Presenters:
Stephanie Cameron, Division for Behavioral Health, DHHS
Dr. Kim Livingstone, Plymouth State University
Transcript:
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Michelle Wagner, NAMI NH (she/her): Good afternoon, everyone. We’re going to just take a few seconds and let people join us for the Webinar today.
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Michelle Wagner, NAMI NH (she/her): So, hello! My name is Michelle Wagner and I’m with NAMI New Hampshire working on the First Episode Psychosis Early Serious Mental Illness Initiative. Thank you for joining us for today’s webinar
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Michelle Wagner, NAMI NH (she/her): The title is Critical Time Intervention, Creating Community Connections after Hospital Discharge. Today’s presentation is being recorded, and you’ll be able to find it on the education page of onwardnh.org.
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Michelle Wagner, NAMI NH (she/her): There is a short evaluation we’re asking folks to complete after today’s presentation. You’ll also receive a follow up email with links to both the survey and the recording. This is a Zoom Webinar which means your camera and microphone are off.
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Michelle Wagner, NAMI NH (she/her): The Q&A feature is working. So, please enter any questions you have there. We’ll have time at the end for questions and answers, and my colleague, Rebecca Bennett and I will work together to get those questions answered for you as best we can
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Michelle Wagner, NAMI NH (she/her): with us today, or two individuals who can help us understand CTI Critical time Intervention. With us is Stephanie Cameron, who works at DHS as the Director of Care Transition For the Division of Behavioral Health,
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Michelle Wagner, NAMI NH (she/her): and we also have Kimberly Livingstone, who is at Plymouth State University, working as their social work program director and the assistant professor and an assistant professor in social work. We welcome you both.
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Michelle Wagner, NAMI NH (she/her): So, Stephanie, I’m going to turn it over to you to share with us about critical time intervention, and why it’s important.
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Stephanie Cameron: Thank you, Michelle. Going to share my screen.
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Stephanie Cameron: Okay. So, we’ll start with a, a, quick introduction of ourselves, and then I’ll hand it over to Kim to get us started. So, as Michelle mentioned, I’m Stephanie Cameron, I work for uh, the Division for Behavioral Health at DHS Director of Care Transitions
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Stephanie Cameron: Um, which my primary responsibility at the moment is leading the implementation of the CTI program statewide, but I am also charged with looking at how people transition through care through the behavioral health continual.
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Stephanie Cameron: I did work similar to this, uh previously in my role as an administrator for the reach one IDN, which was the uh Sullivan
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Stephanie Cameron: uh, Cheshire, and so forth regional um, and have done much of my career and program implementation and quality improvement.
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Stephanie Cameron: Kim:
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Kim Livingstone (she/her): Thanks, Stephanie. I’m Kim Livingstone. I am the Short Program Director at Plummet State University. Um, and I moved here. Um, from New York City in two thousand and seventeen um, prior to moving into academia, I worked in a Permanent Supportive Housing in New York.
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Kim Livingstone (she/her): Um, doing program management and case management with people experiencing or, um with histories of uh, homelessness and severe and persistent mental illness.
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Kim Livingstone (she/her): Um, While living in New York, I a chance to work at the Center for The Advancement of CTI with um, Dan Herman and Sally Conover, and so have been doing work with CTI um, Since 2013, so in moving to New Hampshire, had a chance to work with the district programs.
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Kim Livingstone (she/her): Um, in their implementation and have been able to continue on in the statewide iteration of CTI. So, I’m happy to be here. I’m going to lead us off. Um, thanks, Stephanie.
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Kim Livingstone (she/her): Um, So, I’m going to try to be brief. In an overview of CTI this um we’ve done this training in a day. Um, I’m going to try to give you like a twenty-minute um, information about CTI. So, the story of uh CTI starts um in the 1990’s.
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Kim Livingstone (she/her): Um, it began during a boom of homelessness that they were experiencing in the city.
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Kim Livingstone (she/her): Um, this is a picture of the Fort Washington Armory Um, which became an emergency shelter.
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Kim Livingstone (she/her): Um, and CTI started in a program much like this. In the wintertime they would put a thousand cots on the floor of the armory, and they would have, you know, a thousand people who were experiencing literal homelessness. Um, on any given night.
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Kim Livingstone (she/her): Um, and so at that time um, in a shelter uh, like this there was a team of, uh, folks epidemiologists, psychiatrist um, people working in social services. Sally Conover was one of those people on that team,
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Kim Livingstone (she/her): Um, and they were seeing people who had been placed in housing elsewhere, coming back into the shelter system. And so they were, seeing what we now know as the revolving door. Um, those people who experience homelessness often, um.
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Kim Livingstone (she/her): You know, go through um into shelters, into um, institutional settings like um hospitals incarceration, So that that revolving door.
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Kim Livingstone (she/her): Oh, I’m, thank you. Um, So
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Kim Livingstone (she/her): What they what they were seeing um, they, they could tell that there was something particular about transitions. Was this, um known as like a critical time? Was there a critical time during a transition?
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Kim Livingstone (she/her): Um, what we now know and what we knew then is that transitions are challenging. Um, People who are connected with services um, are oftentimes needing to navigate difficult service systems. Um, we know that our service systems are, are not, you know,
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Kim Livingstone (she/her): perfect Um, we also know that appropriate resources are often limited.
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Kim Livingstone (she/her): Um, folks that experience homelessness um, are often dealing with other circumstances that can make them vulnerable um to fall through the cracks. We know that um, people are sometimes um, when we talk about hospital discharge to community services.
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Kim Livingstone (she/her): They’re moving through a continuum um, of care where there is a difference in um service acuity, so they might have a high-level need and they’re transitioning to like a community-based services.
