Community Outreach, Referral
and Early Intervention (CORE)
2014-2019
Division of Prevention and Behavioral Health Services
Division of Substance Abuse and Mental Health
1
Delaware History (2007-2013)
2
It’s a process…
 94% of individuals receiving treatment in DE’s public
mental health system for psychosis related disorders
are adults however, the median age of onset for
psychosis is 16 years old;
 1 in 4 cases in the adult system have dropped out of
high school;
 2 of 3 cases are unemployed;
 Services most commonly accessed by adults are
crisis and inpatient services.
*DPBHS/DSAMH case records 2004-2013
3
A divide between divisions
DPBHS
DSAMH
4
Executive Order: Now Is The Time

Closing gun background check loopholes;

Banning military-style assault weapons and highcapacity magazines;

Making schools safer;

Increasing access to mental health services for
transitional age youth.
WH.GOV/NOW-IS-THE-TIME
5
Executive Order: Now Is The Time
Support individuals ages 16 to 25 at high
risk for mental illness
Efforts to prevent school shootings and other gun
violence can’t end when a student leaves high school.
Individuals ages16 to 25 are at high risk for mental
illness, substance abuse, and suicide, but they are
among the least likely to seek help. Even those who
received services as a child may fall through the
cracks when they turn 18. The Administration is
proposing $25 million for innovative state-based
strategies supporting young people ages 16 to 25 with
mental health or substance abuse issues.
6
Community Outreach, Referral and
Early Intervention (CORE)
PIER
• Outreach
• Assessment/Engagement
• Preventive Service
Youth Coordination
• Public education
• Advocacy
• Peer-to-peer
7
CORE: Administration
Delaware CORE
Psychotherapeutic
Services Inc.
8
Organizational Structure
9
Susan Cycyk
M.Ed., CRC
Principal
Investigator,
DPBHS
Chuck Webb Ph.D.
Co-Investigator,
DPBHS
Gerard Gallucci
M.D., M.H.S.
Co-Principal
Investigator ,
DSAMH
Gwen Derr M.B.A
Project Director,
DPBHS
10
CORE: Clinical Team New Castle
Mary Diamond MD
Team Leader,
PSI
Sinchen Sanchez MSW
Social Worker,
PSI
Sinchen McDuffy MS
Social Worker,
PSI
Chuck Webb Ph.D.
Clinical Back-up,
DPBHS
11
CORE: Clinical Team New Castle
Springer Building, Holloway Campus, DHSS
12
CORE: Clinical Team Kent/Sussex
Christine Hanna-Ronald MSN
Team Leader,
PSI
Samantha Eklund
Social Worker,
PSI
Angela Williams MS
Social Worker,
PSI
Tracy Washington MSW
Clinical Back-up,
PSI
13
CORE: Clinical Team Kent/Sussex
630 West Division Street , Dover DE (PSI)
14
Occupational Therapy and
Supported Ed/Voc
Rosemary Lanza
OTR\L
Occupational
Therapist
Melissa Clendaniel
Educational/
Vocational
Advocate
15
Youth Coordinator
Evaluation
Geeta Kotak
Youth
Coordinator
Ryan Beveridge Ph.D.
Timothy Fowles Ph.D.
Briana Haut Psy.D.
Evaluation
16
Transition Team
Name
Title
Organization
Barbara Messick
Family Coordinator
DPBHS
Carl Gartner
Nemours Emeritus
Program
Alfred I. DuPont Hospital
Jim Lafferty
Executive Director
Emily Vera
Assistant Director
Yasser Payne
Associate Professor
University of Delaware
Dubard McGriff
Community Organizer
PAR/The People’s Report
Yolanda Jenkins
Executive Assistant
DPBHS
Regina Johnson
Youth Coordinator
DPBHS
Eileen Cozzi-Bodnar
Coordinator, OEBP
DPBHS
Daniel Jones
Psychologist
DPBHS
Mental Health
Association
Mental Health
Association
Step 1: Training
Didactic
hours
Assessment
Consultation
frequency
7
Structured Interview of Psychosisrisk Symptoms (SIPS)
Prevention
Bi-monthly
40
Clinical
Bimonthly
Multi-family Group
Bimonthly
Occupational Therapy
Supported Education /Vocation
Monthly
Outreach
Monthly
Psychiatric
Quarterly
18
Step 2: Outreach
1-3% Prevalence Rate
19
Community Mapping Tool
Key Stakeholders
Supportive
Community Allies
DPBHS
YMCA
Elected
Officials
MHA
West End
Neighborhood
House
DSAMH
Transition
Team
State
Police
Employers
NAMI
Child
Welfare
Parent
Information
Centers
DOJ
Military
Churches
La Red
Community
Activists
Insurance
Companies
La
Esperanza
First
Responders
EAPs
LACC
**Boys &
Girls Club
CDCP
New Castle
High Schools
(## public,
## private)
CORE
Individual
Practitioners
Behavioral
Health
Agencies
Pediatricians
Medical
Professional
Groups
Alternative
Schools
District
Offices
Residential &
Psychological
Tx Facilities
Hospitals
Public
Health
Centers
Medical Community
Contacts
Crisis
CAC
GPs &
NPs
Public
Colleges &
Universities
(##)
**New
Castle
Middle
Schools
(## public,
## private)
**Kent
Middle
Schools
(## public,
## private)
**Indicates future population
Private
Colleges &
Universities
(##)
**Sussex
Middle
Schools
(## public,
## private)
Kent
High Schools
(## public,
## private)
Sussex
High Schools
(## public,
## private)
Academic Contacts
and Supports
Health Disparities
Phase 1
19801,19802,19803,19804,
19805,19808, 19809,19810,
19703,19732,19710,19735,
19736,19711,19717,19712
Sussex County
Phase 1
Year 1-1.5
21
Health Disparities
Phase 2
Years 2.5-5
22
Latino Outreach: Year 1
Latino
Families
19805 20%
19947 21%
• Spanish pamphlet;
• Bilingual clinicians on both teams;
• Translating website, presentation,
and voice-mail message.
23
African American Outreach: Year 1
African
American
Families
19801 72%
19802 74%
• Committee to coordinate inner-city;
• Community based service;
• C-TECC tracking referral/admission
rates.
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Outreach: Media
www.delacore.com
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Outreach: Screening
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Step 3: Assessment & Engagement
•
Rapid ( short DUP for FEPs)
• Phone screen in 2 days;
• Assessment in 9 days;
• Admissions in 16 days.
•
SIPS: Sensitivity = 100% ; Specificity= 73% at
24 months;
•
Joining
• Most comfortable (e.g., where, with whom)
• “What do you want to do?”
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Case Example
28
Step 4: Prevention Services
• ‘Prevention’, not ‘treatment’
• Prodrome
• FEP
Secondary
Tertiary;
• 150 youth in 4 years;
• Multi-family groups
• Community based,
• Linguistic homogeneity,
• Address negative symptoms.
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Step 5: Evaluation
•
Outcomes
• Symptoms (positive, negative);
• Functioning (social, vocational);
• Substance use;
• Education or employment;
• Social embeddedness;
• Stigma .
•
Effects
• Main;
• Moderated (e.g., race; ethnicity);
• Anecdotal (e.g., LGBT).
30
Step 6: Sustainability
• Fee-for-service model;
• Sustaining uncovered services;
• Hospital admission rates.
31