C4 Innovations

Community & Behavioral Health | Recovery | Social Change

Critical Time Intervention

An episode of the “Changing the Conversation” podcast

Bebe Smith and host Jeff Olivet discuss how Critical Time Intervention (CTI)—a care coordination model—mobilizes support for vulnerable individuals during transitions.

August 31, 2020

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Erika Simon, Producer: [00:00] Hello and welcome to Changing the Conversation. While we take a brief hiatus from producing new episodes, we are re-releasing this fan favorite for your listening pleasure. We will be back soon with new episodes.

Erika: [00:12] Before we get started, we want to acknowledge that as our communities respond to the COVID-19 outbreak, this is a difficult time for everyone, especially for people who are marginalized and those providing health and human services.

Erika: [00:25] We are deeply thankful to all the health and human service providers and community leaders who are working tirelessly to keep people safe and well, and to help folks who are sick to recover. We appreciate you beyond measure.

Erika: [00:39] Please email us at info@c4innovates.com if we can support you or your programs in any way. All of us at C4 wish health and strength to you, your families and friends, and the people you work with.

Erika: [00:52] C4 is offering an online course, Understanding Critical Time Intervention, taught by Bebe Smith, for five Mondays beginning October 19th.

Erika: [01:02] For registration and more information about the course, visit c4innovates.com/cticourse.
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Jeff Olivet, Host: [01:14] This is Jeff Olivet with Changing the Conversation. Our topic today is Critical Time Intervention or CTI, and we are joined by one of the national experts on CTI, Bebe Smith. Bebe is a social worker and consultant and Critical Time Intervention trainer. She is calling us from Durham, North Carolina. Bebe, thank you so much for joining us.

Bebe Smith, Guest: [01:35] It’s my pleasure. I’m glad to be on with you today, Jeff.

Jeff: [01:38] Let’s just start at the beginning. I don’t want to make any assumptions that when our listeners hear the term CTI, that all of them know what that is. So can you just talk for a little bit about what is Critical Time Intervention?

Bebe: [01:50] Critical Time Intervention is an intensive case management model that’s designed for people who have complex social needs. It was originally designed for people who were experiencing homelessness and who had a mental illness, and it was designed to be offered at a time of transition. So kind of in the original creation of CTI, it was timed for when the person who was homeless and had a mental illness at the time that they were moving into housing. And the idea was that that was a critical transition, a critical time for the person and that if extra supports and connections to community could help make sure that the person would keep their housing and kind of make a successful transition for the long-term.

Bebe: [02:36] It’s also been used for some other times of transition for people who’ve been leaving psychiatric hospitals and for leaving prisons. There’s currently research that’s going on and using the model for people who are experiencing interpersonal violence. And there’ve been implementations with families and people with HIV. So it’s used in a lot of different kinds of settings and populations.

Jeff: [03:02] Many years ago, I was a case manager and working in the context of supportive housing. And I remember at this moment of transition that you describe, often people might really struggle. And I was working with individuals and families who were exiting homelessness into housing, many for the first time in years.

Jeff: [03:21] And faced a lot of difficulty during that transition, and a time that you imagine would be this sort of very happy, wonderful time, could also be a time of real isolation, disconnection from friends and social networks, and a restart to a new chapter in a person’s life. How does CTI functionally address the challenges that go along with these transitions?

Bebe: [03:52] Yeah, so I guess I see CTI as an intervention that focuses on making sure people’s basic needs are met. So like housing, access to resources in the community and to food and all those kinds of things, but it’s also delivered in the context of relationship and focused on engagement. The teams are generally led by a clinician or at least have a clinical supervisor for the teams. And I’ve always seen it as kind of a bridge between mental health services and services for people who are experiencing homelessness.

Bebe: [04:23] The CTI worker kind of walks alongside the person, but really does look at sort of practically what are the things that this person needs in their lives to just make sure they’ve got all the basics there and social connections? So the social connections might be to formal services in their particular community. Or it might mean kind of working to perhaps repair some relationships with family members that have been strained or to develop some new relationships or some new connections into the community where they’re now living. So it’s kind of flexible in that way.

Bebe: [04:57] I think for me too as a social worker, it resonated with my social work practice principles in terms of meeting the person where they were, looking at environmental interventions, as well as interventions with the individual, but then sort of starting where the person was. But also I’ve always been kind of a practical problem solver in my practice. So there’s a lot of that that goes along in CTI, but you’re sort of doing it in partnership with the person and supporting all those recovery principles as well.

