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First Episode Psychosis: On the Ground Lessons Learned
Panel Members▶ Lisa Dixon, MD, MPH
Director, OnTrackNY
Professor of Psychiatry, Columbia University Medical Center
▶ Mary Brunette, MDNAVIGATE leadership team
Associate Professor of Psychiatry, Geisel School of Medicine at Dartmouth
▶ Raquel Carerra, LCPC, NCCOnTrack Maryland at Family Services, Inc, Recovery Coach
Bilingual Psychotherapist
▶ Cathy Adams, LMSW, ACSW, CAADC ETCH: Early Treatment and Cognitive Health, Clinical Director
Michigan FEP Trainer and Consultant
Certified NAVIGATE Trainer
Coordinated Specialty Care for First Episode Psychosis▶ Overview
▶ Expansion of CSC for young people after RAISE project and allocation of Block Grant for CSC
▶ CSC Components
• Community education/outreach and engagement into service
• Pharmacotherapy and primary care coordination
• Family support and education
• Supported employment and education
• Psychotherapy
• Case Management
▶ Importance of shortening duration of untreated psychosis for outc
Recruitment, Retention and TransitionThis Photo by Unknown Author is licensed under CC BY-NC-ND
Recruitment
▶ Develop and sustain relationships with community partners (inpatient, NAMI, Schools, Faith Communities, Mental Health Courts, PHP’s/IOP’s, Mental Health fairs).
▶ Capacity can be reached quickly—consider how you will handle overflow (wait list, referring to OMHC’s or CMHC’s, cultivating other community supports at home or school, etc). Don’t overextend!
• Using other providers/supports to screen, gather data regarding symptoms, family history and assess needs.
▶ Invest time in meeting with family members or potential clients during inpatient stays, or before enrollment.
• Set up “Meet and Greet” to allow primary introductions of team members and exploring the setting/space (likely not a billable service).
Retention▶ Engage and re-engage—no resting on your laurels
▶ Let go of “old ways”—3 missed appointments and discharge letter sent out won’t work
▶ Be prepared to meet people more than halfway
▶ Problem solve barriers immediately and continuously
▶ Pay attention to who on the team has the strongest connection—use it!
▶ Build a bridge to families—early and often; on-call services, increased response rate in comparison to other clinical settings, utilizing cultural competency
▶ Create a “youth centric” space- soft lighting, music in waiting room, art as décor (decrease overstimulation of noise and light).
▶ Don’t overmedicalize—this can lead to loss of hope and motivation
▶ Use your community—meet out of the office; traveling to homes, community centers or local coffee shops/libraries.
▶ Consider social engagement groups with an eye to migrating to community offerings
Create an atmosphere that encourages people to linger…
Transition▶ Recognize that there is no set clock—two years may not be enough.
▶ Consider a phases of care model which has a framework for intensity at the beginning and easing of supports over time. Be transparent with young people and their families about phases and relapse.
▶ Incorporate stages of change philosophy into assessing where a participant is in phases of care.
▶ Establish your transition framework early—e.g. cultivating community referral sources post-CSC, in-house graduation/alumni status, peer supports with seamless return to more intensive care PRN
Challenges and SolutionsThis Photo by Unknown Author is licensed under CC BY
Challenges and Solutions▶ Staffing: Finding the right staff for the spirit of the model, preparing for turnover and re-training▶ Clinical Skills: Consider options to heighten skills beyond CSC core model
• Examples can include- CBTp, Cultural Competency, Motivational Interviewing, Engagement strategies for Transitional Aged Youth- TAY
▶ Team Self-Care: There are lots of peaks and valleys—nurture a culture of self-care and mutual support
• Flexibility to manage your own schedule, PTO, autonomy, salaried positions
▶ Crisis Intervention: Traditional channels for crisis intervention may not be useful—individualize a crisis response using safety/crisis planning, or mobile crisis team.
▶ Reimbursement: Many young people are still on parent’s insurance…be assertive about paneling your clinicians with all regional insurers. Have an expert biller available.
Challenges and Solutions▶ Language, language, language—pay attention…essential to engagement, reducing self-stigma, etc.
• Using terms that are comfortable for family/client; client preferred saying “my things” instead of “illness or symptoms”
• Person-Centered language- “client” or “consumer” or “participant” vs. “patient”
▶ Shared Decision Making or Motivational Interviewing for drug use, or uncertainty about whether to take medication.
▶ Developmental Place—be aware of unique needs and challenges.▶ TEAM Collaboration and Cohesion—meet weekly, create a system to be sure to discuss every
participant routinely▶ Supervision/Consultation—team members appreciate easy access to clinical leadership and/or
collegial consultation. Have a system that allows this.▶ Productivity standards may require consideration/adjustment….indirect time for team, supervision,
case management, consultation, etc.
Shared Decision Making Explained▶ Decisions that are shared by providers and clients, informed by the best evidence available and
weighted according to the specific characteristics and values of the clients.
▶ Professionals are often concerned with symptoms and illness management, while clients are concerned with practical matters (e.g. not having side-effects, returning to work, feeling better…etc.)
▶ SDM is an integrative process between client and clinician that:
• Engages client in decision making
• Provides the patient with information about alternative treatments
• Facilitates the incorporation of patient preferences and values into the medical plan.
• Acknowledges that multiple “experts” are in the room.
Cultivating a Recovery-Oriented Atmosphere▶ Maintaining hope is crucial
▶ Treatment does work
▶ Alliance is very important and requires regular attention, like all relationships
▶ Input from family members is always valuable
▶ Knowledge is power- families need us to teach them and model how to navigate this new experience
▶ Connect participants with peers—hearing about recovery is one thing…seeing it in someone else is another
Helpful ResourcesLINKS:
▶ http://navigateconsultants.org/
▶ www.ontrackny.org
▶ www.strong365.org
▶ www.michiganminds.org
▶ https://marylandeip.com/
▶ http://www.fs-inc.org/services/programs/ontrack-maryland
▶ https://www.hopkinsmedicine.org/psychiatry/bayview/medical_services/child_adolescent/early_psychosis.html
PUBLICATIONS:
▶ The Complete Family Guide to Schizophrenia, Kim Mueser, PhD and Susan Gingerich, MSW, 2006
▶ I Am Not Sick, I Don’t Need Help, Xavier Amador, PhD, 2007
Wrap Up/Questions
Because everyone deserves an equal opportunity to chase their hopes and dreams.
