2005-2009 Statewide Comprehensive Plan for Mental Health Service Services
Chapter 5: Services Research

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Mental health services research integrates research, practice, and policy directions into mainstream practice. It takes place in “real-world” settings and examines characteristics of individuals, families, providers and the service system; aspects of social, psychological and cultural environments and their influence on how people seek care; the nature and type of care selected or provided; and what occurs during service delivery and the outcomes of care. The overall goal is to improve treatment and services for people with mental illness by helping them get the best possible care. While evaluation and services research conducted by OMH is the focus of Chapter 5, information about OMH basic and clinical research related to the treatment and prevention of mental diseases is found in Chapter 4.

A 1999 National Institute of Mental Health (NIMH) report, Bridging Science and Service, focuses attention on the need for mental health services research that is useful and practical for people with mental illnesses, clinicians, purchasers, and policy makers.¹ OMH conducts rigorous services research that is strongly influenced by the demands of the public mental health system and, in turn, influences the development of policy and practice on a wide range of pertinent issues. A significant portion of OMH services research is conducted in the Evaluation Research (ER) branch of the OMH Center for Information Technology and Evaluation Research (CITER), with additional services research being conducted at the New York State Psychiatric Institute and the Nathan S. Kline Institute for Psychiatric Research. Evaluation research and statistical analysis on agency operations provide information that improves the effectiveness and facilitates the management of mental health services in New York State. New knowledge gained through these activities leads to improved public mental health outcomes in meaningful and measurable ways. This information affects the organization, financing, management, delivery, and access to services, as well as the course, cost, and consumer level outcomes of care.

This chapter reviews 2004 OMH services research regarding a number of evidence-based practice initiatives designed to improve the quality of care offered to adults with serious mental illness and children with serious emotional disturbance. It also highlights care coordination initiatives, which are designed to support important OMH program initiatives. Together, OMH program and care coordination initiatives are contributing to the base of knowledge in New York State and nationally on effective clinical strategies that support individuals with serious mental illness as they strive toward recovery.

Science Informing Practice: Evidence-Based Initiatives

Mental health services research has demonstrated that some specific treatment approaches are effective in improving outcomes for individuals diagnosed with serious mental illness. Called evidence-based practices (EBPs), these interventions are rooted in reliable scientific inquiry, and supported by a body of evidence; they have demonstrated effectiveness in improving outcomes in areas relating to wellness (e.g., physical health, self-esteem, symptom management, and behavior management) and community integration (e.g., housing, employment, and education). Adherence to specific population, outcome, and implementation standards is key to producing outcomes consistent with recovery.

OMH's Winds of Change campaign continues the drive to promote recovery from serious mental illness through the implementation of EBPs in routine mental health settings. The implementation of EBPs in New York State has been guided by a model that builds on strategies for change through three phases: consensus building, enacting, and sustaining. As described in Table 5-1, the process is dynamic and involves careful coordination, monitoring, and ongoing evaluation of the implementation of EBPs.

A cornerstone of the Winds of Change campaign is involvement of stakeholders at all levels of the system in continual quality improvement efforts. During 2003-2004, approximately 6,000 individuals who used mental health services participated in public forums to provide input on the EBP campaign. Additionally, ongoing support for the seamless integration of EBPs into the OMH quality agenda occurred when more than 400 people from New York State and around the nation attended a July 2001 symposium on EBPs and trauma treatment.

OMH evaluations of specific EBPs share common components and target areas specific to the practice under study. Common elements include tracking the number of programs, staff trained in the delivery of the intervention and individuals served; measuring clinician satisfaction with training; examining program adherence to EBP standards (better known as fidelity to implementation); and assessing the quality of programs being implemented and clinical outcomes.

Table 5-1
OMH Planning Matrix For Evidence-Based Practice Implementation

Adult Services

The implementation of EBPs among the adult population with serious mental illnesses is being studied across service settings: inpatient, outpatient, and in jails and prisons. Principal areas of study currently under way include medication management, Assertive Community Treatment, family psychoeducation, and consumer assessments of service quality.

Improving the Quality of Medication Practices

Medications are a critical component of the treatment of serious mental illness. Two important studies of medication management have been designed to better understand their impact on the quality of medication practices in the public mental health system. The first study is aimed at investigating the effect of an innovative software application called PSYCKES, which has been developed by OMH for use in State hospitals to improve the quality and safety of medication prescribing practices. The second involves collaboration with the State Department of Health (DOH) to extend the reach of the PSYCKES concept to physicians throughout the State, who prescribe antipsychotic medications for Medicaid clients with schizophrenia.

Implementation of PSYCKES, an Automated Clinical Decision Support Tool.

OMH researchers have developed the Pharmacy Service and Clinical Knowledge Enhancement System (PSYCKES), a novel Web-based, clinical and management decision support system, to support evidence-based decision making in the State mental health system. PSYCKES is designed to increase the quality of care and enhance consumer safety by improving clinician access to medical record information, relevant clinical practice guidelines, and medical reference information. It is contributing toward standardizing practice patterns and error proofing through automated, guideline-driven performance measures that profile quality, safety, and conformance to EBPs at the hospital and physician levels. In making data available to the clinician at the point of practice, PSYCKES addresses a key barrier to implementing evidence-based guidelines-the lack of knowledge of which medications were tried in the past. When deciding which medication to try next, the clinician is able to obtain from PSYCKES critical decision making information, for example, which medications have been previously tried, for how long, at what dose, and in what sequence.

PSYCKES is currently available at 18 OMH inpatient facilities and training sessions have been held at ten facilities. Full statewide implementation at the remaining facilities is anticipated by April 2005. Currently, more than 400 clinicians have access to the system and data collected during PSYCKES training sessions show that PSYCKES is user-friendly and a practical clinical tool. Clinicians gave the system high average usability scores (6 or more on a 7-point scale), rated PSYCKES as the single most useful source of information about medication histories (8.8 on a 10-point scale), and gave it high average usefulness scores (6 or more on a 7-point scale). Preliminary findings also show that PSYCKES meets clinical information needs in a time-efficient way. Due to the fact that many individuals who have serious mental illness have lengthy treatment histories spanning multiple years and are often served during the course of their treatment by multiple providers, physicians often lack access to full and complete information documenting an individual's complete history of medication trials. Physicians without access to PSYCKES correctly identified only 24.6% of medication trials; with PSYCKES, the physicians improved to 76.9% and also recorded a 59.8% decrease in the time needed to assemble a medication history. Further analysis will explore factors associated with use and the impact of PSYCKES on clinical prescribing practices.

Incorporating Quality Indicators into Antipsychotic Drug Utilization and Review Processes.

OMH researchers are also working with NYS Department of Health (DOH) staff to review the prescribing practices of physicians outside of the State mental health system who prescribe antipsychotic medications for clients who have schizophrenia. The two agencies are working to incorporate quality indicators adapted from PSYCKES into the DOH Drug Utilization and Review processes. The overall goal is to educate physicians outside of the public mental health system on best practice guidelines, with the potential over the long term of using a PSYCKES-type information system to improve the quality of care.

Assertive Community Treatment (ACT): A Measure of the Quality of Care

ACT is a model of care that includes outpatient treatment, rehabilitation, case management, and support services. It is aimed at adults with serious mental illness who have not fared well in traditional treatment settings. Research has consistently found that ACT, when compared to other case management approaches, is more effective at decreasing psychiatric hospitalizations and improving housing stability among individuals with mental illness.²

ACT services are delivered by a mobile, multidisciplinary mental health treatment team that shares caseloads and includes specialists from the fields of psychiatry, nursing, psychology, social work, substance abuse, and vocational rehabilitation. Team members collaborate, plan and deliver a set of integrated services that are responsive to clients' individual choices and preferences and tailored to meet their specific needs. Services are delivered primarily in the community and include medication management, counseling and psychotherapy, housing support, job search and retention assistance, life skills development, integrated mental health and substance abuse treatment, and family support and education. The staff-to-client ratio is small and services are provided 24-hours a day, seven days a week, for as long as they are needed.

