person-centered. Methods: Based upon the recovery-oriented practice of person-centered care planning, the 10-item PCCP-AM tool rates service plans on the inclusion of service user strengths, personal life goals, natural supports, self-directed actions and the promotion of community integration. As part of a large randomized controlled trial of person-centered care planning, service plans completed by community mental health clinic providers were rated using the PCCP-AM. Reliability was tested by calculating inter-rater reliability across 168 plans and internal consistency across 798 plans. To test concurrent validity, PCCP-AM scores for 84 plans were compared to expert rater scores on a separate instrument. Results: Interrater reliability for each of the 10 PCCP-AM items as measured by Kendall's W ranged from W = 0.77 to W = 0.89 and percent of scores within ± 1 point of each other ranged from 85.7 to 100%. Overall internal consistency as measured by Cronbach's alpha across 798 plans was α = 0.72. Concurrent validity as measured by Kendall's W ranged from W = 0.55 to W = 0.74 and percent of item scores within ± 1 point of expert rater scores ranged from 73.8 to 86.8%. Conclusions: Findings demonstrated that the 10-item PCCP-AM was a valid and reliable objective measure of person-centered care. Using the service plan as an indicator of multiple domains of person-centered care, the measure provides a valuable tool to inform clinical supervision and quality improvement across programs. More psychometric testing is needed to strengthen the measure for research purposes.

The Promise and Pitfalls of Electronic Health Records and Person-Centered Care Planning.

Person-Centered Care Planning is a recovery-oriented practice designed to meet the increasing demand to deliver person-centered care. Despite widespread dissemination efforts to train providers in person-centered care, behavioral health agencies are still struggling to implement person-centered care approaches. One of the barriers is poorly designed electronic health records that are not aligned to reflect the goal of providing individuals with meaningful choices and self-determination. The pitfalls of EHR design include service planning templates that rely on automated formats that are problem-driven and preclude the entry of unique information, whereas a well-designed EHR can become a key strategy for the delivery of person-centered care by having the functionality to reflect individual goals, actions, and natural supports. The promise and pitfalls of EHR design demonstrates the importance of having a treatment planning platform that allows providers to actualize person-centered care.

'Men just drink more than women. Women have friends to talk to'-Gendered understandings of depression among healthcare professionals and their implications.

Little is known about how gendered understandings of patients can inform professionals' discretionary actions and decisions to include or exclude in clinical practice. Using Connell's poststructuralist perspectives on gender as an analytic framework, this article aims to investigate how professionals' articulations of depression are framed by signs of masculinity and femininity, and how these articulations inform service provision to patients with depression in clinical psychiatry. Building on interview data drawn from an ethnographic study, the article shows how the professionals' articulations reflected a gender binary that framed how the feminized patients were often connected to psychiatric care while masculinized patients were referred to separate alcohol or substance use treatment outside the psychiatric institution. The article discusses the societal and institutional conditionality of gendered understandings in psychiatry. In spite of several limitations, the article elucidates how professionals' understandings might have wide-ranging implications for the accuracy of epidemiological research and policy, and how they reflect a power struggle between patients and professionals about the legitimate right to interpret patients' conditions and efforts to manage their illness-related problems.

Person-centered planning in mental health: A transatlantic collaboration to tackle implementation barriers.

Collaborative, person-centered approaches to care planning are increasingly recognized as instrumental in supporting attainment of personal recovery outcomes. Yet, though much is known about factors that support person-centered planning, successful implementation often remains an elusive goal. This article reviews international efforts to promote person-centered care planning (PCCP) in the context of a randomized clinical trial in the United States and in the Meaningful and Measurable initiative, a collaborative action research project involving diverse provider organizations in Scotland. The authors review the history of international efforts to implement PCCP and offer preliminary evidence regarding its positive impact on both process outcomes (e.g., the nature of the primary therapeutic relationship and the service-user's experience) and personal recovery outcomes (e.g., quality of life, community belonging, and valued roles). PCCP will be defined through descriptions of key principles and practices as they relate to both relational aspects (e.g., shifts in stakeholder roles and conversations) and documentation/recording aspects (e.g., how person-centered relationships are captured in written or electronic records). Similarities and differences between the United States and Scottish experiences of PCCP are highlighted and a series of recommendations offered to further implementation of this essential recovery-oriented practice.

