Results of a Coordinated Specialty Care Program for Early Psychosis and Predictors of Outcomes

Demographic and clinical characteristics of the sample (N=325) are described in Table 1. For 54% of participants, time to intervention was less than six months. There were no differences in baseline demographic and clinical characteristics between those who dropped out before 12 months and those who remained enrolled, except in baseline medication adherence (p=.049) and GAF symptom score (p=.044). Those who were discharged before 12 months were less likely to be taking prescribed medication and were more likely to have higher (better) GAF symptom scores at baseline compared with those who were still enrolled at 12 months.

A total of 133 (41%) participants had complete data for up to 12 months. Sixteen percent were discharged or dropped out before 12 months, and 43% were censored before 12 months (because of staggered enrollment) (Table 2). Program evaluation data were also reported for QI purposes just after data were deidentified in August 2016. These data indicated that 334 individuals were enrolled during the study period and that 99% (N=329) were retained at three months. The slight lag between the time of deidentification and the QI report explains why there were 325 individuals in this study and 329 in the QI report.

Figure 1 demonstrates the model-estimated mean scores for the GAF over time and the model-estimated prevalence of engagement in education or employment and psychiatric hospitalization over time. The mean GAF score at baseline across the 10 sites ranged from 35.2 to 65.5 for social functioning, 25.5 to 54.0 for occupational functioning, and 25.4 to 43.1 for symptoms. Whereas more than 70% of participants were hospitalized in the three months prior to enrollment, the hospitalization rate following enrollment decreased to an estimated 10% per quarter. The estimated risk of rehospitalization for a psychiatric condition within one year of enrollment was 34% (95% confidence interval [CI]=28%–41%).

Approximately 40% of participants were engaged in school or work at baseline, which increased to an estimated 80% by six months. The estimated probability of being employed or in school at some time during the year after admission was 88% (CI=83%–92%). At baseline, 10% of clients were employed only, 29% were in school only, and 5% were both employed and in school. Of the 50 clients who were employed, 44 (88%) had a competitive job. Of the 260 clients with data at six-month follow-up, 77 (30%) were employed only, 75 (29%) were in school only, and 47 (18%) were both employed and in school. Of the 124 clients who were employed, 81 (65%) had a competitive job.

Table 3 reports the estimated change in outcomes between each time point. The greatest improvement in GAF scores and education or employment status occurred between baseline and three months, with continued improvement to month 6. Statistically significant improvements in social functioning scores were seen at each additional time point, whereas symptom scores continued to improve through month 9. Statistically significant reductions in hospitalization were seen from baseline to month 3 and from months 3 to 6, and hospitalization rates remained low thereafter. [A table showing the percentage of clients with GAF scores >40 and >70 is available in the online supplement.]

Table 4 shows the estimated effects of predictors on longitudinal outcomes. Site was significantly associated with all GAF outcomes (social functioning, χ²=27.30, df=9, p=.001; occupational functioning, χ²=26.59, df=9, p=.002; and symptoms, χ²=19.06, df=9, p=.025) but not with education or employment or hospitalization. However, only 4% of the variability in baseline social functioning scores was due to site, compared with 7% of the variability in occupational scores and 5% for symptom scores (data not shown). Baseline scores in each domain were highly associated with subsequent scores in that domain, and baseline participation in education or employment was highly associated with subsequent education or employment.

Compared with women, men had significantly lower (worse) occupational scores and lower odds of being in school or employed. Compared with non-Hispanic whites, Asians and Hispanics had significantly lower occupational scores and lower odds of education or employment. Compared with non-Hispanic whites, blacks had lower odds of education or employment. Compared with individuals who had not yet completed high school, individuals with a high school degree or GED had lower educational or employment status at follow-up. Having some college (versus less than a high school degree), shorter time from onset of psychosis to program enrollment, and medication not prescribed (versus nonadherence) predicted higher (better) symptom scores. A lower (worse) baseline symptom score was associated with higher odds of having a psychiatric hospitalization. We repeated the analysis while controlling for parents’ highest education, with the only difference being that age became significantly associated with the occupational score. Older clients had significantly lower (worse) occupational scores.

To determine whether some predictors that were not significantly associated with outcomes would become significant if the analyses did not control for the other predictors, we repeated the analyses, this time controlling for baseline demographic characteristics and baseline outcomes but not mutually controlling for other predictors. We found no differences in significance between the approaches, except that compared with medication nonadherence, not being prescribed an antipsychotic was significantly associated with lower odds of a psychiatric hospitalization.

This is the first large-scale report of outcomes from a CSC program in the United States that is not part of a research study. The data demonstrate improved symptoms and occupational and social functioning, increased education and employment status, and decreased hospitalization rate. The greatest gains were seen in the first three months following enrollment, with continued improvement over time.

