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Treatment of Mental Illness and Recovery Support Services
Adult and Child Mental Health Center, Inc.
Adult and Child Mental Health Center, Inc (Adult&Child) is a community mental health center that serves adults with a serious mental illness and children with serious emotional disturbance in Marion County (Indianapolis) and Johnson County in Indiana. Over the past seven years, Adult&Child has been an early adopter of several SAMHSA-identified evidenced-based practices (EBPs) including assertive community treatment (ACT), supported employment (SE), illness management and recovery (IMR), and integrated dual disorders treatment (IDDT). Much of Adult&Child’s service structures revolves around ACT or ACT-like team structures. Because ACT has been criticized as being paternalistic or coercive, and even with good intentions of providers, may facilitate dependence on the mental health system, the agency made a strategic decision to implement IMR as a way to help consumers and teams embrace recovery.
Several aspects of our IMR approach are unique: 1) implementation of IMR on ACT teams, highlighting the successful integration of EBPs; 2) trained peer specialists (PRS) provide the majority of IMR services; and 3) use of a systematic training and mentoring approach to ensure that the model is implemented with fidelity and that the practitioners have necessary supports in place to sustain the practice over time. The program has achieved high fidelity implementation (4.6 out of 5.0 on IMR Fidelity measure), and has expanded to a total of 130 participants across the 3 ACT teams alone (51 graduates, thus far). In the early pilot phase with the original team, Recovery assessment scale scores improved from a mean of 3.7 prior to IMR to 4.1 following IMR on a 5-point scale (Cohen’s d effect size=.88). In the ongoing evaluation of IMR, clinician-rated illness management improved from 2.87 at baseline to 3.77 at 12-month follow-up on a 5-point scale. Highlighting the more personal nature of IMR’s impact, one consumer stated: “The IMR classes I participated in taught me to believe in myself. That I could actually set a goal and achieve it. That was a whole new concept to me. I still use some of the interventions I learned for coping with my illness like counting and deep breathing and they really help a lot.”
Alegent Health Behavioral Services
Alegent Health is the largest not-for-profit, faith-based healthcare system in Nebraska and southwestern Iowa, serving 16,000 + patients in our Behavioral Service line during the 2008 fiscal year. Alegent Health is ranked first in the country in quality and patient satisfaction according to the Network for Regional healthcare Improvement (NRHI). Patients come from both rural and metropolitan communities, and have a diverse array of cultural, educational and financial backgrounds, with minorities compromising over 20% of our population. As the primary provider of acute care mental health beds (76% of community beds), Alegent Health Behavioral Services is vividly aware of the violence and trauma in and surrounding the community. From 1990 – 2001, 26.6% of Nebraska deaths were violence related and the suicide rate from 1994 – 2002 was 6.11 (metro) and 7.50 (Nebraska non-metro) per 100,000. The National suicide rate for the same period was 4.79 and 6.55, respectively. These statistics, as well as recent advances on the effects of trauma, prompted Alegent Health Behavioral Services to transform current patient care delivery systems to include trauma informed clinical interventions.
Trauma Informed Care is an evidence-based approach to patient care that focuses on the science and neurobiology of the brain and research related to the prevalence of trauma. Trauma Informed Care is at the core of Alegent Health Behavioral Service’s commitment to creating a culture that is patient centered and intentionally reduces the coercive interventions that may inadvertently re-traumatize individuals. Utilizing the core strategies of the Inventory of Seclusion and Restraint Reduction Interventions (ISRRI) to ensure fidelity with Trauma Informed Care principles, continued progress has occurred toward improving quality patient outcomes, including a 56.23% reduction in seclusion and restraint events since January 2005. In addition, Mental Health Outcomes change scores, which measure patient symptoms, behaviors, and impairment of functioning from admission to discharge, have shown an overall improvement. Rates for programs that historically utilized seclusion and restraint interventions most heavily but who now incorporate Trauma Informed Care principles show the most change. As Trauma Informed Care has transformed the Alegent Health Behavioral Services culture, it has cemented the agency’s commitment to its Mission - providing patient focused care for the body, mind and spirit of every person.
