The Maryland Resilience Breakthrough Series Collaborative: A Quality Improvement Initiative for Children’s Mental Health Services Providers
Abstract
The Maryland Resilience Breakthrough Series Collaborative (BSC), a recent quality improvement initiative for children’s mental health services providers, is aimed at bridging the gap between resilience theory and mental health service practices. Six provider teams across the state attended resilience training sessions and incrementally implemented practice improvements at their agencies. Group discussions and surveys administered to teams before and after the BSC indicate that the BSC facilitated breakthrough changes in the areas of resilience-enhanced assessment and treatment practices, as well as family and community resilience. This column presents quantitative and anecdotal outcomes and makes recommendations for the provider community.
Resilience—defined as a dynamic process of positive adaptation in the face of adversity—is a concept with important implications for mental health care providers (1,2). In a broad sense, resilience represents universal prerequisites for good mental health: personal strengths, positive relationships, and supportive communities (3). In a more targeted sense, resilience concepts are particularly relevant to—and, indeed, were first studied among—children and youths faced with adversity. Decades of longitudinal research have uncovered powerful protective factors that are associated with healthy social and emotional development. Such factors are important targets for child-serving systems (4).
In Maryland, mounting awareness of this body of literature led to a consensus that services for struggling youths should be resilience based, or focused on harnessing strengths, skills, and resources to promote wellness (4,5). However, despite this consensus, providers struggled to apply resilience theory to concrete, measurable mental health practices. (Such application can be challenging given the structure of the mental health system, which pays providers under a medical model and which is generally more deficit and impairment based.) To address this issue, the Maryland Department of Health and Mental Hygiene collaborated with the University of Maryland Division of Psychiatric Services Research to conduct a Breakthrough Series Collaborative (BSC) focused on translating resilience concepts into concrete mental health practices.
Model and Approach
The BSC is a quality improvement model designed to help health care providers bridge the gap between scientific knowledge and real-world practices. Initially developed by the Institute for Healthcare Improvement for use in medical contexts (6), the model has since been successfully adapted for child welfare and mental health settings (7,8). The Maryland BSC involved six teams statewide, chosen through a written application process. Teams came from children’s outpatient mental health clinics or psychiatric rehabilitation programs. The teams represented mostly nonprofit agencies that provide services, such as community education, individual and family counseling, substance abuse treatment, respite, and crisis response. These agencies serve from 664 to 18,000 individuals annually in predominantly urban and rural populations throughout Maryland and are funded through grants, Medicaid, and fee collection. Each provider team included at least one senior leader as well as a supervisor, clinician or counselor, and consumer (that is, a caregiver whose child was receiving or had received services from the provider agency). The involvement of team members who play diverse organizational roles is a key BSC strategy intended to incorporate distinct perspectives and coordinate practice improvements across multiple levels at an agency. The inclusion of consumers as full team members was further intended to elevate consumer voice through all phases of quality improvement, including evaluation. In addition to these teams, six content and practice experts served as BSC faculty. Participants were involved in the BSC between January and June 2013.
BSC methodology provides a supportive structure that facilitates implementation, adaptation, and sustainability of theory-based practices. Efforts are guided by a collaborative goals framework—developed through an iterative process of discussion among experts and providers—that outlines key focus areas for teams to address. In the Maryland BSC, these areas included resilience-enhanced assessment and treatment, as well as family and community resilience. (These areas are described in more detail below.) Underlying these areas was a focus on core concepts that research suggests are central to resilience—a sense of competence, caring and respect for self and others, problem-solving and coping skills, optimism and hope for the future, ability to reframe stress, and sense of purpose and meaning. [An online supplement to this report includes a poster that describes the core concepts.] The BSC aimed to help teams promote these competencies among the youths and families with whom they worked and in their communities. The Maryland BSC was also informed by recent theory and research in positive psychology, which emphasizes promotion of well-being through developing and nurturing strengths, positive experiences and emotions, positive relationships, and positive institutions (9–11).
Core BSC methodological components include three full-day learning sessions, in which teams come together to learn about resilience-related theories and practices, to develop plans for resilience-related incremental tests of change to be implemented by their teams, and to share practices that teams had implemented since the previous learning session. Another key methodological component consists of two action periods, sandwiched between the learning sessions, in which teams return to their agencies and incrementally test and adapt changes in practice related to the resilience focus areas. A third component involves organizational self-assessments, in which teams monitor their progress toward collaborative goals. Additional information was gathered through a variety of anecdotal reports from team members about specific shifts in practice, as well as a six-month follow-up survey of team members to evaluate maintenance of change (that is, sustainability). [The self-assessment and follow-up survey forms are available in the online supplement .] The University of Maryland Institutional Review Board deemed the project as not involving human subjects; it was categorized as a quality improvement initiative rather than research.