ACT is documented to be effective by the National Institute of Mental Health's Schizophrenia Patient Outcomes Research Team (PORT) study,³ and is endorsed in the Surgeon General's 1999 report on mental health as an essential treatment for many individuals who have serious mental illness. Additionally, families and clients have generally indicated high levels of satisfaction with ACT. The federal Centers for Medicare and Medicaid Services has authorized ACT as a reimbursable treatment service, and the Substance Abuse and Mental Health Services Administration (SAMHSA) has designated access to ACT as a measure of the quality of a state's mental health system.

OMH has fostered growth of the ACT treatment model through the development of a new licensed program category in Medicaid billing. As of December 2004, 61 ACT programs were licensed, serving 3,037 individuals. An additional 11 ACT teams are in the licensing process, bringing the capacity of individuals served to 4,656.

The ACT evaluation is also examining the impact of introducing ACT model fidelity requirements into the licensing and certification process.

Using feedback from the provider community, OMH recently enriched funding of the ACT model, enabling more effective recruitment and retention of qualified staff and providing additional funding for training. These enhancements underscore OMH's commitment to this form of care coordination.

ACT Evaluation

OMH continues to support an ongoing evaluation of ACT in the State, with a focus on contributing to the base of knowledge that will improve care in New York State and nationally. The evaluation of ACT covers seven specific areas, from better understanding of who is served by ACT and clinical outcomes of ACT in relation to other forms of case management, to an examination of factors related to successful implementation of the ACT model. The evaluation is also examining the role of licensing in ACT implementation and is helping to determine how effectively a nationally developed toolkit facilitates program implementation.

The OMH Child and Adult Integrated Reporting System (CAIRS) is an important tool in meeting a number of ACT evaluation aims, including the capacity to aid clinicians in monitoring individual client outcomes. Data from CAIRS provide a picture of the characteristics of individuals from around the State who are being served by ACT. Based on eligibility criteria for admission to ACT, of the 1,039 clients on new ACT teams, 60% are considered high risk, including 17% with involvement in the criminal justice system/jail in the past six months, 32% with two psychiatric hospitalizations in the past year, 24% homeless, and 11% assigned to ACT through Assisted Outpatient Treatment (AOT) court orders.

Current data are consistent with the results of early evaluations of favorable clinical outcomes with ACT. Data from CAIRS are being used to examine outcomes for ACT recipients after their first six months of ACT services. As of November 2004, the results indicate a significant reduction in emergency room visits, from an average of 0.59 to 0.38 visits; a decrease in number of admissions to psychiatric hospitals, from an average of 0.79 to 0.61 admissions; and a dramatic decrease in length of hospitalization, from an average of 25.89 to 10.07 days.

The next phase of OMH's ACT evaluation is focusing on obtaining additional feedback on implementation processes, including EBP trainings, licensing audits, field office technical assistance, monthly team leader conference calls, billing systems, documentation burden, and SPOA referrals. It is also assessing organizational factors that may be related to fidelity (e.g., cohesion, commitment, and leadership); examining factors that may contribute to staff continuity and burnout (e.g., job satisfaction, skill variety and role ambiguity); and investigating recovery practices, an area of focus for policy development.

As part of the ACT evaluation, OMH has been collaborating with seven other states in the national Implementation Toolkit Project, a project funded by SAMHSA to study the implementation of EBPs. The study is examining the implementation process, identifying barriers and strategies, and assessing specific observational criteria to better inform implementation initiatives and policy development. Study findings will be used as a basis for revising and refining the national toolkits, which have been used by New York State providers and others in implementing EBPs.

Family Psychoeducation

Over the past 25 years, research has clearly demonstrated that family psychoeducation interventions significantly improve the lives and independent functioning of people with serious mental illness by reducing relapse and promoting personal goal attainment such as employment. Based on the work of McFarlane (2002),⁴ current initiatives aim to support the competent provision of evidence-based family psychoeducation approaches that combine education about mental illness, family support, crisis intervention, effective communication strategies, and problem solving skill training. The main goal in working with families is to help them develop the knowledge and skills to support the recovery of their family members.

OMH is working with mental health providers and stakeholders to improve the quality of mental health services through the provision of comprehensive and recovery-oriented family psychoeducation and support services. The agency is currently involved in two different family psychoeducation implementation initiatives: the implementation of family psychoeducation in 41 programs statewide, in collaboration with the Family Institute for Education, Practice and Research at the University of Rochester Medical Center, and the implementation of a federally funded family psychoeducation research project in three culturally diverse communities in New York City.

Statewide implementation

OMH has established a partnership with the Family Institute for Education, Practice and Research at the University of Rochester Medical Center to support the implementation of family psychoeducation statewide. The newly formed Family Institute is educating mental health providers throughout New York State concerning how to effectively provide family services to individuals with a mental illness and their families. An evaluation of the implementation process is focusing on the identification of factors associated with the successful incorporation of family psychoeducation among 41 participating programs. The evaluation will serve to inform further dissemination of the model statewide.

Three different models of implementation are being compared, including on-site, one-to-one consultation, and group supervision. The preliminary evaluation of fidelity to the national model at baseline has shown that all three of the conditions are equal. The three consultation models will have assessments of fidelity to the national model at 12, 18 and 24 months post training. The 12-month fidelity scale assessments began in January 2005 and findings are expected to be available in September. As of November 2004, 65% of the one-to-one consultation sites and 31% of the group supervision sites have had family psychoeducation workshops.

Family psychoeducation training evaluation and implementation in three diverse communities

SAMHSA is funding a three-year study to explore how to best implement family psychoeducation in the African American, Chinese, and Hispanic communities. While evidence suggests that the effectiveness of family psychoeducation generalizes to nearly all major cultural populations, there is awareness that culture and language can pose significant barriers to the provision of family psychoeducation, requiring culturally relevant adaptations and further study. OMH researchers have designed the study to provide insights into culture-specific barriers related to accessing quality mental health services and to develop culturally based enrichments for the national Family Psychoeducation Implementation toolkit. The necessary cultural adaptations and “lessons learned” can be replicated in other settings in the State and incorporated into the final refinement of the national Family Psychoeducation Implementation toolkit.

Consumer Assessment of Community-Operated Outpatient Services: Peer-Professional Collaboration

As part of our efforts to improve quality of care and promote recovery from serious mental illness, OMH is continuing to seek stakeholder input in promoting quality care. We are particularly interested in levels of satisfaction among persons receiving services and perceptions of how services have impacted their quality of life.

Every two years, OMH conducts a statewide survey of consumer assessment of services. During the most recent survey in 2004, OMH partnered with peer-run and peer advocacy programs to sponsor a consumer assessment of care in non-residential community programs in eight counties. The initiative examined the value of the assessment tool, the Mental Health Services Survey (MHSS), and the partnership approach with consumers in the conduct of the survey. The MHSS, which was developed by OMH with extensive consumer participation, is used to evaluate the quality of services in four service domains: access, appropriateness, global satisfaction, and outcomes. The overall goal of the assessment in non-residential community programs was to develop a basis for quality improvement in the full spectrum of community-operated public mental health services for adults.

To maximize diversity of the survey sample, evaluators divided the State into two upstate urban and rural regions and two downstate urban and suburban regions. Two counties were randomly selected in each of the four regions, with the single condition that a peer organization be present and operational in each county. Peer programs in each selected county chose two consumers who received one day of training and assisted OMH staff in administering the surveys in accessible locations. The peer advocates also publicized the surveys and pre-registered up to a maximum of 50 participants per site. OMH and peer program partners enlisted consumers from a stratified mix of different types of non-residential community programs, such as case management, clubhouses, and psychosocial rehabilitation. In the eight counties, a total of 388 individuals participated in the anonymous survey and early results indicate that the initiative was successful in both the consumer partnership and its data collection methods.

