Innovative Treatment Programs Recognized at APA Institute

At first glance, the winners of the 2001 Psychiatric Services Achievement Awards appear to be a diverse group. Among the clientele of the programs honored at APA’s 2001 Institute for Psychiatric Services last month in Orlando, Fla., are toddlers, refugees, former jail inmates, and persons with serious and chronic mental illness.

Staff of these programs, however, share an ability to bring ingenuity, persistence, and good humor to some of the most intractable problems facing mental health practitioners. And many of them also manage to generate cost savings in tax dollars, while simultaneously creating a series of daily miracles for those they serve.

The Gold Award winner in the category of small community-based programs was the Thresholds, State, County Collaborative Jail Project of Chicago. This program targets, for example, “chronic, nonviolent detainees who have severe and persistent mental illness.” The program came about after the realization that Cook County Jail in Chicago had become the state’s largest psychiatric facility because of the number of people with mental illness that it housed.

Many of the criteria for admission show the intent of staff to “screen in” persons who face considerable challenges in their efforts to live in the community, rather than to select those who will offer quick and visible success stories. The first 25 participants were required to have at least two state inpatient psychiatric hospitalizations and a history of “difficulty in being linked to services.”

Outreach workers typically see participants seven days a week and help them with housing, job placement, finances, and medication management. Services cost $26 a day, compared with $70 a day for jail incarceration. Even more impressive savings are apparent when costs of hospitalization ($500 a day) are added to costs of jail.

The Gold Award winner in the category of large academically or institutionally sponsored programs was the Short-Term Acute Residential Treatment (START) Program, sponsored by the Community Research Foundation in San Diego. START also took on a difficult task—providing interventions that would keep patients suffering from acute psychotic episodes from requiring psychiatric hospitalization. START offers crisis stabilization in six large homes in San Diego County.

START maintains a 1-to-4 staff-to-client ratio, which enables the program to provide individualized care. Planning for discharge begins almost as soon as the client comes to the home, according to staff. Since more than half of the residents also have substance abuse diagnoses, as well as other mental health problems, the homes provide on-site Alcoholics Anonymous meetings and assistance in getting to meetings at other locations.

A study funded by the Veterans Administration (VA) is comparing services, outcomes, and costs for veterans who were randomly assigned to a psychiatric unit in a VA hospital or to the START program. Preliminary findings show that START costs considerably less than hospitalization. (The figures are $2,775 average cost per episode in START, compared with $6,976 for those who receive care in the VA hospital.)

Each winner of the Gold Award received a plaque and $10,000 cash grant from Pfizer Inc.

Certificates of Significant Achievement

The Baltimore Capitation Project, sponsored by Baltimore Mental Health Systems Inc., also targets persons with serious mental illness. In fact, the first group of enrollees came from state hospitals, and most of them had been hospitalized more than six years.

Capitation, which is a single payment rate per enrollee, allows the staff flexibility in terms of services and even offers opportunities for incentives such as dinner in a restaurant. Caseloads are small—eight or nine people—and each enrollee is visited an average of 12 to 16 times a month.

State psychiatric hospitalization in Maryland costs at least $72,000 a year. The average expenditure for residential rehabilitation is $53,000 annually, while the capitation rate is $27,000.

Hmong, Lao, Cambodian, Vietnamese, Somali, and Spanish are languages heard in the streets of South Minneapolis and spoken by the staff of the Community-University Health Care Center. The center’s mental health division won a certificate for its multidisciplinary effort to offer culturally appropriate mental health services to refugees and other immigrants.

A mime was brought in to help staff become more comfortable communicating without words, when language problems proved difficult. That gesture was one of many ingenious efforts to bridge cultures. In addition to a comprehensive array of conventional services such as group therapy, medication and case management, and independent living skills, the program provides activities, such as meditation and ethnic dance, that reflect the various cultures of participants.

Staff of the Multnomah County Early Childhood Mental Health Program take their services to their young clients. The first impetus for the effort occurred in 1990 when a Head Start program director noticed that children in the program were not well served by existing mental health services. Instead of focusing on conventional outreach methods, the program places early childhood mental health clinicians and child psychiatrists in public community agencies, such as schools, Head Start programs, and day-care centers that serve young children. Staff found that the stigma associated with mental illness is alleviated when services are offered outside of mental health clinics and that family members are more likely to be involved in the child’s treatment if it is part of an educational or community setting. In a recent survey, nearly 100 percent of families indicated that they were satisfied with the program.

The winning programs were selected from among 75 applicants by the 2001 Psychiatric Services Achievement Awards Committee, chaired by Michael Silver, M.D., of Providence, R.I. APA is accepting applications for the 2002 awards. The deadline for receipt of those applications is January 14, 2002.

More information about the achievement awards is available on APA’s Web site at www.psych.org/pract_of_psych/awards.cfm. Here are the Web sites of the cited organizations: Thresholds, www.thresholds.org; Community Research Foundation of San Diego, www.comresearch.org; Baltimore Mental Health Systems, www.bmhsi.org; Multnomah County Early Childhood Mental Health Program, www.co.multnomah.or.us/dcfs/; and Community-University Health Care Center, www.ahc.umn.edu/CUHCC. ▪