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. Author manuscript; available in PMC: 2022 Oct 1.
Published in final edited form as: Early Interv Psychiatry. 2020 Nov 12;15(5):1376–1381. doi: 10.1111/eip.13070

Toolkit for assessing and addressing cognitive health in early psychosis: Evaluation of feasibility and utility in a coordinated specialty care setting

Alice M Saperstein 1, Alice Medalia 1,2, Igor Malinovsky 2, Iruma Bello 2, Lisa B Dixon 1,2
PMCID: PMC8272079  NIHMSID: NIHMS1716200  PMID: 33185025

Abstract

Aim:

Methods to identify and harness individual cognitive strengths while addressing relative weaknesses have the potential to complement recovery services for first-episode psychosis but systematic implementation is needed. We developed a cognitive health toolkit, trained teams from OnTrackNY, a network of coordinated specialty care (CSC) programs and examined toolkit feasibility and clinical utility during the first year of roll-out.

Methods:

The toolkit includes a clinician manual, assessment and decision-making tools, and a menu of cognitive health service options. Assessment uses the WRAT5-Reading subtest and a new Self-Assessment of Cognitive Functioning which, together, determine participant- and clinician-perceived cognitive health need. Program-level data were analysed for rates of assessment, identification of cognitive health needs and cognitive health service provision.

Results:

Data from 18 OnTrackNY teams included 933 participants, including 310 new admissions. Across teams, 43.9% of newly admitted participants received a WRAT5-Reading and 41.3% received a self-assessment. Of all assessments completed in the study period, 50.7% were at or within 3-months of admission and 69.1% were within the first year of program participation. Cognitive health need was identified by self-report (57.6%) and clinician-report (69.9%) and led to provision of specific services, including psychoeducation, compensatory skills training and in some cases restorative cognitive training.

Conclusions:

Preliminary feasibility data are encouraging but barriers to assessment need to be identified and addressed. Rates of identified cognitive health need warrant further study of the implementation process and outcomes so that cognitive health assessment and treatment practices may ultimately be disseminated to CSC programs more broadly.

Keywords: assessment, cognition, cognitive health, coordinated specialty care, first-episode psychosis

1 |. INTRODUCTION

OnTrackNY is a community-based coordinated specialty care (CSC) program in New York State that delivers early intervention services to young people, age 16–30, experiencing a first episode of non-affective psychosis. Multidisciplinary OnTrackNY teams offer a range of evidence-based treatments which are delivered in a personalized, culturally competent fashion to promote recovery (Bello et al., 2017). While OnTrackNY maintains the core evidence-based services encompassed by the CSC model, scientific updates on best practices and an evolving understanding of teams' experiences garnered through quality improvement evaluations, supervision and case consultations inform ongoing program development and training needs. Most recently, we identified a need to better address cognitive health in the context of OnTrackNY services.

Cognitive health refers to the brain's ability to support thinking, learning and the cognitive skills needed to perceive, acquire, understand and respond to information. This includes the abilities to pay attention, remember, process information, solve problems, organize and reorganize information and communicate. Research suggests the presence of cognitive impairment in at least 70% of people with schizophrenia (Keefe et al., 2005; Kremen et al., 2000), which is evident in a range of cognitive domains and manifest early in the course of illness (Bilder et al., 2000; Mesholam-Gately et al., 2009). Harnessing cognitive strengths and addressing relative weaknesses may mitigate the potential negative impact of cognitive impairment on community functioning (Bowie & Harvey, 2006; Bryce et al., 2019; Nuechterlein et al., 2011; Santesteban-Echarri et al., 2017), and support recovery. The efficacy of behavioural interventions that address cognitive dysfunction at the time of first episode are supported by the research literature (Kidd et al., 2019; Medalia & Saperstein, 2019; Mendella et al., 2015; Vidarsdottir et al., 2019, 2020).

