Hunter College Silberman School of Social Work City University of …files.constantcontact.com/1f19db8e001/bce78da7-22da-4a83... · 2017-06-08 · 6/6/17 1 Background, Overview and

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Background, Overviewand Evidence

Daniel Herman Ph.D.Hunter College Silberman School of Social Work

City University of New York

CenterfortheAdvancementofCriticalTimeIntervention

Aims § Background§ Model description§ Evidence for effectiveness§ Implementation issues


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BACKGROUND AND RATIONALE


Fort Washington ArmoryMen’s Shelter, 1990s


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Transitions can result in discontinuity of support

multiple complex needsloss of supportive relationships

fragmented community servicesrisk of adverse outcomesCenterfortheAdvancementofCritical

TimeIntervention

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CTI aims to solidify supports as it spans the period of transition

CTI


critical time of transition?§ Loss of social support§ Lack of engagement

with services§ Exacerbation of MH &

substance use problems

§ Housing instability§ Return to hospital, jail,

shelter


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critical time of transition?§ Often characterized by

energy & renewed sense of hope

§ Barriers to successful community integration can be identified and removed

§ Consumers may be open to trying new strategies

§ Opportunity to establish long-lasting connections to the community


MODEL DESCRIPTION


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Guiding values§ Individualized§ Client centered§ Recovery oriented§ Harm reduction


CTI differs from traditional case management

Time limited PhasesFocused


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Model phases


Unlike some other approaches

• Timing of movement through phases is defined by program model NOTclient “readiness”


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Establish initial relationship before transition beginsPre-CTI


Implement transition plan while providing emotional support

Phase One

Transition


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§ Home visits§ “Introduce”

consumers to providers

§ Meet with caregivers§ Substitute for

caregivers

§ Help negotiate ground-rules for relationships

§ Mediate conflicts§ Build self-advocacy

skills§ Assess potential of

support system


Phase Two

Try-Out

Facilitate and test consumer’s problem-solving skills

andcapacity of the support system


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§ Monitor effectiveness of support system§ Modify as necessary § Less frequent meetings§ Crisis intervention and troubleshooting


Phase 1

Phase Three

Transferof Care

Terminate CTI services with support network

safely in place


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§ Consultation but little direct service§ Ensure key caregivers meet and agree on

long-term support system § Formally recognize end of intervention and

relationship


Focus areas are population-specific

§ Finances§ Housing crisis management§ Psychiatric treatment and medication

management§ Substance misuse § Family relationships§ Legal§ Other?


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What do we mean by “active linking”?

§ Developing relationships with community resources

§ Actively observing support network to identify problems

§ Mediating relationships to resolve problems

§ Waiting to see the response of supports in crises

§ Confirming long-term commitment by support network


EVIDENCE FOR EFFECTIVENESS


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“Interventions shown in well-designed and implemented randomized controlled trials, preferably conducted in typical community settings, to produce sizable, sustained benefits to participants and/or society.”


§ Randomized trial§ 100 men with SMI following shelter

discharge § 9-month intervention/18-month follow-up

Fort Washington ArmoryHomeless Men (NIMH)


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Probability of retaining housing over 18 months

0

0.2

0.4

0.6

0.8

1

0 6 12 18

Susser et. al, 1997, American Journal of Public Health

CTI

Usual

Month

CTI in the Transition fromHospital to Community (NIMH)

§ Randomized trial§ 150 men and women with psychosis following

discharge§ 9-month intervention/18-month follow-up§ CTI provided by hospital social work assistants


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Nights Homeless(mean)

PercentHomeless(endpoint)

CTI 31 5

Usual Services 41 19

Herman, D., et.al. (2011). A randomized trial of critical time intervention in persons with severe mental illness following institutional discharge. Psychiatric Services.


Date of download: 1/21/2013

Copyright © American Psychiatric Association. All rights reserved.

From: The Impact of Critical Time Intervention in Reducing Psychiatric Rehospitalization After Hospital Discharge

Psychiatric Services. 2012;63(9):935-937. doi:10.1176/appi.ps.201100468

Proportion of participants in two groups who had at least one night of psychiatric rehospitalization in any interval during the 18-month follow-up

Figure Legend:


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Percent of subjects who were homeless over follow-up period (ITT)

0

2

4

6

8

10

12

14

16

18

20

Control

Experimental

OR = 0.22 (.06, .88)

18months9months

Center for the Advancement of Critical Time Intervention

Nights Hospitalized

(mean)

Percent Hospitalized(endpoint)

CTI 81 18

Usual Services 107 27

Tomita, A., Herman, D. (2012) The impact of critical time intervention in reducing psychiatric rehospitalization after hospital discharge. Psychiatric Services, 63:935-937.


