Research and Integrated Care
Presented at the Roadmap to Integrated Care Conference
Chateau on the Lake, Branson, MO
June 4, 2015
Paul Thomlinson, PhD
Objectives for Presentation
1. List the key components of the RAISE study and
how this relates to treatment of patients with
serious mental illness (SMI);
2. List and describe how to implement the empirically
supported treatment program from RAISE; and
3. Demonstrate how to access current research
findings and translate those into practice.
Burrell is a National Institute of Mental Health
Outreach Partner. This workshop is part of our ongoing
efforts to promote empirically supported treatment and
evidence-based research.
A Prefatory Word (or Two) about EvidenceBased Practices…
National Institute of Mental Health (NIMH):
Recovery After an Initial Schizophrenia Episode (RAISE)
• Two different RAISE projects:
– Early Treatment Program (ETP)
• With the Feinstein Institute for Medical Research, the
research branch of the North Shore-LIJ Health System
in Manhasset, NY. The Principal Investigator is John
Kane, MD.
– Connection
• With Columbia University and provider organizations
from NY state. The Principal Investigator is Lisa Dixon,
MD, MPH. Developed/evolved into OnTrackNY.
What is RAISE ETP?
• “The goal of the RAISE Early Treatment
Program randomized clinical trial is to
compare NAVIGATE (a multifaceted
intervention) to Community Care in
individuals with early phase schizophrenia
in order to investigate whether NAVIGATE
can change the outcome and prognosis of
individuals during a two-year treatment
period.”
Aims
1. To conduct an RCT in community clinical
settings that will compare NAVIGATE, a
comprehensive and integrated treatment
intervention, to Community Care in the
treatment of first episode psychosis.
2. To assess the overall clinical impact and costeffectiveness of NAVIGATE and Community
Care on functional outcomes, symptom
remission, recovery and cost.
What is So?
• “Schizophrenia is a major mental illness
characterized by psychosis, negative
symptoms (e.g., apathy, social withdrawal,
anhedonia), and cognitive impairment.”
• “…in 2001 approximately one-third of all
spending for mental health treatment in the
U.S. was accounted for by schizophreniaapproximately $34 billion…”
So What?
• RAISE ETP sought to change the trajectory and
prognosis of schizophrenia through coordinated and
aggressive treatment in early stages of the illness.
• To reduce the likelihood of long-term disability, and
increase the chances of helping individuals suffering
from this disorder to lead productive, independent
lives.
• to reduce the costs related to treatment (both
medical and behavioral health) and other supports
(e.g., housing, disability, transportation, etc.).
So?
• We’re not sure yet…
• We’re just starting to get word of
publications and outcomes.
Key Components of RAISE Services
• The Coordinated Specialty Care (CSC) approach
was used when developing the treatment model
for both RAISE projects.
– CSC is a team-based, collaborative, recovery-oriented
approach to treating first episode psychosis (FEP) that
involves relatives and clients as active participants in
treatment.
• Emphasizes shared decision-making, collaborative treatment
planning, establishing positive therapeutic alliances, and
integration (with primary medical care).
• Evidence of effectiveness from broad implementation in
Australia, UK, Scandinavia, and Canada.
Key Components of RAISE Services
• Components of care include:
–
–
–
–
–
Assertive case management,
Individual and/or group therapy,
Supported employment and education,
Family education and support, and
Low doses of select antipsychotic drugs.
• Ideally designed for younger populations (15-25), with
non-organic, non-affective psychotic disorders, who
have been ill for five years or fewer.
CSC & ETP NAVIGATE Protocol
• Participants received any combination of:
–
–
–
–
Medication Management – monthly visits
Individual Resiliency Training (IRT) – weekly
Family Education (FE) – weekly
Supported Employment and Education (SEE) –
weekly
– Any other ‘standard’ community care services that
may be necessary
• E.g., community support/case management, substance
abuse treatment, trauma-informed care, etc.
RAISE ETP NAVIGATE Protocol
• Project Director/Team Leader
– Coordinated/Supervised RAISE team members (weekly or biweekly
supervisions)
– Facilitated weekly RAISE team meetings to discuss each clients’ needs,
service utilization/ engagement, treatment plans/goals, crises, and
successes.
– Outreach to stimulate referrals
– Screened, consented, & enrolled new clients into RAISE (and other
Burrell services, through internal referral mechanisms)
– Coordinated with Evaluation and Administrative staff for data
collection and administrative purposes.
RAISE ETP NAVIGATE Protocol
• Medication Management
– Monthly medication management visits (30 min) with an online
decision-support tool (Compass) to collect data on symptoms, side
effects, perceptions and use of meds.
• The tool utilized algorithms (from Texas) to make
recommendations on prescriptions.
