Presentation on theme: "Service Integration: Recovery from the Ground Up"— Presentation transcript:
1Service Integration: Recovery from the Ground Up Presented by Services for the UnderServed, Inc.Yves Ades, Senior Vice PresidentWanda Cruz Lopez, Vice President- Mental Health ProgramsNancy Southwell, Vice President- AIDS Services & Urgent Housing
2Services for the Underserved (SUS) SUS is an innovative organization strategically positioned to deliver authentic person- centered, wellness-focused, integrated and coordinated care and housing for homeless and institutionalized people with behavioral and substance use disorders.
3The value of a Recovery based Philosophy A vision of recovery is based on the notion that people can grow beyond a diagnosis and lead a meaningful life in the community of their choice
4Culture and StructureSince 2001, SUS has invested in an ethical and related philosophical transformation that puts the person receiving services at the center of practice and desired outcomes. Organizational immersion in best practices that reflect person centered care: Wellness Self- Management, Integrated Dual-Disorder Treatment, Trauma- Informed Care, Diabetes Self-Management, Smoking Cessation, Cultural Competency, Family Psycho-education, WRAP , Peer Counseling, ACT and structured supervision. Robust staff training and supervision in best practice interventions to ensure staff competency. Robust Risk Management and Utilization Review protocols.
5Service Integration Expected outcomes Service fragmentation and overlap is decreasedImproved communication between providersHousing stability improvedHealth and mental health outcomes improve including decrease in hospitalizations, decrease in hospitalization days, reduction in ER visits & 911 calls.Challenges/ BarriersFunding SilosLimitations in fundingStaffing limitations and staff turnoverBenefitsTo the individualTo the agency
6Integrating Services Using existing funding Staying current on best practices“Borrowing” service models from other fieldsCo-location of servicesStaff capacity buildingRe-allocating resourcesDeploying new initiativesDeveloping data managementEmployment of Peers
7Integrating Services New funding Short term grantsGrants to enhance existing programsResearch opportunities, pilot programs and demonstration projectsDeveloping new capacity by expanding agency mission and/or services
8Achieving Integrated Healthcare Training and development of Wellness Coaches as enhanced Case Managers.Introduction of Nursing to housing support teams.Specific service protocols corresponding serious health (medical and behavioral) conditions and level of risk.Collaborative admission and discharge planning with hospitals (e.g. Woodhull).
9Co-Location of Services The Recovery CenterArticle 31, Wellness Works Mental Health ClinicIt serves as a “clinical home” for individuals living with serious and persistent mental illness by providing continuity in care as well as coordination across the domains of their lives (residence, work or training, family, and mental health); specialized tracks address the specific issues of the medically frail, young adults, and individuals with past experience with the criminal justice system. Psychosocial ClubhouseOperates in accordance with the International Center for Clubhouse Development (ICCD) standards with an emphasis on the work ordered day; the SUS Clubhouse also provides Transitional Employment Program. Additional services include GED classes, computer and Internet classes, evening and weekend recreation, Wellness Self Management, Integrated Dual Disorder Treatment, and vocational counseling groups
10Co-Location of Services Employment ServicesConsist of Supported Employment, Assisted Competitive Employment, and Vocational and Educational Services. Services include vocational counseling, benefits counseling, and job placement services. Individuals are not required to meet any prerequisites in order to receive these services other than a primary diagnosis of serious and persistent mental illness. Assertive Community TreatmentThis mobile interdisciplinary team of professionals (psychiatry, nursing, social work, and rehabilitation) and peers deliver treatment services to persons who have a serious and persistent mental illness that seriously impairs their functioning in the community in their own natural setting.
11The SUS Recovery Center Combination of existing funding and new fundingCo-location of existing ServicesNew capacity and service for agency (MH Clinic, Veteran’s Programs)Utilization of Best Practices (ACT, Clubhouse Model, Supported Employment, Wellness Self-Management).
12Developing new capacity by expanding agency mission and/or services Veterans Service CoordinationSUS’ Veterans Services include three federally-funded programsTwo U.S. Department of Labor Homeless Veterans Reintegration Programs (HVRP) targeting homeless veterans, homeless female veterans, and homeless male veterans with dependent children.U.S. Veterans’ Affairs funded Supportive Services for Veteran Families Program (SSVF) tasked with Veteran-focused care coordination, homeless prevention, and rapid re-housing.
