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Improving Access to Care: Critical Time Intervention to Help Transition

People with Mental Illness out of Homelessness and Incarceration

June 3, 2020

Barbara (Bebe) Smith, MSW, LCSW

Consultant/Trainer

• This webinar was developed [in part] under contract number HHSS283201200021I/HHS28342003T from the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS). The views, policies and opinions expressed are those of the authors and do not necessarily reflect those of SAMHSA or HHS.

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Disclaimer

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Acknowledgments

Special thanks to Dan Herman and Sally Conover Center for the Advancement of CTI

CTI Global NetworkSilberman School of Social Work, Hunter College

NYChttps://www.criticaltime.org/

And the UNC Critical Time Intervention Team, especially Janice Bainbridge, MSW, LCSW and

Nick Lemmon, MSW, LCSW

Objectives for today’s webinar

1. Describe the CTI model

2. Review the evidence base for CTI

3. Describe implementation of a pilot of CTI in North Carolina

4. Discuss practical implementation issues and innovative uses of the model

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What is CTI?

Critical Time Intervention is:

• an evidenced based practice/ model

• designed to help people through a transition

• a time limited intervention implemented during a critical time period

• implemented by care managers in the communities where people live

• an intervention that improves continuity of care and community integration by securely linking people to networks of support

• adaptable to different transitions, populations, and cultures

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CTI History

1970sConsumer choice and psychiatric rehabilitationAssertive community treatment - ACT

1980s & 1990sMotivational Interviewing Harm ReductionHousing First Critical Time Intervention (CTI)

2000s Recovery movement

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Why a critical transition?

Transitions are difficult:

• Social connection and capital is lacking

• Service system navigation is difficult

• People have complex needs

• Appropriate resources are limited

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Why a critical transition?

Supporting change

• Emphasizing relationship and engagement

• Addressing basic needs

• Accessing recovery support

• Supporting opportunity for change and growth

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Evidence

• Susser et al. (1997) – CTI effect = 3 times less likely to experience

homelessness and more connected to community supports after discharge

• Herman et al. (2011) – CTI effect = prevalence of homelessness 5 times lower

• Tomita & Herman (2012)– Reduced risk of hospitalization

• Kasprow & Rosenheck (2007)– 19 % more days housed– Lower psychiatric symptom and use scores

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Evidence

Establishing relationships matter! The groundwork starts before a transition.

• Herman et all (2011) found that having three or more pre-discharge contacts with an individual almost doubled the CTI effect.

– “pre-discharge” from jail, hospital, or other institution.

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Principles and practices that inform CTI

• Motivational interviewing

• Shared decision-making

• Recovery orientation

• Harm reduction

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CTI Component Overview

• One CTI transition

• Three phases

• 9-month clock

• Community-based linking process

• Small caseloads and changing intensity

• Team approach

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CTI Component Overview

• The CTI team– simple makeup:

• Clinical Supervisor

• CTI Worker

• Additional role: Fieldwork coordinator

• Some teams include peer support specialists

• Primarily community-based

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CTI Component Overview

CTI clinical supervisor role:

• Provide clinical supervision and support to the team

• Monitor model fidelity

• Can be a fulltime position, but doesn’t have to be fulltime to meet model fidelity

• At a minimum, clinical supervisor should lead weekly team meetings and be available to staff in the field

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CTI Component Overview

CTI worker’s role:

• Assess strengths and needs of recipients

• Focus on engagement and relationship

• Provide practical help in navigating systems – housing, healthcare, disability benefits, employment, criminal justice systems, and social networks

• Communicate technical information in a way that is easy to understand

• Helps person to base decisions on best evidence plus own values and knowledge about themselves

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CTI Component Overview

One CTI transition

• (e.g. street/ shelter to housing)