Person-centered care planning and service engagement: a study protocol for a randomized controlled trial.

BACKGROUND: Service disengagement is a pervasive challenge the mental health care system faces. Mental health services are of little value should persons with mental illnesses continue to opt out of receiving them. Consumers attribute disengagement from care to an absence of choice in their treatment. In response, the mental health system is adopting a person-centered model, based upon recovery principles, to engage consumers more actively in their care. Person-centered care planning is a promising practice involving collaboration to develop and implement an actionable plan to assist the person in achieving personal recovery goals. METHODS/DESIGN: This study design combines a parallel-group randomized controlled trial of community mental health organizations with qualitative methods to assess the effectiveness of person-centered care planning. Participants at 14 sites in Delaware and Connecticut will be randomized to treatment as usual or the person-centered care planning intervention. Participants will be in leadership (n = 70) or supervisory or direct care (n = 210) roles. The person-centered care planning intervention involves intensive staff training and 12 months of ongoing technical assistance. Quantitative survey data will be collected at baseline, 6 months and 12 months measuring person-centered care planning competency and organizational factors. Consumer outcomes (engagement, medication adherence, functioning and consumer satisfaction) will be assessed by Medicaid and state-level data. Qualitative data focused on process factors will include staff and consumer interviews and focus groups. In this intent-to-treat analysis, we will use mixed-effects multivariate regression models to evaluate the differential impact of the person-centered care planning intervention on each consumer and implementation outcome as well as the extent to which clinician assessments of organizational factors are associated with the implementation outcome. Mixed methods will triangulate and strengthen the interpretation of outcomes. DISCUSSION: The aim of this study is to generate valuable guidance for state systems engaged in scale-up and transformation efforts. Targeted staff selection for training to support sustainability will serve to provide further insight into important intervention implementation strategies. Person-centered care planning has the potential to enhance the impact of all evidence-based and recovery-oriented practices and bring practice into line with the emerging national guidelines in health care reform. TRIAL REGISTRATION: This trial was registered with ClinicalTrials.gov (Identifier: NCT02299492) on 21 November 2014 as New York University Protocol Record PCCP-13-9762, Person-Centered Care Planning and Service Engagement.

A clinical trial of peer-based culturally responsive person-centered care for psychosis for African Americans and Latinos.

BACKGROUND: Providing culturally competent and person-centered care is at the forefront of changing practices in behavioral health. Significant health disparities remain between people of color and whites in terms of care received in the mental health system. Peer services, or support provided by others who have experience in the behavioral health system, is a promising new avenue for helping those with behavioral health concerns move forward in their lives. PURPOSE: We describe a model of peer-based culturally competent person-centered care and treatment planning, informed by longstanding research on recovery from serious mental illness used in a randomized clinical trial conducted at two community mental health centers. METHODS: Participants all were Latino or African American with a current or past diagnosis within the psychotic disorders spectrum as this population is often underserved with limited access to culturally responsive, person-centered services. Study interventions were carried out in both an English-speaking and a Spanish-speaking outpatient program at each study center. Interventions included connecting individuals to their communities of choice and providing assistance in preparing for treatment planning meetings, all delivered by peer-service providers. Three points of evaluation, at baseline, 6 and 18 months, explored the impact of the interventions on areas such as community engagement, satisfaction with treatment, symptom distress, ethnic identity, personal empowerment, and quality of life. CONCLUSIONS: Lessons learned from implementation include making cultural modifications, the need for a longer engagement period with participants, and the tension between maintaining strict interventions while addressing the individual needs of participants in line with person-centered principles. The study is one of the first to rigorously test peer-supported interventions in implementing person-centered care within the context of public mental health systems.

Implementing person-centered care in psychiatric rehabilitation: what does this involve?