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Kim Livingstone (she/her): Um, We also know that people have complex needs and need help from different service. Sectors, and so go here for some help go here for other help. Um, And it can be difficult to bridge that gap between service sectors.
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Kim Livingstone (she/her): Um, We also know that people we work with um are often often dealing with uh complex histories where um social connections and capital um might be limited, or um, they might have had
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Kim Livingstone (she/her): bad experiences with service providers. They might have histories of trauma. Um. They might have difficulty in maintaining relationships. All of those things can kind of plan to uh maintaining connections with support during times of need.
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Kim Livingstone (she/her): Um, but what we do know is that supports um, might already exist right, and that the challenge might just be finding them. Um, and then helping people get connected to those um. So, in CTI the individual really does drive the process. We are joining with them. Um, at a particular time in their life and in their journey and in their treatment.
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Kim Livingstone (she/her): Um, we help them get connected to support
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Kim Livingstone (she/her): um, and we also know that recovery supports. We’re recovery. Supports are crucial. Um, as you’ll see in our talk today, and you might already know about CTI um, is that it is very much rooted in recovery and in the recovery movement. Um, so acknowledging that those supports are very important during times of transition.
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Kim Livingstone (she/her): Thanks, Stephanie. Um, So
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Kim Livingstone (she/her): there are a few important things about CTI um, that make it different than your typical case management.
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Kim Livingstone (she/her): Um, it is an evidence-based practice um meaning that it has been studied with randomized control trials. Um, and I’ll talk briefly about um, A few of the founding RCTS. Um, not a lot. Just one slide.
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Kim Livingstone (she/her): Um, it is designed to help people through a transition. and so, we meet people prior to transition. See them through the transition, and then um, we are working with folks for nine months following transition.
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Kim Livingstone (she/her): Um, it is meant to be a community-based model. So, CTI coaches um work in the communities where people live where they’re transitioning to. So helping people get connected to enduring supports within their home communities.
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Kim Livingstone (she/her): Um, and that’s part of how we improve continuity of care um, is by helping to see someone through the transition. So, seeing them um,
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Kim Livingstone (she/her): whether it’s in a shelter or inpatient hospital um, through that transition into their community, and then helping them get connected to support where they live,
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Kim Livingstone (she/her): and CTI is adaptable to different transitions and populations. Um. It has been implemented
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Kim Livingstone (she/her): through or four different populations and through different transitions. The three main ones where um, it has been studied most heavily our homelessness to housing, and that’s where CTI started
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Kim Livingstone (she/her): um, and then it moved into um, actually, hospital to community was next. But it’s also been studied for people who um are incarcerated and moving back into the community, so homelessness to housing, incarceration to community, and what we’re going to spend our time talking about here.
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Kim Livingstone (she/her): Um, Is the transition of inpatient hospitalization to community
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Kim Livingstone (she/her): critical time intervention is a phase, um program, meaning that it is more intensive at the beginning. We know um, about transitions is that there’s this key point.
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Kim Livingstone (she/her): Um, it does take a while to get through a transition. So it is a nine month model. It’s a time-limited model um, that starts with pre-CTI. So pre-ti starts pre-transition. So for this implementation it would be while someone is in a hospital um in an in-patient hospitalized hospital. Stay,
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Kim Livingstone (she/her): um, and then once they are discharged, they move into phase one of Cti, and that starts the nine month clock
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Kim Livingstone (she/her): um, in phase one coaches work with participants. Um,
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Kim Livingstone (she/her): on a regular basis. It’s the most intensive phase. It lasts for three months, and that is when they start um, the linking process to community supports.
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Kim Livingstone (she/her): Um, I’ll talk more about these key parts of CTI as I go along. Um, phase two, you begin um, stepping back and phasing yourself out.
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Kim Livingstone (she/her): Um, the idea about CTI is that you’re not doing it abruptly, that it is, It’s a transition. Um, and you’re transitioning through the nine months right? So, it’s a, it’s a gradual decrease in intensity over the course of nine months in theory.
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Kim Livingstone (she/her): Um, so in phase two, it’s um, known as like a try out phase. So um, ideally you’ve connected people with supports, and you’re able to try out those supports while the CTI coach is still connected. Um, and you’re gradually handing off um,
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Kim Livingstone (she/her): right that responsibility, or that um the care, the um, working with individuals, either to increase their skill to manage things more independently, or to get connected to those supports in the community. Um, that can help that person for longer than nine months.
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Kim Livingstone (she/her): Um, yeah. So
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Kim Livingstone (she/her): there are some core principles of CTI as an evidence-based practice. There are certain things about it. Um, that makes it different than um, typical case management or um, what you would normally see.
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Kim Livingstone (she/her): Um, it uses a phase time-limited approach that I just went over in briefly. Um, there is a decrease in CIT in intensity over the course of nine months. Um, It is a focused model, and you can imagine we’re working with people um, who are making transitions, and they have complex needs
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Kim Livingstone (she/her): um, complex histories and so um, and you’re doing it in a short timeframe, right? Nine months is not a long time. Um, so you are trying to focus in on the areas of greatest need um, the areas that might make them the most vulnerable to um, go back to the hospital or um, experience homelessness again.
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Kim Livingstone (she/her): Um, and so you’re focusing on specific goals. Um, and your work that you’re doing as a CTI coach is linking them to this enduring support. So the idea isn’t that you’re going to fix the problems
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Kim Livingstone (she/her): um, or cure, or um, right you’re, you’re trying to shore up support for someone so, that they can live um, as independently as possible. Um, and they can live supported in a supported way. Um, in their community um, over the long term
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Kim Livingstone (she/her): it does rely on teamwork. Um, it is not like Act where everyone on the team is meeting with one person. Um, a CTI coach does work uh individually with people on their case load.
