Coordinated Specialty Care (CSC) programs provide evidence-based services for young people with recent onset of a psychotic disorder. (1) New York State's program, OnTrackNY, is a nationally recognized model of CSC treatment. (2) The program is implemented by a multidisciplinary team with specialized training, which provides coordinated, evidence-based treatments based on the interests, needs, and preferences of each participant. The program emphasizes assertive outreach and engagement and is offered for an average of two years. OnTrackNY teams offer participants a range of evidence-based treatment options, including individual therapy based on Cognitive Behavioral Therapy for psychosis (CBTp), psychiatric medications, family education and support, peer support, supported education and employment, case management and community support, and a focus on physical wellness and primary care coordination. Teams focus on helping participants attain individual goals typically related to school, work, and relationships. (3) OnTrackNY has demonstrated improvements in symptoms, functioning, hospitalization, and work/school participation. (4) The rapid rise of COVID-19 has created shocks to the health care system, producing numerous rapid changes in behavioral health service delivery, in the absence of guidance from evidence or experience. It is unclear how these changes will impact the ongoing delivery of CSC services and participant outcomes.
OnTrack Central is an intermediary organization (5, 6) responsible for training and implementation support of OnTrackNY programs. It has created systems for multi-level stakeholder engagement, a centralized data collection protocol for quality improvement and evaluation of program fidelity, and a mechanism to support practice based-research. Initial training provided to OnTrackNY teams includes a multi-day in-person introductory training in the principles and practices of the CSC model, followed by remote consultation, and training in data collection forms, procedures, and the data collection platform. Regular, on-going training is also provided for team members, based on their specialty, through frequent individual, collaborative, role and team-based phone calls, monthly care consultation calls, webinars, and use of data and fidelity reports to highlight strengths and identify areas for improvement. (7)
OnTrack Central’s engagement of the OnTrackNY network has revealed how changes due to COVID-19 have dramatically impacted CSC services. Changes in staffing due to redeployment to medical units, childcare challenges, illness, and agency requirements to provide telehealth services from on-site locations have disrupted team functioning and clinical care. The rapid shift to telehealth without the benefit of planning, technology infrastructure, or training changed service delivery overnight. Telehealth may be challenging to implement in CSC due to common challenges young people with psychosis face including structural barriers (e.g., lack of equipment, WIFI, lack of privacy), cognitive deficits, symptoms of psychosis, and elevated suicide risk. However, staff innovation and creativity could transform these challenges into improvements and advantages. Teams have had to quickly adapt to online education, employment, and community systems to help participants adjust to changes required due to COVID-19 like physical distancing and interruption to school and work. Clinicians have had to develop strategies to assess and manage suicide risk via telehealth.
In 2019, OnTrackNY was awarded a hub within the Early Psychosis Intervention Network (EPINET) to advance a learning health care system (LHS) through enhanced stakeholder participation and improved data infrastructure. (7) The breadth of OnTrackNY sites coupled with OnTrack Central oversight provides a unique opportunity to examine the impacts of the COVID-19 crisis in New York State. The diversity of the 23 OnTrackNY teams located throughout the state enables examination of settings with a high and low prevalence of COVID-19 infections, and diverse regulatory and workforce environments. The OnTrackNY network includes programs that operate within variable settings and communities (outpatient clinics at community agencies, state-operated facilities, and community and academic hospitals in urban, suburban, and rural areas) with very diverse participant populations.
This project will examine the implications of modifications to service delivery within the OnTrackNY LHS during and after the COVID-19 crisis. We will use the implementation science framework, Framework for Reporting Adaptations and Modifications-Enhanced (FRAME), to systematically evaluate modifications and ascertain their impact. The FRAME captures processes for modification, including reasons for the modification, what was modified, level of modification, and timing across phases of treatment. (8) The FRAME's detailed coding system will elucidate if modifications are fidelity-consistent with the CSC model and enhance service delivery, and whether any changes are associated with reduced effectiveness. (8)