Exploring How Service Setting Factors Influence ...

Journal of the Society for Social Work and Research Volume 3, Issue 1, 51-64

February 2012 ISSN 1948-822X DOI:10.5243/jsswr.2012.4

Exploring How Service Setting Factors Influence Practice of Critical Time Intervention Fang-pei Chen Columbia University

The characteristics of the setting in which services are delivered often influence the implementation and practice of evidence-based programs (EBPs). In order to accommodate complex cases in diverse settings, community-based EBPs tend not to have standardized practice instructions. However, variation in practice of EBPs may have significant implications for program fidelity and outcomes. This study identifies service-setting factors associated with variation in practice of Critical Time Intervention (CTI). CTI is an empirically supported community-based psychiatric rehabilitation program designed to reduce homelessness among people with mental illness. Interview data were obtained from 12 CTI practitioners: 3 practitioners using CTI in a clinical trial, and 9 practitioners using CTI in 4 community-based agencies. The data are analyzed using dimensional analysis to contrast the first-hand CTI practice experiences of these practitioners. The results show service structure (e.g., platform for relationship building, staff to manage housing applications, and organizational policy on substance abuse) and agency services (e.g., existing resources and modalities) greatly influence practitioners’ operationalization of shared CTI goals and fundamental practice strategies. Findings inform additional CTI fidelity elements and important assessment of service settings for CTI implementation. The study highlights the crucial role of practitioners in EBP implementation and the importance of seeking practitioners’ feedback on their experiences with EBPs for ultimately improving the implementation of EBPs. Keywords: Critical Time Intervention, evidence-based program, community service setting, implementation, adaptation Critical Time Intervention (CTI) is a communitybased psychiatric rehabilitation program designed to promote housing stability among people with mental illness following discharge or release from psychiatric hospitals, shelters, prisons, or similar institutions. Research has shown that CTI is effective in reducing recurrent homelessness (Herman et al., 2011; Kasprow & Rosenheck, 2007; Lennon, McAllister, Kuang, & Herman, 2005; Susser et al., 1997), is effective in decreasing negative psychiatric symptoms (Herman et al., 2000), and is a cost-effective approach (Jones et al., 2003). CTI is a highly regarded psychosocial intervention model and is not only listed in the National Registry of Evidence-Based Programs and Practices but is also being implemented by an increasing number of community agencies (Campbell et al., 2010). The increasing use of evidence-based programs (EBPs), such as CTI, has led to investigation of many issues related to the implementation of EBPs, including program adaptation. Examining issues related to program adaptation is critical because a program model as originally developed cannot usually be transferred to another setting without changes made for the new setting (Brekke, Ell, & Palinkas, 2007). Indeed, some scholars have argued that adaptation is the norm rather than the exception (von Hippel, 2005). Most

Journal of the Society for Social Work and Research

research on adaptation focuses on changes made to program theory or assumptions, structure, and program content or components (Blakely et al., 1987; Bowen et al., 2010; Castro, Barrera, & Martinez, 2004; Lee, Altschul, & Mowbray, 2008). However, variation in practice of an EBP in different settings, that is, practice variation, has not been fully explored. Perhaps in deference to practitioners’ need for flexibility when working with complex cases and in a variety of settings, most community-based EBPs, including CTI, do not include standardized practice instructions. However, such practice variation and the extent to which such variation is influenced by service settings merit investigation because practice variations may have significant implications on program fidelity and outcomes. A first step toward addressing these questions is to explore the first-hand practice experiences of practitioners using an EBP in their unique service settings. This study examined practitioners’ experiences with CTI practice with the aim of identifying factors in community service settings that influence client engagement and service delivery. The study was guided by two specific questions: Which service setting factors affect CTI practice? In what ways do these factors affect practitioners’ implementation of CTI? To answer these questions, I conducted a secondary

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SERVICE SETTING FACTORS INFLUENCE ON CTI PRACTICE

analysis of data obtained from a grounded theory project investigating first-hand experiences of practitioners implementing CTI in five settings (one clinical trial and four community-based agencies). The implementation of an EBP in a community-based setting relies on practitioners to actively make sense of the new program and seek ways to operate and integrate that program in the service setting (Lyon, Frazier, Mehta, Atkins, & Weisbach, 2011). Rather than a “top-down approach,” which applies existing theories of the implementation of innovations (Greenhalgh, Robert, MacFarlane, Bate, & Kyriakidou, 2004), the “bottom-up approach” which focuses on the practitioners’ in-vivo practice acknowledges the practitioner’s active role in defining and implementing CTI. In addition, this bottom-up approach may help to identify factors that have not been included in previous measures of program fidelity or implementation theories, but are important from the perspective of a practitioner. Moreover, this study contrasts CTI practice across different community-based agencies and compares community-based practice with CTI practice in a clinical trial research setting. This approach assumes that varied practice is not necessarily “flaws” in implementation but meaningful changes for a particular context. Study findings illuminate the influences of service settings on practice, from which suggestions are drawn to inform CTI fidelity measures and program implementation. CTI and the Grounded Theory Project As compared with counterparts with stable housing, homeless people suffer higher rates of health and mental health adversities (D’Amore, Hung, Chiang, & Goldfrank, 2001; Kim, Ford, Howard, & Bradford, 2010; Levitt, Culhane, DeGenova, O’Quinn, & Bainbridge, 2009). In addition, because many communities lack transitional services for those with mental illness who are released from institutions, this vulnerable population is more likely to experience recurrent, vicious cycles of institutionalization and homelessness (Irmiter, McCarthy, Barry, Soliman, & Blow, 2007; Lauber, Lay, & Rossler, 2006; Metraux, Byrne, & Culhane, 2010). CTI facilitates the critical transition from an institution to the community by providing emotional and practical support as well as developing a sustainable system of community support for clients (Herman, Conover, Felix, Nakagawa, & Mills, 2007). A CTI practitioner initiates contact and develops a working relationship with the client while the client is in an institution, such as a psychiatric hospital or shelter. CTI formally starts on the day the client moves into a community residence. The practitioner then assists the client through a sequenced intervention delivered in three phases over a 9-month period.


