Evaluating and sustaining Coordinated Specialty Care for a recent onset of psychosis in non-academic-affiliated community mental healthcare settings

PURPOSE

To improve sustainability of Coordinated Specialty Care (CSC) for a recent onset of psychosis, a better understanding is needed regarding how non-academic-affiliated community mental health centers blend CSC service elements and select key performance metrics to evaluate their approach.

METHODS

A quality and evaluation team embedded within a large community mental health center partnered with CSC site leadership to implement CSC and design a program evaluation strategy informed by CSC research literature. Clinical, family, vocational, and psychiatry services participation, exits, key performance indicators, and standardized measures were examined for participants (n = 47) enrolled for 12-months.

RESULTS

Mean service participation was 55 h (SD = 23.5) in the first 12-months (approximately 4.70 h/month). All participated in clinical; 87% in psychiatry; 67% in vocational; and 57% in family services. Sixty-one percent had planned service exits; 39% had unplanned exits. Across the 12-months, 83% were employed or in school; 72% were not psychiatric hospitalized.

CONCLUSIONS

CSC participation and outcomes were similar to the limited research examining both together. Understanding service participation and provider adjustments to sustain CSC is critical in community mental healthcare settings that rely on fee-for-service billing mechanisms. Findings have implications for national CSC data harmonization and sustainability efforts.

Suicidality and social problem-solving skills among individuals with first-episode psychosis participating in Coordinated Specialty Care

AIM

Although suicidal ideation may decrease over the course of participation in specialized clinical programmes for first-episode psychosis (FEP), it is unclear whether such improvements exceed those that occur during treatment as usual. Clarifying the mechanisms underlying reductions in suicidal ideation and behaviour among individuals with first-episode psychosis may highlight important strategies through which specialized clinical programmes can increase the potency of their services to reduce suicidality among this high-risk population. Thus, the goal of this study is to evaluate the longitudinal relationships between suicidality and social problem-solving skills among individuals with FEP participating in Coordinated Specialty Care.

METHODS

Within-subject mediational and moderational models were applied to explore the interrelationships and longitudinal course of suicidality, social problem-solving and duration of untreated psychosis (DUP).

RESULTS

Over the first 6 months of care, individuals with FEP experienced improvements in social problem-solving skills that were found to mediate concurrent reductions in suicidality. Although longitudinal changes in social problem-solving skills were moderated by DUP, these results should be interpreted cautiously as they may stem in part from a relatively limited number of participants with longer durations of illness.

CONCLUSIONS

Improvements in social problem-solving skills during participation in CSC may facilitate reductions in suicidality. Treatments targeting suicidality among individuals with FEP may thus benefit from working to enhance social problem-solving skills among these individuals. Further research is needed to clarify if and how DUP may influence the magnitude of change in social problem-solving skills during participation in CSC.

Geographic Disparities in Access to Specialty Care Programs for Early Psychosis in Washington State

Supported by the 10% set-aside funds in the Community Mental Health Block grant, distributed at the state level, coordinated specialty care (CSC) have been widely disseminated throughout the U.S. This study explores variations in the geographical accessibility of CSC programs by neighborhood level characteristics in Washington State. CSC locations were geocoded. Socioeconomic neighborhood deprivation (i.e., Area deprivation index) and rurality (i.e., Rural-Urban Commuting Area codes) were neighborhood level characteristics extracted from the 2018 American Community Survey. Geographic accessibility of CSC was assessed using a two-step floating catchment area technique and multilevel linear models were used to examine the association between specific neighborhood characteristics and geographic accessibility. The association between access and socioeconomically deprived neighborhoods varied differentially by neighborhood rurality (an interaction effect). Model estimates indicated that the least deprived, metropolitan neighborhoods had the best access (M = 0.38; CI: 0.34, 0.42) and rural neighborhoods in the second most deprived quartile had the worst access (M = 0.16; CI: 0.11, 0.21) to CSC. There was a clear decrease in accessibility for more rural neighborhoods, regardless of other neighborhood characteristics. In conclusions, findings provide important insight into how resource distribution contributes to geographic disparities in access to CSC. The use of spatial analytic techniques has the potential to identify specific neighborhoods and populations where there is a need to expand and increase availability of CSC to ensure access to rural and socioeconomically deprived neighborhoods.

Estimated Staff Time Effort, Costs, and Medicaid Revenues for Coordinated Specialty Care Clinics Serving Clients With First-Episode Psychosis

As coordinated specialty care for first-episode psychosis is implemented nationally, questions arise regarding financial sustainability. To address this, New York State undertook a time study in which 13 coordinated specialty care sites reported all activities provided to 75 randomly selected Medicaid clients with first-episode psychosis over a 2-week period. The average estimated cost was $1,375 per client per month, yet under optimal billing conditions, estimated revenues were only $662 per client per month, or 48% of the costs. These results underscore the need for continued subsidies and novel payment schemes for coordinated specialty care.

Community-Academic Partnership: Establishing the Institute for Mental Health Research Early Psychosis Intervention Center

Growing evidence suggests that specialized, multicomponent intervention provided early in the course of a psychotic disorder may have a positive effect in ameliorating the morbidity and mortality associated with these disorders. This column describes the development of the Institute for Mental Health Research Early Psychosis Intervention Center, which leverages the unique strengths of a community and academic partnership to provide such specialty care in a youth-friendly, stigma-free environment. Since it opened in 2016, the program has had numerous successes, including securing increased reimbursements rates and performance-based incentives for the treatment of first-episode psychosis.