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Relationship-Based Care

Relationship-Based Care (RBC) is a mental health treatment model for individuals who have pronounced difficulty with engagement and sustained interpersonal contact. RBC was specifically developed for use with homeless adults who have been arrested and diverted from jail because of severe mental illness. This population may face particular challenges to forming positive relationships in which they feel respect, connectedness, and empathy. Difficulty with engagement can, in turn, affect individuals' ability to establish a support network, obtain stable housing, and avoid reinvolvement with the criminal justice system. RBC aims to help individuals develop the healthy relationship qualities necessary to engage in the therapeutic, educational, and rehabilitation opportunities that are available to them, thereby leading to increased psychosocial functioning and stability and reduced recidivism.

Program staff use motivational enhancement therapy techniques, including expressing empathy and indirectly confronting clients by helping them see the discrepancy between their aspirations and current situation. Case management, health education groups, and other supportive services are also provided to encourage clients' active interest and involvement in managing their psychiatric and medical problems. RBC conceptualizes four stages through which clients progress:

1. Engagement. Motivational interviewing techniques are used to engage the client to establish a foundation for treatment.

2. Stability and Commitment. Clients begin to feel secure and safe, leading to greater stability and commitment and stronger relationships with staff. It is not uncommon for individuals to remain in this stage; however, those who progress beyond it may be more likely to experience long-term positive outcomes.

3. Awakening. Clients have an "awakening" and begin to experience a desire for more than just meeting their basic needs.

4. Growth and Differentiation. Clients maintain stability, show signs of psychological flourishing, practice new adaptive behaviors, and are ready to transition to independent living.

The treatment team includes a senior community health practitioner (SCHP) charged with providing clinical supervision; medical staff, typically a nurse and a psychiatrist; and a case manager. Initial, face-to-face contact with the client is handled by a community health practitioner (CHP), who presents the court-provided referral and supporting documentation to the treatment team. The SCHP is a master's-level, licensed practitioner with a degree in social work or psychology. The case manager and CHP are bachelor's-level professionals with a degree in social work or psychology. The case manager should additionally have 3 years of field experience and be certified by Medicaid to provide targeted case management. All staff involved in providing RBC receive training on motivational techniques and other aspects of the program through a combination of online and classroom-based coursework, modeling or role-play sessions, and in-person supervision. The goal of training is to learn how to effectively engage persons who are reluctant to receive services.

This model is best suited for agencies that provide integrated care, combining primary care, mental health care, and housing services. Integrated services allow for easier care coordination and effective clinical staffing sessions. Access to primary and mental health care must be a priority.

Descriptive Information

Areas of Interest Mental health treatment
Outcomes Review Date: April 2012
1: Arrest rates
Outcome Categories No outcome categories are applicable.
Ages 18-25 (Young adult)
26-55 (Adult)
55+ (Older adult)
Genders Male
Female
Races/Ethnicities Black or African American
Hispanic or Latino
White
Race/ethnicity unspecified
Settings Residential
Geographic Locations Urban
Implementation History Citrus Health Network, Inc., a federally qualified health center in Miami-Dade County, Florida, has been using Relationship-Based Care as part of its jail diversion program since 2000. About 430 clients have participated in RBC as of 2012.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: No
Evaluated in comparative effectiveness research studies: Yes
Adaptations No population- or culture-specific adaptations of the intervention were identified by the developer.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: April 2012

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Rivas-Vazquez, R. A., Sarria, M., Rey, G., Rivas-Vázquez, A., & Jardon, M. E. (2009). A relationship-based care model for jail diversion. Psychiatric Services, 60, 766-771.  Pub Med icon

Supplementary Materials

Adult Case Management Recovery Service Plan

Client Satisfaction Survey

Information on Intervention Fidelity and Quality Assurance

Outcome/Performance Monthly Report

Staff Meeting

Supervisor Checklist

Outcomes

Outcome 1: Arrest rates
Description of Measures Arrest rates were obtained using data from the Miami-Dade County criminal justice information system. The number of arrests for each participant was determined for the 1-year period before the date of diversion and the 1-year period after diversion.
Key Findings Study participants were adults who had been arrested and were found to be appropriate for jail diversion. Data for individuals who were diverted to Relationship-Based Care were compared with data for a control group of individuals who had been diverted to other programs providing supportive housing in assisted living facilities and psychiatric treatment as usual in community mental health centers. All individuals were deemed indigent and homeless.