In a program evaluation study conducted with 22 OnTrackNY teams operating in a diverse array of healthcare settings (Saperstein et al., 2020), we found that cognitive health assessment and treatment practices ranged in type as well as frequency. Importantly, while providers identified numerous facilitating factors that would support the adoption of such practices, lack of knowledge of how to discuss cognitive health emerged as a significant barrier. Thus, although data suggested that addressing cognitive health is acceptable and appropriate for the OnTrackNY program, we identified a need for systematic team training and provision of a standard set of tools and services with which to assess and address cognitive health for program participants. That study informed the development and piloting of a cognitive health toolkit for OnTrackNY. The aim of this article is to provide an overview of the toolkit and report data on its feasibility and utility during the first year of roll-out. We focused on studying clinician behaviour and program-level data ahead of examining client-level outcomes in order to gauge program-practice fit and inform the implementation process in community mental health settings (Dixon & Patel, 2020). We examined feasibility with completion rates of cognitive health assessments, and utility with rates of (a) identification of cognitive health needs and (b) cognitive health service provision. These data continue to inform training, supervision and service provision within the expanding network of OnTrackNY programs. Further, data will inform the development of benchmarks to gauge the effectiveness of quality improvement activities for improving rates of toolkit use. Ultimately, we aim to generate generalizable knowledge that may guide the integration of cognitive health assessment and treatment practices into CSC programs more broadly.

2 |. METHODS

2.1 |. Overview

OnTrack Central, housed at The Center for Practice Innovations (CPI) at the New York State Psychiatric Institute, an intermediary organization which oversees training, quality assurance monitoring and quality improvement activities for OnTrackNY, provided the infrastructure to support toolkit development and roll-out. Through its partnership with Columbia University Psychiatry, content experts (authors AS and AM) were identified to lead content development, deliver trainings and provide subsequent supervision. CPI has an online learning management system, accessible to OnTrackNY teams, that housed the toolkit including a manual, assessment and treatment materials (https://practiceinnovations.org).

2.2 |. Toolkit content

The goals of the toolkit were threefold: (a) to provide a rationale for addressing cognitive health, (b) provide a set of tools with which to assess and engage clients in shared decision-making around cognitive health, (c) offer resources to address cognitive health that would be acceptable to both clients and clinicians, and appropriate for this specialized setting. A toolkit manual describes the rationale for addressing cognitive health in first episode psychosis and provides a decision tree to guide assessment and decision making how to address cognitive health in the service of an individual's recovery goals. Assessment and treatment components are each described.

The assessment component of the toolkit aims to capture three elements of cognitive health: cognitive capacity, current cognitive functioning, course of cognitive functioning. Assessment tools needed to balance feasibility, that is, could be practically carried out in the context of routine evaluation by staff with varied professional training and clinical utility, that is, would inform individual needs. Cognitive capacity is assessed with the Wide Range Achievement Test—fifth edition Reading Subtest (WRAT5-Reading; Wilkinson & Robertson, 2017), a 5-min assessment which provides an estimate of general intellectual as well as a reading grade level. Interpreted alongside psychoeducational history and available collateral information, this brief test helps inform learning needs pertinent to program participation, school and work. For example, identification of a sixth grade reading level in a 22-year-old would trigger queries about developmental learning needs and inform educational goal setting; or a college reading level in a 16-year-old dropping out of school might suggest unrealized potential. The WRAT5-Reading subtest is to be administered once at the time of admission in the OnTrackNY program.

We developed the self-assessment of cognitive functioning, a brief (i.e., 5-min) questionnaire that queries participants' perception of their current cognitive abilities in the domains of memory, attention and critical thinking skills (Table S1). The measure is to be administered at admission and may be repeated at any follow-up session to capture evolving cognitive health needs. While acknowledging the limitations of relying on self-report of cognitive functioning (Medalia et al., 2008), we also recognized the importance of ascertaining clients' subjective experience of need to support shared decision making in the context of recovery-oriented care (Dixon et al., 2016). In contrast to existing measures that are deficit oriented, questions are framed in the positive and are oriented toward functioning, for example, “Do you think you could accomplish more if you could stay more organized, plan ahead, or manage your time better?” Additional items query perceived change from a previous level of functioning, when that change occurred, and to what factors the client attributes that change. Such questions appreciate that cognitive health is dynamic and has multiple determinants (e.g., mental illness, stress, sleep, substance use), all of which may be addressed in treatment. Summary items based on the assessment indicate whether the individual self-identifies cognitive health needs and the clinician believes, taking into account self-report, collateral information and observation, that cognition is interfering with daily functioning or goal attainment. An accompanying discussion guide includes prompts to (a) highlight both perceived strengths and areas of need as revealed by the assessment (b) link cognitive skills to functioning, and (3) fold cognitive health into recovery-oriented service planning (Table S2).In the case that a more comprehensive cognitive evaluation is needed to inform next steps, a referral is then made to a provider outside the team.