Among outcomes, the majority (81%) of survey participants rated the overall improvement they made as good or excellent and 83% indicated as good or excellent the likelihood that they would continue to use services when needed. Eight out of ten respondents also rated as good or excellent the staff's belief that they could change, grow and recover. A number of areas were also identified by respondents as opportunities for improvement; for example, in the area of receiving assistance in obtaining housing, vocational or educational services, six out of ten survey participants gave this item a rating of good to excellent.

As has been documented in other evaluation studies, it appears that peer program co-sponsorship and peer participation in survey administration contribute to objective assessment and the identification of opportunities for improvement by consumers of services.^5,6 Moreover, the Institute of Medicine Report, Crossing the Quality Chasm,⁷ indicates that consumer participation is a key strategy in improving the delivery of healthcare in the U.S. Thus, in addition to planning quality initiatives around the findings from this survey, OMH plans to continue to expand peer participation to the annual evaluation of community programs statewide, and, where possible, utilize Web-based protocols in facilitating the evaluation process.

Forensic Mental Health Services: Supporting Recovery

In the forensic mental health system, OMH services research is directed toward minimizing the disabling effects of serious mental illness. Evaluations are lending support in modifications to the forensics system, including evaluation-informed changes for inmate-patients with serious mental illness in special housing units, and for inmate-patients re-entering communities from maximum security prisons. Additionally, a study is under way to investigate interventions to improve the discharge planning process for all inmate-patients returning to the community.

Evaluation of Mental Health Services for Inmates in Special Housing Units

The New York State Department of Correctional Services (DOCS) has more than 5,000 disciplinary Special Housing Unit (SHU) cells. Inmates who are transferred into these cells for the most serious infractions of prison rules receive mental health services. To better meet the mental health needs of SHU inmates, an evaluation study was initiated in 2002 in the SHU cells of 11 maximum security prisons. The study examined the characteristics of inmates, their mental health needs and diagnoses, their disciplinary records, and the amount of mental health services they were receiving.

Based on the 2002 results, a comprehensive plan was implemented to improve mental health services to patients in SHU cells. Important elements of the plan were the creation of private mental health treatment space to which patients would be escorted out of their SHU cells; a joint DOCS/OMH committee to review mental health needs of inmates for possible transfer; a designated OMH SHU clinician; an increase in private mental health treatment to a minimum of two non-physician and one physician sessions per month; an increase in OMH cell-side visits to all inmates in SHUs to every work day to screen for mental health needs; and measurement of psychiatric functioning every 90 days. The study was repeated in 2004 to determine the extent to which the SHU plan of improvement was being implemented. Key results from the 2004 study show the following:

• A dramatic increase in private mental health treatment hours. Between 2002 and 2004, average patient private contact hours per SHU increased from .4 to 1.73 hours per month (a rise of 333%) for inmates classified as requiring the highest level of mental health care, Level 1. The average private contact hours increased from .2 to 1.31 per month (a 555% increase) for inmates at the next level of mental health care, Level 2.
• A significant increase in cell-side contact hours. The average cell-side contact hours per inmate increased to 2.01 hours per month in 2004 from .81 in 2002. Inmates requiring Level 1 mental health care had an average of 2.57 cell-side contact hours per month in 2004 as compared to 1.2 in 2002. Inmates receiving Level 2 mental health care had an average of 2.23 cell-side average contact hours in 2004 compared to 1.0 hour in 2002.
• An improvement in compliance with psychiatric medication use. In 2002, 13% percent of inmates in SHUs refused psychiatric medications. By 2004, noncompliance had significantly decreased to 4%.
• A major reduction in the percentage of inmates diagnosed with a serious mental illness. From 2002 - 2004, there was a 47% decrease in the percentage of inmates with a serious mental illness diagnosis of schizophrenia, bipolar disorder, or major depression in SHU cells.

The results indicate that the SHU plan of improvement was successfully implemented. Mental health contact hours increased dramatically both in the private treatment and cell side. Moreover, the reduction in number of inmates with major mental illness strongly suggests that the joint DOCS/OMH committee has been effective in moving or diverting persons with serious mental illness from SHU cells. The study will be repeated again in March 2005 and ongoing monitoring by OMH will continue with reviews of the DOCS/OMH committee minutes, functional assessment results, and charts of inmate in SHUs by OMH Unit Chiefs. Further study will also explore the outcome of additional contact hours in relation to reductions in mental health disability and disciplinary infractions.

Evaluation of the Community Oriented Re-entry Program (CORP)

Moving from prison to the community is difficult and provokes anxiety in inmates. It is even more difficult for inmates with serious mental illness. In 2003, a 30-bed Community Oriented Re-entry Program (CORP) was opened at Sing Sing Correctional Facility to assist inmates with serious mental illness in their transition to the community. Sing Sing was chosen because it is the maximum security prison closest to New York City where the majority of inmates will return after incarceration.

CORP goals are to improve community living skills; increase the length of stay in the community for former inmates with serious mental illness; and increase access to and use of mental health services in the community. CORP provides a variety of supportive services including community preparation, vocational assessment, peer support, community linkage, discharge planning, orientation to parole supervision, and a psychiatric medications program. Community providers come on-site to participate in pre-release preparation and provide direct linkage to their programs on release of inmates. An evaluation of the CORP program shows promising results:

• A return of 77.4% of CORP participants to the community. Of those CORP participants not returning to the community, 9.4% were transferred to a civil psychiatric hospital, 9.4% to inpatient services at the Central New York Psychiatric Center, and 3.8% to prison.
• A significant improvement in psychiatric functioning. CORP participants' scores on the Global Assessment of Functioning Scale and the Carlson Psychological Survey subscales indicated significant improvement.
• A significant improvement in all areas of resources and skills for community survival. At CORP intake, more than 2/3 of participants had a severe lack of financial, housing, and employment resources. Upon CORP termination, 92% of participants had access to free medications in the community, and 87% were eligible for Social Security and 85% for Medicaid.

Based on the evaluation of the Sing Sing CORP program, this program shows continuing potential for enabling former inmates with serious mental illness to remain in the community with improved community survival skills, psychiatric functioning, and access to entitlements and supportive community programs. Future research will also focus on following former CORP participants for longer periods.

Discharge Planning for Individuals who are Leaving Prison and Returning to the Community

More than 3,000 persons who actively receive mental health services leave New York State prisons each year and return to the community. Many of these individuals have major mental illness diagnoses and require daily doses of psychotropic medications to manage their illness. OMH staff develops discharge plans for all inmates with serious mental illness before they return to the community, with the goals of establishing community treatment services for the inmates that will help them function and cope with their mental illness, and thereby not return to prison. Discharge coordinators secure services in the community, including housing, financial entitlements, and access to psychiatric medication.

In 2004, discharge services data collection was greatly improved and an evaluation study is currently in progress to determine the effectiveness of these services. The goal is to use the data from the evaluation to develop more effective strategies to engage inmates preparing for discharge.

Children's Services

Three parallel State initiatives have been undertaken in the past few years to support expansion of EBPs for youth. First, “manualized” or standardized parent empowerment programs are being tested and linked to family support services in New York City. Second, manualized clinician engagement protocols are being linked to the implementation of EBPs in specialty mental health clinics. Third, the School Mental Health Support Programs are also being expanded to include a wider range of school mental health services, with statewide expansion planned over the next few years. As described in this section, the substantial OMH investment in these three programs for children and adolescents and their families has yielded success.

