Factors Related to Improving Fidelity and Outcomes: Looking Back at the Original Strengths Model Pioneer Sites (Part 2)

In the last EBP Times: CM edition (December 2007), six factors were identified which seem to make the greatest impact on achieving fidelity and improving client outcomes. It is important to look at these factors since evidence is accumulating that as fidelity to the model improves, client outcomes improve as well. 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

6) Having a supported employment specialist assigned to the case management team.

In the November edition, we took a more in-depth look at the role of the supervisor on the team. This month, we will focus on doing quality review of Strengths Model tools.

Supervisors review the two primary Strengths Model Tools (Strengths Assessments and Recovery Goal Worksheets) in multiple formats.

            1) Quality review of Strengths Assessments and Recovery Goal Worksheets

First is through a quality review of the tool itself. Most supervisors have staff submit their Strengths Assessments and Recovery Goal Worksheets directly to them, especially  as staff are first learning to use the tools. Supervisors complete a Quality Review Feedback Form for each Strengths Assessments and Recovery Goal Worksheets they review. This Quality Review Feedback Form is aligned with the needed components to achieve fidelity so staff can get immediate feedback on whether or not their Strengths Assessment or Recovery Goal Worksheet would score well on a fidelity review.

            2) Integration with Treatment Plan and progress notes.

Second is through a review of the charts to see how well these tools are integrated with the Treatment Plan and progress notes. The Strengths Model requires that Treatment Plan goals and objectives are linked to the client’s dreams, desires, and aspirations from the Strengths Assessment. Since treatment plan goals use language of medical necessity, supervisors ensure that these goals are placed in a context that is meaningful to the client. For example, “Reduce interference from distressing voices so I can keep my job” or “Learn to self-manage depression so I better care for my children.” In the two examples, the person keeping their job or being able to care for their children is something that might appear on a Strengths Assessment. Supervisors ensure that what is important to the client is either added to the end of a medically necessary treatment plan goal or put in quotes next to the treatment plan goal.

Progress notes should also reflect use of the Strengths Assessment and Recovery Goal Worksheet in practice. This could include using the Strengths Assessment to develop treatment plan goals and objectives, developing strategies based on the client’s strengths to achieve goals, using the Strengths Assessment to identify naturally occurring resources, using the Recovery Goal Worksheet to break down large goals into manageable and measurable steps, document and celebrating progress towards goals, etc.

            3) Assessment of tools during field mentoring.

Third, supervisors can assess quality of the tools during field mentoring. Some supervisors use field mentoring to teach staff how to use the Strengths Assessment and/or Recovery Goal Worksheet. For example at Pawnee Mental Health Center, we did a field mentoring session with the goal to learn how to use the Strengths Assessment with people who tend not to be as verbal as others. Instead of getting out the Strengths Assessment during the actual meeting with the client, we chose to engage the client in an activity he found enjoyable (playing pool). The case manager was instructed to hold an everyday conversation with the person while keeping the template of the Strengths Assessment in his head. After the meeting with the client, the supervisor and case manager sat down and filled out a Strengths Assessment based on the information they learned. Surprising to the case manager was the amount of information he had learned.

4) Assessment of tools through group supervision.

Fourth is through Group Supervision. Since all case managers are required to bring a Strengths Assessment (and Recovery Goal Worksheet, if applicable) when presenting on a client, this gives the supervisor the opportunity to gauge the quality of these tools. Some supervisors will review the Strengths Assessment of the presenting staff person prior to Group Supervision to ensure that information is detailed and specific enough to be usable for brainstorming.

Most supervisors in the project sites spend at least two hours per week either reviewing Strengths Assessment and Recovery Goal Worksheets individually or reviewing these tools in the context of integration with the treatment plan and progress notes. To achieve the highest rating on the Strengths Model Fidelity Scale, supervisors need to spend approximately 20-30min per week per case manager reviewing Strengths Assessments and Recovery Goal Worksheets. Of course more time might be spent with staff who are new to using the tools rather than seasoned veterans who have displayed competence in using the tool. At the same time, it’s important to regularly review the use of the tools for all staff since there are always challenges to using the tools with various client situations. For example, a case manager might be able to do extremely detailed and specific Strengths Assessments with clients who are easy to engage with, but have difficulty doing the Strengths Assessment with clients who are continually in crisis or offer information that is confusing or seemingly delusional. In this case it might help for the supervisor to focus in on use of the tools in these specific situations.

Labette Mental Health Center is an example of an agency that has done a great job helping staff to learn to use the Recovery Goal Worksheet. During their 18 month review, staff had demonstrated that they knew how to complete a Recovery Goal Worksheet that met the criteria for Strengths Model Practice. Though they could demonstrate this skill, they were only using Recovery Goal Worksheets with less than 25% of all the clients on their caseloads. Alice Nichols, CSS Director, and Tom Schibi, team leader, made a concentrated effort over the next six months to help staff learn how to use the Recovery Goal Worksheet with more clients. All Recovery Goal Worksheets were turned in to her for review and were assessed using the Quality Review Feedback Form. Tom also assisted case managers with the tool during field mentoring. By the two year review, case managers were using Recovery Goal Worksheet with a majority of the all the clients on their caseloads and the quality was still extremely high.