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Regina Shasha, MS, FNP, PMHNP, BC, ANCHORS Elizabeth Dunn, BA, Development Manager, Sarah’s Circle.

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Presentation on theme: "Regina Shasha, MS, FNP, PMHNP, BC, ANCHORS Elizabeth Dunn, BA, Development Manager, Sarah’s Circle."— Presentation transcript:

1 Regina Shasha, MS, FNP, PMHNP, BC, ANCHORS Elizabeth Dunn, BA, Development Manager, Sarah’s Circle

2   1. Describe four domains of need that impact health and housing linkages to services  2. Discuss the Tiered Level of Need Model as a tool to help identify and address the needs of the whole person  3. Discuss program development process, factors contributing to inter- and intra-agency silos, and strategies to improve integration Objectives

3   Program development-developed two programs  Learn about a new tool, and model, to assess patients-Tiered Level of Need Model  Hear what we learned from the program- Health Access ANCHORS Data summary  Discuss lessons learned What we can share

4   Meredith Garafolo, MA, LCPC  Sarah Shapleigh, LCSW, CADC, MISA II  Megan Libreros, BA, Housing Coordinator  Kassie Weber, MA, LPC  Annie Pothour, MSW, LCSW  Emily McKernan, LSW  Elizabeth McNair, MA, LPC, Housing Coordinator  Elizabeth Clark, BSW  Stephanie Williams, MSW Our team

5   ANCHORS  Sarah’s Circle Health Access  Linkage of these programs Program development

6   Assessing and Addressing Individuals' Needs Using a Tiered System of Assessment, Implementation, and Care© ANCHORS©: A Nursing Case management Housing Outreach Resource and Support

7  Goals of the program  See the whole person  Link the whole person to help her successfully find and maintain housing ANCHORS©: A Nursing Case management Housing Outreach Resource and Support

8   Sarah’s Circle is a refuge for women who are homeless or in need of a safe space. By providing housing assistance, case management, referral services, and life necessities, we encourage women to empower themselves by rebuilding both emotionally and physically; realizing their unique potential. Sarah’s Circle

9  Whom we serve, according to intake:  100% women and low-income  70% currently homeless  50% no income  52% mental illness  40% survivors of domestic violence  29% chronic medical health problems  12% physical disabilities  80% racial or ethnic minorities Sarah’s Circle

10   Problems and needs to be address  Is housing enough?  Where are the gaps?  Why are there gaps? (E.g. lack of resources or access to resources) ANCHORS Problem identification

11   Whom are we serving?  Characteristics of the people who are being housed  Demographic data: Age range, gender, ethnicity, and family status ANCHORS Problem identification

12   What health problems and needs are documented for this population?  Severe mental illness  Domestic violence  Substance abuse  Veterans with physical and mental disabilities  Chronic health problems, eg HIV/AIDS, Hypertension/CVD/Diabetes/Skin/Respiratory/GI/De ntal/Vision problems  Health illiteracy  High mortality (25 years shorter life expectancy for SMI) ANCHORS Problem identification

13   What are the barriers to maintaining housing?  Physical health problems  Mental health problems  Poverty  Substance use ANCHORS Problem identification

14   What level of functioning and independence exists and is possible for each individual? ANCHORS Problem identification

15  Program goals  1. Engage agencies housing homeless individuals  2. Utilise Tiered Level of Need Model to help these individuals maintain housing  3. Assess health and well being through an initial biopsychosocial assessment  4. Refer to and link with community resources  PCP/FQHC home  Clinical Case manager  Mental health service if appropriate ANCHORS Goal setting

16  Program objectives  1. Identify housed and homeless individuals at risk using the Tiered System  2. Perform initial biopsychosocial assessment  3. Assess for benefits eligibility  4. Link with PCP and FQHC  5. Link with Clinical Case Manager  6. Maintain housing > 1 year ANCHORS Objective setting

17   1. What resources are needed to accomplish goals and objectives?  Staff  Facility  Equipment and Supplies  2. Identify available funding  Apply for grant funding ANCHORS Resources

18   Hire staff: Clinical case manager, Advanced Practice Nurse (APN)  Purpose statement: Write a description of the program to give to clients  Who is eligible?  Communicate what services will be provided  Engagement  Teaching  Mental health, physical health, substance use, violence screening  Counseling  Smoking cessation  Referrals/Linkage with community resources ANCHORS Program Implementation

19   Documentation: Develop template notes  Initial screening notes for case manager and APN  Treatment plan form, do every 3 months  Progress note for every visit ANCHORS Program Implementation

20   Develop health indicators within the Tiered Level of Need Model to guide determination of level of need; examples of indicators  Strengths  Safety  PCP  Date last annual exam  Mental health provider  Chronic barriers (including health problems)  Benefits status ANCHORS Program Implementation

