CLINICAL QUALITY OF CARE – PRACTICE PARAMETERS  Office of the Chief Medical Officer  Clinical Operations  Street Psychiatry and Field Based Services Clinical Programs - 12   Category: ClinP-12 Published Date: April 2024

PARAMETER GOAL To provide structural guidance to field-based service delivery staff of psychiatric treatment programs including street-based psychiatric services. To delineate some of the: Unique aspects of field-based work Factors that impact individuals who are unhoused Complexity of large health systems Role of the psychiatrist in system navigation, housing, and community reintegration TERMINOLOGY Activities of Daily Living (ADL): A term used to describe a collection of fundamental skills required to independently care for oneself without assistance, including the 6 basic ADLs: Transferring Eating Dressing Bathing Continence Toileting Assertive Community Treatment (ACT): An evidence-based practice requiring fidelity to the model that is characterized by: Low client to staff caseload ratios of no more than 10 clients per staff member Providing services in the community in order for clients to remain in their communities Shared caseloads among various disciplinary team members for all program clients 24-hour availability of team Direct provision of services by the team rather than referral/linkage Services which are not time-unlimited NOTE: ACT level of care is equivalent to services under Full Service Partnership transformation in Los Angeles County. Assisted Outpatient Treatment (AOT): Court ordered community-based treatment for clients with a history of repeated hospitalizations and/or incarcerations. This program addresses the needs of the client by ordering participation in community-based mental health treatment programs in lieu of incarceration. Community Assistance, Recovery and Empowerment (CARE) Court: Voluntary Civil court process where treatment and housing are offered along with social service supports to assist individuals who meet criteria for Schizophrenia or other psychotic disorders along with other impairments to their functioning. CARE aims to assist individuals prior to need for crisis level services and more restrictive settings. Field-based Mental Health Services: A mobile delivery method for intensive outpatient mental health services for individuals with impacted access to clinic-based services. Full Service Partnership (FSP): ACT based programs which provide comprehensive, intensive, community-based mental health services to adults with a severe mental illness meeting certain focal population and impairments to functioning which necessitate field-based team response. Homeless Outreach Mobile Engagement (HOME): Field-based outreach, engagement, support, and treatment to individuals with severe and persistent mental illness who are experiencing unsheltered homelessness.  Instrumental Activities of Daily Living (IADL): Activities related to independent living for example, preparing meals, money management, or using a phone for communication. Long Acting Injectable (LAI) Medications: A special formulation of a medication that is typically injected into the deep muscle and allows for a steady stream of medication to remain in a client's system over a period of time (ranging from 2 weeks to 6 months). Extremely helpful for clients who are non-adherent with oral medications or unable to self-manage oral medications. Outreach and Engagement: The process of building rapport and establishing trust with a client and motivating them to receive and accept services. Outreach is a process rather than an outcome, with a focus on establishing rapport and a goal of eventually engaging people in the services they need and will accept. The engagement period can be lengthy and depends on the unique individual needs of the client. Through staff conversations around the benefits of treatment and the particular ways that a specific program might assist the client with their goals, a context for assessing needs, defining service goals and agreeing on a plan for delivering the services is established. Community Reintegration: Ensuring that people are stably housed and living safely in the community and utilizing the resources available in their community. Psychosocial Arm: The field team staff whose expertise and training tends to utilize behavioral, relational and cognitive methods, such as psychoeducation, incentivizing, rapport building, and motivational interviewing: Performs the majority of Outreach and Engagement Provides expertise in the area of resources for basic needs including housing and Establishes all available benefit assets Includes various team members including but not limited to Psychiatric Social Workers, Mental Health Clinicians, Medical Case Workers, Community Health Workers. Medical Arm: The field team staff whose expertise and training includes medical procedures and clinical requirements for health and mental health care. Street Psychiatry: A model of mental health treatment delivery that brings services directly to individuals experiencing homelessness, who may lack access to mental health services through traditional routes. The population served by street psychiatry may be residing on the streets, in parks, under bridges, or other community-based placed where homeless individuals may be found. Providers visit homeless individuals where they are currently residing to perform diagnostic assessments, prescribe medication, complete safety assessments, activate benefits and provide housing support. 