Silver and Bronze Achievement Awards

Although many homeless people have mental illnesses that affect their ability to seek and maintain housing, it is rare for them to voluntarily seek psychiatric treatment. The Center for Urban Community Services' (CUCS's) Project for Psychiatric Outreach to the Homeless (PPOH) addresses this treatment gap by being the only program in the United States that is exclusively dedicated to recruiting, employing, supporting, and training community psychiatrists to work with homeless and formerly homeless adults in community-based programs and other nontraditional settings.

PPOH began in 1986 as a district branch task force of the APA that was focused on recruiting psychiatrists to work as volunteers with homeless people in New York City. Within a decade it attracted the support of public funding agencies, and by 2005 it was providing services at 32 programs in New York City through the efforts of paid and volunteer staff members. In 2006 PPOH merged with CUCS and has since grown to provide services at 54 program sites in the Bronx, Manhattan, and Brooklyn.

To provide ongoing treatment to even more homeless and formerly homeless adults with mental illness, PPOH recently initiated the development of a volunteer network of psychiatrists who provide free services to formerly homeless people in their private offices.

In recognition of its efforts and innovative approaches to bringing psychiatric treatment services to homeless adults and individuals living in supportive housing, the PPOH was selected to receive APA's Silver Achievement Award for 2010.

There are approximately 40,000 homeless people in New York City, about 10,000 of whom are single adults. About 75% of single, adult homeless people suffer from severe and persistent mental illness, substance use disorders, or both; yet only about 20% of homeless people with mental illness engage in psychiatric treatment in clinics and medical centers.

Because of the small numbers of homeless people voluntarily seeking psychiatric treatment, one of the primary challenges of PPOH psychiatrists is to engage this population. In order to accomplish this goal, PPOH embraces a person-centered approach. This approach begins with meeting people at their current location, whether it is at a shelter cafeteria or park bench, and continues with making psychiatric treatment as collaborative a process as possible.

PPOH also helps to address the challenges that occur when a psychiatrist is transplanted from an office practice or clinic to a community or street setting. In order for psychiatric care to be delivered in an effective manner, it is necessary to reorient the psychiatrist and help programs effectively utilize a psychiatrist. To help psychiatrists, PPOH continues to develop and distribute a handbook that incorporates current literature about homelessness and psychiatry and details the experience of PPOH staff psychiatrists. This handbook provides guidance for managing the variety of situations that community psychiatrists face daily and that are unique to work in the field—from how to help homeless people take medicine accurately and consistently to how to integrate psychiatric practice into social service settings. PPOH also teaches programs how to integrate a psychiatrist into their teams, how to communicate clinical information, and how to safely and accurately monitor medications.

PPOH also faces two other challenges: homeless service providers generally have difficulty paying for the services of psychiatrists and the programs most in need of psychiatric services are the least able to afford these services. To overcome these problems, PPOH leverages government and foundation funding in order to keep the cost of psychiatric services affordable. On average, CUCS's government and foundation grants provide a 59% subsidy to the sites where PPOH provides services. PPOH also remains committed to expanding the number of sites at which it can provide services. To help ensure psychiatric care is delivered where it is most needed, in the past year PPOH began serving eight new programs, including soup kitchens, food pantries, and a housing program for homeless youths aging out of foster care. Fifty percent of PPOH contract sites are located in nationally designated health professional shortage areas, and PPOH continues to work to identify additional programs in these areas in need of low-cost psychiatric services.

PPOH employs 24 full-time, part-time, and per diem psychiatrists and four volunteer psychiatrists. The medical director provides clinical and administrative oversight and supervision of the program. The director of program operations coordinates placements of psychiatrists, responds to new requests for services, and ensures staff and program adherence to practice standards. The assistant program director manages fiscal operations of the program, reports to funders, and uses information systems to document, manage, and report on services delivered. The assistant medical director for education and training supervises the homeless psychiatry rotation, a program of 12–16 psychiatry residents rotating for three hours per week during the academic year. The assistant medical director for clinical operations provides supervision for psychiatrists, investigates incidents, and monitors patient satisfaction, psychiatrist performance, and program site effectiveness.