Jeff: [05:29] CTI gives shape to what otherwise might be an amorphous blob of activity, right? It’s sort of a case management can mean many things to many people. Social work can mean many things to many people. And when I was doing case management work, it meant anything and everything for whoever needed it for as long as they needed it.

Jeff: [05:51] And it was very, very difficult to know where to put your energy, to draw out what was most important to the person who was seeking help. CTI provides a time limitedness to case management and team-based support. It also provides focus to it. Could you talk about how those two components of CTI play out for people? The time limitedness and the kind of clinical focus or social supports focus of it.

Bebe: [06:23] Yeah. So those are two things that are really key to CTI, that it is time limited and it’s focused. And the time limited piece, I think for me, when I was first learning about the model, was one of the hardest things to get my head around, because I had been used to working with people around the long-term. So the time limited focus of CTI doesn’t mean that some people do need things over a longer term period, but because CTI is timed around that transition, the overall goal is to have the successful transition. They might need some other things over the long-term.

Bebe: [07:00] So generally CTI is a nine-month intervention. There have been some variations and implementations that either have it as a shorter model or a longer model, as short as three months around specific people being discharged from a hospital. I’ve also heard of an intervention for transition-aged youth that lasted 18 months. But the idea is that it’s phase-based and time limited, and it’s more intense in the beginning of it. So you’re working very intensively in phase one that typically lasts three months and then the intensity will drop off over the phases, but that’s because you’re connecting the person to other things that they might need in their community and that makes sense for that person.

Bebe: [07:47] The other piece about CTI being focused is that rather than working on every aspect of a person’s life, you’re really focusing on what’s most important for that transition. So if we’re talking about sort of the classic CTI intervention for somebody who’s going into housing after a period of being homeless, the focus areas might include housing, making sure that they kept their housing and learned how to be a good tenant.

Bebe: [08:15] Access to income, which might mean disability benefits or employment. Access to medical care that might be a mental health care, or it might be primary care or substance use treatment. So the things are that you’re just focusing in on what’s most basic and then social connections. So every CTI team can kind of develop maybe five or six focus areas that are kind of the really the most basic and the most key things to lead the person to a successful transition.

Jeff: [08:49] The way you described the phases of CTI and the tapering off of the sort of CTI intervention and the tapering up of more community-based supports, it’s a shift for a lot of providers who, I think, programs are often set where there’s a sort of base level of support that’s provided. And if someone’s in crisis, then you ramp up that support. This sort of flips that on its head and says, “We’re going to start out with a lot of support, a lot of contact, frequent involvement, home visits, time with people.”

Jeff: [09:23] And then as that person’s support network gets built, be that clinical, formal supports, or more informal, friends and family and community and neighborhood, as those pickup, then the CTI team gradually withdraws itself. Is that a good description of how it works?

Bebe: [09:42] Yeah, that is a good description. And I think that CTI workers then need to be sort of very intentional in describing when they start working with clients is that, “We’ve got this time to work together. I’ll be helping you connect the things along this nine month time period, but then that’s when we will sort of step back.” So it’s sort of important about being clear that it’s time limited, but the nature of being time limited does focus the worker’s kind of sense of urgency. We’ve got to get some things moving to get this person what they need to support them over the long-term.

Bebe: [10:21] And I really liked, when we were doing an implementation of CTI in Chapel Hill, I really liked having that first phase, that first three month period, because it really gave you the opportunity to get to know the person very well and to know what their connections were and where there might be some new connections to make or maybe even a particular service in the community that they might benefit from, that they perhaps hadn’t been connected to.

Bebe: [10:50] So it kind of gave the worker a good chance to really assess what’s going on here and doing that in partnership with the person and certainly following their preferences about what they want to be connected to as well.

Jeff: [11:02] You’re clearly very knowledgeable and passionate about CTI. I’m curious about how you got interested in it in the first place. How did CTI hook your curiosity?

Bebe: [11:12] Yeah. So I think that my interest in CTI really started up and the context of what was happening in mental health policy and the state where I live, which is North Carolina. And we had embarked probably in the early 2000s on a mental health reform path, which essentially meant privatization of community mental health system that actually had been a pretty good one, and it was a major shift and a major change.

