Core components of the Coordinated Specialty Care model for first-episode psychosis

The Coordinated Specialty Care (CSC) model for first-episode psychosis (FEP) is an evidence-based wraparound model for improving outcomes for young people with FEP,1 said Jacob Ballon, Stanford University, CA. He described its core components — derived from its recovery-oriented, patient-centered, team-based, shared decision-making philosophy — to healthcare professionals attending an educational course at APA 2019.

Positive and non-labelling language, attitude and expectations are essential

Attitudes and expectations must be positive and optimistic

To facilitate a recovery-oriented approach, all language used around FEP needs to avoid labelling the patient or the illness in any way. This does not come naturally, said Dr Ballon, but changing the language used can change the nature and dynamic of conversation.

In a similar way, attitudes and expectations must be positive and optimistic. Although patients with FEP face challenges, their illness should not define all they can do or will be.

The focus is on the young person who contributes to decisions

A patient-centered approach ensures the focus remains on the patient, who should be involved in all decision-making.

Such partnering with young people developing early symptoms is a new concept for psychiatrists, Dr Ballon commented, but the evidence suggests that it is time to progress from previous models where the psychiatrist knows best what to do.

The decision-making is also shared with all key stakeholders, who have a vested interest in how things will go; and everyone involved — all of whom need to be on same page — must be considered to be an expert.

The personnel contributing to a Coordinated Specialty Care approach underpin its success

For optimal outcomes, it is essential to reduce the duration of untreated psychosis (DUP) from 74 weeks to less than 12 weeks

Dr Ballon highlighted the importance of the CSC team structure comprising:

  • a program coordinator/team leader
  • a case manager
  • a supported employment/education specialist
  • psychotherapist
  • psychiatrist
  • an age- and experience-aligned peer

The psychiatrist facilitates early identification of FEP and referral to a CSC program. For optimal outcomes, it is essential to aim to reduce the duration of untreated psychosis (DUP) from the median DUP of 74 weeks in the RAISE programme1 to less than 12 weeks, said Dr Ballon.

“Place and then train” — placement has a profound impact on prognosis

Supported employment or education is particularly important, and the supported employment/education specialist is the only role that cannot be combined, said Dr Ballon. The role focuses on placing people in jobs or education to keep the patient involved in their life trajectory, and placement has a profound impact on prognosis.

Factors to consider when making decisions on placement include:

  • which is the best role for the patient
  • which trajectory most closely aligns with the patient’s goals
  • how will the role craft their identity

The individual placement support (IPS) model is advocated and focuses on the whole person. Place and then train, and understand the patient’s goals, said Dr Ballon.

The peer role must not be neglected

The peer is a valued member of the team and the role must not be neglected, advised Dr Ballon. The peer is age- and experience aligned with the young person with FEP, and is involved throughout the program. The peer should provide a sense of optimism and help the patient feel comfortable, including when describing intimidating experiences.

Ensure all patients can be linked with services

All recovery-oriented, patient-centered, team-based, shared decision-making components of a CSC program are important, Dr Ballon concluded; and this was the take-home message of the session. If an organization is unable to provide every component, the answer is to partner with a local organization to plug the gap, and ensure that all patients can be linked with services.

References
  1. Kane JM, Robinson DG, Schooler NR, et al. Am J Psych. 2016;173(4):362–72.

Further reading
For further reading on this topic, please see the following pieces in the Progress in Mind Resource Center and Lundbeck Institute Campus:

Pioneering Coordinated Specialty Care Programs for First-Episode Psychosis

What are the decision-making needs for young adults with early psychosis receiving coordinated specialty care?

Strategies to reduce duration of untreated psychosis

Right treatment at the right time: The ‘RAISE’ project in first episode psychosis

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