Supporting Transitions: Critical Time Intervention
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From research to practice, HRC takes a look at the Critical Time Intervention (CTI). CTI supports men and women who have experienced chronic homelessness with severe mental illness following discharge from hospitals, shelters, prisons and other institutions. Dan Herman of Columbia University’s Mailman School of Public Health, Dr. Llana Nossel of Project Connect, and peer specialist, Hermenio Maldonado share insights on helping people build critical support networks with the CTI model.
You have been discharged from the emergency room again and have no place to go. You are facing an overwhelming set of challenges including homelessness, substance use and mental health issues. A Critical Time Intervention (CTI) Peer Specialist who has both professional training and personal experience with these issues meets you at the hospital to help you to manage this critical transition. This begins the CTI model.
CTI is an empirically supported, time-limited case management model. It is designed to prevent homelessness among people with mental illness following discharge from hospitals, shelters, prisons and other institutions.
Columbia University developed the original model in conjunction with the New York State Psychiatric Institute, the National Institute of Mental Health, and the New York State Office of Mental Health. CTI provides emotional and practical support during critical transition periods and provides case management to strengthen an individual’s long-term ties to services, family and friends.
Dan Herman, a researcher at Columbia’s Mailman School of Public Health at Columbia University is working with Dr. Lana Nossel of Project Connect on a research study. The New York City study compares the outcomes of clients who receive CTI with those who receive regular care.
“CTI grew out of the direct experience of workers providing on-site mental health and social services in a couple of large municipally funded homeless shelters, such as big armories responding to the emergency of homelessness,” offers Herman.
Over time the city started to fund mental health and other services to see if they could extend beyond simply providing a cot and shelter. On-site services evolved and teams experienced some success in getting people stabilized. But they found that after the transitional period, many people were returning to the shelters or were homeless again. Trying to find solutions for the challenges of transitions was the impetus for the CTI model.
“We looked at the fact that maybe we were not doing enough in a thoughtful way to help people re-establish in new communities. We realized that people need help transitioning to maximize the chances that change will last,” said Herman.
To date, research in the field has focused mostly on men and women with severe mental illness who are transitioning from shelters and emergency rooms back into the community. Work is also being done to adapt and test the CTI model for transitions from other settings, such as following release from prisons and residential treatment facilities.
Important questions that remain include understanding how best to train people to deliver CTI and examining long-term outcomes. “We have followed people for 18 months to two years,” says Herman, “but it would be great if we could do a study that had a longer time frame.”
Currently work is being done to develop a training curriculum for the CTI model in collaboration with The Center for Urban Community Services. In addition, Herman’s group is working with partners to develop a web-based distance education curriculum to train more providers across the country in CTI.
In New York, Project Connect uses CTI in a pilot program serving men who are homeless after hospital release. The program is breaking new ground by working with peer specialists to build the primary relationship essential to CTI.
“We hired peer specialists for this work because one challenge is that clients have been in the system for years. The CTI specialist is charged with developing a relationship with the client very quickly. These are clients who have not connected to anything stable,” says Nossel. “Peer specialists have the unique ability to talk with clients about their lives and to help foster relationships very quickly.”
Peer specialists successfully engage clients, with unique resources to share from their own experiences. They are able to help clients envision how they would like to change their lives, and to work towards that goal.
Hermenio Maldonado is one of the Project Connect peer specialists. “I go with clients to their appointments. I encourage them and share with them what has worked for me. Recovery is real when they see it in me. They can see living proof. I give them motivation and the hope that they need. This is not coming from a book; this is coming from what I have experienced myself,” shares Maldonado.
Project Connect is also conducting an evaluation to see to what extent CTI would help with the use of community services. The study has enrolled 18 clients and will examine use of services before and after enrollment. It will also compare them with people who are not enrolled but eligible.
Working with CTI peer specialists has been very powerful. “They provide tremendous hope, motivation, and commitment to the work. Working with peer specialists provides ongoing motivation as clients talk about their lives and their desire for things to be different,” says Nossel.
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