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Pre-CTI plus three phases

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Pre - CTI

Phase 1

Transition

1-3 months

Phase 2

Try-out

4-6 months

Phase 3 Transfer of

care

7-9 mos

CTI Component Overview

Consumer & Care worker

Family

Substance use

Mental Health

Money

Spirituality

HousingMedical needs

Employment

Community

Leisure

Food

CTI Component Overview

Traditional case management: Comprehensive and unfocused

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CTI Component Overview

CTI Focused

Family

Social Network

Healthcare

Benefits/

Finances

Living Skills

MH/SUD treatment

Housing

Limited focus areas – what’s essential for the transition

Each team has 5-6 focus areas, relevant to the population served

Teams don’t provide treatment, but intervention is clinically informed

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CTI Component Overview

Phase

Family

BenefitsHousing

Phase Focused • 3 per phase or less

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CTI Component Overview

General rule of decreasing intensity

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Focused

Focus Pre CTI Transition Try-out Transfer of Care

Undefined:pre-

transition

0-3 months post-transition

4-6 months post-transition

7-9 months post-transition

Focus 1

Housing stability

e.g. Weekly (or more) contact: Furniture; food; rent; lease; identify and connect community supports

e.g. Monthly visits: follow the routine; join community support; meeting with client & property manager, watch client cook

e.g. Monthly check in to see that connections continue to go smoothly – rent is paid and room is livable

Focus 2:

Mental health access

e.g. help schedule, accompany & monitor meds

e.g. Attend home health appointment(s), check in with provider/ family member

e.g. Monthly check in to see that connections continue to go smoothly

Focus 3:

Employment

Person indicates: “I’m not ready!” or “I need to get settled first!”

e.g. Strategize; Plan & help with resume; application process; community job center

e.g. Monthly check in to see that connections continue to go smoothly

CTI Component Overview

CTI Component Overview

Case load size will vary depending on how many clients are in each phase.

The general rule of CTI caseload:

• 20 per CTI worker

• Field work coordinators and supervisors may have less than 20

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188 servedFROM DECEMBER 2012

TO JUNE 2015

UNC CTI ProjectPROVIDING SUPPORT OUR STATE NEEDS

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Who are the people who tell the story of CTI?

Are they willing to support and champion CTI?

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CTI Champions

Telling the CTI story

http://unccti.org/27

§ Only 25.5% of CTI clients had Medicaid

§ 30% of all CTI clients had no health insurance when referred

§ Multiple morbidities, including TBIs, SUDs, and mental illness

§ Many with need for ongoing outreach and engagement

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Gaps in the System—CTI pilot in NC

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Outcomes: housing, income, connection to care

Maria is a 59 y.o. woman with a history of schizophrenia, currently homeless and staying in a women’s shelter. She was evicted from her apartment for refusal to pay a rent increase. She has not been in psychiatric treatment for four years, since her former therapist left her position.

She hears that the CTI worker who comes to the shelter can help her find housing. She asks to meet with the worker. At her first meeting, she is very guarded but says she would like help finding housing. She also agrees to see a psychiatrist, but says she is afraid of medicine.

Pre-CTI starts, with goal of engaging Maria.

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Case example

The CTI worker talks with the psychiatrist in the clinic about Maria’s fear. When he meets with her, he works to build trust, but does not push medications. After a couple of visits, she agrees to start taking an antipsychotic medication, hoping it will ease her stress and help her sleep.

Phase 1 of CTI starts when she moves into a senior housing complex. The CTI worker helps her get furnishings. Maria receives SSDI and has been saving money while staying at the shelter. She has funding for household items. The CTI worker accesses special needs funding to pay first month’s rent and security deposit.

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Case example

The phase goals for Phase 1 are to help Maria get her household set up, learn a new bus route, and continue to engage in mental health treatment.

Phase 2 – As Maria’s symptoms improve, she feels more comfortable in her new apartment. She reaches out to her family and starts cooking her own meals.

Phase 3 – During the final phase, Maria reconnects with family and begins attending then volunteering at the local senior center. She continues in treatment as well.

By the end of Phase 3, Maria has connected to some other supports in the community – her family and the senior center – and she remains engaged in psychiatric treatment.

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Case example

Key Ingredients

• Strong clinical leadership• Focus on relationship and engagement• Collaboration between service sectors and

providers• Person-centered• Flexible and practical• Address basic needs first• Access to funds for essential needs, especially

related to housing

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• Limited housing stock

• Some participants with significant functional impairment needed longer term service that wasn’t available

• Long term funding for the model – case rate would be most helpful for financial sustainability

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Challenges

Implementation questions

What is ideal duration of CTI for various populations? Key elements?

