Background: Strengths Model Case Management (SMCM) was developed as a response to traditional deficit-oriented approaches. It is both a philosophy of practice and a set of tools and methods designed to enhance recovery (Rapp & Goscha, 2006). Nine studies (including Barry et al., 2003; Stanard, 1999) have reported positive outcomes using SMCM with people with psychiatric disabilities. Full implementation of SMCM consists of structural components (e.g., low caseload sizes and supervisor-to-case manager ratio), practice components (e.g., use of the Strengths Assessment and Personal Recovery Plan tools), and supervisory behaviors toward front-line staff (e.g., weekly review of Strengths Model tools and feedback on their use in practice). A SMCM fidelity scale was developed by the University of Kansas, School of Social Welfare (KUSSW) to measure adherence. It consists of 11 items in three core areas; structure, supervisor/supervision, and service/clinical. Fidelity reviews are conducted at baseline and every six months during the first two years of implementation. Annual reviews follow. Total scores range between 11 and 55 (45 required to achieve high fidelity). High fidelity is expected to improve the team's performance in client outcomes. This study examined the relationship between SMCM fidelity scores and client outcomes for 13 case management teams representing 10 agencies who served an average of 953 clients over an 18 month period of time.
Methods: Data was collected during regularly scheduled fidelity reviews for each of the teams by at least two consultant-trainers who had extensive experience in SMCM implementation at KUSSW (inter-rater reliability for the scale was .97). All case managers on the team completed reports regarding the current status of each client on their caseload in the areas of psychiatric hospitalization, competitive employment, post-secondary education, and independent living. In order to assess the relationship between fidelity scores and client outcomes, time-varying covariate linear growth modeling was applied using SAS PROC MIXED.
Results: Marginal means and standard deviations for fidelity scores and all outcomes (success ratio: %) follow [Baseline, 6-Mo., 12-Mo., 18-Mo.]: fidelity score [27.43 (9.71), 39.21 (6.94), 44.71(4.78), 47(4.44)]; competitive employment [15.5 (6.5), 17.57 (5.59), 18.07(3.39), 20.23(5.05)]; psychiatric hospitalization [10.79 (5.71), 9.93 (4.78), 5.36(3.23), 4.15(3.05)]; post-secondary education [3.64 (2.98), 4.50 (3.92), 5.43(4.01), 5.69(3.07)]; independent living [89.14 (5.04), 90.29 (6.35), 95.00 (3.66), 95.69(3.20)]. Significant time effect was found for employment (β=1.43[0.71], p=.06), hospitalization (β=-2.48[0.45], p<.001), education (β=0.65[0.31] p=.03), and independent living (β=2.42[0.43], p<.001). However, once the time-varying covariate (fidelity score) was introduced, the time effect disappeared and significant time-varying covariate effects of the fidelity score were found (p<.05), except for independent living (p=.85). The results show that team performance on client outcomes improved over time but improvement depended on fidelity scores. On the other hand, improvement of independent living did not depend on fidelity score changes.
Conclusions and Implications: These results offer promising evidence that higher SMCM fidelity has a positive effect on clients over an 18 month period of time, thereby providing an effective complement to current mental health treatment. Implications for practice and policy from the strengths perspective in social work will be discussed.