The Salience of Staffing in IDDT Implementation: One Agency's Experience

Achieving integrated treatment: a realist synthesis of service models and systems for co-existing serious mental health and substance use conditions

Approximately 30-50% of people with serious mental illness have co-existing drug or alcohol problems (COSMHAD), associated with adverse health and social care outcomes. UK guidelines advocate both co-occurring needs being met within mental health services, but uncertainty remains about how to operationalise this to improve outcomes. Various unevaluated service configurations exist in the UK. A realist synthesis was done to identify, test, and refine programme theories of how context shapes the mechanisms through which UK service models for COSMHAD work, for whom, and in what circumstances. Structured and iterative realist searches of seven databases identified 5099 records. A two-stage screening process identified 132 papers. Three broad contextual factors shaped COSMHAD services across 11 programme theories: committed leadership, clear expectations regarding COSMHAD from mental health and substance use workforces, and clear care-coordination processes. These contextual factors led to increased staff empathy, confidence, legitimisation, and multidisciplinary ethos, which improved care coordination and increased the motivation of people with COSMHAD to work towards their goals. Our synthesis highlights that integrating COSMHAD care is complex, and both individual and cultural behavioural shifts in leadership, workforce, and service delivery are essential to ensure people with COSMHAD receive compassionate, trauma-informed care that meets their needs.

Mixed method study of workforce turnover and evidence-based treatment implementation in community behavioral health care settings

BACKGROUND

Practitioner turnover in behavioral health settings is high and hinders the implementation of new interventions.

OBJECTIVE

This study examined practitioner and organizational characteristics that contribute to high staff turnover in community behavioral health settings.

PARTICIPANTS AND SETTING

Clinicians in nine community-based agencies participated. Included agencies treated a high volume of families referred from child welfare.

METHODS

This study was part of a larger trial testing the effectiveness of a Cognitive Behavior Therapy for family conflict. Authors assessed predictors of turnover quantitatively and qualitatively. Quantitative data was collected prospectively (n = 169) on practitioner and organizational-level variables (e.g., demographics, professional practice, job satisfaction, emotional exhaustion, organizational commitment). Semi-structured interviews with practitioners who left their agencies (n = 40) provided qualitative data retrospectively.

RESULTS

Forth-five percent of practitioners left their agencies over three years. Two predictors of final survival status (lower age and lower job satisfaction) were associated with leaving the agency at the p < .05 level; however, they accounted for very little variance. Qualitative themes highlighted the importance of job characteristics, compensation, productivity requirements, advancement opportunities, and co-worker relationships as influential in the decision to leave.

CONCLUSIONS

This study highlights the value of a mixed-method approach given that themes emerged from the qualitative interviews that were not accounted for in the quantitative results. Additional research is needed to better understand workforce turnover so that strategies can be developed to stabilize the behavioral health workforce.

Associations Among Job Role, Training Type, and Staff Turnover in a Large-Scale Implementation Initiative

Staff turnover is problematic for behavioral health agencies implementing evidence-based practices (EBPs), which are costly and time-consuming. The current study examined the association between EBP training methods and turnover and explored predictors of turnover for different types of staff. Participants (100 clinicians, 50 supervisors, 50 administrators) were randomized to one of three training conditions for an EBP. Results indicated low annual rates of turnover for clinicians, supervisors, and administrators. However, contrary to hypothesis, no statistically significant differences were found in rates of turnover across training conditions. Partially consistent with prior research, organizational climate was a significant predictor of supervisor and administrator turnover at 24 months, but was not a significant predictor of clinician turnover. Implications and future directions for research are discussed.

Improving the Knowledge, Attitudes, and Practices of Mental Health Professionals Regarding Dual Diagnosis Treatment - a Mixed Methods Study of an Intervention

This study examined an intervention, which aimed at improving the dual diagnosis treatment at eight Danish mental health centres. The intervention included training in dual diagnosis treatment to program champions who were intended to implement at their workplace the knowledge gained from training. The study used mixed methods (questionnaires, interviews, and field observations) to examine whether there was a change in the knowledge, attitudes, and practices of the colleagues of the program champions following the intervention. Results showed that the intervention overall yielded improvement in knowledge and attitudes, while the impact on assessment and treatment practices was limited. Possible factors that might have affected the implementation of the intervention as well as the weaknesses of the intervention and the study are discussed.

A Prospective Examination of Clinician and Supervisor Turnover Within the Context of Implementation of Evidence-Based Practices in a Publicly-Funded Mental Health System

Staff turnover rates in publicly-funded mental health settings are high. We investigated staff and organizational predictors of turnover in a sample of individuals working in an urban public mental health system that has engaged in a system-level effort to implement evidence-based practices. Additionally, we interviewed staff to understand reasons for turnover. Greater staff burnout predicted increased turnover, more openness toward new practices predicted retention, and more professional recognition predicted increased turnover. Staff reported leaving their organizations because of personal, organizational, and financial reasons; just over half of staff that left their organization stayed in the public mental health sector. Implications include an imperative to focus on turnover, with a particular emphasis on ameliorating staff burnout.