5x5 Risk Matrix: A visual tool that can be used to assess risks indicating the severity and likelihood of complications. TEAM STRUCTURE A singular staff who is the point person for managing the client's needs and goals May include various disciplines: Psychiatrist, Nurse Practitioner, Physician Therapist, Psychiatric Social Worker, Mental Health Clinician Registered Nurse, Psychiatric Technician Medical Case Worker, Community Health Worker, Peer Specialist, Substance Abuse Counselor Psychosocial Arm is primary in the outreach phase and throughout treatment Medical Arm is introduced during the treatment phase MEASURES (Assessment) Assessment is initially determined by client choice to engage Triage for acute medical needs may include calling paramedics 5x5 Assessment Tool includes these domains rated for level of functioning: Physical Health Mental Health Substance Use Disorder Life Skills ADL's/IADLs 5150/5585 holds may be assessed by appropriately trained staff FIELD-BASED SERVICES Phases of engagement Referral Phase Client profile determined Consider FSP established guidelines Episodic - Multiple periods of homelessness within a given year Not adequately utilizing available resources to maintain housing or treatment needs due the symptoms of severe mental illness Partially treated or untreated mental health symptoms Consider HOME guidelines Chronically homeless, meaning unhoused at the time of referral Some programs considered chronic homelessness is established at a baseline or a period of at least a year, or repeated homelessness within a year Not utilizing available resources for basic needs due to the symptoms of a severe mental illness Untreated mental health symptoms Outreach and Engagement Phase  Community Health Workers, Peer Support Specialists, Social Workers and Substance Abuse Counselors establish a meaningful rapport with the client. Evaluation using 5x5 assessment tool to develop a vulnerability index to guide inventions. Triage for acute needs with medical consultation as needed. 5150 holds are initiated for clients meeting LPS hold criteria. Paramedics are called for clients with medical emergencies. Screen for enrollment with other programs to avoid overlapping or conflicting care plans.  Psychosocial arm offers available resources. The outreach and engagement is primarily completed by the psychosocial arm of the team. Notably, if the client accepts housing resources, then housing is prioritized to address the mortality associated unsheltered homelessness. If the symptoms of the mental illness are preventing utilization of provided resources, then advance to the treatment phase. Treatment Phase A Registered Nurse or a Psychiatric Technician adds to the engagement efforts to provide: A medical assessment Complete vital sign measurement. The field-based psychiatrist then adds to the engagement effort to provide: Psychiatric assessment Comprehensive treatment planning for interventions across the following health domains: Medical Psychiatric Psychosocial If the client consents to medication services: The psychiatrist orders medications from a local or partnered pharmacy and The pharmacy prepares the medication supply for pick up or delivery depending on the clinical situation (e.g. bubble pack vs bottles). Psychiatrists may transfer clients to Clinical Pharmacists for subsequent follow-up visits. Clinical Pharmacists will assess client’s response to treatment and adjust therapy accordingly. Clients who are severely symptomatic and living on the street have difficulty with self-management of medications may: Be provided daily medication support by the appropriately licensed staff in accord with Policy 352.10 Medication Administration, or Have delivery of medication in accord with Policy 352.11 Medication Delivery for observed medication self-administration by the client. Insufficiently managed mental health symptoms are a serious risk factor for causing and perpetuating homelessness. The goal in the treatment phase is to stabilize mental health symptoms and to improve insight and judgement so a client can move to the housing phase. Housing Phase Moving a client off the street and into housing is the ultimate goal of field-based services and should always be prioritized. If a client accepts housing prior to starting treatment then housing should be prioritized with treatment being pursued once the client is housed. Stable housing is only achieved through permanent housing, however, permanent housing options are not always readily available. Use of temporary housing options (either through licensed or unlicensed facilities) can be utilized to immediately address unsheltered homeless and mitigate the serious health risks associated with street homelessness. If placed in temporary housing, the team should develop a plan and a timeline to support a transition into a permanent housing setting that is appropriate for their clinical and psychosocial needs.  