– Performed physical evaluation for movement disorders, reviewed
results of tests for monitoring side effects, participation in weekly
team meetings and treatment planning
RAISE ETP NAVIGATE Protocol
•
Individual Resiliency Training (IRT)
– Provided motivational enhancement interventions: motivational
interviewing, weighing pros & cons of behavior change, breaking goals
into smaller steps, etc.
– Provided psycho-education: information about psychiatric disorders &
treatment.
– Provided cognitive behavioral therapy: social skills training, relaxation
training, coping strategies for persistent symptoms, psychiatric relapse
prevention training, cognitive restructuring, & behavioral tailoring
(incorporating medications into daily routine).
– Providing cognitive behavioral therapy for substance abuse: teaching
social skills, drug/ alcohol refusal, relaxation, coping with persistent
symptoms, relapse prevention & cognitive restructuring
– Participation in treatment planning: short-term & long-term goals (every 6
months)
– Providing assessments: both standardized (PTSD checklist) and nonstandardized
– Participated in weekly team meetings
– Participated in family meetings (as needed)
RAISE ETP NAVIGATE Protocol
• Family Education (FE)
– Provided education to family members about the client’s psychiatric
illness
– Encouraged family members to be supportive of the client in obtaining
desired goals
– Helped elicit strengths, preferences, and history, helped develop
shared understanding of desired goals
– Gathered important information, problem-solving, developed family
coping skills strategies
– Provided motivational interviewing interventions to build family
support
– Taught family members symptom management strategies
– Enhanced family communication styles & problem solving skills
– Provided Cognitive- Behavioral strategies to help families assist clients
to better manage symptoms
– Participated in weekly team meetings
– Participated in family meetings
RAISE ETP NAVIGATE Protocol
• Supported Employment and Education (SEE) Specialists
– Performed assessments: gathered information about functional
impairments from psychosis as they relate to education &/ or
employment goal attainment
– Provided psychoeducation about psychosis as it relates to attaining
education &/ or employment goals
– Provided social skills & relapse prevention training for managing
symptoms as they relate to goals for education &/ or employment
– Provided guidance and education related to employment as it relates
to eligibility for Medicaid and other entitlements, etc.
– Provided job development, due to functional limitations
– Provided assistance with enrollment in education
– Provided follow-along supports, social skills training, relapse
prevention skills
– Participated in weekly team meetings
– Participated in family meetings (as needed)
Implementing EBP for FEP
• H.R. 3547 - Consolidated Appropriations Act, 2014
• Provided funds to the Substance Abuse and Mental Health Services
Administration (SAMHSA) to support the development of early
psychosis treatment programs. National Institute of Mental Health
is collaborating with SAMHSA to ensure fidelity to EBP models and
to develop input for states about promising first episode psychosis
(FEP) treatment models.
• Coordinated Specialty Care (CSC) resources and program
development materials—including treatment manuals, videos,
educational handouts, and worksheets—are available to assist in
efforts to initiate or expand CSC services for youth and young adults
with FEP.
• Resources are available at:
– http://www.nimh.nih.gov/health/topics/schizophrenia/raise/coordinat
ed-specialty-care-for-first-episode-psychosis-resources.shtml
– White Paper
• Evidence-Based Treatments for First Episode Psychosis: Components of
Coordinated Specialty Care
Implementing EBP for FEP
• Components to consider for CSC:
– Components of care & staffing needs,
– Training and supervision requirements,
– Quality assurance, and
– Financing
Implementing EBP for FEP
• Components of Care and Staffing Needs
– CSC Team Leader
• Provides ongoing consultation to team members,
coordinates key services (screening, leads weekly
meetings, treatment planning, referral sources, etc.),
– Case Management
• Assists clients with problem solving, coordinates social
services across multiple areas of need. Regular
community-based meetings.
– Supported Employment and Education
• Facilitates return to work or school through goalsetting, coaching, and integrating vocational and
mental health services.
Implementing EBP for FEP
• Components of Care and Staffing Needs
– Psychotherapy
• Based on CBT principles, emphasizes resilience training,
illness and wellness management, and general coping
skills.
• One-on-one and/or group therapy
– Family Education and Support
• Teaches relatives and other natural supports about
psychosis and treatment. Strengthens supports’
capacity to aide in the client’s recovery
Implementing EBP for FEP
• Components of Care and Staffing Needs
– Medication Management & Primacy Care Coordination
• Uses evidence-based medication management
practices to guide the prescription (selection and
dosing) of antipsychotic and other
psychopharmacological agents.
• Monitors of symptoms, side effects, and attitudes
toward medications at every visit.
• Monitors cardiometabolic risk factors and maintains
close contact with primary care providers.
Implementing EBP for FEP
• Components of Care and Staffing Needs
– Community Outreach
• To identify and engage clients as early as possible, to reduce the
duration of untreated psychosis
– Client and Family Engagement
• Clients and natural supports can be difficult to engage. Specific
techniques and language is necessary to help increase clients and
supports feel comfortable.
