Fidelity scales and performance measures to support implementation and quality assurance for first episode psychosis services

Reduction of DUP in early intervention programmes: No pain… almost no gain

AIM

Considering the negative impact of long duration of untreated psychosis (DUP) on outcome, its reduction has become one of the aims of early intervention programmes. The TIPP programme (Treatment and early Intervention in Psychosis Program) was implemented in 2004 in Lausanne and hoped to reduce DUP, without any specific campaign in this regard, through the provision of accessible and specialized treatment. The aim of this study was to evaluate the evolution of patients' DUP over time and the characteristics of patients with extreme DUP.

METHODS

Clinical follow-up data of 380 patients aged 18-35 years with a first psychotic episode who entered the TIPP programme between 2004 and 2017 were analysed. The evolution of DUP over time as well as referring entities and destination after the programme were assessed. The characteristics of patients with extreme DUPs (>percentile 90) were compared with that of other patients.

RESULTS

The mean value of the DUP was 452.11 days with a median of 88 days. DUP decreased only moderately over time. We also observe a decrease in discharges to specialized outpatient care at our university hospital. The main characteristics of patients with extreme DUP were early age of onset of psychosis, diagnosis of schizophrenia and presence of history of psychiatric treatment for other conditions before onset of psychosis.

CONCLUSIONS

These figures suggest that the DUP has reduced over time but that without specific interventions at this level, this reduction is only moderate.

Implementation of an Adapted Fidelity Scale for Pennsylvania Coordinated Specialty Care Programs for First Episode Psychosis

Coordinated Specialty Care (CSC) is an evidence-based model for early intervention of first episode psychosis (FEP). Monitoring fidelity to CSC models is essential for proper evaluation of program outcomes and quality improvement. To address variability across CSC programs and fidelity assessment-associated burden, an adapted fidelity scale was developed and implemented statewide in Pennsylvania. This report describes the design and preliminary performance of the adapted scale. The Pennsylvania FEP Fidelity Scale (PA-FEP-FS) assesses adherence to the CSC model by focusing on essential model components of other established fidelity scales, in tandem with program evaluation data. Initial data from fourteen PA-FEP sites from 2018 to 2021 were examined as preliminary validation. Assessment-associated burdens and costs were also estimated. PA-FEP-FS captured essential components of CSC models and proved feasible for implementation across varying program structures, while minimizing burden and cost. Programs utilized annual feedback as CSC benchmarks, evidenced by increased scores over time. PA-FEP-FS provides a model for adapting CSC fidelity scales to meet state- or local-level requirements while reducing assessment burdens and costs that may be associated with existing scales.

Policy Complexities in Financing First Episode Psychosis Services: Implementation Realities from a Home Rule State

Over the past decade, significant investments have been made in coordinated specialty care (CSC) models for first episode psychosis (FEP), with the goal of promoting recovery and preventing disability. CSC programs have proliferated as a result, but financing challenges imperil their growth and sustainability. In this commentary, the authors discuss (1) entrenched and emergent challenges in behavioral health policy of consequence for CSC financing; (2) implementation realities in the home rule context of Ohio, where significant variability exists across counties; and (3) recommendations to improve both care quality and access for individuals with FEP. The authors aim to provoke careful thought about policy interventions to bridge science-to-service gaps, and in this way, advance behavioral health equity.

The impact of early intervention for first episode psychosis on cognitive functioning

IMPORTANCE

Impaired cognitive functioning is a core characteristic of schizophrenia, present from the onset of the illness and relatively stable thereafter. Despite evidence supporting the impact of early intervention services (EIS) on improving symptoms and functioning in first episode psychosis (FEP), controlled research has not examined its impact on cognitive functioning.

OBJECTIVE

To evaluate the longitudinal course of cognitive functioning in FEP patients participating in a large, controlled study comparing EIS with usual services.

METHODS

A total of 404 persons ages 15-40 years old with non-affective FEP participated in the Recovery After Initial Schizophrenia-Early Treatment Program. A cluster randomized controlled trial was conducted with 34 community mental health treatment centers across the U.S. randomized to provide either an EIS program (NAVIGATE) or usual Community Care (CC) to FEP patients for 2 years. Cognitive functioning was assessed with the Brief Assessment of Cognition in Schizophrenia (BACS) at baseline and 1- and 2-years later.

RESULTS

Older participants (≥20 years old) in both treatment groups improved on all BACS tests. Younger participants (15-19) in NAVIGATE improved significantly more on Digit Sequencing (working memory) than those in CC, whereas both groups improved on most of the other BACS tests. Improvements in cognitive functioning occurred mostly over the first year and were correlated with reductions in symptom severity.

DISCUSSION

EIS do not improve cognitive functioning more than usual care for older FEP patients but may improve working memory in younger FEP patients. Interventions targeting cognition may be required to enhance cognitive functioning in most FEP patients.