In the first phase, transition to the community, the practitioner provides intensive instrumental and emotional support to a client and helps the client connect with community resources. In the second phase, try out, the intensity of direct services is reduced while the practitioner directs greater focus toward enhancing the client’s problem-solving skills and transferring care responsibilities to community supports. In the final phase, transfer of care, the practitioner reaffirms the supporting roles of community resources and concludes the intervention with a support network safely in place. Although CTI developers have identified core elements of program fidelity measures, including service components (e.g., outreach, early engagement), structure (e.g., caseload, team meetings), and quality control (e.g., intake assessment, phase planning; Conover et al., 2007), the “black box” of CTI service delivery and its essential practice mechanisms need further research. Therefore, I led a research team and launched a grounded theory project to establish practice models in CTI service delivery. This project involved all four community agencies in New York City that were providing CTI services for homeless people with severe mental illness at the time of study. In addition, the study included the clinical team of a National Institute of Mental Health (NIMH) funded clinical trial in the same city, which was also using CTI with homeless persons with severe mental illness. The research team was independent of CTI developers and the clinical trial. The result was a CTI practitioner-client relationship model. Details of this model have been reported elsewhere (Chen & Ogden, 2012). Briefly, CTI practitioners aimed to help clients develop independence and maintain community residency with adequate support. Practitioners focused on helping clients adjust to urban community living, removing barriers to housing stability (e.g., improving client’s money management skills; addressing issues related to unemployment, substance abuse; and helping with contentious family interactions), and developing community supports. All practitioners closely followed the threephased CTI progression; however, the length of each phase was determined by individual clients. Because the practitioners’ work with clients relied on a humanistic, nonauthoritative working relationship, the time needed to develop such relationships varied greatly. In most cases, CTI practitioners began building a relationship with a client before the CTI services started and continued relationship building throughout the three CTI phases. To develop this relationship, practitioners respected client autonomy and maintained flexibility around the format of client contact and service activities. Practice strategies used to facil-

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itate client trust toward the practitioner included following client leads and using informal approaches to relate with clients such as light conversation over coffee, and home visits during evening hours. However, each practitioner operationalized the shared goals and implemented these practice strategies differently in his or her respective service setting. The different service settings also presented varying degrees of service integration. Therefore, the current study explored these variations and the factors associated with the service setting that influence practice in CTI. Method The current study was a secondary analysis of the data obtained as part of the aforementioned grounded theory project. The grounded theory project was conducted from June to November 2008, and received approval from the Columbia University Institutional Review Board. Service Settings and Participants The NIMH-funded clinical trial took place in collaboration with two New York State psychiatric hospitals located in New York City. Psychiatric patients discharged from inpatient care to temporary, transitional residences associated with the hospitals generally represented two subgroups: (a) those deemed unready for the community placement, or (b) those deemed ready for community placement but for whom housing options were unavailable at the time of their discharge. While residing in the transitional residences, clients were provided access to psychiatric treatment and housing placement in the city housing systems. The CTI practitioners involved in the clinical trial initiated client contact while the clients were residing in the transitional residential programs, and continued to work with these clients throughout their transition to community living. The clinical trial outcomes supported the effectiveness of CTI in reducing homelessness (Herman et al., 2011). All four community-based agencies examined in the current study were providing services to people with mental illness. The agencies’ application of CTI was focused on reducing recurrent homelessness