With this staff, PPOH provides nearly 500 hours per week of psychiatrist time to 54 community programs serving homeless New Yorkers. In 2009 PPOH psychiatrists provided services to over 3,000 unique individuals, provided ongoing treatment to almost 700 people, and had over 10,000 visits. PPOH provides psychiatrists for all seven Manhattan street outreach teams and for the Bronx street outreach team. By conducting the evaluations needed to secure housing and entitlements, PPOH has helped these teams house 500 people over the past three years. PPOH also provides psychiatrists to 20 supportive housing programs and has helped over 1,500 persons with mental illness remain psychiatrically stable and housed.

Funding for PPOH is derived from various sources. In fiscal year 2009 PPOH received $438,139 from the U.S. Department of Housing and Urban Development, $334,560 from the New York City Department of Health and Mental Hygiene, $400,000 from the Robin Hood Foundation, and $50,000 from the van Ameringen Foundation. An additional $878,878 in fee-for-service reimbursement was provided by the 54 program sites.

PPOH has seen much success and is considered to be a model program that could be of great benefit to other organizations. PPOH's model of training community psychiatrists to work with homeless adults and then embedding these psychiatrists at street outreach programs, shelters, and other programs serving homeless adults can be readily implemented in other large metropolitan areas.

PPOH also takes several tacks to advance the field of community psychiatry. Each year PPOH hosts 12–16 residents in clinical rotations, serves as a placement site for the Columbia Public Psychiatry Fellowship, and participates in the community psychiatry courses of several psychiatry residency and fellowship programs. PPOH also has an online course for residents and fellows that provides information about the social, economic, and clinical issues pertaining to working with the homeless population, along with practical guidance about how to bring psychiatric practice to the homeless community.

PPOH also provides training to nonpsychiatrist groups, including the Urban Justice Center and to the Chronic Illness Demonstration Project based at Bellevue Hospital Center. These training activities educate clinicians and others about the relationship between homelessness and mental illness and about person-centered approaches and evidence-based practices that are used in working with homeless people with mental illness. In addition, PPOH's seminar and case conference series for psychiatrists have recently been endorsed by the Medical Society of the State of New York to grant up to 34 Continuing Medical Education credits per year.

PPOH engages in ongoing program evaluation to ensure that its services continue to meet patients' needs while continually developing best practices for psychiatry focused on helping homeless adults. Through case conferencing and quality assurance and incident management committees, PPOH provides formal structure for the evaluation of its services. These activities have led to the establishment of outcome targets for services each year. Outcomes are tracked by program type. In total, PPOH served 3,041 individuals in 2009. Sixty-five percent of the individuals who received ongoing treatment showed improvement in their psychiatric conditions, as measured by the Clinical Global Impression Scale. In addition, each year PPOH asks a sample of its patients to complete a Patient Satisfaction Survey in an attempt to examine how effective it is at providing person-centered care. Through this survey, PPOH has found that its patients generally find their engagement with psychiatrists to be respectful and productive. A small number of patients have commented over the years that they wished that their PPOH psychiatrist could see them more frequently. To help meet this need, PPOH is working to recruit clinicians who can provide pro bono therapy and continues to explore additional sources of funding to bring more psychiatrists to this essential work.

This innovative program provides services to a population of psychiatric patients who would otherwise be unable to obtain psychiatric care. The PPOH has shown promise in its success in overcoming financial barriers and in its success in reaching out to patients who are both difficult to engage and difficult to treat.

On a public health level, quality mental health care is not possible without integrating mental health services into primary care settings, but several national initiatives to bridge the efficacy-effectiveness gap in mental health care have fallen short. For example, the strategy of integrating primary and specialty mental health care via colocation makes intuitive sense, but such models typically have resulted in parallel, not integrated, services.

The Behavioral Health Laboratory (BHL) offers a successful model of collaborative care management for primary care of veterans. The BHL originated in 2003 out of Veterans Integrated Service Network 4 (VISN 4) in Philadelphia, and a second BHL opened at the Pittsburgh Veterans Affairs Medical Center (VAMC) in 2007. What started as an assessment laboratory to assist primary care providers in assessing mental health and substance abuse symptoms has expanded into an efficient illness management service to help primary care physicians identify and treat common mental disorders according to evidence-based treatment guidelines and with the expertise of a supervising psychiatrist. In recognition of their excellence in providing these services, the BHLs of Philadelphia and Pittsburgh were selected to receive APA's 2010 Bronze Achievement Award.

