BEST PRACTICES
Use of Peer Staff in a Critical Time Intervention for
Frequent Users of a Psychiatric Emergency Room
Ilana R. Nossel, M.D., Rufina J. Lee, M.S.W., Ph.D., Abby Isaacs, M.S., Daniel B. Herman, M.S.W., Ph.D., Sue M. Marcus, Ph.D.,
Susan M. Essock, Ph.D.
Project Connect, a clinical demonstration program developed
in consultation with the New York State Office of Mental Health,
adapted critical time intervention for frequent users of a large
urban psychiatric emergency room (ER). Peer staff provided
frequent users with time-limited care coordination. Participants
increased their use of outpatient services over 12 months,
Frequent users of emergency rooms (ERs) for psychiatric
reasons consume disproportionate health care resources, with
limited benefits to health outcomes (1). Frequent users’
psychiatric illnesses are often compounded by homeless-
ness, substance abuse, and lack of follow-up care, leading
to destabilization, rapid return to the ER, and ER over-
crowding. To improve outcomes and maximize efficiency,
health care systems must find new strategies to engage fre-
quent ER users in outpatient services that promote recovery.
Critical time intervention (CTI) provides time-limited
care coordination to help vulnerable individuals transition
from institutional to community settings by increasing sup-
port during the “critical time” of transition. The model’s
effectiveness is well documented (2–5), and it has been
implemented in diverse settings serving persons with mental
illness, substance use problems, and homelessness. Conceptu-
alizing ER discharge as a critical transition, Project Connect,
a clinical demonstration program developed in consultation
with the New York State Office of Mental Health (NYS
OMH), adapted and implemented CTI for frequent users of
a large urban psychiatric ER. The program used peer staff
to increase the intervention’s acceptability to frequent users,
many of whom were homeless. ER data indicated that 40%
of frequent users had current or past homelessness. The
program’s goal was to connect frequent users with follow-up
services to decrease their reliance on the ER. Here we report
on the implementation and evaluation of the program.
Project Connect
The model. Three full-time peer CTI specialists, a half-time
clinical director, and a psychiatrist (.1 FTE) staffed the
Psychiatric Services 67:5, May 2016
compared with a similar group not enrolled in the program. For
persons with significant general medical, psychiatric, and social
needs, provision of this intervention alone is unlikely to reduce
reliance on ERs, especially among homeless individuals.
Psychiatric Services 2016; 67:479–481; doi: 10.1176/appi.ps.201500503
program. Peer specialists, who had experienced mental ill-
ness, substance abuse, or homelessness themselves, carried
caseloads of approximately 15 clients. Clients were eligible to
receive services for up to six months after leaving the psychiatric
ER at Columbia University Medical Center, which in 2010 had
approximately 4,500 visits annually.
CTI has two goals: to provide support and practical assis-
tance during a transition and to strengthen individuals’ long-
term ties to services and supports. Peer specialists met with
clients in the community, using assertive outreach strategies to
engage and develop relationships; identify reasons for repeated
ER use; obtain ongoing mental health and substance abuse
treatment, insurance, entitlements, housing, and vocational
training; and facilitate reconnections with social supports.
Implementation. Startup included hiring staff, obtaining
stakeholder input, adapting the CTI manual for peer work-
ers’ use with frequent ER users, building relationships
with ER staff and community providers, and developing
a resource guide. Adaptations included shortening the in-
tervention from nine to six months to increase program ca-
pacity. Experienced peer staff were recruited without difficulty.
They had significant work experience as case managers, sub-
stance abuse counselors, and outreach workers. They received
CTI training and weekly clinical supervision. They had flexi-
bility regarding when and whether to identify themselves as
peers to clients and others.
Each month, program staff used ER data to update lists of
frequent users (three or more ER visits in the prior year) (6).
Individuals with dementia or developmental disabilities or
who lived outside New York City were excluded. If a Project
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BEST PRACTICES
FIGURE 1. Use of behavioral health outpatient services (days
per month) for Project Connect participants (N547) and a
comparison group (N550)
3.5 Comparison
3.0
Project Connect
2.5
2.0
Days
1.5
1.0
.5
0
1 2 3 4 5 6 7 8 9 10 11
Months from study entry date
Connect slot was available when an eligible individual ar-
rived in the ER, a peer specialist approached the individual
to describe the project and offer enrollment. Eligible individ-
uals who entered the ER when none of the 45 slots were open
received usual care. Enrollment occurred between February
2009 and April 2010. Project Connect enrolled 75 clients, of
whom 55 provided informed consent to have their service use
data reviewed; Medicaid claims data were available for 47.
Because we could not examine data for nonconsenters, we
could not determine differences with consenters.
Peer specialists advocated for high-quality discharge
plans that addressed clients’ needs, helped problem solve
before the first follow-up appointment, and assisted them
when aftercare arrangements fell through. Peer specialists
provided “safety nets,” working intensively with clients after
discharge until stable plans were implemented. Peer spe-
cialists focused on facilitating engagement in psychiatric
treatment, enhancing motivation for substance abuse treat-
ment, facilitating access to medical care, finding housing,
providing assistance in obtaining benefits, increasing family
involvement, teaching self-management skills, encouraging
return to work or school, and enhancing hope. Guiding princi-
ples included time-limited, flexible assertive outreach and en-
gagement; recovery orientation; shared decision making; cultural
competence; harm reduction; and motivational enhancement.
Evaluation. According to supervisory staff and ER clinicians,
peer specialists were well received by clients, engaged those
who had been difficult to engage, and helped foster rela-
tionships between clients and community clinicians. Ini-
tially, some ER and inpatient staff were skeptical about
working with peers; however, they quickly came to value
peers’ contributions, sharing their feedback with program
leadership.
