History

The Program for Specialized Treatment Early in Psychosis (STEP) began as a pilot clinic in 2006 within the state-operated Connecticut Mental Health Center (CMHC), in New Haven. CMHC is a Local Mental Health Authority (LMHA), which hosts a public-academic collaboration between the Department of Mental Health and Addiction Services (DMHAS) and Yale University’s Department of Psychiatry. A multi-disciplinary group of social workers, nurses, psychologists and psychiatrists participated in the design and delivery of a specialized team-based service for recent onset schizophrenia-spectrum disorders (henceforth, first-episode psychosis, FEP).

The STEP clinic was modeled on successful services in Denmark and the U.K.,but made several adaptations to fit the resources available within a U.S. public-sector community mental health context³. STEP completed the first U.S. randomized trial (2007-’13) of such an FEP service and demonstrated improvements in relapse and vocational functioning vs usual care4. The results were validated by another study conducted in several community clinics across several U.S. states, and this model of care was subsequently termed Coordinated Specialty Care (CSC) by the National Institute of Mental Health (NIMH)5. The STEP clinic is recognized as a model CSC and its results were influential in subsequent research, program development and the launch of a federal funding initiative for FEP included within the 21st Century Cures Act (co-sponsored by Senator Chris Murphy). Since 2016, SAMHSA has required all U.S. states to allocate 10% of their Mental Health Block Grant (MHBG) funds to such FEP services. This has catalyzed an unusually rapid growth of early intervention services across the U.S.⁶

This clinic has remained continuously operational since 2006 and served as a resource to patients, families, clinicians, researchers and policymakers in Connecticut and has helped stand up new services in other U.S. states.

The STEP Learning Collaborative (STEP-LC) is Connecticut’s statewide learning healthcare system (LHS) for individuals aged 16-35 with recent-onset schizophrenia-spectrum disorders. The goal is to ensure that all persons with schizophrenia can live fulfilling lives by providing rapid access to high-quality treatment for those with recent onset illness. STEP-LC focuses on improving local pathways to care (PTC), reducing the Duration of Untreated Psychosis (DUP), and enhancing population health outcomes.

The STEP-Learning Collaborative leverages the STEP Program as a Hub that builds upon the existing network of 13 DMHAS state-operated and contracted Local Mental Health Authorities (LMHAs). Consistent with STEP’s population health-based approach, each LMHA has a designated catchment area and together the network can cover every eligible individual in the state, regardless of their location. In instances in which the designated LMHA only serves adults (18+), the local DCF-affiliated child guidance clinics are included in the network.

The STEP Program, housed within the Connecticut Mental Health Center (one of the LMHAs) acts as the organizing and expert hub (STEP-Hub) within the collaborative, while also hosting a clinical site (STEP Clinic), which models best practice care for the rest of the partner sites, and continues to conduct research to develop or improve interventions. Five regional Early Detection and Assessment Coordinators (EDAC) were recruited to support the initiative. The EDACs act as the main STEP-LC contact for both the LMHAs and individuals experiencing psychosis. EDACs lead early detection efforts in the region across stakeholder groups (e.g., hospitals, schools, community agencies, advocacy, judicial), capture new cases via a central referral line, assess eligibility, and support engagement into care at the LMHA.

Mindmap is an early detection campaign to improve pathways to care and reduce the duration of untreated psychosis (DUP).

STEP has been able to target access delays. Worldwide, the time from psychosis onset to treatment initiation (or the Duration of Untreated Psychosis, DUP) is often measured in years and has been recognized as a critical barrier to improving outcomes. Even excellent care can have a limited impact on the lives of individuals who access them too long after illness onset. Changing pathways to care in the complex U.S. healthcare system required a multi-year effort with a wide range of expertise including media communication, data analysis and community outreach. STEP completed the first (and so far, only) successful U.S. demonstration of early detection to reduce the Duration of Untreated Psychosis (DUP) across an entire geographic region. The NIMH-funded Mindmap campaign (2014-19) halved the DUP across STEP’s 10-town catchment from about 10 to 5 months.

On February 1st, 2024, the STEP Learning Collaborative launched the statewide Early Detection campaign, Mindmap. This included dissemination of a single referral number for early psychosis screening and referrals. LMHAs committed to accepting all eligible individuals experiencing FEP as quickly as possible, and regardless of insurance status, and to assist with statewide data collection.

STEP has deployed the results of these research projects into a comprehensive Early Intervention Service (EIS) that delivers both rapid access or early detection (ED) and high-quality care (CSC) to all residents of a defined geographic catchment. This population health based model organizes the efforts of STEP to engage all stakeholders within in its 10-town catchment area to help ensure that all new individuals experiencing FEP have rapid, humane access to high quality care that is available regardless of insurance status and to target any disparities in access or care quality based in membership within a vulnerable group (race, gender, socioeconomic class)⁸.

The STEP Program added to its initial clinical service activities to include: outreach and community stakeholder engagement, workforce development, research and healthcare policy.

In summary, Connecticut’s investment in early psychosis care has resulted in a program that has been recognized as a model service that has also produced research that has been influential in national policy. This work was featured by the NIH as a successful case study of successful knowledge translation⁹. STEP has been able to optimize use of state and federal implementation funds to stabilize its clinical and community services while also competing for research dollars (NIH, other foundations) to support testing and continuous improvement of its treatment and service models. This public-academic structure has thus been able to both provide high value care and drive research to develop new interventions.