among those with mental illness. According to descriptions of CTI practitioners, the community Agency A collaborated with a shelter located in the same office building. The staff at the shelter was responsible for housing placement. Similar to the clinical CTI team, CTI practitioners at Agency A initiated client contact while clients were in shelter and waiting for housing. Agency A practitioners also worked with clients throughout the transition to the community. The second agency, Agency B, used a “street to home” approach. Agency B had an outreach staff that engaged homeless clients who were living on the streets and helped these clients apply for housing placements. A separate staff of CTI practitioners from Agency B first met with their clients at the time when the client signed a lease for a community residence; however, in some cases, the CTI practitioners made first contact with clients living on the streets while the housing application was in process. The third agency, Agency C, had comprehensive residential programs providing various levels of intensity of housing support. CTI services were provided to clients in Agency C’s transitional housing program. These clients were referred to the agency by the city’s single point access system. CTI practitioners started working with clients upon their arrival at the agency. The responsibilities of CTI practitioners with Agency C included assisting clients with applications for permanent housing placements and helping clients make the transition to community life. The fourth agency, Agency D, provided blended case management for people with severe mental illness. Blended case management uses a teamwork approach to combine intensive case management and supportive case management services. Agency D applied CTI to serve homeless people with severe mental illness referred to the agency by the city’s single point of access system. At the time of referral, the clients might be living in the streets, a hospital, or a shelter. CTI practitioners first met with their clients at the place where the client was living and started filing housing applications to the city’s housing system. Practitioners continued to work with their clients throughout the transition to permanent housing.

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Table 1 Participant Profile (N = 12) Characteristics

Freq. (%)

Age (years)

Mean (SD)

Range

37.5 (8.5)

26 - 55

Gender Female

8 (66.7)

Male

4 (33.3)

Race Asian

1 (8.3)

Black

5 (41.7)

Hispanic

5 (41.7)

White

1 (8.3)

Highest Education 12th grade

1 (8.3)

2-year college

1 (8.3)

Bachelor’s degree

4 (33.3)

Master’s degree

4 (33.3)

Doctoral degree

2 (16.7) 10.4 (6.2)

1.1 - 22.3

Experience with the current agency (years)

4.2 (4.1)

1.1 - 16.0

Experience in the current position (years)

2.3 (2.7)

0.8 - 10.0

Experience in mental health (years)

I contacted the principal investigator of the clinical trial and the administrators of the four community agencies and explained the purpose of my research was to understand the first-hand experience of CTI practitioners. The principal investigator and administrators granted their permission for me to access their CTI staff without their further involvement in study recruitment. I approached all of the 13 CTI practitioners and asked for their voluntary study participation. Of these potential participants, one practitioner did not respond to multiple invitations to participate, but the other 12 CTI practitioners agreed to participate in this study (see Table 1). Among the study participants, three practitioners were involved with the clinical trial and nine participants were from the four community agencies. All study participants had received CTI training through a workshop that included presentations and discussions on the design and research on CTI, program structure, intervention components, service processes, principles of practice, and case examples. In addition, all study participants received ongoing consultation on CTI practices from the workshop trainers.


Research Design The research applied the constructivist approach to the grounded theory methodology (Charmaz, 2000, 2006) to establish practice models in CTI. The grounded theory approach holds that, rather than being an independent social reality, human perspectives and actions are fundamentally influenced by contexts and social interactions. The use of this methodology helped to capture the processes through which settings were integrated into practitioners’ conceptualizations of CTI and their interpretations of practices in various situations. Data Collection and Theoretical Sampling I conducted one individual interview with each of the participants. Before each interview, I explained the procedures and obtained written informed consent from each participant. The interviews lasted an average of 60 minutes (range 40 to 90 minutes) and each interview was audiotape recorded and then transcribed verbatim. In a grounded theory study, the questions used in the interview process evolve as the study progresses.

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Initial questions were generic and open-ended, such as “Please tell me about your work.” The nonspecific questions allowed participants to speak about significant experiences from their own perspectives. Followup probes asked for examples, details, and clarifications. Analysis was conducted immediately after each interview. The result of the analysis informed the generation of questions for subsequent interviews. The evolving process of question generation on the basis of ongoing analysis was to facilitate theoretical sampling of practice scenarios. Sampling targets in this project were practice scenarios. Practice scenarios were purposively sampled according to key concepts identified through analysis to seek the most relevant examples for comparison to develop the practice model. For instance, the concept of the client’s initial motivation for stable housing was recognized as having an influence on how a practitioner engaged a client. Theoretical sampling then was conducted in the following interviews by purposively asking participants to describe practice scenarios involving different types of initial motivation for housing, such as clients who aimed for stable housing and those who had no interest in housing. The various examples were then compared to identify how practitioners developed a working relationship with a client and to establish the conceptual relationships between client motivation and the working relationship. Likewise, theoretical sampling was conducted on key concepts such as housing types and barriers to stable housing, which were then compiled as a collection of practice scenarios. These scenarios are the basis for the secondary analysis. As the interview-analysis process evolved, the practice model essentially focused on the practitionerclient relationship and its influences on client motivation for housing. Service settings were not the focus of question generation. Thus, rather than responding to specific questions, participants were free to identify relevant service-setting factors from their practice experiences. Analysis Dimensional analysis (Bowers & Schatzman, 2008; Kools, McCarthy, Durham, & Robrecht, 1996; Schatzman, 1991) was used to analyze verbatim transcripts. Dimensional analysis is an analytical model that is “generally informed by the core ideas and practices of grounded theory” (Schatzman, 1991, p. 303). This analytical model assumes that a concept is defined within a perspective, and explicates the thinking process and "the multiple ways in which the concept is constructed and used (i.e., the multiple meanings of the concept)" (Caron & Bowers, 2000, p. 296). For example, the concept of barriers to housing


