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									                                                                               Effects of Integrated Treatment Fidelity on 1-Year Client Outcomes:
                                                                                             A Comparison of Implementation Models
                                                                                                                            Laurel             Mangrum a,                                          Richard                                         Spence a,                                        & Molly       Lopez b
                                                                                               aUniversity     of Texas at Austin, Addiction Research Institute, bTexas Department of State Health Services



                                                                                                   IDDT Implementation Models and Fidelity Scores
                                                                                                                                                                                                                                                                                                                             Texas Integrated Treatment Integrity Scale
                                                                                                                    Integrated Treatment                                                                                                                Adjunct Services                                                                      Scores Integrated
Introduction                                                                                                                                                                                                                                                                                                                                                     Adjunct
                                                                                                                                                                                                                                                                                                                                                                          Treatment
                                                                                                                                                                                                                                                                                                                                                                            ( n =3)
                                                                                                                                                                                                                                                                                                                                                                                      Services
                                                                                                                                                                                                                                                                                                                                                                                       ( n =3)
                                                                                                                                                                                                                                                                                                                               Staffing and Treatment Team Structure
                                                                                                                                                                                                                                                                                                                                Caseload Size                                 4.5         4
                                                                                                                                                                                                                                                                                                                                DDX Provider Meeting                           4        4.33
                                                                                                                                                                                                                                                                                                                                Team Approach                                  5        2.33
The measurement of treatment fidelity is an important, yet often omitted component in                                                                                                                                                                                                                                           Attendance at Staffings                      4.67       3.67
examining the efficacy of various treatment models. Fidelity measures are useful in                                                                                                                                                                                                                                             Continuity of Staffing                        4.3         2
                                                                                                                                                                                                                                                                                                                                Staff Capacity                                4.5         4
evaluation studies as a means of documenting appropriate implementation and                                                                                                                                                                                                                                                     Intake Rate                                    5          5
adherence to the model under study, as well as confirming treatment differentiation in                                                                                                                                                                                                                                          Substance Abuse Specialist on Staff            5        3.67
                                                                                                                                                                                                                                                                                                                                Mental Health Specialist on Staff              5          5
research designs that include control groups. Further, fidelity measures may also                                                                                                                                                                                                                                               Psychiatrist on Staff                          2        3.33
                                                                                                                                                                                                                                                                                                                                Dual Diagnosis Training                      3.33         2
provide a method for determining critical ingredients in treatment models that are most                                                                                                                                                                                                                                         Open Communication                             4        3.33
strongly associated with client outcomes. Although research is limited, most studies                                                                                                                                                                                                                                            Centralized Treatment                        3.67         3
                                                                                                                                                                                                                                                                                                                               Total                                         4.21       3.51 *
examining the effects of treatment fidelity in the areas of supported employment and                                                                                                                                                                                                                                           Treatment Program Structure and Services
assertive community treatment have revealed a positive association between degree of                                                                                                                                                                                                                                            Intensity of Service                         2.33         4
                                                                                                                                                                                                                                                                                                                                Frequency of Contact                         1.33        1.5
fidelity and outcomes in clients with severe mental illness. Continued research is                                                                                                                                                                                                                                              Dual Disorders Groups                        2.67       4.33
                                                                                                                                                                                                                                                                                                                                Adapted Substance Abuse Treatment              3        3.33
needed to determine the effects of departures from fidelity; as evidence-based practices                                                                                                                                                                                                                                        In-Vivo Services                             2.33       1.67
are diffused in real-life clinical settings, treatment models are often adapted according to                                                                                                                                                                                                                                    Work with Support System                     2.67       1.67
                                                                                                                                                                                                                                                                                                                                Assertive Outreach                           1.33         3
local resource constraints and other community and system characteristics.                                                                                                                                                                                                                                                      Assertive Engagement Mechanisms                1        1.67
Measurement of the potential effects of these adaptations may inform technology                                                                                                                                                                                                                                                 Housing Services
                                                                                                                                                                                                                                                                                                                                Employment Services
                                                                                                                                                                                                                                                                                                                                                                               1
                                                                                                                                                                                                                                                                                                                                                                             1.33
                                                                                                                                                                                                                                                                                                                                                                                          3
                                                                                                                                                                                                                                                                                                                                                                                          3
transfer practices by identifying crucial aspects of treatment models associated with                                                                                                                                                                                                                                           Tailored Intensity                           2.67       2.33
                                                                                                                                                                                                                                                                                                                                Assertive Retention                          2.67       1.67
client outcomes that are less amenable to change.                                                                                                                                                                                                                                                                              Total                                         2.03       2.23
                                                                                                                                                                                                                                                                                                                               Integrated Treatment Documentation
                                                                                                                                                                                                                                                                                                                                Admission Criteria                             4          4
The current study examines the effect of integrated dual diagnosis treatment (IDDT)                                                                                                                                                                                                                                             Integrated Treatment Plans                    4.5         5
fidelity on 1-year outcomes of 256 clients with severe mental illness and substance use                                                                                                                                                                                                                                         Integrated Progress Notes                      4          5*
                                                                                                                                                                                                                                                                                                                                Involvement in Discharge Planning            2.67       3.33
disorders. Treatment programs were participating in the Texas Dual Diagnosis Pilot                                                                                                                                                                                                                                              Stage of Treatment                           3.33         4
                                                                                                                                                                                                                                                                                                                               Total                                          3.4       4.27
Project, which was designed to develop integrated treatment programs through
coalitions of state-funded substance abuse and mental health treatment providers.                  Client Characteristics and 1-Year Outcomes                                                                                                                                                                                  Overall Fidelity Score
                                                                                                                                                                                                                                                                                                                               * p < .05
                                                                                                                                                                                                                                                                                                                                                                             3.21       3.34


