Charles A. Rapp

Fidelity Outcomes in the National Implementing Evidence-Based Practices Project

OBJECTIVE This article presents fidelity outcomes for five evidence-based practices that were implemented in routine public mental health settings in the National Implementing Evidence-Based Practices Project. METHODS Over a two-year period 53 community mental health centers across eight states implemented one of five evidence-based practices: supported employment, assertive community treatment, integrated dual disorders treatment, family psychoeducation, and illness management and recovery. An intervention model of practice dissemination guided the implementation. Each site used both human resources (consultant-trainers) and material resource (toolkits) to aid practice implementation and to facilitate organizational changes. External assessors rated fidelity to the evidence-based practice model every six months from baseline to two years. RESULTS More than half of the sites (29 of 53, or 55%) showed high-fidelity implementation at the end of two years. Significant differences in fidelity emerged by evidence-based practice. Supported employment and assertive community treatment had higher fidelity scores at baseline and across time. Illness management and recovery and integrated dual disorders treatment had lower scores on average throughout. In general, evidence-based practices showed an increase in fidelity from baseline to 12 months, with scores leveling off between 12 and 24 months. CONCLUSIONS Most mental health centers implemented these evidence-based practices with moderate to high fidelity. The critical time period for implementation was approximately 12 months, after which few gains were made, although sites sustained their attained levels of evidence-based practice fidelity for another year.

A decade of case management: A methodological review of outcome research

The last decade has witnessed a burgeoning interest in case management services to people with severe mental illness. While the literature on case management is proliferating, there remains a paucity of rigorously designed outcome research. This paper provides a methodological review of that outcome research on case management, which found that the term case management is used to describe a diverse array of interventions that yield differing client outcomes. Suggestions for the direction of future inquiry are described.The last decade has witnessed a burgeoning interest in case management services to people with severe mental illness. While the literature on case management is proliferating, there remains a paucity of rigorously designed outcome research. This paper provides a methodological review of that outcome research on case management, which found that the term case management is used to describe a diverse array of interventions that yield differing client outcomes. Suggestions for the direction of future inquiry are described.

How Evidence-Based Practices Contribute to Community Integration

Since the groundbreaking work of the Robert Wood Johnson Conference in 1998 identifying six evidence-based practices (EBPs) for people with severe mental illness (SMI), the mental health field has moved in the direction of re-examination and redesign of service systems. Surprisingly, one area that has not been fully explicated is the role that EBPs play in promoting community integration. In this paper, we explain how community integration is a unifying concept providing direction and vision for community mental health for people with SMI. As one crucial aspect of the recovery process, community integration clarifies the link between EBPs and recovery. We propose an alternate view, grounded in the empirical literature, to the assertion by Anthony, Rogers, and Farkas [2003, Community Mental Health Journal, 39, 101–114] that “EBP research has rarely demonstrated a positive impact on recovery related outcomes.”

Best practices: a program to support shared decision making in an outpatient psychiatric medication clinic.

This column presents preliminary findings of an intervention to support shared decision making in psychopharmacology consultation. The waiting area in an urban psychiatric medication clinic was transformed into a peer-run Decision Support Center featuring a user-friendly, Internet-based software program with which clients could create a one-page computer-generated report for use in the medication consultation. The Decision Support Center was used 662 times by 189 unique users from a young-adult and general adult case management team from October 2006 to September 2007. All clients had severe mental disorders. Only ten clients refused to use the intervention at some point during the pilot study. Focus groups with medical staff (N=4), clients (N=16), case managers (N=14), and peer-specialist staff (N=3) reported that the intervention helped to create efficiencies in the consultation and empower clients to become more involved in treatment-related decision making. A randomized controlled trial is currently in process.

The promise of shared decision making in mental health.

