Hello and welcome. Thank you for joining the Third National Conference on Advancing Early Psychosis Care in the United States presented by SMI Advisor. We are pleased to present today's session, Providing Crisis and Assessment Services Remotely. Hi, I'm Dr. Daniel Shapiro, I'll be presenting today. I am an assistant professor at the University of California, Davis, where I serve as the director of operations for our early psychosis programs here. And on the research side, I'm really interested in provision of care for early psychosis, as well as dissemination of evidence-based practice in order to increase access to these wonderful services to as many people as possible. And also broadly in the role that culture and the way people understand or think about mental illness affects their decisions about whether to access care and what that ought to look like. And hi, I'm Rachel Lowy. I am an associate professor at the University of California, San Francisco in the Department of Psychiatry. I'm a licensed clinical psychologist, and I've been doing work in research and services development for early psychosis for about 20 years with a particular interest in screening and assessment. Okay, I have no financial disclosures to report. I have no financial relationships with commercial interests, no conflicts of interest to report. Great, well, welcome, everybody. Good afternoon or evening or morning, whatever it is, wherever you are. We're really excited to be presenting today. Broadly, we have a couple of learning objectives, specifically after this presentation, we hope that you will be able to list at least two evidence-based assessment measures used in the early psychosis population. We are going to be really focusing on crisis care and how we have adapted services for remote assessment and remote provision of care. So we hope you can describe at least two such adaptations and also identify two approaches or more for addressing system issues that have impacted remote assessment and crisis services during COVID-19, but also more broadly in providing telehealth. Next slide, please. So this past year has brought many new and unique challenges. I think probably the biggest is a need for a really phenomenal and quick transformation of how we provide care, you know, and it has become so clear in these unprecedented times. Sadly, the effects of this transition have disproportionately burdened and impeded access to those who are already underserved. So it's really excited that we're having this talk, that you are here watching it and hopefully learning some things. So next slide, thank you. We are, Dr. Lowy and I today are going to talk about these transformations, really trying to focus on providing crisis services. And in order to do that, we're going to be talking about the early psychosis population, because this is a population that has a really high rate of crisis. And I think it applies really to most of our serious mental illness populations. I'll begin with a brief primer of the coordinated specialty care model of early intervention for psychosis. I will describe the SACI clinic at UC Davis, which is a nice exemplar of this model. We will discuss a gold standard crisis intervention model and then also show you how we and other clinics like ours have adapted this model so that we can provide the same quality care via telemed. And we will also show a little bit of data on how our service has changed from everything we have read. Our service seems to represent others as well. So I think it is a representative sample. We'll talk about how you can shift your practice to telehealth and also share some recommendations for transforming care for your population and for our population as well. Next slide, please. So I think we have sort of settled on a handful of words to sum up what a difficult year 2020 has been to sort of shorthand coronavirus and the effects that it's had. And if we look broadly at the timeline of how telemedicine has shifted, we can truly get a sense of how, you know, unprecedented the year has been. I'm not going to go into a ton of detail, but this figure charts some major developments in telemedicine. And I think the major takeaway here is that the technology for providing medical care remotely or from a distance has developed with each technological revolution. Early steps here involved connecting really clinics in one place to clinics or providers in another place, initially with audio links and then with the advent of television with closed circuit TV signals. And as time went on, this moved increasingly to trying to connect providers in one place with clients or consumers in another. And then I think the major, major developments came with the advent of the Internet. And so you can see this timeline sort of steadily moving along in the United States. At least some big shifts here came around the turn of the century when Medicare, our public health system began paying for telehealth, really focused on rural communities. So connecting people who lived someplace where they could not access expert care to those expert providers elsewhere. Around 2010 to 2015, this then saw another big shift with video telehealth programs, mobile health. And then all of a sudden, 2020 hits, and this 100-year sort of span of development results in this flurry, this really precipitous shift towards telemed almost instantaneously, almost 100 percent of care. You can click through to the next slide, please. Thank you. So today, at least my portion of this talk, focusing on crisis services, I'm going to talk about the UC Davis early psychosis programs. It's a nice exemplar. Very quickly, our program was established in 2004, and we operate with a variety of different funding sources, including the Mental Health Block Grant. We also have a private insurance and public insurance side of the clinic. We have a number of research grants. We are fully integrated. And in California, in the state of California, we have what's called the Mental Health Services Act, which allows for the use of some tax dollars to support some of our services. The important thing to note here is we serve Sacramento County, which is a metro area of about 1.4 million people. We are the only specialty early psychosis program serving this this full population. And certainly in the United States and elsewhere in much of the world, this is fairly represented. So very large population, very small number of experts. So actually really illustrates the importance of being able to provide telehealth far beyond COVID and 2020. Next slide, please. This is our coordinated specialty care model. I'm not going to go into a ton of detail, but this is sort of representative of the gold standard model. And other talks you can access discuss this model and the research evidence supporting it in quite a bit of detail. So we won't do that here, but I wanted to show you this to help illustrate how we have transformed services. And also because whatever team you operate in, whether it's a clinic or you are in a private practice or you have some colleagues, crisis care occurs in this context of whatever team you're operating. So just really super quickly in the UC Davis model, this coordinated specialty care program includes a mixture of evidence based therapy, both individual group and pharmacotherapy approaches. We have a number of case managers on our team. We have a full time supported education and employment specialist. We also have a few peer providers who themselves have lived experience and use this with our clients and family members to help with engagement and sort of navigate this very scary and often mysterious process alongside families. We have a number of trainees in our particular program and as part of this model, spend a lot of time focusing energy on outreaching to the community to really help train the larger Sacramento and California population on what signs and symptoms to look for. We have a very strong focus on relapse prevention and crisis management, which we'll discuss today. That is involved in every case in some aspect, really from the beginning. And you can move to the next slide, please. So in 2020, we, like you and many of our colleagues, very quickly moved to a almost 100 percent remote care model. And so using that coordinated specialty care model I showed you on the last slide, I wanted to illustrate some of the ways we have done this, because, again, this is this is part and parcel of providing crisis care. The first step in providing crisis care is always preparing, understanding which of your clients are potentially at risk because they've had crises in the past or because they have some