Service provision relies on shared decision-making, using the assessment results as a reference. A menu of cognitive health services recognizes that no one approach to cognitive health is right for all persons and accounts for the variable resources, knowledge and interests reported by OnTrackNY teams (Saperstein et al., 2020). The menu includes psychoeducation for program participants and for family members (Medalia & Revheim, 2002), compensatory skills training (Twamley et al., 2003) and a restorative approach to cognitive remediation (Medalia & Saperstein, 2019). Services can be flexibly implemented, for example, individually or in small groups, and are complementary to other recovery services as well as to each other. Services are provided by primary clinicians although other trained team members (e.g., supported education/employment specialist) are encouraged to reinforce skills that are learned.

2.3 |. Cognitive health training

Training was delivered to each team between May and December 2018 in a series of three interactive webinars. Training content supported the three goals of the toolkit. The goals of the first webinar were to define cognitive health and foster the adoption of a common vocabulary, raise awareness of how cognitive functioning impacts recovery by drawing from the research literature and case examples, and provide a ‘roadmap’ from assessing to addressing cognitive health needs. The second training focused on assessment followed by practice assignments and individualized feedback. The third focused on service options and delivery. Clinical trainers for OnTrackNY were simultaneously trained to support the integration of cognitive health services with other aspects of the OnTrackNY model (e.g., supported education/employment).

2.4 |. Data collection and analysis

OnTrackNY clinicians routinely complete standardized admission, follow-up, and discharge forms quarterly, based on chart review, measures and reports from clients and their families. A cognitive health form is submitted at admission (i.e., within 1 month of enrolment) and every subsequent 3 months for every OnTrackNY participant. Data collection and analysis were conducted as quality improvement activities, with program-level as opposed to identifiable individual-level data. The procedures were deemed exempt from Institutional Review Board review. Since the toolkit was rolled out gradually, we extracted cognitive health form data from each team to assess implementation following completion of training. The study period was defined as 10 months post-training to maximize the data available for analysis from teams to-date.

First, to assess completion rates of cognitive health assessments we queried the database to (a) determine how many participants admitted during the study period completed a WRAT5-Reading and/or a Self-Assessment of Cognitive Functioning and (b) characterize the time-points (admission or follow-up) at which these assessments were completed. We then expanded this query to include all active participants, inclusive of new admissions, within the same 10-month period. Second, to examine the rate of identification of cognitive health needs, we determined the proportion of individuals who were classified (yes/no) as experiencing cognitive problems that interfere with daily functioning or goal attainment, based on self-assessment and/or clinician judgement. Third, we determined the percentage of active cases who received a cognitive health service within the study period and the service(s) received.

3 |. RESULTS

At the time of writing18 of 22 trained OnTrackNY teams had at least 10 months of cognitive health data. Across 18 programs, there were a total of 933 unique individuals active at the time of the training and over the 10 months post-training (range 24 to 88 by team) including 310 new admissions (range 7 to 38 by team).

Assessment of New Admissions: The percentage of newly admitted participants who received a WRAT5-Reading test ranged by team from 0% to 85.2%, with 136 out of a total of 310 new admissions, or 43.9%, assessments completed across programs. The percentage who received a Self-Assessment of Cognitive Functioning ranged from 0% to 84.6%, with a total of 128, or 41.3%, assessed. The ranges for assessment rates are summarized in Figure 1. We found that 158 (50.9%) received at least one assessment and 106 participants (34.2%) received both. Among new participants who were assessed for cognitive health, the majority of assessments were completed at the time of admission (Table 1). Ten individuals completed a reading assessment at more than one time point and 11 individuals completed more than one self-assessment.