Center for Urban Community Services
The Center for Urban Community Services (CUCS) is widely recognized as a leader in the advancement of progressive housing and service initiatives for homeless and low-income individuals and families, particularly those with mental illness and other special needs. CUCS provides services at supportive housing programs in New York City that serve 1375 tenants, including 475 with mental illness. CUCS implemented Supported Employment (SE) in its supportive housing sites to better meet the needs of mentally ill tenants and to help expand the field’s focus on housing stability to include more of a recovery framework. Prior to implementing SE, 10.6% of our program’s mentally ill tenants were employed. CUCS planned to increase the percentage of mentally ill tenants in the workforce through the introduction of SE.
SE is an evidence-based practice that is proven to assist mentally ill adults in obtaining competitive employment. At CUCS, however, many consumers and some staff believed that employment wasn’t a realistic option, requiring that a series of organizational change practices be introduced to help convince the wider group that a culture of work and employment was worth pursuing. To ensure that SE was implemented with a high degree of fidelity, CUCS hired outside experts to conduct fidelity reviews. On these, CUCS received a score of 4 on a 0-5 scale, indicating a strong fidelity to the model.
CUCS’ program has greatly increased the percentage of mentally ill tenants who are employed or seeking employment. At the site where CUCS first implemented SE, 30% of mentally ill tenants are now employed or engaged in the program. The average hourly wage for those working full-time is $10.90. In addition, CUCS has demonstrated that SE can be woven into the existing structure of supportive housing programs.
Institute for Community Living, Inc.
Since July 2005, the Institute for Community Living, Inc. (ICL), a large behavioral health agency based in New York City, has partnered with another New York based not-for-profit, CAMBA, in the implementation of Project Aspire, a SAHMSA funded initiative aimed at positively impacting sustainable housing placements for homeless women with mental illness and chemical abuse histories in Brooklyn, New York. The project utilizes three evidence-based practices: Critical Time Intervention (CTI), a time-limited intervention aimed to help clients overcome barriers and subsequently achieve independence; Seeking Safety, a present-focused group therapy for people with trauma, PTSD and substance abuse histories; and Wellness-Self Management (WSM), the New York State adaptation of the SAMHSA evidence-based practice toolkit, Illness Management and Recovery (IMR), a curriculum based practice which promotes recovery.
Fidelity reporting for the three interventions demonstrate exceptional outreach to project participants, formation of community linkages, utilization of motivational and teaching techniques with participants, emphasis on positive possibilities in participants’ lives, focus on personal strengths, and encouragement toward functional decision making processes. Additionally, data collection measures indicate 1) high levels of self-reported abstinence from both alcohol and illegal drugs, 2) significantly low levels of recidivism with regard to project participants returning to the shelter after being housed, 3) low frequencies of criminal activity, 4) and throughout the course of their involvement with the project, an increased number of project participants enrolled in either full-time or part-time school, job-training programs, and/or employment.
Missouri Pharmacy Partnership Program
Since 2003, the Behavioral Pharmacy Management Program (BPM) has been improving the psychiatric medication prescribing practices of thousands of Missouri physicians. The improved prescribing has resulted in better adherence, reduced inappropriate medication usage and reduced hospitalizations for many thousand patients and saved millions of dollars in healthcare costs. Behavioral Pharmacy Management (BPM) developed by a public private partnership between Missouri Department of Mental Health, Missouri Medicaid, and Comprehensive Neuroscience, Inc (CNS) utilizes the evidence based medicine approach of applying the available evidence for a specific individual clinical decision point in a manner consistent with physician and patient values. The intervention is educational, voluntary and protects patient-physician autonomy in making individual clinical decisions.
BPM routinely analyzes pharmacy claims, comparing them with a set of quality indicators based on published practice guidelines that signal questionable prescribing patterns. DMH then shares the results along with current best practice standards to encourage modification of prescribing patterns. Prescribers are given clear, simple suggestions based on literature evidence or recognized expert opinion for improving the quality of treatment. Implementation strategies include frequent and ongoing modifications to the intervention based on feedback from a diverse advisory group and individual prescribers. This work has improved the quality of psychiatric prescribing and clinical outcomes in addition to saving the state millions. BPM physician-oriented intervention is associated with a decrease in hospitalizations, as evidenced by reductions in the overall rates of admission, the mean number of admissions per patient, and the total patient days. In addition there is an overall reduction in the total average non-pharmacy cost of care for inpatient and outpatient services for Medicaid recipients.