21   Assess each individual’s health and wellbeing and organize engagement around level of need using the Tiered Level of Need Model ©  Adjust case management and APN support based on level of need ANCHORS Program Implementation

22   Outcome measures  Utilise quality of life and mental health rating scales  Perform baseline, quarterly, at discharge ANCHORS Program Implementation

23   Accountability  Evaluate goals in grant and assess if objectives are being met  Develop a system for reporting to funding agencies  Address systems for program to remain viable ANCHORS Program Implementation

24   Staff responsibilities  Obtain malpractice insurance  Recruit collaborating physicians  Develop collaborative relationships within the agency and with community resources ANCHORS Program Implementation

25   1. Identify the client while in shelter  Engage and prepare for the transition to housing  Clinical case manager does initial engagements  2. Identify individual specific barriers to wellness and health problems through initial screening  Hypertension and diabetes screening  Mental illness screening  Substance abuse screening, including tobacco, drugs, ETOH  Safety screening  Pain screening  Nutrition screening  Eligibility for benefits screening ANCHORS Plan of Care

26   Identify individual specific strengths and successes  Identify level of need based on tiered system  Identify resources available to address the needs and gaps in services  Case management  Community clinics and mental health centers  Healthy nutrition options-Food pantries  Substance abuse treatment referrals  Employment referrals ANCHORS Plan of Care

27   Linkage: Match needs with existent resources  Link community resources  Community housing agencies  Community healthcare agencies  Community support systems ANCHORS Plan of Care

28   Monitor, reassess and evaluate individual’s status within tiered system  Adjust intensity of services as tier status changes ANCHORS Plan of Care

29   Ongoing evaluation of program  Team meetings  Monitor individuals’ status, functioning, intensity of services and support needed using the Tiered Level of Need Model  Assess if objectives are being met ANCHORS Evaluation

30   A fluid model of assessing an individual’s level of need for resources and services.  Need is determined during individual assessments, reevaluated each visit, and changes are implemented and incorporated into the plan of care.  Level 3 High need-maximum services and support required  Level 2 Moderate need-fluctuating services and support required, periods of high and low, more and less, need  Level 1 Low need- minimal services and support required Tiered Level of Need Model©

31   Tiered models have been used since Maslow identified the tiered model of needs that informs the beginning of every nursing program.  Tiered models have been used in education to structure classrooms to better provide education to a diverse level of students.  These models date back to 1980 and provide a well researched system of interventions by identifying student skills and classroom strengths to best utilize the resources TIERED LEVEL of NEED MODELS

32   Minnesota public health has used a three tiered model to group patients with medical needs into different tiers that translated into different service levels.  This model is used to focus limited public health monies to attain the best outcomes for the greatest number of patients. TIERED LEVEL of NEED MODELS

33   Assesses the overall complexity of patients by grouping them into “complexity tiers” based on the number of major chronic condition categories that apply to them.  Assessing complexity allows a more complete picture of complexity not limited by diagnosis codes  Ensures more accurate payment through the use of complexity to approximate the time and work of care coordination  Also helps shape programs and helps care coordination agendas TIERED LEVEL of NEED MODELS

34   A seven tiered model of need has been used successfully in Australia to coordinate services for a population with dementia.  "Our model provides the basis for comprehensive planning of service delivery. We believe that it is representative of the prevalence of different severities of behavioural and psychological symptoms of dementia (BPSD). Current funding is very sparse for intervention at tier 1 and tier 7 levels, even though the resource need per patient is greatest at the top and the population to be served is greatest at the bottom of the triangle.”  Targeting funding to lower levels may reduce the demand for higher-level services — this is the principle of preventive medicine.  Education for all staff working in residential-care settings has the potential to reduce the prevalence and severity of BPSD and the subsequent demand for more specialised (and more expensive) services TIERED LEVEL of NEED MODELS

35   Vulnerability Assessment Tool, Vulnerability Index, Service Prioritization Decision Assistance Tool, VI- SPDAT: Used to determine who should be placed in RRH, PSH, or no additional support  Denver Acuity Scale: used to determine case management service intensity  Camberwell Assessment of Needs: Focused on SMI  Outcome Star, Arizona Self-Sufficiency Matrix: designed to be used collaboratively with client Alternative Assessment Tools

36   Domains of need impacting health and housing linkages to services and success  Medical Risks  Mental Health (MH)  Social Risks and Supports  Financial Resources Tiered Level of Need Model© Four Domains

37  Tiered Level of Need Model© Score Key

38  Medical Risks (Linked=visit in past 12 months) Level 3Level 2Level 1 *No PCP visit >3 yrs*Linked with Primary care provider (PCP *High mortality risk health problem *AIDS, Renal or Liver disease *Pregnancy *No health problems or controlled chronic health problems, includes Controlled pain /No pain *Chronic disease AND >60*20-40 years old (using contraception) *ER >3 visits in 6 months*ER visit 1 visit/ year or less *Active substance use with impairment *Substance use goals attained or *Active Mental and Physical health problems AND substance use No use >6 months or No substance use Tiered Level of Need Model© Medical Risks