Within three months of Project Connect admission, re-
search staff approached clients to request informed consent
for accessing their data. We used Medicaid claims data to
compute the number of emergency visits, inpatient hospi-
talizations, and outpatient mental health services for each
client before, during, and after the intervention and for a
480 ps.psychiatryonline.org
comparison group. For the comparison group, we identified
Medicaid enrollees in the ER database who were otherwise
eligible for Project Connect but who were not referred be-
cause of limited capacity, selecting 50 who entered the ER
immediately after a Project Connect slot was filled. The NYS
Psychiatric Institute Institutional Review Board granted a
waiver of consent to review service use data from this group.
Service use data were examined for three periods of Medicaid
eligibility: six months before enrollment, six months after
enrollment, and six months after completion. For the com-
parison group, we selected a comparable period six months
before and 12 months after an index ER visit.
We analyzed claims data from 47 consenting participants
12 and the 50-member comparison group using t tests and zero-
inflated Poisson regression models. Participants (N597)
were mostly male (N582, 85%), with mean age of 43611 years.
All were eligible for Medicaid on the basis of disability. Data
on race-ethnicity and homelessness were available only for
the 47 Project Connect participants. Thirty (63%) were
homeless at entry, and most were non-Caucasian (Hispanic,
N520, 42%; African American, N519, 41%; and other or
mixed race, N55, 11%). Although both groups were high users
of behavioral health services in the six months before study
entry, Project Connect participants had significantly more
inpatient and emergency services days than the comparison
group (p5.02). A larger proportion of Project Connect par-
ticipants had a substance use disorder, but the difference was
not significant (p5.07). These differences may be attributable
to the fact that individuals who used the ER more frequently
had more chances to arrive when a program slot was open.
Program participants had 1.45 times (95% confidence
interval [CI]51.02–2.07) the rate of use of emergency or
inpatient services (general medical or behavioral health)
than the control group during the six months after the index
ER visit. Both groups reduced use of emergency and in-
patient services .46 times (CI5.35–.61) per log-transformed
month. For both groups, intensity of service use in the six
months before the index ER visit significantly predicted
subsequent service use, with higher use at baseline pre-
dicting slower rates of decrease.
Figure 1 shows trends over time for outpatient service
use, which increased for Project Connect participants from
less than one day per month at study entry to about three
days per month at 12 months. The increased use extended
beyond the six-month intervention. For the comparison
group, use of outpatient services decreased over the
12-month period. Across both groups, individuals with
co-occurring substance use disorders engaged in outpatient
services .64 times (CI5.48–.84) less than those without co-
occurring disorders.
Discussion
Project Connect had two primary aims: to reduce use of ER
and inpatient services among frequent users of a busy urban
psychiatric ER and to increase their use of outpatient services.
Psychiatric Services 67:5, May 2016

Findings suggest that reductions in ER and inpatient service
use may reflect regression toward the mean. However, out-
patient service use increased significantly among Project
Connect clients, whereas it declined in the comparison
group, suggesting that the intervention may have met one of
its aims.
The results are similar to those of a study that used CTI
with veterans with serious mental illness after discharge
from inpatient psychiatric treatment (2). That study, which
did not focus on frequent ER users and did not use peers, also
found greater increases in use of outpatient treatment
postdischarge for the intervention group but no differences
in ER visits or hospitalization days. Two other studies of CTI
found that the intervention reduced psychiatric rehospital-
ization. One found that CTI reduced early rehospitalization
among individuals with recent readmissions (7). The other
found that CTI reduced rehospitalization among formerly
homeless individuals with severe mental illness (8). Other
studies of CTI have demonstrated its impact on decreasing
homelessness (3,5).
There are many reasons for frequent ER use for psychiatric
reasons. In addition to psychiatric needs, frequent users may
have unmet social needs, including housing instability, which
may increase ER use (9). Many have substance use problems.
For some frequent users, expedited access to housing may
reduce ER use.
Program leaders of Project Connect worked with high-level
policy makers at NYS OMH to inform them about the program,
system barriers identified, and lessons learned. At the request
of NYS OMH, project leaders described the model and shared
their experiences with leaders at local hospitals and com-
munity agencies. Peer specialists made presentations at a peer
specialist conference.
Conclusions
Our findings may be valuable for others seeking to address
the challenge of decreasing ER use and improving care
among frequent users. Using peer staff to engage frequent
ER users in time-limited care coordination appeared to
promote engagement with outpatient services. Nonetheless,
for persons with significant general medical, psychiatric, and
social needs and limited supports, provision of such a brief
Psychiatric Services 67:5, May 2016
BEST PRACTICES
intervention alone cannot be expected to reduce reliance on
the ER, especially for individuals who are homeless.
AUTHOR AND ARTICLE INFORMATION
Dr. Nossel and Dr. Essock are with the Department of Psychiatry,
College of Physicians and Surgeons, Columbia University, and with the
New York State Psychiatric Institute, New York City (e-mail: irn1@
cumc.columbia.edu). Dr. Lee and Dr. Herman are with the Silberman
School of Social Work, Hunter College, City University of New York, New
York City. Ms. Isaacs is with the Department of Healthcare Policy and
Research, Weill Cornell Medical College, New York City. At the time this
work was done, Dr. Marcus was with the Department of Biostatistics,
Mailman School of Public Health, Columbia University, New York City.
She is currently an independent consultant. Marcela Horvitz-Lennon,
M.D., M.P.H., is editor of this column.
The New York State Health Foundation partially funded this work. The
authors thank Sheila Donahue, M.A., and Carlos Jackson, Ph.D.
The authors report no financial relationships with commercial interests.
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