Advancing Early Intervention After First Episode Psychosis in South Florida

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Delay of initial treatment is an area of unmet need for mental healthcare in the U.S.1 For example, some evidence suggests that a longer duration of untreated psychosis in schizophrenia can be associated with a poorer response to treatment.2 It is commonly thought that early identification and appropriate treatment of mental illness may improve outcomes for individuals with serious mental illness.3
Henderson Behavioral Health (Henderson) is among organizations that believe a focus on early intervention may help alleviate some of the persistent challenges associated with undiagnosed, untreated or undertreated mental illness, such as increased emergency room visits and hospitalizations and increased risk of substance abuse, depression, homelessness, unemployment and legal involvement. In order to better understand, treat and serve those with mental illness in South Florida, Henderson participates in cutting-edge research, evaluating best practices and recovery-promoting services for individuals with serious mental illness.
  • Since 2010, Henderson has participated as a behavioral health care study site in the National Institute of Mental Health’s “Recovery after Initial Schizophrenic Episode (RAISE)” research project, designed to evaluate the potential benefits of a comprehensive pharmacological and psychosocial treatment package for individuals with first episode psychosis.4
  • Early Intervention: Henderson also is developing its own evidence-based early intervention program focused on promoting recovery after a first episode of psychosis – the first program of its kind in the state of Florida. The program will feature psychoeducation support, outreach and engagement, relapse prevention planning and vocational support, among other elements. The hope is that early intervention programs have the potential to reduce the likelihood of long-term disability for those with serious mental illness as well as the financial impact on public systems that often must support these individuals.4
Henderson attributes its overall positive impact in South Florida to a number of other key strategies, in addition to early intervention. The following strategies help the organization provide high quality services and access to care for individuals with serious mental illness:
  • A “Housing First” model that provides housing support to individuals as a first priority, followed by services and treatment support to encourage stability, as needed.
  • Participating in behavioral health care research that aims to improve the diagnosis, treatment and prevention of mental illness and substance abuse disorders.
  • Serving on Broward County’s Criminal Justice Mental Health Task Force to address broad concerns about the mentally ill in the criminal justice system, particularly those in local correctional facilities.
Henderson was established in 1953 and has since evolved to become the largest, community-based non-profit behavioral health care system in South Florida. Henderson provides a comprehensive array of accessible, cost effective, evidence-based services to more than 23,000 individuals annually.
  • When surveyed for Henderson’s 2011-2012 annual report, 98% of Henderson’s clients (n=1,491) reported they were satisfied or very satisfied with the services they received; 97% reported that they were able to better manage their life as a result of the services they received at Henderson.5
  • Henderson helps more than 700 adults annually live an independent lifestyle through its supportive housing program.
  • Henderson worked with several judges to establish the first Misdemeanor Mental Health Court in Florida and supports the court with a licensed clinician and designated residential treatment beds.

References:

  1. Wang, P., et al. (2005). Failure and Delay in Initial Treatment Contact After First Onset of Mental Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62 (6), pp. 603-613.
  2. Drake, R., et al. (2000). Causes and Consequences of Duration of Untreated Psychosis in Schizophrenia. The British Journal of Psychiatry, 177, pp. 511-515.
  3. Downey, L., et al. (2012). Undiagnosed Mental Illness in the Emergency Department. The Journal of Emergency Medicine, 43 (5) , pp. 876–882.
  4. (2013). Recovery After an Initial Schizophrenia Episode (Raise): A Research Project of the NIMH. National Institutes of Health, National Institute of Mental Health. Retrieved October 4, 2013 from http://www.nimh.nih.gov/health/topics/schizophrenia/raise/index.shtml.
  5. (2013). Outcomes & Accomplishments. Henderson Behavioral Health. Retrieved October 15, 2013 from http://www.hendersonbh.org/outcome.php.

