2004 APA Gold Award: Involving the Community in the Rehabilitation of Persons With Serious Mental Illness

In the early 1980s, adults with mental illness who lived in the Atlanta area faced a void as they tried to bridge the gap between hospitalization and community life. In their quest to prevent relapse and achieve recovery, they found that no intermediate services were available. A prominent local businessman who was nearing retirement learned about the plight of these individuals through a friend whose family had first-hand experience with mental illness. He saw an opportunity to fulfill one of his personal goals: to make a real difference to a community cause associated with great need but scarce resources. In 1982 he established the George West Mental Health Foundation to fulfill his dream.

Skyland Trail, a community-based program aimed at providing high-quality rehabilitation services to help clients become independent and reintegrate into community life, opened in 1989 and quickly became the Foundation's identity in the Atlanta area. The next decade saw rapid growth in Skyland Trail's programs, treatment options, and facilities. In 1991 a funding campaign raised $500,000 to establish a community-based case management program and independent living options. The board and staff adopted a forward-thinking approach, implementing an ambitious long-range plan in 1995, in effect inventing a new treatment and service delivery model that emphasized comprehensive community-based therapy. Such a plan required heavy capital investment. It called for focusing the original residential treatment center exclusively on individuals who needed long-term treatment. A separate residence for short-term clients was also needed. Most ambitious of all, the plan proposed a large freestanding day treatment facility to serve both residential and community-based clients. Over the next three years, a capital campaign exceeded its $12 million goal by raising $13.5 million from the private philanthropic community.Today, in accordance with this plan, the Skyland Trail program encompasses three unique, freestanding facilities. The Health and Education Center (HEC)—a day and evening psychiatric rehabilitation treatment facility encompassing 30,000 square feet with the capacity to serve up to 100 adult clients daily and consisting of two buildings complete with extensive gardens and a greenhouse—opened in 1999 without debt and on schedule. Skyland Trail South—a 10,000-square-foot personal care home adapted for re-use as a voluntary residential treatment facility that serves up to 24 short-stay clients—opened in 2000, also without debt and on schedule. Skyland Trail North—the original facility that opened in 1989—is a 13,740-square-foot apartment complex adapted for re-use as a voluntary treatment facility and serves up to 22 longer-term clients.In recognition of Skyland Trail's remarkable success in attracting community involvement and funding for a full range of rehabilitation services for adults with serious mental illness, the American Psychiatric Association has selected Skyland Trail as winner of the 2004 Gold Achievement Award in the category of small community-based programs. The winner for large academically or institutionally sponsored programs is described on page 1168. The awards will be presented on October 6 during the opening session of the Institute on Psychiatric Services in Atlanta. Each winning program will receive a plaque and a $10,000 prize made possible by a grant from Pfizer, Inc.

Model of care

Skyland Trail developed through the efforts of volunteers from the psychiatric, business, and religious communities who embraced the concepts of recovery and reintegration. Their efforts resulted in a unique, privately funded rehabilitation network offering day and residential treatment, vocational services, dual diagnosis services, case management and transitional services, and family support. In these programs, the strengths of the client are emphasized to overcome, compensate for, or minimize the impact of psychological deficits. A client-specific biopsychosocial approach to treatment balances the medical model, including medication and therapy, with the educational model of treatment that helps clients learn new skills and socialization capabilities. Clients move through a continuum of care that first focuses on achieving stability by treating symptoms and then progresses to rehabilitative therapies and development of skills in preparation for reintegration into society. The expectation for each client is attainment of the highest possible level of social functioning and personal satisfaction.

Within this integrated model of care, a broad range of therapeutic tools are used to promote recovery, as outlined below.

Assessment and treatment planning

Upon admission, the client undergoes an in-depth evaluation of symptoms and disabilities. With input from the client and from his or her private psychiatrist and family members, a comprehensive treatment plan is developed around the client's needs and goals. A primary counselor supervises the client's progress and adapts the plan as recovery proceeds, leading a team of medical, therapeutic, and other staff who have an ongoing role in the client's treatment.

Individual counseling

Each client attends a weekly session with his or her primary counselor to review progress in treatment, adjust the treatment plan, and address and update individual needs. These counseling sessions are tailored to each client's cognitive capacity.

Therapeutic groups

Group learning activity is central to the process of recovery at Skyland Trail. As a client gains essential skills and insights, natural socialization takes place. The variety of therapeutic groups allows clients to engage at different stages of readiness for group work.

