Implementa)onStrategiesandOvercomingChallenges
TaraNiendam,Ph.D.AssistantProfessor,UCDavisDepartmentof
PsychiatryDirectorofOpera)ons,UCDavisEarlyPsychosis
Programs(EDAPT&SacEDAPTClinics)
BEHAVIORAL HEALTH CENTER OF EXCELLENCE
Objec)ves• Describeimplementa)onofearlypsychosisspecialtyprogramsinSacramentoCounty
• Describepopula)onserved,fundingsources,staffing/trainingconsidera)ons,andassessment/treatmentapproaches
• Describehowtoovercomechallengesofimplemen)ngearlypsychosiscareinacommunityseIng
California Early Psychosis Programs
• Alameda • Butte • Contra Cosa • Fresno • Lake • Los Angeles • Madera • Mendocino • Monterey • Napa • Orange • Sacramento • San Diego • San Francisco
• San Joaquin • San Luis Obispo • San Mateo • Santa Barbara • Santa Clara • Santa Cruz • Shasta • Sierra • Solano • Sonoma • Stanislaus • Tehama • Ventura • Yolo
• El Dorado • Inyo • Lassen • Marin • Mariposa
• Merced • Riverside • Trinity • Tuolumne
CurrentlyAc7vePrograms(n=28)
ProgramsInDevelopment(n=9)
UCD-AffiliatedEarlyPsychosisPrograms
• 2004–CameronCarter,MD.establishedanearlypsychosisresearchprogramandoutpa)entclinic(EDAPT)atUCD– Firstepisodepsychosisandclinicalhighrisk,ages12-40– Moreinfo:hUp://earlypsychosis.ucdavis.edu
• Expandedourclinicin2011–SacramentoCountyEDAPTClinic(SacEDAPT)– Firstepisodepsychosisandclinicalhighrisk,ages12-30– Moreinfo:hUp://earlypsychosis.ucdavis.edu
• Supportedimplementa)onofEPcareinNapa(2014)andSolano(2015)incollabora)onwithAldeaChildandFamilyServices– Firstepisodepsychosisandclinicalhighrisk,ages12-40– Moreinfo:
hUp://hUp://www.aldeainc.org/services/behavioral-health/early-diagnosis-preventa)ve-treatment
CoordinatedSpecialtyCareModel
hUp://www.nimh.nih.gov/health/topics/schizophrenia/raise/coordinated-specialty-care-for-first-episode-psychosis-resources.shtml
CommunityOutreach&Educa7on↓S)gma↑Referrals
Coordina7onwithPrimary
Care
OtherStaffop)ons:• Nurse• OT
Popula)onsServed• Coun)escanchoosewhichpopula)onstoserve
– Fullypsycho)c• Whichdiagnoses?Schizophreniaspectrumonly?MoodDisorders?Others?• MHBGrecentspecifiedSchizophreniaspectrum• Dura)onofpsycho)csymptoms(1-5years)
– ClinicalHighRisk/Prodromal• GenerallydefinedbyAUenuatedposi)vesymptomsofpsychosis• AccordingtoSIPS?Morebroadlydefined?
– BothCHRandFirstepisode• Ourclinicis80%Firstepisodeand20%CHR
– Agesserved• MHSA=12-25àaffectswomenwhomayhavelateronset
– Whoisnotbeingserved• Substancedependence,IQ<70,Countyofresidence,Uninsured,Undocumented…
FundingSources
• California’sMentalHealthServicesAct(MHSA)Prop63votedintolawin2004– Preven)onandEarlyInterven)on(PEI):provideservicesforthosedemonstra)ngearlysignsofmentalhealthchallengesinorderto“preventmentalillnessesfrombecomingsevereanddisabling”andimprove“)melyaccesstoservicesforunderservedpopula)ons.”
• ManyCAcoun)eshaveusedtheseflexiblefundstosupportEPprogramdevelopment
FundingSources• OtherCounty-basedfunds
– EPSDT/Medi-cal– 26.5funds
• Federalfunds:MentalHealthBlockGrant– SupportenhancementofcurrentprogramsORdevelopmentofnewprograms
• Privateinsurance– Significantlimita)onsonwhenandhowservicescanbeprovided
• Self-payorslidingscale
• Donorfunds
• Researchgrants
Staffing/Training
• EPProgramguidelinesdelineatecorestaffcomponents
• Fundingoqendetermineswhocanbehired– #ofstaff,leveloftraining/licensure,)mededicatedtotheproject
• Goal:Buildinganappropriateteamtomeettheneedsofthecommunitybeingserved
Staffing/Training• Challenges:
– Findingthe“right”staffwhowanttoservethispopula)on(appropriatetraining,interest,skills)
• Staffingshortagesinsomefields(e.g.psychiatry)orsomeareas(e.g.rural)
• Limita)onsingraduatetrainingrelatedtoseriousmentalillness–workforcedevelopmentissue
– Needtoprovideaddi)onaltrainingtothestaffyouhire.• Programsneedongoingsupportfor1)trainingnewstaffand2)maintainingfidelitytothemodelastheprogramcon)nuesviasupervision
– Staffturnoverishighàongoingcycleofhiringandtraining• HowdoweKEEPthestaffwehave?Salary,ongoingprofessionaldevelopment,support
AssessmentApproaches• Accurateassessmentanddiagnosisiscorecomponentofthemodel– Useofsemi-structuredinterviewsarekey–butalso)me-consumingandtraining-intensive
– Mustensureyouarecoveringalltheareas:psychosis,mood,substanceuse…butalsotrauma,suicidalidea)onandbehavior,developmental/medicalissues
• Needforongoing,standardizedoutcomesevalua)on– Monitoringtreatmentprogress,iden)fywheregoalsweremet/newgoalstoworkon
– Understandwhereprogramisworking–andwherechangesneedtobemade
TreatmentApproaches• EPprogramsshouldincorporateevidencebasedtreatmentsfor
individualsandtheirfamiliesExamplesinclude:– Cogni)veBehavioraltherapyforpsychosis(CBTp)– Mul)-FamilyGrouptherapy(MFG)– Func)onalFamilyTherapy(FFT)
• However,othertreatmentapproachesshouldbeincorporatedtoaddressvarietyofneeds– Substanceuse,emo)onalregula)on/coping,trauma,cogni)ve
impairment,weightgain,socialskills
• Needongoingstafftrainingandsupervisiontosupportuseoftheseinterven)ons
ChallengeswithImplementa)oninCalifornia
• Suppor)ngaccessacrossthestate– 38%ofCAcoun)ess)lldonothaveaprogramduetovariousbarriers– Strongrela)onship/collabora)onwiththecountyisessen)alforsuccess
• Needforparityacrossfundingstreams– HavinginsurancecanpreventyoufromgeIngappropriatecare
• Needforstandardiza)oninapproach– Howtoimplementcorecomponentswithlimitedfunds
• Needforongoingtrainingandtechnicalassistance– Howtosupportworkforcedevelopment– Partnershipwithestablishedprograms,universi)esisagoodwaytoensure
youareontherighttrack.
