1. Evidence-Based Treatment for First Episode Psychosis
Robert K. Heinssen, Ph.D., ABPP
Amy B. Goldstein, Ph.D
Susan T. Azrin, Ph.D.
July 28, 2014

2. Disclosures
I have no personal financial relationships with commercial interests relevant to this presentation
The views expressed are my own, and do not necessarily represent those of the NIH, NIMH, or the Federal Government

3. National Programs for First Episode Psychosis3

4. Early Intervention Principles
Early detection of psychosis
Rapid access to specialty care
Recovery focus
Youth friendly services
Respectful of clients’ autonomy & independence
Twin goals are to reduce DUP and provide EIS to instill hope, reduce disability, and promote long term recovery.
Youth and young adults, ages 15-30
Non-affective psychoses
Schizophrenia, Schizoaffective Disorder, Schizophreniform Disorder, Brief Psychotic Disorder, or Psychotic Disorder NOS
≤3 years since onset of psychosis
≤5 years since onset of psychosis in LEO, OPUS
RAISE Connection Program ≤2 years

5. Early Intervention Services
Team-based, phase-specific treatment
Assertive outreach and engagement
Empirically-supported interventions
Low-dose antipsychotic medications
Cognitive and behavioral psychotherapy
Family education and support
Educational and vocational rehabilitation
Shared decision-making framework

6. For information on how to implement first episode psychosis treatment models, please visit the NIMH RAISE CSC resources page.
Go to the NIMH home page, type ‘first episode psychosis’ in the search bar; the first link takes you to the resource page..
Evidence-based Treatments for First Episode Psychosis: Components of Coordinated Specialty Care
RAISE Early Treatment Program Manuals and Program Resources
RAISE Coordinated Specialty Care for First Episode Psychosis Manuals
OnTrackNY Manuals & Program Resources
Voices of Recovery Video Series

7. Ryan – Fulfilling My Dream
Screen shots of CSC resources available at no cost at and outside links.

8. Client Coordinated Specialty Care Model
Medication/ Primary Care
Psychotherapy
Family Education and Support
Supported Employment and Education
Case Management
Person-centered care, assisted by care manager who helps clients and family members to navigate among treatment options.

9. Coordinated Specialty Care Model
Client
Medication/ Primary Care
Psychotherapy
Family Education and Support
Supported Employment and Education
Case Management
Person-centered care, assisted by care manager who helps clients and family members to navigate among treatment options.

10. Coordinated Specialty Care Model
Client
Medication/ Primary Care
Psychotherapy
Family Education and Support
Supported Employment and Education
Case Management
Person-centered care, assisted by care manager who helps clients and family members to navigate among treatment options.

11. Pharmacotherapy and PC Coordination Supported Employment and Education
CSC Roles and Functions
CSC Role
Services
Credentials
Pharmacotherapy and PC Coordination
Medication management; coordination with primary medical care to address health issues
Licensed M.D., NP, or RN
Psychotherapy
Individual and group psychotherapy (CBT and behavioral skills training)
Licensed clinician
Family Therapy
Psychoeducation, relapse prevention counseling, and crisis intervention services
Care Management
Care management functions provided in clinic and community settings
Supported Employment and Education
Supported employment and supported education; ongoing coaching and support following job or school placement
BA; IPS training and experience
Team Leadership
Outreach to community providers, clients, and family members; coordinate services among team members; provide ongoing supervision
Licensed clinician; management skills
A CSC team requires sufficient staff to cover six key roles and associated functions The first three – pharmacotherapy, psychotherapy, and family therapy – can be reimbursed via private and public insurance. Care management and supported employment are not generally covered by commercial insurance, but may be reimbursed by Medicaid if the state’s Medicaid waiver includes these services. Team leadership is critical for CSC success; this role is not typically reimbursed by private or public insurance plans. The 5% set aside can be used to cover reimbursement gaps in care management, supported employment, and team leadership.

