NAMI NC -System Reform- Technical Assistance Bulletin #1:
Best Practices     

Best Practices
Assertive Community Treatment
 Supported Employment
Family Psychoeducation
Social Skills Training
Illness self-Management
Integrated Dual Disorder Treatment
Other Practices Being Studied

 

Best Practices:

The local business plan must show compliance with models of best practice determined by the state. The state, however, has not officially released its list of best practice models. What we do know is that the state intends to adopt nationally recognized, evidenced-based models as its best practices. This technical assistance bulletin focuses evidenced based services for adults with serious mental illness, what those services should look like (essential elements), and who benefits from those services. We also have provided ways you can get additional information should you and your community need it. These resources should not be considered exhaustive but will give you a good place to start.

The field of establishing research based service practice is a new, evolving, and exciting field. It is driven by the belief that, in a world of limited resources, mental health organizations should try to maximize the effectiveness of the services they provide to individuals with mental illness. If this is to occur, however, researchers must show conclusively which services work and which do not.

In response to this need, there is a national effort to establish research based "best practice" services. This effort is evaluating not only what are the most effective services, but how can we ensure our local mental health systems adopt those services. In the coming year, the Robert Wood Johnson Foundation will be publishing "tool kits" of best practice to help communities implement the best of what we know works with individuals with mental illness. These tool kits are not yet available, but we know that the Division of MH/DD/SA will likely accept these tool kits to define and implement "best practice" in North Carolina. What is presented below are the best practices that will be reflected in these "tool kits" as well as practices that are currently being studied but are likely, in the near future, to be considered "best practice."

In advocating for best practices, it is important to point out that evidence-based services are most effective when implemented as closely as possible to the accepted model. In other words, extensive changes of evidence-based practices to "local circumstance" are not appropriate or effective, unless for culture, race, and ethnicity. Other key aspects of best practices implementation are high consumer demand for evidence-based practices, extensive provider training and education about evidence-based practices and how to implement them, and long-term support and feedback to providers about their use of evidence-based practices. Financial incentives, administrative rules, and government regulations must also support the implementation of evidence-based practices.

Finally, all services should be offered within a recovery model philosophy. Elements of the recovery model are a system that encourages and expects recovery. This includes:

Recovery is the ultimate measure of effectiveness in client-centered mental health services. It is the goal by which all mental health services should be evaluated in evidence-based practices research and in North Carolina’s new system.

 

Best Practice Services for Individuals with Severe Mental Illness

Assertive Community Treatment

Essential Elements

Who Benefits

  • Services provided by a team that is responsible for all client needs

  • Team members share responsibility for all clients

  • High case manager to client ratio (roughly 10 clients per team member is recommended)

  • Services provided in clients’ natural setting

  • 24-hour coverage

  • Shared caseloads among clinicians

  • Flexible direct services

  • Broad team skills and training (team has a psychiatrist, vocational specialist, nurse, substance abuse specialist, etc.)

  • Client advisory mechanisms that provide oversight of the service

  • Clients with high utilization:

    • -Long periods in the hospital
    -Frequent hospitalizations
    -Repeated emergency room visits

  • Clients with severe impairment in psychosocial functioning

  • Homeless clients

  • Financers of mental health services: ACT services can be expensive, but they save money by decreasing the use of even more costly services (hospitalizations, ER visits, etc.)

  • Some clients feel ACT teams are too intrusive and paternalistic. This may relate to how an ACT team is implemented, although more research is needed.

Comments and additional resources: In North Carolina there are very few ACT teams yet this is probably the most effective service for individuals with severe mental illness. NAMI has developed a detailed manual for developing an ACT team. You can get this manual at www.nami.org/about/pact.htm as well as other useful information and links. Several Area Programs have also developed excellent ACT teams, including OPC (Spence Lyerly – 490-5503, ext. 4367) and Blue Ridge (Cathy Rubindall 828-258-2900).

 

Supported Employment

Essential Elements

Who Benefits

  • Focus on and commitment to competitive work

  • Rapid job search and placement

  • De-emphasis on pre-vocational training & assessment

  • Attention to client preferences

  • Places all who desire employment, regardless of disability or skills

  • Follow-along supports provided indefinitely

  • Integration with case management and clinical services

  • Supported employment is the most effective vocational rehabilitation approach for all persons with mental illness, regardless of work experience or disability

  • But, individuals with prior work history have better outcomes

  • Clients interested in competitive work

Comments and additional resources:

Included in the category of supported employment are transitional employment activities such as those found in Fountainhouse Clubhouse programs and job coaching. It does not include sheltered workshops or pre-employment services. The Association for Persons in Supported Employment (APSE – www.apse.org) is the national organization for supported employment participants. Their state chapter is the NC-APSE (www.ncapse.org; contact: Pat Keul, 704-333-8220; call 1-800-662-7030 for supported employment providers in NC). Kay Miller at Central Piedmont Community College (704-330-6144, kay_miller@cpcc.cc.nc.us) is also a resource for developing supported employment programs. Adventure House (704-482-3370) and Threshold are excellent examples of Fountainhouse Clubhouse programs.