Mental health education groups help clients grasp the importance of medication self-management, overcome denial of illness, identify warning signs of relapse, and eliminate barriers to recovery. Proper use of psychiatric medications, the importance of adherence, and potential side effects are part of the curriculum.Groups to enhance coping skills utilize a number of approaches, including cognitive and dialectical behavior therapy techniques to teach clients to manage symptoms and to deal with deficits in areas such as attention, memory, decision making, problem solving, and management of anger and stress.Life skills training groups teach the skills necessary for managing a home and functioning independently. Cooking, nutrition, budgeting, using public transportation, and personal grooming are among the topics addressed in group sessions.Unique adjunctive therapies promote self-expression and self-awareness and also encourage nonstressful interaction with others. These include horticultural therapy, expressive art, and recreation therapy. Skyland Trail's horticultural therapy program has emerged as one of the nation's leading programs. Through this therapeutic modality, clients improve their social and cognitive skills as well as their psychological health and well-being. The program is also used to teach clients job skills. Each year, Skyland Trail hosts a special event for the community—"Arts in the Garden"—in collaboration with other mental health organizations. Held in Skyland Trail's expansive gardens, the event promotes mental health awareness in the community by showcasing clients' artwork and musical and dramatic performances.Expressive arts include painting, drama, and music therapies, which provide opportunities for self-expression, improved social skills, and insights from personal thoughts and feelings. Painting, poetry, photography, and woodwork are examples of the types of groups offered.Clients participate in group and individual therapeutic recreation activities in the on-site fitness center and gymnasium. Supervised groups help clients find comfortable roles, take risks, engage in teamwork, and extend themselves in a safe, nonthreatening environment, particularly in outings outside of Skyland Trail.

Vocational services

Being a productive member of the community is a defining point of recovery for most clients. The vocational services program is an integral component of the overall continuum of care at Skyland Trail and provides individual counseling, training, and assistance to help clients attain their personal goals. Despite the persistent nature of the illnesses of many of Skyland Trail's clients, the vocational services program has had impressive results, with 51 percent of the program's clients employed or participating in work adjustment, 14 percent participating in volunteer work in the community, and 36 percent attending school. A client-run coffee shop, Java the Hut, was implemented in 2001, made possible by a grant from a private foundation, and another—a holiday gift shop—in 2003.

Life enrichment adult program

Skyland Trail also offers a life enrichment adult program (LEAP), a social and recreational program that encourages social interaction through a variety of activities, creative arts, and outings, allowing clients to practice activities of daily living and address the challenges they have traditionally faced in socializing and making friends.

Family services

Skyland Trail has also introduced several unique programs to augment clinical treatment and group therapies. The family support, training, and education program (STEP) is a revolving 12-week program that provides extensive insight and information to families and caregivers. Through STEP, families develop a network of peers, helping to overcome the isolation and challenges that accompany being a caregiver. In 2002, Skyland Trail was one of five nonprofit organizations in the United States to receive the Rosalynn Carter Institute Caregiver Award in recognition of exemplary programs to support families and caregivers of persons with mental illness.

Dual diagnosis services

It is well recognized that, for some clients, traditional 12-step programs for addressing substance abuse are too confrontational. Skyland Trail's unique dual diagnosis program integrates best practices from research and clinical work in motivational enhancement, behavioral skills training, neurocognitive science, 12-step recovery programs, and relapse prevention. The program has been adopted by other service providers in the southeast.

Transitional services

Independent living is a primary goal of most Skyland Trail clients. As they advance in their recovery, clients move to more independent residential settings. In these settings, clients take responsibility for their care with moderate support from community-based case managers. Case managers make weekly in-home visits to monitor progress and provide assistance as needed.

Elements of a successful program

Innovative funding

As a private, nonprofit organization, the Foundation relies on various sources of income to support Skyland Trail's operations, including client fees, financial aid, and charitable contributions. In 2003, total revenue was categorized as follows: 54 percent client fees, 8 percent financial aid, and 37 percent charitable contributions. Of these charitable contributions, 47 percent were from individuals, 32 percent from private foundations, and 21 percent from businesses. Skyland Trail's ability to privately fund its programs—without public assistance—is a truly remarkable aspect of this project, one that helps to promote community awareness and alleviate the stigma so often associated with mental illness.

An active and committed Board of Directors and community volunteers spearhead major fundraising efforts, including an annual fund campaign, a planned giving program (the Cypress Society), an extensive grantwriting program, and a variety of special events. These events include the annual Skyland Cup golf tournament, the "Arts and Flowers" art auction, and the annual signature gala, "Benefits of Laughter." These development efforts net well over $1 million annually in donations for Skyland Trail, which is used to support client financial aid awards, staff and program enhancements, and capital improvements.The financial aid program was implemented in 1999 to ensure that all clients who seek treatment at Skyland Trail are given the opportunity to participate, even those who otherwise would not be able to afford treatment. Since the program's inception, the private philanthropic community has contributed $1 million. In 2003 alone, close to $300,000 was granted to 27 percent of Skyland Trail clients.

