Presentation on theme: "Evidence-Based Treatment for First Episode Psychosis"— Presentation transcript:
1Evidence-Based Treatment for First Episode Psychosis Robert K. Heinssen, Ph.D., ABPPAmy B. Goldstein, Ph.DSusan T. Azrin, Ph.D.July 28, 2014
2DisclosuresI have no personal financial relationships with commercial interests relevant to this presentationThe views expressed are my own, and do not necessarily represent those of the NIH, NIMH, or the Federal Government
4Early Intervention Principles Early detection of psychosisRapid access to specialty careRecovery focusYouth friendly servicesRespectful of clients’ autonomy & independenceTwin goals are to reduce DUP and provide EIS to instill hope, reduce disability, and promote long term recovery.Youth and young adults, ages 15-30Non-affective psychosesSchizophrenia, Schizoaffective Disorder, Schizophreniform Disorder, Brief Psychotic Disorder, or Psychotic Disorder NOS≤3 years since onset of psychosis≤5 years since onset of psychosis in LEO, OPUSRAISE Connection Program ≤2 years
5Early Intervention Services Team-based, phase-specific treatmentAssertive outreach and engagementEmpirically-supported interventionsLow-dose antipsychotic medicationsCognitive and behavioral psychotherapyFamily education and supportEducational and vocational rehabilitationShared decision-making framework
6For information on how to implement first episode psychosis treatment models, please visit the NIMH RAISE CSC resources page.Go to the NIMH home page, type ‘first episode psychosis’ in the search bar; the first link takes you to the resource page..Evidence-based Treatments for First Episode Psychosis: Components of Coordinated Specialty CareRAISE Early Treatment Program Manuals and Program ResourcesRAISE Coordinated Specialty Care for First Episode Psychosis ManualsOnTrackNY Manuals & Program ResourcesVoices of Recovery Video Series
7Ryan – Fulfilling My Dream Screen shots of CSC resources available at no cost at and outside links.
8Client Coordinated Specialty Care Model Medication/ Primary CarePsychotherapyFamily Education and SupportSupported Employment and EducationCase ManagementPerson-centered care, assisted by care manager who helps clients and family members to navigate among treatment options.
9Coordinated Specialty Care Model ClientMedication/ Primary CarePsychotherapyFamily Education and SupportSupported Employment and EducationCase ManagementPerson-centered care, assisted by care manager who helps clients and family members to navigate among treatment options.
10Coordinated Specialty Care Model ClientMedication/ Primary CarePsychotherapyFamily Education and SupportSupported Employment and EducationCase ManagementPerson-centered care, assisted by care manager who helps clients and family members to navigate among treatment options.
11Pharmacotherapy and PC Coordination Supported Employment and Education CSC Roles and FunctionsCSC RoleServicesCredentialsPharmacotherapy and PC CoordinationMedication management; coordination with primary medical care to address health issuesLicensed M.D., NP, or RNPsychotherapyIndividual and group psychotherapy (CBT and behavioral skills training)Licensed clinicianFamily TherapyPsychoeducation, relapse prevention counseling, and crisis intervention servicesCare ManagementCare management functions provided in clinic and community settingsSupported Employment and EducationSupported employment and supported education; ongoing coaching and support following job or school placementBA; IPS training and experienceTeam LeadershipOutreach to community providers, clients, and family members; coordinate services among team members; provide ongoing supervisionLicensed clinician; management skillsA CSC team requires sufficient staff to cover six key roles and associated functions The first three – pharmacotherapy, psychotherapy, and family therapy – can be reimbursed via private and public insurance. Care management and supported employment are not generally covered by commercial insurance, but may be reimbursed by Medicaid if the state’s Medicaid waiver includes these services. Team leadership is critical for CSC success; this role is not typically reimbursed by private or public insurance plans. The 5% set aside can be used to cover reimbursement gaps in care management, supported employment, and team leadership.
