Implementing Evidence Based Practices in New York
Outreach Partnership Program 2005 Annual Meeting
Saturday April 2, 2005
Robert Myers, Ph.D., Senior Deputy Commissioner
New York State Office of Mental Health
Dr. Myers began by saying that his talk would illustrate the New York State Office of Mental Health’s commitment to quality of care through the implementation of evidence-based practices, the use of information technology to support a quality agenda, and two initiatives in the area of public mental health promotion. The mission of the Office of Mental Health is to promote the mental health of all New Yorkers, not just to those with serious and persistent mental health illnesses. In addition to its regulatory and oversight responsibilities, the Office of Mental Health provides inpatient and outpatient care in a number of hospitals, conducts research to advance prevention, and promotes public mental health. The conceptual framework for accomplishing its mission has three components: accountability, best practices, and coordination of services.
The “Winds of Change” campaign, which began about three years ago, emerged from the Office’s desire to focus on quality and to introduce evidence-based practices. The strategies for change are awareness, education, structure and clinical improvement, and continual improvement and support. These change strategies are being accomplished in three phases: consensus building, enacting and sustaining.
There is some striking evidence from research by Ian Falloon and colleagues suggesting that evidence-based practices work best in combination, not in isolation. This research has shown that a person who experiences a psychiatric episode, is hospitalized, and receives treatment and case management services has a 54 percent chance of relapsing within one year. By providing evidence-based family psychoeducation, the relapse rate can be cut in half, and the rate is further reduced by adding problem solving and skill development. We are beginning to think about managing mental illness in much the same way we manage diabetes or heart disease, with an array of lifestyle as well as medical treatments.
Dr. Myers focused on New York’s efforts to implement five evidence-based practices: medication, family psychoeducation, illness management and recovery, supportive employment, and Assertive Community Treatment (ACT).
New York’s psychiatric services and clinical knowledge enhancement system (PSYCKES) monitors the prescribing practices of physicians in state-operated services, to check on appropriateness of dose and duration and help identify areas of potential cost savings.
Family psychoeducation training and evaluation projects have been initiated, utilizing the multiple family group approach. There are now 41 multiple family group teams that have undergone intensive training and receive ongoing technical assistance, face to face and by telephone. Feedback from participants has been positive. However, it is a very expensive methodology to implement: it involves a nine-month commitment and heavy staff involvement. It may be possible to bill Medicaid for this service. New York intends to move forward on implementing the program on a statewide basis, but has also begun discussions with the statewide NAMI group about partnering to provide a spectrum of family services. Families would be able to choose intensive, evidence-based family psychoeducation, or the NAMI family-to-family approach, or self-help.
Under a SAMHSA grant, family psychoeducation is being introduced to three culturally diverse communities in New York City: mixed Asian/Latino, Mandarin Chinese and African American. The challenge is to determine how to adapt the basic tool kit model to make it effective in culturally diverse communities, and at the same time, to retain the outcomes that result from using the “gold standard.”
Illness management and recovery (IMR), called wellness management in New York State, teaches individuals how to manage their illness and develop skills; it includes teaching people the importance of adhering to medication, managing stress, etc. As part of the national tool kit project, New York is implementing IMR in four sites. We are learning that simply giving the tool kit to the clinical staff is not adequate, because most of the staff members are not trained in educational and skill development interventions. We need to think in terms of providing a psychoeducation teaching skill development model.
Surveys show that about 70 percent of adults with serious and persistent mental illness want to work, but only about 15 percent are employed. New York has implemented performance-based contracting, which pays contractors in increments for documented results. Payments are made for doing an assessment, finding someone a job, and keeping the person on the job for specified periods of time (4 weeks, 3 months, 6 months, etc.). The contractor receives higher payments for placing individuals with a poor work history or history of frequent hospitalizations. New York has used this system for three years, and obtained a 47 percent employment rate — comparable to the best supported employment results obtained by Bob Drake and colleagues at Dartmouth. However, job retention is a problem, as it is in other tests of supported employment programs.