 

Family Psychoeducation

Essential Elements

Who Benefits

  • Multiple successful formats (single or multiple family sessions; duration of 9 months to 5 years; locations include clinics, homes, family practices, and other community settings; techniques include didactic, cognitive-behavioral, and systemic)

  • Longer, more thorough programs are more successful to a point

  • Key element of psychoeducation is its focus: must be on expectations and common goal setting, social and clinical needs, education needs, communication needs, family strengths and weaknesses, stress-reduction, problem-solving, coping, crisis plans, skills training, and other support

  • Oriented to future, not to past

  • Clients in regular contact with relatives more than 4 hours per week

  • Clients with time and resource intensive needs: emotional support, case management, financial assistance, advocacy, housing, etc.

  • Clients with little support outside of their family

  • Benefits of family psychoeducation confirmed for a broad range of disorders, including schizophrenia, schizoaffective disorder, bipolar disorder, major depression, obsessive-compulsive disorder, anorexia nervosa, and borderline personality disorder

Comments and additional resources: NAMI’s Family-to-Family Education Program is recognized as a best practice model of a short-term family education and support program. Many local NAMI affiliates offer the Family-to-Family Education Program. For more information contact the NAMI North Carolina office at 919-788-0801.

 

Social Skills Training

Essential Elements

Who Benefits

  • Modeling, role playing, positive and corrective feedback, homework use social learning principles to teach social skills

  • Multiple weekly sessions

  • Individual and group formats

  • Training lasts 3 months to over a year

  • Training occurs in client’s natural setting

  • Most research on social skills training has been done in individuals with schizophrenia

  • Research suggests that any client with poor social functioning could benefit from social skills training

Comments and additional resources: Social skills training is not an identified services in North Carolina. Often elements are provided through clubhouse programs, client behavior intervention, or psycho-educational programs. It should be developed as a separate service that could include using consumers as leaders in a recovery model approach.

Social Skills Training for Schizophrenia: A Step-by-Step Guide, by Bellack, Mueser, and Gingerich is a guide to social skills training available for $35.00 at www.amazon.com.

 

Illness self-Management

Essential Elements

Who Benefits

  • Psychoeducation about illness including diagnosis and symptoms, effects of medication, stress-vulnerability model, effects of alcohol and drugs

  • Allows avoidance and minimization of relapses through recognition of early warning signs of relapse, avoidance of alcohol and drugs, regular sleep and exercise

  • Allows enhancement of medication adherence through behavioral tailoring, motivational interviewing, skills training for client-doctor interactions

  • Likely all clients

  • Clients at risk of symptom exacerbation, rehospitalization, and relapse have been shown particularly to benefit

Comments and additional resources: Illness management is not an identified service in North Carolina. Often elements are provided through clubhouse programs, medication management classes, or psycho-educational programs. It should be developed as a separate service and that could include using consumers as leaders in a recovery model approach. A guide to illness self-management strategies has been published at www.bhrm.org/guidelines/illness-self-mgmt.pdf.

 

Integrated Dual Disorder Treatment

Essential Elements

Who Benefits

  • Concurrent treatment of mental illness and substance abuse by the same clinicians who assume responsibility for treating both disorders

  • Key features include assertive outreach, stage-wise treatment, harm-reduction approach, counseling, motivational interventions, and social support interventions

  • Must be linked with comprehensive mental health services, culturally sensitive, and focused on long-term goals and recovery

  • Likely to benefit all individuals with co-occurring disorders

  • Research and state reform efforts thus far have focused on individuals with serious mental illness and co-occurring substance use disorders

  • About 50% of individuals with serious mental illness have a co-occurring substance use disorder. Dual disorder treatment is very important.

Comments and additional resources:

Dual diagnosis is associated with higher rates of negative outcomes, including relapse, hospitalization, violence, incarceration, and homelessness. Dual diagnosis treatment improves outcomes over traditional treatment in all of these areas. The Tennessee Department of MH/DD has an excellent website devoted to integrated dual disorder treatment (www.dualdiagnosis.org) if you would like more information.

 

Other Practices Being Studied and Likely to be Determined "Best Practice"

Supported Housing
For more information, you can contact Grier Weeks at Housing Works, 828-255-8484 or Julia Bick in the Department of Health and Human Services 919-733-4534.

Crisis Services
For more information go to www.emergencypsychiatry.org

Peer support/Consumer services
 Piedmont Behavioral Health is leading the way on recovery and peer support services. For more information on recovery and peer support programs contact George Muse at 704-721-7000.

Jail Diversion Programs
For more information, you can contact Ken Marsh at the NC Division of Mental Health/Developmental Disabilities/Substance Abuse Services, 919-715-1294.

Excellent information is also available from the Bazelon Center for Mental Health Law (www.bazelon.org/decrim.html).  Blue Ridge Area Program has a good jail diversion program paired with its ACT team. Contact Debra Bedgood at 828-258-8816 for more information. OPC has a Community Resource Court. Contact Tim Williams or Jeffery Demagistris 919-913-4014