OnTrackNY's Learning Healthcare System

This application proposes OnTrackNY as a regional scientific hub for the Early Psychosis Intervention Network (EPINET) program as part of NIMH's creation of a national learning health care system (LHS) for early psychosis care. As a continuation of the NIMH-supported RAISE-Implementation and Evaluation Study, OnTrackNY has grown into the 22-site (and still expanding) network under the leadership of Lisa Dixon, MD, MPH. OnTrackNY is a nationally recognized model for providing CSC for adolescents and young adults within two years of the onset of non-affective psychosis. OnTrackNY sites are located in licensed outpatient clinics at community agencies, state-operated facilities, and community and academic hospitals in urban, suburban, and rural areas throughout New York. This network has served over 1,600 individuals to date, with 451 new enrollees in calendar year 2017. Thanks to its sponsorship by the New York State Office of Mental Health (OMH), OnTrackNY has progressed to meet its goal of providing CSC to any young person with early psychosis in New York State, regardless of ability to pay. OnTrackNY includes OnTrackCentral-the "hub"-a team of nine staff, who provide training and technical assistance to sites and manage data collection, and the 22 teams which are its "spokes." From its inception, OnTrackNY has sought to deliver high-quality, data-driven, accountable care consistent with an LHS. (See Facilities for details on sites.)

The Foundations of a LHS in OnTrackNY: Several factors facilitated OnTrackNY's LHS foundations: 1) OnTrackNY evolved from the data-oriented RAISE-Implementation and Evaluation Study; 2) its location within the Center for Practice Innovations, an OMH-funded and empirically driven technical assistance center for scaling up evidence-based practices housed within Columbia Psychiatry; and 3) a strong commitment by OMH to high quality, accountable care. OnTrackCentral obtains stakeholder input from clinicians, program directors and state administrators. All OnTrackNY teams are contractually obligated to follow established protocols requiring specific service components and standardized client- and site-level measures for treating first episode psychosis (FEP). OnTrackCentral provides ongoing technical assistance to support the model, identify programmatic gaps and problems, and facilitate practice-based learning and research.

The Opportunity for OnTrackNY to Build a Better LHS: EPINET provides the opportunity to leverage the nascent LHS foundations of OnTrackNY and build a large, state-of-the-art LHS for early psychosis care. The investigators propose to expand and restructure the continuous quality improvement (CQI) process to: (Aim 1) include key stakeholders at every phase of the LHS and (Aim 2) provide accurate and appropriate delivery of real-time data to clients and providers to facilitate measurement-based care.

LHS Frameworks and Conceptual Model: This LHS is based on the principles of the Institute of Medicine's (IOM) (now National Academy of Medicine) model for a continuously learning healthcare system which brings together stakeholders to review data and technologies to develop and apply strategies to improve quality and increase efficiency. The investigators will use the IOM's LHS model, operationalizing the components according to the six LHS phases described by the Group Health Cooperative. While this LHS model provides an aspirational roadmap for a cyclic improvement approach, significant knowledge gaps limit translation and implementation of knowledge into evidence-based communications, campaigns, guidelines and other tools, products, and interventions. The investigators will draw on the Knowledge to Action (KTA) framework, which guides knowledge translation and implementation activities within each phase of the LHS model. The KTA planning tool directs knowledge creation and action cycles through questions for stakeholders to consider during each LHS phase. Through an iterative process, knowledge creation begins with stakeholders, data and mixed methods practice- based research during the LHS Scanning and Surveillance phase. The Action Cycle outlines a process, representing the activities needed for knowledge to be implemented in practice. Knowledge is adapted to the local context, and barriers and facilitators to its use are explicitly assessed. Stakeholders are centrally involved in tailoring knowledge and interventions to those who will use it.

This proposal will thus build a stakeholder-driven LHS that will establish the data infrastructure needed to promote measurement-based treatment within a structure supporting continuous quality improvement which, in turn, supports practice-based research-with the overall goal of improving care and outcomes for individuals with early psychosis. This EPINET-supported LHS will create an engine to optimize the potential of CSC to improve the lives of people with schizophrenia.