Pam Harrison

October 12, 2016

UPDATED October 14, 2016 // WASHINTON, DC — A novel way of delivering healthcare services to the severely mentally ill may prevent the predictable downward spiral to homelessness, provided patients have a home where these services can be delivered and a family member who can provide psychosocial support, preliminary results suggest.

"The basis of all our work is the network meeting, which is typically a 90-minute meeting conducted in an open dialogue style with the client, the family, in the patient's home, along with a peer or a social worker or a family therapist or a psychiatrist," James Mills, LCSW, Visiting Nurse Service of New York, in New York City, told Medscape Medical News.

"And we've had great success in engaging people and working with them in a very collaborative, joined way," he added.

The results were presented here at the Institute of Psychiatric Services (IPS): The Mental Health Services 2016 Conference.

Peer Support

The program, known as Parachute NYC, is a community-based mental health initiative that deploys mobile teams to treat seriously mentally ill individuals in their homes.

"All of the team clinicians as well as peers are trained in intentional peer support," Mills noted.

The team includes current patients — often coming to treatment in crisis, adds David Lindy, MD, clinical director and chief psychiatrist, Visiting Nurse Service of New York ― plus at least one unpaid member of the client's natural network, usually a family member, accompanied usually by two staff members.

"Network meetings occur as frequently as the network determines they need to meet to try to stabilize the crisis and to establish goals for going forward in a totally transparent, nonhierarchical, noncoercive manner," said Dr Lindy.

"And we want to hear all voices, we want to respect all points of view, and we want to create a climate in which it is safe for everyone to say their piece so that natural systems problems will emerge from this group process as well as solutions, rather than clinicians imposing solutions on clients in a more paternalist way," he said.

The model also includes "peer specialists" who serve on the team as full clinicians and who have a "particularly important role" to play on that team because they can tell the client, 'I've been there'," said Dr Lindy.

Parachute teams have operated since 2012 as part of the Visiting Nurse Service of New York's community mental health services. Funding for the first 4 years was provided by federal and state grants.

Low Hospital Readmission Rates

Preliminary analyses of aggregate outcomes from Parachute's three teams are impressive.

On average, approximately 34 clients are served every month; about 2.6 new individuals added to the team's network every month.

Hospital admissions per month remain low, at 1.6. per team. Hospital readmissions within 30 days of discharge are similarly low, at an average rate of 1.2 per team.

Although comparisons with other readmission rates in New York City for the mentally ill are tenuous, Dr Lindy pointed out that for a very similar population of patients, rehospitalization rates are typically approximately 13%, compared to Parachute's annual rate of 4% for all three teams.

Between July 2015 and August 2016, Parachute teams held approximately 47 network meetings, which involved approximately 75 face-to-face visits.

A recent count indicated that the Parachute NYC care model had served 110 clients, 61% of whom had beeb diagnosed with schizophrenia (including psychosis), and another 17% had a diagnosis of affective psychoses.

Five percent had been diagnosed with bipolar disorder, and 9% had been diagnosed with major depressive disorder. The remaining 8% had been diagnosed with other illnesses, including posttraumatic stress disorder.

Tolerance of Uncertainty

"My assumption going into this study was that since we don't push medications, we would find lower rates of people being on psychotropic medication," said Dr Lindy.

Instead, team members found that 85% of their clients were receiving psychiatric medications and that 75% of this group were receiving antipsychotic medication.

"This would suggest that rather than getting into power struggles around medication and compliance, we get to work with the client and the family such that they agree to take the medication voluntarily, rather than having it being pushed down their throats, which is such a common part of the system otherwise, unfortunately," Dr Lindy said.

One of the principles of the needs adapted treatment model underpinning the Parachute philosophy is a tolerance of uncertainty, Mills elaborated.

"We have to be okay with leaving a network meeting without any decisions having been made except the decision to come back. Our only goal is ongoing, continued engagement with the client and solutions that emerge from the network — the client, his or her family, and supporters — and we feel these solutions will have a much more lasting and powerful impact than anything we could come in with and dictate," he added.

Dr Lindy also noted that the team hopes to expand its preliminary findings to create a compelling picture that will appeal to managed care providers, who then will be persuaded to embrace Parachute-like models for care programs.

"This was initially a grant-funded program, but for it to be continued and to have real sustainability, we've got to be able to show managed care providers that we reduce hospitalization rates, we reduce ER utilization, and that our model saves money, so managed care providers will be willing to pick up the tab, because it's a wonderful model," Dr Lindy said.

Novel Approach Encouraging

Commenting on the findings for Medscape Medical News, Harsh Trivedi, MD, president and CEO, Sheppard Pratt Health System, Baltimore, Maryland, and chair, Council on Healthcare Systems and Financing, American Psychiatric Association, said he is always encouraged to see novel approaches to a problem that affects more than 40 million Americans living with mental illness.

"As the president and CEO of Sheppard Pratt Health System — the largest nonprofit provider of mental health services in the nation — I know that there are a number of obstacles that prevent those suffering with mental illness from getting help, including issues with access to care and lack of support networks," said Dr Trivedi.

"So it's great to see a program like Parachute NYC removing both of these barriers by including a trusted family member in the treatment process and by bringing care directly to a patient's home," he added.

Dr Trivedi also noted that he and his colleagues are well aware that all too often, mental illness spirals into homelessness.

Indeed, it is estimated that 46% of homeless adults living in shelters in the United States have severe mental illness or problems with substance abuse.

"Community-based mental health programs such as Parachute NYC can provide the critical intervention that prevents someone on the brink of homelessness from falling any further," said Dr Trivedi.

None of the authors have disclosed any relevant financial relationships.

Institute of Psychiatric Services (IPS): The Mental Health Services 2016 Conference. Abstract 18. Presented October 7, 2016.

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