FIGURE 1.

FIGURE 1

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Cognitive health assessment rates in OnTrackNY programs

TABLE 1.

Cognitive health assessments completed for new admissions by time

Admission % Month 3% Month 6% Month 9% Discharge %
WRAT5-readinga 77.9 25.0 2.9 0.0 1.5
Self-assessmentb 72.7 29.7 3.9 0.78 1.6
Open in a new tab
a

Wide range achievement test—5th edition Reading Subtest; percentages are calculated based on the total number of new admissions who received the WRAT5-Reading (n = 136).

b

Self-Assessment of Cognitive Functioning; percentages are calculated based on the total number of new admissions who received the Self-assessment (n = 128).

Assessment of Actively Enrolled Participants: During the study period, about 33% of all 933 active OnTrackNY participants received some assessment of cognitive health need. Specifically, 299 (32%) received the WRAT5-Reading and 269 (28.8%) received the Self-Assessment of Cognitive Functioning. cognitive health needs assessments were completed with participants at different phases of treatment. Among those completed during the study period, 50.7% of assessments occurred at participants' admission or 3-month follow-up visits, 69.1% occurred between participants' admission and 12-month visits, and 30.8% were completed with participants at any later phase of their program participation.

Identification of Cognitive Health Need: Across all 933 active participants, 203 (21.8%) were identified as having cognitive health needs. However not all active participants were assessed. Among active participants who received a cognitive health assessment, in 57.6% of the cases the participant identified current cognitive difficulty and in 69.9% of cases, the clinician indicated cognitive health needs.

Provision of Cognitive Health Services: Among all 933 active participants, cognitive health services were delivered to 211 individuals (22.6%) during the study period. Among those who received any cognitive health service, psychoeducation was the most commonly implemented (89%), followed by compensatory skills training (48%), and then restorative cognitive training (8%). In addition, 13.6% of the total sample received more than one cognitive health service during the study period.

4 |. DISCUSSION

Addressing cognitive health during the early phase of psychosis has the potential to inform recovery-oriented service planning, yet methods to assess or treat cognitive problems are not a systematic part of CSC in the U.S. We previously reported a readiness to integrate cognitive health in the model of OnTrackNY, a network of CSC programs, but identified a need for training and resource development. To that end, we developed a cognitive health toolkit and training curriculum which were then implemented and evaluated for feasibility and utility.

Program data analysed from 18 OnTrackNY teams represented an aggregate of 933 unique participants. We analysed the data during the 10-month period following each team's training to characterize feasibility of using the cognitive health assessments, and their outcomes with respect to identifying need and provision of services. The feasibility of integrating cognitive health assessment practices is suggested by the initial assessment rates at admission with about 50% of new program participants receiving any cognitive health assessment, and several teams achieving assessment rates between 60% and 85%. We found similar completion rates for the WRAT5-Reading subtest, a standardized objective assessment (43.9%), and the Self-Assessment of Cognitive Functioning, a subjective questionnaire (41.3%). Considering all active OnTrackNY participants during the study period who were assessed for cognitive health, the majority were evaluated at admission, consistent with our guidelines which intended to facilitate the integration of cognitive health into the initial process of evaluation, case conceptualization and service planning. Most of the remaining cognitive health assessments were completed at the 3-month follow-up.

Although teams ranged widely in use of assessments for participants who were admitted during the study period, the overall rate of assessment at admission in this study compares favourably to assessment of cognitive health needs among seniors (65+ years) in primary care settings (Bradford et al., 2009; Sabbagh et al., 2020).Yet, the variability in team adoption of cognitive health assessment practices, particularly the low rates of uptake among some teams, warrants further study. While all teams received the same set of trainings and had equal access to the toolkit materials thereafter, implementation outcomes can be affected by myriad factors. Further exploration with respect to individual clinician characteristics as well as characteristics of the inner setting, such as the structural characteristics (e.g., size, age, stability) of the team and implementation climate (e.g., shared receptivity, workflow compatibility), may reveal significant, but potentially mutable, differences across sites that impact adoption, fidelity, and maintenance (Damschroder et al., 2009;Proctor et al., 2011). While training aimed to provide knowledge, we may find a need to better support motivation and self-efficacy for applying that knowledge given the multiple demands on clinician time. The importance of identifying barriers in the use of the cognitive health toolkit throughout OnTrackNY programs is suggested by our preliminary data demonstrating rates of cognitive health need among OnTrackNY participants.