can be described as having two dimensions: (a) the severity of the barrier and (b) the urgency to remove the barrier. A practitioner holding the perspective of harm reduction might recognize a client’s substance use as a severe problem but consider removing the substance use problem low urgency as compared with a higher urgency need for housing. Therefore, the practitioner prioritizes seeking housing opportunities over finding substance abuse treatment. Dimensional analysis involves two distinct analytic processes (Caron & Bowers, 2000; Schatzman, 1991). The first phase is identification of dimensions. Through line-by-line coding of the interview transcripts, researchers identify as many potential dimensions as possible that are important and meaningful about a concept. For example, a practitioner described her observation of a client’s motivation for housing: You [the practitioner] could find me [the client] a place yourself….It doesn’t mean I’m going to move when I’m comfortable where I am. Until . . . I’m no longer comfortable, I’m not going to make any changes. From this excerpt, identified dimensions of the concept client motivation for housing included the initial motivation for housing, the comfort level with the living space, the extent of client-practitioner agreement regarding seeking housing, priority of client decision making, variability of motivation over time, and actions of change. Similarly, the identified dimension of the concept working relationship included practice strategies (formal and informal relating approaches). The second phase of dimensional analysis is logistics. In this phase, researchers describe conceptual relationships among dimensions and integrate those relationships into a model. For example, the less initial motivation a client had for stable housing, the more likely it was that the practitioner used informality or casual approaches as a practice strategy to engage the client at the outset of the relationshipbuilding process. Moreover, in the logistics phase, researchers focus on differentiating context, processes, consequences, and conditions among identified dimensions (Kools et al., 1996; Schatzman, 1991). Context is the situation in which the dimensions are embedded. Processes are sets of actions or interactions, and consequences are the outcomes of a given process. Conditions are dimensions representing factors that may alter a course of action or interaction. That is, dimensional analysis allows analyzing practice variations in relation to conditional factors. In the case of CTI, examples of a condition included the client’s initial motivation for housing, structured phases of

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service provision, the organizational structure of service settings, and the availability of needed resources. Although the main finding of the grounded theory project (i.e., the parent project) was a practitioner-client relationship model to promote client motivation toward finding and retaining stable housing, the conditions identified through practice scenarios permitted exploration of the influences of service setting factors on variation in the operationalization of that practice model.

Study Rigor The parent grounded theory project adopted multiple approaches to enhance rigor (Lincoln & Guba, 1985; Padgett, 2008). The research team checked the transcripts against interview recordings to enhance accuracy. Two research team members coded the data and each kept separate coding and analytical memos as audit trails. These team members met on a regular basis to compare the analysis and discuss question generation. In discussion, these researchers applied reflexivity and challenged each other to elaborate on the codes and identified conceptual relationships to detect assumptions and biases that each might have brought to the analysis.

Secondary Analysis I conducted a secondary analysis, which focused on a comparison of practice scenarios across the community agencies as well as a comparison of the community settings with the research setting. I reviewed the practice scenarios that had been analyzed and coded with a focus on conditions related to service settings. For example, to develop a working relationship CTI practitioners used various approaches to engage their clients, the choice of which depended, in part, on whether the practitioner had responsibility for managing the clients’ housing applications. As part of this review, case examples where CTI practitioners were responsible for housing applications were compared with cases from agencies where separate staff managed housing applications. The aim of the comparison was to examine how a practitioner’s responsibility for managing housing applications might affect the process of client engagement and the development of a working relationship. I classified the conditions being compared into two categories—service structure and agency services—and analyzed their respective influences on CTI practice.

Results The factors classified as service structure that affected practice in CTI include the availability of a platform for relationship building prior to the client’s transition to a community residence, the availability of staff to manage client’s housing applications, and organizational approaches or policy regarding clients’ substance abuse issues. The factors classified as agency services that affected practice in CTI include an agency’s existing resources and modalities. Table 2 summarizes the distribution of service setting characteristics among the five settings. The impact of these service setting factors on practice might depend, in part, on the situation of individual clients. For example, whether a CTI practitioner could begin relationship building with a client before the client’s move to a new residence depended in part on (a) the client’s location while the housing application was in progress, and (b) the timing when the case was assigned to the CTI practitioner.

