Factors Related to Improving Fidelity and Outcomes: Looking Back at the Original Strengths Model Pioneer Sites:

There are currently six (Pawnee, Labette, South Central, Horizons, Bert Nash, Central Kansas) Strengths Model Case Management projects going on right now in Kansas with six additional sites planned to start between now and the end of 2008. This will mean that by the end of 2008, almost half of all Kansas Mental Health Centers (12 of 26) will have either one or multiple teams involved doing Strengths Model Case Management.

Now is a good time to look back at the original pioneer project sites and ask the question: Does achieving high fidelity in Strengths Model Case Management have an impact on client outcomes? While three sites is hardly sufficient to make any definitive conclusions, the data accumulated to date suggests that there is at least a tentative impact in the areas of hospitalizations, competitive employment and post secondary education.  

As you can see from the table above, these outcomes are cumulative based on the time of the sites first fidelity review to the present date. Pawnee Mental Health Center, the first project site in 2004, just had their 3 year fidelity review in September 2007. Labette and South Central started as project sites in 2006 and just finished with their 18 month fidelity reviews in September and October of 2007.

All three projects rated low in Strengths Model fidelity at baseline, but all three had achieved high fidelity by 18 months. Correspondingly all three projects sites have had a significant decrease in hospitalizations and post secondary education since baseline. Both Pawnee and South Central also had significant increased in competitive employment since baseline, while Labette has yet to see any improvement in this particular outcome area. Much of this can be attributed to Labette having been a Supported Employment (SE) project site just prior to the start of the Strengths Model Case Management project. During their time as an SE project, they had already made substantial gains in this outcome area.  Independent Living was the only outcome area not impacted at all from the increase in fidelity. Much of this can be attributed to the fact that all three of these sites already had very good outcomes (over 90%) in this area prior to beginning the project.

              So what can we learn from these early project sites? Drawing from the collective wisdom of the KU Consultant and Trainer, the supervisors of these project sites, and case management staff carrying out the work, we have identified six factors that seem to make the biggest difference in terms of achieving fidelity and improving client outcomes. These factors are:

1) the role of the supervisor on the team;
2) the group supervision process;
3) doing quality review of Strengths Model tools;
4) providing field mentoring;
5) incorporating the strengths assessment into daily practice; and
6) having a supported employment specialist assigned to the case management team.

Throughout 2008, we will focus more in-depth on each of these factors, but in this issue we start with an overview of the role of the supervisor.

The Role of the Supervisor on the Team

Pawnee was the only site to have a dedicated team leader for the Strengths Model project at baseline. Correspondingly, they reached high fidelity earlier than the other two sites. Labette and South Central initially had the Community Support Services (CSS) Director supervise the Strengths Model team. By 12 months, both of these sites had decided to hire a team leader to supervise the team. By 18 months they were able to reach high fidelity.

      The supervisor is key to helping staff learn and use the tools/skills required by the model (i.e. strengths assessment, integration of the strengths assessment with the treatment plan, recovery goal worksheet, use of naturally occurring resources). While some staff are able to learn the basic concepts of the tools and skills in a formal training setting, most have difficulty being able to apply these tools and skills in the diverse and complex situations they face in actual practice.

      The supervisor needs to assume a teaching role for staff to become proficient in using EBP tools and skills in practice settings. To be able to do this, the supervisor needs to spend time with staff.  The amount of time that the supervisor was able to spend with staff (both individually and collectively) appeared related to how quickly they were able to learn the tools and skills.

      The way the supervisor spends time with staff is even more critical that the amount of time. None of the three initial project sites made significant movement in the clinical items on the fidelity scale until the supervision items approached high fidelity. This included using the Group Supervision Model format, doing quality review of strengths model tools, giving staff regular feedback on tools and skills, and providing field mentoring. These supervisory activities structured the way supervisors spent time with their staff and kept them focused on helping staff learn how to use Strengths Model tools and skills to impact a person’s recovery.

      It is important to note that five of the six key factors identified are directly related to the supervisor of the team. This has led us to placing more emphasis on structuring the role of the supervisor early on with project sites. It is important that agencies make a commitment that allows supervisors to spend time directly with their case managers. Supervisors also need to make a commitment to learning the tools and skills associated with the model and then structuring their time in a way they can effectively teach their staff to use these tools and skills.

In future additions of the EBP times, we expand upon the role of the supervisor by looking more closely at the other key factors identified, along with discussion of  some of the successes and challenges programs have faced putting these into practice.

Rick Goscha authored this piece.  If you have additional questions about strength's based case management practice or the EBP model, please contact the Strength's Based Case Management trainers/consultants: Rick Goscha or Paul Liddy at 785-864-4720.

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