Implementation of early intervention clinical services within the National Health System in Italy: Third wave survey with focus on structures, resources, and fidelity to the evidence-based model

BACKGROUND

Early intervention in psychosis (EIP) is a well-established approach aimed at detecting and treating early signs and symptoms of psychosis to prevent its long-term consequences. The present study aimed at detailing the current status of EIP services in Italy, covering all the Departments of Mental Health (DMHs) operating in 2018.

METHODS

All directors of public DMHs operating in Italy in 2018 (n = 127) were invited to fill in a Census form about EIP structure and activities. The first episode psychosis services fidelity scale (FEPS-FS) was used to investigate fidelity to the EIP model of the centre.

RESULTS

An active EIP service was reported by 41 DMHs (32% of the total DMHs; 56% of those who took part in the survey). Most EIP services had an autonomous team. The large majority of the Italian EIP centres provided psychosocial interventions to their patients, principally psychotherapy, family support, and psychoeducation. Among those with an active EIP, 29 DMHs filled in the FEPS-FS. Internal consistency was good when based on the replies of the respondents, but reliability was weak when measured on the basis of an independent evaluation (Cohen's kappa = 0.571). The fidelity to the guidelines for early intervention was uneven, with some criteria met by most centres, especially those peculiar to the Italian community psychiatry.

CONCLUSION

A further spreading of the early intervention model across the Italian DMHs was found. A lack of resources might limit the use of specific psychosocial treatments, such as cognitive-behavioural therapy or manualized family support.

Barriers and facilitators to the implementation of an early intervention in psychosis service in three demonstration sites in Ireland

BACKGROUND

Programmes for early intervention (EIP) in psychosis for people experiencing a first episode of psychosis (FEP) have been found to be both clinically and cost effective. Following the publication of a new EIP model of care (MoC) in Ireland, the aim of this research is to describe how people participated in and responded to the MoC including service users, family members, HSE clinical staff and HSE management.

METHODS

Qualitative design using the UK Medical Research Council's process evaluation framework. Purposive sampling techniques were used. A total of N = 40 key informant semi-structured interviews were completed which included clinical staff (N = 22), health service managers and administrators (N = 9), service users (N = 8) and a family member (N = 1). Thematic analyses were conducted.

RESULTS

Unique features of the EIP service (e.g., speed of referral/assessment, multidisciplinary approach, a range of evidence-based interventions and assertive MDT follow up) and enthusiasm for EIP were identified as two key factors that facilitated implementation. In contrast, obstacles to staff recruitment and budget challenges emerged as two primary barriers to implementation.

CONCLUSIONS

The findings from this research provide real world insights into the complexity of implementing an innovative service within an existing health system. Clear and committed financial and human resource processes which allow new innovations to thrive and be protected during their initiation and early implementation phase are paramount. These elements should be considered in the planning and implementation of EIP services both nationally in Ireland and internationally.

Intervention Programs for First-Episode Psychosis: A Scoping Review Protocol

Early intervention programs for first-episode psychosis aim to intervene in the early stages of the disease. They are essential to prevent and delay the progression of the illness to a more advanced stage, but information about their characteristics is not systematized. The scoping review considered all studies of first-episode psychosis intervention programs, regardless of their context (hospital or community), and explored their characteristics. The scoping review was developed according to the Joanna Briggs Institute methodology and PRISMA-ScR guidelines. The PCC mnemonic (population, concept, and context) addressed research questions, the inclusion and exclusion criteria, and the search strategy. The scoping review sought to identify the literature that meets the predefined inclusion criteria. The research was conducted in the following databases: Web of Science Core Collection, MEDLINE, CINAHL Complete and PsycINFO, Scopus, Cochrane Library, and JBI Evidence Synthesis. The search for unpublished studies included OpenGrey (a European repository) and MedNar. It used sources in English, Portuguese, Spanish, and French. It included quantitative, qualitative, and multi-method/mixed methods studies. It also considered gray or unpublished literature. After removing duplicates, two independent reviewers extracted the relevant information after selecting the articles. If there were disagreements, a third reviewer was used. The researchers have developed a tool based on the JBI model that will allow them to extract the relevant information for the review. The results are presented schematically in narratives and tables. This scoping review maps first-episode psychosis intervention programs by identifying their characteristics, participants, and specific implementation contexts and allows researchers to create multicomponent programs tailored to different contexts.

Identifying indicators of community participation-promoting efforts within coordinated specialty care: A modified e-Delphi study of stakeholder perspectives

AIM

Community participation in occupational, social, recreational, and other domains is critically important during young adulthood. Coordinated Specialty Care (CSC) programs provide developmentally tailored care to young adults experiencing early psychosis within the United States, but little is known about the breadth of efforts to promote community participation. This study aimed to develop and evaluate indicators of these efforts based on the perspectives of a national multi-stakeholder group.

