Silver Award: Providing Recovery-Oriented Early Intervention Services to Youths Experiencing First-Episode Psychosis
Psychotic disorders can be devastating, causing reduced life expectancy and high rates of disability. For young people, they can upend dreams for education, work, and social relationships. Fortunately, a growing body of evidence indicates that early intervention can dramatically improve outcomes among young persons with first-episode psychosis (FEP).
The OnTrackNY program at the Washington Heights Community Service (WHCS) is a pioneer in this rapidly evolving field, providing evidence-based, recovery-oriented treatment for up to 50 young adults with FEP. The OnTrackNY model was created by a team led by Lisa Dixon, M.D., M.P.H., Director of Behavioral Health Services and Policy Research at Columbia University Medical Center, and grew out of the Recovery After an Initial Schizophrenia Episode (RAISE) Implementation and Evaluation Study, which was funded by the National Institute of Mental Health. OnTrackNY represents the commitment of the New York State Office of Mental Health to beginning a process of scaling up early-psychosis services statewide, with the goal of linking clients to the program no later than two years after the beginning of psychotic symptoms. Treatment is provided by a team of specialists and includes a wide array of interventions designed to limit disability and optimize recovery. Treatment decisions are made through a process of shared decision making and involve family members as much as possible.
Key measures indicate that the program is achieving its goals, according to WHCS Director Jean-Marie Bradford, M.D. Between 88% and 98% of clients maintained enrollment and every participant has received at least one visit in the community from a team member in the first year of treatment, she said. Through this high engagement, the program has been able to decrease the percentage of participants with one or more visits to the emergency room (ER, from 80% of participants on admission to the program to 14% over the course of treatment. It has also been able to decrease inpatient hospitalization rates, falling from 66% to 10% of participants with one or more hospitalizations over the course of treatment.
After one year of treatment, 84% of participants were in school or working, more than double the percentage of clients (40%) engaged in school or work on admission to the program. Over the course of treatment, participants increase their quality of life rating from “mostly dissatisfied or mixed” to “mostly satisfied or pleased.” On average, clients have enrolled within six months of the onset of psychosis, significantly faster than the national standard. “Recovery from a first episode of psychosis is an attainable reality for the young people enrolled in our program,” said Program Director Nannan Liu, Ed.D., L.M.H.C.
In recognition of its commitment to providing recovery-oriented early intervention services to youths experiencing FEP, OnTrackNY/WHCS was selected to receive APA’s 2016–2017 Silver Psychiatric Services Achievement Award.
Limiting Disability/Optimizing Recovery
Delays in treatment of FEP can have devastating effects. Research indicates that longer duration of untreated psychosis predicts poorer treatment response; worse global, vocational, social, and cognitive functioning; greater positive and negative symptom severity; higher risk of relapse; and lower quality of life. Treatment is often too fragmented to halt the debilitating effects of psychosis and prevent long-term dependence on the mental health system.
OnTrackNY/WHCS uses assertive outreach strategies that place a high priority on engaging and retaining clients in treatment, with the support and participation of clients’ families whenever possible. Most treatment takes place in the program’s youth-friendly office, but clinicians make community and home visits and allow for flexible and after-hours scheduling and crisis work. “We have found that these approaches have allowed our participants to view this program as safe, helpful, and open to their unique needs,” said Dr. Bradford. Services are provided in individual and group formats according to clients’ preferences, and no treatment component is mandatory.
The program is based on the coordinated specialty care (CSC) model, a multidisciplinary team approach for reducing relapse and long-term disability among youths with FEP. The CSC model was shown to be effective at two pilot sites funded in 2008 by the National Institute of Mental Health, one of which was located in New York. Based on the pilot’s success, the New York State Office of Mental Health earmarked state funds to expand FEP services. In 2013, CSC programs were established at four locations in New York, including the WHCS, a community-based clinical service associated with the New York State Psychiatric Institute. The state’s CSC program was named OnTrackNY to epitomize its positive and hopeful mission.