NYC Parent Empowerment Program (PEP)

The Youth Services Evaluation Bureau in OMH is studying the effectiveness of the New York City Parent Empowerment Program. An important component of PEP is its manualized training program, which is designed to increase the self-efficacy⁸ of minority families and their children, thereby facilitating improved access and quality of mental health services through increased consumer demand and knowledge. Research shows that among children with an identified mental health problem who receive no treatment or services, unmet need is highest among minority children.⁹

PEP was developed following a systematic review of the literature and all available evidence concerning documented and manualized parent empowerment programs (Table 5-2). Its development has included input from all of the major mental health advocacy organizations, including the Federation of Families for Children's Mental Health, the National Alliance for the Mentally Ill, the National Mental Health Association, and Children and Adults with Attention-Deficit/Hyperactivity Disorder.

PEP uses a “train-the-trainer model,” and it is through parent advocates that the content of the training manual is delivered. Parent advocates are “professional” parents, oftentimes themselves parents of children with mental illness drawn from the communities in which they work. Advocates are knowledgeable about mental illness and how to advocate for and gain access to mental health treatment and other community resources.

PEP has an Advisory Board where decision-making authority is shared equally among all partners, including parents and State/City policy representatives. The Board has sought and obtained broader stakeholder input on how the PEP manual might be most effectively adapted to the needs of New York City families, and it has identified several new content areas to be added to the manual. New content areas include self-efficacy exercises, role-plays, and general training on how to access New York City's mental health, primary care and school services. Additionally, the Advisory Board has requested that specific information on common service issues related to depression, conduct problems, trauma/post-traumatic stress disorder (PTSD), attention-deficit/hyperactivity disorder (ADHD), co-morbidity, and medication management be added. Thus, the manual is now conceptualized as containing a flexible set of content areas, to which modules can be added as needed to address the interests of specific parent groups.

Results from a small pilot test conducted in 2003 with 30 parent advocates suggested that participation in the PEP training program led to changes in knowledge about EBPs, improvements in collaborative skills, and increased self-efficacy. The National Institute of Mental Health recently funded a two-year study to examine the impact of the PEP initiative on both parent advocates' knowledge, skills, attitudes, self-efficacy, and behavior, as well as the skills, attitudes and behaviors of the caregivers with whom the advocates work. The study, which began in the fall of 2004, will test PEP's effectiveness with a group of 40 advocates and 180 caregivers of children with mental health problems in New York City. Preliminary results will be available in one year, and final results in two years.

Child and Adolescent Trauma Treatment Services (CATS): Engagement of families in services

Research has identified a lack of clinician engagement with families as a key issue contributing to the high attrition rates of families from mental health services, especially among low-income populations.^10,11,12 In New York City, similar to other urban populations, rates of attrition from mental health services range from 30-50%.¹³

In addition to the parent empowerment programs, OMH has been working to extend engagement strategies to a range of evidence-based implementation initiatives for youth. The Child and Adolescent Trauma Treatment Services program (CATS) is the largest evidence-based youth initiative in New York State in which engagement strategies to decrease attrition rates have been delivered and are being evaluated. The CATS program was implemented in response to the World Trade Center disaster of September 11, 2001, through a $3 million grant to OMH. Awarded by SAMHSA, the grant is focused on implementing evidence-based trauma treatments for school-age children affected by the disaster. A needs assessment commissioned by the New York City Board of Education determined that, six months after the terrorist attacks, as many as 75,000 children (10.5%) in the New York City school system had symptoms consistent with PTSD.¹³ Because the issue of family retention in services was considered critical to the success of the CATS program, OMH provided engagement training to the consortium of nine participating sites.

Launched in 2002, the CATS program is a cooperative agreement study with OMH oversight. The CATS Consortium developed a common protocol, selected a core set of evidence-based screening and assessment instruments, and agreed to train, supervise and deliver cognitive behavioral therapy (CBT) trauma treatments to all eligible youth and families. Two empirically validated trauma treatments were selected for implementation in this project: Cognitive Behavioral Therapy for Traumatic Bereavement in Children, manualized by Cohen and colleagues from the Center for Traumatic Stress in Children and Adolescents in Pittsburgh;¹⁴ and Trauma/Grief-Focused Group Psychotherapy, developed for adolescents and manualized by Layne, Saltzman and Pynoos.¹⁵ To date, 615 children and adolescents, ages 5-21 have been enrolled in the treatment study, which compares youth receiving the evidence-based trauma treatments to those receiving trauma treatments as usually delivered in standard care.

The formal protocol for the CATS engagement intervention, developed by Dr. Mary McKay of Mount Sinai School of Medicine, was used to improve initial contact with the family and youth and improve retention over time. This engagement intervention was modified to reflect recent research findings with inner-city families on salient factors associated with keeping child mental health appointments. Specifically, the engagement intervention in CATS targets empirically defined attitudes toward mental health care, while simultaneously helping parents gain confidence in their ability to bring their child to a mental health appointment. In addition, the intervention encourages discussions with members of each family's social support network about help seeking before the first appointment.

Thus far at each of the sites, four to eight staff members, including clinical and administrative staff, have received a two-day training focused on engaging youth with mental health needs and their families in clinic services. In addition, at each of the sites an “engagement team” has been organized, consisting of the site's intake workers, representatives from the clinical and administrative staff, and supervisors. This team oversees the implementation of the intervention at each site. Further, monthly meetings are held with each site team to fine tune interventions and to collect child mental health outcome data. Preliminary data from the CATS study on retention rates for 296 caregivers at eight weeks, as shown in Figure 5.1, demonstrate that this approach to enhancing clinicians' skills in engaging families was highly effective, with overall engagement rates of 89% across the nine sites.

These rates are particularly impressive for treatment, considering that prior research indicates that rates for initial appointments can range from the rate of 72% to 85% at the high end with some type of engagement interventions16 and as low as 40% to 50% in standard care conditions.^10,17 These data also indicate that engagement rates are high regardless of service settings, but are highest in community-based programs (Figure 5.2).

School Support Projects (SSP): Strengthening School-Based Mental Health Services

The largest school initiative in New York State involves a joint partnership between OMH and the State Education Department (SED). The School-Based Mental Health Demonstration Project, called the School Support Projects (SSP), was launched in 2001. Originally in seven schools, it was expanded in 2003 to 60 schools. The purpose of SSP is to support inclusion of mental health services, including EBPs, in schools. SSP mandates that at least one parent advocate and at least one school mental health professional be employed to deliver mental health services.

After a series of consultations, the Steering Committee selected a common core assessment battery for use across all of the sites. Pilot testing was undertaken to determine its acceptability and usefulness to clinicians and families. Providers at all sites were trained in the use of measures included in the battery and routine monitoring procedures were put into place to ensure that complete data were collected. The Steering Committee then selected a set of EBPs targeted at the identified problems. These included CBT for anxiety (the Coping Cat program)18 and interpersonal therapy for adolescents (IPT-A) for depression,19 as well as classroom consultation methods and algorithms for the optimal use of medications for children with ADHD and other disruptive behavior disorders.

To illustrate how these methods have been used to increase the application of EBPs, specific clinical decision points were built into assessment and treatment algorithms and then used as quality indicators to track decision making and treatment implementation. Indicators, for example, were developed to encourage school-based mental health specialists to implement classroom-based behavioral therapy methods and to consider medication referrals earlier in the course of treatment, with the goal of improving outcomes. A database registry developed by SED to track all participants allows all cases and records to be flagged when they meet specific symptom-level thresholds on teacher or parent behavior checklists. The tracking system combined with the quality indicators allows school mental health staff and supervisors to receive case-level feedback. Group supervision of school mental health staff is provided by expert clinicians.

An evaluation is being completed to assess the feasibility of implementing these procedures. Preliminary data indicate that, after one year of intensive technical assistance and consultation, five of the original seven SSP schools are fully operational and have routinely incorporated EBPs. Examination of the two other clinics reveals that organizational factors at the school such as staff turnover have hampered efforts to implement the program. Among the five schools that are implementing EBPs, administration rates of the assessment battery to eligible students range from 70% to 95%, with a mean rate of 89%.