How should CTI be targeted?

What are feasible funding options?

How does CTI interrelate with other care coordination approaches in current US healthcare reform efforts?

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• Prison reentry

• Post drug treatment

• Post opioid overdose in ED

• Rapid rehousing

• Interpersonal violence

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Current adaptations

Tools to monitor fidelity

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CTI Additional Information

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Selected References

Articles

Anderson, D., Choden, T., Sandseth, T., Teoh, T., Essock, S., & Harrison, M. (2019). NYC START: A New Model for

Securing Community Services for Individuals Hospitalized for First-Episode Psychosis. Psychiatric Services.

Draine, J., Herman, D.B. (2007). Critical time intervention for reentry from prison for persons with mental

illness. Psychiatric Services, 58(12), 1577-158

Herman, D., Opler, L., Felix, A., Valencia, E., Wyatt, R.J., & Susser, E. (2000). A critical time intervention with mentally

ill homeless men: impact on psychiatric symptoms. Journal of Mental and Nervous Disorders, 188(3), 135-140.

Kahn, L.S., Vest, B.M., Kulak, J.A., Berdine, D.E., & Granfield, R. (2019). Barriers and facilitators to recovery capital

among justice-involved community members. Journal of Offender Rehabilitation.

Kasprow, W. J., & Rosenheck, R. A. (2007). Outcomes of critical time intervention case management of homeless

veterans after psychiatric hospitalization. Psychiatric Services, 58(7), 929-935.

Lako, D., Beijersbergen, M., Jonker, I., de Vet, R., Herman, D., van Hemert, A., and Wolf, J. (2018). The effectiveness

of critical time intervention for abused women leaving women’s shelters: a randomized controlled

trial. International Journal of Public Health, published online.

Samuels, J., Fowler, P.J., Ault-Brutus, A., Tang, D., & Marcal, K. (2015). Time-limited case management for homeless

mothers with mental health problems: Effects on maternal mental health. Journal of the Society for Social Work and

Research, 6(4), 515-539

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Selected References, continued

Shaffer, S.L., Hutchison, S.L., Ayers, A.M., Goldberg, R.W., Herman, D., Duch, D.A., Kogan, J.N., & Terhorst, L.

(2015). Brief Critical Time Intervention to reduce psychiatric rehospitalization. Psychiatric Services, 66(11),

1155-1161.

Shinn, M., Samuels, J., Fischer, S.N., Thompkins, A., & Fowler, P.J. (2015). Longitudinal impact of a Family

Critical Time Intervention on children in high-risk families experiencing homelessness: A randomized

trial. American Journal of Community Psychology, 56(3-4), 205-216.

Susser, E., Valencia, E., Conover, S., Felix, A., Tsai, W.Y., & Wyatt, R.J. (1997). Preventing recurrent

homelessness among mentally ill men: a “critical time” intervention after discharge from a shelter. American

Journal of Public Health, 87(2), 256-262.

Thornicroft, G., Susser, E. (2001). Evidence-based psychotherapeutic interventions in the community care of

schizophrenia. The British Journal of Psychiatry, 178(1), 2-4.

Tomita A., Herman D.B. (2015). The role of a critical time intervention on the experience of continuity of care

among persons with severe mental illness after hospital discharge. Journal of Nervous and Mental Disease,

203(1), 65-70.

(2014). Critical Time Intervention in Los Angeles’ Skid Row: Learning from the Downtown Women’s Center’s Pilot Intervention. Los Angeles, CA: Downtown Women's Centerhttps://www.criticaltime.org/wp-content/uploads/2014/11/DWC_CTI-Final-Report_Combined_8-13-14-2.pdf

Jacob, R. (2018). UK Crisis Report: Preventing Homelessness. United Kingdom: .https://www.crisis.org.uk/media/239551/preventing_homelessness_its_everybodys_buisness_2018.pdf

SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities.

www.samhsa.gov

1-877-SAMHSA-7 (1-877-726-4727) ● 1-800-487-4889 (TDD)

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Barbara B. (Bebe) Smith, MSW, LCSW

bebe@bebesmith.com