SRF Webinar - What It Will Take to Make Coordinated Specialty Care Available to Anyone Experiencing Early Schizophrenia: Lisa Dixon

Presentation made March 22, 2017, during the live webinar hosted by Schizophrenia Research Forum (SRF). Event recording and additional slides at http://www.schizophreniaforum.org/forums/achieving-effective-treatment-early-psychosis-united-states

1. Lisa Dixon, MD, MPH
Professor of Psychiatry
Columbia University Medical Center
New York State Psychiatric Institute

2. NIMH RAISE Projects
•RAISE-ETP: Cluster Randomized Trial
comparing clients (N= 223) at 17 sites
randomized to Navigate vs at 17 sites
randomized to usual care (N=181) for two
years
•RAISE-IES: Connection Program delivered
in two sites (Baltimore and NYC)(N=65).
Assess outcomes, engagement, develop
materials to scale up

3. Two Key Scientific Findings
•Longer duration of untreated psychosis
(DUP) is associated with poorershort
term and long term outcome
•DUP is the time between onset of psychosis
and specified treatment (e.g., antipsychotics
or CSC)
•Treatment with coordinated specialty care
(CSC) is associated with betteroutcomes

4. Coordinated Specialty Care
Clinical Services
•Case management, Supported
Employment/Education, Psychotherapy,
Family Education and Support,
Pharmacotherapy and Primary Care
Coordination
Core Functions/Processes
•Team based approach, Specialized training,
Community outreach, Client and family
engagement, Mobile outreach and Crisis
intervention services, Shared decision making
http://www.nimh.nih.gov/health/topics/
schizophrenia/raise/coordinated-specialty-care-for-first-
episode-psychosis-resources.shtml

5. Challenges
•Financing
•Workforce Development
•Community Activation: Getting the Word
Out
•Fidelity and Measuring Outcomes
•Youth/Consumer Involvement

6. H.R. 3547, 113th Congress
January 17, 2014
•Increased Community Mental
Health Block Grant (CMHBG)
program by $24.8M
•Funds allocated for first
episode psychosis (FEP)
programs
•NIMH and SAMHSA to
develop guidance for States
regarding effective programs
for FEP

7. Financing Early Psychosis Programs
http://www.medicaid.gov/federal-policy-
guidance/federal-policy-guidance.html
“RAISE-ETP, RAISE-IES, and STEP demonstrate convincingly (1) the feasibility of
first episode psychosis specialty care programs in U.S. community mental
health settings; (2) that young people with psychosis and their family
members accept these services; and (3) that CSC results in better clinical and
functional outcomes than typical treatment.”
Financing Early Psychosis Programs

8. Consolidated Appropriations Act,
2016: Mental Health Block Grants
$50,000,000 increase over FY 2015 for the Mental
Health Block Grant program
Increases the set-aside to 10 percent
SAMHSA directed to continue its collaboration with
NIMH to ensure that funds from the set-aside
are only used for programs showing strong
evidence of effectiveness and targets the first
episode of psychosis.
http://docs.house.gov/billsthisweek/20151214/CPRT-114-HPRT-RU00-SAHR2029-
AMNT1final.pdf.

9. Financing
•Need to develop strategies to pay for CSC
regardless of disability status and insurance
•Current funding typically blend of block grant,
Medicaid, state support, other grants, private
insurance
•Specific service components not typically
covered (e.g., SEE, outreach)
•Challenge of uncertain future of ACA and
Medicaid

10. Workforce Development
•Child providers less familiar with
psychosis, but comfortable with family
and developmental perspective
•Adult providers comfortable with
psychosis, but not with families and
development
•Unlearn disability expectation
•Practice shared decision making
•CSC OnDemandin development

11. Community Activation: Reduce
DUP
Onset of
Symptoms
Help
Seeking
Referral to
Mental
Health
Services
(Could
receive
criterion
treatment in
MHS)
Referral to
EIS

12. Current System
Mental
Health
Clinic
Help
seeking
ER/I
P
Police
Stigma
Lack of Knowledge
Distrust
Poor Insight
Insidious Onset
Dropout from
Care
Referral from GP
Lack of Access
Unaffordability
and Inefficiency of
health care
Compton M, Broussard B: Current Psych Reviews 2011, 7, 1-11

13. Individual
with FEP
FEP
Onset/Illness
Factors
Family
Members
Misattribution
Stigma
Self-reliance
13

14. Cloud of Uncertainty
➢Cause of symptoms
➢Level of severity
➢Appropriate treatment
➢Connecting with care
Ambiguityaround:
Ambivalencetoward:
➢Mental illness
➢Appropriate treatment
➢How to find treatment
Lack of knowledge of:
➢Level of necessary concern
➢Need for treatment
➢Acknowledgement
of a mental health problem
➢Enlisting outside help
What is happening?
Who and when to tell?
Where and when to go?
What to do?
What are the options?
14

15. Individual
with FEP
FEP
Onset/Illness
Factors
Family
Members
Misattribution
Stigma
Self-reliance
Shorter
DUP
Longer
DUP
Health Service Factors
Interpersonal
Connections
Quality of Care
Family
Involvement
Care
Transitions
15

16. Strategies to Reduce DUP:
Enhance…
•Recognition of psychotic symptoms
•Referral to mental health treatment
•Diagnosis of a psychotic disorder
•Referral to a CSC program
•Enrollment in a CSC program and/or
initiation of CSC treatment
•Engagement in CSC services

17. Strategies to Reduce DUP
•“Supply side” approaches targeting
clinical and community systems
•Training primary care physicians and nurses,
school and college counselors, emergency
department staff, police, and mental health
“generalists” to recognize signs of early
psychosis, and the improvement of referral
networks to fast-track the initiation of FEP
care.

18. Strategies to Reduce DUP
•Demand sideapproaches targeting people with
FEP and their family members, friends,
caregivers and others close to the affected
individual
•improve recognition of early symptoms, help-
seeking, access, and engagement in care for
persons with FEP and/or youth at high clinical risk for
psychosis, through education, decision-support
systems, and other tools, including social marketing,
social media and social networking.

19. Fidelity and Measuring Outcomes
•Need strategy/tool to ensure programs
being delivered as intended and achieving
expected outcomes
•Evolving model without existing well-
tested fidelity tool; need scalable
approach; several being developed
•Availability of PhenXtoolkit for
psychometrically sound outcome
measures

20. Youth/Consumer Involvement
•Need youth input into oversight and
development of programs
•EASA Young Adult Leadership Council
•Sussex NHS trust early intervention
service: Youth Advisory council and Youth
Research Council
•OnTrackNYjust started Youth Advisory Board
•Peer support within programs

21. Challenges
•Financing
•Workforce Development
•Community Activation: Getting the Word
Out
•Fidelity and Measuring Outcomes
•Youth/Consumer Involvement