State Partnerships for First-Episode Psychosis ServicesSusan M. Essock, Ph.D., Howard H. Goldman, M.D., Ph.D., Michael F. Hogan, Ph.D., Brian M. Hepburn, M.D.,Lloyd I. Sederer, M.D., Lisa B. Dixon, M.D., M.P.H.

The RAISE (Recovery After an Initial Schizophrenia Episode)Connection Program was a partnership that involved statemental health authorities (SMHAs) in Maryland and NewYork with research funding from the National Institute ofMental Health. The SMHAs collaborated with researchersto implement a team-based approach designed to servepeople with newly emerged schizophrenia to maximize

recovery and minimize disability. This column explains whystates are interested in first-episode psychosis services anddescribes the development of the successful partnership,financing mechanisms, and plans to add teams in bothstates.

Psychiatric Services 2015; 66:671–673; doi: 10.1176/appi.ps.201400117

TheRAISE (Recovery After an Initial Schizophrenia Episode)Connection Program was a state-academic partnership thatinvolved state mental health authorities (SMHAs) in Mary-land and New York. SMHAs collaborated with researchers toimplement a team-based approach, serving people with first-episode psychosis (FEP) (1,2). The National Institute ofMentalHealth (NIMH) provided funding to study FEP service imple-mentation in two states. This column describes development ofthese partnerships, states’ interest in FEP services, and financingof Connection Program treatment teams.

BUILDING ON HISTORIC PUBLIC-ACADEMIC RELATIONSHIPS

The RAISE Connection Program built on long-standing closepartnerships between SMHAs and public-sector mental healthservices research programs at Columbia University and theUniversity of Maryland. Descriptions of these partnershipshave outlined the history of SMHA support for evaluation andpolicy analyses, use of public mental health settings for conductof scholarly research, and products of those collaborations (3–6).

When designing theRAISEConnection Program, researchersworked closely with state partners to ensure that new FEPservices would fit within existing systems of care. SMHAs,in turn, committed to funding costs of the clinical teams, atleast during the research project, once federal funds wereexhausted. Originally, this was a substantial commitment, be-cause the initial randomized, controlled design involved foursites in each state, and federal funding could not support theentire service requirement. Eventually, because of federalfunding reductions, the RAISE Connection Program wasconverted to an implementation study with one site per state,with federal funds covering teams’ initial costs. Each SMHA,

however, committed to continuation funding for the FEP teamsand, ultimately, went on to fund additional sites.

Beginning in 2008, investigators preparing the RAISEConnection Program proposal considered how FEP servicesmight be delivered within public mental health service sys-tems. Study planners assumed that most individuals eligiblefor FEP services would not haveMedicaid or other insurancethat covered FEP services not found in routine benefit pack-ages (for example, supported education and employmentservices). Therefore, the emphasis was on using categoricalpublic mental health funding rather than relying on Medicaidor other insurance. The planning occurred before passage ofthe Affordable Care Act (ACA), which expanded Medicaid inboth states for single adults who were not already disabled.The ACA allowed us to change some assumptions about howbest to finance services, because it made health insurance, in-cluding behavioral health benefits, available to many individ-uals who would seek FEP services.

WHY ARE STATES INTERESTED IN FEP SERVICES?

A confluence of factors has increased interest in FEP ser-vices. Changes in health care financing stimulated by theACA increased awareness about problems associated withepisodic fee-for-service treatment of long-term disorders.Reports of the effectiveness of routinely available FEP ser-vices in many European countries, Canada, and Australia sup-ported a public health approach fostering early recognitionand referral to specialized services (1). Well-publicized in-stances of violence by young adults, however inappropriatelyassociated with FEP, have heightened public awareness ofthe paucity of readily available, youth-friendly mental healthservices. NIMH’s RAISE initiative focused attention on the

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negative consequences of long durations of untreated psycho-sis. Schizophrenia affects individuals across socioeconomicstrata and is thus well suited to an insurance pool in whichall members of a population participate at shared expense. Thepromise that specialized FEP services would reduce costs tostates and the federal government (direct health care expensesand disability payments) provides a fiscal incentive to promoteFEP services (1).

BASIC ASSUMPTIONS ABOUT IMPLEMENTINGFEP SERVICES

The goal of the project was to assess the implementationof the RAISE Connection Program in environments whereclients’ needs—rather thanwhat insurancewould cover—droveservice decisions. The project set expectations for FEP serviceteam size (25 clients) and staffing (full-time team leader andsupported employment–education specialist, .5 full-time equiv-alent (FTE) recovery coach, and .2 FTE psychiatrist), and teamswere charged with providing high-fidelity implementations ofthe intervention within those constraints (7). The study in-vestigated which participants received how much of whatservices, and the service design minimized fiscal incentives toover- or underserve. This “all comers” strategy allowed esti-mation of the impact of the availability of such services ona population basis independent of selection effects due toability to pay or availability of particular types of insurance.