sort of escalation of symptoms that could result in a need for higher level of care. So very quickly, and you can read some more detail on the slides, we were able to move both individual and group care to a telemed approach using video conferences pretty quickly. Individual care transitioned really right away. And from what we've seen in the literature, actually this happened pretty broadly, much more easily than people had thought. Groups were a little bit more complicated. From a systems perspective, a lot of the groundwork here came in the form of finding secure or encrypted ways to meet with people, secure and encrypted ways to share information about our clients between staff members, and to coordinate the care we're providing if we're each working from our own staying at home sort of isolation. The other thing this really did to transform our team and probably your practice was to blur the lines actually quite a bit between these different members of our team. And so, you know, if you're an independent practice or a psychologist like I am or a psychiatrist or any other health care provider, you may find yourself doing a lot of case management or supported education or working with family members to help them understand how to provide support to take care of themselves at the same time. So we did a lot of this and you can read here some of the ways that we've been doing that. Next slide, please. So a lot of these were our own efforts to adapt care. So it's focused not just on the care itself, but increasing sort of access to the different types of services. You know, this included using translators where possible, creating fillable forms that clinicians could use to do evidence-based assessment via a webcam or a telephone, translating therapy materials or summaries of, you know, medication information and side effects into different languages, into writing so that different people could see it. We really tried to transform our service in order to provide higher frequency of contacts, although maybe shorter visits to account for Zoom fatigue and the fact that you can't do the same things via a webcam as you can when somebody is in front of you in person. And again, we really discovered here, I said this before, that our lower resource families, our traditionally underserved families are sort of getting hit again with some of the burden of technology. The biggest limitation actually we found was that lots of our clients, Internet's not really the problem, but many are coming to therapy sessions on their phone, even going to school over the phone. So dealing with resource issues like that actually is relevant, both in providing good care and in crisis care, because these stressors melt. Next slide, please. Some great resources for you if you're interested in more suggestions are out there. So on this slide is a summary of some recommendations written in this paper here. You could read more, a collaboration of a number of coordinated specialty care experts discussing how they've transformed their services. Some great recommendations that I'd like to quickly highlight, again, sort of the foundation for providing crisis care, are keeping in mind just what we're all experiencing. So shorter, more frequent contacts, as I mentioned, may be focused not on the same traditional treatment targets, but things like behavioral activation, helping people get out of the house, encouraging connection between friends or family, getting physical movement and scheduling these into your days. A lot of our really stressed young people and clients are being asked to spend like six hours a day passively learning on Zoom links, and this is really difficult and really stressful. So some other good suggestions are transforming the way you're connecting with folks. So if you can provide written materials, ways to check in with somebody that doesn't rely so heavily on our eyeballs, because we're meeting with people over a camera. So, you know, using written check-ins or pictures to have people represent how they're feeling today, or a feelings thermometer, like a red light, green light, yellow light, we found to be really helpful and easily translatable to other providers who may be working with them. We also need to know what expectations there are for safety if you are meeting in person with your clients. So if you are working as part of a team, you should get the input of all of your staff members, what they are up for and willing to do. If you can co-meet or piggyback sessions so that you kind of grab people while you already have them, this is going to help to maintain contact, and blurring those lines, a lot of providing good care now is supporting people in the weird things that we're all doing in our real life, like e-learning, going to school via a computer, or working with colleagues in a virtual setting where we don't know what's going to happen in the real world. So, all of this is with the goal of increasing structure, increasing check-ins, and providing more sort of non-traditional mental health support as ways of preventing crises. Next slide, please. I think for us as providers, the other really important thing to adjust is our own expectations. We're operating as providers in the same difficult scenario. So, accepting that none of us are going to be as productive as we would like, that much like our clients, our therapy goals may need to shift, and that we ourselves are limited and affected. So, trying to find some ways to support yourself or your staff members in doing this work is really key as well. Next slide, please. So, transitioning here into really the meat of our talk, on crisis management. So, included here is a sort of gold standard, typically functioning clinic crisis management policy that takes into account what we know in the research that we're doing, and how we're going to be able to support our clients, our staff, and our clients in their crisis management efforts. So, I'm going to go through steps of a standard crisis management policy, and then illustrate how this needs to be shifted to providing the same crisis assessment and care via telemedicine. So, I'm going to go through steps of a standard crisis management policy, and then illustrate how this needs to be shifted to providing the same crisis assessment and care via telemedicine. So, step one, actually, really before safety, I mentioned was, you know, some prevention work. It's also important to put this type of policy in writing, so that you are aware, if you are working as a member of a team, everybody's aware and can kind of practice beforehand. So, once you are with your client, though, and you've determined that there is some possible safety concern, step one is always to assess your own safety. So, if you're in the office with somebody, assess your own safety. If you need to leave the room, leave the room, and make sure that there is somebody sort of standing by to keep an eye on your client. If you've determined it is safe, your next step is to assess the crisis. We are really here determining if there's a need for a higher level of care, or in California, what we call a 5150, an involuntary hold. You should always consult, should always get assistance. When in doubt, get more consultation, get more assistance. So as you're doing this, keep in mind that a client in potential crisis really should not be left alone. If you're in a clinic, they shouldn't have to wait in a general waiting area if you can provide a quiet, calm place for them to be alone, that's ideal. And here you should use an evidence-based assessment tool. At SAC-EDAPT, we use the CSSRS to assess suicidality and danger to self. If you determine here through step two that there is a need for higher level of care, next step is to put together your team. So assemble your team and people should be aware of what their roles are on the team beforehand. As you do this, keep your client informed unless letting them know what's going on would potentially be dangerous to you or them. If they leave, do not physically stop your client from leaving. You can call the police or whoever the other sort of public safety authorities are where you're working. In the early stages, you should determine where your client will go. For some services, this is an emergency department. In some places, providers need to find an actual psychiatric bed for their clients. It could take a really long time. Some places there are crisis mental health services or assessment teams who can come to you. Whatever it is where you work, determine what this step is gonna be because this can take some time. So sometimes you may need a medical clearance. So this will