Focus Areas: Definitions and Outcomes
Resilience-Informed Assessment and Treatment
Resilience-informed mental health services recognize and harness consumer strengths in promoting healthy development (4). Asset identification via a strengths-based assessment is a crucial first step in providing such services. Although many validated strengths assessments exist, there are few formal guidelines for incorporating results into goal planning and treatment. The limited guidelines reflect a comparative lack of applied resilience research related to mental health services, as opposed to theoretical and population-based research. Because of this significant gap in the literature and the centrality of this theme area to the overarching BSC aims, all teams focused heavily on testing practice improvements in this area.
All teams reported increasing resilience-informed assessment and treatment practices during the BSC, and 100% of participants reported that changes were sustained six months later. [Figures in the online supplement present data on these outcomes.] One team made particularly effective practice improvements related to strengths-based treatment planning. This team was already assessing strengths by using the Child and Adolescent Needs and Strengths assessment (12); however, the team did not formally utilize identified strengths in treatment planning or activities. With input from a BSC faculty, the team redesigned the intake process to include the following components. First, after completing the intake assessment, staff discussed the identified strengths with the child and family, using resilience language adapted from the resilience core concepts chart (3) and the Values in Action classification of strengths and virtues (10,11). Second, treatment goals were reframed as skills or strengths that the youth and family would like to build, rather than as problem areas to address. Third, the intake specialist and family collaboratively developed a strengths-based treatment plan by using the following three guidelines: goals include resilience- and strengths-based language; goals incorporate consumer strengths and interests into treatment activities or settings; and goals are positively phrased, describing behaviors for the child to engage in rather than stop. Similarly, case conceptualization and progress note structures were revised to explicitly discuss child and family strengths. Feedback on these new processes was highly positive. Staff reported increased positivity and job satisfaction, and consumers reported that they appreciated being engaged in terms of their strengths, which contributed to increased engagement and attendance.
Family and Community Resilience
Recognizing that the social environment plays a central role in youth wellness (2,4), special attention was paid to family and community resilience. Specifically, teams focused on raising family and community awareness of resilience concepts and on identifying and promoting family strengths. All teams reported that they increased family and community resilience practices over the BSC duration, and 95% of participants reported that changes were sustained at the six-month follow-up. [Figures in the online supplement present data on these outcomes.] One team successfully addressed this area by introducing peer-led resilience education in family support groups. Peer support is an increasingly utilized practice in mental health services, with research indicating increased empowerment, social support, and hope as common outcomes, Therefore, peer-led education was hypothesized to be an excellent conduit for family resilience education (13). The team’s two consumer members spearheaded this practice improvement, because they were advantageously positioned at the interface of the provider organization and other family members. Specifically, they disseminated the Maryland resilience poster (3), presented resilience core concepts, and led strengths-spotting activities to help caregivers identify their own and their children’s strengths. Positive family feedback—both informal and through consumer satisfaction surveys—confirmed that peer-led education raised family awareness of resilience and strengths. By operating from a focus on strengths, caregivers increased family engagement in treatment, and caregivers reported a better relationship with their child. This focus on family strengths and engagement was further enhanced with programs that instituted, as a result of the BSC, collaborative documentation at the end of therapy sessions (14).
Discussion
The Maryland Resilience BSC generated several promising strategies for promoting resilience in the provision of mental health services. Several practices are recommended: use resilience-based assessments to drive treatment planning; engage youths and families around their strengths by discussing assets identified at intake; help youths and families reframe treatment goals to positively describe ways to use current strengths and develop new ones; and use peer support groups to disseminate resilience information to consumer family members. Peer groups highlight consumer leadership and can support family members in identifying their strengths.
Although this project represents significant progress in operationalizing resilience concepts, additional work on several fronts is needed. BSC themes for practice improvements included systemic change and community resilience; however, these areas proved overwhelmingly large in scope and were thus inadequately addressed during the project. Future efforts and research should emphasize these larger contextual factors, some of which continue to be developed through the ongoing statewide Resilience Committee at the Behavioral Health Administration. It is important to note that this initiative was a quality improvement project rather than a research study; as such, data collection was geared to provide rapid, context-specific feedback in support of the iterative improvement process. Although an effective means to support implementation and adaptation (6–8), this method of data collection involves several limitations. Reliance on organizational self-reports may have biased outcomes, although participation of all team members (including consumers) in the self-assessment process was designed to mitigate this risk. In addition, the lack of systematic, standardized evaluation of treatment outcomes (that is, attendance and adherence) or perceptions of youths and family members warrants caution in interpreting results. Future research with a rigorous evaluation program is therefore requisite to clarify whether resilience-based practices have a direct impact on consumer engagement and mental health outcomes. However, notwithstanding these limitations, the Maryland Resilience BSC represents an important first step in operationalizing resilience concepts in mental health settings, and it produced important findings applicable to both providers and consumers.
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Information & Authors
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Cover: The Violoncellist, by Lilla Cabot Perry, 1906. Private collection.
History
Published online: 1 May 2015
Published in print: August 01, 2015
Authors
Funding Information
This project was funded by the Behavioral Health Administration at the Maryland Department of Health and Mental Hygiene. The authors are grateful for the assistance of the late Jan M. Markiewicz, M.Ed., whose leadership, vision, and expertise contributed greatly to the success of this project.The authors report no financial relationships with commercial interests.
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