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Kim Livingstone (she/her): um, but we do work as a team. Um, to problem solve to support each other um, teams regular team, team supervision is important. Um, to review clinical stuff that comes up.
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Kim Livingstone (she/her): Um, and then we also have a team meaning the community of practice. So, everyone who’s practicing CTI throughout the State of New Hampshire comes together on a monthly basis
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Kim Livingstone (she/her): to talk over common barriers that we’re experiencing either with implementation of the model, or in trying to help the people that we’re serving. Um, and so we really do have a network of support for CTI providers, while we’re trying to build those networks of support for our clients.
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Kim Livingstone (she/her): CTI, as an evidence-based practice sits within these other um evidence-based practices or movements. Um, And this is just a timeline. I like to show um, so you can see where Cti fits into the larger picture. Um, We had psychiatric rehabilitation and, act back in the 1970’s.
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Kim Livingstone (she/her): Um, in the nineteen eighties and nineties we had motivational interviewing harm reduction housing first and CTI,
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Kim Livingstone (she/her): and then we have the recovery movement. Um, more recently, even though 2000’s. I’m aging myself by saying it’s recent right?
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Kim Livingstone (she/her): Um, CTI is um, works in conjunction or um, like you could use motivational interviewing uh, alongside CTI. Um, you’ll see a lot of the theory of CTI is rooted in Psychiatric Rehabilitation Act.
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Kim Livingstone (she/her): Um, and really fits in well with the recovery movement.
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Kim Livingstone (she/her): There are, I, I, always. I only review very few studies when we talk about the founding evidence. Um, so, sir, um, as a sister was another um, person who was there at the beginning. Um,
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Kim Livingstone (she/her): Stephanie Cameron, and a couple of other folks um, and the initial study Randomized control trial. Um, looked at uh, homelessness to housing, and how we were able to help people with CTI as they moved out of homelessness.
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Kim Livingstone (she/her): And what they found is that there was a CTI effect. Um. Where people were three times likely to experience homelessness. Um, three times less likely to experience homelessness, and they were more connected to community support after discharge from a shelter.
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Kim Livingstone (she/her): When they were attached to a CTI worker. Um, then versus usual care.
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Kim Livingstone (she/her): Um, and then Dan Herman, who is now the um, director of the Center for the Advancement of CTI in New York. Um, He came on the scene Um, when they were studying um, the hospital to Community um, transition,
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Kim Livingstone (she/her): and the CTI effect was that there um, the prevalence of homelessness was five times less for people who were um, included in the CTI um, cohort versus those who got
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Kim Livingstone (she/her): discharge services as usual. Um, and in conjunction with that, Tomita was one of um Dan’s students. Um, and
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Kim Livingstone (she/her): in that same study they looked at the risk of rehospitalization, and there was a reduced risk of rehospitalization for folks in addition to the reduced risk of homelessness.
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Kim Livingstone (she/her): Um, it is noted as an evidence-based practice by Samsa’s National Registry and um, it’s noted as top-tier evidence for the coalition for evidence-based policy.
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Kim Livingstone (she/her): I mentioned earlier that it could be um, adapted to various transitions and populations. Um, it has been most widely studied for the transitions. I noted
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Kim Livingstone (she/her): Um, but right, prison release is one of those. Um, there’s also there have been programs that have adapted the model um, to work with different specific populations or for um, different transitions, and these are some of them
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Kim Livingstone (she/her): um, folks, you know, with histories of intimate partner, violence or Survivors of Intimate Partner Violence. Um, there’s been an adaptation for families who are experiencing homelessness. Um, they’ve adapted it alongside, or um, for folks who are dealing with first-episode of psychosis,
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Kim Livingstone (she/her): and then the ctits is a particular model of CTI that was implemented in Latin America. Um, and there are some specific things that were changed about the model. In that case. Um, but there are CTI has some flexibility. Um, and it
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Kim Livingstone (she/her): I don’t know it can what be widely helpful. It is an evidence-based. Practice. So there are core components that um,
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Kim Livingstone (she/her): you know, need to stay true. You need to stay true to the model, but um, transitions are widely experienced, and there are a lot of populations, um, of people that we work with who can, I guess, benefit from increase support during times of transition? So it’s been widely adapted.
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Kim Livingstone (she/her): If you want to learn more about that on the center, for the advancement of CTI has a um, website. It’s Www.Criticaltime.gov
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Kim Livingstone (she/her): that is at the Silverman School of Social Work at Hunter College in New York.
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Kim Livingstone (she/her): So, while um, noting that, it’s an evidence-based practice, I think, what brings me to the work, and many of us to the work of Critical Time Intervention um, goes beyond um, the scientific research. So, I was
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Kim Livingstone (she/her): telling um, Michelle um, earlier that um,
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Kim Livingstone (she/her): the CTI works well within our systems, because evidence-based practices. Um, right. We have
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Kim Livingstone (she/her): as long as we’re being true to the model, we have some assurance that we’ll get some positive outcomes right. We have uh It’s been researched, and um, with randomized control trials, and that’s great. Um, It works well,
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Kim Livingstone (she/her): and I think the thing that brings many of us to this work is that um,
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Kim Livingstone (she/her): individuals who are dealing with mental illness um, scientific research alone um, can’t solve right the the issues or it doesn’t. Um, we need to bring more to um,
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Kim Livingstone (she/her): the problem of solving um, what people are facing. So uh, Thomas um, has done some writing and some talks um, and on the next slide stuff maybe you don’t mind advancing the slide.