BACKGROUND: It has been challenging to move beyond the rhetoric of "recovery" and "person-centered care" to concrete practices that embody these lofty, if also obvious, values. METHOD: This paper describes two examples of person-centered care: the practices of person-centered care planning from the U.S. and Open Dialogue from Finland. RESULTS: The key strategies that these two practices involve are 1) reorientation from patient to personhood; 2) reorientation of what is considered valued knowledge and expertise, and; 3) partnership and negotiation in decision-making. LIMITATIONS: This review focused on two examples of person-centered care which appear to be promising. Preliminary findings will need to be replicated and elaborated for such practices to be considered evidence-based. CONCLUSION: It is possible to embody the values of person-centered care and recovery in everyday clinical and rehabilitative practice. A primary shift involved is in the role of patients and their family, friends, and peers and in the importance accorded their everyday life experiences and challenges.

Creating a recovery-oriented system of behavioral health care: moving from concept to reality.

This article describes challenges and successes seen in the first four years of efforts the state of Connecticut has made to reorient its behavioral health system to promoting recovery. Beginning in 2000, the Connecticut initiative was conceptualized as a multi-year, systemic process that involved the following interrelated steps: a) developing core values and principles based on the input of people in recovery; b) establishing a conceptual and policy framework based on this vision; c) building workforce competencies and skills; d) changing programs and service structures; e) aligning fiscal and administrative policies; and, finally, f) monitoring, evaluating, and adjusting these efforts. Following descriptions of the first four steps, the authors offer a few lessons that might benefit other states engaged in similar processes of transformation.

Play, pleasure, and other positive life events: "non-specific" factors in recovery from mental illness?

As part of the emerging recovery paradigm, there is an increasing need for psychiatric treatment and rehabilitation to be strengths-based and to be driven by the desires and preferences of the person with mental illness. Yet if mental illness is a brain disease, it is not at all clear how these characteristics contribute to improvement in the person's condition or influence the course and outcome of the disorder. To avoid these aspects being relegated to the role of nonspecific factors, the field must develop an understanding of the role of strengths and interests in recovery. To contribute to this effort, we review the existing empirical research on the protective and stress-buffering effects of positive life events and qualitative data on the importance of play and pleasure in the lives of people with mental illness. We conclude by considering briefly the implications of this research for clinical practice.

The top ten concerns about recovery encountered in mental health system transformation.

The notion of "recovery" has recently taken center stage in guiding mental health policy and practice. However, it is not yet clear what the term means and what is to be entailed in transforming the nation's mental health system to promote it. The authors discuss the various meanings of recovery as applied to mental illness and list the top ten concerns encountered in efforts to articulate and implement recovery-oriented care. These concerns include the following: recovery is old news, recovery-oriented care adds to the burden of already stretched providers, recovery involves cure, recovery happens to very few people, recovery represents an irresponsible fad, recovery happens only after and as a result of active treatment, recovery-oriented care is implemented only through the addition of new resources, recovery-oriented care is neither reimbursable nor evidence based, recovery-oriented care devalues the role of professional intervention, and recovery-oriented care increases providers' exposure to risk and liability. These concerns are addressed through discussion of the two over-arching challenges that they pose, namely the issues of resources and risk.

The fundamentals of workforce competency: implications for behavioral health.

Increasing attention is being directed to the competency of those who deliver healthcare in the United States. In behavioral health, there is growing recognition of the need to define, teach, and assess essential competencies. Since attention to this issue in behavioral health is relatively recent, there is much to be gained by learning from the principles, definitions, and conceptual models of competency that have been developed in other fields. This article outlines the forces that drive the current focus on competency of the healthcare workforce. Relevant history, principles, definitions, and models that have evolved through research and application in business and industry are reviewed. From this analysis, recommendations are offered to guide future work on competencies in behavioral health.

Strategies for developing competency models.

There is an emerging trend within healthcare to introduce competency-based approaches in the training, assessment, and development of the workforce. The trend is evident in various disciplines and specialty areas within the field of behavioral health. This article is designed to inform those efforts by presenting a step-by-step process for developing a competency model. An introductory overview of competencies, competency models, and the legal implications of competency development is followed by a description of the seven steps involved in creating a competency model for a specific function, role, or position. This modeling process is drawn from advanced work on competencies in business and industry.

Workforce competencies in behavioral health: an overview.

