The Results of a Coordinated Specialty Care Program and a QA with Dr. Ilana Nossel
We caught up with Dr. Ilana Nossel to discuss her exciting new Psychiatric Services article, “Results of a Coordinated Specialty Care Program for Early Psychosis and Predictors of Outcomes”.
Within Columbia Psychiatry, Dr. Ilana Nossel is the medical director and co-associate director of OnTrackNY, nestled in the Center for Practice Innovations (CPI) at the New York State Psychiatric Institute (NYSPI), and an assistant professor of clinical psychiatry at Columbia University Irving Medical Center (CUIMC).
Columbia Psychiatry: Help us who are not experts understand the significance of your new article, “Results of a Coordinated Specialty Care Program for Early Psychosis and Predictors of Outcomes.”
Dr. Nossel: Within the past 5 years there has been a rapid expansion across New York state and throughout the country of a new treatment model called coordinated specialty care (CSC). This model focuses on young people who have recently experienced the onset of a psychotic disorder, such as schizophrenia. OnTrackNY is a type of CSC that provides a multidisciplinary team approach to treatment, including medication, psychotherapy, support with school and work, case management, and family support to help young people recover from psychosis, stay on track, and meet their goals. This is the first report in the U.S. of outcomes of CSC provided to individuals in the community, outside of a research context.
Columbia Psychiatry: How did you become involved in this study?
Dr. Nossel: I had the powerful opportunity to work with young people and their families as the psychiatrist on the Washington Heights CSC team during the RAISE Connection Program study, when it became one of the first OnTrackNY teams. Working with young people in this critical time after developing a psychotic illness was the most inspiring work I have ever done—helping people to achieve their goals and move forward with their lives after receiving what I had been trained to think of as a devastating diagnosis. I saw firsthand the powerful impact of this new, team-based approach. I now serve as medical director for OnTrackNY and it is of critical importance to us, and the NYS Office of Mental Health who funds and supports this program, to understand the impact of the program for participants. This is why we undertook this study.
Columbia Psychiatry: Briefly describe the methods and key findings.
Dr. Nossel: In this study we use de-identified data that had been collected for quality improvement and fidelity monitoring purposes to examine the outcomes for young people enrolled in OnTrackNY. Clinicians provided reports on patients every three months. We found that participation in school and work increased from 40% at the time of enrollment to 80% at 6 months, and this rate was sustained over a year. In addition, hospitalization rates decreased from 70% in the 3 months prior to enrollment to 10% per quarter following enrollment. Symptom scores and social functioning improved significantly as well.
Columbia Psychiatry: What is significant and/or novel about the findings? Did the findings surprise you at all?
Dr. Nossel: What really stood out to us were the high rates of engagement in school and work. Traditionally individuals with schizophrenia and other psychotic disorders have high rates of unemployment and disability. Our finding that 80% of OnTrackNY participants enrolled in school or work is striking and demonstrates the success that CSC can have in helping young people remain on track.
Columbia Psychiatry: To piggyback on the last question, what are the implications of this report?
Dr. Nossel: This study helps to further solidify CSC as the standard of care for young people with the recent onset of a psychotic illness. We have demonstrated that with strong state support, CSC can be implemented with great success in the community outside of a research context.
Columbia Psychiatry: Where does the implementation go from here?
Dr. Nossel: We have the unique opportunity to collect data as part of the program implementation and evaluation—this is not traditional “research” but instead learning from real-world implementation. We are working to enhance the program, for example, by adding a component to address cognitive health. In addition, we are interested in learning whether the positive benefits from CSC are sustained following discharge from the program and what is the optimal length of time for individuals to receive CSC.
Columbia Psychiatry: Why do you think CSC is so successful?
Dr. Nossel: I think CSC’s success is due to the coordinated team approach and the focus on individual’s goals and preferences, family involvement, and supported education and employment. Often young people with psychosis or schizophrenia may be hesitant to engage in treatment or may not believe they have an illness—the CSC approach is to meet people where they are, use a shared decision making approach and to help people to achieve the goals that are important to them.
Columbia Psychiatry: What is next on the docket from your team?
Dr. Nossel: We are using the de-identified data that has been collected to answer additional questions, such as examining the pathway to care to understand how best to shorten the time from the onset of psychosis to enrollment in OnTrackNY, since we know that outcomes are best when the duration of untreated psychosis is minimized. In addition, we are collaborating with colleagues to study how to optimize medication for individuals with a recent onset of psychosis, are creating a video game as a novel way for individuals to learn about psychosis and recovery, and are studying how best to train providers in the CSC model.
Columbia Psychiatry: Is there anything else you’d like to highlight about this important new article?
Dr. Nossel: This study is possible because of New York State’s commitment to supporting data collection. We built data collection into the rollout of the program statewide. Collecting data allows us to engage in quality improvement, provide feedback to our teams so that they can improve the care they provide, monitor program fidelity so that we know that the dollars spent are going to high quality services with meaningful impact, and allows us to answer important questions such as those explored in this study.
The authors of “Results of a Coordinated Specialty Care Program for Early Psychosis and Predictors of Outcomes” are: Ilana Nossel, M.D., Melanie M. Wall, Ph.D., Jennifer Scodes, M.S., Leslie A. Marino, M.D., M.P.H, Sacha Zilkha, Ph.D., Iruma Bello, Ph.D., Igor Malinovsky, Psy.D., Rufina Lee, Ph.D., Marleen Radigan, Dr.P.H., Thomas E. Smith, M.D., Lloyd Sederer, M.D., Gyojeong Gu, M.P.P., and Lisa Dixon, M.D., M.P.H.
Dr. Nossel, Dr. Wall, Ms. Scodes, Dr. Marino, Dr. Zilkha, Dr. Bello, Dr. Malinovsky, and Dr. Dixon are with the New York State Psychiatric Institute, New York. Dr. Nossel, Dr. Wall, Ms. Scodes, Dr. Bello, Dr. Malinovsky, Dr. Smith, and Dr. Dixon are also with the Department of Psychiatry, Columbia University Medical Center, New York. Dr. Smith is also with the New York State Office of Mental Health, Albany, where Dr. Radigan, Dr. Sederer, and Mr. Gu are affiliated. Dr. Lee is with the Silberman School of Social Work, Hunter College, New York.
The authors report no financial relationships with commercial interests.