13Borrowing from other Service Models Scatter-site Mobile TeamAn interdisciplinary Team assigned to formerly homeless and institutionalized individuals living in scatter-site supportive housing. Team care coordination practice incorporates many elements of ACT.
14Decision to ChangeWhat We HadWhat we Wanted10 distinct Housing Programs Staffing pattern consisted of a Program Director, Assistant and Case managers Staff had no particular specialty training We were limited in the services which we could provide to our tenants High number of grievances, incidents, hospitalizationsBetter coordination of services To Provide staff with efficient and effective methods of intervention, particularly in times of crisis Quicker response to ongoing issues Reduction in incidents, hospitalizations and grievances
15Central Maintenance Dept. Program StructureAssistant Team LeaderPsychiatristTeam LeaderCommunityLiaisonNurseService CoordinatorMaintenance /Central Maintenance Dept.AdministrativeAssistantPeer Specialist
16Team Meetings / ACT Team Meetings Team Meetings are short and include: The Mobile team meets three times per week. The team meeting are critical for sharing information about consumers functioning and expressed needs.Team Meetings are short and include:A discussion of all tenants receiving Protocol III servicesRoutine service review of tenants at each meetingUpdates and revisions to the staff schedule to meet tenant needsTreatment plan review and revisions, as needed
17LEVEL OF CARE / RISK MANAGEMENT Service Innovation The Mobile Team has the capacity to increase and decrease contacts basedupon daily knowledge of the tenant’s behavioral and primary healthcare needsPROTOCOL I- ONGOING SERVICESTenants receive services from his/her Service Coordinator/Case Manager. May need time limited services from other team members.PROTOCOL II- CRISIS PREVENTIONTenant receive services from his/her Service Coordinator/Case Manager. Assessment indicates tenant’s need for services from other team members, particularly the services of the, Nurse and Psychiatrist due to crisis and medical need.Maintenance management-Tenant’s maintenance issues, concerns and repairs are discussed and a plan of action is immediately formulatedRent Collection-helping tenants to avoid court litigation/evictionPROTOCOL III-CRISIS INTERVENTIONAssessment indicates tenant’s need for extended services from several team members
18New Funding/Program Enhancement Wellness Works! in AIDS Services Transitional Housing Programs Problem:High incidence of Incidents including fights, arguments, arrests, and hospitalizations.High incidence of substance useHigh incidence of program participants with histories of Mental Health issuesStaff feeling overwhelmed and frustrated.Solution:New short term grant funding (SAMHSA)Apply mental health evidence based best practices to meet service needs of people with HIV/AIDSEnhances existing programs through new staff competencies to achieve better health outcomes.
19Wellness Works! Program Goals include, in equal importance: Treatment Services (assessment, individual counseling, and groups)Service integration through improved linkages with other systems of careStaff Training and Capacity Building for sustainabilityOpportunity for data collection to measure outcomes
20Wellness Works! Tools Motivational Interviewing Wellness Self Management CurriculumIntegrated Dual Diagnosis Treatment GroupsIndividual on site counselingJoint Service PlanningFollow up on housing discharges
21Wellness WORKS! Outcomes after 2 years: Increase in permanent housing placement rateIncrease in treatment engagementDecrease in deaths in general, including deaths on site and overdosesDecrease in substance use.Decrease in mental health symptoms.Decrease in Incidents involving interpersonal conflicts.Improved staff satisfaction and self assessment of competency.Need to look further into measuring:Health OutcomesConsumer Satisfaction
22SummaryIntegrated Healthcare delivery is possible even when resources are limitedRigorous staff training in, and application of , wellness promoting evidence based practices enhances healthcare integration.Even in an environment of funding silos, it is possible to deliver integrated healthcare by importing proven service models across diagnostic boundaries.Re-allocation of existing funding to create integrated healthcare service models results in better health outcomes and use of agency resources.Getting involved in demonstration projects and finding grant opportunities are essential for testing new models and maximizing organizational capacity for integrated healthcare.
23Have Fun Summary (continued) Be Nimble Be Creative Be Informed Take RisksHave Fun