An analysis of data from a school clinician survey showed that between two-thirds and four-fifths of the clinicians who had been trained to deliver a set of evidence-based interventions in the schools agreed or strongly agreed that the training they received in EBPs had been valuable and helped them in their work with students.

Innovative Care Coordination Initiatives

New York State is committed to identifying and evaluating innovative supportive clinical practices, thereby increasing the pace of new treatment development and applying knowledge drawn from basic behavioral sciences. Consistent with recommendations in the President's New Freedom Commission on Mental Health, enhanced care coordination places a heavy emphasis on the development of individualized plans of care for adults with serious mental illness and children with serious emotional disturbance and the involvement of individuals and families in working toward recovery.

Decision Support for Care Coordination: Single Point of Access (SPOA)

The SPOA process is the mechanism by which Local departments of mental health statewide have centralized their intake and referral systems to prioritize access to services based on need. The SPOA infrastructure is designed to improve access to services for individuals with the greatest need, thereby enabling county mental health departments to manage resources with a greater recognition of who is being referred to and receiving services. Counties have considerable flexibility in structuring their SPOA systems as long as the general purposes of SPOA are addressed.

All SPOAs are required to establish the following major components: a system for identifying and prioritizing individuals with the highest needs; a screening process to identify the specific service needs of each individual; and mechanisms for coordinating and making available an array of service options to meet the needs that are identified. In addition, the children's SPOAs are expected to develop the capacity to conduct comprehensive functional assessments that support the tailoring of service plans to the strengths and needs of individual children and their families.

Counties are beginning to use the OMH Child and Adult Integrated Reporting System (CAIRS), a critical decision support system used by State and local providers, to coordinate and manage care to high-risk mental health clients in the community. To date, 10 counties have become active in using CAIRS and submitting data. Other counties are currently reviewing their Local referral processes to determine how best to utilize CAIRS. OMH continues to work intensively with all counties to detail Local referral practices and determine the best technical solution to their needs.

All counties in Upstate New York and Long Island have SPOAs for children. In New York City, a SPOA initiative in the Bronx has developed algorithms based on John Lyons' Child and Adolescent Needs and Strengths Survey (CANS). These algorithms are guiding the objective assignment of a service level based upon the completion of a valid and reliable functional assessment instrument. Plans are also progressing to expand the SPOA system for children to the remaining boroughs.

Throughout the State, approximately 20,000 children and families have had service plans coordinated through SPOAs, with county mental health authorities reporting a variety of positive outcomes. In Livingston County, for example, 30 different agencies are participating in its SPOA initiative, the Youth Assessment Committee. At intake the average score for a child on the Child and Adolescent Functional Assessment Scale had been 109, demonstrating a level of functioning that would require intensive services from multiple sources. After three months, however, the average score fell to 83, indicating a significant increase in the level of functioning and a reduction in the risk for out-of-home placement and intensive service provision. Similarly, in Genesee County, the Family Court Diversion Project, which is an organized effort between the Coordinated Children's Services Initiative (CCSI), SPOA, Family Court, probation and law enforcement agencies, has resulted in a cost savings of approximately $35,000 annually due to a reduction in court-ordered psychiatric admissions. The reduction was made possible largely by improved assessment of clinical functioning by the county SPOA, and a close working relationship with Family Court judges who relied on the determinations and used them in lieu of court-ordered psychiatric evaluations.

Assisted Outpatient Treatment (AOT): Kendra's Law

On August 9, 1999, Governor George Pataki signed Kendra's Law (Chapter 408 of the Laws of 1999), creating a statutory framework for court-ordered Assisted Outpatient Treatment (AOT) to ensure that individuals with mental illness and a history of hospitalizations or violence participate in community-based services appropriate to their needs. Kendra's Law was named in memory of Kendra Webdale, a young woman who died in January, 1999 after being pushed in front of a New York City subway train by Andrew Goldstein, a man with a history of mental illness and hospitalizations. The law became effective in November of 1999.

Since that time, OMH has been evaluating the impact of Kendra's Law on individuals receiving court-ordered services. In January, 2003 OMH issued an Interim Report required by Kendra's Law, which reviewed the implementation and status of AOT and presented findings from OMH's evaluation of the program.²⁰ A Final Report on the status of AOT in New York State is available on the web.

Implementation of Assisted Outpatient Treatment

Kendra's Law established new mechanisms for identifying individuals who, in view of their treatment history and circumstances, are likely to have difficulty living safely in the community without close monitoring and mandatory participation in treatment. It also established mechanisms for ensuring that local mental health systems give these individuals priority access to case management and other services necessary to ensure their safety and successful community living.

The statute created a petition process, found in Mental Hygiene Law section 9.60, designed to identify at-risk individuals using specific eligibility criteria, assess whether court-ordered outpatient treatment is required, and if so, develop and implement mandatory treatment plans consisting of case management and other necessary services.

Kendra's Law requires that each county in New York State and New York City establish a local AOT program to implement the statute's requirements, and charges OMH with the responsibility for monitoring and overseeing the implementation of AOT statewide. Implementation of Kendra's Law and AOT has been a joint responsibility and collaboration between OMH and local mental health authorities.

Eligibility Criteria for AOT

Kendra's Law contains the following summary description of the AOT target population:
"…mentally ill people who are capable of living in the community with the help of family, friends and mental health professionals, but who, without routine care and treatment, may relapse and become violent or suicidal, or require hospitalization."

The statute further defines specific eligibility criteria, which are listed below.

An individual may be placed in AOT only if, after a hearing, the court finds that all of the following have been met. The individual must:

1. be eighteen years of age or older; and
2. suffer from a mental illness; and
3. be unlikely to survive safely in the community without supervision, based on a clinical determination; and
4. have a history of non-adherence with treatment that has:
   a. been a significant factor in his or her being in a hospital, prison or jail at least twice within the last 36 months; or
   b. resulted in one or more acts, attempts or threats of serious violent behavior toward self or others within the last 48 months; and
5. be unlikely to voluntarily participate in treatment; and
6. be, in view of his or her treatment history and current behavior, in need of AOT in order to prevent a relapse or deterioration which would be likely to result in:
   a. a substantial risk of physical harm to the individual as manifested by threats of or attempts at suicide or serious bodily harm or conduct demonstrating that the individual is dangerous to himself or herself; or
   b. a substantial risk of physical harm to other persons as manifested by homicidal or other violent behavior by which others are placed in reasonable fear of serious physical harm; and
7. be likely to benefit from AOT; and
8. if the consumer has a health care proxy, any directions in it will be taken into account by the court in determining the written treatment plan. However, nothing precludes a person with a health care proxy from being eligible for AOT.

Program Evaluation Findings

OMH's ongoing evaluation of AOT examines the outcomes of AOT judicial proceedings; how many individuals have received court-ordered AOT; how long individuals typically remain under court-ordered treatment; the characteristics of AOT recipients and outcomes for AOT recipients. These findings derive from several sources:

• OMH Central and Field Office staff record basic information on each court order and the status of each order in an electronic tracking system. This system is used to generate regular aggregate reports on the volume of court orders throughout the state and the number of individuals receiving AOT.
• OMH collects additional information concerning AOT recipients from their case managers via a paper-based survey data collection process. Case managers complete a standardized assessment for each AOT recipient at the onset of the court order (baseline), at the end of the initial court order (six month follow-up), and, if the court order is renewed, every six months for the duration of the order. The assessments capture: demographic characteristics of AOT recipients; their status in areas such as living situation, services received, engagement in services, and adherence to prescribed medication; incidence of significant events such as hospitalization, homelessness, arrest, and incarceration; functional impairment in the areas of self-care, social skills, and task performance; and any incidence of harmful behaviors. These assessments are sent to OMH and the results entered into an evaluation database. OMH uses the resulting data to assess outcomes for all AOT recipients as a group. Due to time lags inherent in paper-based survey data collection and processing, and the limited scope of the data collected on the standardized assessments, OMH does not use the evaluation database to monitor the clinical status of individual recipients.