dictate as part of your team and then also be aware if you are operating as part of some institution, there may be some reporting policies to your department, to your clinic, to your county, depending on where you are and there may be some requirements on what records to send along. As you're in this early stages, it's time to contact family members or other important supports to coordinate some releases of information, to share information with wherever this person's going. Next slide, please. Okay, so this is what a standard crisis management team looks like. Typically, and again, this is gonna shift a little bit depending on your system, but typically there needs to be a licensed staff member who can write a hold or sort of write the beginning stages of a hold, which could be written elsewhere. Typically, you need a physician if that is not the same person and one other support person. If you have trainees, this should be a supervisor. If you're not a trainee, it could still be a supervisor. Again, I think more consultation and more people is typically better. So you should have a communicator as part of this team. This is somebody to document what's going on, to fill out whatever necessary paperwork there will be, and to contact those primary supports and keep them posted. You may need a support person who can sit with the client and the family members. In our clinic, and I would suggest this for yours, we have a crisis basket, which has some snacks and water, a deck of cards. I think we have like Uno and a board game in there. Sometimes this takes a while. You wanna make this easy and comfortable. This is often confusing and scary and typically not something people want to do. You should really never leave the person in a potential crisis unattended. Somebody should be there. You'll also need a coordinator to make arrangements, make those phone calls. If you're calling an emergency service, the police, to do a transport, they need to make those calls. Sometimes you're looking for a bed. Sometimes you're prepping copies of documents to send. And often there needs to be a medical support, somebody to do vitals, sign a medical transport form, discuss these results with whoever is receiving your client or patient. So the next step, be prepared. I mentioned this before. This probably should be step sub one or negative one. Should have a written policy. Everybody should be aware. If you have some steps on what typically happens in a hospitalization that you can write in hand to family, that's great. They're typically stressed during this process and are not gonna hear everything that you have to say. And then once everything happens, you will need to debrief. So if your client is leaving, sorry, I forgot this step, you may wanna plan for discrete entry and exit. So for example, where I work, if people are transported, they have to be transported by ambulance. It's not ideal. We don't love it. This means that EMTs come in with a gurney and it's best not to have that on full display. If you can have sort of a quiet and discrete entry and exit for your client and the family member, that really reduces the stress of this really stressful day. Okay, next slide, please. As part of this, you should have a standard safety plan. So if you know that your client has a history of crises or seems to be escalating in their symptoms, this also is like a step negative one. I'm not gonna go into detail here. This is our safety plan. You can see that includes some pre-work, pre-work meaning work that you've done with your client in moments of calm to pick apart previous crises, to identify coping strategies they can use on their own. You should have one place where their plan for what happens if things escalate exists. So here, that is in the form of what people are gonna pull in, phone numbers of providers and phone numbers of crisis services, crisis teams, ways to make the environment safe. Next slide, please. Just like you, we and all of the other clinics have had to adapt this plan. So looking back two slides ago to our crisis plan, here are some suggestions for how to modify this to do it via telehealth. So the steps broadly are the same. So step one is still to assess safety, but now we're not assessing your own safety because we're in different places. Your job now is to assess the safety of whoever's in the home with your at-risk individual. And it can help here to develop some rating scales. I really like the subjective units of distress scale, sub scale, or a feelings thermometer, sort of the same thing, ways to really quickly assess how people are doing without using lots of complex words. It could be one to 10, one to 100. You really need to know when people are escalating or when hopefully people are sort of going back towards their baseline. That safety plan that I just showed you should be shared. So if you know your client is escalating, you should share that with whoever their primary supports are and work with them in how to check in with the young person and what to do as things escalate. They too should know that SUDS rating scale so that they have a quick way to assess how this person is doing. Sometimes our job as providers here as things escalate is to try to problem solve stressors. Lots of different things mount up. So again, that's where this blurring of line, blurring of lines among team members can really come into play. And if somebody is escalating as best as you can, try to check in every day, even if it's super fast or via text or checking in with the provider, with the collateral or family member who's checking in. So step two, we've come to assessing risk. Use video as possible. Sort of the most senses you can lay on the person is gonna be better. So video is better than phone, phone is better than email and so on. Check also your COVID related systems issues. So some places might have these folks come in in person. We do this sometimes, again, because just the process of coming in provides a better assessment. Somebody though needs to be aware of whatever your systems issues are. So what are the rules and regulations for your department or your clinic? Or if you're operating on your own for a place that might be receiving clients who are in a crisis. If you can see people in person again, this can take some coordination and be aware too that all of our normal workflows are totally upended. So if you have like an urgent care, a mental health urgent care or an emergency department, some of those are now only seeing COVID cases and are no longer seeing mental health emergencies. You need to know this, you need to know this ahead of time. If you're seeing people in person, do you have PPE? Is it in a convenient place and do you have it for your client and for yourself? And then again, being aware of what's going on around us. If your community has a high COVID rate, as certainly ours does at the moment that we're recording this, this again is gonna affect who goes where and also the sort of risk benefit ratio. So your threshold of tolerating the sort of risk of being with people may shift depending on what's going on in the community. Next slide please. Again, you will need to gather your team at this point. The team broadly is similar. So again, you'll need a coordinator to assess, to coordinate a response, to start bringing all of the people together. And depending on where you're sending your client, somebody may need to go somewhere. So in ideal, if it's safe, if you're sending your client and they're willing to go to an urgent care ED, can you meet them there? That's gonna help support them. Can you call ahead so that somebody knows who they are and that they're coming? If you have an emergency response team where you work, you may need to call them and again, provide some information and sort of start the process of gathering the team. You will again need a support person, somebody to stay on the phone with your client while you're doing these pieces, or if a parent or partner or other support person is at work or at school, pull them in, let them know what's going on. You may need a third coordinator here depending on how your team works to make some of the arrangements, depending on what's happening. Medical support is very different when doing this from home. So you may need that to write a possible hold, you may not. And again, be attentive to staff limitations if you're working with others. You know, we are all humans providing care for others. We may have exposure in our household. So different team members may be limited in what risk they're willing to accept. Okay, so next step as we determine where people go, this is a big change when