NYAPRS Note: Over the last month, following recent research demonstrating the efficacy of early intervention with first episode psychosis, The Center for Medicaid and CHIP Services, the National Institute of Mental Health, National Institutes of Health, and the Substance Abuse and Mental Health Services Administration issued a letter in concurrence, encouraging its expanded use. Several states are currently using Medicaid and grant funding to support these early intervention services, including Maryland, Massachusetts, and Ohio. In addition to clinical services, supported employment and education services are offered both as goals and as next steps to keep people engaged.
States’ Activities on Early Intervention Programs Continue to Gain Momentum
Mental Health Weekly November 9, 2015
In the nearly two fiscal years since Congress directed the Substance Abuse and Mental Health Services Administration (SAMHSA) to require states to set aside 5 percent of their Mental Health Block Grant (MHBG) allocation to support services that address the needs of individuals with early serious mental illness, including psychosis, states have gained momentum in treating youth and young adults and their families.
“Over the past year and a half, we have witnessed tremendous momentum as a result of the MHBG set-aside,” Pat Shea, deputy director of technical assistance and prevention at the National Association of State Mental Health Program Directors, told MHW. “States have engaged in program planning and implementation; conducted extensive staff training; developed and/or expanded relationships with diverse stakeholder groups; and educated referral networks about recognizing signs of a first episode of a serious mental disorder.”
Shea added, “Collectively, these efforts are making a meaningful difference in increasing the capacity of states to respond to individuals’ needs at an earlier stage, with the goal of reducing the duration of untreated illness. The 5 percent setaside in MHBG funding is an incredible benefit. It gives states an avenue to support that type of work.”
The challenge with the set-aside is that it is based on the formula for the block grant, so there’s much variability in the level of funding per state, Shea said. “States even with limited resources are doing very good work, but not all states are given enough funding to establish comprehensive programs to address first-episode psychosis,” she said. “Nationally, we could do a lot more if Congress provided more funding for this purpose. The needs are tremendous.”
Maryland
The state of Maryland was an initial site in the National Institute of Mental Health’s RAISE [Recovery After an Initial Schizophrenia Episode] project in 2009, said Cynthia Petion, director of the Office of Planning for the Maryland Department of Health and Mental Hygiene.
As part of this project, investigators developed a Coordinated Specialist Care program located in West Baltimore that continued to be funded by the state after the completion of the research. The care team established to assess and treat youth with early psychosis and their families included a team leader, supported employment and education specialists, a recovery coach and a team psychiatrist.
Once the NIMH pilot was completed, the governor appropriated additional money to expand outreach and early identification for youth at risk of or who have early psychosis, said Steve Reeder, director of adult services for the Maryland Department of Health and Mental Hygiene. The state combined that funding with the 5 percent setaside and established programs at two sites: Baltimore City and Montgomery County.
The Department of Psychiatry at the University of Maryland School of Medicine, the Maryland Early Intervention Program and the Maryland Department of Health and Mental Hygiene all provided training and support for the program.
Petion said Maryland officials have spoken with other states to discuss issues and challenges with establishing first-episode programs [FEP]. Regarding funding, for example, the state used funding from Medicaid, General Fund dollars and funding from the Division of Rehabilitative Services, said Petion.
Supported employment and recovery-based treatment services are reimbursed by Medicaid and Medicare, she said. However, they have run into some issues with reimbursement from third-party payors, she said. Some network private insurers are not accepting new patients, she said.
Experience has also taught officials how important it is to monitor fidelity, said Reeder. “One of the things we learned when RAISE ended and the services sustained was that nobody was monitoring fidelity on an ongoing basis,” he said. “We’ve been working with national researchers and looking at fidelity scales being developed. We’re developing a plan to help inform our [efforts] going forward.”
Other efforts include linking youth-funded services to FEP whenever possible, said Reeder. “We have a lot of special services with youth and young adults,” he said. The University of Maryland will provide screening and training assistance to other agencies that have FEP but may be in a region that’s too far to travel for some. “There are ways to reach out to other jurisdictions, including through the use of telepsychiatry,” said Reeder.
Reeder added, “We want to work with individuals so that their lives are not disrupted by mental illness. The key is employment and education — often the ‘hook’ to get people into services. They’re concerned about their lives and their future at this age.”
Mass. program expansion
“Our PREP [Prevention and Recovery in Early Psychosis] program has been in existence since 2000,” said Margaret Guyer, Ph.D., with clinical and professional services at the Massachusetts Department of Mental Health. PREP is an intensive outpatient clinical services composed of the core components of Coordinated Specialty Care, in addition to a therapeutic peer group program, cognitive remediation services and family treatment.
The 5 percent set-aside was used to replicate the initial program in Western Massachusetts, a more rural part of the state, said Guyer. The state’s second PREP program officially opened July 1, 2015, she said. “We now have two hubs in the state of Massachusetts, addressing early intervention [programs],” Guyer said.
The program creates a community of families that support one another, she said. About 15 young adults, ages 16 to 30, and their families participate. The multidisciplinary team of support includes a team leader or medical director and a clinical psychologist, who oversees cognitive therapy and family work.
The state Department of Mental Health has provided “incredible support” for early intervention programs long before the federal government raised everyone’s awareness of how important it was,” said Guyer.
Program officials say the state Department of Mental Health expanded the early intervention clinical services of the PREP program in metropolitan Boston through the funding of two new positions: a substance abuse specialist and an education/employment specialist. The department is also working with both PREP programs to extend community outreach to include school and primary care physicians, provide training and consultation and develop a PREP website with information and resources for young adults.
“The main thing is to focus on creating a community of young adults and families to support each other in addition to using NIMH’s RAISE model,” Guyer said. “What’s unique about PREP is the way that the community is fostered and supported.”
Ohio
Through a Request for Proposals, the Ohio Department of Mental Health and Addiction Services (OhioMHAS) awarded SAMHSA’s 5 percent set-aside fund to Greater Cincinnati Behavioral Health Services and Coleman Professional Services. The two agencies used the funds to expand or implement FEP programming for persons ages 15–25 using a Coordinated Specialty Care approach. The agencies also collaborated with the Best Practices in Schizophrenia Treatment Center (BeST) at Northeast Ohio Medical University on the expansion and implementation of the programs.
“We worked with the RAISE program and secured grant funding to work with community providers and organizations to develop the specialty care team,” Kathy CoateOrtiz, LISW, chief of mental health services in the medical director’s office for OhioMHAS, told MHW. The department wanted to build on the strengths of the professional organizations and the university involved with the program, she said.
“We expanded on the BeST program through use of the SAMHSA funds in nine counties supported by three different providers to improve best practices,” Mark Hurst, M.D., FAPA, medical director of OhioMHAS, told MHW. Besides the MHBG funding, Ohio used grant funds to support the program, he said.
Regional teams are established in the northeastern, northwestern and southwestern parts of the state. The northeastern and northwestern program officials work closely, said Hurst. Together, the program involves 65 active clients, and 67 percent of them are working or in school, the key components of the project, he said.
Rather than rely exclusively on the 5 percent set-aside, OhioMHAS is working with Medicaid and Medicaid managed care organizations, said Hurst. “We want to stretch the 5 percent set-aside as far as we can by capitalizing on Medicaid insurance plans,” he said. “We want to capitalize on resources that are available and become increasingly sustainable beyond grant funding.