Table 2 Service Setting Factors Research

Agency A

Agency B

Agency C

Agency D





Service Structure Access to a relationship-building platform



a





a

Separate staff to manage housing applications







Use of harm reduction approach





a



Agency Services Existing resources Modalities similar to CTI a













Yes for most cases


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Service Structure Although the clinical team was freestanding, and the influences of the service structure were controlled or eliminated by the research design, the existing structure inevitably influenced practices in community applications. First, when the service structure allowed access to a platform through which the practitioner could establish contact with the client before the transition to a community residence, that structure enabled practitioners to have a head start or advantage in engaging clients. In turn, the advantage of early contact also enabled practitioners to begin addressing clients’ specific barriers to stable housing prior to the clients’ move to a community residence. Similar to the transitional residences associated with the psychiatric hospitals involved in the clinical trial, the platform in community agencies was exemplified by the access to the shelter that was operated by an agency in collaboration with Agency A, and the transitional housing program operated by Agency C, which provided temporary housing while clients waited for their community housing placements. The accessibility of the platform in regards to the frequency and duration of CTI practitioner-client contact prior to the transition influenced the development of the practitionerclient working relationship. The following comment by a CTI practitioner illustrates the effect of platform accessibility on client engagement strategies. During the time [while clients are in the shelter] …I’m saying hello to them. I’m engaging them. I’m trying to get to know them. … So, by the time I get to them [to start CTI services], we already kind of have a relationship… Sometimes it takes everyday [contact] just for a person to learn that maybe they can trust you, maybe learn that they can tell you some secrets, or tell you some things that maybe they think other people don’t know or shouldn’t know. So, we build this relationship; we talk. I escort her to appointments. Sometimes we’ll go out for coffee, things like that. In contrast, the development of a working relationship could be difficult if there was little or no contact before the client’s transition to a community residence. The following comment from a CTI practitioner reflects the impact of limited access to a relationship-building platform. In this case, the limited access to the platform increased the difficulty of the practitioner’s work toward reducing barriers to housing and developing the client’s support network. He was given to me like a week before he was moved….When they were moving, I wasn’t there. I was able to only visit [the client] the week after [he was] moved so that is


one of the problems that we’ve been having…I don’t really have that kind of relationship with him because every time I go he is not around. He would be going somewhere so I couldn’t see him….So, the problem is really knowing each other. Moreover, when a platform was available, practitioners tended to communicate more often with staff at the location where a client was residing. This type of practitioner–staff communication was sometimes carried out on a regular basis, and typically involved sharing knowledge, observations, and information about the client. Such exchanges tended to facilitate the transition, as shown below. You also have to ask [hospital staff] about them [clients], what’s going on with them on a day-to-day basis… In [hospital] what I do is I go there when they [staff] have a meeting in the morning so that I meet all the [staff]... I have the chance to learn more about the client and at the same time ask questions. Then [I] decide the best approach to help the client. However, it took a commitment from all parties to collaborate on the development of effective communication. Even in cases with an available platform, poor communication can hinder effective practices, as illustrated below. I asked the social worker what’s wrong with [the client]….The psychiatrist and social workers are not communicating, so the social worker doesn’t know what her [the client’s] diagnosis is. She’s [the client] just taking her medication from the psychiatrist… I ask the psychiatrist, [but] he doesn’t call me back. The second way in which existing structure influenced CTI practice in community applications involved whether staff other than CTI practitioners were available to manage clients’ housing applications. When separate staff at the service setting were given responsibility for coordinating housing applications, CTI practitioners were more likely to focus their efforts on engaging clients and developing the working relationships. Managing housing applications typically involves collecting a client’s personal history, medical history, and psychiatric information; arranging housing application interviews and preparing or coaching the client for those interviews, and following-up on the application throughout the (usual) extended waiting period for housing assignments. When the responsibility for managing the housing application process was part of the CTI practitioner’s duties, the client-practitioner interactions tended to revolve around “helping clients put up with the sys-

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tem,” rather than enhancing the client’s capacity to retain stable housing. The following comment from a CTI practitioner illustrates the impact of having to manage the housing application process while trying to build a relationship with the client. Ultimately, when the housing placement did not meet the client’s expectation, the practitioner described using a strategy of persuasion and encouragement to keep the client motivated for finding acceptable stable housing. We found an apartment....Everybody that comes to the building has to show IDs, and they will have a record when she [the client] is coming out or coming in. She was feeling uncomfortable but I tried to engage her, explain that’s the way it is…“You have to feel like somebody who lives in New York City, in a doorman apartment. The doormen know when you coming in, coming out. They are always going to say ‘Hi!’ to you.”…She understood that…. she can find a job, get healthy, and continue with her life. But right now, this is what she has and it’s better to live in the apartment than on the street. And she’s doing okay now. In contrast, in service settings as well as the clinical trial setting where CTI practitioners were not responsible for managing the client’s housing applications, the CTI practitioners were more likely to develop a working relationship by focusing on the client’s needs and wishes. The following comment was made by a CTI practitioner who worked with an agency that had an outreach team. The outreach team initiated contact with clients and began the housing application process, thus enabling the CTI practitioner to focus on helping the client make the transition to community housing. We have an outreach team…. My job is after the homeless people get housed, I’m their extra support, to make sure that they’re linking up with their other case managers and things like that…. Let them know we are still here even though they are housed. The third way in which existing structure influenced CTI practice in community applications involved organizational approaches to substance abuse issues. An essential practice approach in the CTI relationship model is to “follow the client’s lead”; however, to put this approach into practice requires demonstrating respect for clients’ wishes to manage their substance abuse issues, which is a common diagnosis among this population. Nevertheless, the extent to which respecting clients’ wishes regarding substance abuse issues could be realized, depended in part on organizational approaches or policy on substance