Summary of AOT Proceedings

Referrals/Investigations, Petitions, Court Orders and Service Enhancements

Between November 1999 and December 31, 2004, 10,078 individuals were referred to local AOT coordinators for investigation to determine potential eligibility for an AOT court order. Referrals resulted in petitions filed for the issuance of an AOT court order for 4,041 individuals (40% of all individuals referred); of these, petitions were granted and court orders issued for 3,766 individuals (93% of all individuals with petitions filed). Investigations led to service enhancements rather than court orders for 2,863 individuals (28% of all investigations).

Court orders and service enhancements have been issued in all regions of New York State, with 58% of all court orders and service enhancements occurring in New York City. Table 5.3 summarizes data on outcomes of the judicial procedures associated with AOT.

Length of Time in AOT

As noted in Table 5.3, as of December 31, 2004, 3,766 individuals had received court ordered treatment through AOT. Initial court orders for AOT recipients are generally six months in duration. Court orders, however, can be renewed and recipients may receive additional court orders after previous orders expire. About one third of AOT recipients spend six months under court order. Court orders for most AOT recipients (64%) are renewed and so the majority of individuals remain under court order for more than six months (Table 5.4).

Figure 5.3 shows the total amount of time spent by recipients in AOT. The average length of time recipients remain under court order is 16 months.

Incidence of Hospitalization, Homelessness, Arrest and Incarceration.

Table 5.5 summarizes the incidence of hospitalizations, homelessness, arrest and incarceration for persons in AOT prior to court-ordered treatment. In the three years prior to the court order, 97% of individuals had at least one psychiatric hospitalization. On average, these individuals had been hospitalized approximately three times during that period with some individuals having had as many as 13 hospitalizations. Nineteen percent of individuals had experienced at least one episode of homelessness in the three years preceding their court order. Thirty percent were arrested at least one time in the three years prior to AOT. These individuals had as many as ten arrests during that time. Twenty-three percent were incarcerated at least once in the three years prior to their court order. Some individuals had as many as ten incarcerations in those three years.

When compared with a similar population of mental health service recipients,²¹ AOT recipients were twice as likely to have had a previous episode of homelessness and 50% more likely to have had contact with the criminal justice system prior to their court order. In addition, AOT recipients were 58% more likely to have a co-occurring substance abuse problem.

Outcomes for Recipients during the First Six Months of AOT

Initial court orders for AOT recipients are usually six months long. The six month milestone is critical because it is at this juncture that decisions are made regarding renewal of the court order. Outcome findings presented in the next section focus on change between the onset of the court order and the status of recipients after six months. The results presented below are for AOT recipients for whom both baseline (onset of court order) and six-month follow-up assessments were available in the OMH evaluation database at the time of this report's preparation.

AOT was designed to ensure supervision and treatment for individuals who, without such supervision and treatment, would likely be unable to take responsibility for their own care and would be unable to live successfully in the community. For persons in AOT, the goals are to increase access to the highest intensity services and to better engage them in those services. An additional goal is to reduce the incidence of behaviors harmful to themselves or others. Participation in AOT should result in improved adherence to prescribed medication and decreased hospitalization, homelessness, arrests, and incarceration. In addition, AOT recipients should benefit through improved functioning in important community and personal activities.

Increased Participation in Case Management and Other Services

Table 5.6 compares participation in services by AOT recipients prior to and subsequent to the initial court order. For all categories of service, a greater percentage of individuals are participating in the service while under court order than were receiving it prior to thecourt order. A dramatic example is in the area of case management. As prescribed by the legislation, all individuals receiving a court order are enrolled in case management. However, prior to AOT, only 53% of these individuals were receiving this service.

In addition, the percentage of AOT recipients who are receiving substance abuse services increased by 67% as a result of their court-ordered treatment plan, increasing from 24% to 40%. Similarly, the percentage of persons in AOT who receive housing services as a result of their court-ordered treatment plan also increased from 19% to 31%. Substantial increases are also seen for urine or blood testing used to assess adherence to medication or substance abuse.

Increased Engagement in Services and Adherence to Prescribed Medication

Two important goals of AOT are increased engagement, i.e., active and regular participation in services; and increased adherence to prescribed medication, i.e., taking medications necessary to manage psychiatric symptoms as directed by the treating physician. To assess engagement, case managers were asked to rate the engagement of persons in AOT using a scale ranging from "not at all engaged in services" to "independently and appropriately uses services." Recipients were considered to have "good engagement" if they received a rating of either "good - able to partner and can use resources independently" or "excellent - independently and appropriately uses services." Data collected since the onset of AOT show the percent of individuals who exhibit good engagement in services increased significantly from 41% to 62% at six months.

To assess medication adherence, case managers were asked to rate adherence of persons in AOT using a scale ranging from "taking medication exactly as prescribed" to "rarely or never taking medication as prescribed." Recipients were considered to have "good adherence to medication" if they were rated as either "takes medication as prescribed most of the time" or "takes medication as prescribed." The resulting data show that the percent of individuals with good medication adherence increased significantly from 34% to 69% after six months. Figure 5.4 displays the improvement in engagement in services and adherence to medications after six months of AOT participation.

Improved Community and Social Functioning

The evaluation database also documents changes in AOT recipients' day-to-day functioning. Measures that are used for this assessment are the Global Assessment of Functioning (GAF) and three sets of items that assess individuals' abilities in specific functional areas: self-care, social and community living skills, and task performance. The GAF is a commonly used measure of overall functioning. It includes social, occupational, academic, and other areas of personal performance and results in an overall numerical rating score which can range from 0 to 100. A score of 50 or below denotes serious impairment in social, occupational or school functioning. At the onset of an AOT court order, 39% of individuals had a GAF score below 50. After receiving services under an AOT court order for six months, the percentage of persons with a GAF score below 50 dropped to 33%.

AOT recipients' functioning in the area of self-care and community living also improved after six months of program participation. Table 5.7 displays the change in these measures. The table compares the percentage of persons in AOT who were reported as having difficulty at the onset of their court ordered treatment with the percentage reported as having difficulty six months later. For all items, there were fewer individuals rated as having difficulty, and in all measures the change was statistically significant. Although changes are relatively small in magnitude for any single measure, a consistent pattern of overall improvement (reduction in difficulties) is seen across all areas of self-care and community functioning.

Among the items included on Table 5.7, some measures can be linked to the AOT program's goals of increasing adherence to medication and increasing engagement in services. In particular, the percent of AOT recipients who had difficulty managing medication decreased from 36% to 27% between the onset of the court order and six months. Similarly, the percent of recipients who had difficulty following through on health care advice and making and keeping appointments declined from 26% to 19% and 27% to 20% respectively.

Tables 5.8 and 5.9 display the changes during the initial six months of AOT in the areas of social, interpersonal and family functioning and task performance. On 15 of the 16 measures for these areas, the reduction in difficulties experienced by AOT recipients between the onset of the court order and at six months was statistically significant. For instance, the percent of recipients who had difficulty effectively handling conflict and managing assertiveness dropped from 50% to 36% and 44% to 33% respectively. Similar to the findings noted above for self care and community living, an overall pattern of reduced difficulties and therefore improved functioning characterizes the findings concerning social, interpersonal and family functioning, and task performance.

Reduced Incidence of Harmful Behaviors

Case managers also reported reductions in the incidence of harmful behaviors for AOT recipients at six months in AOT when compared with a comparable period of time prior to AOT. Table 5.10 shows significant declines in the incidence of behaviors harmful to self, behaviors harmful to others, and harmful behaviors directed at property. Similarly, substantial declines are also seen in alcohol and substance abuse. In summary, during the first six months of court-ordered treatment, individuals in AOT showed a significant decline in the incidence of harmful behaviors. The average percent decrease in harmful behaviors was 44%.

