Gold Award: 24/7 Wraparound Services That Help Persons With Serious Mental Illnesses to Live in the Community

The era of warehousing patients with serious mental illness has long since passed, and good riddance. But replacing long-term psychiatric hospitalization with a better alternative has been challenging, especially for patients with serious mental illnesses.

In Baltimore, Chesapeake Connections has made significant progress in reducing psychiatric hospitalization among persons with serious mental illness by surrounding them with all the supports necessary to remain in the community. Key offerings include intensive case management, life skills training, housing assistance, money management, individual and group therapy, and general medical care. Staff are expected to do “whatever it takes” to help program members stay healthy and avoid hospitalization. That can mean responding to a 2 a.m. phone call when a member is anxious, locating a volunteer opportunity, or taking someone to a medical appointment.

Membership in the program is extended to individuals with only the most severe and persistent mental illnesses, said program director Denise Chatham. To be admitted, members must be a Baltimore resident and have been confined in a state psychiatric hospital for six or more consecutive months, have been hospitalized in a psychiatric unit at least four times within the past two years, or have been seen in an emergency room at least seven times in the past two years for a psychiatric reason. Put bluntly, said Ms. Chatham, “If not for this program, our members would be on the street or in jail.”

In recognition of its intensive wraparound services that help persons with serious mental illnesses to live in the community, Chesapeake Connections was selected to receive the 2018 Gold APA Psychiatric Services Achievement Award in the category of community-based programs.

24/7 Wraparound Services

Deinstitutionalization was intended to provide a robust network of community treatment centers that would replace the need for long-term psychiatric hospitalization. “But it hasn’t worked out that way,” according to Dan Martin, senior director of public policy at the Mental Health Association of Maryland. Because of a lack of treatment, people often end up on the streets and in trouble with the law, instead of where they belong—in the public health system, he said.

“We take a prophylactic approach to mental health care,” said Ms. Chatham. Services are provided 24 hours a day, year-round, by 47 dedicated professionals. The program currently enrolls about 166 people between the ages of 20 and 70, although most are between 35 and 65, with a fairly even split between men and women. Chesapeake Connections is supervised by Tim Allen, the division director of outreach services at Mosaic Community Services, a nonprofit provider of community-based mental health and addiction services and a member of the Sheppard Pratt Health System.

Intensive case management is provided by three clinical teams, each consisting of a coordinator; a team leader; five case managers who help members develop and implement a treatment plan; two team assistants who help members with medical appointments, shopping, and other day-to-day activities; and a licensed practical nurse and a half-time prescriber (either the program’s psychiatric nurse practitioner or psychiatrist) to manage health care. Each case manager is assigned to work with eight or nine members, with assistance from the team.

A team of coordinators provides a variety of life skills training and support, with each team member assuming responsibility for a different area. The life skills coordinator is in charge of creating and coordinating volunteer and educational opportunities, a peer support specialist facilitates peer support activities as well as social and recreational outings, and a vocational specialist coordinates supported employment services.

Specialists work with each clinical team to locate suitable and appropriate living arrangements—including board-and-care homes and independent housing—and help members access public benefits and prepare a budget. A therapist provides both individual and group therapy. Currently there are groups for co-occurring disorders, anger and stress management, and relationships as well as a men’s group and a women’s rap group.

Because most members battle one or more general medical conditions—such as diabetes or cardiovascular disease—the program employs a health support team to help members manage chronic diseases. The team consists of a nurse coordinator; a part-time acupuncturist; a part-time nutritionist, who teaches cooking classes and facilitates a group for members with diabetes or its risk factors; and a medical assistant responsible for tracking members’ health care appointments, medications, tests, and other medical procedures. Data entry, billing, and other activities are managed by three administrative assistants.

These wraparound services have helped members achieve stability after many years of cycling in and out of institutions. Just over half live independently in the community with the program’s intensive supports, and the remaining members are enrolled in supported housing. Members can continue receiving services for as long as they’re needed. In fact, a few members have been with the program since its founding in 1994. Many others have stayed in the program until they reached a point in their recovery where less intensive supports were needed. And some, understandably, have needed to receive services in other settings, such as nursing homes, due to their changed health status. A total of 426 unique individuals have been served since the program’s inception.

Member Choice

Honoring the individual needs of each member is an important value at Chesapeake Connections, a practice it calls “member choice.” Each individual has the right to chart his or her own course, said Ms. Chatham. Our job, she said, is to “help each member realize their unique hope, empowerment, self-responsibility, and meaningful life roles.”

Sometimes that involves helping members to take calculated risks, according to Andre Sturkey, coordinator of life skills. “We encourage members to imagine their “best life, but we don’t expect them to achieve their goals without help,” he said. Instead, staff practice “high risk/high support,” helping members think through potential risks and rewards, make an informed decision, and implement a plan.

