New Tools for Implementing Evidence-Based Care for Serious Mental Illness

Serious mental illnesses, including schizophrenia, bipolar disorder, and recurrent major depression, are debilitating and costly mental disorders that present significant challenges to patients and their families as well as to the health care organizations responsible for the care of these patients (1). Occurring in approximately 4.2% (11 million) of adults in the United States (2), these disorders account for the majority of patients treated at outpatient public mental health clinics. A number of evidence-based treatments for this population support recovery and improved quality of life (3–7). For example, clozapine improves symptoms in many patients with schizophrenia who previously have not responded to treatment (8); individuals with a psychiatric advance directive are more likely to report feelings of autonomy and empowerment and are less likely to require coercive interventions during mental health crises (9–11); and vocational rehabilitation programs such as individual placement and support allow up to half of patients to return to competitive employment (12). Despite the effectiveness of these strategies, most people with serious mental illnesses who need these evidence-based practices do not receive them. Roughly one-third of adults with serious mental illnesses in any given year receive no mental health services at all (13). Outcomes for those receiving usual care are much worse than for those receiving state-of-the-art protocols, with higher rates of relapse and higher risk for homelessness, hospitalization, incarceration, and premature death.

Efforts to improve the quality of care for those with serious mental illness have been modest at best (14). Evidence-based services are often not provided at all or not provided with fidelity, and when they are provided, they are often underutilized (14). Furthermore, across care settings, facilitators of service delivery are absent or underutilized. This includes underutilization of mental health peers in care delivery, low adaptation of novel delivery modalities such as telehealth, and few incentives to work with populations with severe and treatment-resistant illness. Improving care is a major undertaking, and innovative and comprehensive approaches are needed.

A New Model for Technical Assistance and Supporting Clinicians

The Substance Abuse and Mental Health Services Administration (SAMHSA) is one federal agency that works to reduce the impact of substance abuse and mental illness, supporting the field through numerous initiatives and practitioner training programs, including a continuum of training and technical assistance programs. SAMHSA funded an initiative to address national issues in delivery of evidence-based practices for those with serious mental illness. This Clinical Support System for Serious Mental Illness (CSS-SMI), also known as SMI Adviser (www.SMIAdviser.org), began in July 2018 with the mission of advancing the use of evidence-based practices and a person-centered approach to care for people who have serious mental illness. SMI Adviser is focused primarily on addressing barriers at the provider and clinician level, but it also provides access to resources to those living with a serious mental illness and their families.

Unlike SAMHSA-funded technical assistance centers which have focused on supporting grant recipients, SMI Adviser offers technical assistance in the form of educational training events, on-demand consultation, and access to hundreds of resources applicable to front-line clinicians caring for those with serious mental illness.

Early in the project launch, a national quantitative needs assessment focused on serious mental illness was conducted with front-line clinicians and staff to identify and prioritize workforce knowledge and skills deficits. A second needs assessment was conducted with state behavioral health authority administrators to understand knowledge gaps and technical assistance needs at the state level. These data informed the development of initial SMI Adviser educational initiatives and resources made available to clinicians. An organizational taxonomy was developed and aligned with the domains identified by the Interdepartmental Serious Mental Illness Coordinating Committee to serve as a guiding framework and further identify areas of need (2).

The technical assistance offered by SMI Adviser is led by a Clinical Expert Team (CET), a group of national experts in serious mental illness from psychiatry, psychology, psychiatric nursing, patient advocacy, and peer support services. Together, the CET members have expertise in implementation science, clozapine, measurement-based care, Web/mobile technology, recovery-driven care models, and patient-centered care delivery. Representatives from more than 20 national mental health organizations serve as content partners and provide guidance via an advisory board. All services are free and can be easily accessed at www.smiadviser.org on laptops, tablets, and mobile devices.

