Background, Description and Evidence

Fort Washington ArmoryMen’s Shelter, 1990s

Transitions can result in discontinuity of support

multiple complex needs loss of supportive relationships

fragmented community services

CTI aims to solidify supports as it spans the period of transition

CTI

CTI differs from traditional case management

Time limited Three phases

Focused

Implement transition plan while providing emotional support

Phase One:

Transition

Pre-discharge connection

• Home visits

• “Introduce” clients to providers

• Meet with caregivers

• Substitute for caregivers

• Help negotiate ground-rules for relationships

• Mediate conflicts

• Assess potential of support system

Phase Two:

Try-Out

Facilitate and test client’s problem-solving skills and capacity of the support system

• Monitor effectiveness of support system

• Modify as necessary

• Less frequent meetings

• Crisis intervention and troubleshooting

Phase 1

Phase Three:

Transfer of Care

Terminate CTI services with support network safely in place

• Consultation but little direct service

• Ensure key caretakers meet and agree on long-term support system

• Formally recognize end of intervention and relationship

Focus areas

• Psychiatric treatment and medication management

• Money management• Housing crisis management• Substance abuse • Family psychoeducation

Design

• randomized trial

• 100 men with SMI following discharge

• 9-month intervention/ 18-month follow-up

Results

• 3-fold reduction in risk of homelessness

• Effect persisted beyond 9 months

Fort Washington Armory Susser, Valencia, et. al. 1997

Design

•“effectiveness” trial•non-randomized pre-post design•men & women with SMI following hospital discharge•multiple sites nationally•N=484

Results

•19% more days housed over one year•lower drug, alcohol and psychiatric problem scores

Design

• randomized trial

• 150 men & women with SMI following discharge

• 9-month intervention / 18-month follow-up

CTI in the Transition from Hospital to CommunityNIMH R01-MH59716

Percent of subjects who were homeless over follow-up period(ITT)

18 months9 months

Percent of subjects who were homeless over follow-up period(as treated)

adapting the model?

Dan Herman

Columbia University & New York State Psychiatric Institute

dbh14@columbia.edu

www.criticaltime.org

Critical Time InterventionMontgomery County, PA

Critical Time Intervention in Montgomery County, PA

• Developed to enhance case management and housing support services for individuals with mental illness who are residents of the only singles adult shelter in the county

• Served the first person in February of 2008

Development Structure• Utilized Re-investment funding for start up

(2008)• Certified program under Intensive Case

Management/Blended Case Management Model• Enhanced educational requirements of

supervisor and team members• Added regular consultation time with psychiatrist• Rolled into HealthChoices funding (2008)• Added County Funding (FY 09/10)• Included Pre-CTI phase• Tweaked Phase III: Transfer of Care• Parallel development of Housing Resources

Implementation Characteristics

• Agency selection – Connection with Shelter• Monthly/Quarterly Stakeholder Workgroup

– Quarterly reporting– Discussion/work between meetings

• Partnership with CUCS– Trainings– Ongoing supervision with Team and Team

Leader– Fidelity review

• Learning day with Camden CTI team hosted by University of Pennsylvania

Start Up Characteristics

• Availability of Housing: Average Number in Pre-CTI is 118 Days (Highest 487, Lowest 10)

• CTI Specialist provides ‘Housing Case Management’

• Develops person-centered plan focusing on three out of six treatment areas at a time

• Replicate positive shelter experiences

Participants in CTI Phases

0

5

10

15

20

25

30

Pre-CTI Phase 1 Phase 2 Phase 3 Discharges

Participants

Challenges

• Affordable and adequate housing (transitional and permanent)

• Developing relationships• Staff turnover• Effects of extended Pre-CTI phase• Providing service within a fee-for-service model• Productivity-billing• Transfer of Care (length and activities)• Balancing caseloads• Jail engagement

Successes• Total Number of Clients Served: 83• Total Number of Clients Successfully Discharged:

26• Types of Housing Subsidies Received:

– Housing Choice Voucher (HUD)– Tenant Based Rental Assistance (CHIPPs/HOME)– Halfway There (HUD Transitional Shelter)– Permanent Solutions (HUD SHP-Chronically

Homeless)– Shelter Liaison (HUP SHP)– Starting Point Housing (County Funded Program)– Self (SSDI Income)

Outcomes• Funding

– Fee for Service Structure (Payer Source)• Stable Housing

– Nights in Shelter (Pre-CTI)– Nights NFHH (Average 41 this year)

• Treatment Engagement– Percent of MH, SA, Dual Inpatient Services (1.5%)– Average Percent of Members Admitted to IP Care

(1.96%/4.4%)– Percent Seen 31-60 Prior to Admission (75%/90.80%)– Percent Seen within 7 Days of Discharge (100%/74-

84%)

Outcomes

• Transfer of Care– Number of Readmissions within 30 days

(1/37) – Number eligible and receiving CM during

last 30 days of CTI service (86%/67%)– Number of Cases continuing Outpatient

Service for 90 days post discharge from CTI (67%)

Next Steps

• Creativity with reunification• Flexibility with referrals• Continued interest in jail diversion• Team growth• Trainings/partnerships

Laura Morris, LSWResources for Human Development

LauraM@hd.org

www.rhd.org