As with all young adults, a central focus for Transition Age Youth and Young Adults (TAYYA) ages 16 to 25 with serious mental health challenges is building a life in the community. Doing so requires completing their education and getting satisfying work. If these young people have spent serious time in various service systems – mental health, child welfare, juvenile justice – more therapy is not high on their agenda. Young people with serious mental health conditions, who may have received services as children, discontinue them – either by dropping out or being forced out by eligibility changes, although consistent treatment can decrease symptoms and increase functioning.1
And, as with any innovative program initiative, challenges are numerous: how can the variety of essential services fit with what’s come online under New York State’s new Children and Family Treatment Support Services and even bridge to the adult system? How can managed care and health homes provide important infrastructure? How can technology support individual TAYYA and put the inter-agency pieces together across mental health, child welfare, justice, education, and vocational systems?
The goal, after all, is a young adult who has benefited from all of it. It’s up to the program implementers and funding mavens to put the pieces together behind the scenes.
Engagement and Building Relationships are the Essential First Steps. The first task in helping TAYYA is to engage them. Testing out effective approaches, SAMHSA is funding drop-in centers via its Healthy Transitions initiative. Such centers emerged from the consumer mental health movement; they create safe and welcoming spaces for consumers to interact with peers. They offer an informal structure without a lot of restrictions or parameters and are designed also to provide easy access to behavioral health services and supports.2 In Framingham, Massachusetts, a state-funded Tempo Young Adult Resource Center provides a one-stop resource center for young adults, with laundry facilities to support their community life and computers for finding work.
The Florida Healthy Transitions Project, in Tampa and surrounding areas, meets potential clients in public places such as malls where young adults hang out. Its staff is 80% young adult peers. They also work with the local hotline to identify young adults in crisis or other need, use social media, and canvass in the community to identify young adults and engage them in services. In Oklahoma, mental health program leaders build connections with local businesses and engage with people in business to find young adults who have severe mental health conditions through the many other community organizations. More complex engagement strategies deploy multiple components.3
With engagement central to working with this age group, principles of good practice emphasize relationships built on a positive developmental approach, a focus on self-determination and self-efficacy, and work on multiple domains of functioning.4 Positive developmental interventions seek to restore or enhance developmental processes that have been compromised by high levels of risk and trauma.5 Mental health recovery requires a shift in perception by the young adult so they can trust the worker and overcome mistrust and shame.6
The TIP Model Frames Integrated Approaches Built on Relationships. Early in the field’s development, the Transition to Independence Process (TIP) emerged as an empirically-supported systems model and it continues to serve as an overarching framework for organizing services and supports for TAYYA.7
The distinctive TIP Core Practice emphasizes engaging young people through relationship development, person-centered planning, and a focus on their futures, i.e., the one-to-one relationship that characterizes effective work with all youth. Research and best practices on disparate young adult topics affirm the centrality of this core practice of relationship development and of a focus on the young adult’s future.
Five Transition Domains and Sub-domains comprise the TIP concept. Three setting domains are: Employment/career, Educational opportunities, and Living situation. They are held together around domains of: Personal Effectiveness and Wellbeing that encompasses Community and Life Functioning.
Education and Employment Are Central to an Integrated Approach. Finding and keeping employment at a living wage is a top priority for youth who have experienced major public child-serving systems as a result of their emotional or behavioral difficulties, and is a powerful springboard for physical, emotional and mental health. TAYYA who found meaningful work became stable and successful in other ways.8
Opportunities are available for guiding TAYYA to employment in statutory initiatives such as the federal Workforce Innovation & Opportunity Act (WIOA) and state vocational rehabilitation agencies (in New York State, ACCES-VR). For TAYYA to take advantage of these opportunities, the key is a person-centered relationship with a trusted peer or other staff member, often in a mental health provider agency.
New research is supplementing employment strategies tailored to the TAYYA population. HYPE (Helping Youth on the Path to Employment) is a manual-based intervention to better assist transition-aged youth and young adults with mental health conditions to develop their careers. The goal is to gain competitive employment in the primary labor market and enable TAYYA to live meaningful and economically self-sufficient lives. HYPE is built off of the Individualized Placement and Support (IPS) approach to Supported Education by prioritizing education early in employment services.9
Getting to employment requires better education outcomes. More than 50% of students aged 14 or older with a mental health condition drop out of high school, which is the highest dropout rate of any disability group. Initiatives are now available to help such students stay in school and graduate. TEST (Translating Evidence to Support Transitions) works with special education to promote student-led IEPs, provide credits for career and technical education, and partner with community organizations to assist in transition planning, all of which have been shown to be effective in improving education outcomes for this population.10
Strategies Toward Integrated Care: With so much programmatic and service evidence, how can we build an integrated TIP-based system to enable TAYYA to make a life in the community?