Integrated Dual Disorder Treatment Implementation in a Large State Sample

Individuals with co-occurring illnesses are at risk for poor outcomes related to criminal justice, hospitalization, housing, and employment. High fidelity evidence-based models, including integrated dual disorder treatment (IDDT), are associated with significant outcome improvements. A descriptive analysis of secondary datasets including the full sample of IDDT fidelity reviews completed from 2006 to 2012 in one state was completed. Total IDDT fidelity significantly improved from baseline fidelity review (68) to second review (40) [t(38) = 35.00, p < .001], and from second review to third review (13) [t(12) = 22.60, p < .001], with adequate inner-rater reliability by the second review. Individual items that were lower across reviews included practice penetration and family interventions, and higher individual items included multi-disciplinary team, integrated treatment specialist, and time-unlimited services, and treatment measures are higher than organizational measures in baseline and subsequent reviews. In this large state-wide sample, IDDT took time to implement, and improved fidelity occurred from baseline to third review, and variance between components of the practice was significant.

Systematic review of EBPs for SMI in rural America

This systematic review of the implementation of evidence-based practices (EBPs) for adults with severe mental illnesses (SMI) in rural mental health settings examined peer-reviewed literature, grey literature, and public information. Included articles had to report implementation efforts of EBP(s) for SMI in rural settings or adaptations for rural service delivery. Only three peer-reviewed articles and two publicly available reports met inclusion criteria. Findings suggest little attention is focused on studying factors affecting implementation of EBPs for SMI in rural areas. Adaptations are occurring in rural settings, though rarely documented or tested; their impact on fidelity and consumer outcomes is unclear.

Substance use disorder counselors' job performance and turnover after 1 year: linear or curvilinear relationship?

The main goals of the current study were to investigate whether there are linear or curvilinear relationships between substance use disorder counselors' job performance and actual turnover after 1 year utilizing four indicators of job performance and three turnover statuses (voluntary, involuntary, and no turnover as the reference group). Using longitudinal data from 440 matched counselor-clinical supervisor dyads, results indicate that overall, counselors with lower job performance are more likely to turn over voluntarily and involuntarily than not to turn over. Further, one of the job performance measures shows a significant curvilinear effect. We conclude that the negative consequences often assumed to be "caused" by counselor turnover may be overstated because those who leave both voluntarily and involuntarily demonstrate generally lower performance than those who remain employed at their treatment program.

The experts rate: supervisory behaviors that impact the implementation of evidence-based practices

The purpose of this study was to identify the critical behaviors of supervisors for the successful implementation of evidence-based practice in adult mental health. Experts who work with supervisors to support implementation in three evidence-based practices were surveyed. The three evidence-based practices included Assertive Community Treatment, Integrated Dual Diagnosis Treatment, and Supported Employment. There was substantial agreement among experts as to the importance of supervisory behaviors in the areas of facilitating team meetings, building and enhancing staff skills, monitoring and using outcomes, and continuous quality improvement activities.

Staff turnover in statewide implementation of ACT: relationship with ACT fidelity and other team characteristics

Staff turnover on assertive community treatment (ACT) teams is a poorly understood phenomenon. This study examined annual turnover and fidelity data collected in a statewide implementation of ACT over a 5-year period. Mean annual staff turnover across all observations was 30.0%. Turnover was negatively correlated with overall fidelity at Year 1 and 3. The team approach fidelity item was negatively correlated with staff turnover at Year 3. For 13 teams with 3 years of follow-up data, turnover rates did not change over time. Most ACT staff turnover rates were comparable or better than other turnover rates reported in the mental health and substance abuse literature.

The sustainability of evidence-based practices in routine mental health agencies

The research presented here reports on sustainability of the practices within the National Implementing Evidence Based Practices Project for people with serious mental illness. Forty-nine sites completed the initial 2-year implementation phase and were the focus of our study. Our aims were to discern the number of sites that sustained practices 2 years after implementation, the reasons for sustaining or not sustaining, differences in characteristics between the two groups, and the extent and nature of practice adaptations. We used a mixed-methods approach, based on a telephone survey that gathered qualitative and quantitative data from site representatives and others familiar with the sites and practices during the follow-up period. We found that 80% of sites sustained their practices for 2 years post-implementation, that sustainers differed from non-sustainers in several domains: financing, training, fidelity and agency leadership, and that most sites adapted practices moderately to meet state and local needs.