Scaling up with Support: Critical Time Intervention Fidelity Review Results from a Statewide Program

Background and Purpose: Since 2021, Critical Time Intervention (CTI) has been implemented across New Hampshire (NH). The goal of the program is to ensure coordination and continuity of care for individuals who have received acute behavioral health services at State-funded facilities. In NH, successful implementation included coordinated communication and buy-in from stakeholders throughout and across service sectors, a sensible and sustainable funding model, and resolute adherence to fidelity. CTI is an evidence-based model with a large foundation of research showing the impact of CTI on key outcomes like rehospitalization rates, returns to homelessness, and recidivism to incarceration. To ensure positive outcomes, programs should implement the model with high fidelity. Fidelity reviews allow programs to identify areas of strength and areas needing additional support or intervention.

Methods: In 2024, CTI program fidelity reviews were conducted (N = 10) across the state using the 15-item CTI fidelity rating scale developed by the Center for the Advancement of CTI. For each program, the review team collected data through chart reviews, and interviews and focus groups with CTI personnel. Data was compiled and analyzed by team and aggregated to show trends across teams and fidelity items.

Results: CTI teams demonstrated areas of strength including the workers’ ability to engage clients early (x̄ = 92%) with high intensity (x̄ = 83%) and maintain connection through the full program (x̄ = 82%), including in final meetings with clients (x̄ = 86%). Additionally, teams demonstrated the ability to do phased (x̄ = 91%), time-limited work (x̄ = 98%) with clients. Notably, the programs demonstrated “ideal implementation” on most of the worker- and team-based fidelity items evidencing high quality work in the CTI worker and supervisor roles.

Teams were challenged to connect with supports early with high intensity (x̄ = 41%) and in the community (x̄ = 50%). Over time CTI teams were unable to step back with clients (x̄ = 48%) while increasing their clients’ reliance on supports (x̄ = 26%). With some clients, CTI workers did not meet the contact minimum. With others, workers met over the maximum amount of expected contacts in phase three.

Conclusions and Implications: The teams demonstrated high quality team supervision, and found support from the team and center where they were located. Their persistent efforts to engage with clients early on provided context for their success with maintaining connection with clients for the duration of the model. The team demonstrated difficulty engaging with members of clients’ support networks during phase one, phase three as workers stepped back, and prior to discharge. Engagement with clients’ supports throughout the phases is a vital component of the model and providing high-fidelity CTI is difficult without community-based supports. CTI is designed to provide assistance that decreases in intensity while helping clients make connections to enduring supports, improving continuity of care as clients transition to community-based services. Without sufficient community-based and natural supports, workers are required to continue high-intensity work with clients through the 9 months and CTI clients risk facing insufficient support once CTI ends.