Fidelity to Person-Centered Care in Community Mental Health Clinics

Background and Purpose: While person-centered care is widely endorsed as key to delivering high quality health services, providers still struggle to translate this care approach to their clinical practice.  Person-centered Care Planning (PCCP) is an emerging evidence-based practice which promotes person-centered care through the service planning process within mental health programs. This recovery-oriented practice articulates a collaborative process to develop a service plan driven by personal life goals. Providers learn how to reframe symptoms and impairments as barriers to goal attainment and identify measurable objectives building on a person’s strengths and integrating natural supports. This multi-site randomized controlled trial examined the effectiveness of implementing PCCP in community mental health settings.

Methods: The study was set within community mental health clinics from two states. Seven sites were randomized to training in PCCP and seven sites to treatment-as-usual.  Supervisors and direct care staff in the experimental condition received 2-days of in-person training and a year of bi-monthly technical assistance calls. Fidelity to PCCP was measured by an objective chart review tool (PCCP-AM) that assessed the person-centeredness of service plans using 13 items. Service plans (N=798) were sampled from participating supervisors (N=60) at baseline, 12, and 18-months. A mean PCCP-AM sum score was calculated per supervisor per time point. Hierarchical linear model analyses using a three-level, fully random intercepts and slopes model examined cross-level effects of the PCCP training on fidelity over three time points. Covariates were organizational level workload measured by an aggregated site level mean score (level 3), implementation climate measured by an aggregated mean score (level 2), and supervisors’ years of experience in mental health (level 2).

Results: On average, 12.77 (SD=10.77) charts were sampled per supervisor. Mean years in mental health services for supervisors was 10.33 (SD=6.52). On a scale from 10-50, mean site stress scores were 33.16 (SD=9.24). On a scale from 1-5, mean climate scores were 3.27 (SD=.84) across supervisors. Fidelity to PCCP did not differ between treatment and control groups at baseline (p=.26). However, there was a significant time by condition interaction such that fidelity improved at a significantly greater rate in the treatment group relative to control (.084, p=.027). In the control group, there was no significant change in fidelity from baseline to 18 months (d=-.28, p=.21), whereas in the treatment group, fidelity improved by a medium effect size of d=.44 from baseline to 18 months. 

Conclusions and Implications:  These findings suggest that PCCP training significantly improved the delivery of person-centered care using an objective fidelity measure and controlling for provider experience and organizational factors. The study adds to the growing body of evidence that person-centered care can be translated into specific practice changes that can be implemented successfully through prolonged training of direct care staff and their supervisors. The next step is to examine whether the delivery of person-centered care improves clinical outcomes.