METHODS

Seventeen stakeholders (i.e., young adults with early psychosis, family members, experts by profession) participated in a modified e-Delphi study, conducted in two rounds. The purpose of round one was to generate a comprehensive list of community participation-promoting indicators. During round two, stakeholders rated the importance and feasibility of the implementation of each indicator. Descriptive statistics and percentage of agreement regarding round two ratings were assessed.

RESULTS

During round one, 186 indicators of activities and/or practices designed to promote community participation were identified; this list was reduced to 44 by eliminating redundancies or indicators not related to community participation. In round two, we found broad agreement regarding the importance, but significant variation in perceived feasibility of indicators. The highest-rated indicators in both categories pertained to staff knowledge (regarding barriers and supports to participation and the importance of participation to health) and strategies for addressing participation barriers.

CONCLUSIONS

This study is expected to facilitate the identification and development of promising CSC activities and practices designed to promote community participation among young adults while potentially also enhancing engagement in services and improving clinical outcomes.

The cognitive-phenomenological assessment of delusions and hallucinations at the early intervention in psychosis service stage: The results of a quality improvement project

AIM

Clinical assessments are vital for gaining an understanding of a patients' presenting problem. A priority for Early Intervention in Psychosis Service staff is understanding and supporting their patients' experiences of hallucinations and/or delusions. We aimed to identify what cognitive-phenomenology dimensions of hallucinations and delusions EIPS staff were assessing with their patients.

METHODS

We developed a brief checklist of cognitive-phenomenological dimensions of hallucinations and delusions called the Lived Experience Symptom Survey (LESS) based on relevant literature. As part of a Quality Improvement Project, we reviewed the health records of a sub-sample of EIPS patients using the LESS identifying whether each dimension was present or absent.

RESULTS

We found that all patients had been asked about the content of their hallucinations and/or delusions, and the majority had been asked about the valence of this content. Despite patients having experienced psychosis for almost 2 years on average, less than half of patients were asked about the potential or actual harm associated with these symptoms. All other cognitive-phenomenological dimensions were assessed inconsistently.

CONCLUSIONS

The assessment of hallucination and delusions in our EIPS was inconsistent and incomprehensive. These findings require replication in other EIPS' but may point to a need for guidelines and training around how to conduct a thorough assessment of hallucinations and delusions for current and future EIPS staff. Improved assessment of these symptoms will aid the development of risk assessments and treatment plans.

A Scoping Review of Measures Used in Early Intervention Services for Psychosis

OBJECTIVE

The early intervention service (EIS) model for psychosis has been implemented with increasing frequency; yet, improving outcomes across domains for all patients remains challenging. Measurement-based care can strengthen outcomes by optimizing interventions and promoting alignment with standards, but it is still not widely deployed in EIS. The authors conducted a scoping review by systematically identifying and synthesizing measures used in EIS related to purpose (i.e., to assess patients, families, and programs), domains (e.g., symptoms, quality of life), and reporting perspectives (of patients, families, and clinicians).

METHODS

EMBASE, MEDLINE, PsycINFO, CINAHL, and Cochrane Library databases were searched for pertinent literature published between 2000 and 2020. Two reviewers independently screened titles, abstracts, and full texts and extracted data. Measures were classified as clinician-reported outcome measures (CROMs), patient-reported outcome or experience measures (PROMs/PREMs), or family-reported outcome or experience measures (FROMs/FREMs).

RESULTS

In total, 172 measures of 27 domains were identified from 115 articles. Nineteen measures had been used to assess programs on fidelity, service engagement, and satisfaction; 136 to assess patients on duration of untreated psychosis, symptoms, functioning, quality of life, and others; and 17 to assess families on coping and burden, background, and others. Sixty percent were CROMs, 30% were PROMs/PREMs, and 10% were FROMs/FREMs.

CONCLUSIONS

Greater inclusion of PROMs and FROMs is needed because they align with the EIS philosophy of patient and family engagement and may improve shared decision making and outcomes. A comprehensive, meaningfully synthesized archive of measures can advance measurement-based care, services research, and data harmonization in early psychosis.

COVID-19 pandemic's effects and telehealth in Early Psychosis Services of Quebec, Canada: Will changes last?

AIM

To explore the impacts of the COVID-19 pandemic first wave in Quebec, Canada on practices in early intervention services (EIS) for first-episode psychosis, including reorganization of clinical and administrative practices and teleconsultation use.

METHODS

Adopting a cross-sectional descriptive study design, a 41 questions online survey was sent to the team leaders of all the 33 Quebec EIS, of which 100% responded. Data were collected from 18 May to 4 June 2020 and analysed using descriptive statistics and content analysis. Programmes were categorized as urban/non-urban and results were compared between these.

