A Pilot Test of Commonground Based Shared Decision-Making for Psychiatric Visits: Fidelity Development and Initial Outcomes of Consumers and Prescribers

Background: Shared decision-making (SDM) has become a central tenet of recovery-oriented, person-centered mental health care. CommonGround is a web-based program that helps consumers be active participants in decision-making specifically related to medication and psychiatric treatment. The intervention involves a Decision Support Center equipped with an interactive touch screen computer decision aid and staffed by trained peers who provide coaching to consumers. Consumers complete a one page health report (including goals, concerns, etc.) prior to the appointment to discuss with the prescriber. This is the first clinical trial of CommonGround that monitored fidelity and evaluated outcomes.  

Methods: A total of 167 consumers who received services at a community mental health center participated in the study (one group pretest-posttest with follow-up design). The participants were predominantly male (57%), 70% had a schizophrenia spectrum disorder, 42% had less than a high school diploma, 50% lived independently, 54% were African American, and the mean age was 44±10.4 years old. Four treatment teams participated in the study, each with a prescriber.  However, due to turnover, a total of 8 prescribers participated during the 18-month study. Consumer outcomes (Hope, Autonomy Preference Index, Health Care Relationship Trust Scale, Patient Activation Measure, Patient Perception of Patient-Centeredness Questionnaire, Recovery Assessment Scale [RAS]) and a provider outcome (measured by satisfaction, effectiveness, consumers’ participation in the decision-making process, etc.) were measured at baseline (prior to intervention), 12 months, and 18 months. Mixed effects regression was used to examine the intervention effects over time.

Results: The dropout rate at 18 months was 50%. Average frequency of CommonGround use over 18 months was 2.7±3.8 times. Consumer outcomes neither improved nor deteriorated, except for the RAS subscale “No domination by symptoms” that improved over time (p=.002). However, prescribers felt more satisfied with the session and consumers’ commitment to decision making over time (p=.01). Fidelity assessments showed difficulty implementing some aspects of the program, particularly direct service staff integration and supervision.

Conclusions and implications: CommonGround is a practical program that integrates SDM tools at different system levels of care, including consumers, prescribers, direct care providers, and peer support to amplify the consumer voice in treatment and empower consumers to follow through with the decision. However, the agency had high levels of turnover, and difficulty implementing some aspects of the model. We speculate that the low fidelity and lack of repeated use contributed to the lack of expected effect on consumer outcomes. Given the emphasis of self-determination and SDM in medication management for mental health consumers, the current study identifies areas that social workers can contribute to supporting client-centered care and empowerment in medication management. Implications for social work practice in shared decision-making will be discussed.