Participation in school or work was comparable to or exceeded rates seen in other CSC studies (5,13). OnTrackNY programs have a full-time supported employment and education specialist, which has been shown to improve vocational outcomes (17). The increased participation in school and work among OnTrackNY participants may also be due to the fact that the duration of untreated psychosis (DUP) among participants in this study was relatively short, compared with studies that did not limit DUP. Eligibility for OnTrackNY services is limited to individuals with DUP of less than two years; DUP in this study was an average of 225 days (median=160 days, or 5.3 months). Shorter DUP has been associated with better outcomes overall (14,18) and improved school or work outcomes (19–21). The shorter time to intervention may be due in part to the emphasis on outreach; each OnTrackNY has a part-time outreach and recruitment coordinator responsible for outreach (equal to .5 full-time-equivalent positions, approximately). DUP was longer in the RAISE-ETP study, which limited enrollment based on prior treatment but not duration of psychosis; the median DUP in the RAISE-ETP study was 74 weeks (5).

Rates of enrollment in the Supplemental Security Income (SSI) or the Social Security Disability Insurance (SSDI) programs among participants in OnTrackNY were somewhat lower than those observed in the RAISE-ETP study (22,23). In that study, the mean±SE percentage of participants enrolled in SSI/SSDI at baseline was 14%±2.9% for those enrolled in community care (CC) and 6%±1.5% for those enrolled in Navigate, the CSC model tested in the study. Rates rose to 36%±4.2% and 34%±3.2% at one year and to 48%±5.8% and 55%±4.2% at two years for CC and Navigate, respectively. In OnTrackNY, only 3% of individuals received SSI/SSDI at baseline. Participation was estimated to be 11% (CI=9%–15%) at one year and 18% (CI=14%–24%) at two years (14–21,24–26). Notably, some participants in the RAISE-ETP study may have needed to apply for SSI/SSDI in order to obtain Medicaid and receive treatment services, which was likely a factor in the SSI/SSDI participation rates in the RAISE-ETP study. It is possible that OnTrackNY participants were less reliant on applying for SSI/SSDI as a strategy to obtain health care coverage because OnTrackNY services are provided regardless of insurance status. We did not assess whether disability at baseline was a predictor of participation in work or school because baseline rates of disability were relatively low. Also, given the relatively high rates of employment and school participation, we anticipated that receipt of SSI/SSDI would result from poor work and school functioning rather than the other way around.

Other studies of early psychosis have also found that baseline levels of education and employment predicted school and work outcomes (19,20,24,25). We were not able to measure baseline cognitive and premorbid functioning, which have been found to predict vocational outcomes in first-episode psychosis (FEP) (25–27).

It is noteworthy that social functioning improved over every time point and that the percentage of clients with scores in the normal range was higher for social functioning than for the other GAF subscales at every time point. Other studies have also found that baseline social functioning predicted follow-up social functioning (28). Similar improvements in social functioning have been seen in other FEP studies (29).

Compared with medication nonadherence, no medication prescription was associated with higher (better) symptom scores. That may be because those with fewer symptoms were less likely to agree to antipsychotic medication.

The rate of hospitalization, 34% in one year, was similar to the rates in other studies of CSC. In the RAISE-ETP study, 34% of participants in CSC and 37% of participants in community care were hospitalized over a two-year period. In the Specialized Treatment in Early Psychosis study, 24% of participants in CSC and 44% in usual treatment (5,13) were hospitalized. Reductions in hospitalization are to be expected given the high rates of recent hospitalization at enrollment. Other studies have identified prior hospitalization, older age, lower GAF scores, and substance use as predictors of hospitalization (30–32).

Of note, substance use was not a significant predictor of any of the outcomes studied. This finding differs from some of the literature. Lower use or no use of substances has been identified as a predictor of recovery, and substance use has been identified as a negative predictor of education and employment (25,33,34). Substance use may have been underreported, given that we did not use a standardized assessment or collect self-report or collateral data.

The study was limited by the constraints of data collection in a context not associated with research. First, without a control condition, we cannot say that OnTrackNY caused the observed outcomes. All ratings were performed by clinical staff and, therefore, were subject to clinician bias. Diagnosis, substance use, and medication adherence were not determined by using a structured interview or tool. We did not use self-report or collateral measures and did not examine which components of the model were utilized. Although teams were closely monitored for adherence to the clinical model, we did not utilize a formal fidelity scale, although one is in development. OnTrackNY has the benefit of strong state support, including funding for a statewide TA center.

This study demonstrated that providing CSC in community settings and not as part of a research protocol was associated with significant improvements in education and employment and a decrease in the hospitalization rate among individuals with early psychosis. Several demographic variables and baseline education predicted education and employment outcomes. CSC teams should make particular effort to support the work and school goals of individuals who may be more likely to struggle in achieving engagement in work and school, including male participants and participants from racial and ethnic minority groups.