Bebe: [11:38] And at the same time that we were privatizing services, we were also seeing cutbacks in funding, and we were a state that did not expand Medicaid. So we were seeing this kind of a contraction of services available in our community. And at the time, I was working in a specialty clinic for people with psychotic disorders, and we were seeing more people in our community who were having complex social needs going along with their need for mental health treatment.

Bebe: [12:08] And as part of my practice as a social worker, I’d always looked at the social needs. I’d helped people find housing. I had helped people apply for disability benefits and all those sort of practical things that went along. And we were finding it harder and harder to get people that kind of help. And our state also went through shifting to managed care, and in the shift to managed care, there was an elimination of a basic case management service in the state.

Bebe: [12:35] So that’s when I sort of had a professional existential crisis. How do we help the people who are coming to us in our clinic with lots of pressures on us for doing services that were billable? So then I kind of came upon CTI and thought, “Well, this is a time limited evidence-based practice.” And perhaps there would be some support for it. So we were able to apply for a grant from a foundation in North Carolina and got funding to do a pilot of CTI back in 2012. And so that pilot lasted from 2012 to 2015, and that was really our opportunity to learn about CTI.

Bebe: [13:15] And in fact, one of the first things we did when we got the grant was take the course, the online course on Critical Time Intervention through the Center for Social Innovation. And we kind of had some other partners that we sent through that training as well. And I started talking to state policymakers in North Carolina to our officials at the Division of Mental Health and Developmental Disabilities and Substance Abuse Services. And they got interested in Critical Time Intervention as well and decided to adopt the model for a statewide expansion.

Bebe: [13:52] So back in 2014, 2015, 2016, there were some funding available from the state to start up new teams and some efforts at training and dissemination in the model as well. So that was exciting to see that. It wasn’t the answer to all of our challenges in our mental health system in North Carolina, but I do like to think about CTI as being one solution to some of the things that we were seeing.

Jeff: [14:21] And can you talk about some of the challenges to implementation? I mean, you described this process by which the model was implemented across the state and your role in that. What were some of the bumps in the road along the way?
Bebe: [14:35] So I think one of the things that drew me to CTI in the first place is that it was a kind of a structured, but flexible model, and built into it were social work practice principles that made it appealing to me. I think when it became a shift to being defined in a state service definition, it lost some of its flexibility. So I think that’s a challenge, and sort of, how do you take an evidence-based practice and make it something that is billable to Medicaid or to state funds?

Bebe: [15:05] The other pieces that we also saw, CTI was going to work best if it was in a context where there was a wide range of affordable housing available, for instance, and other services that might support people with a high degree of complexity in their needs. And we were seeing quite a shift in the housing environment as well. And even over the course of our pilot from 2002 to 2015, in our local community of Chapel Hill, which is a college town that draws in a lot of retirees and a lot of affluent people, we were seeing kind of a shrinking of the affordable housing supply. Everything is connected. So that was a challenge as well.

Bebe: [15:51] I think in terms of implementing evidence-based practices of figuring out how do you get the training to people, how do you get good training to people? How do you sustain training efforts and what do you do about monitoring fidelity to the model?

Bebe: [16:09] Some of the things that I’ve appreciated about CTI and working with the Center for Advancement of CTI at the Silberman School of Social Work, that’s Dan Herman and Sally Conover, is that they’ve been very collaborative, and they have developed tools that support communities and agencies and states in implementing CTI. And I’m doing kind of a fidelity self-assessment for teams as they start up. And they were interested in doing CTI to good fidelity to the model. And so their tools are available and fairly simple to use.

Jeff: [16:47] You spoke earlier about the online training course, you are now an instructor of that course, and you offer online courses on Critical Time Intervention. What is your approach to teaching that course, and what can participants expect when they take one of your courses?

Bebe: [17:03] I’ve actually been very pleased to be able to teach the course through C4. When we had our grant, we had each year of the grant, we had people go through the course. So I got pretty familiar with it and then was asked to co-teach it and now I’m teaching it. I’ve been teaching it solo for the past few years. So it’s material that I’m very familiar with. I actually do some case-based training, both with taking an individual through the model to kind of demonstrate what the phases might look like for a person who is going through CTI.

Bebe: [17:34] And then I also do case-based implementation examples using what we did in Chapel Hill several years ago, and kind of looking at well, if you want to bring this to your community, what are the steps you might want to go through? What are the partnerships you need to build? How do you get buy-in? How do you let your community know that you’re doing this particular model? And what are the things that you might need to think about as an agency that’s working towards implementation?