Once the client is housed, more intensive support and skills training should be provided by the team to: Encourage adaptation to the new environment Develop strategies to manage specific risks Elopement Treatment fallout  Community Reintegration Phase Once housing is secured and the client is stably housed in that setting for at least 3-4 months without repeated elopements or treatment fallout, meaningful community reintegration efforts can truly begin. Meaningful community reintegration includes: fun activities groups job training therapy and life skills training The goal is to firmly connect the individual to the community by work towards rehabilitation and purposeful living. Integration of Field-Based Services: Each field team has its own unique target population, staffing, services, and resources. HOME FSP New Field Teams (Ex: Hollywood 2.0) CARE Court Field teams should partner with other field teams on the continuum to ensure coordinated recovery Street homelessness and/or unstable housing HOME team intensively engages clients who are street homeless and utilizes street psychiatry services to stabilize and house clients directly from the street. HOME can get chronically homeless clients off the streets into housing and then transfer care to FSP for maintenance and community reintegration efforts. Stable housing and community reintegration. FSP teams manage clients who have unstable housing or are housed but need extra support and treatment to maintain housing to achieve meaningful community reintegration. FSP care shows sufficient improvement then care can further be transitioned to local community clinics to support more independent living. Client independence is always a priority. An integrated pathway to community reintegration is the goal.  Level of care adjustments in field-based services may mean transferring care to a more intensive level. OUTCOMES AND MONITORING Increased risk of mortality associated with street homelessness. A client experiencing homelessness or unstable housing despite intensive field-based services, the level of care may need to be adjusted to preserve life.  Stable housing is a critical outcome measure for any field-based team. This follows a housing-first model, which is an evidenced model to support recovery.  For example, if FSP services results in housing loss, transfer to the HOME team for intensive services.  A level of care adjustment may include inpatient stabilization for clients in the field. Field teams are advised to build partnerships with inpatient facilities to allow for more collaborative inpatient stabilization and discharge planning. For clients in field-based services and requiring repeated inpatient admissions, field teams may need to activate court proceedings for assisted outpatient treatment or outpatient conservatorship to facilitate recovery. STAFF TRAINING Effective engagement strategies Motivational interviewing Operating at the top of one's skill set with flexible roles Live communication and active plan development Synchronizing care plans with all team members Medication support services enhancement Deliveries vs administration Screening for acute needs  SUPERVISION AND CONSULTATION Emergent holds and medical consultation Complex system navigation questions Conservatorship testimony Client death RESOURCES Challenges for Psychiatry in Serving Homeless People With Psychiatric Disorders | Psychiatric Services (psychiatryonline.org) Psychiatry on the Streets-Caring for Homeless Patients - PubMed (nih.gov)  Implementing the Street Psychiatry Model in New Haven, CT: Community-Based Care for People Experiencing Unsheltered Homelessness - PubMed (nih.gov) L.A’.s first street psychiatrist makes his sidewalk rounds, transforming homeless lives - Los Angeles Times (latimes.com) Assertive Community Treatment as an Evidenced-Based Practice: US Department of Health and Human Services, Office of the Inspector General - Assertive Community Treatment Case Western Reserve University, Center for Evidenced Based Practices - Assertive Community Treatment Substance Abuse and Mental Health Services Administration, Assertive Community Treatment (ACT) Evidenced-Based Practices (EBP) KIT (2008) Rapid Evidence Review (2016) Moving Assertive Community Treatment into Standard Practice SMI Advisor, A Clinical Support System for Serious Mental Illness, Key elements of ACT Maintaining Fidelity to ACT: Current Issues and Innovations in Implementation