19.2 RECOVERY THROUGH RELOCATION: FROM NURSING HOME TO COMMUNITY USING COGNITIVE ADAPTATION TRAINING

Abstract Background Texans with severe mental illness live 29 years less than other Americans and have more health problems earlier in life. Since 2001, over 46,000 Texans have returned home under the State’s Money Follows the Person program and federal demonstration grant. Despite this impressive achievement, people with mental health and substance use conditions continue to be institutionalized in nursing facilities (NF). Nationally, the number of NF residents under age 65 with a primary diagnosis of mental illness is nearly three times that of older residents. The Texas Money Follows the Person Behavioral Health Pilot (MFP-BHP), assists nursing facility residents with co-morbid mental and physical illnesses relocate into the community. The transition from institutionalization to independent living is a crucial time for treatment intervention to maintain independence and reduce high risk adverse outcomes, including hospitalization, exacerbation of symptoms or homelessness. Methods In addition to service coordination from Managed Care Organizations, participants receive Cognitive Adaptation Training (CAT) for six months in the nursing facility and one year in the community. CAT is a home-based psychosocial treatment utilizing environmental supports such as medication containers, signs, checklists and the organization of belongings to bypass deficits in cognitive functioning and cue and sequence adaptive behavior, to improve functional outcomes for individuals with mental illness. This demonstration project assessed the effectiveness of providing CAT to improve functional and social outcomes, measured at baseline, each three months for one year, and each six months post intervention for one additional year. Results Over 500 individuals have been transitioned into the community since 2008, with 60% maintaining independence. Findings indicate a significant improvement in targeted functional outcomes post facility discharge on the Multnomah Community Ability Scale (p<.0001), Social and Occupational Functioning Scale (p<.001) and the Quality of Life Scale (p< .01). Preliminarily analyses indicate that Medicaid costs for participants are considerably lower on average than costs prior to discharge. At the end of 2015, the savings to the state via the Pilot were tens of millions. The Pilot ends in December 2017 and final cost analyses will be conducted at this time. Discussion CAT was successfully applied to persons with co-occurring mental and physical disorders relocating from nursing facilities to independent living environments with good preliminary outcomes indicating better quality of life, social and occupational role function and in overall community functioning. The majority of persons have successfully remained in the community. The MFP Behavioral Health Pilot shows Medicaid participants residing in nursing facilities with significant mental health issues can successfully maintain their residence in the community which results in significant cost savings, even taking into account the standard MFP costs plus the intervention. MFP Pilot participants improved their functional status, which extended after the intervention period ended. Current implementation efforts are in place to integrate and sustain CAT in the statewide managed care system.