doing this via telemed. So we're not transporting somebody, we're not holding on to somebody until somebody else comes to get them. We're coordinating a trip or we're coordinating possibly emergency services coming to your client. And again, when you're done, you'll need to follow up and debrief. Okay, next slide, please. I really wish we could be having this presentation in person. So we had really hoped to have a nice discussion here today. If you're watching this at home, I would invite you to take just a really quick moment to think back to March, March of 2019, about what your fears were about transitioning to remote care. So as COVID was starting, what were the things that you were really afraid of? And it's very interesting because what we're discovering and what I think many clinics and services are discovering is that some fears have been accurate. And some has really not borne out or things have come to pass very differently. So this is an image from back in March. This, I know, at least in our team, is what we really feared. You know, we saw these really heartbreaking images and footage of systems and people in crisis of hospitals and EDs and intensive care units really overrun and sort of thought that it was our goal to do whatever we could to not contribute to these large numbers and keep our people at home. So we really had this fear that we were going to have clients and families in crisis and we were gonna be working really hard to manage this crisis at home. Luckily, in many places, this has not been the case. Sadly, in some cases it has. We have really identified some common worries though and some things that have gone much better than we thought. So next slide, please. To illustrate this, I'm gonna really quickly show some data from our SACUDAP clinic and then I'm gonna hand things over to Dr. Lowy. Next slide, please. So I know back in March, one of our biggest fear was not only would we be managing crises at home, but we were really scared that our clients and families would sort of flounder at home, fall off the radar, really struggle to keep people engaged. And I'm gonna show some data here that is looking at April through August of 2019 compared with April through August of 2020. In the next couple of slides, these are sort of gonna be on top of or next to each other. So at SACUDAP, we actually, one of our findings that seems to be consistent with what colleagues are writing about or what we've heard from colleagues is that the transition to telemed happened much more easily than we really feared. So looking at our data from last year, you can see in our clinic, we were primarily providing services in person or over the phone. Literally almost no video visits and some portion of our visits were done in the community. So we would meet people someplace, school or at home or at a work site. Looking at the same period from 2020, you can see almost a complete and very quick transformation. So about three quarters of our services being done via telemed, literally with a camera and the other quarter over phone. And this has been consistent from what I've seen of other clinics. Now, this is another area, as I mentioned before, where barriers are disproportionately spread out. And so lower SES families who may have inconsistent internet or use their phones or perhaps have no private place in the house to take a phone call, parents who are working from home, other siblings in the house, or even on unstable housing, of course, makes it difficult to do any of this. Next slide, please. So our other major fear was that our clients would disengage. We would lose track of them and that they would be managing crises on their own and we wouldn't actually be able to help. What we found here, and again, this seems to be pretty consistent, is we had a bit of a decrease in our census, but not as large as we thought, with a couple of very interesting patterns of shift. So these two figures you can see in the blue are some data of patients served and number of visits by month from March until August. And you can see our means here. Very interesting pattern here. So broadly speaking, overall, we were about 10%, 13% actually down in overall visits. A bit down, not a ton. Our census, which here you can see it sort of hovered around 75 last year, that's by design, that's our target in our clinic, down about 10%. But interestingly, with these two paths, roughly similar except for over the summer. And that's a theme I'm gonna highlight here in the next set of slides as well, with this interesting sort of seasonal pattern. So in clinics like ours, in many mental health clinics that treat youth, there is a sort of standard spring, summer, fall pattern, where as people who are in school start to move towards the summer, there is a sort of flurry of services to try to get connected before school's out. And then typically what we see is as the stress of the new year, the new school year sets in in August and September, there is sort of another bump. There is a fall bump with another flurry of referrals as the stress mounts, or as people who have maybe had some escalation over the summer, now again, come in contact with people who are in the position to notice. Next slide, please. In order to break this down, I have a couple of slides here showing two things. First, I think our other worry was that no-shows would skyrocket. And in fact, this is not what we found. And actually does not seem to be what most clinics are finding. No-shows are not really a problem. We're up about 10%. You can see in looking at these slides that there was a really high rate of no-shows early on in the pandemic, as people sort of adjusted to the new normal and figuring out how they would connect. But then broadly, our patterns are pretty similar to 2019. Intakes, however, you can see there is a consistent gap across time from March to August. So to try to understand what might be explaining this in ways that I hope are helpful for you in finding your clients, figuring out who is most at risk of crisis. We see sort of an interesting breakdown. So for us, intakes overall have been about 30% lower in 2020 compared to the same period of time in 2019. So for us, this looked like 10 a month going down to about seven. And referrals coming in are also down for us 17%. So this was from about 30 per month to about 25 per month. Interestingly, it seems that the shelter-in-place order has really shifted who is making the referrals. And this is really based on who our young people are interacting with. So on the right here, we've broken down our sources of referral into what we typically get. And there are a couple of trends I'd like to highlight because they're probably similar to the trends that you're seeing. So first, and if you can click the next slide, it'll highlight some different elements of this figure. So first is community mental health. 2019, you can see, is on the left hand of this figure. 2020 is on the right hand. So we see this sort of typical pattern of other community mental health agencies referring young folks to us with, again, the same sort of pattern of a big burst in the spring, decrease in the summer. And interestingly, we did not see that same trend this year. Probably this is because the spring is when we were all figuring this out, and people were really disconnected from providers. In contrast, if you can click again, we saw a major shift in referrals coming in from the ED, from emergency rooms, from our crisis stabilization units in the hospital, with almost two-fold increase. So this is really demonstrating that people are coming to us much more frequently after they've experienced a crisis than before. So they're not getting referred to the services that might be in a position to prevent a crisis. Really, they're finding us much more frequently after it's already happened. You can click the next again, please. Interesting trend here, if we're looking at referrals, again, this is young people who are perhaps experiencing serious mental illness for the first time. So in 2019, we saw a large number of referrals, you know, in a significant proportion coming from schools. In the spring, in the lead up, our students are not in schools. They're not having the same kind of direct contact with teachers or guidance counselors. So these have almost entirely dropped off. These are the people who are perhaps in the best position to identify signs of risk of crisis. And then looking at the next group, if you could click again, please. Similar trend here for primary care, for doctors. We're not going in to see our primary care providers. So those people also are not in the greatest position