Howard H. Goldman

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.

Continuity of Care and Client Outcomes in the Robert Wood Johnson Foundation Program on Chronic Mental Illness

The impact on services and outcomes of the local mental health authorities (LMHAs) developed under the RWJF Program on Chronic Mental Illness (CMI) was evaluated in Baltimore, Cincinnati, Columbus, and Toledo. Two cohorts of clients with CMI discharged from an episode of acute 24-hour care were recruited in each city: the first cohorts were drawn shortly after the demonstration began and the second, two years later. The LMHAs in the three Ohio cities increased case management for the second cohorts at two months, but not at 12 months, after hospital discharge. The second cohorts in Baltimore and Cincinnati experienced lower turnover among case managers during the year after discharge, but there was no significant improvement in client outcomes. Creation of LMHAs may be a necessary, but not sufficient, step toward improving outcomes and should be followed by improvement in the quantity and quality of services.

Service system integration, access to services, and housing outcomes in a program for homeless persons with severe mental illness

OBJECTIVES This study evaluated the hypothesis that greater integration and coordination between agencies within service systems is associated with greater accessibility of services and improved client housing outcomes. METHODS As part of the Access to Community Care and Effective Services and Supports program, data were obtained on baseline client characteristics, service use, and 3-month and 12-month outcomes from 1832 clients seen at 18 sites during the first year of program operation. Data on interorganizational relationships were obtained from structured interviews with key informants from relevant organizations in each community (n = 32-82 at each site). RESULTS Complete follow-up data were obtained from 1340 clients (73%). After control for baseline characteristics, service system integration was associated with superior housing outcomes at 12 months, and this relationship was mediated through greater access to housing agencies. CONCLUSIONS Service system integration is related to improved access to housing services and better housing outcomes among homeless people with mental illness.

Evaluating the Robert Wood Johnson Foundation program on chronic mental illness.

Community-based services for mentally ill individuals have developed in a fragmented and uncoordinated manner over the last 30 years. In response, the RWJF initiated a five-year demonstration in nine cities: the Program on Chronic Mental Illness (CMI). The projects background is described, as are its accomplishments and limitations. One outcome of sponsorship by the RWJF and the U.S. Department of Housing and Urban Development was to assure the problem of CMI a place in the public policy agenda. Despite specific improvements in quality of life for individuals with CMI, however, there was no general improvement for this population. The program thus demonstrated that structural changes alone are insufficient; quality of care must be attended to as well. Despite its drawbacks, the project revealed that interventions can be implemented with positive results.

Project IMPACT: A Report on Barriers and Facilitators to Sustainability

Project IMPACT is a collaborative care intervention to assist older adults suffering from major depressive disorder or dysthymia. Qualitative research methods were used to determine the barriers and facilitators to sustaining IMPACT in a primary care setting. Strong evidence supports the program’s sustainability, but considerable variation exists in continuation strategies and operationalization across sites. Sustainability depended on the organizations’ support of collaborative care models, the availability of staff trained in the intervention, and funding. The intervention’s success was the most important sustainability factor, as documented by outcome data and through the “real world” experience of treating patients with this intervention.

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.

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.

The history of community mental health treatment and rehabilitation for persons with severe mental illness

The authors review the evolution of the treatments for persons with severe mental illnesses over the past 40 years in three areas: pharmacological and other somatic treatments, psychosomatic treatments, and rehabilitation. Current treatments are based on a much stronger evidence base, are more patient-centered, and are more likely to target autonomy and recovery.

Assisting Social Security Disability Insurance Beneficiaries With Schizophrenia, Bipolar Disorder, or Major Depression in Returning to Work

OBJECTIVE People with psychiatric impairments (primarily schizophrenia or a mood disorder) are the largest and fastest-growing group of Social Security Disability Insurance (SSDI) beneficiaries. The authors investigated whether evidence-based supported employment and mental health treatments can improve vocational and mental health recovery for this population. METHOD Using a randomized controlled trial design, the authors tested a multifaceted intervention: team-based supported employment, systematic medication management, and other behavioral health services, along with elimination of barriers by providing complete health insurance coverage (with no out-of-pocket expenses) and suspending disability reviews. The control group received usual services. Paid employment was the primary outcome measure, and overall mental health and quality of life were secondary outcome measures. RESULTS Overall, 2,059 SSDI beneficiaries with schizophrenia, bipolar disorder, or depression in 23 cities participated in the 2-year intervention. The teams implemented the intervention package with acceptable fidelity. The intervention group experienced more paid employment (60.3% compared with 40.2%) and reported better mental health and quality of life than the control group. CONCLUSIONS Implementation of the complex intervention in routine mental health treatment settings was feasible, and the intervention was effective in assisting individuals disabled by schizophrenia or depression to return to work and improve their mental health and quality of life.

Trends In Mental Health Cost Growth: An Expanded Role For Management?

Mental health spending attracts attention from payers and policymakers. Historically, the public sector paid directly for a good deal of care, and special institutions and rules governed private-sector spending. During 1971-2002, spending on mental health care grew at much lower rates than spending on other health care. In recent years, the delivery and financing of mental health care have come to look more like those for general health care. We show that in spite of this convergence, important differences remain between general health and mental health care in patterns of spending growth.