RESULTS

All 33 existing Quebec EIS (16 urban and 17 non-urban) completed the survey. Among them, 85% did not experience redeployment of EIS team staff and 58% reported stable frequency of patient interactions, either in-person or through telemedicine. During the studied period, 64% of programmes reported that all professionals used teleconsultation at least occasionally. However, 73% of programmes, mostly in non-urban areas, reported some limitations regarding clinicians' degree of ease with teleconferencing platforms and half of EIS could not access technical support to use them. The majority of EIS (94%) expressed interest to participate in a training program about the use of technologies for teleconsultations. Many smaller clinics reported interest in offering multiregional/multiclinics group teletherapy, therefore merging their pool of patients and clinical staff workforce.

CONCLUSIONS

Further studies are warranted to improve access to and use of technology-mediated treatment, which seems to be a promising alternative to provide high-quality mental healthcare during the COVID-19 pandemic and beyond.

The History of Coordinated Specialty Care for Early Intervention in Psychosis in the United States: A Review of Effectiveness, Implementation, and Fidelity

Coordinated Specialty Care (CSC) is a multidisciplinary team approach to providing care for young and emerging adults having their first episode of psychosis. CSC programs have expanded rapidly throughout the United States going from 12 programs in 2008 to over 160 programs a decade later. The purpose of this historical review is to document the process and conditions that led to the accelerated dissemination of these programs across the country. CSC models began in the US in the early 2000s, but nationwide expansion followed the 2008 Recovery After an Initial Schizophrenia Episode trial. As programs have grown, debates have risen about fidelity to CSC models. The challenges facing CSC programs today include lack of evidence on what are the core components of CSC and how fidelity monitoring relates to positive client outcomes.

Inpatient Early Intervention for Serious Mental Illnesses Is Associated With Fewer Rehospitalizations Compared With Treatment as Usual in a High-volume Public Psychiatric Hospital Setting

OBJECTIVE

High-acuity publicly funded inpatient psychiatric settings usually feature short lengths of stay and high readmission rates. This study examined the influence of an early intervention program for serious mental illnesses (SMI) on readmissions at 6 and 12 months postdischarge at a high-volume, urban public inpatient psychiatric hospital.

METHODS

The Early Onset Treatment Program (EOTP) is a cost-free, 90-day inpatient multidisciplinary service intervention program for uninsured patients who are within 5 years of SMI onset, funded as a pilot program by the Texas state legislature. Rehospitalization rates at 6 and 12 months were extracted from electronic medical records for EOTP participants (n=165) and comparison patients matched on demographics and diagnosis (n=155). The comparison group received treatment as usual at the same psychiatric hospital. Group re-admission rates were compared using logistic and Poisson regression analyses.

RESULTS

Group membership was a significant predictor of rehospitalization (P<0.0001) at both 6 and 12 months. Expressed as 1/odds ratio (OR), the EOTP group was less likely to readmit once and more than once at 6 months postdischarge (1/OR=3.82 and 4.74, respectively) compared with the non-EOTP group. The EOTP group was also less likely to readmit once and more than once at 12 months postdischarge (1/OR=2.96 and 3.51, respectively).

CONCLUSIONS

The results suggest that participation in the EOTP service in this high-acuity setting was significantly related to reduced likelihood of rehospitalization at 6 and 12 months. Several variables may account for this observation, including length of stay, longer medication adherence, environmental stability, and more individualized and extensive psychotherapy treatment.

Specialized inpatient treatment for young people with early psychosis: acute-treatment and 12-month results

The objective of the study was to investigate the development of clinical outcomes of young people with early psychosis in a specialized inpatient treatment and assess the feasibility of such an intervention in an inpatient setting. The study was a prospective cohort study of patients with early psychosis treated at the specialized inpatient treatment "Fühinterventions-und Therapiezentrum, FRITZ" (early intervention and therapy center) in Berlin, Germany. The primary outcomes were attitudes towards psychiatric medication and patient satisfaction with treatment after 6 weeks. Secondary outcomes were clinical symptoms, functioning, remission, recovery, all-cause treatment discontinuation, and rehospitalisation at 6 and 12 months after inpatient treatment. We recruited 95 inpatients with early psychosis. Attitudes towards psychiatric medication (Δ_6weeks = 3.00, d_6weeks = 0.55; Δ_6mo = 2.15, d_6mo = 0.35; Δ_12mo = 3.03, d_12mo = 0.52) and patient satisfaction (Δ_6weeks = 0.21, d_6weeks = 0.40; Δ_6mo = 0.32, d_6mo = 0.43; Δ_12mo = 0.13, d_12mo = 0.17) changed with medium effect sizes at six weeks up to a 6- and 12-month follow-up. Clinical outcomes changed significantly with medium-to-large-effect sizes over 12 months CGI_Δ12mo = 1.64, d_12mo = -1.12; PANSS total_Δ12mo = 20.10, d_12mo = -0.76; GAF_Δ12mo = 19.58, d_12mo = 1.25). The all-cause treatment discontinuation rate was 13.69% (n = 13) at a 6-month and 35.79% (n = 34) at a 12-month follow-up. The rehospitalization rate was 30.53% (n = 29) at a 6-month and 43.16% (n = 41) at a 12-month follow-up. Patients with specialized inpatient treatment for early psychosis showed improvements in attitude towards psychiatric medication, patient satisfaction, symptoms, and functioning for up to 12 months.Trial registration: DRKS00024351, 2021/02/11 retrospectively registered.