Advancing Creative Use of Technology in Massachusetts

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Massachusetts can be considered a leader in health care delivery reform in the U.S., as well as a hub for innovations in biotechnology.1,2 As part of the state’s ongoing health reform efforts, public health leaders identified significant gaps in the ability to care for both the physical and psychological health of individuals living with serious mental illness.3 In Massachusetts and elsewhere in the country, many primary care practices are not always equipped to address the combined needs of those with serious mental illness.4 If such conditions are untreated or undertreated, it can have a profoundly negative impact on the health of these individuals, and also on the utilization of vital community resources, such as physician offices, outpatient and emergency departments. 5,6,7
Vinfen is leading the way in identifying and implementing a novel technology solution to connect two critical aspects for people living with serious mental illness – their physical and mental health needs. In 2012, Vinfen – in partnership with three other community behavioral health organizations (Bay Cove Human Services, North Suffolk Mental Health Association and Brookline Mental Health Center) and a non-profit care delivery system (Community Commonwealth Care Alliance) – won a three-year Center for Medicare and Medicaid Innovation Health Care Innovation Award (HCIA) to support the organization’s study on “Community Behavioral Health Homes for Individuals with Serious Mental Illness.” This study uses Bosch Healthcare’s Health Buddy Telehealth System (Health Buddy) along with the Dartmouth-developed Integrated Illness Management and Recovery (IIMR) training curriculum to integrate health care and behavioral health care for individuals with serious mental illness and chronic medical illnesses utilizing real time feedback.
  • Vinfen was introduced to the Health Buddy by Dr. Steve Bartel and his team at Dartmouth Medical School. Vinfen and Dartmouth have maintained a decade-long partnership anchored in a shared focus on emerging best practices and innovative health solutions for those with serious mental illness. Dartmouth is also a partner in the HCIA study grant.
  • The Health Buddy is a small device with four buttons and a display screen designed to help individuals manage their physical and mental health needs on a daily basis, identify potential risks and work as a team with providers. Each person utilizing the Heath Buddy is assigned an individualized series of daily questions based on their physical and behavioral conditions. The data from each Health Buddy session is coded by algorithms based on level of urgency and sent to a dedicated nurse practitioner for review and action to ensure proper disease management.
  • Once enrolled in the study, individuals are given the Health Buddy device to use in their homes at no financial cost, as costs associated with the Health Buddy are covered for study participants under the HCIA.
  • The Health Buddy and IIMR systems study aims to teach individuals with serious mental illness how to help manage their chronic medical conditions and access care sooner to try to avoid more severe complications.
In addition to the Health Buddy, Vinfen is engaged in a variety of innovative approaches, including:
  • Integrating Nurse Practitioners and Health Outreach Workers into existing community based psychiatric rehabilitation and recovery teams to merge physical and behavioral health care.
  • Continuing to develop close relationships with local hospital providers, research institutions and government agencies to better coordinate care among individuals’ various care providers.
Administrators at the Massachusetts Mental Health Center and Harvard Medical School, who sought to provide residential services for people with developmental disabilities and mental illness, founded Vinfen in 1977. Vinfen is a non-profit organization that provides a comprehensive array of services to people of all ages with psychiatric, developmental and behavioral disabilities. Vinfen operates more than 300 programs in eastern Massachusetts and northern Connecticut.
  • Preliminary findings suggest that roughly one-third of Vinfen’s study participants (n=30)8 use the Health Buddy Telehealth System 85% of the time, and 10-15% of participants use the system 90% or more of the time.
  • Vinfen estimates that using the Health Buddy often results in participants providing more truthful and frequent answers to questions that they may not have wanted to otherwise, or were too embarrassed to tell their treatment teams face-to-face.
  • Vinfen’s Nurse Practitioners report that more than 35 emergency room visits have been directly averted since the start of the study in 2012.
  • Vinfen estimates that use of the Health Buddy may save the health care system $3.79 million over a 3-year period.