The treatment group had a significant reduction in arrest rates from 1 year prior to the intervention to 1 year after intervention (p < .001), whereas arrest rates for the control group remained unchanged over the same period.
Studies Measuring Outcome Study 1
Study Designs Quasi-experimental
Quality of Research Rating 2.2 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 18-25 (Young adult)
26-55 (Adult)
55+ (Older adult) 		87% Male
13% Female 		50% Hispanic or Latino
24% Black or African American
17% White
9% Race/ethnicity unspecified

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures 		Validity
of Measures 		Fidelity Missing
Data/Attrition 		Confounding
Variables 		Data
Analysis 		Overall
Rating
1: Arrest rates 2.5 3.0 1.5 1.8 2.0 2.3 2.2

Study Strengths

Arrest rates were measured using data obtained from the county criminal justice information system, which are likely to have acceptable reliability and validity. Comparing a full year of arrest data before and after program participation provides a strong outcome measure, and matching subsamples based on pretreatment arrest rates was a good way to provide evidence for treatment effectiveness. An intent-to-treat analysis strategy was used. Sample size was adequate.

Study Weaknesses

The information provided on intervention fidelity does not demonstrate that the fidelity measures are established instruments with documented reliability and validity. Although there is documentation that staff received training and forms were used to record services, no discussion or results were presented to show how these steps contributed to intervention fidelity. Missing data were taken into account by simply comparing participants who left and those who remained. A large number dropped out of the treatment group, and data were insufficient to determine if the groups were equivalent after dropout. Because the study was retrospective with a nonrandomized comparison group, one or more variables could have contributed to differences in outcomes between the study groups. Analyses did not control for differences between the study groups in pretreatment arrest rates, age, or ethnicity.
Readiness for Dissemination
Review Date: April 2012

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Citrus Health Network, Inc. (2001). Outcome/performance measurements monthly report. Transitional housing: Mental health/dual-diagnosis.

Forms:
  • Admission Checklist
  • Adult Case Management Assessment
  • Case Management Recovery Plan & Review
  • Client Satisfaction Survey
  • Recovery Plans L1-L4
  • Relationship Based Care Health Education
  • Supervision Checklists:
    • Stage 1: Engagement
    • Stage 2: Stability and Commitment
    • Stage 3: Awakening
    • Stage 4: Growth and Differentiation
  • Transitional Housing Program Case Staffing Meeting

Netsmart University online training courses, https://www.netsmartuniversity.com/

Sarria, M., Rivas-Vasquez, R., Jardon, M., & Rivas-Vasquez, A. (n.d.). Relationship Based Care training manual. Hialeah, FL: Citrus Health Network.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials 		Training and Support
Resources 		Quality Assurance
Procedures 		Overall
Rating
2.5 2.5 2.5 2.5

Dissemination Strengths

The manual clearly outlines the essential elements required to implement the intervention. Various forms to use with clients, such as treatment plans and supervision checklists, are easy to understand and easily replicable. The online training covers a variety of relevant content areas, is clearly written, and is accompanied by downloadable documents for clients. Training is competency based, and supervisors are notified when trainees are unable to pass the training quizzes. Supervision checklists for staff and graduation requirements for clients contribute to fidelity. The program's model for monitoring fidelity features the use of a performance council and performance improvement program.

Dissemination Weaknesses

Implementation of the intervention requires collaboration with existing community programs that provide multiple levels of care, but no guidance is provided for adapting to variation in the scope and quality of these community programs. Limited guidance is provided on how to implement the health educational groups required by the intervention. Some materials lack professional quality. The training courses offered online do not include sufficient guidance for implementation, and there is no training specifically for supervisors or other collaborators. Little information is provided on how to create a performance council and performance improvement program. It is unclear how new implementers monitor outcome data and fidelity.
Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Implementation manual $30 each Yes
Master set of handouts on CD-ROM Free Yes
2-day, on-site training $500 per person for up to 25 participants, plus travel expenses No
2-day, on-site consultation $1,500 plus travel expenses No
Online training courses through Netsmart University Varies depending on course and/or number of users No
Phone and email support Free No
Replications

No replications were identified by the developer.
Contact Information

To learn more about implementation, contact:
Manuel Sarria, LCSW
(305) 825-0300
mannys@citrushealth.com

To learn more about research, contact:
Rafael A. Rivas-Vasquez, Psy.D.
(305) 825-0300
rrv@citrushealth.com

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.