Shared decision making is a verb. It connotes a process, supported by specific information technologies, that reengineers how practitioners and people with diagnoses work together (Montori, Gafni, & Charles, 2006). Undoubtedly, the foundational values and principles of shared decision making are familiar to the readers of this journal. Person-centered care, respect for individual autonomy, choice and collaboration are well known and widely embraced in behavioral health and psychiatric rehabilitation (Anthony, 1979; Cohen, Farkas, Cohen, & Unger, 1991; USPRA, 2009). Shared decision making advances these principles through the use of specific information technologies such as decision aids and electronic decision support programs (O’Connor et al., 2009). When carefully designed and strategically inserted into the everyday workflow, these technologies hold the promise of helping busy practitioners put person-centered and recovery-based values into practice. In this paper we discuss the promise of shared decision making for advancing our field.

Barriers to Evidence-Based Practice Implementation: Results of a Qualitative Study

This study reports on a qualitative study of barriers to EBP implementation in one state that sought to implement supported employment and integrated dual diagnosis treatment. The study found that the most significant obstacles emanated from the behavior of supervisors, front-line staff and other professionals in the agency. A lack of synergy profoundly impeded implementation.

Strategies for Improving Fidelity in the National Evidence-Based Practices Project

Background: The National Evidence-Based Practices (EBPs) Project developed and tested a model for facilitating the implementation of five psychosocial EBPs for adults with severe mental illness in the United States. Methods: The implementation model was tested in 53 sites in 8 states. In each site, one of the five EBPs was adopted for implementation and then studied for a 2-year period using a combination of qualitative and quantitative methods. Findings: At baseline, none of the sites had programs attaining high fidelity. Four factors were identified as influencing fidelity: (a) EBP-specific factors, (b) governmental factors, (c) leadership factors, and (d) fidelity review factors. Conclusion: A multipronged implementation strategy was effective in achieving high fidelity in over half of the sites seeking to implement a new EBP.

The State Policy Context of Implementation Issues for Evidence-Based Practices in Mental Health

OBJECTIVES This study analyzed implementation issues related to several evidence-based practices for adults with serious mental illness that were included in a national demonstration project. The five evidence-based practices included in this investigation are assertive community treatment, family psychoeducation, illness management and recovery, integrated dual diagnosis treatment, and supported employment. The objective of the study was to assess the role of state mental health authorities as agents of change. METHODS Two-person teams conducted interviews with state mental health authorities, consumers, families, representatives of local mental health authorities, and representatives of other relevant state agencies--more than 30 individuals at each of the eight sites. Interviews took place at two time points at least one year apart and probed the facilitators and barriers to implementation at the state level. Data were assessed qualitatively to identify common trends and issues across states related to leadership, training, and regulatory issues for each evidence-based practice. RESULTS Each of the five practices has different critical contingencies for statewide implementation and requires unique assets to address those contingencies by the state mental health authorities. The contingencies are related to these critical areas: financing and regulations, leadership, and training and quality. CONCLUSIONS States are key to implementing evidence-based practices, but state mental health authorities should note that each of the practices requires different skill sets and involves different stakeholders. Thus implementing many evidence-based practices at once may not yield economies of scale.

The Active Ingredients of Effective Case Management: A Research Synthesis

As we move to managed care, the nature and roleof case management is in flux and undetermined. Based onthe outcome research, this paper seeks to identify thecommon elements of effective case management practice to guide its development under the newfinancing schema.

Evidence-based practices: Setting the context and responding to concerns.

After nearly 20 years of progress in general medicine, the evidence-based practice movement is becoming the central theme for mental health care reform in the first decade of 2000. Several leaders in the movement met to discuss concerns raised by six stakeholder groups: consumers, family members, practitioners, administrators, policy makers, and researchers. Recurrent themes relate to concerns regarding the limits of science, diversion of funding from valued practices, increased costs, feasibility, prior investments in other practices, and shifts in power and control. The authors recommend that all stakeholder groups be involved in further dialog and planning to ensure that practices emerge that represent the integration of the best research evidence with clinical expertise and consumer values.