References:

  1. (2010). Health Care Access. Health of Massachusetts, Commonwealth of Massachusetts Department of Public Health. Retrieved October 4, 2013 from: http://www.mass.gov/eohhs/docs/dph/commissioner/health-mass.pdf
  2. (2011). Quarterly Census of Employment and Wages. U.S. Bureau of Labor Statistics. Retrieved October 4, 2013 from http://www.bls.gov/cew/home.htm.
  3. The Commonwealth of Massachusetts. (2012). Department of Mental Health's 2012-2013 State Mental Health Plan. (OMB No. 0930-0168). Boston, MA: Department of Mental Health.
  4. (2012). Fact Sheet on Accelerating Integration of Primary Care, Behavioral Health and Prevention: The SBHA Role. National Association of State Mental Health Program Directors. Retrieved October 4, 2013, from http://www.nasmhpd.org/docs/Policy/Behavioral%20Health%20Primary_Fact%20Sheet%20Accelerating%20Integration%20of%20Primary%20Care.pdf.
  5. (2013). The History of the Department of Mental Health. Health and Human Services: Departments & Divisions. Retrieved October 4, 2013 from http://www.mass.gov/eohhs/gov/departments/dmh/about-the-department-of-mental-health.html.
  6. Rosemarie K., et al. (2012). Attitudes Toward Mental Illness. Centers for Disease Control and Prevention. Retrieved October 4, 2013 from http://www.cdc.gov/hrqol/mental_health_reports/pdf/brfss_report_insidepages.pdf
  7. (2013). Mental Health. Centers for Disease Control and Prevention, Office of Information Services. Retrieved October 4, 2013 from http://www.cdc.gov/nchs/fastats/mental-health.htm
  8. Internal Vinfen Document: CMMI HCIA Presentation

The project described is supported by Funding Opportunity Number VMS-1C1-12-0001 from Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation. The contents of this publication are solely the responsibility of the authors and have not been approved by the Department of Health and Human Services, Centers for Medicare and Medicaid Services.

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Advancing Service Integration in Bexar County, TX

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With limited state resources available to address mental health, Texas ranks 50th among states and the District of Columbia for mental health agency spending per capita.1 Throughout the state, non-violent individuals with serious mental illness are often “trapped” in the criminal justice system with few alternatives.2, 3 Bexar County experienced massive jail overcrowding and significant issues of homelessness, which can be problematic for an economy dependent on tourism. 4,5,6
To address the emerging crisis facing Bexar County, The Center for Health Care Services (CHCS) pioneered a number of integrated services intended to improve the care of individuals with serious mental illness:
  • Its Bexar County Jail Diversion Program diverts non-violent individuals with serious mental illness from incarceration to treatment and crisis services outside the criminal justice system.
  • CHCS built a 24-hour Crisis Care Center (CCC), which receives individuals exhibiting signs and symptoms of serious mental illness from law enforcement 24/7 and diverts them away from jails and the streets into treatment and recovery centers. By integrating this program with local law enforcement training and providing incentives for officers, CHCS has made it possible for officers to “drop off” individuals with serious mental illness at the CCC for care rather than bringing these individuals to jails or emergency departments, which is costly to the local health care system and time-intensive for officers on active patrol duty. Based on the program’s success, CHCS’s Crisis Intervention Team training is now mandatory for patrol officers.
  • To encourage stability and the pursuit of treatment, CHCS also provides housing with close accessibility to the organization’s behavioral and physical health support services.
  • CHCS’s Restoration Center provides medical detox and a broad array of substance abuse services as well as sobering services and medical clearance screening. The Restoration Center also supports homeless individuals struggling with substance abuse and people experiencing serious mental illness by integrating psychiatric care, transitional housing systems and general health services.
In addition to promoting service integration, CHCS employs several communication strategies to generate support for programs and funding, including:
  • Meeting with various stakeholders beyond the mental health community once a month to discuss concerns and develop solutions related to mental health resource utilization and spending.
  • Securing private and public funding by quantifying how CHCS has leveraged resources and tied outcomes to success metrics to demonstrate cost savings to the community, state and nation.
  • Tailoring outreach for mental health funding and support to each audience (i.e., focusing on cost savings when talking to politicians and public health benefits when speaking to third party advocates).
In 2000, CHCS began a series of initiatives to improve the public safety net and the lives of people with mental illnesses, developmental disabilities and substance abuse challenges. CHCS strives to reduce the overrepresentation of individuals with mental illnesses in inappropriate settings by integrating with community stakeholders and providing a comprehensive suite of services.
  • The Bexar County jail — once so overcrowded that the county had to consider whether it needed to build another jail — now routinely has a surplus of roughly 1,000 empty beds due in large part to CHCS’s efforts.
  • The U.S. Substance Abuse and Mental Health Services Administration has hailed the successes of CHCS’s jail diversion program, noting CHCS is “transforming the way mental health services are delivered.”7
  • CHCS has:
    • Saved Bexar County an estimated $9 million annually in jail costs and inappropriate emergency room admissions — close to $50 million alone in savings to the community since 2008.
    • Trained more than 2,500 law enforcement officers in working with people living with serious mental illness, which is more than half of the officers in Bexar County.
    • Diverted more than 1,100 people per month from jails or hospitals.
    • Assisted more than 21,000 individuals in total through its various initiatives.
    • Provided safe sleeping areas for more than 700 individuals at its Prospects Courtyard.

