Fairweather Lodge Fidelity Standards

Principles, Practices, Outcomes and Satisfaction

Fidelity to the principles and practices of the Fairweather Lodge is important for a number of reasons. But participant outcomes and participant satisfaction are a test of fidelity at least as important to the spirit of the Fairweather Model as any checklist of programmatic elements. A comprehensive assessment of Lodge success, therefore, involves: 1) Adherence to the Lodge Principles; 2) Implementation of Lodge Practices; 3) Demonstrated Outcomes; and 4) Participant Satisfaction (see page 6).

Principles

In his ground-breaking 1963 book, Community Life for the Mentally Ill, Dr. Fairweather established thirteen principles for successfully integrating people with mental illness into the community. Although all thirteen were valid at the time, the eight principles updated for this assessment tool are those which remain relevant to distinguishing the unique values of a Fairweather Lodge. A program which is at odds with these principles might be a wonderful program, but it is not a Fairweather Lodge.

Practices

Over the last forty years, as practitioners have experimented with the Lodge Model, a wide variety of practices have been implemented with various degrees of success. The sixteen practices selected for this assessment are those which have enjoyed the greatest success. We recognize that conditions vary from one setting to the next, and that the most successful practitioners are those who can adapt to local conditions, but these sixteen practices are highly recommended, especially for new programs.

Outcomes

We presume that anyone associated with a Fairweather Lodge will have a philosophical affinity for the values defined by the eight Principles and sixteen Practices. And it is easy to get engrossed in implementing the principles and practices while at the same time struggling to obtain/maintain funding, hire/supervise staff, recruit/ screen participants. But hopefully, the reason practitioners choose the Lodge Model in the first place is because of the potential outcomes, and any assessment of Lodge success needs to examine the outcomes produced.

Housing, Employment, Social and Autonomy

Although a Fairweather Lodge is understood to be a package of highly-integrated services, we have broken the assessment into four domains for the purpose of evaluation. Surveys of the needs/wants/desires of people with serious mental illness provide three obvious domains -- housing, employment, and a social life. To this we add the uniquely Fairweather perspective of group autonomy. A successful Fairweather Lodge should score well across all four domains.

Housing

Principle I. The lodge must provide a safe, healthy and caring environment, which reinforces the recovery process.

Practice A. Lodges should be located in a safe and accepting neighborhood.

Practice B. Lodges should be attentive to exercise and nutrition.

Practice C. Lodges should control the use of alcohol and street drugs

Proposed Outcome Measures:

Number of undesirable interactions (e.g., getting mugged, name-calling) in the neighborhood per participant-year, (or versus desirable interactions.)

Percentage of participants eating healthy.

Percentage of participants exercising regularly.

Percentage of participants using drugs or alcohol.

OR

4.a Undesirable incidents related to drugs or alcohol.

Principle II. The Lodge must be part of the plan for managing symptoms and promoting good mental health.

Practice D. Good quality psychiatric care (implying a doctor-patient partnership) should be available.

Proposed Outcome Measure #5:

Average length of wait for non-routine psych visit.

Practice E. Lodges should have a standard mechanism for ensuring medication compliance (This mechanism should be adjustable in response to variance in earned autonomy.)

Proposed Outcome Measure #6:

Percentage of medications taken as prescribed.

Principle III. Services must be available as long as the participant wants and needs them.

Practice F. (Except as established by the Lodge) There should not be any minimum or maximum time limits on participation.

Principle IV. People with psychiatric disabilities increase their community success and raise their social status through employment, through accumulating wealth, and through direct (not third-party) consumerism.

Practice G. Everyone of working age should be employed (except in the event of temporary incapacity) and employment should begin immediately upon entry into the lodge.

Proposed Outcome Measure #7:

Average weekly wages per participant.

Practice H. Employment (and costs related to participation in the Lodge) should be structured so as to ensure financial reward for increasing participation in employment.

Proposed Outcome Measure #8:

Percentage of participants earning more than the cost of their room and board.

Practice I. Employment may be offered in the form of a (affirmative) business operated by the lodge. If employment through an affirmative business is provided:

  1. Work opportunities should include a range of tasks from simple to complex, with appropriate accommodations for the illness;
  2. Participants should be paid commensurate with their contribution to the business;
  3. There should be frequent and realistic evaluation of performance and an opportunity to advance; and
  4. Participants should have a choice between working in the affirmative business and outside employment, especially if the affirmative business does not provide opportunities commensurate with the participant’s skills and experience (but not working should not an option, and neither should prolonged job-search).

Social

Principle V. Above and beyond economic roles, participants need to perceive (and to have) meaningful social roles in both the Lodge and the larger community.

Practice J: Every participant should contribute to the collective good to the limit of his/her ability. (Equity of contribution and autonomy from one participant to the next is of secondary importance).

Proposed Outcome Measure #9:

Social adjustment/level of functioning.

Principle VI. Successful Lodges resemble a healthy family.

Practice K. Participants should share at least one meal a day.

Practice L. Participants should share at least one social/recreational event a week.

Proposed Outcome Measures 10 & 11:

Number of meals per week shared by at least 75% of members.

Number of social/recreational event per month shared by at least 75% of members

Autonomy

Principle VII. In order to progress, people with psychiatric disabilities need autonomy commensurate with their behavioral performance, with the ultimate goal of full autonomy. Similarly, the Lodge needs autonomy commensurate with its behavioral performance, with total autonomy being the ultimate goal. (Peer support is ultimately more powerful than assistance from paid service providers.)