The investigators and their public-sector service partnersmade several assumptions about how to implement and fi-nance the intervention. First, FEP services should meet theneeds of a defined geographic area and its population. Anyonein the area meeting the eligibility criteria would be offeredservices, regardless of insurance status. Second, a dedicatedteamwould provide FEP services; thus teams would be placedin population centers large enough to support a team (8). Third,the team would not be responsible for filling its own caseload;separate outreach and referral staff were responsible foroutreach and eligibility determination. This is consistent witha real-world model that requires teams to take all eligible in-dividuals referred as long as the team has an opening.

Fourth, in addition to funding for recurring costs, siteswouldneed funding for significant start-up costs associated with FEPservice implementation (for example, acquiring and furnishingspace, training the team, and staffing a team fully while it wasstill reaching a full caseload). Fifth, services delivered by theteam would include traditional, medically oriented psychiatricservices; support services, such as supported employment andeducation; and clinical case management—all carried out in acontext of shared decision making to enhance engagement and,presumably, outcomes. Sixth, clinical staff would meet weeklyas a team, separate from meetings with service recipients andfamily members, even though such meetings would not bebillable in routine practice. Seventh, teamswould be embeddedin existing mental health programs; RAISE Connection Pro-gram and local agency leadership would share responsibilityfor supervision and regulatory oversight, with the assumption

that local agencies would assume full responsibility at theconclusion of the study. Site selection was a joint effort be-tween project investigators and state leadership.

The eighth assumptionwas that, ultimately,Medicaidmightbe a financing mechanism for many of these services. We an-ticipated that some potential participants would be covered byMedicaid—on the basis of income and age, through TemporaryAssistance for Needy Families, or via some other state Med-icaid option for poor or medically indigent individuals—and that few, if any, would have Medicaid by virtue ofqualifying for Supplemental Security Income (SSI) benefitsdue to disability because individuals who received SSI be-cause of a mental impairment would be unlikely to qualify foran FEP program. By virtue of their meeting SSI’s disabilitycriterion, the duration of their illness would have been at least12months, bywhich time theywould have been ill for too longto meet the duration criterion for eligibility for FEP services(within a year of emergence of psychotic symptoms).

The SMHAs recognized that a potential benefit of in-vesting in FEP programs is that such programs might fore-stall the disability so often associated with schizophreniaand, therefore, could help individuals stay in school and em-ployed as opposed to requiring life-long state-funded services.The RAISE initiative and the SMHAs’ goals of reducingpsychiatric disabilities were, therefore, well aligned. Thepartnership involved training, support for implementingevidence-based practices, and evaluation and research activi-ties related to delivering behavioral health services. The col-laborative work between the SMHAs and their academicpartners also meant that a natural infrastructure was availableto train staff, implement the new services, monitor imple-mentation fidelity, and conduct required assessments.

START-UP AND EXPANSION TO ADDITIONAL SITES

Limited public resources in behavioral health characterizedthe period for planning and implementing the RAISE Con-nection Program. Indeed, the funding for RAISE came fromthe federal government’s stimulus plan in response to a re-cession. Despite this climate, leadership in both states rec-ognized the importance of FEP services and embraced theopportunity. Each state committed to paying the staffingcosts (approximately $250,000 per team), costs of psychotropicmedications for participants without insurance coverage for theprescribed medications, and modest flexible funding (approxi-mately $10,000 per team per year) for transportation and otheritems to facilitate treatment engagement. In addition, each stateprovided space and the overhead services associated with clin-ical space (such as security and housekeeping).

Both Maryland and New York State have opted to launchadditional FEP teams modeled on the RAISE ConnectionProgram. State leadership saw that the research had estab-lished the feasibility of such teams in routine practice settingsand the success of teams in engaging and retaining consumers.Further, participation in the program was associated withpositive outcomes, including enhancement of participation in

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school and work and reduction of clinical symptoms. NewYork State’s budget for the Office of Mental Health nowincludes $2.5million annually to facilitate the implementationof FEP programs as part of an initiative called OnTrackNY thatis a direct outgrowth of the RAISE Connection Program. Theinitiative in New York (practiceinnovations.org/CPIInitiatives/OnTrackNY/tabid/202/Default.aspx) is live in four sites, withplans to expand to an additional ten sites in the coming year. Infiscal year (FY) 2014, Maryland launched the Early Interven-tion Program, which combines funding for community out-reach, a range of services, and research on various aspects ofearly intervention in psychotic disorders. In FY 2015, the EarlyIntervention Program plans to train and implement two FEPservice teams modeled on the RAISE Connection teams and tocontinue the original RAISE Connection team site.

