Promoting the Success and Sustainability of Coordinated Specialty Care Teams in Ohio

Despite the proliferation of CSC in Ohio, most counties still lack a CSC program. This unavailability of CSC services is problematic because the rapidity of access to CSC after the initial onset of psychotic symptoms may be influenced by how far individuals live from available programs. For example, we have found that the duration of untreated psychosis for individuals with FEP increased by 1 month for every mile between an individual’s home and the CSC program (5). However, data from the County Health Rankings and Roadmaps project (6) indicate that compared with Ohio counties with a CSC team, counties without a CSC team tend to have smaller populations (68,679 vs. 213,431), a greater percentage of rural areas (53% vs. 42%), and fewer mental health professionals relative to the overall population (one provider per 1,081 residents vs. one provider per 680 residents). Consequently, establishing brick-and-mortar CSC programs in these counties may not be viable because of the limited number of potential program participants and clinical staff.

To address this challenge, OMHAS partnered with the Ohio State University EPICENTER to develop a hybrid CSC team to serve Ohio counties that lack existing CSC teams. Within this model, CMHCs in counties without a CSC team can partner with EPICENTER in a comanagement model in which the two organizations collaborate to provide a complete CSC service package. Specifically, providers from the local CMHC will be responsible for providing case management, nursing, and supported employment and education services in person or via telehealth, and EPICENTER providers will provide family psychoeducation, medication management, and psychotherapy via telehealth. CMHCs participating in the hybrid CSC team will participate in weekly team meetings with EPICENTER clinicians to review CSC team operations and facilitate effective comanagement of care for program participants between the two agencies. Ultimately, hybrid teams may increase equitable access to CSC in communities that historically have experienced longer delays in accessing specialized FEP care (e.g., the predominantly rural Ohio counties currently lacking a CSC team [7]).

In fiscal year 2023, EPICENTER will pilot the hybrid team model with two CMHCs in counties without an existing CSC team with the plan to expand access to an additional six CMHCs in fiscal year 2024 and, ultimately, to all counties without an existing CSC team in fiscal year 2025. This pilot project will be subject to a rigorous mixed-methods implementation evaluation guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. The product of this evaluation will be an implementation blueprint that includes suggested key performance indicators, implementation of best practices, and training modules to facilitate the planned program expansion throughout the state.

At present, clear strategies to help individuals with FEP transition out of CSC programs are lacking (8). This absence of transition plans is problematic because current treatment guidelines highlight that CSC is designed to be a time-limited intervention that provides phase-specific clinical services to individuals with FEP during the first few years of the illness (9). Moreover, indefinite participation in such high-intensity services is often inconsistent with the recovery goals of individuals with FEP (10) and may limit the ability of CSC teams to enroll new participants in their programs (9).

Given the heterogeneous nature of the early course of psychotic disorders (2), development of a single transition plan that can successfully be applied to guide the step-down process for all individuals participating in CSC would prove challenging. Rather, an ideal step-down strategy will need to be personalized to the specific strengths and needs of the individual with FEP and to be informed by clinical support tools and algorithms to guide clinical decision making. Thus, developing the step-down strategy for Ohio CSC teams will involve two components. First, using data collected within the HONE data informatics system, CSC staff will be alerted via their HONE dashboard when CSC participants have met their personalized recovery goals (e.g., return to work or school or increased peer socialization). This alert will not result in an individual being discharged from the CSC program but, rather, will trigger a structured discussion among the CSC providers, the CSC participant, and other relevant stakeholders (e.g., family members) about the appropriateness of transition from the CSC team to a less intensive care model. Second, individuals who are determined to be ready to step down from CSC services will then participate in a modified critical time intervention (CTI) currently under development by technical consultants at Ohio State University and Northeast Ohio Medical University in consultation with Ohio CSC team staff. CTIs have been applied to improve continuity of care and reduce negative outcomes during transitions from higher to lower levels of mental health care (such as transition from inpatient care to a CSC team) in which a specialized care provider (e.g., a member of the CSC clinical team) facilitates successful transition to a lower level of care via time-limited consultative activities with the participant, staff at the new clinical program, and other relevant stakeholders (11).