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Kim Livingstone (she/her): Um, we know that uh, individuals need more to recover, and so, um, it’s great to have the evidence, right, and that’s what brings me here. Um, we also know that people um, do recover. People need to find support
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Kim Livingstone (she/her): um, to have a place to heal um, and that
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Kim Livingstone (she/her): you know we need that fire in our belly um, to be able to discover a purpose or a mission in what we do. Um, CTI is very much about helping people make connection um, in their community and connections to themselves. Um, and
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Kim Livingstone (she/her): as I say that right I, I can just hear the roots of CTI and the recovery movement.
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Kim Livingstone (she/her): So, um,
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Kim Livingstone (she/her): The spirit of CTI really being based in the recovery movement. Um, some of the things that we’ve had a chance to hear from teams, and that we know from implementing the model. Um, it is that we are redefining success. Um, so in case management, you often are trying to help someone reach their goals.
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Kim Livingstone (she/her): Um, when you’re working with someone from a recovery perspective. You’re joining in with them on their journey. Um, so we are active in the process, but we’re not driving the process. We know we are temporary. Um, we have a purpose um, in helping them, and over the course of nine months.
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Kim Livingstone (she/her): Um, but we’re not the focus right. The focus remains on the individual and their journey, and what they’re um, what they’re going through. And so, while we are planting seeds for for the future, we’re working with people to help make connections. Um,
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Kim Livingstone (she/her): we’re able to redefine success and really draw spotlight on
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Kim Livingstone (she/her): right, these smaller bits that we know are important, but don’t always get the attention. Um, or you know the celebration that they warrant um, and so we might be celebrating the fact that someone is, you know um, leaning into support.
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Kim Livingstone (she/her): Um, that’s not something that’s often, uh, you know, celebrated.
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Kim Livingstone (she/her): So, there are smaller um bits of success, and we see them as planting seeds that will hopefully have long lasting effects. Um, in people’s lives well beyond our time together. Um, in that nine months that we get to work with them. So, um,
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Kim Livingstone (she/her): the recovery movement and CTI um, It’s very important, and it’s very much in the spirit of what we do.
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Kim Livingstone (she/her): Um, So CTI is something that can help people right now. Um, In our systems that exist today, even though we know that our systems are deeply imperfect, and we’re working to improve those two. Um, but there really is something to people need help now.
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Kim Livingstone (she/her): And so, CTI is something that’s able to help people from a person-centered perspective in the systems as they exist today.
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Kim Livingstone (she/her): So, i’m going to hand it off to Stephanie to talk more about what’s happening in New Hampshire. Thanks,
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Stephanie Cameron: Thanks Kim. Alright, so now that you have for the background of CTI. I want to to bring information about how we’re using it in New Hampshire.
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Stephanie Cameron: So just a little bit of a history of it being in New Hampshire. So back when the State was running the district 1115 waiver, it was piloted by several of the audience across the state,
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Stephanie Cameron: focusing on different transitions. Um, and it was there wasn’t really any standardization. But there’s a lot of fruitful success that came out a bit, and so, as a result,
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Stephanie Cameron: did you just decide to adopt the model and move it forward as a, a statewide implementation with standardization and high fidelity to the model? So, in January of this year we launched our three pilot sites. Um, and then
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Stephanie Cameron: July of this year the remaining CMHCS launched the, the, program. So, we have ten programs across the State. Look at each of the CMHCS,
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Stephanie Cameron: and then, as we continue to build the program and move into maintenance stage and see how uh, it’s working. We’ll be able to look at how we
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Stephanie Cameron: expand the program into other transitions that Kim spoke about earlier.
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Stephanie Cameron: Stephanie, can you just tell us what this RIP is that that acronyms come up couple of times. Sure, it is the delivery system uh, reform incentive payment waiver. So it was the 1115 Waiver um, away. A State can
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Stephanie Cameron: find new ways of delivering care and have it be funded through CMS: Thank you.
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Stephanie Cameron: So, our initial transition here in New Hampshire is focused on those who are transitioning out of inpatient psychiatric states into the community. So, this includes both New Hampshire Hospital and each of the designated receiving facilities.
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Stephanie Cameron: This includes both new and old clients, also those who are receiving behavioral health services external to the CMH. So, an individual does not have to be receiving behavioral health services at the Community Mental Health Center in order to be able to uh, participate in this program.
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Stephanie Cameron: Um, They also um,
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Stephanie Cameron: cannot be receiving ACT services, not to say that we might not look at doing this in the future. Um, but we have a limited population that we can serve. And so, since act right now is so uh, robust in their services. That was sort of one way to tailor in to a population.
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Stephanie Cameron: Um, it is for an adult program. So, it’s for those who are eighteen years or older.
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Stephanie Cameron: Uh, it’s pair agnostic. So, whether they have Medicaid Commercial Insurance or no insurance at all. They’re able to benefit right now from utilizing this program with no cost to them, and is a voluntary program. So, individuals need to want to participate in the program,
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Stephanie Cameron: and then we also provide access to our teams for flexible funding. So this they’re able to tap into these funds to say, help someone go and get
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Stephanie Cameron: uh, clothing for an interview or um. One of the coaches recently went and bought one of her clients some art supplies, because that’s really what brought that individual joy um, and helping them to
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Stephanie Cameron: get back in love with that and figure out how to connect in that way into their community.
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Stephanie Cameron: So, how does the client transition? Uh, in our process here? So, once a client is admitted to New Hampshire Hospital or one of the DRF. The social workers there will review and see. Is this person meeting the criteria for the CTI program?
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Stephanie Cameron: Um, if they are, and remembering that includes that the individual wants to participate, then the Drftinghamshire Hospital, or send a referral to the appropriate CTI team. So, wherever that catchment area is for that individual um is going to be discharged to which is not always known.