To date, there have been 130,933 unique website visits and 13,702 visitors subscribed to the SMI Adviser newsletter, which alerts subscribers to new training opportunities, consultation availability, and new resources recently added to the SMI Adviser website. All SMI Adviser technical assistance can also be accessed through the SMI Adviser smartphone application (app) available in the Apple app and Google Play stores. The app has frequently used rating scales (e.g., nine-item Patient Health Questionnaire, seven-item scale for Generalized Anxiety Disorder) that are immediately scored and interpreted for ease of use in session.

Training events for clinicians have included, to date, 161 unique accredited events, available live (www.smiadviser.org/calendar) and on demand (www.smiadviser.org/education). Accredited 1-hour webinars on hot topics are delivered almost weekly. Recent webinars have been on topics such as new changes to use of the clozapine Risk Evaluation and Mitigation Strategy; taking a systems approach to suicide prevention; and implementing assisted outpatient treatment. Twelve-week learning collaboratives allow small cohorts to delve into a specific topic and emerge with practical tools to take back to their workplace. Recent collaboratives have included “Treating the Whole Patient: Addressing the Physical Health Needs of Individuals With SMI” and “Infusing Quality Improvement Into Your Peer Support Program.” Across all events to date, 21,027 individual clinicians have been trained and 17,060 credit hours have been claimed by psychiatrists, nurses, and psychologists. Accreditation will be offered for licensed clinical social workers starting in November 2020. Participation in the training events has been across all 50 states, the District of Columbia, and Puerto Rico. Training events are rated highly by learners. On examining 33,702 course evaluations, we found that 96% agreed that the “course was relevant to my practice” and 98% agreed that the “quality of the course was excellent.” On average, learners have participated in two training events, further indicating the applicability and quality of the offerings.

Consultation to clinicians is delivered on demand through the website (www.smiadviser.org/submit-consult) and live at conferences and other events. Responses occur within one business day, and requests have increased since COVID-19 stay-at-home orders, when access to expert colleagues has been more limited. To date, SMI Adviser has responded to 217 direct consultations (received through the website) and 615 indirect consultations (addressed in person at meetings, conferences, and presentations). Of the direct consultations, the top three topics have been focused on (in order) clozapine, schizophrenia, and suicide prevention and crisis management. Consultations have been received from psychiatrists, psychologists, nurses, social workers, peers, and mental health administrators. SMI Adviser also offers in-depth consultations to organizations that want to tackle larger quality improvement issues for care. Topics have included metabolic side effect tracking for use by nurses, brief behavioral interventions to be used by counselors, and guidance on safety considerations to be used for home visits.

Peer-Reviewed Rigor Applied to Just-in-Time Learning Needs

Thousands of evidence-based resources exist to help clinicians implement evidence-based care; however, the quality of these resources and the density of the material often becomes a barrier to utilization. SMI Adviser has applied a peer review approach that vets resources and creates a brief abstract of key points that are most relevant to frontline clinicians.

Resources for clinicians are vetted by the CET, and if deemed relevant to caring for those with serious mental illness, evidence-based, and current, the resources are made available to the field via the website (www.smiadviser.org/knowledge). To date, a total of 801 resources have been vetted, and 594 (74.2%) were selected by the SMI Adviser CET for inclusion in the website’s Knowledge Base. Each resource made available has a short thumbnail summary and is tagged with key words so that it can be identified through a search. Resources are also gathered by topic and are presented together so that clinicians can easily scan resources within a topic of interest. Resources are constantly updated; some current topic areas of interest include manualized psychotherapies, collaborative care/integrated care models, comorbid substance use disorders, and forensics.

Resource selection and development is prioritized on the basis of real-time user data. SMI Adviser is supported by a sophisticated data management system that collects usage of the technical assistance in real time. For example, these data identify areas of interest and use by the field (e.g., highly accessed resource topics; high attendance of a training event), evidence-based topics for which there are a limited number of resources available (e.g., high levels of consultations requested), and areas of the country engaged in learning (e.g., high number of learners by state or SAMHSA region). These data allow SMI Adviser to be agile and responsive to the needs of the field. This has led to at least three topic areas for training, consultation, and resources: psychiatric advance directives, clozapine and long-acting injectables, and COVID-19.