to provide referrals. If you can click again, we're lucky in Sacramento that we have a centralized access point for a lot of our services. So while we had very few self-referrals in 2019, you can see a huge increase in self-referrals in 2020. So families who are identifying some form of crisis, doing their best to find the resources themselves. Okay. You can go to the next slide, please. Okay. And this is sort of other. So with that, I will hand things off to Dr. Lowy. All right. Thank you. So this is a good time to follow our own advice and for everyone to take a minute, maybe stretch, or if you're watching after the fact, pause, get up, take a break, come back. Because this is the Zoom fatigue that we were talking about. So I'm going to talk a bit now about remote assessment services. And I'm going to take the same approach as Dr. Shapiro, talking first about what is the gold standard approach, and then how might you adapt it for remote work. Next slide, please. So we'll talk about evidence-based assessment approaches for early psychosis, strategies for integrating them into programs, a little bit on screening for early psychosis, then thinking about some cultural considerations, remote adaptations, and thinking a bit about the future of remote assessment. Next slide, please. So there are multiple goals of assessment when we're talking about the context of early psychosis care. One unique feature of early psychosis programs is often that they have more rigid criteria around eligibility for the program than your typical community mental health services. In a lot of places, you might have an outpatient clinic that just serves everyone with a mental health issue within a certain age range, if you see adults or if you see kids, or in a certain catchment area. But we have much more specific criteria around a certain diagnosis or diagnoses, and then also the duration of time someone's been experiencing those symptoms that need to be assessed. So it makes for much more complex assessments. We also need to think about these difficult differential diagnoses. So often, folks referred to these kinds of programs have complex presentations. The referring source isn't quite sure what's going on, and there's a service provided whether or not that individual is actually eligible for care in the early psychosis program. So even those who, it turns out, maybe have a different kind of problem going on, the assessment and the results of that assessment can be really useful to the individual, to their families, or to the referring provider who can then maybe help that person get care in the right place. And those are diagnostic considerations that require some expertise, and so they're often not able to be done in usual outpatient care. So that's the specialty care service that early psychosis programs provide to communities. And then there's also thinking about where is the best fit for care. What are the presenting needs of this individual, regardless of their particular, you know, they may have an early psychosis diagnosis. Is this the right place for them right now? Also, you're thinking about treatment planning. So you're gathering information to help guide the plan of care. Another really important piece is engagement. So throughout this process, you're trying to gather information as a provider to help you make decisions. But one of the most important pieces is that this is a young person often engaging in care for either the first time, or perhaps for the first time in a way that they may feel fully understood. And so part of the information you're gathering, and the way you do that, and the way you provide the results to them really impacts their sense of engaging in the service, sense of connection, and what's going to happen next for them in their treatment. And then, of course, there's everyone's favorite part, all the required paperwork that is involved often in the intake process and getting someone set up for care. And so these are all different pieces that we have to address simultaneously. It's a lot going on. And it's important to remember each of these goals. It can sometimes be easy to get caught up in, oh, I have to check some boxes, kind of assessment, feeling when really, this is your chance to engage with an individual and potentially with their supports and their family members, again, often for the first time, especially when someone is in adult systems of care. No one may have asked to involve their family before. And this is a critical piece of early psychosis care. So when you off the bat involve important supports from their life, that sends a certain message that that kind of support is important. Another piece is thinking about assessment as an ongoing process. So there's lots of information we collect at the very beginning of someone engaging in specialty care. But over time, sometimes things change, or sometimes a person is more comfortable being able to share information they didn't share originally. Or sometimes as their symptoms start to improve a bit, they are able to share or remember more about things that change your diagnosis or change the results of your initial assessment. So it's really important to think of this as a cycle, right? You're doing an initial assessment, but then you've got to have plans to go back, reassess. It's more of a continuous process where then that informs what's going on with the individual. Okay, next slide, please. So here are some examples. For those of you working with the clinical high risk for psychosis population, it really does require a specific instrument to help you diagnose that syndrome, given that the diagnosis that is in the DSM currently doesn't provide adequate detail to be able to do this in a non-structured way. So the SIPs is the most common one used in the United States. It is the structured interview for psychosis risk syndromes. It has several, you see listed here, the first four items are the different diagnoses that it assesses. So the first three, attenuated positive symptoms, brief intermittent psychotic symptoms, genetic risk and deterioration, those are considered the at-risk syndromes, with the first one, the attenuated positive symptoms being, by and large, the majority of cases people see, at least 80% of most clinics find folks in that category. It also assesses whether someone has a fully psychotic syndrome, indicating some sort of threshold where the person would be considered to have a first episode of psychosis. It does assess on the structured, on the SOPS, which is a PISA symptom rating scale within the SIPs, positive, negative, disorganized, and general symptoms, although the diagnoses hang primarily on those positive symptoms. There is also a newly released Mini-SIPs that is specifically intended for individuals in clinical settings, rather than a research instrument, that may be more amenable to efficient use in clinical settings. So the positive symptoms are integrated into only three that you're assessing, and it also has more simplified ratings, so that you're thinking about whether someone is in the non-psychotic spectrum range, attenuated, fully psychotic range, and that's it. Makes it a little easier. The CARMS is a very similar instrument to the SIPs. It is used often in other countries. It was the basis, actually, for developing the SIPs, and there's very similar syndromes, slightly different format, ratings, anchors, definitions. There are ways to compare across the instruments that have been developed. Next slide, please. So thinking about structured interviews for a first episode of psychosis, often you might actually use a semi-structured interview that is more formally for DSM diagnoses like the SCID, including psychosis, mood, and differential diagnoses at a minimum to determine whether someone is having a first episode of psychosis and what that diagnosis is. You may use additional modules to cover areas that you are interested in that are very common, so you might use a substance use module. Many, many people with first episode psychosis have a lot of anxiety. There's a very large proportion who have a trauma history, so those are things that you want to assess in one way or another, just as examples, and then maybe in addition to that, other pieces that pop up for an individual person. For clinical use, there is an initial purchase, but no licensing fee. Some folks also use the Mini, which was initially developed for research but can be used in clinical settings, the Mini International Neuropsychiatric Interview. The CD, which is based on the World Health Organization diagnostic criteria, is at this point in 2020 a little bit outdated for its use, and