Many persons with serious mental illnesses (SMI) and a history of psychiatric hospitalizations are struggling with a cycle of institutional recidivim (repeated hospitalizations, incarcerations, and homelessness) and a lack of personal recovery. These problems are in part driven by fragmented, inaccessible community services; unengaged local stakeholders who could be partners in community support after hospitalization; frequent police contacts and poor communication between mental health and the police; and limited recovery support. For many, the promise of modern conceptualizations of recovery remains an unrealized promise. The Opening Doors to Recovery (ODR) model was developed to help such persons reduce institutional recidivism and engage in recovery. It does this by providing the participant with community support from a team of three Community Navigation Specialists (CNSs): a licensed social worker (the Professional CNS), a peer specialist with lived experience (the Peer CNS), and a family member of someone with SMI who has experience with the stress imposed on family members by the SMI and a complex, fragmented mental health system (the Family CNS). This team provides community navigation (mapping of all available community resources) and is embedded within the local community. They also provide ongoing recovery support by focusing on: (1) ensuring adequate treatment, (2) maintaining safe housing, (3) developing a meaningful day, and (4) using technology to support recovery. At least two other features of ODR distinguish it from other community-based services: a group of collaborative local partners is committed to supporting ODR and the work of the CNSs, and a novel linkage system with the police allows CNSs to respond immediately when one of their clients has an encounter with local law enforcement. All of these components of ODR work together to reduce institutional recidivism and promote recovery. Through a large-scale pilot/demonstration project involving 100 participants, we have demonstrated all aspects of feasibility, thoroughly established acceptability from diverse stakeholders, and shown promising effects in terms of reduced hospital stays and enhanced recovery. ODR is now ready for a more definitive randomized, controlled trial, and the research team is ideally suited and highly experienced to carry out such a trial. We will randomize 240 persons with SMI and a history of >2 inpatient stays in the past 6 months to ODR (n=120, followed for 12 months, with a maximum CNS caseload of 40) versus the existing Community Support Team (CST) model (n=120). Assessments will be conducted at baseline (at hospital discharge), and at 4, 8, 12, and 18 months. Our hypotheses center on ODR participants having fewer days of hospitalization, fewer arrests, better housing outcomes, and greater recovery, the latter measured with a diverse set of recovery measures (e.g., community adjustment, mental health recovery, community navigation competencies, meaningful day activities, hope, and empowerment). If our hypotheses are proven, we will have the needed evidence to move forward with dissemination activities for this new service model.
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