Measuring the fidelity of implementation of a mental health program model.

A fidelity index of program implementation for assertive community treatment (ACT) was developed. In Study 1, 20 experts rated the importance of 73 elements proposed as critical ACT ingredients, also indicating ideal model specifications for elements. Agreement among experts on ratings of importance was high (intraclass r = .98). In Study 2, a 17-item subset of the expert-identified critical ingredients was used to construct a fidelity index with three subscales: Staffing, Organization, and Service. Internal consistencies ranged from .50 to .72, with a .81 reliability for the total scale. Fidelity was linearly related to program "generations," suggesting "program drift." In 18 ACT programs, fidelity also was associated with measures of reduction in days in psychiatric hospitals. The correlation was significant for the total scale and for the Organization and Staffing subscales but not for the Service subscale.

A multisite study of client outcomes in assertive community treatment.

OBJECTIVE: This study examined outcomes of clients admitted to assertive community treatment programs simultaneously implemented at six sites in northeastern Indiana. METHODS: A total of 212 clients at risk for psychiatric rehospitalization were assessed at baseline and at six-month intervals for 18 months after admission to assertive community treatment programs. Data on rehospitalization, quality of life, and level of functioning were compared using t tests. Progressive improvement was also examined by linear trend analysis. RESULTS: Frequency of psychiatric hospitalization was reduced by one-third and the number of inpatient days by 50 percent after admission to the program. Improvements were progressive, with continued reductions over the 18-month period. Progressive improvements also occurred in quality of life as measured by both client and staff ratings. Case managers rated clients as having improved family and social support, increased self-reliance and independence, and improved daily living skills. Clients reported significantly more legal problems, which may have been an artifact of increased monitoring during treatment. A key element of the programs' success was the position of clinical coordinator, important functions of which are described. CONCLUSIONS: Results of this study provide support for wide-scale dissemination of assertive community treatment as an effective form of community care for persons with serious mental illness.

Translating addictions research into evidence-based practice: the Polaris CD outcomes management system.

Converting the findings from addictions studies into information actionable by (non-research) treatment programs is important to improving program outcomes. This paper describes the translation of the findings of studies on Patient-Services matching, prediction of patient response to treatment (Expected Treatment Response) and prediction of dropout to provide evidence-based decision support in routine treatment. The findings of the studies and their application to the development of an outcomes management system are described. Implementation issues in a network of addictions treatment programs are discussed. The work illustrates how outcomes management systems can play an important role in translating research into practice.

Relationship between case manager contact and outcome for frequently hospitalized psychiatric clients.

OBJECTIVE: Case management services and client outcomes in seven programs based on the assertive community treatment model were examined to determine variability in the frequency and location of services, to determine the relationship of frequency of services with reduction in hospital use and with client satisfaction with services, and to identify subgroups of clients who received different patterns of services. METHODS: Correlational and cluster analyses were used to examine patterns of service use for 155 clients with serious mental illness who averaged 10.6 lifetime psychiatric hospitalizations. Data were drawn from four earlier studies of the treatment model. RESULTS: The programs varied substantially in the mean frequency of service provided. Contrary to expectations, service intensity was not linearly related to client outcomes. However, programs that delivered very low frequencies of service were ineffective in reducing hospital use. Finally, cluster analysis of service variables identified five client subgroups. These subgroups differed on demographic characteristics and mental health history but not on outcomes. CONCLUSIONS: A minimum intensity of services, individualized for each client, may be necessary to reduce hospital use for frequently hospitalized clients. Service utilization clusters may represent clients with different service needs and preferences.