12. Must I hire 6 new FEP specialists?
In the RAISE initiative, clinicians from multiple disciplines learned, mastered, and applied the principles of CSC
Many providers achieved competency in more than one CSC function, and fulfilled dual roles on the treatment team
Many sites leveraged existing resources to create cost efficiencies that supported the CSC program

13. CSC Team Model 1 Suburban Mental Health Center; 20-25 Clients
Clinical Roles
Percent Full Time Employee
From Heinssen et al. (2014), pages 13-14:
Example 4 (suburban setting): One CSC program was formed within a suburban mental health center that anticipated a caseload of clients with FEP. Four agency personnel were selected for new clinical positions on the FEP treatment team. The CSC team leader and family therapist roles were combined into a single full-time position. Likewise, psychotherapist and case manager roles were performed by one full-time provider. The psychiatrist and supported education/employment specialist were full-time employees of the mental health center, but devoted 0.2 FTE and 0.5 FTE level of effort to the CSC program, respectively. The psychiatrist and supported employment specialist worked with all CSC participants, but also served clients from other agency programs. The non-CSC caseloads of the employment specialist and the psychiatrist were reduced to accommodate the needs of clients in the FEP treatment program.

14. CSC Team Model 2 Urban Mental Health Center; 25-30 Clients
Clinical Roles
Percent Full Time Employee
From Heinssen et al. (2014), page 13:
Example 3 (urban setting): One CSC program was developed in a mental health center that served a small urban area. With a catchment area covering ~160,000 individuals, agency administrators anticipated an FEP caseload of clients. An existing team-based treatment program for outpatients at high risk for hospitalization (HRH) was leveraged in order to form a team of CSC providers. A subset of six HRH team members were selected for the roles of CSC team leader (0.3 FTE), family therapist (0.25 FTE), supported employment/education specialist (0.5 FTE) and psychiatrist (0.2 FTE). Two additional clinicians (0.5 FTE each) filled the role of psychotherapist/case manager. While the primary function of the CSC subgroup was to care for FEP clients, team members also provided services in the HRH program. Each provider’s HRH caseload was adjusted downward based on the number of CSC clients enrolled in the program.

15. Revising the FY14 MHBG Plan
Set-Aside Amount
Current CSC Capacity in the State or Territory
≥1 CSC Program
≥1 Developing Program
No CSC Programs
≥ $1M
> $100K, < $1M
< $100K
Determine current capacity for FEP care
At least one fully operational CSC program?
At least one partially operational CSC program?
No operating CSC programs?
Determine the amount of set-aside funding
≤ $100K?
> $100K, < $1M?
≥ $1M
Depending on current capacity and set-aside amount:
Expand or augment existing CSC services
Fill gaps to create at least one operational program
Create infrastructure for a future CSC program

16. Revising the FY14 MHBG Plan
Set-Aside Amount
Current CSC Capacity in the State or Territory
≥1 CSC Program
≥1 Developing Program
No CSC Programs
≥ $1M
> $100K, < $1M
< $100K
Consider targeted investments to build core CSC capacities
Shared decision making tools and training
Supported employment specialists
Regional collaborations to build FEP expertise

17. Goals for FY2015 and Beyond Achieve and maintain fidelity to CSC model
Benchmark and monitor key quality indicators
Duration of untreated psychosis
Client retention at 3 months
Inpatient episodes, ED visits, crisis intervention
Academic, vocational, and social recovery
Health risk factors and medical comorbidities
All cause mortality (suicide behaviors, accidents, etc.)
Connect CSC programs into a “learning community” that shares expertise, resources, and quality monitoring data

18. FEP Learning Healthcare System
FY2015
Science and informatics
Patient-clinician partnerships
Incentives aligned for value
Feedback loops for ongoing system improvement
Culture of continuous learning

19. Thank you RAISE partners!TX UT MT CA AZ ID NV OR IA CO KS WY NM MO MN NE OK SD WA AR ND LA IL OH FL GA AL WI VA IN MI MS KY TN PA NC SC WV NJ ME NY VT MD NH CT DE MA RI
Phase-specific specialty care for First Episode Psychosis vs. TAU
Representative patients, providers, and community clinics
Focus on clinical and functional recovery, cost of care, societal benefits
Early deliverables on DUP, guideline-concordant pharmacotherapy, medical comorbidity in FEP, and implementing CSC in public mental health systems
2 Studies
22 States
36 Sites
134 Providers
469 Participants

20. RAISE Principal Investigators
RAISE Early Treatment Program
RAISE Connection Program
John Kane
Nina Schooler
Delbert Robinson
Lisa Dixon
Susan Essock
Jeffery Lieberman

21. For More Information