References:

  1. (2010, September). Table 1: SMHA Mental Health Actual Dollar and Per Capita Expenditures by State, FY 2010. National Association of State Mental Health Program Directors Research Institute, Inc.. Retrieved October 4, 2013 from http://www.nri-inc.org/projects/Profiles/RevExp2010/T1.pdf.
  2. (2010). Another Look At Mental Illness and Criminal Justice Involvement in Texas: Correlates and Costs. Texas Department of State Health Services, Decision Support Unit Mental Health and Substance Abuse Services. Retrieved October 4, 2013 from website: http://www.dshs.state.tx.us/mental-health/.
  3. (2008). Solutions to jail overcrowding problem are vast. County of Bexar, Office of Bexar County Commissioner Tommy Adkisson, Precinct 4. Retrieved October 4, 2013 from http://home.bexar.org/adkisson/docs/Symposium_LeonEvans.pdf.
  4. (2005). Treatment in lieu of jail: Diversion succeeds. Substance Abuse and Mental Health Services Administration. Retrieved October 4, 2013 from http://www.samhsa.gov/samhsa_news/VolumeXIII_3/article3.htm.
  5. (2010). Commissioners Pleased Jail Passes Inspection on First Round. Bexar County Commissioners Court. Retrieved October 4, 2013 from http://www.bexar.org/.
  6. Grantham, D. (2001). Right Place, Right Time, Right Approach: Texans Collaborate to Build a ’Model’ Jail Diversion and Crisis Mental Health System. Behavioral Healthcare, 31(8), pp. 14-19.
  7. Mann, A. (2006, May). Treatment in Lieu of Jail: Diversion Succeeds. Substance Abuse and Mental Health Services Administration News, 13 (3).