the newest version is in development, but that is something to consider when it becomes available. Next slide, please. Next slide, please. So, thinking about the duration of psychosis, which is one of the biggest questions we have to answer when determining eligibility for an early psychosis program, right? What does early mean? So, most services will have some sort of definition, whether it is within one year of the onset of psychosis, within two years, within five years. There's differences depending on the particular program, but that's typically the range. Ideally, towards the shorter end in terms of where you might have the most impact on someone's outcomes. So, there's thinking about the eligibility of an individual. We're also thinking about fidelity to some sort of particular model, whether you are providing coordinated specialty care, and there are a number of different exact models of that. Of those differences, that's beyond the scope here, and other talks cover that, but you have the idea that you have to link the assessment you're doing to the population you are serving and to the model of care that you are providing, so there will be some differences from site to site. But the duration of psychosis prior to entry into specialty coordinated care is related to both short-term and long-term outcomes for individuals, and so that is something to consider. There's really no standard instrument for assessing that period of the duration of psychosis. There's not a standard instrument for research, although there are many that are available, and there's definitely no instrument that is standard for clinical use. However, it is something we all have to assess. Often, it's just answered on a yes or no basis. Are they within one year or not? Yes or no? Or, at best, what is the month and year that we guess things started? And there are a lot of anchors that can be used to determine that, whether it's using information about hospitalization and service history, self-report, thinking about collateral report, and using as many sources of information as you can is always important. We are working on a DUP measure, which would also serve this piece, how long have they had psychosis for entry into clinics, but that's still in development. So, in terms of self-report, internal experiences are going to be best reported upon by the individual. Often, family members are really unaware of the extent of someone's internal experiences around psychosis, unless they have informed them, but those are hard to see from the outside. However, their behaviors that often are related to whether this is over a threshold of full psychosis or not can be often reported by family members very well or other collateral informants, so that's important information. There are, of course, memory biases for both the individual, more strongly often for the individual if they have cognitive deficits, so that's something to consider as well. Records can often document diagnoses, but diagnoses in medical charts and electronic health records are there often, as we all know in practice, for different reasons and are often biased by the goals of the individual providing the diagnosis that may not always be just about being accurate, so there's a lot of stigma associated, unfortunately, with a psychotic disorder diagnosis, and often people don't want to put that in a medical chart, and so you can't rely on it in quite the same way. That's just something to consider when you're looking back at records. There's also change over time. As we all know, these are often young people, late adolescence, early adulthood. Things change. Diagnoses change. Symptoms change, and so whatever has been in records previously may have been accurate at one point in time, but it's still your job to assess what's accurate right now, and it may be different. Next slide, please. So just thinking a bit about your particular programs and what's the best choice for you, there are advantages to using a more structured instrument. There will be more validity and accuracy as well as more specificity about exactly which diagnosis the person has, more reliability. People are asking the questions and assessing them in the same way, so multiple people using the same kind of instrument are going to come up with similar answers. Sometimes it can give confidence to novice interviewers by having a bank of questions that they can use and trust to ask about these kinds of symptoms, and then there's also thinking about what kind of quality of care do we owe to the people we see in providing them some sort of answer about what's going on. On the other side, there's a lot of training and supervision time that has to be invested, and so you have to have the resources to be able to do this, and it is about trying to get services properly resourced. There is more client burden in terms of time up front. There are costs associated with some of the instruments. Sometimes there are attitudes providers hold about another measure that I need to learn, another evidence-based treatment or practice that I'm supposed to learn when I really trust my own expertise that I've developed over time, and these instruments are not meant to contradict that person's expertise or intuition, but it does take appropriate training and how to integrate that into your ongoing practice, and then one of the biggest investments is really unfortunately around the high levels of staff turnover that plague all of public mental health, but also specialty care where the work can be intense, and often there are trainees who are learning these skills, but then once they get licensed or have other changes in their life, decide to go and work elsewhere, and then you have to do all of these trainings again with a new workforce, so there is a certain level of investment. Next slide, please. Overall, it's really about, as I've said, balancing that rigor with engagement, and I'm highlighting this because sometimes there's an impression that structured interviews are cold and impersonal and somehow take away from the engagement process, and the goal is the exact opposite, so it does require sufficient training so that someone can use it fluidly. If someone is very uncomfortable with the measure, that is when it can come off as more of a I'm checking boxes on paper rather than relating to the person, so that does take some practice. It's also important in all of this to have a strengths focus, so the instrument itself often is asking about symptoms and diagnoses, but it needs to be embedded in a process where you are also trying to understand what are the person's strengths, what are the important supports in their life. This is going to go directly into their plan of care. Identifying their goals. This is a great place for that conversation. What is going on now? What's happened in the past? And where do they want to go? What are their individual goals? So that is also something embedded here. Thinking about relationship building. In some programs, the person doing these initial assessments will also be the person providing individual care or in other cases, there are people doing intakes and then the person transfers to a different therapist or case manager and other providers. And so the role may be different, but you as the first person having contact with someone is really setting the stage for the kinds of relationships that they can expect in this program. Will they be met with respect and empathy? Will you have an individual relationship or are you a representative of the team and showing how the team is going to relate to them? So those are important pieces to really give them and their family members a welcoming experience. Next slide, please. As I've noted, there are different staffing considerations and models, the pros to having a designated person or persons doing the intakes and assessments is that they really develop some in-depth expertise. And if their primary responsibility is assessment, there's a lot more flexibility in their schedule. They don't have ongoing clients in the same amount of a caseload. Although on the other hand, then they do an in-depth assessment and hand someone over to a new person. So sometimes that people report that feels like it impacts the relationship. Other times, if you have a really well-integrated team, staff and consumers report that it doesn't feel disruptive. But again, the high impact of staff turnover means if you're one or two people who are highly trained to do the assessment leave, that's a lot of work to do for the program and it could impact your ability to take in new clients. On the other hand, if all staff are trained, then someone