12Must I hire 6 new FEP specialists? In the RAISE initiative, clinicians from multiple disciplines learned, mastered, and applied the principles of CSCMany providers achieved competency in more than one CSC function, and fulfilled dual roles on the treatment teamMany sites leveraged existing resources to create cost efficiencies that supported the CSC program
13CSC Team Model 1 Suburban Mental Health Center; 20-25 Clients Clinical RolesPercent Full Time EmployeeFrom Heinssen et al. (2014), pages 13-14:Example 4 (suburban setting): One CSC program was formed within a suburban mental health center that anticipated a caseload of clients with FEP. Four agency personnel were selected for new clinical positions on the FEP treatment team. The CSC team leader and family therapist roles were combined into a single full-time position. Likewise, psychotherapist and case manager roles were performed by one full-time provider. The psychiatrist and supported education/employment specialist were full-time employees of the mental health center, but devoted 0.2 FTE and 0.5 FTE level of effort to the CSC program, respectively. The psychiatrist and supported employment specialist worked with all CSC participants, but also served clients from other agency programs. The non-CSC caseloads of the employment specialist and the psychiatrist were reduced to accommodate the needs of clients in the FEP treatment program.
14CSC Team Model 2 Urban Mental Health Center; 25-30 Clients Clinical RolesPercent Full Time EmployeeFrom Heinssen et al. (2014), page 13:Example 3 (urban setting): One CSC program was developed in a mental health center that served a small urban area. With a catchment area covering ~160,000 individuals, agency administrators anticipated an FEP caseload of clients. An existing team-based treatment program for outpatients at high risk for hospitalization (HRH) was leveraged in order to form a team of CSC providers. A subset of six HRH team members were selected for the roles of CSC team leader (0.3 FTE), family therapist (0.25 FTE), supported employment/education specialist (0.5 FTE) and psychiatrist (0.2 FTE). Two additional clinicians (0.5 FTE each) filled the role of psychotherapist/case manager. While the primary function of the CSC subgroup was to care for FEP clients, team members also provided services in the HRH program. Each provider’s HRH caseload was adjusted downward based on the number of CSC clients enrolled in the program.
15Revising the FY14 MHBG Plan Set-Aside AmountCurrent CSC Capacity in the State or Territory≥1 CSC Program≥1 Developing ProgramNo CSC Programs≥ $1M> $100K, < $1M< $100KDetermine current capacity for FEP careAt least one fully operational CSC program?At least one partially operational CSC program?No operating CSC programs?Determine the amount of set-aside funding≤ $100K?> $100K, < $1M?≥ $1MDepending on current capacity and set-aside amount:Expand or augment existing CSC servicesFill gaps to create at least one operational programCreate infrastructure for a future CSC program
16Revising the FY14 MHBG Plan Set-Aside AmountCurrent CSC Capacity in the State or Territory≥1 CSC Program≥1 Developing ProgramNo CSC Programs≥ $1M> $100K, < $1M< $100KConsider targeted investments to build core CSC capacitiesShared decision making tools and trainingSupported employment specialistsRegional collaborations to build FEP expertise
17Goals for FY2015 and Beyond Achieve and maintain fidelity to CSC model Benchmark and monitor key quality indicatorsDuration of untreated psychosisClient retention at 3 monthsInpatient episodes, ED visits, crisis interventionAcademic, vocational, and social recoveryHealth risk factors and medical comorbiditiesAll cause mortality (suicide behaviors, accidents, etc.)Connect CSC programs into a “learning community” that shares expertise, resources, and quality monitoring data
18FEP Learning Healthcare System FY2015Science and informaticsPatient-clinician partnershipsIncentives aligned for valueFeedback loops for ongoing system improvementCulture of continuous learning
19Thank you RAISE partners! TXUTMTCAAZIDNVORIACOKSWYNMMOMNNEOKSDWAARNDLAILOHFLGAALWIVAINMIMSKYTNPANCSCWVNJMENYVTMDNHCTDEMARIPhase-specific specialty care for First Episode Psychosis vs. TAURepresentative patients, providers, and community clinicsFocus on clinical and functional recovery, cost of care, societal benefitsEarly deliverables on DUP, guideline-concordant pharmacotherapy, medical comorbidity in FEP, and implementing CSC in public mental health systems2 Studies22 States36 Sites134 Providers469 Participants
20RAISE Principal Investigators RAISE Early Treatment ProgramRAISE Connection ProgramJohn KaneNina SchoolerDelbert RobinsonLisa DixonSusan EssockJeffery Lieberman