Background, Overview and Evidence. Daniel Herman Ph.D. Hunter College Silberman School of Social Work City University of New York

Transcription

1 Background, Overview and Evidence Daniel Herman Ph.D. Hunter College Silberman School of Social Work City University of New York Aims Background Model description Evidence for effectiveness Implementation issues 1

2 BACKGROUND AND RATIONALE Fort Washington Armory Men s Shelter, 1990s 2

3 Transitions can result in discontinuity of support multiple complex needs loss of supportive relationships fragmented community services Center for the Advancement risk of Critical of adverse outcomes 3

4 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 4

5 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 5

6 Guiding values Individualized Client centered Recovery oriented Harm reduction CTI differs from traditional case management Time limited Focused Phases 6

7 Model phases Unlike some other approaches Timing of movement through phases is defined by program model NOT client readiness 7

8 Pre-CTI Establish initial relationship before transition begins Phase One Transition Implement transition plan while providing emotional support 8

9 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 and capacity of the support system 9

10 Monitor effectiveness of support system Modify as necessary Less frequent meetings Crisis intervention and troubleshooting Phase 1 Phase Three Transfer of Care Terminate CTI services with support network safely in place 10

11 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? 11

12 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 12

13 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. Fort Washington Armory Homeless Men (NIMH) Randomized trial 100 men with SMI following shelter discharge 9-month intervention/18-month follow-up 13

14 Probability of retaining housing over 18 months 1 CTI 0.8 Usual Month Susser et. al, 1997, American Journal of Public Health CTI in the Transition from Hospital 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 14

15 Nights Homeless (mean) Percent Homeless (endpoint) CTI 31 5 Usual Services Herman, D., et.al. (2011). A randomized trial of critical time intervention in persons with severe mental illness following institutional discharge. Psychiatric Services. From: The Impact of Critical in Reducing Psychiatric Rehospitalization After Hospital Discharge Psychiatric Services. 2012;63(9): doi: /appi.ps Figure Legend: Proportion of participants in two groups who had at least one night of psychiatric rehospitalization in any interval during the 18- month follow-up Date of download: 1/21/2013 Copyright Center for the American Advancement Psychiatric of Critical Association. Time All rights Intervention reserved. 15

16 Percent of subjects who were homeless over follow-up period (ITT) Control Experimental OR = 0.22 (.06,.88) months 18 months Nights Hospitalized (mean) Percent Hospitalized (endpoint) CTI Usual Services Tomita, A., Herman, D. (2012) The impact of critical time intervention in reducing psychiatric rehospitalization after hospital discharge. Psychiatric Services, 63:

17 From: Randomized Trial of Critical to Prevent Homelessness After Hospital Discharge Psychiatric Services. 2011;62(7): Figure Legend: Critical time intervention or usual care participants with any homelessness during each follow-up interval over 18 months Date of download: 1/21/2013 Copyright Center for the American Advancement Psychiatric of Critical Association. Time All rights Intervention reserved. Percent of subjects who were hospitalized over follow-up period 35 Exp Control OR = 0.11 (.01, -.96) months 18 months Tomita, A., Herman, D. (2012) The impact of critical Center time for intervention the Advancement in reducing of Critical psychiatric rehospitalization after hospital discharge. Psychiatric Services, 63:

18 Pre-discharge worker contacts Low-fi High-fi Experimental only Percent None or to or more

19 Percent of subjects who were homeless over follow-up period (as treated) 20 Control Exp High Fidelity OR = 0.10 (.03,.35) months 18 months Cost savings Estimated cost per person for CTI over 9 months Average cost saving per person over 18 months $6,290 $24, dollars, Coalition for Evidence-Based Policy retrieved from May 13,

20 Brief CTI Allegheny County Usual Care CTI OPD Visit<30 Days OPD Visit Days Hospitalized <30 Days Hospitalized Days 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. Center for Psychiatric the Advancement Services, of Critical 66:

21 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 21

22 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 22

23 Training is necessary but not sufficient Implementation challenges Provider 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 23

24 Implementation challenges Provider 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 Phase 1 Phase 2 Phase SCE 2.0 SCE 1.0 SCE 0.5 SCE 24

25 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 25

26 Implementation challenges Community level Distances impede community-based work Short supply of formal treatment and services Lack of culture of coordination between providers Implementation challenges Funder 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 26

27 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 27