Bebe: [18:02] It’s a nice interactive course. That’s something that I’ve also worked hard on getting people to interact and ask questions. And in the final class, we have all the participants give a presentation on what CTI might look like if they’re implementing it in their agency. And that’s kind of my favorite of the classes because I hear from people all over the US and sometimes from other countries. We’ve had people from Canada and from the UK go through courses through C4. And that’s always interesting to have an environment where people can be learning from each other.

Jeff: [18:42] And what advice would you have or what guidance would you have for people who are interested in CTI and not quite sure if it’s the right fit, if it’s the right intervention for them? Where would you tell people to start?

Bebe: [18:54] I mean, I think starting with the online course is a good thing. I think that C4 also offers some maybe shorter introductions to the model, but the online course, which goes for five weeks, is a good place to learn the basics of CTI. There are also opportunities for face-to-face trainings, and I’ve done a number of those in a number of different states as well. And for agencies, I would encourage people who are interested in implementing CTI to connect with other people, either in their state or in their communities who are doing the model, to learn from them and to maybe even build kind of their own learning collaborative, to keep on learning from each other.

Bebe: [19:36] I think when we did our implementation, we were lucky because we were based in a university. The team was actually based in an academic department of psychiatry, but we also had a strong connection to the School of Social Work. So we had a number of graduate students who were able to work with the team as interns, and they helped guide us through some fidelity assessments.

Bebe: [19:59] So we kind of created a learning team, but we started out just by doing it. Okay? And then we refined how we did it. And I would say that we got better doing it as we went along. So I think kind of building in your own kind of learning community, but finding all the resources that you can. That’s a good strategy for implementing evidence-based practices.

Jeff: [20:21] I have one last question for you and that has to do with the human impact of CTI. What happens for people? What difference does it make? Why do it in the first place?

Bebe: [20:32] The most significant impacts I saw, and I guess if I think about a couple of women that I worked with, I kind of connected with them first at the point in time when they were homeless, and then they got housing, and there was so much to kind of rebuild in their lives. I think about one woman that I worked with when she moved into an apartment, she got a permanent supportive housing voucher. Her first night and her new apartment, some of her friends in the community actually had a slumber party to support her as kind of a celebration. That’s not the typical thing you hear about, but she actually slept outside in a chair. She didn’t sleep in her bed. And it took her a while to get used to sleeping inside. She was somebody who had been living in a tent for a couple of years.

Bebe: [21:24] And then one of the things that she told me early on is like, “I don’t know how to grocery shop.” So that became part of what we did. And it turned out that she actually knew a whole lot more than she thought she did. Because I just asked her, “What have you cooked before? What would you like to cook?” And she had a lot of ideas, and she was able to do some things, but a lot of it was kind of building some confidence and kind of getting new routines started, and kind of reassessing some of her relationships.

Bebe: [21:53] She was able to have more control over who came into her apartment than she had when she was living in a tent. So there were all kinds of changes that were happening over the period of time that she was working in CTI. And it wasn’t always a smooth line.

Jeff: [22:10] And it sounds like Critical Time Intervention provided the context in which much of that healing and reconnection could happen.

Bebe: [22:17] And I think that’s one of the key things about it being relationship-based is sort of thinking that change is going to happen within the context of relationship. And while you’re not doing sort of traditional talk therapy, you’re still building that connection with people and helping with the very practical things and walking alongside them.

Jeff: [22:37] Bebe Smith. Thank you so much for your work and thank you for joining us today.

Bebe: [22:40] Oh, it’s been my pleasure. Thank you, Jeff. Thank you for all you do too.

Jeff: [22:44] I appreciate that. To our listeners, join us next time on Changing the Conversation.

Erika: [22:49] Want to know more about CTI? C4 is offering an online course, Understanding Critical Time Intervention, taught by Bebe Smith, for five Mondays beginning October 19th. Registration and more information about the course can be found at c4innovates.com/cticourse.

Erika: [22:39] Visit c4innovates.com and follow us on Twitter, Facebook, and LinkedIn for more resources to grow your impact. Thank you for joining us. This episode was produced by Erika Simon and Christina Murphy. Our theme song was written and performed by Peter Hanlon. Our hosts are Jeff Olivet and Kristen Paquette. Join us next time on Changing the Conversation.

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