Competency-based training approaches are being used more in healthcare to guide curriculum content and ensure accountability and outcomes in the educational process. This article provides an overview of the state of competency development in the field of behavioral health. Specifically, it identifies the groups and organizations that have conducted and supported this work, summarizes their progress in defining and assessing competencies, and discusses both the obstacles and future directions for such initiatives. A major purpose of this article is to provide a compendium of current competency efforts so that these might inform and enhance ongoing competency development in the varied behavioral health disciplines and specialties. These varied resources may also be useful in identifying the core competencies that are common to the multiple disciplines and specialties.

From rhetoric to routine: assessing perceptions of recovery-oriented practices in a state mental health and addiction system.

The Recovery Self Assessment (RSA) was developed to gauge perceptions of the degree to which programs implement recovery-oriented practices. Nine hundred and sixty-seven directors, providers, persons in recovery, and significant others from 78 mental health and addiction programs completed the instrument. Factor analysis revealed five factors: Life Goals, Involvement, Diversity of Treatment Options, Choice, and Individually-Tailored Services. Agencies were rated highest on items related to helping people explore their interests and lowest on items regarding service user involvement in services. The RSA is a useful, self-reflective tool to identify strengths and areas for improvement as agencies strive to offer recovery-oriented care.

Evidence-based teaching practice: implications for behavioral health.

Educational practices and strategies have changed very little over the years, and even emerging advances in technology have become the prisoners of traditional academic norms. Thus, while there is increasing emphasis on evaluating and aligning caregiving processes with the strongest evidence of effectiveness, there is little demonstration or role-modeling of this same expectation in either the formal or continuing educational processes of behavioral healthcare providers. This "disconnect" is a significant problem in the field. This paper addresses the urgent need to inform the education and training of the behavioral health workforce with current theories regarding the teaching-learning process and evidence about the effectiveness of various teaching strategies. The relevant theories and available bodies of evidence are described, and the implications for workforce education and training are identified.

Training in evidence-based practice.

Controversy surrounds the concept of EBP. Many individuals question whether research is capable of guiding decisions about diagnosis and treatment, or whether it simply gives oversimplified answers to highly complex questions about human behavior. These concerns aside, it is hard to envision a future in which consumers and payers do not demand that the health professions ground their interventions in an evidence base. It is sobering to recognize that training in EBP has been far from the norm in the various behavioral health disciplines. This is just one aspect of a much larger crisis in behavioral health workforce education. Graduate and residency programs have not kept pace with many of the changes in behavioral health care delivery over the past decade. The field continues to use continuing education strategies that are ineffective, and little training is offered to the paraprofessional and bachelor-prepared staff members who comprise a large segment of the workforce in public sector and inpatient settings. Broad strategies are needed to overcome the lethargy in behavioral health education and training programs to make them more relevant to contemporary clinical practice. Incorporating evidence-based approaches to treatment is one critical element of needed reforms. General medicine has laid a foundation that can be built on for teaching the process of EBP. Psychiatry and psychology have taken the lead in identifying those interventions to be taught that are evidence-based or empirically supported. Research on continuing education and adult learning illuminates the educational strategies that are likely effective in teaching evidence-based interventions and an evidence-based process of care. Additionally, the research on changing provider behavior shows the importance of ensuring practice environments that support and reinforce, rather than thwart, the practice of evidence-based treatment. There are many resources to draw on but the task facing educators is substantial.

The Connecticut Mental Health Center Patient Profile Project: application of a service needs index.

This article describes a quality assurance effort aimed at defining the characteristics of the patient population of the Connecticut Mental Health Center, a statefunded agency that provides comprehensive clinical and rehabilitative services to persons with mental illness. Also described is how this information guided management decisions in both caseload distribution and clinical service development. This "Patient Profile Project" was informed by research principles which view evaluation as continual, rather than terminal activity that involves key stakeholders from all levels within the mental health system of care and makes maximum use of data in ongoing performance improvement initiatives. The service-need index that the project produced represents our first efforts to accurately capture service need and use it in clinical decision making. This review of the Connecticut Mental Health Center Patient Profile Project illustrates the utility of a continuous evaluation system in promoting improvements in a large mental health treatment system.