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Stephanie Cameron: Um, and then the individual enters into Pre-CTI that Kim talked about. So the
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Stephanie Cameron: coaches go into the hospital meet with the individual several times, building that relationship prior to their discharge, and then at discharge uh, the coaches there to support them over the next nine months which can include helping them home, transporting them home from the hospital.
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Stephanie Cameron: Uh, we really encourage this for our coaches, because it gives them an opportunity of the individuals interested to go in to where it is. They end up in the community and do an observational assessment of what they might need in those immediate hours after discharge. Um, so say they get discharged
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Stephanie Cameron: uh, with no food. Give them an opportunity to go and get them some food for those first twenty-four hours while they’re securing those um, ongoing services.
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Stephanie Cameron: Some of our goals in implementing this is to reduce remissions to psychiatric facilities. Decrease length of stay uh, for hospital stays that do happen.
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Stephanie Cameron: Ensure that there’s high fidelity to the model. Uh, because we want to make sure that it is doing what we know can do to
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Stephanie Cameron: improve connecting clients to services in the community. We want to be able to expand the model to multiple transitions in the future and to achieve long term sustainable funding.
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Stephanie Cameron: So again, each
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Stephanie Cameron: um, of the community mental health centers has an active team. Um, we currently have twenty-two of our thirty uh, resource coaches hired um, with several sort of in the hiring process, which is really exciting. Um,
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Stephanie Cameron: And then each uh,
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Stephanie Cameron: we have each of our supervisors at each of the sites.
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Stephanie Cameron: So, a team is made up of a Cti coach, which is a bachelor of a bachelor level. professional uh, with experience in the the transitional field.
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Stephanie Cameron: Each of the program teams at each of the CMH’s has two to four coaches depending on. So, what the data tells us, for discharges to that area. Um, and they have a Max weighted case load of twenty individuals,
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Stephanie Cameron: and then there’s the CTI Supervisor, who’s a master level clinician with experience in the field. Um, and each of the team. Each of the program teams has a Point Five Supervisor uh, because the ratio of supervisor to coaches is an eight-to-one.
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Stephanie Cameron: Um, and they are responsible for several things. But that also includes weekly team meetings, one on one supervision and helping to ensure program integrity.
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Stephanie Cameron: And, as Ken mentioned before, we provide monthly uh, community of practice calls, and also quarterly in person
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Stephanie Cameron: uh, community practice meetings which we have our next one tomorrow, which are really some of the most fun. Work um, in rolling this out and then offering a lot of cross partner facilitation. So if they’re running up against a challenge.
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Stephanie Cameron: Um, Kim and I are there to help them navigate what they’re the challenge to that. They’re going through or connect them with other coaches that we hear similarities and challenges, so that they can support one another and what they’re going through.
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Stephanie Cameron: We meet with several other programs across the country who are deploying CTI on a regular basis as our own way, to learn about
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Stephanie Cameron: um, what others are doing and share resources or deliverables that people have created. Um, So it’s really great for us to be able to connect and hear a lot of the similarities and challenges that they’re facing, that we have also experience um, but also the same of the same successes as well.
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Stephanie Cameron: Most of the transitions that are happening. Focused transitions in the US are focused on the um, homelessness to housing
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Stephanie Cameron: um, which is exciting as we look to
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Stephanie Cameron: um,
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have that as one of our next transitions.
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Stephanie Cameron: So, I wanted to share some of our early data from the program. Um, again, very early data. But it’s very exciting to see the quick growth that’s happening. So, as of October 14, we have 182 active clients across the State.
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Stephanie Cameron: Uh, we’re receiving referrals from all of our referral partners. Um, New Hampshire Elliot and Parkland being um,
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Stephanie Cameron: very similar in the amount that they’re referring.
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Stephanie Cameron: And then we have
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Stephanie Cameron: of those one hundred and eighty-two one hundred and twenty-nine of base, one twenty-eight and phase two hundred and twenty-five and phase three, with two people already completing the program, which is really exciting it’s a huge milestone. Um, but this front loading of the number of one hundred and twenty-one base one is because the program
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Stephanie Cameron: is still in that starting phase. So, you expect to see a lot more people in phase one, and over the next several months we expect to see this level up uh,
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Stephanie Cameron: quite a bit.
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Stephanie Cameron: And this is just the program growth over time since we started in January again, back in January to June our first three pilots were going, and then um, In July we had the rest of the program teams come on. So lots of great consistent growth happening over time.
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Stephanie Cameron: Um, This shows what focus areas our teams have been working on with each client. So we collect data on them. Of what are the top three things that you’re working on with the clients that you’re serving. And so that, being psychiatric treatment, housing self, self advocacy, and daily living skills as the top four, which I think really speaks to the spirit of CTI of both connecting people to services,
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Stephanie Cameron: but also helping them connect successfully to their community. So, being able to advocate for themselves and situations that may not be the best for them, but also just what are those day-to-day things that they need to keep themselves on track, whether it’s let’s get you a calendar so that we can write down all your appointments.
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Stephanie Cameron: Um, or that living situation. Isn’t the best for you, and this is how you they can be better. Um, and you’ve in fact, can access that service, or you, in fact, won’t get uh,
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Stephanie Cameron: charged for doing that.
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Stephanie Cameron: So just a lot of great um, building up of people and helping them to know that they can do this in the future.
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Stephanie Cameron: So, some of the things that we’re currently working on as we’re implementing the program. Still pretty new. Um, it’s one is workforce, and I’m sure that’s not a surprise to anyone. Um, there’s just workforce challenges all around. So, this is very um, multifaceted,
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Stephanie Cameron: but we’re doing pretty well with hiring our coaches, which is great. Um, It’s just keeping up that momentum to match the progress of the growth of the program. Um, but also workforce at our referral partners, either between
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Stephanie Cameron: um, short staffed or turnover. There’s just a lot of consistent work with them to make sure they continue to understand the model and support them. Um, as they help us with referrals to workforce and challenges in the community,
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Stephanie Cameron: and how that affects services that are accessible, and so that
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Stephanie Cameron: goes into the community resources, and either having limitations and how they can access those services or restrictions on those services, and how that affects the ability of connecting an individual to what it is that they need, and then not making that criteria
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Stephanie Cameron: Uh, referral timing is another one. So, ideally we’d like to have a lot of time during pre-CTI for our coaches to be able to build those relationships. But given the length of stay from our referral partners.