Adult Homes: A New Care Coordination Model of Support, Empowerment and Collaboration

Adult homes are residences in the community licensed by the New York State Department of Health (DOH) and ranging in size from less than 20 beds to more than 300. The majority of individuals served by OMH live in a cluster of homes often referred to as “impacted adult homes,” meaning that either 25 residents or 25% of the total resident population received mental health services.

In Spring 2002, Governor Pataki appointed an Adult Home Workgroup comprised of key stakeholders, including advocates, home operators, DOH, OMH, the State Commission on Quality of Care for the Mentally Disabled, and the State Office for the Aging. This Workgroup was charged with making recommendations to improve conditions for residents living in DOH-licensed adult care facilities. Consistent with the Workgroup's recommendations for change, OMH and its sister agencies developed a comprehensive service package to support adult home residents, improve their access to mental health services, and help them meet their recovery goals. The package includes provisions and activities that focus on health and safety, appropriateness of care, quality of care, quality of life, housing, and public awareness.

To promote resident recovery and independence, a new model of on-site case management and peer support services was proposed for adult home residents. The model is a unique combination of coordinated and integrated services that focuses on resident strengths and needs and the provision of supports to ensure independence and personal choice. Rehabilitation principles and values that emphasize support, empowerment, and collaboration are expected to result in a merger of consumer and professional perspectives. OMH's commitment to this initiative has been strengthened by a recent increase in the rate for blended case management, as well as the issuance of two Request for Proposals aimed at the development of supportive case management, utilizing supportive case managers and peer services. The first was issued in 2003 with services beginning in 2004, and the second was issued in November 2004 with services to begin in 2005. When fully implemented, the case management/peer support initiative will be providing services to approximately 3,500 individuals residing in adult homes in New York City, Long Island, and various Upstate counties.

Under this initiative, existing adult home treatment services are being restructured to provide an evidenced-based set of services focusing on wellness and self management techniques. The case management/peer support program engages service recipients and involves family and friends by providing educational information regarding the range of multiple community resources available. On-site social and recreational opportunities enhance the quality of life for residents of adult homes and opportunities are created for participation in a variety of home and community activities. The case management/peer support initiative has resulted in the facilitation of numerous groups and activities not previously available to residents of adult homes (see Table 5-11).

Many community-based and on-site enrichment activities are attended by residents on a regular basis. Attendance at on-site activities at four adult homes averages 300 residents per month. Some events are coordinated and supported by case managers and peers, while others are coordinated through the OMH Office of Consumer Affairs.

The Office of Consumer Affairs also plays a key role in offering support to a number of self-governing, resident-run Resident Councils. The councils meet regularly to discuss issues and concerns, which are communicated to staff designated to serve as liaisons. The Office of Consumer Affairs provides training and technical assistance to the Resident Councils and other adult home staff and has also worked to identify community partners for the Councils.²⁰ As requested by Resident Council leaders, the Office of Consumer Affairs is coordinating training on hope. This training will be provided by the Mental Health Empowerment Project as a pilot project to five adult homes in New York City over the next year.

The OMH Office of Consumer Affairs is supporting an initiative in Queens, where residents are being offered information about community resources and assistance in linking to groups in their neighborhoods. Adult home operators, case managers and peer specialists provide support for a range of guests and activities, including faith-based groups, computer literacy groups, volunteer opportunities, and voter registration activities. Approximately 150 residents per month attend these programs. Additionally, traditional mental health services such as supportive employment agencies have been introduced, but with a focus on securing jobs outside of the mental health system, for example, a volunteer opportunity available at a local museum. Based on the success of the Queens initiative, this pilot project will be replicated in three homes in New York City and one in each region of the State.

The provision of rehabilitation and recovery training to the case managers and peer specialists was a primary focus of 2004 and will continue into 2005 and beyond. Training has been aimed at effectively assisting residents of adult homes to successfully attain and maintain their personal recovery goals and to develop and or strengthen natural community and social supports. Building on these efforts, the Adult Home Monitoring and Training Team, which is responsible for facilitating the mental health component of the statewide interagency team, will provide training programs to case managers and peer specialists on strategies for effective education of adult home residents who have mental illness. The training will focus on engaging participants in skills development that will enable them to work toward their recovery goals. Importantly, residents who identify educational and vocational goals now have the opportunity to attain these goals under a vocation and education initiative, which is organizing job fairs and providing GED opportunities.

Translating Evaluation and Services Research Findings into Practical Clinical Treatments and System Supports

OMH research is also improving the quality of care by translating research findings into practical clinical tools, treatments and services in our communities and State psychiatric hospitals. Below, we highlight several initiatives conducted by OMH's two research institutes that illustrate the immediate, real-world translational benefits of research. We include some examples that have been widely disseminated in New York State, as well as demonstration projects that serve specific target populations in small geographic areas. OMH is examining the possibility of expanding successful demonstration projects to broader populations.

Child and Adolescent Psychiatric Evaluation Service

The Child and Adolescent Psychiatric Evaluation Service (CAPES) fills a noticeable gap in evaluating children for psychiatric illness. The service provides expert consultation to primary care physicians and families with children ages 3 to 17 years who may suffer from behavioral, emotional and developmental problems. CAPES is partnering with pediatricians throughout New York City, and has evaluated over 600 individuals to date. In addition to psychiatric consultation, children referred to CAPES are guaranteed a free and thorough evaluation comprising a psychological interview, structured diagnostic assessment, child cognitive screening, a multifaceted symptom assessment, and expert consensus on diagnosis and treatment recommendations.

Cultural Competence

The President's New Freedom Commission on Mental Health cited the lack of culturally competent mental health services as a key factor in creating disparities in access to care for various racial and ethnic groups. OMH researchers have developed an 11-item scale for behavioral healthcare agencies to assess their cultural competency. Use of the scale is intended to motivate agencies to develop culturally competent behaviors and to guide the development of culturally competent adaptations of EBPs. NIMH has awarded funds to study the psychometric properties of this scale. Future plans include the development of an instrument applicable to mental health authorities or umbrella agencies and a version of the scale for agencies that serve a single culture.

Memory Education and Research Initiative

The Memory Education and Research Initiative (MERI) is a State and Local collaborative project that offers at no cost a memory and cognitive evaluation to individuals with memory complaints who live in Rockland County. Since its inception, the program has screened more than 300 individuals. Many of these individuals had concerns about memory loss or were worried because they had close relatives with Alzheimer's disease. Most of those screened did not, in fact, have the disorder but were reassured by the positive results of the evaluation. These individuals will be followed annually in an effort to look for some of the earliest predictors of decline. In cases where the evaluation determined that individuals were at the early stages of the disorder, the individuals were able to benefit from early diagnosis and treatment.

Movement Disorders

Some individuals who take antipsychotic medications over extended periods are at risk for the development of tardive dyskinesia, a medication side effect characterized by repetitive and abnormal involuntary movements and may occur in the face, mouth, tongue, hands and or feet. The efforts of an OMH researcher have produced an amino acid food product (classified by the FDA as a medical food) that is reported to offer a safe and effective treatment for the disorder among men, reducing symptoms by as much as 86%. The rights for this novel treatment have been assigned to OMH, the Research Foundation for Mental Hygiene (RFMH), the organization responsible for administering and directing the conduct of all sponsored research programs carried out by scientists at OMH research institutes and facilities, and the National Institutes of Health.

RFMH has entered into a licensing agreement with an international company to manufacture and market the food that is now available commercially under the trade name, Tarvil. Patents have been obtained and work has begun to extend the same formulation to a second disabling dyskinetic disorder, L-dopa induced dyskinesia, seen in individuals who suffer from Parkinson's disease. Work has also begun to study the same product as a treatment for schizophrenia and bipolar disorder.