There are five core components of the BHL system of care: first, a well-structured screening program to identify patients in need; second, flexible, patient-centered delivery of services through virtual clinics, telephone-based assessments, and face-to-face services; third, evidence-based care management protocols, with care managers (typically supervised by a psychiatrist) providing education, patient activation, and decision support to patients and their primary care providers; fourth, retention of the primary care provider at the center of treatment planning, including prescribing antidepressants with monitoring from the care management team; and fifth, interventions that are time limited to optimize the program's capacity.

On receiving a referral from the physician, a trained BHL mental health technician or clinician conducts a standardized assessment in person or by telephone. VISN 4 data show that 95% of all patients contacted by the BHL agree to complete the initial assessment. The evaluation takes 20–30 minutes and consists of a series of validated instruments designed to detect the presence (as well as the symptom severity) of an array of mental health syndromes. The assessment includes demographic information and questions about depression, anxiety (including generalized anxiety, panic, and posttraumatic stress disorders), cognitive impairment, quality of life, alcohol use and dependence, illicit drug use, and suicidal ideation; it also screens for psychosis and mania.

The assessor enters the patient's responses into a software program, which automatically generates a note for inclusion in the electronic medical record or chart along with an initial treatment plan recommended to the primary care physician. These assessments generate quantifiable mental health data that physicians find familiar and actionable, similar to laboratory data from blood work. In addition, the BHL software includes decision support logic, clinical reports, and administrative reporting functions that can be monitored and used for quality assurance.

The BHL assessment is the foundation for the treatment plan. Treatment pathways may include watchful waiting for subsyndromal symptoms, monitoring for depression after prescribing antidepressants, depression and anxiety care management, brief interventions for alcohol misuse, and referral management for patients who need specialized mental health care. A referral management module assists patients in overcoming any treatment barriers, including ambivalence about attending a specialty care appointment. A recent randomized study of BHL referral management found that using it significantly improved treatment engagement (70% versus 32%).

The cultural change needed for integrating mental health care with primary care is always challenging. At the center of the BHL model, time-strapped primary care physicians needed efficiencies, not new burdens. Before the Philadelphia BHL launch, for example, physicians seeking specialty mental health referrals had to sift through multiple options and make an educated guess about the appropriate contact. This process often resulted in misdirected or unanswered referrals. The BHL offers an efficient, "no wrong door" solution: it receives all referrals, then conducts further assessment to stratify level-of-care needs and assists with treatment planning. Also, the BHL psychiatrist's educational seminars and individual consultations have eased physicians' hesitancy in prescribing antidepressants, and the psychiatrist cosigns any psychotropic medication recommendation. These measures fit the primary care culture in a way that allows the provider to feel comfortable addressing mental illness and to feel secure that the treatment plan is appropriate.

The psychiatrist plays a central role in the clinical operations of the BHL. He or she supervises the care managers, who then convey treatment recommendations to the physicians. Therefore, one psychiatrist can provide weekly consultation on a multitude of primary care patients. The psychiatrist also provides individual consultation to physicians and care managers, educational seminars, and BHL program direction.

VISN 4 currently operates as a "hub and spoke" model with support staff (health technicians) and clinic directors located in Philadelphia and Pittsburgh and care managers located at all other VISN 4 medical centers. This allows for efficient use of staffing via a regional call center that conducts structured assessments and provides data and support to the other sites. The Philadelphia BHL has processed over 16,000 patients since 2003 and receives approximately 300 new patients per month for the Philadelphia VAMC and outpatient primary care clinics and another 70 referrals per month from three other VAMCs in the VISN. The staff includes nine full-time staff (health technicians and care managers) and a half-time psychiatrist who serves as the BHL medical director. The VA funds the Philadelphia BHL at an estimated $1.14 million annually.

The Pittsburgh BHL began in July 2007 and has triaged over 2,800 veterans. It has five full-time health technicians and care managers and one half-time psychiatrist who serves as BHL medical director. The Pittsburgh site generates about 50 consultations per month and provides about 70 additional consultations per month for two satellite medical centers. The VA funds the Pittsburgh BHL at an estimated $500,000 annually.

The BHL model represents an innovative, easily replicated platform of care that has significantly improved the mental health care of a large primary care population. It offers psychiatrist-led, patient-driven, team-based care that is efficient, collaborative, and interdisciplinary. The BHL model is now an integral part of over 30 VAMCs nationwide and serves as a model for other U.S. mental health programs, including the award-winning DIAMOND program of the Institute for Clinical Systems Improvement (see page 1042).