Each program was trained on the essential elements of the IDDT model and
subsequently designed and implemented a treatment program unique to their local
characteristics.                                                                                                                  Integrated          Adjunct
                                                                                                                                  Treatment
                                                                                                                                   (n = 120)
                                                                                                                                                      Services
                                                                                                                                                      (n = 136)
                                                                                                                                                                                         Psychiatric Hospitalization Days During Past Year                                                                            Results and Conclusions
                                                                                                       Male                          60%                51%
                                                                                                                                                                                                        12
                                                                                                                                                                                                                                                                                          Group Difference = ns
                                                                                                       Mean Age                      39.0               35.2      *                                                                                                                                                  Comparisons on the TITIS fidelity measure indicated a significant difference between
Sample and Method                                                                                      Race/Ethnicity
                                                                                                                                                                                                        10                                                                                                           the IT and AS models on the Staffing and Treatment Team Structure scale score but
                                                                                                         Black                       15%                14%                                                                                                                                                          no differences were found on the Treatment Program Structure and Services,
                                                                                                         Hispanic                    19%                11%
                                                                                                         White                       63%                74%
                                                                                                                                                                                                         8                                                                                                           Integrated Treatment Documentation, or Overall Fidelity scores. Group contrasts on
Fidelity was assessed through two process evaluation site visits during the second year                  Other                       3%                 1%
                                                                                                                                                                                                                                                                                                                     individual TITIS items revealed that the AS programs scored higher on one item
of the project, consisting of semi-structured interviews assessing the essential elements              Principal Diagnosis                                                                               6                                                                                                           measuring Integrated Progress Notes. Results of client outcome analyses revealed
                                                                                                                                                                                                                                                                 b
of IDDT. In addition, the Texas Integrated Treatment Integrity Scale (TITIS) was                        Schizophrenia                43%                13%       †
                                                                                                                                                                                                                                                                                                                     no differences between the two models in the number of psychiatric hospitalization
                                                                                                        Major Depression             23%                34%
completed for each site using multiple data sources, including interview data, site self-               Bipolar Disorder             16%                19%                                              4                                                                                                           days or arrests at 1-year post-baseline.
report instruments, client chart review, and service records. The TITIS is based on the                 Substance Use Disorder       5%                 10%
                                                                                                        Other                        13%                24%
Dartmouth Assertive Community Treatment Scale (DACTS), adapted to capture service
                                                                                                                                                                                                         2
system features in Texas. Each TITIS item is scored on a 5-point scale, with higher                    Hospitalization Days                                                                                                                                                                                          The two implementation models that emerged from the process evaluation reflected
                                                                                                       (12 Months Pre-Baseline)      10.1               1.2       *
scores indicating greater fidelity. The process evaluation site visit data identified two                                                                                                                                                                                                                            differences in service structure. One model displayed structural characteristics that
general modes of implementation across programs: the integrated treatment model (IT;                   Number of Arrests                                                                                 0
                                                                                                                                                                                                                                 Pre-Baseline                                       Post-Baseline                    had greater fidelity to the ideal implementation of IDDT, with the dual diagnosis team
