An unresolved issue in the field of implementation research is how to conceptualize and evaluate successful implementation. This paper advances the concept of “implementation outcomes” distinct from service system and clinical treatment outcomes. This paper proposes a heuristic, working “taxonomy” of eight conceptually distinct implementation outcomes—acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability—along with their nominal definitions. We propose a two-pronged agenda for research on implementation outcomes. Conceptualizing and measuring implementation outcomes will advance understanding of implementation processes, enhance efficiency in implementation research, and pave the way for studies of the comparative effectiveness of implementation strategies.

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Outcomes for Implementation Research: Conceptual Distinctions, Measurement Challenges, and Research Agenda

In the past few years several major reports highlighted the gap between our knowledge of effective treatments and services currently being received by consumers. These reports agree that we know much about interventions that are effective but make little use of them to help achieve important behavioral health outcomes for children families and adults nationally. This theme is repeated in reports by the Surgeon General (United States Department of Health and Human Services 1999; 2001) the National Institute of Mental Health [NIMH] National Advisory Mental Health Council Workgroup on Child and Adolescent Mental Health Intervention Development and Deployment (2001) Bernfeld Farrington & Leschied (2001) Institute of Medicine (2001) and the Presidents New Freedom Commission on Mental Health (2003). The authors call for applied research to better understand service delivery processes and contextual factors to improve the efficiency and effectiveness of program implementation at local state and national levels. Our understanding of how to develop and evaluate evidence-based intervention programs has been furthered by on-going efforts to research and refine programs and practices to define "evidence bases" and to designate and catalogue "evidence-based programs or practices". However the factors involved in successful implementation of these programs are not as well understood. Current views of implementation are based on the scholarly foundations prepared by Pressman & Wildavskys (1973) study of policy implementation Havelock & Havelocks (1973) classic curriculum for training change agents and Rogers (1983; 1995) series of analyses of factors influencing decisions to choose a given innovation. These foundations were tested and further informed by the experience base generated by pioneering attempts to implement Fairweather Lodges and National Follow-Through education models among others. Petersilia (1990) concluded that "The ideas embodied in innovative social programs are not self-executing." Instead what is needed is an "implementation perspective on innovation--an approach that views postadoption events as crucial and focuses on the actions of those who convert it into practice as the key to success or failure". (excerpt)

Implementation research: a synthesis of the literature.

Objectives. We examined the longitudinal effects of a Housing First program for homeless, mentally ill individuals’ on those individuals’ consumer choice, housing stability, substance use, treatment utilization, and psychiatric symptoms. Methods. Two hundred twenty-five participants were randomly assigned to receive housing contingent on treatment and sobriety (control) or to receive immediate housing without treatment prerequisites (experimental). Interviews were conducted every 6 months for 24 months. Results. The experimental group obtained housing earlier, remained stably housed, and reported higher perceived choice. Utilization of substance abuse treatment was significantly higher for the control group, but no differences were found in substance use or psychiatric symptoms. Conclusions. Participants in the Housing First program were able to obtain and maintain independent housing without compromising psychiatric or substance abuse symptoms. (Am J Public Health. 2004;94:651‐656)

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Housing First, Consumer Choice, and Harm Reduction for Homeless Individuals With a Dual Diagnosis

The article defines peer support/peer provided services; discusses the underlying psychosocial processes of these services; and delineates the benefits to peer providers, individuals receiving services, and mental health service delivery system Based on these theoretical processes and research, the critical ingredients of peer provided services, critical characteristics of peer providers, and mental health system principles for achieving maximum benefits are discussed, along with the level of empirical evidence for establishing these elements

Peer Support/Peer Provided Services Underlying Processes, Benefits, and Critical Ingredients

We test whether significant differences in mental illness exist in a matched sample of Mental illness and the criminal justice system. In T. L. Scheid T. N. Brown (Eds.), A handbook for the study of mental health: Social contexts, theories. Find 9780521567633 A Handbook for the Study of Mental Health : Social Contexts, Theories, and Systems by Horwitz et al at over 30 bookstores. Buy, rent. A review of mental health problems in fathers following the birth of a child. for the study of mental health:Social contexts, theories, and systems (2nd ed., pp.