Implementation case study: Multifamily group intervention in first-episode psychosis programs

AIM

Family interventions are a core component of first-episode psychosis (FEP) treatment; however, low implementation rates are consistently reported. As such, work is needed to understand the factors impacting real-world treatment delivery. The present paper describes the implementation of the McFarlane-model multifamily psychoeducational groups (MFG) in established FEP early intervention programs within a single state. The aims were to examine (a) training participation and implementation of MFG, (b) barriers and facilitators to implementation, and (c) modifications made to MFG.

METHODS

Practitioners from six established FEP early intervention programs received in-person training and ongoing consultation in MFG. Training participation data were obtained via attendance and implementation outcomes were obtained from practitioner reports. Fifteen months following the initial training, practitioners reported on clinic-specific barriers, facilitators, and modifications across four categories (context, intervention, practitioner, and recipient).

RESULTS

Twenty-three practitioners across six clinics received in-person training and were offered ongoing consultation to support implementation. Difficulties in starting MFG were salient as the earliest group was run 7 months after the initial training, thereby resulting in low overall frequency of groups. A number of barriers spanning context, intervention, practitioner, and recipient domains were noted, the majority of which were clinic-specific. Despite challenges, practitioners identified several facilitators and made modifications to the intervention and its delivery in service of implementation.

CONCLUSIONS

Results from this implementation case study highlighted the challenges of delivering MFG in real-world FEP early intervention programs. Further, this paper emphasizes the value in identifying and addressing clinic-specific factors when implementing MFG.

Implementation of early psychosis services in Latin America: A scoping review

AIM

The evidence of the effectiveness and cost-effectiveness of early intervention for psychosis (EIP) services has motivated their implementation worldwide. However, complex interventions of such EIP services require local adaptations to successfully match population needs and cultural differences. Latin America is a heterogenous region where EIP services are progressively being adopted. Our aim is to map such initiatives in the region with a focus on implementation outcomes.

METHODS

A scoping review following the Preferred Reporting Items for Systematic review and Meta-Analysis extension for Scoping Reviews guidelines was conducted. International and regional databases were searched for publications describing EIP programmes in the region. Besides mapping the services, we described implementation outcomes based on the Standards for Reporting Implementation Studies Checklist.

RESULTS

Ten articles describing seven EIP initiatives from the region were found. Four countries were represented: Argentina, Brazil, Chile and Mexico. The implementation outcomes reporting was heterogenous, although it was possible to ascertain EIP services are feasible and adequate for the region's context. Also, there is some evidence of effectiveness in terms of reducing hospitalizations and improving symptoms. Information about fidelity measures was scarce and there was no information about costs or cost-effectiveness.

CONCLUSIONS

Only a small proportion of Latin American countries have adopted EIP services. Although these programmes seem to be feasible and effective, data on other implementation outcomes, such as fidelity, cultural appropriateness, cost-effectiveness and affordability are not available. This might in part explain why this effective approach has not been yet scaled-up at nationwide levels.

The utility of a fidelity measure to monitor implementation of new early psychosis services across Australia

AIM

Early psychosis delivery models have proliferated worldwide, but there is limited research into establishing model fidelity. In this context, this article aims to describe the development and implementation of a fidelity tool in a national network of early psychosis services across Australia-the headspace Early Psychosis program.

METHODS

Following a detailed consultation process, and based on the Australian Early Psychosis model, an 80-item Early Psychosis Prevention and Intervention Centre Model Integrity Tool (EMIT) was developed along with predefined thresholds for fidelity. The tool was used to assess adherence to the model in six clusters of service sites across Australia. Ratings on the EMIT were informed by interviews with site staff and young people receiving the service, routinely collected data and site policies and procedures.

RESULTS

All six clusters of headspace Early Psychosis programs participated in five fidelity assessments across a period of two and a half years. In the initial two visits, the average fidelity score was in the 'low' fidelity range (i.e., <75%). By the fifth fidelity visit, the network average improved to 92.35%, reflecting 'superior' fidelity.