comes in, they stay with the same provider. All staff learn some of these skills, which then they can integrate in the treatment in an ongoing way. There's less impact of staff turnover. On the other hand, there's a greater investment in training. There can be scheduling barriers. If everyone has a full caseload, where do you fit in new intakes? So you have to think about the scheduling a bit. And then there's also variability in skills and outcomes around assessment. Everyone has different strengths as a clinician. Some people are a better fit in a way or enjoy the assessment process more than others. And so there can be some variability there. Next slide, please. A brief bit about screening, which is really something that would be implemented prior to someone coming to a service. That's really the goal of screening is to then help you with your job as someone doing an initial assessment. If there's been a screening, here's an example of a measure that we developed, the prodromal questionnaire brief. It focuses specifically on positive symptom items. It was initially designed to assess for the clinical high-risk syndrome. It can also be used to assess for psychosis in general, but it is always meant to be a two-stage process. It is not diagnostic. None of the screening measures that are out there are meant to be paired with one of the kinds of semi-structured interviews that I mentioned, like the SIPs or potentially a SCID. This example asks about some low-level experiences of attenuated positive symptoms, whether they've experienced them, and then how much distress or impairment is caused by that experience, which is really critical when understanding the difference between an experience and a symptom. So psychotic-like experiences in a young adult adolescent population are actually quite common. If they are in isolation and they don't cause distress or impairment, then it's not a problem and it's not a symptom. But when that experience causes someone to be scared about themselves, changes their behavior, impacts their functioning, then it's something that they deserve help with. When we have used this screening measure in a catchment area, it does identify twice as many individuals with psychosis spectrum conditions compared to clinical judgment alone, which is important to note. So what that means is there are a lot of folks who would meet criteria for an early psychosis program but are not being detected when they're in regular outpatient mental health care. And we know this from lots of the literature on the duration of untreated psychosis and pathways to care. One thing to keep in mind is that the measure was designed to be more sensitive than specific. And what that means is that it is meant to capture as many people as possible but carries a high false positive rate. The idea being we want to make sure we capture as many of these folks who would otherwise go unidentified. And then the next step of the interview process can help to identify, okay, who really needs this service and who has something else going on. It's meant to be in that two-stage process. That is the goal of the way it was designed. So that's something to understand. If you use it, you will get a higher number of false positives than you might expect because that is the way it was designed. You can use different thresholds for different settings. You do need to think about the balance of resources if you're doing lots of assessments with folks who are these false negatives or false positives in a sense. Then you do need the staff who can assess them. That's where a very useful and intensive phone screen can help screen out people who otherwise need many hours of an actual individual assessment. It can be done on paper, it can be done on electronic tablets, on smartphones, and it's being done online with a number of organizations. Next slide, please. I'd like to talk for a minute about cultural considerations in assessment. So if you're not familiar with it, I highly recommend taking a peek at the cultural formulation interview that was designed to go along with the DSM-5. It has a nice way of approaching an individual's experience embedded in context. And what that means is asking the person what is the meaning of these experiences to you? What is the meaning of these experiences to your family? What is the meaning of these experiences to your community? Because those can all be barriers or supports to their recovery, and it's important to understand these different perspectives. It also gets at this idea of the symptom versus the experience. What is the interpretation of the experiences? Who is distressed by them? Is the individual distressed by them? Is it the family? How does the community look at these, a broader family group look at these experiences? It can also help think about some of the power dynamics and cultural considerations and experiences of discrimination that have been highlighted in 2020 and only made worse, unfortunately, by the COVID pandemic in really demonstrating the structural inequities that are faced by a lot of Black Americans, other minorities in the United States. So thinking about that context is, of course, very important. For example, one of the most common differential diagnoses that we get asked by people referring a client to a specialty care program is the question, is it trauma or is it psychosis? That's a very common question that community providers ask, and the answer, of course, is it doesn't have to be either or. It is often both. So someone who has experienced discrimination may be suspicious. Someone who has been in a community where they have been exposed to violence may have very real concerns about safety, and they can also have emerging psychotic symptoms, and it takes some expertise to tease that apart. You wouldn't want to make assumptions either way. So that's just something to consider. These are questions to be asking whether you use this formal particular tool or not. Next slide, please. So the main point of today is thinking about how do we take some of these gold standard approaches and adapt them to remote assessment. We're talking about this in the context of this COVID pandemic, and as Dr. Shapiro nicely laid out, there's a long history of the development of telemedicine that has now really taken root, but this will also be relevant after the pandemic is over. It will be relevant when serving people to meet them where they are, just because it is more convenient for them when you're trying to serve remote populations, when you are trying to provide services, but you don't have an entire coordinated specialty care team in one location. These are all relevant. These are things to think about. So number one is flexibility. So being flexible about whether you are seeing them in clinic, in home, by phone, by video, thinking about being able to change as necessary for different pieces of the assessment, however you need to do it to get things done to whatever the person is able to do at the time. Thinking about preparing ahead. So often at this point, many people who have received medical services during this year are used to remote assessment of some kind. Primary care is often video visit first. If they're being referred from some other mental health care, they've done this before. However, if this is the first time they're getting any kind of care, they may be new to this. And so really helping set their expectations. What do they need to do to prepare? How do they set up a private location to be able to talk to you about sensitive information? Who else would be around? What kind of internet connection do they have? Are they able to get, does it need to be done by phone? This is where I'll talk a bit more later about the impact of the digital divide, really, in who has been able to benefit from telemedicine the most and who is still unfortunately underserved. So simple things like making sure that they're using headphones or earbuds or something for private information. Often when you're using video platforms, Doxy, Zoom, whatever it is that you're using through your clinic, there's often a way to call in by audio on your phone, even if you're using video so that at least the audio isn't interrupted by internet problems or everyone being at home, homeschooling this year and distance learning. So that's something people are working from home, studying from home, things to consider. Having backup options and potentially in the long term when this is really about assessment in remote areas, there could be a specialty care team and this is done sometimes where the person comes into some sort of centralized location that is not