In recent decades, the organization of mental health services for individuals with serious mental illnesses has changed dramatically, partly driven by shifts from institution- to community-based treatment. As a result of the restructuring of health care services and shorter stays in psychiatric hospitals, more people with serious mental illnesses now live much of their lives in the community. Yet most communities have inadequate resources to assist them, and many consumers endure repeated hospitalizations. Engagement in effective outpatient treatment reduces recidivism—a relapse that results in inpatient readmission—and therefore such treatment is an appealing alternative to costly inpatient care.
Assertive community treatment (ACT) is one effective approach to reducing repeated hospitalizations (1). Although studies have demonstrated that ACT reduces hospital readmissions, little research has focused on other collaborative, community-based programs to reduce recidivism, especially recidivism that encompasses hospitals, detention facilities, and homelessness. In addition to ACT and related community support teams, peer support programs represent a relatively recent innovation in community-based services. In Georgia, a certified peer specialist program combines consumer-provided services and consumer advocacy and has resulted in consumer influence on policy (2). Certified peer specialists help consumers direct their own recovery and make use of resources in the community, while providing colleagues with personal insights into serious mental illnesses and factors that facilitate recovery.
Informed by ACT and the peer support movement, Opening Doors to Recovery in Southeast Georgia (ODR) is a broadly collaborative program designed primarily by the Georgia affiliate of the National Alliance on Mental Illness (NAMI-Georgia) with input from diverse stakeholder agencies and organizations in academic, public, and nonprofit sectors. The program addresses recidivism among high utilizers of the Georgia Regional Hospital at Savannah (GRHS) and of three crisis stabilization units (CSUs) in the region. More generally, the program addresses recidivism in terms of hospitalization, incarceration, and homelessness. As an exemplar of a public-academic partnership (more accurately, a public-private-not-for-profit-academic partnership), the program seeks to reduce the number of days spent in inpatient units or detention facilities or days homeless in an initial sample of 100 participants with serious mental illnesses discharged from GRHS or the CSUs in the region. In this way, ODR aims to enhance community integration, support consumers in developing a meaningful day, ensure access to adequate treatment, and facilitate stable housing, improved relationships, and desired vocational, volunteer, or educational activities.
The partnerships that created ODR saw the need for such a program during a unique mix of successes and crises within the state. Obtaining grant support and conceptualizing the project were greatly influenced by two successful programs in an otherwise troubled state mental health system—Georgia's crisis intervention team (CIT) program and the state's peer specialist accomplishments. Local and state cooperation to create ODR was facilitated by relationships and confidence established previously by the success of the CIT program (3), a collaboration between law enforcement, advocacy, and mental health systems. Because several local NAMI-Georgia chapters had successfully built community collaborations and had earned a reputation for educating, advocating for, and supporting police officers, local partners in CIT were eager to assist in addressing recidivism. Similarly, peer support programming is a successful collaborative effort in Georgia (2), which greatly influenced the conceptualization of the ODR program.
Although these successes appear to have provided proof to the various partners that success was possible, the more palpable motivation behind ODR was a sense of crisis in the state, particularly as perceived by advocacy groups and community mental health care providers. A precipitating event was a plan by state government to close the state hospital in Savannah. The hospital leadership, law enforcement, local government, advocates, and community providers were united by concerns that alternate resources in the community would not be adequate. The partners in the ultimately successful campaign to resist the hospital closure collaborated on a regional plan to offer to the state government as a blueprint for community mental health services. Many proposals for adequate community alternatives to hospitalization were subsequently taken up by NAMI-Georgia and incorporated into ODR. The diverse partners involved in ODR hope that the program will set the tone for success in future programs in Georgia and in other states aiming to address deficiencies in both hospital- and community-based services.
The partnerships appear to be sustained by a spirit of collaboration and pride derived in part from success stories. The collaborative spirit of ODR is exemplified by grass-roots efforts to engage local legislators, mayors, chiefs of police, sheriffs, judges, faith-based communities, mental health care providers, emergency departments, and higher educational institutions in the 34-county region of Southeast Georgia. Such relationships are crucial to the program's work, which partly consists of mapping all accessible and reliable resources in the region to facilitate recovery. Program leadership is multidisciplinary, with contributions from various local partners, including housing, social services, employment, recreation, and transportation agencies, uniquely positioning the program to support consumers' recovery.
Ongoing partnering—for example, bimonthly blue-ribbon task force meetings—is maintained in part via a spirit of initial accomplishment. NAMI-Georgia has served as the organizational champion of the program. Personal stories about how loved ones no longer endure repeated hospitalizations, incarcerations, and homelessness and have secured safe housing undoubtedly invigorate stakeholders.
The key innovation of ODR is the use of a team of community navigation specialists, or simply navigators, including a licensed mental health professional (social worker), a family member of an individual with a serious mental illness, and an individual in recovery (a peer specialist with lived experience of having a serious mental illness). Because mental health care consumers generally have the same aspirations as the rest of the population—meaningful work, decent housing, friendships, good health, financial security, and an acceptable quality of life—ODR focuses on helping participants develop a meaningful day, establish safe housing, and access adequate treatment. Navigators are trained in and committed to providing extensive community-based, wrap-around navigation services for consumers being discharged from inpatient care who have a history of recidivism.