Advancing Continuity of Care in Los Angeles, CA

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High rates of homelessness and incarceration among individuals with serious mental illness are a major concern in the state of California.1, 2 According to the Los Angeles Homeless Services Authority, 24 percent of the homeless population within Los Angeles in 2009 was comprised of individuals with mental illness.3 Additionally, the Los Angeles County Sheriff’s Department reports that of the nearly 20,000 inmates housed daily within Los Angeles County jails, approximately 2,000 are diagnosed with a mental illness.4 Furthermore, the Los Angeles County jail system is typically thought of as one of the largest inpatient psychiatric facilities in the nation.2, 4 These figures reinforced a need for state-initiated programs to help alleviate the impact of serious mental illness on other aspects of society.
MHA Village (“The Village”) offers nationally-recognized support to the Los Angeles community by treating adults with serious mental illness and providing continuity of care (i.e., consistent care over time through a multi-faceted approach in which individuals receive the care that they need without significant gaps in coverage or treatment quality) in the following ways:
  • The Village focuses its services on individuals living with serious mental illness who frequently utilize expensive mental health services (i.e., emergency rooms, inpatient treatment following psychosis), with an aim of providing more consistent treatment and care to reduce costs and improve the quality of their lives.
  • The Village takes a comprehensive approach to continuity of care, providing care coordination, housing and employment assistance, psychiatric rehabilitation, substance abuse recovery and medication support, among other services.
  • The Village runs three businesses staffed by its members to help increase their self-sufficiency and community integration.
Along with its continuity of care approach, The Village employs the following strategies to assist those with serious mental illness:
  • Providing care coordination to improve members’ access to treatment for their physical health care conditions.
  • Hosting weekly Village Community Meetings for members to express their concerns, questions and thoughts.
  • Leveraging an influential community stakeholder living with a mental illness – Nancy Foster, the First Lady of Long Beach – as a spokesperson at community events and with local media to alleviate stigma related to serious mental illness.
  • Disseminating the organization’s continuity of care approach through training and consultation in California and nationally.
  • Advancing local and state policy efforts to strengthen mental health programs and services with the belief that focusing on policy is critical to reducing stigma associated with serious mental illness. The Village also advocates for policies that encourage supportive housing.
Founded in 1990, MHA Village was created by individuals in California who were not satisfied with the care their family members with serious mental illness were receiving in the public sector. MHA Village started as a pilot program to improve continuity of care for individuals with serious mental illness and is now a permanent program. Its parent organization, Mental Health America of Los Angeles, operates a number of programs serving people with severe and persistent mental illness in the greater Los Angeles area.
MHA (Mental Health America) Village’s approach to providing continuity of care was:
  • Selected by President George W. Bush’s New Freedom Commission as a promising model for study.
  • Recognized by President Bill Clinton as a program that “exemplifies best employment practices for people with psychiatric disabilities.”
  • Selected as the model for California’s Integrated Services for the Homeless Program (AB 34 and 2034), a statewide initiative that has demonstrated success in reducing homelessness and incarceration among people with mental illness.
  • Incorporated into the Mental Health Services Act of California.
A 2004 UCLA outcomes study on the effectiveness of MHA Village (unpublished, n=190), based on the 2003 California State Department of Mental Health report to the legislature on the AB34/2034 program, found that on average:5,6
  • Consumer days of psychiatric hospitalization decreased 74%.6
  • Days of homelessness decreased 78%.6
  • Days of incarceration decreased 66%.6
  • Days of full time employment increased 223%.6

References:

  1. Quigley, J., et al. (2001). Homeless in America, Homeless in California. The Review of Economics and Statistics, 83 (1), pp. 37-51.
  2. Quanbeck, C., et al. (2003). Mania and the Law in California: Understanding the Criminalization of the Mentally Ill. American Journal of Psychiatry, 160 (7), pp. 1245-1250.
  3. (2009). Housing the Homeless 2010 Annual Report. Los Angeles Homeless Services Authority. Retrieved October 10, 2013 from http://documents.lahsa.org/Communication/WebDocuments/flipbook/LAHSA_Annual_Report_2009-2010/lahsa-AR-2009-10.html .
  4. (2010). Jail Mental Health Services. The Los Angeles County Sheriff’s Department: Correctional Services Division. Retrieved October 10, 2013 from http://sheriff.lacounty.gov/wps/portal/lasd.
  5. California Department of Mental Health (2003, May). Effectiveness of Integrated Services for Homeless Adults with Serious Mental Illness. Retrieved October 10, 2013 from http://cooklibrary.towson.edu/helpguides/guides/APA_govLegal.pdf .
  6. Erickson, F. (2004). A Quality of Heart: Continuity, Change and Distinctiveness in Service Delivery at the Village, ISA. Unpublished Paper from The Graduate School of Education & Information Studies University of California, Los Angeles. Retrieved October 10, 2013 from http://mhavillage.squarespace.com/storage/erickson_quality_of_heart.pdf .