Behavioral Health Pilot, CAT has been used in conjunction with substance use treatment and managed care service coordination to assist people in moving from nursing facilities to community living. 65% of all enrollees in the program have sustained independent living at 1 year. Improvements in functional outcome are evidenced by significant improvement in social and occupational role functioning, community living and quality of life. In addition, cost savings to the state for these Medicaid recipients is sizeable. It takes only 1.4 additional months of community residence to recover intervention costs; 97% of participants met these criteria. Also in Texas, in a program for high utilizers of hospital and emergency services, CAT provided by bachelor's and master's level psychologists has been used to identify the unique cause of multiple hospitalizations and emergency visits, set up supports to address these problems, and reduce inappropriate service utilization. This program has reduced hospitalizations by 80% and saved an average of $40,000 per participant across 9 months. In Finland, CAT has been used to reduce the need for sheltered housing and for improving the quality of life for outpatients with psychosis. CAT has been found to fit well in the Finnish service system and providing interventions in the patient's daily living environment has been found to be more suited to the patients' need than traditional outpatient clinic visits. An outcome study is ongoing. In Australia, CAT has been adapted for the recent onset psychosis population by including greater use of technology and focusing on return to work and school. The versatility of the CAT program, its facility for training, and its ability to be adapted across cultures and countries suggests that CAT could be a useful tool in value-based care in which CAT is used to reduce the overall cost of care and to improve outcomes that matter to patients. Background: Cognitive Adaptation Training (CAT) has consistently demonstrated effectiveness in enhancing community functioning in clinical trials of its 9-month application by a specialist. This is a compelling development in the field as clinicians struggle to support gains in independent functioning among patients with schizophrenia. However, outreach interventions delivered by specialists are difficult to support in many contexts where investment in mental health care is insufficient for population needs. This presentation will describe research and implementation efforts that support the delivery of CAT in routine clinical practice. Methods: This program of work began with a feasibility study of a modified version of CAT. CAT was modified to decrease the duration of specialistdelivered CAT to 4 months, with the intervention subsequently supported by the individual's case manager who received rudimentary training and could consult specialists. Twenty-three people with schizophrenia participated in this study of symptom and functional outcomes, evaluating improvements after 4 months of CAT specialist intervention and after an additional 5 months of case manager support. Also described briefly will be (i) preliminary findings from a superiority randomized controlled trial of modified CAT in an early intervention population comparing CAT (n=25) with Action Based Cognitive Remediation (n=23) and (ii) efforts to build out CAT implementation in a tertiary facility enabled through the above clinical trial resources. Results: Analysis of feasibility study findings revealed significant improvements in adaptive functioning, psychiatric symptomatology, and goal attainment that were maintained throughout case management follow-up. Effect sizes for the specialist delivered period ranged from .33 (negative symptoms) to 2.01 (goal attainment scaling) with a modest decline in the follow-up period with community functioning remaining at ES=.66. Improvement in the large effect size range was also observed in community functioning in the trial of modified CAT in early intervention. In this period over 70 allied health clinicians were intensively training in CAT locally and regionally and a community of practice was established. These impacts were further extended through the development of an open-access CAT guide for families that can be used independently or with clinician support. Discussion: This study supports a model for extending the accessibility of CAT in settings that might not otherwise sustain the intervention as it was originally designed. Functional impacts similar to the original clinical trials were observed in a briefer period of specialist delivered CAT and show the promise of being largely sustained over an indefinite period by rudimentary-trained case managers in a consultation model. This observation would appear to apply to both early intervention and general schizophrenia populations. Additionally, this program of work has demonstrated how research-practice synergies can foster implementation that can be sustained after initial research investments.  (NF). Nationally, the number of NF residents under age 65 with a primary diagnosis of mental illness is nearly three times that of older residents. The Texas Money Follows the Person Behavioral Health Pilot (MFP-BHP), assists nursing facility residents with co-morbid mental and physical illnesses relocate into the community. The transition from institutionalization to independent living is a crucial time for treatment intervention to maintain independence and reduce high risk adverse outcomes, including hospitalization, exacerbation of symptoms or homelessness. Methods: In addition to service coordination from Managed Care Organizations, participants receive Cognitive Adaptation Training (CAT) for six months in the nursing facility and one year in the community. CAT is a home-based psychosocial treatment utilizing environmental supports such as medication containers, signs, checklists and the organization of belongings to bypass deficits in cognitive functioning and cue and sequence adaptive behavior, to improve functional outcomes for individuals with mental illness. This demonstration project assessed the effectiveness of providing CAT to improve functional and social outcomes, measured at baseline, each three months for one year, and each six months post intervention for one additional year. Results: Over 500 individuals have been transitioned into the community since 2008, with 60% maintaining independence. Findings indicate a significant improvement in targeted functional outcomes post facility discharge on the Multnomah Community Ability Scale (p<.0001), Social and Occupational Functioning Scale (p<.001) and the Quality of Life Scale (p< .01). Preliminarily analyses indicate that Medicaid costs for participants are considerably lower on average than costs prior to discharge. At the end of 2015, the savings to the state via the Pilot were tens of millions. The Pilot ends in December 2017 and final cost analyses will be conducted at this time. Discussion: CAT was successfully applied to persons with co-occurring mental and physical disorders relocating from nursing facilities to independent living environments with good preliminary outcomes indicating better quality of life, social and occupational role function and in overall community functioning. The majority of persons have successfully remained in the community. The MFP Behavioral Health Pilot shows Medicaid participants residing in nursing facilities with significant mental health issues can successfully maintain their residence in the community which results in significant cost savings, even taking into account the standard MFP costs plus the intervention. MFP Pilot participants improved their functional status, which extended after the intervention period ended. Current implementation efforts are in place to integrate and sustain CAT in the statewide managed care system.