abuse. The priority that practitioners give to obtaining substance abuse treatment for clients was influenced by both the service settings (i.e., where clients are waiting for housing) and the client’s future community residence. In a setting that incorporated a harm reduction approach (i.e., substance abuse issues did not restrict access to services), practitioners tended to have more flexibility in following a client’s lead and pace in managing substance abuse issues without compromising the client’s opportunity for permanent housing, as described in the following practitioner comment: The way my organization is: you [a client] can be into drugs, and all kind of stuff like that – We still are gonna work with you. … We don’t tell them “no” because they’re on drugs and stuff. I feel everybody should have a home…. Sometimes the process is a little longer…that for us – it does not matter. You know, our main goal is for them [clients] to be housed. In sharp contrast, service settings with strict abstinence rules typically called for practitioners to prioritize substance abuse treatment for clients to prevent termination of the case or eviction of the client based on violation of the abstinence rules. A practitioner described this type of service setting: [If you, a client] uses drugs in the shelter, you can get kicked out, you can get transferred. And then of course you don’t get housed because you’re using drugs…I work with a young lady that was using drugs….So, the client comes to meet with me. We talk about it and then we allow the client to think of her own treatment. Agency Services CTI practitioners working in community agencies frequently reported taking advantage of their agency’s existing resources to facilitate their work with clients. A similar use of organizational resources did not occur in the research setting. These community-based practitioners were able to apply existing measurement tools to support their assessment of clients’ needs and evaluate client achievement. In addition, some agencies had ongoing support groups for clients with drugrelated issues, or offered additional services such as social skill trainings, vocational services, and day programs. Practitioners associated with these agencies were able to connect clients with these existing resources for engagement to help clients work on barriers to retaining stable housing. For example, a practitioner referred a client to a support group through which the client learned social skills. The client was then able to apply her newly acquired social skills to

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resolve issues she was experiencing with her coworkers.

well as “trading” arrangements for mutual benefits that are described below.

In addition, some agencies had existing client alumni groups. Although CTI practitioners might not provide direct services to the alumni, the availability of the group ensured continuous support to clients who had completed the CTI program and the group offered clients an opportunity to be around their peers and build a social network. One practitioner commented on the value of the alumni group for clients:

It’s easier to get them [clients] into our housing than other agencies’ housing because we know the client and we can vouch for the client….We know when our vacancies are coming up. And we can kind of make arrangements – I’ll take your person if you take my person…So it’s easier to do that within the agency. So the first person that we got… he’s doing really well….So that helps me with the way for future placements.

Even though I’m hands on and then I’m hands off [once clients complete the CTI program], I’m still there and that is what the alumni [group] is. It’s just that I’m still here and that there are more [people] like you [i.e., having shared the experience of being homeless]. And they really feel good about that and look forward to it every month. Moreover, when the agency had similar existing service modalities, CTI practitioners conceptually and practically integrated CTI into those modalities. This integration was particularly salient in two service settings. The first setting was Agency C, which had a comprehensive system of housing programs, including a 16-month transitional housing program. The practitioners considered that some of their responsibilities were the same for clients in CTI and clients in the transitional program, including conducting assessments, meeting clients’ basic living needs in the community (e.g., getting furniture, doing grocery shopping), and connecting clients with other community services. Further, practitioners considered the three phases of CTI to somewhat parallel clients’ systematic advancement through the agency’s residential programs toward independent living. However, practitioners recognized that CTI had a shorter, prescribed timeframe, explicated phases, and different paperwork than the transitional program. Given these differences, when selecting clients to participate in CTI, the agency selected clients who were more likely to secure stable housing within 9 months, and offered the 16-month transitional housing program to other clients who were likely to need a longer period of services before achieving independent living. Notably, when this agency first implement CTI, the practitioners found it difficult to “pull back” or reduce the intensity of direct services when the case progressed to the second phase of CTI, and attributed this difficulty to their having worked in the 16-month transitional housing program. Moreover, clients served by this agency were more likely to be placed in the agency’s housing programs because of the “insider” knowledge of vacancies, the trust and relationships among colleagues, as


These CTI practitioners considered such arrangements as beneficial to clients and helpful to practitioners because the arrangements simplified the work of developing community supports. After transitioning to community housing, clients were usually able to continue attending the same service programs offered by the agency that the client had attended initially. The collegial relationships among practitioners helped to enable efficient communications, assisted with coordination of service providers’ efforts, promoted sharing of in-depth knowledge of the clients, and increased providers’ abilities to handle problems timely and effectively. The second setting in which practitioners conceptually and practically integrated CTI into existing service modalities was the Agency D setting with blended case management for people with severe mental illness. The practitioners considered CTI and blended case management similar in preparing a client to be independent, linking the client with community resources, maintaining mutual communication with other community providers to ensure that the client had appropriate supports, transitioning care to community providers, and then graduating the client with a discharge plan that addressed potential risks to maintaining independent living. When practitioners described CTI practices, they did so in relation to their practices in the case management model. Practitioners used the same assessment tool for case management and CTI, and they related the intensity of services in the first phase of CTI to be at least equal to the level of services in intensive case management. However, practitioners recognized the difference between CTI and case management. Generally, practitioners regarded CTI as having a more structured timeframe than case management. Further, practitioners distinguished CTI from case management by describing CTI as intended to serve exclusively homeless clients for their needs for housing stability. In contrast, practitioner perceived that blended case management had a more flexible timeframe, and was intended to serve any individual with severe mental illness regardless of his or her housing status. The two approaches were