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Stephanie Cameron: Um, the referral timing tends to be pretty quickly with a pretty quick PRE-CTI. So, we’re constantly working with our referral partners on how we can improve that referral timing. And then, as I mentioned program growth, we have a lot of great growth going on, and so we just want to make sure we’re balancing um,
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Stephanie Cameron: not having our coaches burn out from the quick growth uh, while also making sure we have the workforce to meet the demand.
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Stephanie Cameron: And what do things like look like for the future? We’ve touched on this quite a bit. But um, we want to make sure that we’re achieving community connectedness that we’re helping to look at where the gaps are in the community for services and use the information and data that we collect to build up those services in the community.
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Stephanie Cameron: We want to ensure long term sustainability of the program which includes securing funding from appropriate resources, as well as ensuring that there is supportive policy in place.
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Stephanie Cameron: We want to be able to expand to tested transitions that Kim spoke about earlier, but also expand into new transitions. After that that may not have been tested. One that get asked frequently about is emergency department and people transitioning out of the emergency department back in the community. I think that’s one that a lot of people are interested in, and that we’re hoping to look at in the the future,
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Stephanie Cameron: and then I always like to end with um, some positivity, and what some of our clients in the program are saying about it. So, um, we had one who is a, a bit further on in the program, and they start their coach out and
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Stephanie Cameron: public, and they ran over to them and thanked them for changing their life. They said,
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Stephanie Cameron: Um, we had one recently said that without CTI help, but they would be in jail right now. The staff was able to get them to their court hearing, and if they didn’t have them for transportation, then there would have been a warrant out for their arrest.
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Stephanie Cameron: Another said that their coach gave
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Stephanie Cameron: uh, them different ideas for ways to get involved in their community, and another, so that the coach was there when I needed them, either in person or over the phone. They always followed up,
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Stephanie Cameron: and Kim and I have the absolute privilege to talk with these teams frequently, and here many of these stories, which is definitely a reward of this program
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Stephanie Cameron: and any questions.
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Michelle Wagner, NAMI NH (she/her): Thank you both for wonderful presentations. And we already do have one question. I don’t see Peer Support on the connecting to community focus areas.
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Stephanie Cameron: Uh, yes, even though they do focus on doing that, it’s might be categorized under a different focus area on there. Um, we’re also looking in the future. Some of the programs across the country have peer support as part of the team.
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Stephanie Cameron: Um, so, we’re looking at that in the future. And I was telling Michelle and Rebecca earlier that a few of our coaches are also peers, so, it’s been very beneficial to have them in these group network settings to offer their expertise and um, insight.
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Stephanie Cameron: But, yes, there definitely is a focus to to ensure that there is that connectedness to peer supports
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Michelle Wagner, NAMI NH (she/her): terrific. Yeah, and nice to have it named, because we certainly are becoming very aware of how important that is.
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Michelle Wagner, NAMI NH (she/her): Um, I have a whole bunch of questions.
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Michelle Wagner, NAMI NH (she/her): So,
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Michelle Wagner, NAMI NH (she/her): you talked about people uh, finishing out the program graduating and from the program. Is there anyway that you’re going to reconnect with those people, or once they launch, because there’s a hard stop at nine months right
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Michelle Wagner, NAMI NH (she/her): once they’re on their way, Is that it? The cord is cut
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Stephanie Cameron: Um, essentially. But a lot of the uh, people who experience or go through the CTI program are
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Stephanie Cameron: clients of the CMHCS, and so the coaches
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Stephanie Cameron: feel that they will just pop in on them every now and again, and just say, hey, how, how you doing? And so forth. But really any prolonged service after that um,
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Michelle Wagner, NAMI NH (she/her): it’s not part of the model, right? So no service, but maybe an occasional just check in
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Stephanie Cameron: um, in terms of how the CTI programs are embedded in into. Is there cross collaboration with the CMH, you know. So that was one of the early things that we worked on with the teams is um,
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Stephanie Cameron: and helping them to set boundaries to make sure that CTI maintains the CTI model and didn’t become an extension for other resources. Um, and how that they effectively communicate and work with those internally. So, a lot of early education going on across their organizations about what it CTI is and what is not
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Stephanie Cameron: um. and then
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Stephanie Cameron: each one doesn’t a little bit differently about how they work with their teams, whether it’s um, sitting in on team meetings or, or,
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Stephanie Cameron: but, they really are a standalone
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Stephanie Cameron: team
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Stephanie Cameron: that will communicate with other programs.
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Michelle Wagner, NAMI NH (she/her): And you may have already said this, and maybe I missed it. But are they physically housed within the CMH. They have office space within the CMHCS. They do, They do, although we do expect that most of their time will be out in the community. Right? Yup: Okay, Great. So we have some other questions from folks. Uh, is the program offered only for those who have had an involuntary admission. No, it can be voluntary emissions as well.
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Stephanie Cameron: And I was one at the DRF Facilities. Not um, voluntary, inpatient unit psychiatric units. Okay, Okay, So it has to be a DRF a designated receiving facility or New Hampshire Hospital, which would be involuntary. We’re off to those other ones. But okay,
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Michelle Wagner, NAMI NH (she/her): once we have more resources, right, right, which is coming. We know that I had a question related to that, but I’ve lost it so I’ll move into the list here as homelessness or housing, and security is a challenge for many. What if that is an additional complexity to their hospitalization discharge?