– Mobile Outreach and Crisis Intervention Services
• To engage clients who have difficulty with clinic-based services, or
who need assistance in addressing complex needs.
• 24-hour crisis line can effectively avert many emergency
department visits and hospitalizations
Implementing EBP for FEP
• Components of Care and Staffing Needs
– Transition of Care
• Highly coordinate, gradual transition to standard
behavioral health services.
• Evidence suggests that continuity of care for up to five
years after psychosis begins can improve the durability
of effects of early intervention CSC services.
• Step-down in care should involve ongoing connection
with one member of the CSC team for an additional 1-3
years.
CSC Role
Services
Coverage Status
Team Leadership
Cultivate referral networks; facilitate access to care; outreach to patients and family members;
coordinate clinical services among team members; provide ongoing clinician supervision
Not Covered
Psychotherapy
Provide individual and group psychotherapy sessions, including integrated substance abuse
sessions when needed
Billable via CPT 90832;
90834; 90853
Case Mgmt
Perform assertive case mgmt functions in clinic and community settings
Inconsistently covered
(may only include
Medicaid)
Family Education & Support
Provide psychoeducation, relapse prevention counseling, and crisis intervention services.
Billable via CPT 90846;
90847; 90849
SEE
Implement IPS model of supported employment and supported education; provide ongoing
client support following job or school placement
Inconsistently covered
(may only include
Medicaid)
Med Mgmt & Primacy Care
Coordination
Medication management; coordination with primary medical care
Billable via CPT 99214
CSC Team-Level Activity
Team meetings, coordination of services among team members, CSC training, clinical
supervision, 24-hour phone coverage for managing crisis situations
Not Covered
*Note – this table was taken originally printed in the Evidence-Based Treatments for First Episode Psychosis: Components of Coordinated Specialty Care document, pp-14-15;
http://www.nimh.nih.gov/health/topics/schizophrenia/raise/coordinated-specialty-care-for-first-episode-psychosis-resources.shtml
Implementing EBP for FEP
• Training and Supervision Requirements
– Training for EBP in FEP is necessary to ensure fidelity and
efficacy
– Two levels:
• Philosophy of team-based care for FEP
– For all team members
– Includes:
» Theoretical framework of CSC
» Recovery potential for FEP clients
» Developmental issues specific to adolescents/young adults
experiencing FEP
» Concepts of shared decision-making
» Concepts of person-centered care
» Maintaining optimistic therapeutic perspective
» Engagement barriers and strategies
» Co-occurring substance use problems
» Suicide risk during early years of treatment
• Specialized services that support recovery after FEP
– Specific to each specialized role on the team
Implementing EBP for FEP
• Training and Supervision Requirements
– Ongoing supervision and continuing education for all staff
– Weekly case reviews to reinforce CSC treatment principles
and ensure competence in FEP care
• Training materials developed by both RAISE ETP and
Connection programs
–
–
–
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Rational for early intervention
Principles of team-based care
Providers’ roles and related clinical services
Core competencies related to specific treatment
modalities
Implementing EBP for FEP
• Quality Assurance and Performance
Improvement
– Primary questions:
• Are CSC team members implementing interventions as
intended?
• Are providers delivering what was promised in the
service contract?
• Have CSC services achieved desired clinical and
functional outcomes for clients with FEP?
Implementing EBP for FEP
• Quality Assurance and Performance
Improvement
– Assuring Fidelity
• Through records reviews, surveys, and interviews.
• Routine Service Logs, EHR, medical records.
• ID indicators or proxies for primary principles in clinical
documentation and track over time.
• Client satisfaction surveys
• Staff Perception, Engagement, or Satisfaction Surveys
Implementing EBP for FEP
• Quality Assurance and Performance
Improvement
– Outcomes measurement
• Functioning/ functional indicators (school/ work
involvement, ER visits, hospitalizations, drug use,
arrests/ legal involvement, etc.), symptoms, quality of
life, etc.
CSC Program Development Resources
• http://www.nimh.nih.gov/health/topics/schizophrenia/raise/coordi
nated-specialty-care-for-first-episode-psychosis-resources.shtml
• NIMH White Paper
– Evidence-Based Treatments for First Episode Psychosis: Components of
Coordinated Specialty Care
• RAISE Connection
– CSC for FEPT Psychosis Manuals
• Manual I: Outreach and Recruitment
• Manual II: Implementation
– Video Series: Voices of Recovery
– Performance, Quality, and Fidelity Indicators
– Additional resources:
http://practiceinnovations.org/OnTrackUSA/tabid/253/Default.aspx
CSC Program Development Resources
• RAISE ETP
– NAVIGATE Team Members Guide
– NAVIGATE Team Leader Manual
– IRT Manual & Demo/Training Videos
– Family Education Manual
– SEE Manual
– Medication Management Manual
– http://navigateconsultants.org/materials/
Conclusions and Q&A