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also distinguished by that CTI practitioners worked alone, whereas case managers worked as part of threeperson teams that shared a caseload. However, the agency practitioners’ operationalization of CTI did not vary substantially from the operationalization of CTI by the clinical research team. Discussion The results of the study showed five service setting factors that influence CTI practice. These findings illuminate issues of practice adaptation in CTI implementation and inform key fidelity elements for consideration. It is evident in all settings that access to a relationship building platform before the inception of CTI is important so that CTI practitioners may start building a working relationship with a client. Research has established the importance of pre-CTI contact relative to clients’ positive housing outcomes (Herman et al., 2011). In addition, the pre-CTI phase has been explicated in the fidelity items (Conover et al., 2007). The current finding further suggests that the platform component should be included in the setting requirements for implementing CTI. Moreover, the findings show that to maximize the potential benefits of a relationship-building platform, training in how to use the platform to enhance communication and collaboration should be offered not only to CTI practitioners but also to other staff interacting with clients in the setting in which the platform is hosted. The comparison across settings shows having separate staff (i.e., staff other than CTI practitioners) to manage clients’ housing applications is beneficial to practitioners’ implementation of CTI practices. Research has suggested that juggling multiple service functions creates tension and role conflict for practitioners (Henwood, Stanhope, & Padgett, 2011). CTI practitioners who worked in settings with a separate housing staff were better able to focus their efforts on meeting clients’ needs and on developing clients’ capacity for stable housing. In contrast, practitioners who worked in settings without staff to manage housing applications (i.e., the CTI practitioner was responsible for managing the client’s housing application) also sought to meet clients’ needs and develop capacity for stable, independent living, but those efforts seemed to be easily compromised by the added responsibility related to housing applications. Although the way in which a setting with or without staff to manage housing applications affects clients’ housing outcomes merits further research, this finding points to the importance of considering service structure as an essential element in the organizational ecology for CTI delivery (Raghavan, Bright, & Shadoin, 2008).


Similarly, integrating a harm reduction approach manifests respect for clients’ self-determination, which is critical to CTI practices (Chen & Ogden, 2012). When applying CTI in settings without using a harm reduction approach, CTI practitioners were faced with the dilemma between respecting client autonomy and securing client access to services. Although a defining principle of the CTI model (New York Presbyterian Hospital and Columbia University, n.d.), harm reduction remains a controversial approach, and as such, harm reduction has not yet been widely adopted in the United States (Nodine, 2006). The impact of implementing CTI without integrating a harm reduction approach on housing outcomes is beyond the scope of this research. However, this finding highlights the importance of harm reduction in CTI practice, and therefore, a real challenge to broad CTI dissemination and implementation according to the principles of CTI. This finding may indicate a need for an overall examination of organizational approaches to substance abuse issues in the mental health and housing systems. Community applications of CTI illuminate two additional service setting factors that influence CTI practice. First, CTI practitioners in community service settings commonly incorporate existing services and programs in their attempts to engage clients and to enhance clients’ capacity to retain stable housing. Blakely and colleagues (1987) have suggested that local supplemental components to an empirically supported service program might enhance the effectiveness of the program. Their suggestion implies that incorporating existing resources in service settings according to clients’ needs and wishes may be beneficial. However, it is likely that further examination of such additions is necessary because these supplemental components might not coincide with the intended goal of the service program. For instance, CTI aims to transfer the support for clients from CTI practitioners to the community support network, and encourages agencies and practitioners to assume a complete “hands-off” approach once the client has completed CTI. However, an alumni group that is sanctioned and sponsored by the agency serves the opposite purpose; that is, an alumni group maintains the connections between clients, practitioners, and the agency. On the one hand, the addition of alumni groups to the CTI program could be considered a violation of the fundamental goal of CTI, and therefore, should be avoided. Further, this view regarding the alumni groups in relation to CTI also implies that to ensure program fidelity, the interaction of CTI with existing services or agency resources needs close examination. A thorough review of existing resources in the service setting as part of the implementation

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procedure would help align the goals of different resources or identify the complementary roles of various recourses. On the other hand, incorporating an alumni group into the CTI program addresses the common issue of isolation among people with severe mental illness living in system housing (Friedrich, Hollingsworth, Hradeck, Friedrich, & Culp, 1999; Siegel et al., 2006). For clients who were formerly homeless, the quality of the clients’ relationships with program staff might be significantly better than other sources of social connections (Carton, Young, & Kelly, 2010). In this sense, the alumni group may serve as community support and may be considered as a post-CTI service for enhancing the social connection of clients. This suggestion speaks to the value of gaining insights from practitioners’ experiences to examine program design and assumptions. Aiming to achieve client independence and program efficiency, CTI was designed as a structured, time-limited intervention. However, as implemented in community settings, CTI practitioners’ supplemental use of alumni groups may indicate an aspect of client need that was not met by the current program design. Although further research is needed to test whether continuing the connection after CTI is indeed beneficial to clients, discovering the alteration to the program opens an opportunity to review the match between client need and program design. Second, practitioners seemed to develop their understanding and practices of CTI in relation to existing modalities in the service setting, especially modalities with shared features. This finding not only confirms the argument that practitioners are indeed active agents of adaptation trying to make sense of and incorporate a new program into existing programs, but also reflects the importance of the context of the community setting that shapes and frames the new program (Bauman, Stein, & Ireys, 1991). Rather than an isolated act, implementation of an evidencebased program indeed involves a series of dynamic interactions of adaptation in community settings. Research has documented the importance of selecting community agencies according to the agency’s capacity to implement and carry out programs (Elliott & Mihalic, 2004; Racine, 2006; Wandersman et al., 2008). The finding on practitioners’ integrating CTI into existing modality further suggests that it is essential to conduct a detailed assessment of the service structure, existing resources, service policies and philosophies of community agencies, and the skills and knowledge of the staff. The assessment would assist with tailoring the implementation plan to the setting’s specific strengths and gaps, and designing staff train-