CONCLUSIONS

Results of the longitudinal fidelity assessments indicate the successful implementation of the Australian Early Psychosis model across the headspace Early Psychosis program. Utilisation of ongoing fidelity assessments has proved an effective method to improve and maintain adherence to the model.

Feasibility and acceptability of a volunteer peer fidelity assessment model in early psychosis intervention programmes in Ontario: Results from a pilot study

AIM

Fidelity monitoring can support high-quality service delivery but is resource-intensive to implement. A fidelity assessment model utilizing volunteer assessors was trialled as a low-cost strategy for conducting fidelity assessments. This article reports on the acceptability and feasibility of this model.

METHODS

Twenty volunteer assessors were trained to conduct fidelity assessments in nine Early Psychosis Intervention programmes across Ontario, Canada. Assessments were conducted using the First-Episode Psychosis Services Fidelity Scale based on a 2-day site visit, during which assessors interviewed staff, clients and families; reviewed charts; observed a team meeting and reviewed programme materials. The model was evaluated based on assessor focus groups, programme interviews, consensus meeting data and time-tracking logs. General inductive analysis was used to code and synthesize qualitative data. Quantitative data were aggregated and summarized.

RESULTS

Participant feedback was positive and indicated that use of peer assessors and the in-person site visit added value to the process. The model was perceived to provide valuable information to support internal quality improvement efforts. Assessors reported direct benefits from participating, including networking and learning opportunities. Key challenges were the high time demand on assessors and turnover in the assessor team.

CONCLUSIONS

The volunteer peer fidelity model was perceived to be a valuable improvement process by participants, but the high cost and reliance on ongoing volunteerism makes its sustainability uncertain. Next steps may include exploring remote assessment strategies or direct payments, although these strategies risk reducing the acceptability, and therefore uptake, of the assessment.

International application of standards for health care quality, access and evaluation of services for early intervention in psychotic disorders

AIM

Standards for health care quality, access and evaluation of early intervention in psychosis services are required to assess implementation, provide accountability to service users and funders and support quality assurance. The aim of this article is to review the application of standards in Europe and North America.

METHODS

Descriptive methods will be used to illustrate the organizational context in which standards are being applied and used, specific measures being applied and results so far.

RESULTS

Both fidelity scales and quality indicators of health care are being used. Fidelity scales are being applied in Australia, Canada, Denmark, Italy and United States. In England, quality indicators derived from the National Institute for Health and Care Excellence guidance are being used.

CONCLUSION

In the last 4 years, significant progress has been made in the development and application of measures that assess quality and access to evidence-based practices for early intervention in psychosis services. This represents an important step towards providing accountability, improving outcomes and service user experience. The methods used allow for comparison between the services that are assessed with the same methods, but there is a need to compare the different methods. Further research is also required to explore links between quality of care and outcomes for community mental health services that deliver early intervention in psychotic disorders.

Advancing a cascading train-the-trainer model of frontline HIV service providers in South Africa: protocol of an implementation trial

BACKGROUND

South Africa is marked by high rates of both HIV and alcohol use, and there is a detrimental synergistic relationship between these two epidemics. The Institute of Medicine recommends integrated care for alcohol use treatment and HIV, but implementation of integrated services remains a challenge in South Africa. This protocol describes a study designed to evaluate trainer, provider-, and patient encounter-level outcomes relating to the national rollout of a cascade train-the-trainer model of task-sharing to build capacity of the HIV workforce to deliver Screening, Brief Intervention, and Referral to Treatment (SBIRT) to address risky alcohol use.

METHODS

This 5 year protocol consists of two phases. First, we will finalize development of a robust SBIRT train-the-trainer model, which will include an SBIRT Trainer Manual, Provider Resource Guide, fidelity observational coding system, case vignettes, and a curriculum for ongoing consultation sessions. Materials will be designed to build the capacity of novice trainers to train lay workers to deliver SBIRT with fidelity. Second, we will recruit 24-36 trainers and 900 providers in order to evaluate the effects of the SBIRT train-the-trainer model on trainer- (e.g., fidelity, knowledge), provider- (e.g., SBIRT attitudes, confidence, acceptability), and patient encounter- (e.g., proportion receiving screening, brief intervention, referral to treatment) level variables. Data on patient encounters will be tracked by providers on programmed tablets or scannable paper forms in real-time. Providers will report on SBIRT delivery on an ongoing basis over a 6-months period. Additionally, we will test the hypothesis that trainer-level factors will account for a substantial proportion of variability in provider-level factors which will, in turn, account for a substantial proportion of variability in patient encounter-level outcomes.

DISCUSSION

This protocol will allow us to take advantage of a unique national training initiative to gather comprehensive data on multi-level factors associated with the implementation of SBIRT in HIV service settings. In the long-term, this research can help to advance the implementation of integrated alcohol-HIV services, providing lessons that can extend to other low-and-middle income countries confronting dual epidemics.