A Handbook for the Study of Mental Health: Social Contexts, Theories, and Systems

The outcomes of a reform of the Denver mental health system, cosponsored by the state and the RWJF, are contrasted with changes in a comparison area of the state. The study examines the structural characteristics of the mental health system, staff attitudes and satisfaction, and client-reported services and outcome. Results indicate that, in Denver, structural changes, the introduction of new services, and an intervening financial crisis increased worker dissatisfaction. Client reports documented parallel changes in the following variables: continuity of care, unmet need for case management services, frequency of symptoms, and satisfaction with services. The reform had no impact, however, on most quality-of-life indicators. The possibly adverse consequences of centralizing the system and the indirect influences of system integration on quality of life are discussed.

Client Outcomes II: Longitudinal Client Data from the Colorado Treatment Outcome Study

Objective The study examined whether employing mental health consumers as peer specialists in an intensive case management program can enhance outcomes for clients with serious mental illness. Methods A quasiexperimental, longitudinal, nonequivalent control group design was used to compare outcomes of clients assigned to three case management conditions: teams of case managers plus peer specialists, teams of case managers plus nonconsumer assistants, and case managers only. Outcomes were measured at baseline and at three six-month intervals. Repeated-measures analysis of variance was used to assess between-group differences. Results Complete data were available for 104 clients. Compared with clients in the other two groups, clients served by teams with peer specialists demonstrated greater gains in several areas of quality of life and overall reduction in the number of major life problems experienced. They also reported more frequent contact with their case managers and the largest gains of all three groups in the areas of self-image and outlook and social support. No differences in outcomes were found between clients served by teams with nonconsumer assistants and those served by case managers only. Conclusions Integration of peer specialists into intensive case management programs appears to lead to enhanced quality of life for clients and more effective case management.

Consumers as peer specialists on intensive case management teams: impact on client outcomes

We illustrate Fairweather's approach to Experimental Social Innovation and Dissemination with two experimental studies of programs to reduce homelessness for 168 and 225 people with mental illness and often substance abuse. Literally homeless participants were randomly assigned to programs that emphasized consumer choice or to the usual continuum of care, in which housing and services are contingent on sobriety and progress in treatment. A drop-in center that eliminated barriers to access to services was more successful than control programs in reducing homelessness, but after 24 months only 38% of participants had moved to community housing. A subsequent apartment program, in which individuals in the experimental condition moved to subsidized apartments directly from the street, with services under their control, had 79% in stable housing (compared to 27% in the control group) at the end of 6 months. Groups in this study did not differ on substance abuse or psychosocial outcomes.

Consumer preference programs for individuals who are homeless and have psychiatric disabilities: a drop-in center and a supported housing program.

OBJECTIVES: This study tested a psychiatric rehabilitation approach for organizing and delivering services to street-dwelling persons with severe mental illness. METHODS: Street-dwelling persons with severe mental illness were randomly assigned to the experimental program (called Choices) or to standard treatment in New York City. We assessed study participants at baseline and at 6-month intervals over 24 months, using measures of service use, quality of life, health, mental health, and social psychological status. The average deviation from baseline summary statistic was employed to assess change. RESULTS: Compared with persons in standard treatment (n = 77), members of the experimental group (n = 91) were more likely to attend a day program (53% vs 27%), had less difficulty in meeting their basic needs, spent less time on the streets (55% vs 28% reduction), and spent more time in community housing (21% vs 9% increase). They showed greater improvement in life satisfaction and experienced a greater reduction in psychiatric symptoms. CONCLUSIONS: With an appropriate service model, it is possible to engage disaffiliated populations, expand their use of human services, and improve their housing conditions, quality of life, and mental health status.

Serving street-dwelling individuals with psychiatric disabilities: outcomes of a psychiatric rehabilitation clinical trial.

In the early 1990s the National Institute of Mental Health sponsored projects in four cities that served a total of 896 homeless mentally ill adults Each project tested the effectiveness of different housing, support, and rehabilitative services in reducing homelessness Most homeless individuals resided in community housing after the intervention The proportion in community housing varied between sites A 475 percent increase in community housing was found for those in active treatment conditions At final follow-up, 78 percent of participants in community housing were stably housed The findings indicate that effective strategies are available for serving homeless individuals with severe mental illness

David L. Shern

Papers

Client Outcomes II: Longitudinal Client Data from the Colorado Treatment Outcome Study

Consumers as peer specialists on intensive case management teams: impact on client outcomes

Consumer preference programs for individuals who are homeless and have psychiatric disabilities: a drop-in center and a supported housing program.

Serving street-dwelling individuals with psychiatric disabilities: outcomes of a psychiatric rehabilitation clinical trial.

Housing outcomes for homeless adults with mental illness: results from the second-round McKinney program.