Connect Explicitly with Triple Aim: An integrated strategy for services for TAYYA aligns with New York State’s triple aim for Medicaid: Improving the patient experience, improving the health of populations, and reducing per capita cost of care.
Improving outcomes for TAYYA depends on implementing a portfolio of connected work across not only the mental health and health systems, but across education, employment, and the justice system as well. With the TIP approach grounded in a care management platform, can Health Homes and new specific service options create the necessary range of supports and opportunities for young adults with serious mental health challenges? How can a focus on discovery (of future possibilities) and recovery (of skills and resilience) be funded?
Use Technology to Engage Individuals and to Make Inter-Systems Arrangements Work. Transition Age Youth and Young Adults with mental health conditions respond positively to technology. After all, it’s what these young folks live with and how they communicate.
Oklahoma’s TAYYA programs use refurbished iPads in a telehealth model; consumers like that. The technology has been helpful in responding to crisis situations across the state: a clinical professional communicates with the young adult in crisis situations. Responding to crises is an engagement strategy with this population to link them to on-going services. Patients also text with their providers. How can technology solutions make the difference in communications among young person, the Transition Facilitator, supported education or employment specialists in other systems and others working on behalf of the young adult?
Given the inter-systems nature of the TAY model, how can technology focus on outcomes the young person wants, using services across systems that historically don’t coordinate? Instead of counting service inputs in each domain, can technology help funders count human outcomes, e.g., patients’ improved health, contentment, and functioning in a variety of services and vocational programs? Collecting good data across systems can benefit from technology so that the focus remains on outcomes for the young adults, not systems inputs.
The Institute for Health Improvement, the Triple Aim’s architect, recommends: a change process that includes development of a portfolio of project work that is sufficiently strong to move system-level results, and rapid testing and scale up that is adapted to local needs and conditions.” (author italics).
A TIP-based initiative for TAYYA, with care management and integrated arrangements across systems, constitutes just such a portfolio. It is a key to achieve a good Return on Investment by launching TAYYA into productive adult life rather than keeping them dependent service-users for years.
Evelyn Frankford, MSW, is a New York-based consultant working on projects in several states, including for the NYS OMH, to improve outcomes for TAYYA. Contact her at Evelyn.Frankford@gmail.com.
Footnotes
- Munson, Michelle, PhD., et.al., Cornerstone program for transition-age youth with serious mental illness: study protocol for a randomized controlled trial. BioMed Central. 2016.
- SAMHSA Healthy Transitions, Now is the Time Technical Assistance Center. Designing and Implementing Drop-in Centers for Youth of Transition Age: Lessons Learned from the Field. No date.
- Munson, Michelle, PhD., LMSW, “Multi-Component Engagement Program: Considerations for Service Provision to Young Adults Early in their Recovery,” NYU Silver School of Social Work, Webinar, May 22, 2019.
- Walker, Janet, Seibel, Celeste, Jackson, Sharice, & Ossowski, John. Introduction to the Special Section: Positive Developmental Strategies for Engaging Emerging Adults and Improving Outcomes. July 8, 2016
- Walker, Janet, A Theory of Change for Positive Developmental Approaches to Improving Outcomes Among Emerging Adults with Serious Mental Health Conditions, J of Behavioral Health Services & Research. Feb. 19. 2015.
- Munson, Michelle, PhD., NYU Silver School of Social Work, Personal communication, Oct 28, 2018.
- Clark, Hewitt B. “Rusty” & Hart, Karen, Navigating the Obstacle Course: An Evidence-Supported Community Transition System, in Clark, Hewitt B. & Unruh, Deanne (Eds), Transition of Youth and Young Adults with Emotional or Behavioral Difficulties: An Evidence-Supported Handbook. 2009. Baltimore: Paul H. Brookes Publishing Co. For more information, see also the TIP website: www.tip.fmhi.usf.edu/.
- Evaluation of Tempo MetroWest Young Adult Resource Center, Framingham, MA, 2010.
- www.umassmed.edu/hype/