The program averages 1900 adult & child prescriber interventions and 7400 patients touched per month in Missouri. In addition, based on the Missouri model and results, BPM is now operating in 22 state Medicaid agencies and has been expanded in to Medicare and commercial markets.
Portland Dialectical Behavior Therapy Program, PC
The Portland Dialectical Behavior Therapy (DBT) Program is the only agency in the State of Oregon offering full-fidelity DBT to adults, adolescents and their families. This program has grown exponentially since its inception in 1996 and currently serves hundreds of clients per year while striving to maintain high standards of training and supervision necessary to implement an evidence based practice in a “real world setting.” A scientist-practitioner model of service delivery with is used with comprehensive procedures to monitor treatment adherence, measure client outcomes, and evaluate consumer satisfaction. Rigorous implementation of an evidence based practice has proven to be the most efficacious and ethical way of delivering compassionate care to our clients and interacting with the greater community mental health service system.
The Portland DBT Program is a free-standing, outpatient clinic serving both public and private sectors. Standard DBT programs are offered for adults, young adults and teens, as well as “specialty tracks” for substance abuse, eating disorders, and trauma. A number of services to family members of program clients are also offered in an attempt to treat the contexts in which clients live and generalize treatment gains to natural environments. DBT training and consultation services are provided to other mental health professionals and agencies in the community emphasizing developing adherent DBT services and maintaining them overtime through on-going, site-based consultation. Close monitoring of implementation of DBT occurs though frequent supervision, videotape review, consultation and training with DBT experts, and directed reading groups. Multiple sources of evaluation data (symptom checklists, diary cards, referral data, missed appointment patterns) inform the practice and better meet the needs of clients. Outcome data demonstrates a consistent reduction in symptoms as well as restrictive service use for clients in the DBT program.
West Michigan Community Mental Health
West Michigan Community Mental Health Services (WMCMHS) is a rural Public Mental Health program providing services to adults and children experiencing severe mental illness or severe developmental disabilities in Ludington, Michigan. WMCMHS established a Dialectical Behavior Therapy (DBT) team to provide comprehensive treatment for fifty adult consumers with Borderline Personality Disorder or high expressive emotions. The DBT Team is assisting with an adolescent and a family training program.
Peer fidelity checklists of individual therapy and skills building session show model fidelity at 98%. Similar fidelity levels have been achieved for individual therapy and skill group sessions which are video taped, reviewed and fidelity coded. Consumers provide feedback after every individual therapy and skills group session and on overall treatment quarterly. Over a two-year period there was a 28% decrease in urges to self-harm, an 85% decrease in self-harm actions and a 550% increase in the use of effective coping skills among fifty-five consumers.
Western Psychiatric Institute & Clinic
Exposure and Response – Prevention (ERP)
412-246-6811 or 412-624-2000
In response to the pressing need for evidence-based treatment for pediatric Obsessive-Compulsive Disorder (OCD) in the Western Pennsylvania community, Western Psychiatric Institute and Clinic (WPIC) of the University of Pittsburgh Medical Center launched The Intensive Outpatient Program for Children and Adolescents with Obsessive-Compulsive Disorder. Prior to the opening of this clinic there were no existing treatment centers in Western Pennsylvania for children and adolescents with OCD. The clinic is a comprehensive treatment facility, specializing in providing group and individual psychotherapy, education, family therapy, school-liaison services, and pharmacotherapy for children and adolescents who are struggling with OCD as well as their families. The operation is one of only a few intensive outpatient programs in the country specializing in treating pediatric OCD, yet has been well-received by the managed care community and achieved fiscal self-sustainability in 2007.
Analysis of treatment effects of over 70 consumers since the intensive outpatient program started in fall 2005, reveals an approximate 65% reduction in overall OCD symptom severity from intake to discharge, suggesting that this evidence-based treatments yields important and targeted symptom improvement in this population.
An essential component of the OCD clinic is its innovative approach to treatment and research. WPIC has developed an integrative and translational program that combines evidence-based treatments for children and families with careful symptom assessment and monitoring, and cutting-edge technology aimed at understanding the neural correlates of OCD.
Substance Abuse & Mental Health Services Administration • 1 Choke Cherry Road • Rockville, MD 20857