Advancing the Field With an Emphasis on Key Topics

Psychiatric Advance Directives (PADs)

A PAD is a legal document that allows an individual to state preferences about treatment to be used during a mental health crisis. A PAD is also called a crisis plan. Needs assessments have indicated that most patients would like to establish a PAD if they could receive help completing the paperwork. Unfortunately, many providers are unclear as to how to assist in establishing a PAD and are unaware of their state’s laws pertaining to PADs. An important part of person-centered care (9), a PAD can enhance the therapeutic alliance between individuals and those on their treatment team (10). It can improve continuity of care. In the case of a mental health crisis, a PAD may lessen the trauma of the event; evidence indicates that individuals who have a PAD are more likely to feel their personal needs for mental health services are met (11). SMI Adviser offers training opportunities to understand and facilitate completion of a PAD, including state-by-state laws and directives. Additionally, SMI Adviser has developed an app for smartphones and iPads, called My Mental Health Crisis Plan, which leads an individual through establishment of a PAD (www.smiadviser.org/padapp). An accompanying facilitator guide supports the app.

Clozapine and Long-Acting Injectables

A Clozapine Center of Excellence (www.smiadviser.org/clozapine) and a Long-Acting Injectables Center of Excellence (www.smiadviser.org/LAI) have been established by SMI Adviser to provide guidance in the use of these medications. These evidence-based treatments are underutilized by the field. The centers provide technical assistance through trainings, consultations, and clinical tips. Across the two centers, 6,388 clinicians have been trained through webinars, modules, and live trainings, and 93 clinical tips are available, including practical guidance on starting or switching medications, administration and monitoring, management of side effects, and other challenges. There is an active LISTSERV associated with the centers, with 278 current subscribers.

COVID

The public-sector behavioral health system has been experiencing unprecedented changes related to the COVID-19 pandemic. Face-to-face delivery of care is being replaced by telehealth services across a range of inpatient, residential, and outpatient settings and practices. Prescribing of psychotropic medication is shifting away from use of modalities requiring in-person visits, and federal agencies have relaxed requirements around prescription of medications, including clozapine. Many community mental health providers are facing financial shortfalls due to reduced visit volume and state budget cuts. Although this landscape is evolving rapidly, it appears increasingly evident that many of these changes will endure, which will have major implications both for mental health clinicians and for service users. To support the evolving impact of COVID-19 on the field, SMI Adviser has gathered technical assistance in one place (www.smiadviser.org/covid), including educational opportunities, trending questions, guidelines and tools, patient handouts, and information from the Centers for Disease Control and Prevention. Highly attended recent educational opportunities, which are now available on demand, focus on laws pertaining to telepsychiatry in the era of COVID-19; tailoring service delivery to assertive community treatment teams, group homes, and supportive housing; and caring for the public and ourselves during COVID-19. Highly utilized tools include an infographic for individuals with serious mental illness on how to prepare for a telehealth visit and a primer for clinicians to identify the various types of telehealth visits and associated billing codes.

In summary, SMI Adviser is a novel initiative, sponsored by SAMHSA, to address gaps in care for people with serious mental illness through the support of clinicians implementing evidence-based, patient-centered care. Improving the quality of care for serious mental illness nationally is a tremendous undertaking. Passive diffusion of guidelines through published articles and systematic reviews has had little impact on the field (15). Instead, SMI Adviser recognizes that the field needs easy access to vetted materials, on-demand consultation, and free accredited learning offered on a regular basis if quality of care is to improve. Topics need to be timely and practical. SMI Adviser offers targeted, career-long education and technical assistance for clinicians. All clinicians should be encouraged to access the services of SMI Adviser through its website or mobile app and join the efforts of others supporting the needs of patients with serious mental illness.