Implementing Coordinated Specialty Care for First Episode Psychosis: A Review of Barriers and Solutions

Specialized early interventions (SEI) for individuals diagnosed with a first episode of psychosis (FEP) are effective treatment modalities (Azrin et al. in Psychiatr Ann 45(11):548, https://doi.org/10.3928/00485713-20151103-05 , 2015). SEI offered immediately or shortly following a first episode improves functional and clinical outcomes for those individuals with, and at risk for, serious mental illness (SMI; Correll et al. in JAMA Psychiatry 75(6):555-565, https://doi.org/10.1001/jamapsychiatry.2018.0623 , 2018). In the United States, SEI programs referred to as Coordinated Specialty Care (CSC), have been utilized to provide a beneficial, team-based, multi-component method of treating FEP. However, despite the success, CSC programming is still met with considerable challenges. This article reviews existing CSC literature to identify and explore relevant barriers to successful implementation of CSC. Identified barriers include stigma, cultural competence, disengagement, measurement and evaluation, workforce development, implementation in rural areas, and financial stability. The ongoing efforts to address these barriers are described and areas for continued improvements are discussed.

Reliability and Feasibility of the First-Episode Psychosis Services Fidelity Scale-Revised for Remote Assessment

OBJECTIVE

The authors sought to evaluate the interrater reliability and feasibility of the First-Episode Psychosis Services Fidelity Scale-Revised (FEPS-FS-R) for remote assessment of first-episode psychosis programs according to the coordinated specialty care model.

METHODS

The authors used the FEPS-FS-R to assess the fidelity of 36 first-episode psychosis program sites in the United States with information from three sources: administrative data, health record review, and phone interviews with staff. Four raters independently conducted fidelity assessments of five program sites by listening to each of the staff interviews and independently rating the two other data sources from each site. To calculate interrater reliability, the authors used intraclass correlation coefficients (ICCs) for each of the five sites and across the total scores for each site.

RESULTS

Total interrater reliability was in the good to excellent range, with a mean ICC of 0.91 (95% confidence interval = 0.72-0.99, p<0.001). Two first-episode psychosis program sites (6%) achieved excellent fidelity, 25 (69%) good fidelity, and nine (25%) fair fidelity. Of the 32 distinct items on the FEPS-FS-R, 23 (72%) were used with good or excellent fidelity. Most sites achieved high fidelity on most items, but five items received ratings indicating low-fidelity use at most sites. The fidelity assessment proved feasible, and sites required on average 10.5 hours for preparing and conducting the fidelity review.

CONCLUSIONS

The FEPS-FS-R has high interrater reliability and can differentiate high-, moderate-, and low-fidelity sites. Most sites had good overall fidelity, but the FEPS-FS-R identified some services that were challenging to implement at many sites.

Fidelity Scale: From Black Box to Holy Grail

Fidelity scales are indispensable in the pursuit of evidence-based mental healthcare. Without fidelity checks, treatment remains a mysterious black box. The aim of this article is to comment on the studies in this special section, and to discuss some general issues with regard to fidelity assessment. Despite all of their supposed benefits, resistance to fidelity scales persists among mental health practitioners. One way to overcome this resistance is to conduct fidelity assessments in the context of a well-guided learning community. The predictive validity of fidelity scales is considered the single most valuable attribute of these instruments. Research on predictive validity requires large sample sizes, which is difficult to achieve. It should nevertheless not prevent us from rigorously searching for this Holy Grail of fidelity assessment. In addition, fidelity assessment should be placed in a broader perspective. The quality of care for people with severe mental illness cannot be assessed conclusively according to the extent to which separate interventions have been applied with good fidelity. These individuals need access to high-quality treatment and support systems within the community, which can enable them to live their lives as valued citizens. In conclusion, fidelity assessment, both at the level of interventions and systems, contributes to a highly desirable transparency in practice variations within the field of mental healthcare.

Coordinated Specialty Care Discharge, Transition, and Step-Down Policies, Practices, and Concerns: Staff and Client Perspectives

OBJECTIVE

In recent years, optimizing the process of transition and discharge from coordinated specialty care (CSC), a program that provides early intervention in psychosis, has emerged as an important focus area for program administrators, clinicians, and policy makers. To explore existing CSC policies and practices and to understand frontline provider and client views on discharge, the authors conducted a comprehensive analysis of staff and client interview data from the Mental Health Block Grant 10% Set-Aside Study.

METHODS

Data from 66 interviews with groups of CSC providers and administrators representing 36 sites and 22 states were analyzed, as well as data from interviews with 82 CSC clients at 34 sites. Transcripts were coded by using systematic content analyses.