Excellence in staffing

Skyland Trail employs a multidisciplinary team with expertise in psychiatry, psychology, nursing, social work, counseling, pastoral counseling, horticultural therapy, recreational therapy, residential care, art and music therapy, and vocational services. The direct care staff of 41 is led by a medical director, who oversees the clinical care on a day-to-day basis, and three clinical managers specializing in day services, residential services, and community services. A low staff-to-client ratio (an average of 1:12) is maintained in all areas. The clinical team is supported by a strong administrative group with expertise in development, finance, marketing, and operations. In 2002 the Community Foundation for Greater Atlanta named Skyland Trail the winner of its "Managing for Excellence" award, a coveted nonprofit award recognizing excellence in leadership, management, and service delivery.

Skyland Trail is also involved in community and professional education and serves as a training site for a wide range of academic institutions both locally and nationally. Through these relationships, Skyland Trail attracts interns from the fields of psychiatry, psychology, social work, and counseling.

Community collaboration

Over the years, Skyland Trail has developed a variety of community relationships that are integral to its continued success, including a longstanding relationship with Emory University's department of psychiatry and behavioral sciences. Another unique aspect of Skyland Trail is its relationship with the psychiatric community, including collaboration with more than 80 psychiatrists who provide individual psychiatric services to the program's clients. In 2003 a professional advisory board comprising psychiatrists from the Atlanta area was established to advise on and support clinical programs. In 2004 Skyland Trail was able to further enhance services by incorporating another nonprofit, Compeer Atlanta, into its continuum of care. Compeer Atlanta, an organization that matches trained volunteers with adults with mental illness in therapeutic, one-to-one relationships, now operates under the Skyland Trail umbrella, serving 60 adults; there is a waiting list of more than 100.

Measures of a successful program

Census growth

Skyland Trail has served more than 1,100 clients in its 15-year history. Since the opening of the HEC in 1999 and the second residential facility, Skyland Trail South, in 2000, programs have experienced a 142 percent increase in the number of clients served and a 131 percent increase in total client days. The year 2003 ended with a record number of clients being served and residential facilities filled to capacity. Census growth in 2004 has continued, with a projected increase of 36 percent in the number of clients served. This growth has occurred despite a generally unstable national and regional health care market.

Outcomes

Key outcome indicators tracked are clients served and program effectiveness. Demographically, the gender distribution and average age of clients served at Skyland Trail is 45 percent female with an average age of 36 years and 55 percent male with an average age of 31 years. Approximately 90 percent of clients fall within four primary diagnostic categories: schizophrenia, schizoaffective disorder, bipolar disorder, and major depression. Length of stay varies within each program, with the overall average being 4.7 months. Programmatically, length of stay is as follows: long-term residential (Skyland Trail North), four months; short-term residential (Skyland Trail South), 2.5 months; day treatment, three months; intensive outpatient, five months; case management, five months; and LEAP, ten months. These data show that effective treatment of serious mental illnesses goes far beyond inpatient hospitalization to offer individuals the opportunity for community reintegration.

The clinical effectiveness of the programs is demonstrated by using assessments of psychopathology and functional ability. Specifically, Skyland Trail uses the Basis-32, Beck Depression Inventory, Beck Hopelessness Scale, Global Assessment of Functioning, and Multnomah Community Scale. In addition, postdischarge surveys are conducted with clients at 30-day, six-month, and one-year intervals to determine sustained functioning over time. Outcomes data show statistically significant improvement in all areas, including a reduction in symptoms, illness stabilization, a reduction in hospitalizations, and successful reintegration to the community.Client satisfaction is assessed with the Perceptions of Care survey, which is a measure of perceived quality of care. Clients' satisfaction with individual groups is also measured. Finally, providers and families are also invited to complete program and service evaluations on the client's discharge. These outcomes data are collected on a systematic basis—on admission, at discharge, whenever there is a change in level of care, monthly, quarterly, and annually—and are reported at monthly quality improvement meetings and quarterly board program committee meetings. Satisfaction ratings are very favorable, but any deficiencies are quickly identified, and a quality improvement team is formed to assess the problem and to make recommendations for improvement.

Plans for the future

Looking toward the future, the board recently adopted a strategic plan that includes three areas of focus. The first is to continue to provide clinically excellent programs and services through enhancement of existing treatment, collaboration with outstanding partners, and retention of high-quality staff. The second is to develop research and education capabilities that foster best practices and promote innovation in community-based mental health services. To that end, Skyland Trail and Emory's department of psychiatry are co-hosting a national symposium, "Innovations in Mental Health," in November 2004. Skyland Trail plans to increase recognition and awareness of its programs at the national and regional levels for the sake of serving clients and encouraging replication of the model.

For more information, contact Elizabeth E. Finnerty, Executive Director, Skyland Trail, 1903 North Druid Hills Road, Atlanta, Georgia 30319; e-mail, [email protected]; Internet, www.skylandtrail.org.