n = 3) and the adjunct services model (AS; n = 3). Programs in the IT category were                    (12 Months Pre-Baseline)      .13                .13
                                                                                                                                                                                                                                                Integrated Treatment   Adjunct Services                              coordinating and delivering services. By contrast, the other model implemented a
characterized by complete integration of substance abuse and mental health systems,                   * p=.003, † p=.0001                                                                                                                                                                                            case manager structure with the dual diagnosis team as one of an array of adjunct
with the dual diagnosis team coordinating and delivering services. In the AS model, a
                                                                                                                                                                                                                                                                                                                     service types. Few differences were found between these two models on TITIS
case manager coordinated a team of specialized service providers and the dual
diagnosis team was one type of service in this array.                                                                                                                                                                                                                                                                fidelity scores other than treatment team structure, suggesting that although the
                                                                                                                                                  Number of Arrests During Past Year                                                                                                                                 method of service delivery may have differed, both model types implemented
TITIS ratings of the IT and AS models were compared using Wilcoxon rank sums tests to                                                                                                                                                                                                                                comparable levels of the essential elements of IDDT and achieved similar 1-year
explore potential differences in fidelity scores. One-year outcome analyses were                                                               0.16
                                                                                                                                                                                                                                                                                                                     client outcomes. These findings indicate that, in this sample of IDDT programs, the
conducted contrasting clients who received IT (n = 120) versus AS (n = 136) on                                                                                                                                                  Group Difference = ns                                                                departure from the ideal IDDT service delivery structure did not differentially affect
psychiatric hospitalization days and arrests. Baseline comparisons indicated that the IT                                                                                                                                                                                                                             client outcomes, suggesting that other critical elements of the treatment model may
group was older, had a higher proportion of schizophrenia-spectrum diagnoses, and had                                                          0.14
                                                                                                                                                                                                                                                                                                                     be a stronger factor in determining client outcomes than method of service delivery.
greater levels of psychiatric hospitalization in the year prior to admission; consequently,
propensity scores were used to adjust for these initial group differences in outcome
                                                                                                                                               0.12
analyses. General linear modeling with repeated measures and Poisson distribution was
conducted to compare psychiatric hospitalization and arrests during the 1-year periods
pre- and post-baseline.                                                                                                                         0.1

                                                                                                                                                                                                                                                                                                                      Acknowledgements
                                                                                                                                               0.08

                                                                                                                                                                                                                                                                                                                     The authors acknowledge the Texas Department of State Health Services
                                                                                                                                                                                                                                                                                                                     (TDSHS), Mental Health and Substance Abuse Services Division for their
                                                                                                                                               0.06
                                                                                                                                                                  Pre-Baseline                                           Post-Baseline                                                                               assistance in retrieving archival data for this study.
                                                                                                                                                                                 Integrated Treatment        Adjunct Services
                                                                                                                                                                                                                                                                                                                     The findings and conclusions of this presentation are the opinions of the authors
                                                                                                                                                                                                                                                                                                                     and do not necessarily reflect the official position of TDSHS.


                           Presented at the Addiction Health Services Research Conference,
                           Little Rock, Arkansas, October 24, 2006

								
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