RESULTS

Analyses of data from providers and administrators showed the heterogeneity of CSC program practices and strategies regarding discharge and highlighted a range of concerns related to postdischarge service accessibility and quality. Analysis of data from client interviews reflected the heterogeneity of transition challenges that clients confront. A significant number of participants reported concerns about their readiness for discharge.

CONCLUSIONS

CSC discharge policies and practices vary across CSC programs and states. Frequent clinician and client concerns about optimal program length, transition, and postdischarge services highlight the importance of sustained policy and research efforts to develop evidence-informed practice guidelines and possible modifications to the time-limited CSC model that currently dominates the field.

Early Intervention in Psychosis in Young People: A Population and Public Health Perspective

Over the past two decades or more, the creation of early intervention services (EIS) for psychoses has been regarded as one of the most significant developments in the reform of mental health services. The development of EIS is based on evidence of their superior effectiveness on multiple domains compared with regular care and the well-established relationship between delay in treatment of psychosis and outcome. The benefits of EIS may, however, be underutilized because of a patchy implementation even within high-income countries, low attention to actively reducing delays in treatment, inadequate knowledge about the length and dose of EIS required, and a lack of a population perspective in research and service planning. In this commentary, we offer some suggestions of how to address these challenges.

Understanding the implementation of coordinated specialty Care for Early Psychosis in New York state: A guide using the RE-AIM framework

AIM

Consistent evidence shows that early interventions for individuals with psychosis lead to improvements in symptoms, social functioning and treatment satisfaction. These results, combined with the allocation of specific funds for early psychosis services, have contributed to the emergence and dissemination of coordinated specialty care for early psychosis in the United States. Despite the rapid growth of such services across the country over the last 5 years, implementation processes are not yet well understood. We employ the RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) framework to describe processes, achievements and challenges of an early psychosis program called OnTrackNY that has been implemented in New York State.

METHODS

OnTrackNY is a coordinated specialty care program that delivers early intervention services that include both medications and psychosocial interventions to youths experiencing a first episode of non-affective psychosis. By drawing on outcome and care process data that are collected quarterly from all OnTrackNY sites, we describe the status of each RE-AIM dimension regarding OnTrackNY implementation followed by an evaluation of both achievements and shortcomings.

RESULTS

In general terms, OnTrackNY has shown to be a scalable and sustainable model for addressing early psychosis, reaching and providing recovery-oriented services to a large population in need.

CONCLUSION

Despite its advancements, a series of limitations pose challenges to the implementation and maintenance of the model including, but not to, the lack of incentives for coordination of services, the fragmentation of child and adult services, and concerns about financial sustainability.

Key performance indicators and administrative data in an early psychosis service

AIM

This study aimed to introduce a set of administrative key performance indicators (KPIs) for Early Psychosis Services.

METHODS

The study design was longitudinal with data retrieved from a 4-year period between January 2009 and December 2013 included in the study. Descriptive statistics and t tests were used to evaluate the KPIs.

RESULTS

Results in the 1 year before early psychosis (EP) intervention and 1-year postintervention were calculated for most items, and entry and exit scores were calculated for involuntary treatment orders (ITOs) and Health of the Nation Outcome Scale (HoNOS) scores. There was a 54% reduction in mental health emergency department presentations representing a cost saving of $62 524.00 (AUD). There was also an improvement in the number and duration of mental health admissions with a financial saving of $1 653 534.00 (AUD). Patients improved on all HoNOS scores from entry to exit from the services. ITOs were reduced by approximately 29% on discharge from the service.

CONCLUSIONS

Administrative data can provide useful KPIs to measure the effectiveness of EP teams and allow benchmarking with similar services.

Implementation and fidelity assessment of the NAVIGATE treatment program for first episode psychosis in a multi-site study

The NAVIGATE program was developed for the Recovery After Initial Schizophrenia Episode-Early Treatment Program (RAISE-ETP) study, which compared NAVIGATE to usual Community Care in a cluster randomized design involving 34 sites and 404 patients. This article describes the approach to training and implementing the NAVIGATE program at the 17 sites (including 134 practitioners) randomized to provide it, and to evaluating the fidelity of service delivery to the NAVIGATE model. Fidelity was evaluated to five different components of the program, all of which were standardized in manuals in advance of implementation. The components included four interventions (Individualized Resiliency Training, Family Education Program, Supported Employment and Education, Personalized Medication Management) and the overall organization (staffing and structure) of the NAVIGATE team. Most of the sites demonstrated acceptable or higher levels of fidelity in their implementation of the four interventions and the organization of the program, with all 17 sites demonstrating at least acceptable overall fidelity to the NAVIGATE program. The results indicate that the NAVIGATE program can be implemented with good fidelity to the treatment model in a diverse array of community mental health care settings serving persons with a first episode psychosis.