The Advocates Inc. Collaborative Pathway Fund will enable the Collaborative Pathway team to serve families of ordinary means by supplementing their health insurance with philanthropic support. Fund donations will also support the necessary research to show the safety, effectiveness and cost-effectiveness of this clinical model so that it can be adopted by communities across the nation and the world.
Where the problem lies
For young people experiencing early psychosis, and for their families, treatment options are often limited, and focus on rapid and early psychopharmacological interventions. Many young people experience the current mental health system as harsh, devaluing, and unattuned. Many young people also feel as if treatment is forced upon them, and reject this treatment, either openly or surreptitiously. Many families feel excluded from the treatment team. Both families and the person at the center of concern feel inadequately involved in critical decision making about care, including whether, when and for how long to use psychiatric medications.
Help is on the way
Five years ago, we learned about a better approach: Open Dialogue, developed in Finland, provides services to young people experiencing severe psychiatric crisis, including psychosis, by providing a mobile, multi-disciplinary team, which meets with the person at the center of concern and the family network in the home when possible, or at least in the least pathologizing setting possible. The team provides services that allow for open discussion of what might be contributing to the present crisis, and what options might be available to help. The team includes social workers, psychologists, nurses and psychiatrists, as needed. In a spirit of openness and transparency, the clinical team commits to the person at the center of concern and the family that all decisions will be made transparently, in front of the network, with the network invited to comment or disagree. This is true for all decisions, even those which have to be made unilaterally by the team, such as a decision to hospitalize a person deemed a grave danger to himself or herself, for example. In this system, there is substantial time and space for the natural resolution of problems. Medications are used, but are used more sparingly and for shorter periods of time than is general practice in the US.
Results in Finland have been very promising. At five year follow-up, roughly 80% of young people with early episode psychosis are working or in school, and less than 30% are receiving antipsychotic medications.
Open Dialogue has been possible in the region of Finland in which it was developed in part due to the richness of resources and the integrated care available there. There are serious obstacles to replicating this model in the US. However, at our non-profit agency in Massachusetts, we have developed an Open Dialogue team over the past three years. We have been trained by the foremost expert in the US on Open Dialogue, Dr. Mary Olson, and have a 24/7/365 mobile crisis team on which our program, called the Collaborative Pathway, is based.
Our early results show that this approach is safe and very much appreciated and preferred by the people we’ve served. The challenge is that this approach is expensive and for the most part not yet covered by third party payers. Part of the expense involves the practice in Open Dialogue of always having more than one clinician involved in the network meetings. Another cost comes from the expense of traveling to and from people’s homes and being available for more frequent meetings than insurance companies typically authorize.
Our Fund enables us to supplement third party payments so that families of ordinary means can have access to Open Dialogue services in the Collaborative Pathway. The Fund also supports outcomes research to enable us to demonstrate to third party payers that this approach is both clinically preferable and actually cost-effective, especially over the long term. Even with high intensity services, the Collaborative Pathway costs less than $30,000/year, with average costs of approximately $15,000/year. By bending the clinical curve away from hospitalization, ED use, and chronic illness, the Collaborative Pathway and Open Dialogue, we believe, are good investments over the short term. If the model succeeds in keeping young people from becoming chronically enmeshed in the mental health system, the benefits and savings are of course enormous.
Thus far our pilot data indicate a greater than 70% decline in hospital days after initiating care in the Collaborative Pathway, and a significant increase in days working or in school; a very high degree of satisfaction with care and reported sense of collaboration and partnership. We have experienced both young people managing their crisis with less or no antipsychotic medications and we have also experienced young people finding antipsychotic medications and other treatments that feel effective and helpful to them – and which represent their own active choice, rather than treatment imposed upon them.