ings that would help integrate the new program with existing modalities. Such an assessment might also help to identify community agencies that are most likely to achieve the optimal potential of CTI. CTI, as a transitional service program, intends to facilitate continuity of care in a fragmented system. Using CTI in a setting with built-in structure for continuity of care, such as a system of comprehensive residential programs, raises questions of efficiency and necessity. It would perhaps be most beneficial for a community agency to include an EBP based on need instead of the notion of EBPs are “nice to have” (Racine, 2006). A thorough examination of the fit between CTI and the setting may help maximize the program’s benefits. Finally, the findings also have significant implications for implementation practice and research in general. The use of EBPs has greatly increased in the past decades. Social workers and other health and mental health practitioners play key roles in the implementation process of such programs (Brekke et al., 2007). The findings of the current study suggest that implementation of an EBP does not happen in a vacuum. Thus, as in social work practice, using the ecosystems perspective and recognizing “program in environment” in program assessment and implementation are essential. Further, the findings show the importance of practitioners’ capacity to critically analyze an EBP model, the service setting, and the required skills for service delivery, so that the EBP may demonstrate its maximum effectiveness while well integrated in the service setting. Findings also suggest the importance of studying implementation from the practitioners’ experiences, which will enrich the implementation research with practice-based points of view. Study Limitations and Future Research This study was limited to CTI practitioners’ perceptions of agency structure and services, which was not triangulated with other sources of information given the constraints of resources. Moreover, the nature of a secondary analysis limited further exploration of CTI practitioners’ perceptions of and elaborations on these setting factors and deliberations of their impact. Further, findings from this study may not be generalized to CTI applications on other types of transitions such as transition from inpatient care to outpatient care (Dixon et al., 2009) and populations such as community reentry from jail or prison (Draine & Herman, 2007) because these applications may vary greatly in their foci, processes, and the environment of practices. This research focused solely on CTI practitioners’ practice. Future research should verify the impact of

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the variation in practice due to service setting factors on clients’ housing outcomes in CTI. Moreover, as the implementation of a new evidence-based program may enact a process of service integration, future research needs to focus on mutual adaptation (Dearing, 2009; Seidman, 2003). That is, both how the intervention is customized to fit in the service setting and how the service setting may be modified to accommodate the intervention merit further exploration. Conclusions Practicing CTI is clearly a dynamic process that is influenced by characteristics of community service settings because variation in practice was observed across settings in this study. The result suggests both agency structural factors and agency services have important influences on CTI practice, including whether a platform exists for relationship building, whether staff is available to manage housing applications, whether an agency incorporates a harm reduction approach to substance abuse, and the extent to which the existing resources and modalities are incorporated into CTI practice. Although further research is needed to evaluate the effects of variation in CTI practice on clients’ housing outcomes and to conclude the legitimacy of varied practice of CTI, the findings from this study have significant implications regarding the additional CTI fidelity elements and important steps to take in the implementation process to incorporate the influences of service setting factors. In addition, this study underscores the importance of gaining insights into the first-hand experiences of CTI practitioners in community service settings. Feedback from CTI practitioners helps examine and improve the implementation process of CTI. Author Note Fang-pei Chen is an assistant professor in the Columbia University School of Social Work, 1255 Amsterdam Avenue, New York, NY 10027 . Correspondence regarding this article should be sent to Dr. Chen at [email protected] Acknowledgement This research was supported by the Columbia Center for Homelessness Prevention Studies (P30 MH071430). The author thanks Dr. Daniel Herman for his invaluable support for this research and the development of the manuscript, and Drs. Denise Burnette and Rogério Pinto for reviewing preliminary drafts of this paper. Earlier versions of the paper were presented at the Second Annual NIH Conference on the Science of


Dissemination and Implementation, Bethesda, MD, January 2009, and the 14th Annual Conference of the Society for Social Work and Research, San Francisco, California, January 2010.

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APA Citation for this article: Chen, F-P. (2012). Exploring how service setting factors influence practice of Critical Time Intervention. Journal the Society for Social Work and Research, 3, 51-64. doi:10.5243/jsswr.21012.4 Journal of the Society forofSocial Work and Research

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