FINANCING FEP SERVICES

Because of the expense so often associated with people whohave been disabled by schizophrenia, states may bemotivatedto implement FEP services to forestall disability andmaximizerecovery. An increase in FEP servicesmeans an increased needto train providers to deliver these services, to measure per-formance to ensure availability of such services, and to financetraining and performance monitoring. For a fuller discussionof monitoring implementation fidelity and FEP financingstrategies, including an innovative financing model to alignpayment incentives with best practices, see the column byEssock and colleagues (7) and the Economic Grand Roundscolumn by Frank and colleagues (9). In addition, Goldmanand colleagues (10) reviewed financing approaches taken invarious U.S. settings in a column published in 2013.

CONCLUSIONS

The RAISE Connection Program in NewYork andMarylandbenefited from closeworking relationships between the SMHAsand university investigators. The basic financing plan used statemental health dollars and a public health approach to funda team todeliver FEP services to individualswith early psychosisregardless of insurance status in an effort to maximize recoveryand forestall disability that would result in increased disabilitypayments by the states. Media reports in the United States haveheightened public awareness of the need for appropriate treat-ment for youths with mental health problems, and the RAISEConnection Program has demonstrated how such treatment canbe implemented and sustained.

AUTHOR AND ARTICLE INFORMATION

Dr. Essock and Dr. Dixon are with the New York State Psychiatric In-stitute and the Department of Psychiatry, Columbia University Collegeof Physicians and Surgeons, New York City (e-mail: se2176@columbia.edu). Dr. Goldman is with the Department of Psychiatry, University ofMaryland School of Medicine, Baltimore. Dr. Hogan was formerly thecommissioner of the New York State Office of Mental Health, Albany. Dr.Hepburn is with the Mental Hygiene Administration, Department ofHealth and Mental Hygiene, Catonsville, Maryland. Dr. Sederer is withthe New York State Office of Mental Health, New York City. Fred C.Osher, M.D., served as guest editor of this column. This column is part ofa special section on RAISE and other early intervention services.

This work was supported in part with federal funds from the AmericanRecovery and Reinvestment Act of 2009 and the National Institute ofMental Health under contract HHSN271200900020C, by the New YorkState Office of Mental Health, and by the Maryland Mental HygieneAdministration, Department of Health and Mental Hygiene.

As part of the RAISE Connection Program, Dr. Essock, Dr. Goldman, andDr. Dixon may be part of training and consultation efforts to help othersprovide the type of FEP services described here. They do not expect toreceive compensation for this training other than that received as part ofwork done for their employers. The other authors report no financialrelationships with commercial interests.

REFERENCES1. Lieberman JA, Dixon LB, Goldman HH: Early detection and in-

tervention in schizophrenia: a new therapeutic model. JAMA 310:689–690, 2013

2. Dixon LB, Goldman HH, Bennett ME, et al: Implementing co-ordinated specialty care for early psychosis: the RAISE ConnectionProgram. Psychiatric Services 66:692–699, 2015

3. Sundeen SJ, Goldman HH, Nieberding DJ, et al: The PracticeResearch Network: a successful collaboration in Maryland. Psy-chiatric Services 64:407–409, 2013

4. Hansen EB, Seybolt DC, Sundeen SJ: Building a successful public-academic partnership to support state policy making. PsychiatricServices 65:710–712, 2014

5. Covell NH, Margolies PJ, Smith MF, et al: Distance training andimplementation supports to scale up integrated treatment for peoplewith co-occurring mental health and substance use disorders. Journalof Dual Diagnosis 7:162–172, 2011

6. Salerno A, Dixon LB, Myers RW, et al: A public-academic partner-ship to support a state mental health authority’s strategic planningand policy decisions. Psychiatric Services 62:1413–1415, 2011

7. Essock SM, Nossel IR, McNamara K, et al: Practical monitoringof treatment fidelity: Examples from a team-based intervention forpeople with early psychosis. Psychiatric Services 66:675–677, 2015

8. Humensky JL, Dixon LB, Essock SM: An interactive tool to esti-mate costs and resources for a first-episode psychosis initiative inNew York State. Psychiatric Services 64:832–834, 2013

9. Frank RG, Glied SA, McGuire TG: Paying for early interventions inpsychoses: a three-part model. Psychiatric Services 66:678–680, 2015

10. Goldman HH, Karakus M, Frey W, et al: Financing first-episodepsychosis services in the United States. Psychiatric Services 64:506–508, 2013

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