Being able to use funds flexibly is an important tool for tailoring support services for different members. Most members have a primary diagnosis of schizophrenia, but a significant proportion have depressive and bipolar disorders as their primary diagnosis, and nearly 50% also have a substance use disorder. As one of only two capitation programs in Maryland, the program receives funding from the state’s Department of Health and Mental Hygiene based on a fixed monthly rate per member served. In fiscal year 2017, the program received a total of $4.5 million, which the program pooled to address individual member and staffing needs.

At the individual member level, funds can be used to address immediate needs or achieve personal life goals, whether that means covering prescription medications or paying for a college course. At the program level, flexible funding allows for creating a staffing structure that is responsive to the program population over time.

Evidence indicates that the flexible funding arrangement has led to significant improvements in quality of life, including a dramatic drop in the number of psychiatric hospitalizations. Between fiscal year 2005 and 2016, members had 24 collective admissions to the state hospital prior to their enrollment, compared with zero after enrollment. Prior psychiatric admissions to community hospitals dropped from 88 to 13. Between July 1, 2016, and June 2017, members made only 22 visits to the emergency department for a psychiatric issue and were incarcerated for just six days total. In all, only nine members required psychiatric hospitalization.

What’s more, members are living personally meaningful lives—25 are working in either paid or volunteer jobs and another eight are attending school. Members are encouraged to volunteer for “Pay It Forward” activities, individual and group community services that meet a one-time or ongoing community need. Along with the many social and recreational activities, volunteer activities help members to contribute to the vibrancy and well-being of their communities.

“This model is the world’s best for patients who tend to cycle in and out hospitals,” said Ms. Chatham. “It really keeps people living a life, whether it’s helping them get to school or helping them find volunteer or paid work.”

A Tradition of Innovative Treatment

As a member of the Sheppard Pratt Health System, Chesapeake Connections is part of a tradition of humane and innovative treatment of serious mental illness. Founded more than 125 years ago, Sheppard Pratt, originally called Sheppard Asylum, was an early proponent of recovery and wellness at a time when most institutions were shackling patients and calling them lunatics.

Everything about the facility, from its sweeping front lawn to its wide front porches, was meant to convey dignity and respect. Rather than restrain patients, Sheppard Pratt pioneered the use of therapeutic activity, engaging patients in art, music, and sports. The hospital was intended to ensure the “courteous treatment and comfort of all patients,” according to cofounder Moses Sheppard. “No patient was to be confined below ground,” he said, “[and] all were to have privacy, sunlight, and fresh air.” Treatment was to be curative, combining science and experience for the best possible results.

This same commitment to recovery permeates the downtown quarters of Chesapeake Connections. Although it occupies a decidedly grittier corner of Baltimore, the program shares Sheppard Pratt’s legacy as a welcoming and therapeutic environment. On any given day, members are likely to be found socializing with each other and enjoying a warm cup of coffee. It’s like family—a home away from home, according to one member who drops in about three times a week. Having spent many years as a patient at three different state mental hospitals, he appreciates the program’s basic services—giving him soap, helping him with hygiene, and getting him clothes. We all help each other out, he explained.

Staff can often be found in the program’s joint workspace, designed to encourage teamwork and cooperation. Given the challenge of doing whatever it takes to help members remain in the community, Chesapeake Connections has created an intensive team structure that promotes shared problem solving as well as shared responsibility for creating solutions—both for individual members and the program as a whole. Sharing a workspace facilitates quick communication as well as daily team sessions to identify priorities, discuss specific issues, plan and coordinate efforts, and assess results. If a clinical team needs backup, this is where they can arrange for help, ensuring that assistance is available 24 hours a day year-round.

Up to the Challenge

Despite its success, Chesapeake Connections faces many of the same challenges confronting other community mental health providers. Stigma continues to limit opportunities for persons with mental illness, as neighbors resist locating group homes in their communities or hospitals avoid treating psychiatric patients, often for financial reasons. Furthermore, insurers may not reimburse for mental illness in the same way as for other illnesses, said Ms. Chatham. “Insurance companies give you like five days to get better from your schizophrenia,” she said dryly.

Chesapeake Connections also grapples with the best way to help members manage diabetes and other chronic health conditions. Although members have been remarkably successful in avoiding psychiatric hospitalization, inpatient stays and emergency visits for purely medical reasons remain too high, said Ms. Chatham. Members were hospitalized for a medical reason for 175 days between June 2016 and July 2017, more than for psychiatric treatment. During that period, there were 140 emergency visits for medical reasons compared with only 22 for psychiatric treatment.

So far, the inevitable challenges facing Community Connections have served to strengthen the program’s commitment to its core values. “We must continually evolve to be effective and responsive to the individuals we serve,” said Ms. Chatham. As it evolves, however, the program will continue to do whatever it takes to help members live in the community, free to experience the simple pleasures that Moses Sheppard valued so deeply—privacy, sunlight, and fresh air.