Inside the Black Box of an EBP: Critical Time Intervention from an Implementation Perspective

Background:

Critical Time Intervention (CTI) is an evidence-based psychosocial intervention designed to prevent recurrent homelessness among people with severe mental illness by enhancing continuity of care during the transition from institutional to community living. CTI involves 3 three-month phases, including (a) transition to the community; (b) try-out, and (c) transfer of care. While CTI's structure has been well articulated, details about model implementation in community settings require further specification in order to identify essential practice skills, bolster model fidelity, and inform program dissemination. From the first-hand experiences of CTI workers trained by the model developers, this study aims to identify workers' perspectives on the goals and functions of CTI, theorize essential strategies in implementation, and conceptualize key structural influences on CTI practices.

Methods:

This grounded theory study involved twelve participants who experienced in the delivery of CTI, including clinical staff from an NIMH-funded clinical trial as well as workers from four community agencies providing CTI services in New York City. They varied in their racial and educational backgrounds, age (26 – 55 years), and time in the current position (0.8 – 10 years). Data were collected through semi-structured, one-on-one, audio-taped, 40-90 minute-long interviews with the principal investigator. The initial interviews involved broad, open-ended questions which then evolved on the basis of ongoing analysis for each subsequent interview to collect most relevant data for the conceptualization of CTI practices. Verbatim transcripts were analyzed line-by-line by using dimensional analysis procedures to identify and conceptualize key elements that altered CTI workers' practices with clients.

Results:

CTI workers perceived the ultimate goal as to help clients to develop independence and live stably in community housing with adequate support. CTI thus functioned to help clients to adjust to community living, remove barriers to housing stability, and develop community supports. Practices were influenced by client variations, the model design, service settings, and systemic constraints

Significant client variations included the impact of homelessness over client life course, clients' awareness of their mental health condition, and clients' goals and motivations in receiving CTI services. To facilitating client readiness for transition, CTI workers developed a trusting relationship and moved clients along by motivating clients, making use of client motivation, and keeping clients motivated.

Workers also integrated structural influences into CTI practices. Workers used CTI phases to guide service progression and the timeline to stay focused. They took advantages of agency housing application services, residential programs, and existing support/treatment programs to facilitate the transition. They also needed to accommodate systemic constraints such as limited housing and providers' availability to match with client preference in CTI practices.

Conclusions:

Findings suggest that specific practices addressing client variation are important to consider in implementing the model and developing fidelity measures. Findings show CTI's role as a transitional model where both ends of the transition – the host setting of CTI and the housing placement for the client – shape practices and strategies used to achieve program effects. Thus, effective dissemination requires knowledge of broader service systems and organizational resources that may facilitate or hinder successful program adaptation.