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Date of download: 1/21/2013

Copyright © American Psychiatric Association. All rights reserved.

From: Randomized Trial of Critical Time Intervention to Prevent Homelessness After Hospital Discharge

Psychiatric Services. 2011;62(7):713-719.

Critical time intervention or usual care participants with any homelessness during each follow-up interval over 18 months

Figure Legend:


0

5

10

15

20

25

30

35

Exp

Control

9months 18months

Percent of subjects who were hospitalized over follow-up period

OR = 0.11(.01, -.96)

Tomita, A., Herman, D. (2012) The impact of critical time intervention in reducing psychiatric rehospitalization after hospital discharge. Psychiatric Services, 63:935-937.


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Experimentalonly

Percent

None 19.5

1 or 2 24.73 to 5 28.66 or more 27.3

Pre-discharge worker contacts

Low-fi

High-fi


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0

2

4

6

8

10

12

14

16

18

20

Control

ExpHighFidelity

18 months

OR = 0.10 (.03, .35)

9 months

Percent of subjects who were homeless over follow-up period(as treated)


Cost savings

Estimated cost per person for CTI over 9 months

Average cost saving per person over 18 months

$6,290 $24,000

2013 dollars, Coalition for Evidence-Based Policyretrieved from www.toptierevidence.org, May 13, 2015


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Brief CTI—Allegheny County

0

10

20

30

40

50

60

70

OPD Visit<30 Days

OPD Visit 31-180 Days

Hospitalized <30 Days

Hospitalized 31-180 Days

Usual CareCTI

Shaffer, S., Hutchison, S., Ayers, A., Goldberg, R., Herman, D., Duch, D., Kogan, J., Terhorst, T. (2015). Brief Critical Time Intervention to Reduce Psychiatric Rehospitalization. Psychiatric Services, 66:1155-1161.

.



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IMPLEMENTATION ISSUES


Model flexibility has led to numerous adaptations§ NYS “Health Home” populations§ Prison & jail release§ Substance use treatment§ First episode psychosis treatment§ “Moving on” from supportive housing§ Youth transitions§ Domestic violence shelters§ ”Rapid-Rehousing” for homeless families


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What are core elements in CTI?

§ Transition period§ Time-limited§ Three phases § Decreasing contact§ Community-based§ Highly focused§ Individualized§ Active linking


Certified training for workers and supervisors


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Training is necessary but not sufficient


Implementation challengesProvider level

§ Natural drift toward “business as usual” § Poorly trained staff/staff turnover§ High caseloads§ Inadequate supervision§ Agency culture inconsistent with time-limited,

recovery-oriented model§ Documentation requirements fail to support

model implementation


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Implementation challengesProvider level§ Practitioner challenges

§ Resistance to time-limited approach§ Reduced attention to phase-specific activities

and planning§ Lack of narrow focus§ Too little in vivo work§ CTI workers assume ongoing primary

responsibility for directly providing assistance (rather than linking)


Caseload size§ Amount of time per client depends on phase § Divide cases by clients in different phases§ Weighting system for standard case “equivalent”

Pre-CTI 1.5 SCEPhase 1 2.0 SCEPhase 2 1.0 SCEPhase 3 0.5 SCE


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Supervision• Weekly team supervision-selected cases

are discussed• Fieldwork coordinator selects cases for

discussion • New cases may be presented at this time


CTI QA tools

§ Case planning and progress notes§ Fidelity self-assessment tool§ Full-scale external fidelity assessment

process


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Implementation challengesCommunity level

§ Distances impede community-based work § Short supply of formal treatment and services§ Lack of culture of coordination between

providers


Implementation challengesFunder level

§ Underdeveloped referral process§ Inadequate “break-in” period§ Payment structure not well aligned with

service model§ No ongoing fidelity assurance procedures§ No capacity for ongoing training & coaching


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Common misunderstandings

§ CTI is a good model for ongoing case management§ CTI creates new treatment resources§ Consumers must be “ready” to move through

phases§ Intervention should continue for consumers who

need ongoing support§ CTI cannot be used unless there are abundant

community treatment resources


www.criticaltime.orgCenterfortheAdvancementofCriticalTimeIntervention

Documents

Hunter College Silberman School of Social Work City University of …files.constantcontact.com/1f19db8e001/bce78da7-22da-4a83... · 2017-06-08 · 6/6/17 1 Background, Overview and