Assertive Community Treatment: Facilitators and Barriers to Implementation in Routine Mental Health Settings
Assertive Community Treatment: Facilitators and Barriers to Implementation in Routine Mental Health Settings
复制标题
DOI：
10.1176/appi.ps.60.2.189
复制
发表时间：
2009-02-01
影响因子：
3.8
通讯作者：
Burns, Barbara J.
中科院分区：
文献类型：
--
作者：
Mancini, Anthony D.;Moser, Lorna L.;Burns, Barbara J.
目的：本研究确定的障碍和促进者，以高保真实施自信的社区治疗。研究方法：作为循证做法多州实施项目的一部分，向两个州13个新成立的自信社区治疗小组提供了培训和咨询。在基线和6、12、18和24个月时评估模型保真度。通过对关键信息提供者的访谈、调查和每月现场访问，监测与障碍和促进者有关的执行进程。结果：州精神卫生当局的许可程序为实施提供了关键的结构性支持。这些支持包括一个专门的医疗补助计费结构，启动资金，持续的忠诚度监测，模型培训和技术援助。忠诚度较高的站点拥有有效的管理和项目领导、较低的人员流动率、良好的人事实践和熟练的员工，并且在人员配备、办公空间和汽车方面分配了充足的资源。忠诚度较低的网站与资源不足、实施中的财务问题优先、缺乏变革文化、士气低落、工作人员之间的冲突和工作人员流动率高有关。在跨州比较中，财政政策、许可证发放程序和技术援助的具体性质似乎会影响执行情况。结论：州精神卫生当局可以在自信的社区治疗实施中发挥关键作用，但应仔细设计计费机制，促进技术援助中心，将项目要求与忠诚模型联系起来，并限制官僚要求。要在组织一级成功实施，就需要坚定的领导、分配充足的资源和认真的聘用程序。（精神病学服务60：189-195，2009）
Objective: This study identified barriers and facilitators to the high-fidelity implementation of assertive community treatment. Methods: As part of a multistate implementation project for evidence-based practices, training and consultation were provided to 13 newly implemented assertive community treatment teams in two states. Model fidelity was assessed at baseline and at six, 12, 18, and 24 months. Key informant interviews, surveys, and monthly on-site visits were used to monitor implementation processes related to barriers and facilitators. Results: Licensing processes of the state mental health authority provided critical structural supports for implementation. These supports included a dedicated Medicaid billing structure, start-up funds, ongoing fidelity monitoring, training in the model, and technical assistance. Higher-fidelity sites had effective administrative and program leadership, low staff turnover, sound personnel practices, and skilled staff, and they allocated sufficient resources in terms of staffing, office space, and cars. Lower-fidelity sites were associated with insufficient resources, prioritization of fiscal concerns in implementation, lack of change culture, poor morale, conflict among staff, and high staff turnover. In cross-state comparisons, the specific nature of fiscal policies, licensing processes, and technical assistance appeared to influence implementation. Conclusions: State mental health authorities can play a critical role in assertive community treatment implementation but should carefully design billing mechanisms, promote technical assistance centers, link program requirements to fidelity models, and limit bureaucratic requirements. Successful implementation at the organizational level requires committed leadership, allocation of sufficient resources, and careful hiring procedures. (Psychiatric Services 60: 189-195, 2009)