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Stephanie Cameron: Yeah, this is Kim. Do you want to. I was just going to jump in that um,
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Kim Livingstone (she/her): We often we’ll talk about addressing like one transition um, per team or at a time, and with hospital discharge. We often see homelessness and with incarceration. A community to homelessness is layered on top of that um, and so a CTI worker can work with an individual, no matter where they go or where they’re receiving their services or where they’re connecting them to. And so um, CTI programs aren’t limited in in that way. Um, meaning they follow
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Kim Livingstone (she/her): the needs of the person. Um, it would be an area of immediate, you know, to address um, the immediate need. Um, we likely don’t get to see the housing issues. Resolved. Um, within nine months um, there are times that we do, and um,
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Kim Livingstone (she/her): I tell the CTI workers that they are miracle workers. Um, we are well connected in our communities, and we work really hard to connect people to whatever resources we can find. And we’re very creative and flexible. And so we’re resourceful um,
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Kim Livingstone (she/her): But we often don’t see many issues, including housing issues resolved within nine months. It’s the bitter sweetness of working with someone from a recovery perspective. Um, it’s, you know, owning the fact that you’re joining in with them on their process. But you, as the worker don’t often get to see things tied up neatly in a bow and sending them on their way. That’s what made me smile about the question of, Do we get to check in with them? It’s one of the
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Kim Livingstone (she/her): hardest things is to to join with someone in the journey, and to have them moving on
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Kim Livingstone (she/her): um, without everything neatly resolved. But in reality that’s life. Life, is not. We don’t often have, you know, things that are neatly resolved in our lives. Um, so there’s an owning of that within the CTI model. That
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Kim Livingstone (she/her): um, is helpful, but also very challenging for CTI workers. So, housing issues get right in there. Um, and I would just add the if the hosting issue Isn’t resolved it’s
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Stephanie Cameron: the charge of the coach to make sure they’re linking them to the sports that are going to in the future. Help them resolve it
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Stephanie Cameron: whether it’s they’re helping them to just fill out the paperwork, even though it’s going to be a while to get into somewhere that they have everything lined up. So, as soon as they’re able to, they’re ready to go, but also connecting them with you see, one of the questions in is that or in here’s maybe the housing liaison that’s within the CMHC. That is not CTI. They are more long term,
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Stephanie Cameron: and so, maybe they’re connecting them to that individual, so that when the availability comes up they’re able to help them after the nine months.
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Michelle Wagner, NAMI NH (she/her): That is, and housing has and will continue to be, an issue. So, this is something we’re all invested in improving to help these folks, as well as many others. Um, someone also asked, How is it determined if an individual gets CTI or goes on in acting? Absolutely? Yeah. So um, act
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Stephanie Cameron: has a certain assessment and criteria. So, everyone that we are working with ends up with. I don’t know if everyone’s sort of be is assessed for act. So, in short act is the first step, and so if they
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Stephanie Cameron: are assessed for act, and that’s what they get
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Stephanie Cameron: are assigned to um, then they’ll go to act first. Um, but if not, then CTI is available for them as well.
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Stephanie Cameron: Uh, we’ve had a quite a few actually, where people will be discharged um, and be in the CTI program, and they’re later assessed, and it’s found that act is appropriate for them. So, they’ll uh, be closed from the CTI program. And um,
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Stephanie Cameron: with the act team from there.
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Michelle Wagner, NAMI NH (she/her): Excellent! That’s good. Uh, and asks, how do community programs connect with their local CTI workers to be a referral resource? Wonderful question. Um,
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Stephanie Cameron: I who,
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Stephanie Cameron: I think that what you could do is reach out. If you are interested in
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Stephanie Cameron: connecting with CTI, and I can help make that connection.
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Stephanie Cameron: Um, I’d be willing to send out everyone’s uh, information, but I don’t think I can see that right now without asking them first,
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Michelle Wagner, NAMI NH (she/her): but, definitely! We want
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Michelle Wagner, NAMI NH (she/her): everyone to know about it and to be able to get as many people connected as possible with the population that we talk about. With the First Episode Psychosis work. We have people who are often reluctant. Sometimes they’re distrustful of others. You said, This is a voluntary program We also mentioned Kim did motivational interviewing.
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Stephanie Cameron: Do you work with People might be a little bit reluctant to get them into the program.
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Stephanie Cameron: Then we’ll have the coach still. Go in and talk with them, and explain to them a little bit more about what the program is, because ultimately the coaches know the program more than anyone.
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Stephanie Cameron: Um, And so they’ll go in and do their own level of motivational interviewing and and just work with them and see. Do you want to continue afterwards? Now everyone continues to stay engaged, And that’s okay. Um, but some of the things that we have been seeing is that people who have been
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Stephanie Cameron: um, sort of reluctant to participate in uh, other services at the Community Health Center are now actually wanting to participate in. So, we’re seeing a lot of re-engagement and the
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Michelle Wagner, NAMI NH (she/her): Oh, which is amazing. We, we need those numbers that would be great we would want funding. So,
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Michelle Wagner, NAMI NH (she/her): um, Mary, as I’ve heard, there’s a housing liaison, a community partner. Is this part of the CTI program.
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Stephanie Cameron: Uh no, that is a separate
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Michelle Wagner, NAMI NH (she/her): Okay, yeah. Housing is on everyone’s mind that’s for sure. Can you speak to the folks who have had an episode of uh, psychosis. So their first episode of psychosis. So we now have several
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Michelle Wagner, NAMI NH (she/her): programs around the state within four of our community mental health centers that can provide treatment specifically for early psychosis. These folks are also eligible for CTI. Can you explain that?
