Outcomes and incomes: Implementing a mental health recovery measure in a medical model world

Because social work practice and policy changes are often not easily implemented under everyday conditions, increasing attention is being focused on implementation (NIMH, 2002, 2005). The aims of this qualitative case study are twofold: (1) to describe how frontline clinicians and clients implement a state-mandated mental health policy; and, (2) to articulate the system processes connected to and embedded in frontline implementation experiences.;Ethnographic methodology was employed to explicate the processes through which frontline clinicians implemented a state mental health policy mandating completion and clinical utilization of a 67-question outcomes survey with adults living with severe mental illness (mental health consumers). Data was collected through participant-observation of 17 consumer-clinician dyads (n= 17 consumers and 9 clinicians recruited from 4 mental health centers) completing and/or discussing the survey. To trace processes embedded in clinical experiences, a bottom-up, snowball sampling interview strategy was used to collect data from other stakeholders (n =22). Atlas.ti was used to manage and analyze data. Thematic analysis provided descriptive information about the processes through which unplanned confluences of systemlevel/institutionalized processes manifested in frontline experiences and served to hinder implementation efforts. Consumers and clinicians identified several overlapping work processes related to what both groups of participants referred to as "doing the outcomes". Embedded within and across these processes were two overarching, institutionalized processes: a paradigm conflict between the medical model and mental health recovery (manifesting at the frontlines as difficulty in integrating a symptom-focused treatment plan with an outcomes measure of broader mental health recovery constructs such as empowerment); and compliance-driven organization of time with regards to clinical documentation. These institutionalized processes served to undermine consumer and clinician attempts to meaningfully use the outcomes measure.;Grounded in frontline experiences, this study offers a detailed description of an implementation in which interrelated system processes converge, manifest and are negotiated at the frontlines. Through taking up perspectives of frontline workers in naturalistic settings, problematic confluences of system processes where the =rubber meets the road' can be explicated and intervened upon, rather than remaining unarticulated barriers to implementation.