More than 45 percent of the mental health budget in New York State comes from Medicaid. The question is how to implement evidence based practices by using Medicaid to drive quality. Recognizing that Medicaid is open to considering reimbursing rehabilitation-oriented services if structured appropriately, New York proposed a state plan amendment that was approved and is now being implemented in several counties. Personalized recovery oriented services (PROS) has several components focusing on rehabilitation--basic community rehabilitation and support, goal-oriented intensive rehabilitation, symptom stabilization, intensive integrated treatment (including family psychoeducation), and ongoing support to enable sustained employment. Clinical treatment (medication) can also be provided. PROS provides clients with integrated rehabilitation, support and treatment services. Licensed providers are reimbursed for these services on a monthly basis.
After it was determined that Medicaid would fund assertive community treatment (ACT), New York established 70 Medicaid-funded ACT teams with the capacity to serve about 4,000 people. To ensure that the teams are practicing according to the ACT fidelity standards set out in the tool kits, New York is providing training and basing its licensing standards on adherence to the standards. National data show that ACT works well on measures like keeping people out of the hospital and in housing, but it falls short in rehabilitation, employment outcomes and family involvement. New York is now using ACT as a platform for training interdisciplinary teams to provide other evidence based practices: supportive employment, integrated treatment and family psychoeducation.
Assisted outpatient treatment (AOT), a civil court ordered treatment program, was established in New York after an untreated individual with command hallucinations pushed a young woman onto subway tracks, resulting in her death. AOT is a care coordination model in which the individual in treatment is assigned to a case manager or an ACT team. Because the provider is held accountable for providing services, and there is oversight in terms of integration of services and actual service delivery, results have been very positive. Over a six-month period, there are significant reductions in psychiatric hospitalization, homelessness and incarceration.
New York has developed the Child and Adult Integrated Reporting System (CAIRS), a web-based platform for data exchange and outcomes monitoring being used by various programs. Over the next couple of years, it will be moved into other programs, including the PROS. The goal of this and other technologies is to help providers to achieve continuous quality improvement.
Until very recently, the Office of Mental Health has focused on direct care, treatment, and support for people with serious and persistent mental illness, but is now also focusing on public health promotion--specifically suicide prevention. This effort dovetails with the recommendations of the New Freedom Commission. The statewide SPEAK campaign is a public health model that raises awareness about depression and suicide in men, women, older people and teenagers and urges people to seek treatment if they have symptoms. Thousands of SPEAK kits have been distributed throughout the state, including to the school system.
Project Liberty is a public health partnership with SAMHSA and CMHS that was put into place after the World Trade Center tragedy on 9/11. The goal was to reduce the long-term psychological impact of this terrorist event in individuals and populations. About 1.3 million people received face to face crisis counseling and group education services. Project Liberty reached out to people in numerous venues—schools, bars and other community gathering places--and had a positive impact.
Dr. Myers concluded by stating that New York has a deliberate, broad strategy to improve quality in the state by advancing evidence-based practices and, by overcoming the many challenges to implementation, to eventually make them routine.
Questions and Answers
On the question of how to distinguish between assisted outpatient treatment (AOT) and ACT, Dr. Myers said that whereas ACT is an evidence-based treatment approach, AOT is court-ordered treatment. AOT is an example of care coordination that can improve outcomes.
Dr. Myers was asked how much of the work of the New York State Office of Mental Health serves individuals that have anxiety and depressive disorders. Dr. Myers said that many outpatient clinics, both state-run and funded through not-for-profits, serve a range of individuals, including people with anxiety and depressive disorders. The state has a role in ensuring sufficient training of clinicians to serve these individuals. He also again mentioned the SPEAK campaign on depression and suicide prevention.
A participant asked whether research has looked at psychoeducation for mental health consumers themselves, and how Dr. Myers regards implementation of psychoeducation in the broader picture of mental health services. Dr. Myers said that the psychoeducation model he had described educates families to provide support to consumers. However, he regards the illness management and recovery (IMR) tool kit as a psychoeducation model for consumers, as it educates consumers themselves about their illness, strategies to manage illness and stress, medications, relapse prevention and advance directives, and teaches them skills. The IMR tool kit is not a self-help kit; it is used by staff in a mental health agency to facilitate individual and group work.
Disclaimer
* This document is intended to summarize a speaker presentation at the NIMH Outreach Partnership Program’s Annual Meeting and is not an official statement or opinion of the NIMH. This information is in the public domain and may be used or reproduced for educational purposes without additional permission from the NIMH.
