This month we learn about the first agency in Kansas to achieve high fidelity without becoming a project site. Rick Goscha, consultant and trainer in the Office of Mental Health Research & Training at KU's School of Social Welfare details the three critical factors that made a substantial difference at this agency.

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By Rick Goscha, MSW

In April 2009, The Mental Health Association of South Central Kansas (MHASCK) became the 8^th agency in Kansas to achieve high fidelity according the Strengths Model of Case Management.  The typical process for an agency to achieve fidelity is to become a Strengths Model project site.  This entails a two-year partnership, where a Consultant and Trainer from the University of Kansas works closely with the agency to change any structures (e.g. job responsibilities of case managers and supervisors, caseload sizes, model of supervision, etc.) needed to support fidelity, provide training on the tools of the Strengths Model, and help staff develop the skills needed to use the tools effectively in their practice.

MHASCK’s path to high fidelity though was different than other sites.  MHASCK achieved fidelity without ever becoming a project or having the support of an onsite Consultant and Trainer from the University of Kansas.  This issue of the EBP Times should be informative to sites within Kansas who are currently striving to achieve or sustain fidelity, but also to agencies that are trying to implement the Strengths Model of Case Management outside of Kansas.  Through an interview with Carol Manning, the Vice-President of MHASCK, and Kristina Fouquet, the Director of Adult Case Management Services at MHASCK, we learned the critical steps they took to achieve high fidelity.

Three factors stand out that were critical to MHASCK’s success:

1)      Buy-in at all levels of the agency to implement Strengths Model Case Management with high fidelity

2)      Having the supervisory structure needed to support staff in learning the model.

3)      Supervisory staff offering the support needed for staff to learn the skills through regular field mentoring and on-going feedback.

MHASCK expressed interest in becoming a Strengths Model project site back in 2007, but because of the number of centers that had also expressed an interest; they were placed on a waiting list to begin as an official site. So MHASCK decided to try to start implementing high fidelity Strengths Model practice on their own.  Since MHASCK had previously implemented two other Evidence Based Practices: Supported Employment and Integrated Dual Diagnosis Treatment, they not only knew the value of doing an evidence based practice, but also the commitment needed to attain and sustain fidelity.  As Kristina says, “We knew the validity of doing an evidence based practice. We know that it works.”      

Carol and Kristina decided to do their own baseline fidelity review just to see where they stood.  While their initial review revealed that they still had a ways to go to meet fidelity, they started going through each item and planning for ways that they could improve.  As Carol Manning says, “We walked through it together. We read everything we could about the Strengths Model.  We talked to other sites that were doing the Strengths Model projects.  We did mini-trainings with staff on using the tools.  We took some wrong turns, but then we would back up and start again.  We were all learning this together.”

Getting Buy-in

As Carol Manning says, “An important first step for us was getting the buy-in of our case managers and management staff.”  This holds true for any site that attempts to implement an Evidence Based Practice.  Upper administration and front-line supervisory staff should embrace the philosophy of the practice and place improvement in client outcomes as a guiding factor in their decision making.  Front-line staff who are implementing the practice should also be well apprised of the expectations for using the tools and continuously developing their skills.

            Carol and Kristina noted that embracing Strengths Model philosophy was easy for most staff in the agency, since MHASCK has long strived to provide recovery-oriented services.  Putting these philosophies into actual practice by using the tools though meant continually re-evaluating practice behaviors. Kristina says, “We started to challenge each other.”  

While it was hard work, Carol feels like staff embraced the change.  She says, “I feel like our staff is invested in doing what’s best for clients. Seeing a difference in clients is what motivates them.” Staff also saw that it was making a difference in how they approached their work.  Carol says, “We had a few people say, ‘I finally feel like I know how to do my job.”

   Supervisory Structure

Kristina decided to go back through the Basic Case Management Training and also started sending staff who had been around for a while back to the training as well. Kristina also attended all the Supervisory trainings that KU offered in order to re-familiarize herself with the best practices in supervision.

One of Kristina’s first steps was to re-structure their current group supervision so that it aligned with the Strengths Model’s group supervision.  As Kristina says, “Our supervision used to be only one hour and people couldn’t wait to get out of there.  When we increased the time of group supervision to two hours and started to use the Strengths Model format, we expected some resistance.  But, because of the quality of group supervision, they loved it.  They were getting so many ideas; the time seemed to fly by for them.”

Supervisory Support

Kristina realized quickly that she would not be able to provide all the support needed to help her staff learn the Strengths Model tools and do them with a high degree of quality.  Research shows that reviewing tools, giving staff specific feedback, and offering field mentoring are the most effective ways to help staff develop their skills.  Since MHASCK has 20 case managers, they decided to hire two more team leaders and structure the case managers into three teams.  This way each team leader would be able to spend approximately 2 hours per week reviewing Strengths Assessments and Recovery Goal Worksheets, 2 hours of giving staff specific feedback on the tools, and 2 hours per week doing field mentoring.

Kristina recognized that the supervisor is the key to implementing an evidence based practice.  Not only does the supervisor need to have a philosophy that aligns with Strengths Model Practice, they also need to develop the skills themselves to do the practice.  As Kristina says, “If you don’t have a supervisor who believes in it and doesn’t learn the practice, it won’t work.”  An important move for MHASCK was hiring a team leader, Angela Sawyer, who had previous experience implementing the Strengths Model at a different agency.

To assist KHASCK in monitoring their progress towards fidelity,  Kristina and Angela started sending in Strengths Assessments and Recovery Goal Worksheets to a Consultant and Trainer at the University of Kansas to review and offer feedback.  Over the course of about six months, they had turned average Strengths Assessments and Recovery Goal Worksheets into some of the best we have seen.  Some staff developed their skills more quickly than others, so Kristina and Angela started using these as models for the other case managers.

Conclusion

In March of 2009, MHASCK requested KU to come out to do a fidelity review to determine fidelity.  On completing the review it became clear that all their efforts had paid off.  In a span of approximately 18 months, MHASCK had:

1)      Obtained a commitment from all levels of the agency that they were going to achieve high fidelity in the Strengths Model Case Management practice;

2)      Hired the supervisory staff needed to support three smaller case management teams;

3)      Restructured the format of their weekly group supervision;

4)      Had supervisors start doing weekly review of tools, giving feedback and providing field mentoring;

5)      Helped case managers develop the skills needed to do high quality Strengths Assessments and Recovery Goal Worksheets;

6)      Changed the way they wrote treatment plan goals to meet both Medicaid and Strengths Model criteria;

7)      Formed a core group within the agency (the Leadership Team) to oversee implementation and sustaining fidelity efforts.  

By bringing together the focus of everyone in the agency, and raising to a level of prominence the efforts to put this practice into place, MHASCK had achieved high fidelity to the Strengths Model without the formal assistance of a KU Consultant and Trainer.  In essence, Kristina Fouquet and Angela Sawyer replicated many of the tasks and responsibilities that normally would have been done by a Consultant and Trainer assigned to a project site.  Their achievement deserves applause and their efforts afford a wonderful learning opportunity for all those attempting to implement an evidence-based practice.