The navigators' curriculum is a month-long training focused on tenets of recovery, considerations of whole health and resiliency, and in-depth exposure to local resources. The curriculum was developed with extensive input from the Georgia Mental Health Consumer Network and the Appalachian Consulting Group, which started the peer support movement in Georgia. The trained navigators serve as a case management team but with more broadly defined goals and strategies than those of traditional case management. In addition to providing typical case management services, such as health care coordination, consumer and family education, resource identification, referrals for financial needs, and identification of other recovery supports in the community, there are several innovations that make this model novel. The most prominent innovation is the unique team approach. All three team members together support the consumer's recovery, although each brings different experiences. For example, although the mental health professional may be experienced in connecting consumers to diverse social services, the family member is uniquely positioned to address families' concerns and needs. The peer specialist plays a major role in supporting recovery, because of his or her personal experience. A peer perspective in both the training and the composition of the navigator team may be especially important in promoting sustained empowerment of participants to help them achieve eventual independence of the project and the services it provides.
Several other features make ODR novel, and indeed cutting edge, six of which are noted here. First, through collaboration with the Georgia Bureau of Investigation, and after in-depth informed consent processes with the consumer, any Georgia law enforcement officer who has an encounter with an ODR participant will receive an automated notice when checking the state's computerized criminal history database, stating, “This individual is a participant in the Opening Doors to Recovery Project. Call 1-800 …” This unique communication between sectors is designed to reduce incarceration and rapidly reconnect consumers with their navigator team if they become entangled in a police or criminal justice situation. Second, an electronic recovery record is being piloted with participating consumers. This secure, Web-based application includes a centralized repository of consent forms, psychiatric advance directives, recovery plans, service logs, safety plans, and other documentation and provides navigators and consumers access to recovery plans. Third, navigators are fully connected to the Internet and have access to rapid communication with services and consumers through personal electronic devices. Consumers also receive such devices when indicated as part of their personal recovery plan. Fourth, grant support from CSX Corporation ensures that participants have adequate access to transportation services, a commonly unaddressed barrier to recovery in rural and remote regions. Fifth, a close partnership with the Georgia Department of Labor facilitates enhanced capacity for linking participants with employment opportunities. Finally, the project strives to educate the community to recognize signs and symptoms and to find help for someone dealing with a mental illness, while empowering the community to actively support people with serious mental illnesses who are in crisis.
ODR—with its chief innovation of the team-based navigator model—aims to improve efficiencies and practices for the purpose of transforming the public mental health care system in this region, ultimately enabling adults with serious mental illnesses to engage in a recovery-based model that will assist them to live, work, learn, and participate fully in their communities. The overarching goal is to reduce recidivism to inpatient units, local jails, and homelessness. In an effort to improve the standard of care for people with serious mental illnesses, not only in the southeast region of Georgia but potentially throughout the state, partnerships with multiple state agencies have considered sustainability from the beginning. Because Georgia recognizes peer support as a Medicaid-billable service, ODR leadership is working with the Community Service Boards and Georgia Medicaid with an ultimate goal that if effectiveness is demonstrated, navigators' services will become reimbursable, which would extend services to many more who could benefit from the new model.
A research project runs parallel to the navigator program to establish an initial evaluation and evidence base. Designed and implemented by an academic partner with separate funding from the Bristol-Myers Squibb Foundation, a qualitative program evaluation will be conducted, as well as a study involving 100 participants who meet specific eligibility criteria (for example, discharge from GRHS or a CSU after a stay of two or more nights and a prior stay of two or more nights within the past six months). In addition to longitudinal data collection, one-year retrospective data will allow for a quasi-experimental design in which participants serve as their own historical controls. It is hypothesized that the 100 consumers will have fewer days of hospitalization, incarceration, and homelessness while receiving the services from the navigator team for one year, compared with the year before enrollment.
Opening Doors to Recovery in Southeast Georgia represents a novel, advocacy- and grassroots-initiated, multidisciplinary, multiagency, collaborative effort to address an unmet mental health services need for the region's most seriously disadvantaged individuals with serious mental illnesses. Initial funding was complemented by funding for academic research that will objectively evaluate the program from several perspectives. The navigator model resembles several empirically validated approaches, such as ACT, community support teams, and peer support programs. However, it differs in the composition of the team (for example, by including a family member with experience in the complexities of navigating care systems), in some of the main objectives of the service (for example, by focusing on helping consumers develop a meaningful day), and in the level of engagement not only with the consumer but with numerous agencies within the region (for example, criminal justice, banking, education, and transportation services). In light of the scope of engagement between the participating consumers and the navigators, it should be noted that issues around confidentiality and professional boundaries must be continuously considered. Issues pertaining to Health Insurance Portability and Accountability Act regulations have also been carefully addressed through legal consultation.
Few mental health services approaches have focused on the problem of recidivism among individuals with serious mental illness, especially recidivism in terms of incarceration and homelessness—that is, beyond psychiatric rehospitalization. Although community support teams and peer specialist programs are effective models for some key outcome domains, the use of community navigation specialists may offer special advantages by virtue of the diverse experience of the navigator team members, their specialized training that includes extensive consumer input, and the level of community engagement they enjoy. In partnering with university-based researchers, the program strives for empirical evaluation from the outset. Through this public-private-not-for-profit-academic partnership, ODR aims to support community-based recovery for an initial group of consumers, with the goal of establishing an evidence base and ensuring long-term sustainability.
Both ODR and the research study are funded by grants from the Bristol-Myers Squibb Foundation.
The authors report no competing interests.