APPLYING COGNITIVE ADAPTATION TRAINING IN FINLAND: INTERIM RESULTS OF THE FINNISH CAT IMPLEMENTATION PROJECT
Tuukka Mehtala* ,1 , Satu Viertio 2 , Eila Sailas 3 1 HUS; 2 National Institute for Health and Welfare; 3 Kellokoski Hospital Background: In Finland, approximately 50 000 people have a diagnosis of schizophrenia. In practice 6% of them reside permanently in mental hospitals. There is a national target to reduce the number of psychiatric hospital beds. However, as hospitals are closed there is a tendency to place schizophrenia patients in different types of sheltered housing instead of supporting them to live independently in the community. In the Danish OPUS-study 94 patients with first episode schizophrenia were followed and even those who had attended a vigorous rehabilitation program lived about two and a half months in sheltered housing in the fifth year after their diagnosis. Thus, with deinstitutionalization we are building up a poorly monitored system of sheltered housing for schizophrenia patients. This system may increase chronic need for support, is expensive and marginalizes a large section of people from the community. When service users are asked they usually prefer having their own homes. Cognitive adaptation training (CAT) is a home-based, manual-driven treatment that utilizes environmental supports and compensatory strategies to bypass cognitive deficits and improve target behaviors and functional outcomes in individuals with schizophrenia. Unlike traditional case management, CAT provides environmental supports and compensatory strategies tailored to meet the behavioral style and neurocognitive deficits of each individual patient. CAT has been shown to be effective in improving service users' ability live independently. Methods: The study started in 2014. After formal CAT training the program was implemented in the Hyvinkää Hospital and Helsinki University Central Hospital treatment catchment areas (approx. 1 350 000 inhabitants). For the study we selected patients that were in risk of moving to a more supported housing environment due to the presence of cognitive deficits that threatened their ability to live independently. The only exclusion criteria were heavy alcohol and drug abuse and known aggressive behavior. The outcome measurements include both qualitative and quantitative methods: transfer to a different type of housing, need for hospital treatment, psychiatric rating scales, observed measurements and open interviews, and are measured after 4 months after the start of the intervention, at the end of the 9 month intervention and after a 6 months follow-up period. Results: We report here preliminary interim results for the patients who have completed the study so far. Altogether 48 patients were selected for the intervention, which was found to be well-received with 7 patients dropping out. The mean age was 38.9 year, with 39.3 % women and 60.4 % men. 27.6 % were living independently, 22.9 % with their parents, and 29.6 % living in some form of sheltered housing. Participants had severe to moderately-severe psychiatric symptoms and functional impairment (mean GAF 47.8, mean SOFAS 54.8). Apathetic was the most common behavioral subtype (70.7 %), with disinhibited (14.6 %) and mixed (14.6 %) subtypes following. Discussion: Cognitive Adaptation Training can be used to help patients in a wide range of living situations and with severe psychiatric symptoms and functional impairment to maintain their ability to live independently.

CAT IN FIRST-EPISODE PSYCHOSIS: FEASIBILITY, ACCEPTABILITY AND POTENTIAL TO ENHANCE VOCATIONAL RECOVERY
Kelly Allott* ,1 1

Orygen, The National Centre of Excellence in Youth Mental Health
Background: Cognitive and functioning impairments are present early in the course of psychotic disorder and remain one of the greatest treatment challenges in this population. While Cognitive Adaptation Training (CAT) is found to improve a range of outcomes in chronic schizophrenia, it has received limited investigation in first-episode psychosis (FEP). CAT may be particularly useful for addressing vocational recovery in FEP because the cognitive impairments experienced by individuals with FEP predict poorer vocational outcomes and impede the effectiveness of vocational interventions such as supported employment. The aim of this presentation is to present the findings of a pilot study investigating the feasibility and acceptability of CAT in young people with FEP and to describe the clinical considerations and adaptations required when delivering CAT with this population. Preliminary findings on the potential value of CAT in improving vocational outcomes in FEP will also be presented.

Methods:
This was a single-arm feasibility study of CAT conducted at the Early Psychosis Prevention and Intervention Centre (EPPIC), Melbourne, Australia. Five FEP participants received 9 months of manually-guided CAT. A range of feasibility and acceptability measures were recorded, including participant and case manager satisfaction ratings. Participants' goals, functional needs and clinical observations and adaptations were also recorded. Formal measures of functioning, quality of life and motivation were independently administered pre-and post-intervention. Results: All participants completed the CAT intervention and session attendance rates were very high (95.3%). Participants and their case managers indicated strong satisfaction with CAT as indicated by overall positive mean ratings on the satisfaction items. CAT did not negatively affect existing case management, with case managers reporting that it enhanced their treatment. Vocational recovery (education, employment) was found to be a primary functional goal of most participants. Accordingly, the CAT intervention had a strong focus on vocational functioning, including functional domains that are requisite for successful work or educational outcomes, including organisation and planning, transportation and activities of daily living. Being mindful of factors that may be common in young FEP patients included cognitive heterogeneity, family involvement, flexibility in compensatory and environmental supports used, and the experience of stigma. There were mean improvements from baseline to post-intervention on most formal outcome measures, with the largest effects in global functioning, planning and organisation, and quality of life. Discussion: This study provides encouraging preliminary evidence that CAT is a highly feasible and acceptable intervention in FEP, which may be easily integrated within existing early intervention services. Vocational recovery is important to young people with FEP. CAT is an intervention that appears well suited to addressing this need. The effectiveness of CAT in improving functional outcomes, particularly vocational recovery in FEP warrants further investigation in a larger trial.

THE APPLICATION OF STEM CELL MODELS TO VALIDATE RARE AND COMMON VARIANTS CONTRIBUTING TO SCHIZOPHRENIA Kristen Brennand Icahn School of Medicine at Mount Sinai
Overall Abstract: As expanding genetic studies increasingly demonstrate that both rare variants of large impact and common variants of small effect contribute to schizophrenia, it becomes increasingly critical