Practice M. The lodge participants, through some form of collective decision-making, should be responsible (to the extent that the skills are present) for all aspects of Lodge management including but not limited to finance, maintenance, meal planning and preparation, social life, transportation, rules related to interaction between members and symptom management including the taking of medications. Professionals serve as advisors to the Lodge, never managers.

Proposed Outcome Measure #12:

Average # of hours/week paid service providers are present in the Lodge.

Practice N. If the skills required for certain tasks are not available within the membership, the advisors should provide these skills temporarily. Training should be provided so as to help one or more participants to acquire these skills and advance individual and group autonomy.

Practice O. Lodges typically need assistance and feedback on how they are doing; this need should decrease over time, but may never disappear. It is advisable, especially during the training phase, to have a special communication system which facilitates this assistance and feedback while simultaneously promoting autonomous group decision-making.

Principle VIII. Lodges must not be dependent on resources from any single entity.

Practice P: Lodges and Lodge Programs require strong leadership, committed to all 8 principles and focused on long-term success.

Proposed Outcome Measures 13 & 14:

Number of “engaged” community partners providing on-going resources.

Largest single source of revenue as a percentage of total revenue.

Implementation of Lodge Practices
Housing: Yes No
The Lodge has a plan for controlling the use of alcohol and street drugs.
Participation in the Lodge guarantees good quality psychiatric care, available in a timely manner.
The Lodge has a standard mechanism (adjustable in response to earned autonomy) for ensuring medication compliance.
There are minimum or maximum time limits on participation in the Lodge.
Employment: Yes No
All participants are employed at least 15 hours per week.
Employment begins immediately upon entry into the lodge.
The more participants work, the more disposable income they have.
If employment through an affirmative business is provided: X X
1. Work opportunities include a range of tasks from simple to complex, with appropriate accommodations for the illness.
2. Participants are be paid commensurate with their contribution to the business.
3. There are frequent and realistic evaluation of performance and an opportunity to advance.
4. Participants should have a choice between working in the affirmative business and outside employment.
Social: Yes No
Every participant contributes to the collective good of the lodge.
Equity of contribution from one participant to the next is of secondary importance.
The Lodge (or the members) contribute to society.
Autonomy: Yes No
Lodge participants, as a group, make decisions about: X X
Finances
Home maintenance
Meal planning and preparation
Social life
Transportation
Rules related to interaction between members
Symptom management, including the taking of medications
Training is available to develop individual and group skill related to: X X
Finances
Home maintenance
Meal planning and preparation
Social life
Transportation
Rules related to interaction between members
Symptom management, including the taking of medications
A special communication system is used during training.
This system provides feedback to individuals and group at least once per week.
This system promotes autonomous group decision-making.


Fidelity to Autonomy Principles Yes No
1. Both the Lodge and the Sponsoring Agency endorse full autonomy as the ultimate goal.
2. A system is in place which adjusts autonomy commensurate with Lodge performance.
3. The Lodge is dependent on resources from a single source.
 a. If yes, a plan exists to diversify.

Satisfaction

Although choices are often limited by an under-developed community mental health system, the Fairweather philosophy is based on the assumption that Lodge members participate voluntarily. One of the implications of voluntary participation is that adherence to the principles, implementation of the practices, and even the production of desirable outcomes, are meaningless unless the participants are satisfied that their basic needs are being met.

Most surveys of the needs/wants/desires of people with serious mental illness produce the same general results with respect to the BIG 3 (not always in the same order): a “nice place to live,” a “good job, ” and friends. It is a given that a Lodge provides housing, but is it a “nice place to live?” Does the employment provided meet the standard of a “good job?” Are the other participants really “friends?” And does allegiance to the autonomy principles and a low staffing ratio actually produce empowerment? The most direct way to answer these questions is to ask the participants.

However, one limitation of satisfaction surveys is that some people always express satisfaction, even while planning to leave the program, and others will complain bitterly for years but never contemplate leaving. (This phenomenon is not exclusive to mental illness.) It is important, therefore, to measure retention -- a less direct, but potentially more telling strategy for measuring satisfaction. So we add:

Proposed Outcome Measure #15:

The percentage of participants, at a given starting point, still participating at a certain benchmark.

Public Interest

The taxpaying public has a legitimate interest in the cost-effectiveness of any program supported with public funds. So even though it is an imperfect measure of Lodge success, and not necessarily tied to the Lodge mission, we add:

Proposed Outcome Measure #16:

Number of days of in-patient psych hospitalization as percentage of participant-days.

Lodge Member Satisfaction Survey
Housing Yes No
1. My lodge is in good repair.
2. I feel safe in my lodge.
3. I feel healthier than before I joined the Lodge.
4. The meds I take help me maintain my mental health.
5. The use of alcohol and /or street drugs is causing trouble in my lodge.
Employment Yes No
6. I like my job.
7. I have more spending money than before I came to the lodge.
8. I think more about work than about having mental illness.
Social Yes No
9. I enjoy group meals.
10. I enjoy group social/recreational events.
11. I have at least one good friend in the lodge.
Autonomy Yes No
12. I am increasingly responsible for my own future.
13. I have a voice in the decisions my lodge makes.
14. My lodge-mates and I are increasingly responsible for the future of our lodge.
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