CDOI Practice at CHCS

A More Detailed Description with Data

Recovery is an individual client’s responsibility, but can be assisted by others in both formal and informal supporting roles who believe in the client, focus on strengths and resiliencies, and point out positive changes.  Treatment providers who believe that clients are capable of setting the direction for treatment and that clients are capable of making desired changes, and who are willing to partner with clients, can make valuable contributions to the recovery process. One critical aspect of this approach is intentionally honoring the client’s voice and experiences.

Client-Directed, Outcome-Informed (CDOI) practice, which incorporates PCOMS ( an approved evidence based practice by SAMHSA),  is the approach utilized by the Adult, Child and Family Services (ACFS) department of Community Health and Counseling Services.  Use of  this practice by workers is expected to lead to client recovery, and is based on the research on the factors that make mental health treatment successful (references available upon request, or visit www.heartandsoulofchangeproject.com for reference materials).  This way of practice privileges the client’s voice in treatment to the maximum extent possible, while adhering to professional and ethical standards of practice.  Importantly, CDOI practice incorporates regular measurement of client progress as well as attention to the client’s perception of the treatment process through the use of PCOMS, which are simple tools that can be administered in under a minute (the Outcome Rating Scale (ORS), the Child Outcome Rating Scale (CORS) and the Session Rating Scale (SRS) and Child Session Rating Scale (CSRS), as well as the Group Session Rating Scale, which can be downloaded from the Heart and Soul of Change Project website).  

Unlike other evidence based treatments, which are designed to intervene with specific symptoms or or diagnoses, CDOI practice/PCOMS contains no fixed techniques and no causal theory regarding the concerns that bring people to mental health services.  Any interaction with a client can be client-directed and outcome-informed when the client’s voice is privileged as the source of wisdom and solution, and helpers purposefully form strong partnerships with clients: (1) to enhance the factors across theories that account for successful outcome; (2) to use the client’s ideas and preferences to guide choice of technique and model; and (3) to inform the work with reliable and valid measures of the client’s experience of the alliance and outcome.

Research consistently shows that mental health treatment works, and study after study, as well as metanalyses of studies, demonstrate that the average treated client is better off than 80% of the untreated sample.  However, despite the claims of their proponents, there is no body evidence indicating that any models and techniques utilized for specific diagnoses are more effective than any others. There are now over 100 evidence based treatments for specific diagnoses, but effectiveness has not increased in 40 years.  In fact, all of these years of research on mental health treatment continue to point to the importance of the factors that are common to all treatments: client factors that contribute to the change process and the quality of the helping relationship.  These contribute vastly more to outcome than do model and technique (87% due to client factors, 7% due to allliance factors, and only 1% due to model and technique).  Despite the emphasis in clinicians’ professional training and work settings on model and technique, they make the smallest percentagewise contribution to outcome of any known ingredient.  Quite simply, neither the competence with which a condition is diagnosed nor that of the treatment modality delivered has any relation to the effectiveness of that treatment.  All bona fide treatments work equally well with some people some of the time.  Evidence-based practices which focus on model and technique offer choices for clients, and are as equally effective as other forms of interventions, but only if they fit with the client’s ideas about how change will occur. 

The good news is that even though model and technique do not improve outcome, (i.e. more effectively promote recovery) we now know that feedback to clinicians is instrumental.  We know that if change is going to occur, there are indications of change very early on in the treatment, and we know that the client’s rating of the helping alliance is a better predictor of whether or not clients will stay in treatment and of outcome than are either clinician’s ratings or the model and technique utilized.  Regular, ongoing feedback to workers about the status of the helping relationship and about client progress are essential components to successful clinical decision making.  If the alliance is poor and/or early progress is not being made, rapid adjustments are necessary in order to maximize the chances of a successful outcome. 

Working with clients to understand their theory of change helps us to better ensure a good fit for the interventions we select.  Measuring progress based on self-report of clients at regular intervals allows us to partner with them to note early, small signs of progress or deterioration.  Thus, we are in a position to discuss these small changes with clients, and to make adjustments in our approach so as to maximize the likelihood of a successful outcome.  The use of the PCOMS measurement tools, in combination with our clinical judgment and the continuing input of the client and of others who are concerned about the client’s well-being, provide a vehicle for us to determine when maximum benefit has been attained from services.  In addition, support teams that include the clients and their formal and informal helpers, can make decisions about the viability and efficacy of continuation of services.  Thus, we are able to closely tailor services to the specific level of need of the client and we are able to make services accountable both to clients and to payer sources.

Our experience thus far in implementing this approach to clinical programming indicates that it can be applied to a wide range of mental health services, and is consistent with the Maine DHHS vision for the publicly funded mental health system as well as the Federal government’s New Freedom Commission on Mental Health report guidelines.  Indeed, although Community Health and Counseling Services has been a leader in introducing these ideas drawn from traditional psychotherapy settings into services provided to the “SPMI” population, including Community Integration and Residential services for both adults and children, many agencies throughout the country have now joined us.  In addition, there are other agencies in the country that have pioneered in applying it in substance abuse and criminal justice  settings.  The state of Arizona has designated CDOI as a “Best Practice” for publicly funded services, where the approach is utilized in peer support services as well as in treatment services.

CHCS’ data from the implementation of this recovery focused practice is exciting.  We have reduced our client no show and cancellation rates by 30% in therapy, and have reduced the length of treatment in some programs by 72% (see attached data). Our success has demonstrated that this way of service delivery can be utilized successfully with the clients we and other publicly funded agencies and that the implementation of CDOI makes us more accountable both to our clients and our payer sources.


Average Length of Stay

Program

Pre-CDOI

Post-CDOI

LOS Reduction

Case Management

2.50 years

.6 year

72%

Therapy

1.45 years

.6 year

59%

Residential

1.90 years

1.0 year

47%


Ratio of Long Term Cases

Program

Pre-CDOI

Post-CDOI

Reduction

Case Management

(Open more than 1 year)

49%

24%

49%

Case Management

(Open more than 2 years)

17%

7%

41%



Our Community Integration program serves 1336 per year. By implementing CDOI, we have reduced the number of clients served more than one year from 655 (pre-CDOI) to 321 (post-CDOI), and we have reduced the number of clients served more than two years from 227 (pre-CDOI) to 94 (post-CDOI).
We have reduced the number of No Shows and Cancellations in our Therapy program by 30% as a result of implementing CDOI.
We have not had one client complaint or request to change Therapists in the past two years. Prior to implementing CDOI, we received an average of 6 complaints (informal) and 12 requests to change Therapists per year. This suggests that Therapy clients are more satisfied with the therapeutic relationship and with the services they are receiving and/or that Therapists are introducing conversations about the possibility of transfer based on low SRS scores or client failure to show benefit from the service before the client feels a need to complain.



 


CHCS Mission

Community Health and Counseling Services will provide community health services that are needed and valued by the communities and individuals we serve.