Post-Traumatic Stress Disorder (PTSD)

The aftermath of the 9/11 attacks made it clear that more clinicians needed training in evidence-based treatments for post-traumatic stress disorder (PTSD). The Trauma Studies Program led the effort to train mental health professionals in treating trauma-related problems in New York City after 9/11. Between 2002 and 2004, the team of experts trained roughly 400 clinicians in the latest in cognitive behavioral therapy (CBT) techniques for PTSD. The Trauma Studies Program has also launched the first large-scale, nationwide, Web-based survey of individuals bereaved as a result of the 9/11 attacks. In addition, researchers partnered with primary care physicians in Manhattan's Washington Heights community after 9/11 and the subsequent crash of American Airlines flight 587 to help them meet the demands of individuals dealing with these traumas.

Prime-MD

Primary care physicians often see individuals with psychiatric problems in their practice, but often lack the base of special knowledge and skills for proper psychiatric assessment and diagnosis. OMH researchers knew that by simply asking a few pointed questions, primary care physicians could flush out underlying problems, like depression, which would otherwise go untreated. This led to the development in 1993 of Prime-MD, the first standardized questionnaire designed by both psychiatrists and primary care physicians to help screen, evaluate and diagnose mental health disorders most commonly seen in primary care settings. A self-administered version of the test was introduced in 1999 and is still widely used today.

Telepsychiatry

In New York State, as in other parts of the country, psychiatrists practice almost exclusively in urban and suburban areas, and mental health care providers in small towns generally have no or little access to expert consultation. The Telepsychiatry Consulting Program allows nationally recognized clinicians to examine consumers in virtual face-to-face interviews via videoconferencing. It provides real-time, psychiatric consultations to rural practitioners (non-psychiatric physicians, non-medical mental health clinicians, and adult psychiatrists working at community health programs, correctional facilities, or OMH facilities). These clinicians are located in 25 sites throughout New York State, including 12 mental health units in correctional facilities and 12 in community mental health programs.

This method of delivery to outlying areas is gradually gaining acceptance in other areas of medicine, as well as in psychiatry. After over 180 consultations with individuals between the ages of 5 and 65, with common to fairly unusual disorders, and with varied behavioral interventions, the program has amassed an impressive videotape library that could function as an excellent teaching tool. An in-depth assessment of consumers' reactions to this form of service delivery is under way.

Conclusion

Evaluation and services research are critical to determining the degree to which mental health services support individuals served in the public mental health system. Through these activities, OMH continues to employ shared goals and objectives for measuring performance and relying on the results to improve the quality of care. Evaluation and services research are instrumental to the creation of a culture at all levels of the public mental health system where continuous quality improvement and data-driven, decision making are the principal standards of practice.

Notes
¹ National Advisory Mental Health Council. (1999). Bridging science and service: A report by the National Advisory Mental Health Council's Clinical Treatment and Services Research Workgroup. NIH Publication No. 99-4353.

² Phillips, S.D., Burns, B.J., Edgar, E.R., Mueser, K.T., Linkins, K.W., Rosenheck, R.A., et al. (2001). Moving assertive community treatment into standard practice. Psychiatric Services, 52(6), 771-779.

³ Lehman, A.F., & Steinwachs D.M. (1998). Patterns of usual care for schizophrenia: Initial results from the Schizophrenia Patient Outcomes Research Team (PORT) client survey. Schizophrenia Bulletin, 24(1), 11_20.

⁴ McFarlane, W. R. (2002). Multifamily Groups in the Treatment of Severe Psychiatric Disorders. New York: Guilford Press.

⁵ Polowczyk, D., Brutus, M., Orvieto, A., Vidal, J., & Cipriani, D. (1993). Comparison of patient and staff surveys of consumer satisfaction. Hospital and Community Psychiatry, 44(6).

⁶ Campbell, J. (1997). Towards collaborative mental health outcomes systems. New Directions for Mental Health Services, 71.

⁷ Committee on Quality of Health Care in America, Institute of Medicine. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press.

⁸ Self-efficacy is defined as people's beliefs about their capabilities to produce designated levels of performance that exercise influence over events that affect their lives. (See:Bandura, A. (1994). Self-efficacy. In V. S. Ramachaudran (Ed.), Encyclopedia of human behavior (Vol. 4, pp. 71_81). New York: Academic Press).

⁹ National Institute of Mental Health. (2001). Blueprint for change: Research on child and adolescent mental health. Washington, DC: National Advisory Mental Health Council Workgroup on Child and Adolescent Mental Health Intervention Development and Deployment.

¹⁰ New York City Department of Health and Mental Hygiene and the Mailman School of Public Health at Columbia University. (August 2003). Children's needs assessment in the Bronx. New York: New York City Department of Health and Mental Hygiene. Retrieved November 30, 2004 from http://www.nyc.gov/
html/doh/pdf/pub/na-cmh0803-bx.pdf.

¹¹ Armbruster, P., Gerstein, S. H., & Fallon, T. (1997). Bridging the gap between service need and service utilization: A school-based mental health program. Community Mental Health Journal, 33, 199-211.

¹² McKay, M. M., Pennington, J., Lynn, C. J., & McCadam, K. (2001). Understanding urban child mental health l service use: two studies of child, family, and environmental correlates. Journal of Behavioral Health Services & Research, 28(4),475-83.

¹³ Applied Research and Consulting, Columbia University Mailman School of Public Health, & New York State Psychiatric Institute. (March 2002). Effects of the World Trade Center attack on NYC public school students. Retrieved November 30, 2004, from http://www.nycenet.edu/offices/spss/wtc%5Fneeds/firstrep.pdf

¹⁴ Cohen J.A., Mannarino, A.P., & Deblinger E. (2002). Child and parent trauma-focused cognitive behavioral therapy: treatment manual. Unpublished manuscript.

¹⁵ Layne, C.M., Saltzman, W.R., & Pynoos, R.S. (2002). Trauma/grief-focused group psychotherapy program. Unpublished manuscript.

¹⁶ McKay, M. M., Stoewe, J., McCadam, K., & Gonzales, J. (1998). Increasing access to child mental health services for urban children and their caregivers. Health and Social Work, 23(1), 9_15.

¹⁷ McKay, M. M., McCadam, K., & Gonzales, J. (1996). Addressing the barriers to mental health services for inner city children and their caretakers. Community Mental Health Journal, 32(4), 353_61.

¹⁸ Kendall, P.C., Flannery-Schroeder, E., Panichelli-Mindel, S.M., Southam-Gerow, M., Henin, A., & Warman, M. (1997). Therapy for youths with anxiety disorders: a second randomized clinical trial. Journal of Consulting and Clinical Psychology, 65(3):366-80.

¹⁹ Mufson, L., Weissman, M.M., & Moreau, D. (1993). Interpersonal Psychotherapy for Depressed Adolescents. Roslyn Heights, NY: Libra Publishers.

²⁰ OMH's Interim Report on Kendra's Law is available on the OMH Web site.

²¹ OMH derives its estimates of the number of people served annually by the public mental health system from its Patient Characteristics Survey (PCS). The PCS, which is administered every other year, gathers information about the demographic and clinical characteristics of persons receiving mental health services in programs operated, funded, or certified by OMH during a one-week period. The data presented in this section are derived from the 2003 PCS, which is the most recent available.21 OMH derives its estimates of the number of people served annually by the public mental health system from its Patient Characteristics Survey (PCS). The PCS, which is administered every other year, gathers information about the demographic and clinical characteristics of persons receiving mental health services in programs operated, funded, or certified by OMH during a one-week period. The data presented in this section are derived from the 2003 PCS, which is the most recent available.

Comments or questions about the information on this page can be directed to the Office of Planning.