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Stephanie Cameron: Um,
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Stephanie Cameron: No. I actually don’t know um, how the coaches are, or the people which are navigating it. But I’m certainly happy to reach out to them um, and see if they’re
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Stephanie Cameron: joining efforts which I think would be ultimately the expectation. Um, I mean something we could say is that um, CTI is something that can
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Kim Livingstone (she/her): enhance supports um, and it’s in addition to. So, it’s the main focus of CTI to help people make connections in their home communities. And so, um, it’s not like a duplication of services. Um, it’s meant to uh, help people at that vulnerable time of transition. And so, if you have someone who’s experiencing early psychosis and hospitalized and moving into their home community,
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Kim Livingstone (she/her): um, it could it? It sounds like it would be potentially a good fit to have them connected to a CTI team to help navigate. I mean, these are likely going to be new if it’s an early, You know early episode
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Kim Livingstone (she/her): new connections that they need to establish or helping them, to, you know, re-establish, re grow roots, or um,
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Kim Livingstone (she/her): establish those new connections to those providers.
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Kim Livingstone (she/her): Um, within the nine months that they’re um, first discharged. Um, I guess it’s an important thing to say or um,
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Kim Livingstone (she/her): to reiterate that CTI isn’t something that’s um, in danger of like duplicating services, It is meant to be layered on top of um, to enhance connections and to provide additional support for people during this vulnerable time. And we know that if we’re able to
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Kim Livingstone (she/her): kind of um, work with individuals in this intensive way for the short time we have these enduring outcomes later on. Um,
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Kim Livingstone (she/her): So,
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Kim Livingstone (she/her): I guess in that way it might be helpful to say that
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Michelle Wagner, NAMI NH (she/her): so, and and I didn’t probably didn’t word that very well, but it it’s just complementary services. So, if somebody enters greater Nashua into their whole program helping overcome psychosis early.
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Kim Livingstone (she/her): They also can receive CTI.
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Kim Livingstone (she/her): You know the first um; eligibility criteria is that there has to be a transition. But um, it sounds like that, would you know, overlap for many people? Um, within that program? Yeah.
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Michelle Wagner, NAMI NH (she/her): So they have to. We have to get them to the hospital first before they go into the judicial system. That’s the key for now. Yes, and so that’s another question I have. When are you thinking about?
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Stephanie Cameron: Including those who have been incarcerated. That’s a great question. Um, Where?
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Stephanie Cameron: Always actively looking for that opportunity. Um, Right now, we’re just navigating for that long term financial sustainability, and hoping that we’re able to wrap a lot of these other transitions
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Stephanie Cameron: into that. And then, of course, you know, we could have all the money in the world to be able to stand up programs, but we also need a workforce to support it. And Um, being very cognizant about workforce challenges across the state.
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Stephanie Cameron: Um, how we can be thoughtful about building a workforce to support it without um,
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Stephanie Cameron: hurting other areas as well.
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Michelle Wagner, NAMI NH (she/her): Any final words of wisdom for our folks out there from each of you about CTI? how to get folks into it? What it means?
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Stephanie Cameron: um, is, see about seeing about to go through this process. Feel free to advocate for the individual to um,
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Stephanie Cameron: either be referred if they want to, to CTI, the more that we can help our referring partners identify who is appropriate and send the referral, I think the better. Um, and I also just want to end with um,
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Stephanie Cameron: sort of the, the, heart of CTI, I think, is beautifully wrapped up in a situation that the Commissioner recently experienced with her, her own family, where um they were starting to
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Stephanie Cameron: um, decline because they needed their medication. So she took the day. Off she went and helped them get their medication, and then took a four hour walk with them around the lake, and she said, That’s what I see. CTI doing is having the ability to walk with that person around the lake, if that’s what they need to be better
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Stephanie Cameron: to get better.
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Kim Livingstone (she/her): Um, well, I think that what brings me to CTI, and one of the reasons why I love it so much is that it is um, centered on the individual and um, rooted in the recovery process. So, helping people where they’re at, and
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Kim Livingstone (she/her): um, right the bitter sweetness for us as helpers is that we’re joining in with someone on their journey.
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Kim Livingstone (she/her): It’s not about us right. It’s about us, and our the role that we have. Um, we do have an important role to play for that short time that we get to work with someone. But um, It really does remain focused on the individual we’re working with, and
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Kim Livingstone (she/her): the journey that they’re on um, and their goals. So, I love CTI for a lot of reasons, and that’s one of them. Um, I’m also just really thankful that people are willing to join us during their lunch hour. So, thank you for wanting to hear about CTI while you eat lunch. It is an honor. Um, and
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Kim Livingstone (she/her): yeah, thank you.
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Michelle Wagner, NAMI NH (she/her): Yeah, thank you both very much for joining us. We greatly appreciate it, and thank you to all the viewers. We do ask that you take a moment and fill out the evaluation form. Rebecca has put that survey link into the chat
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Michelle Wagner, NAMI NH (she/her): uh, after you fill it out you’ll automatically receive a certificate of attendance in case you need one of those, just a reminder, a recording of today’s discussion will be posted on the education page of OnwardNH.Org. You’ll receive an email in the next couple of days, which includes links for the website. And once again the evaluation link
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Michelle Wagner, NAMI NH (she/her): for questions or comments. Please reach out to me, Michelle Wagner, at M.Wagner@NAMINH.Org
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Michelle Wagner, NAMI NH (she/her): We look forward to seeing you next month. It’s on Thursday, November seventeenth. At noontime. Again, we’re going to talk about holding on and letting go. Experiences of parents of adult children with early psychosis. Until then, take care. Thank you. Everyone.