about specifically early psychosis care to meet with the early psychosis care team remotely. At the beginning of each session, which is also relevant, as Dr. Shapiro talked about, to crisis assessment, it's important to find out who's at home right now, what's going on in the home, what's the context of what's happening, just so you know who's expected to walk through the room. If you do begin to assess any risk of danger, as Dr. Shapiro mentioned, or history of maltreatment that someone's experienced, don't forget the perpetrator or the abuser could be in the house at that time and it's something that we need to be aware of. Talking to people about those issues is something you can do in a standard way with everyone, even though sometimes in some cases people may not be able to respond as freely as they would if they were seeing you in the clinic by themselves. A lot of times you can still use some sort of electronic signature to be able to talk to collateral informants or get records. Those are still really critical in understanding what's going on with someone. Needing more frequent breaks. So when you've had someone come all the way into the clinic, you often try to pack in as much as you can while they've made this trek and here now you have different options. Often people can't tolerate much more than a little bit of time. That's fine. Meet for 20 minutes, take a break, come back, hang out while the person takes a walk around, have them walk around with their phone if that's what they need to do. You actually have in some ways more options where you can be talking to them while they're walking around the block outside if they're comfortable with that and there's enough space, again, privacy considerations, keeping that in mind, that you can't do as easily sometimes in the clinic. So that's actually something to remember and you can be creative about. Some negative symptoms, obviously, cannot be fully assessed by phone and are even tough by interview. So even right now, you can't really see as much of my body language when you're looking at motor symptoms or movements. That's something to consider. There's really, unless you can get video or an in-person assessment, you really just, those are some things you're not going to be able to assess as well. You can ask informants and a self-report for those kinds of things is often unreliable. You can ask, but you just sort of have to accept this is something we know a little less about. The impact on rapport is really important to acknowledge. So it's in some ways, especially for young people, easier to open up over phone or video or in some way that's not live in person, face-to-face, staring with eye contact, because generationally, that's something they're more comfortable with. People with negative symptoms, that may be something they're more comfortable with. At the same time, the rapport and the connection isn't the same. They don't have a feel for you in the room. You don't have the feel for them. And especially for people who have blunted or flat affect where the emotion is not expressed on their face as well, when that's all you're seeing and you don't have that interaction in the room, it may be more difficult to pick up on what they're really feeling. And that's part of it. That is a downside. It's not always problematic, but in some cases that may be, and you just have to be more explicit about checking in with them about how they're feeling, which is always important to do throughout an assessment process, but even more important when you can't rely on some of that body language or other feeling in the room to know how they're doing and checking in on their stress levels or anxiety or fatigue. And again, important just to note that and say, okay, we're aware this is going on. We'll do the best we can. Some people, especially at the beginning of the pandemic had a much more difficult time with the kind of warm handoffs that are ideal for connecting people to other providers or receiving them from other services. So being able to go to the school physically where a young person has been seeing a school counselor is comfortable. Maybe the family has been to the school. They're comfortable going there. Starting the relationship and the assessment that way is much better than expecting the family to then come to the clinic. There's a lot of dropout that way for all services. We can't quite do that in the same way, but that doesn't mean that with permissions, you can't also add that person. You can join a video chat or a phone call with someone they're more comfortable with and vice versa. So those things are absolutely possible. We just have to think a little creatively about it. Next slide, please. So the question is, what is the impact of all of this telehealth? What is it gonna look like in the future? So we do know it's absolutely feasible. There were a lot of concerns that it wouldn't be. And now we know for sure that it is. There are clear applications where it is more helpful. People who can't access in-person care or don't want to for some reason. Remote and rural populations. When you have staffing training or expertise gaps, there can be a way to complement what your team can provide by bringing in someone who can cover a particular gap by just doing this remotely. It opens up these different possibilities. In some cases, it is easier to access and can circumvent some challenges where people may have difficulty accessing care due to barriers faced by themselves, their families, simple things like logistical barriers, transportation or stigma. They may not need to rely on a family member to drive them somewhere. They can seek care themselves. All of those things are possible. As Dr. Shapiro mentioned, it's not actually true that crises increase. Although as he noted, often people are getting into care now post-crisis rather than prior to it in the way that early psychosis care is really intended to prevent the development of more severe symptoms or experiences. Clearly, it's acceptable to the early psychosis population. Next slide, please. Some of the challenges and unanswered questions is this sustainable in a number of ways? There are emergency payment systems set up so that you can provide this, but will those continue? What do the outcomes look like? We really have no idea, right? What are the long-term outcomes or even really short-term outcomes of telehealth versus some other kind of in-person intervention? What do we lose by not being in person? We've talked some about that. How do we link families to other services and engage them when they are referred? There are lots of impacts on the system as a whole because of COVID, and it can be hard at this point to tease apart what is related to the pandemic and what is about telehealth. We'll see over time which pieces turn out to be sustainable and which pieces need some adaptation. How do we reorient traditional referrers to assess and identify concerning signs and symptoms when teachers are only seeing their students through 20 kids on a Zoom screen? We already know that referrals for child abuse have gone down. We might hope that that means the actual rate of abuse has gone down, but that is doubtful. So a lot of things aren't getting picked up in the same way. The same thing is true about substance use and domestic violence. So those are things that we have to consider. What are we missing? And then the biggest piece, which everyone has probably noticed at this point, is the impact of the digital divide in the United States, at least. So access is very different. Private healthcare systems are seeing everyone through telehealth video technology, very satisfied. Lots of people have access, good computers, good Wi-Fi, whereas lots of families who don't have that same access, and as Dr. Shapira mentioned, are already typically underserved, really aren't able to connect as easily, and that's impacting them. So that's something that we really need to think about. And as he raised rightly, what is the health system responsibility to investing in technology access for the consumers that we are serving? Next slide, please. So thank you for your time and attention. I know that we have gone a little bit long. We hope that that has been useful to you. And thanks very much to SMI Advisor and the National Conference on Advanced Intramuscular Psychosis Care for having us. Thank you.

Dr. Daniel Shapiro

Rachel Lowy

National Conference on Advancing Early Psychosis Care

Remote care

COVID-19 pandemic

Underserved populations

Telemedicine development

Crisis care

Evidence-based assessment measures

Telehealth

Remote assessment services

Rural populations