Contemporary Perspectives in Schizophrenia Care
2 min

Patient-centric care

Coordinated Specialty Care (CSC) on the Rise

The National Institute of Mental Health’s (NIMH) Recovery After an Initial Schizophrenia Episode (RAISE) studies have proven the clinical benefits of CSC programs across the US.1

infographic with stats of CSC programs

Since the RAISE initiative launched in 2008, there has been rapid uptake and implementation of CSC programs nationwide. The Early Treatment Program enrolled more than 400 people at 17 clinics and compared CSC treatment programs for first-episode psychosis vs usual community care. As of 2019, there are more than 350 clinics with established CSC programs across the US.1-3

Infographic of increased CSC programs from 2008 to 2020
$50 million

Additionally, in 2016, in recognition of the success of CSC, the House of Representatives doubled the allocation to the Community Mental Health Block Grant from 5% to 10%, providing an additional $50 million for states to develop and support these programs for first-episode psychosis (FEP) patients.1

But, even with the rapid growth of these programs across the nation and the increase in public funding, more needs to be done to ensure all patients with schizophrenia have access to comprehensive care programs.

GETTING STARTED WITH CSC

Implementing a team-based, patient-centric, recovery-oriented model for FEP patients requires a lot of time, effort, and coordination. This may include hiring additional team members, managing team caseloads, participating in ongoing training, and more. Below are considerations, recommendations, and resources for getting started with CSC. Like with any other type of treatment, program implementation should be tailored to the specific needs of your practice, community, staff, and patients.4-6

Considerations and Recommendations According to the NIMH manuals

CONSIDERATION

Where is the operational location of the team? Within an existing and established mental health clinic or as a separate organization/location?

RECOMMENDATION

When the team is located within an established mental health clinic, they are able to take advantage of the existing efficiencies within a shared infrastructure. But creating a separate organization or location provides additional flexibility and may be less stigmatizing for patients who avoid community mental health programs entirely.5

CONSIDERATION

What are the service boundaries of this program? Are there enough clients to be served in this area?

RECOMMENDATION

A good rule of thumb is that a population base of about 550,000 will have enough FEP patients to keep one team filled at capacity per the NIMH manual on CSC implementation.5

See the resources section below for a report that includes an interactive tool to estimate the resources and costs needed to support a given area.

CONSIDERATION

How far will patients need to travel? Is public transportation available?

RECOMMENDATION

Consider setting service boundaries that are reachable and acceptable for travel for both team members and patients.

Per the NIMH manual on CSC implementation, new teams should consider accepting patients living one-half hour from the clinic if education and employment services are offered. Without these specific service offerings, consider accepting patients no more than 45 minutes away from the team location.5

CONSIDERATION

What are the program eligibility criteria?

RECOMMENDATION

Each program should establish their own eligibility and ineligibility requirements taking into consideration how long an individual has had symptoms, what the psychotic symptoms in fact are, and other patient characteristics like age, comorbidities, housing instability status, presence of legal problems, incarceration history, cultural sensitivity, language, and insurance status.5

CONSIDERATION

Are there nearby emergency care services, substance abuse programs, and other community resources this program can partner with for additional services outside of the CSC program?

RECOMMENDATION

It is very important to connect with other service providers and programs within the community such as emergency care services, inpatient substance abuse treatment programs, and more. It is critical to develop relationships with these kinds of services so they can be easily accessed if needed.5

CONSIDERATION

Is there public funding available for this program?

RECOMMENDATION

Budgetary issues for FEP programs are the same as any other clinic-based program. Public funding for FEP services varies by location and insurance source.5

See the resources section below for a detailed discussion of approaches to financing FEP programs.

CONSIDERATION

What is the best strategy for outreach and recruitment?

RECOMMENDATION

Methods for outreach, establishing a referral network, and guidance on evaluating and admitting patients to a clinic should be tailored to your practice/clinic’s unique needs. The CSC team leader or program director should designate one or more individuals to oversee this process.4,5

See the resources section below for the NIMH manual on outreach and recruitment for more recommendations.

CONSIDERATION

Who will comprise the treatment team?

RECOMMENDATION

In the RAISE study, treatment teams were composed of a team leader, a team psychiatrist, an individualized placement and support specialist, and a recovery coach.5

Per the NIMH manual on CSC implementation, at minimum, teams should have a main leader or coordinator who is responsible for treatment plans and programming. Additionally, each patient should have a team member (this can be the team leader or primary clinician) who provides in-depth individual and family support, crisis management, and assistance with accessing community resources.5

See the resources section below for the NIMH manual on CSC implementation for more staffing recommendations.

CONSIDERATION

What is the appropriate level of training needed to implement this program?

RECOMMENDATION

Again, training should remain ongoing and be tailored to the specific needs of your practice, community, staff, and patients.5

All team members should be trained accordingly on the overall information and philosophy of the program, as well as the responsibilities of their role.5

CONSIDERATION

How is program fidelity measured?

RECOMMENDATION

Fidelity measures are important because they provide valuable information to program stakeholders such as payers, supervisors, and patients/patients’ families.5

Fidelity measures may vary across institutions and programs, but whenever possible, data should be obtained from claims data and other electronic sources to minimize the burden of data collection on the clinical and administrative staff.5

Additional Resources

For additional recommendations and more in-depth explanations, please refer to the following resources:

CSC Program Finder: Find existing programs and collaborate with nearby programs

Cost and Resources Estimator: See the Interactive spreadsheet tool example that helps to estimate cost and resources for FEP initiatives

NIMH manuals

Manual I: Outreach and Recruitment

Manual II: Implementation

Financing Report: Read the report on early intervention financing and resources

SAMHSA Workforce Development Issue Brief: Discover the National Association of State Mental Health Program Directors’ best practices for addressing workforce challenges in CSC programs

References: 1. Dixon L. What it will take to make coordinated specialty care available to anyone experiencing early schizophrenia: getting over the hump. JAMA Psychiatry. 2017;74(1):7-8. 2. Find help for psychosis. Strong 365. Accessed July 23, 2021. https://strong365.org/find-help/. 3. Dixon LB, Goldman HH, Srihari VH, Kane JM. Transforming the treatment of schizophrenia in the United States: The RAISE Initiative. Annu Rev Clin Psychol. 2018;14:237-258. 4. National Institute of Mental Health. Coordinated Specialty Care for First Episode Psychosis Manual I: Outreach and Recruitment. Accessed July 23, 2021. https://www.nimh.nih.gov/health/topics/schizophrenia/raise/coordinated-specialty-care-for-first-episode-psychosis-manual-i-outreach-and-recruitment. 5. Bennet M, Piscitelli S, Goldman H, Essock S, Dixon L. Coordinated Specialty Care for First Episode Psychosis Manual II: Implementation. National Institute of Mental Health. Accessed July 23, 2021. https://www.nimh.nih.gov/sites/default/files/documents/health/topics/schizophrenia/raise/csc-for-fep-manual-ii-implementation-manual.pdf 6. Pollard JM, Hoge MA. Workforce development in coordinated specialty care programs. National Association of State Mental Health Program Directors; 2017. Accessed July 23, 2021. https://www.nasmhpd.org/sites/default/files/DH-Workforce_Development_reference_doc_1.pdf.

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