Rates of identified cognitive health need support the clinical utility of the toolkit. Of those who were assessed, over half of participants self-reported cognitive problems, which is similar to (Burton et al., 2016) or higher than published rates of self-reported cognitive deficit in schizophrenia samples (Medalia & Lim, 2004; Saperstein, Thysen, & Medalia, 2012). That the current measure queried whether individuals would like for their cognition to be better, as opposed to asking about the experience of deficit, may have been facilitative (Allott et al., 2020). That about 70% of clinicians identified cognitive health needs is similar to reported prevalence rates of impairment in adults with schizophrenia when evaluated with standardized neuropsychological batteries(Keefe et al., 2005; Kremen et al., 2000). Yet the assessment methods contained in the toolkit are less resource intensive than neuropsychological batteries which present multiple feasibility issues in CSC settings including cost, administration time, staffing (e.g., presence of a licensed psychologist), and the potential cost of exposing young people to unnecessary testing at a vulnerable time. Given that a 5-min reading test was completed in fewer than 50% of new admissions, we might anticipate lower completion rates for a lengthier (i.e., 30–50 min) battery of tests in this setting.

The toolkit does address the recent call for the development of cognitive screening tools appropriate for young people in mental health settings (Bryce & Allott, 2019) such that need for further evaluation can be flagged. Further, the data suggest that the assessments and decision-making tools served the purpose of assisting with the management of cognitive issues in the context of recovery-oriented care. Cognitive health services were provided to 22.6% of all OnTrackNY participants during the 10-month study period. Psychoeducation, perhaps the most flexible option, was most commonly employed. Utilization of compensatory skills training is consistent with our previous study suggesting this approach is also acceptable, appropriate and feasible to implement in this setting. The less frequent use of restorative cognitive skills training was expected due to the limited availability of cognitive remediation programs among the agencies within which OnTrackNY is housed.

Strengths of this study were the systematic program data collection procedures and a sizable dataset reflecting real-world implementation outcomes for first-episode psychosis services. Although the 10-month time frame set an arbitrary limit on analyses of how implementation evolved, it nevertheless generated feasibility and utility data to inform the implementation process within OnTrackNY. Data provide a baseline with which we can set reasonable benchmarks for assessing and addressing cognitive health and evaluate the effectiveness of ongoing quality improvement activities. Increasing assessment use across all OnTrackNY teams will subsequently allow for a more representative analysis of client-level data (e.g., perceptions and attributions regarding cognition, attitudes towards treatment) that may facilitate our understanding of how to engage young people in addressing their cognitive health. Ultimately, what we learn from further study of clinician behaviour, as well as client satisfaction with cognitive health services and outcomes, may guide the development and integration of cognitive health assessment and treatment practices into CSC programs more broadly. In this way specialized first-episode psychosis services continue to evolve to promote the functional recovery needs and preferences of the individuals they serve.

Supplementary Material

Table S1
Table S2

ACKNOWLEDGEMENTS

This work was made possible by the financial support from a SAMHSA grant (SM061900-05) awarded to Dr Dixon.

Funding information

Substance Abuse and Mental Health Services Administration, Grant/Award Number: SM061900-05

Footnotes

CONFLICT OF INTEREST

The other authors report no financial relationships with commercial interests.

DATA AVAILABILITY STATEMENT

Additional data that support the findings of this study are available from the corresponding author upon reasonable request.

SUPPORTING INFORMATION

Additional supporting information may be found online in the Supporting Information section at the end of this article.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Table S1
NIHMS1716200-supplement-Table_S1.docx (17.9KB, docx)
Table S2
NIHMS1716200-supplement-Table_S2.docx (18.2KB, docx)

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