The treatment approach is person centered and highly individualized. It celebrates the strengths of each young person. The staff of 4.4 full-time-equivalent professionals works closely with the client to set goals and improve wellness. Two full-time primary clinicians provide individual and group cognitive-behavioral therapy, family outreach, and education designed to promote recovery and social skills and avoid relapse. Weekly psychosocial groups target common impediments to full recovery, focusing on integrating clients into the OnTrackNY/WHCS community through social skills and self-advocacy training, family education and support, and exercise and wellness. A supported education/employment specialist, also full-time, helps clients achieve educational and occupational goals by tapping community resources and opportunities. Dr. Liu is an experienced clinician who provides administrative oversight and staff supervision as well as direct treatment. Other members of the team include a psychiatrist; a nurse; and an outreach and recruitment coordinator, who helps decide if the program is a good fit for prospective clients; and a peer specialist whose lived mental health experience enables him to connect with participants, instilling hope and model goal attainment. The director of the WHCS serves as the program manager, providing administrative oversight to the team and supervision to the program director and psychiatrist.
Use of antipsychotics is influenced by shared decision making, and every effort is made to use the lowest effective dose in order to minimize side effects, especially cardiometabolic side effects. The OnTrackNY/WHCS nurse is also a registered dietician and provides support for use of intramuscular medications and nutrition and wellness education and management. The nurse conducts routine lab work to monitor for hypertension, diabetes, and other conditions, and the team coordinates primary care linkages to the integrated WHCS primary care provider or community primary care providers according to client preference. Case management helps clients and their families meet concrete needs, such as for health insurance and housing, and connect clients to outside resources.
Clients are largely Hispanic or African American, and most are young men with an average age of 21. They remain in the program for up to two years. Most participants have Medicaid, but more than one-third have private or other insurance, and 3% are uninsured. Services are provided to referred individuals meeting clinical admission criteria, without wait lists and regardless of their insurance status or ability to pay. Funds for staffing, nonpersonnel expenses, and training and technical assistance are provided by a combination of federal and state funds.
Shared Decision Making
Shared decision making is the framework for maintaining engagement with clients, even those as young as 16. Nowhere is this more apparent than in the goal setting process. “Young adults almost always have school- and work-related goals,” said Dr. Bradford, “and whenever possible, these goals drive treatment planning.” During cognitive-behavioral therapy, the client works with the primary clinician to identify personal goals. The supported employment specialist helps the client to realize these goals, identifying community resources and opportunities that can facilitate rapid placement in the desired work or school setting.
Shared decision making is also used to decide whether the client will participate in individual or group therapy or attend therapy at the clinic or in the community. The decision to use medication is also part of a shared decision-making process.
The client is viewed as the central team member, said Dr. Bradford, but families are involved in shared decision making. Clinicians encourage family involvement in treatment planning and ongoing care and assist family members to forge a collaborative relationship with all team members. Families are also offered more formal services, including individual and group psychoeducation and consultation. “Family involvement is an essential part of treatment,” said Dr. Bradford.
A Rapid Pathway to Care
Four years after opening its doors, OnTrackNY/WHCS is now at the forefront of a national effort to improve outcomes among persons with FEP by providing a rapid pathway to specialized early intervention services. It is among the most popular clinical sites for the public psychiatry outpatient clinical rotation for Columbia University Department of Psychiatry’s residents. LaCheryl Smith, M.D., the OnTrackNY/WHCS psychiatrist, supervises four residents in their third and fourth years. “This generation of trainees will soon be the leaders of our field, and the opportunity to engage them in this learning is exciting and hopeful for the future of psychiatry,” said Dr. Bradford. “We hope that we can instill in these trainees not only the clinical skills to manage psychotic disorders in the outpatient setting, but also the care, compassion, and respect with which we approach our participants,” she added.