39  Mental Health (MH) Risks (Linked=visit in past 6 months) Level 3Level 2Level 1 *No MH provider (MHP) visit >3 yrs *No MH problems/Linked with MHP *Deteriorating MH symptoms (sxs) *Stable MH symptoms *Active Suicidal Ideation, hx attempts *Functioning with Depression/MH sxs *No insight, no reality testing *Adequate insight, intact reality testing *ER >3 visits in 3 months *ER visit 1/ year or less Tiered Level of Need Model© Mental Health

40  Social Risks and Supports Level 3Level 2Level 1 *Harmful/negative support system *Positive/strong support system *Not engaged and safety risk, DV *Engaged Tiered Level of Need Model© Social Risks and Supports

41  Financial Resources Level 3Level 2Level 1 *Homeless*Housed >6 months *No Income or benefits*Working/Adequate Income *Needs disability*Adequate Benefits *No budgeting skills *Budgets well/Access to (healthy) food Tiered Level of Need Model© Financial Resources

42   Sarah Circle links with ANCHORS to develop Health Access program for Women who are formerly homeless Health Access ANCHORS Pilot program

43  Resources  292 (430) hours for Advanced Practice Nurse (APN)  822 (1209) hours for Clinical Case Manager (CCM) Initial steps  Select initial clients  Explain the program  Complete initial assessment  Documentation required: Physical/MH assessments, Specific Case management notes (Treatment Plans) Health Access ANCHORS Pilot program

44  Initial steps (cont’d)  Homes visits  Introduce clients to CCM  Coordination with CMs from supportive housing programs  Schedule visits  Determine data to be collected Health Access ANCHORS Pilot program

45  Year 1 Program goals  70 women receive initial screenings  70 women connected to FQHC home  70 women assessed for benefits, for eligible women, process to be started  80% remain housed after 12 months Health Access ANCHORS Pilot program Year 1

46  Year 2 Program goals  70 women receive initial holistic screening  70 women connected to long-term sustainable primary care and psychiatric care as needed  80% remain in housing for 12 months  85% of the clients scored at moderate to low risk on the holistic health assessment by the time they exit the program Health Access ANCHORS Pilot program Year 2

47  Data Summary  139 (Y1 74, Y2 65) women housed and entered into Health Access ANCHORS program  Number of women with mental illness 93% (129/139 clients) Health Access ANCHORS Pilot program

48  Year 1Year 2 ObjectivesGoalN (%)GoalN (%) Received initial screening 70 clients (74 housed) 74 (100)70 clients (65 housed) 65 (100) Connected to FQHC home 70 clients (74 housed) 7270 clients (65 housed) 57 Assessed for benefits, process started 70 clients (74 housed) 7270 clients (65 housed) 64 Housed 1yr80%85%80% Still gathering data Health Access ANCHORS Program goals

49  Medical RisksInitial assessment Beginning of program Final Assessment End of program Clients’ needsPercent per Tier (n) High need27% (37)11% (10) Moderate need42% (59)20% (18) Low need31% (43)69% (61) Health Access ANCHORS Program Data summary per the 4 Domains

50

51  Mental Health RisksInitial assessment Beginning of program Final Assessment End of program Clients’ needsPercent per Tier (n) High need18% (25)9% (8) Moderate need47% (66)17% (15) Low need35% (48)74% (66) Health Access ANCHORS Program Data summary per the 4 Domains

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53  Social Risks and Supports Initial assessment Beginning of program Final Assessment End of program Clients’ needsPercent per Tier (n) High need17% (24)6% (5) Moderate need46% (64)20% (18) Low need37% (51)74% (66) Health Access ANCHORS Program Data summary per the 4 Domains

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55  Financial ResourcesInitial assessment Beginning of program Final Assessment End of program Clients’ needsPercent per Tier (n) High need44% (61)11% (10) Moderate need51% (71)27% (24) Low need5% (7)62% (55) Health Access ANCHORS Program Data summary per the 4 Domains

56

57   % of women moving from Tiered level 3 High need at beginning of program to level 1 Low need at end  Medical risks: 16% of women went from high to low  Mental health risks: 14%  Social risks and supports: 14%  Financial resources: 20% Health Access ANCHORS Program Data summary

58

59   % of women at Tiered level 1 Low need at beginning of program and at the end of the program  Medical: 27%  Mental health: 25%  Social risks and supports: 27%  Financial resources: 3% Health Access ANCHORS Program Data summary

60  Data summary: Comparing needs across domains  For the Initial and Final Risk Assessments compare level of need (high, moderate, low) in each domain (Medical, Mental, Social, Financial) with each other 1stAssmt Final Financial High Financial Moderate Financial Low MH High14110 MH Mod30273 MH Low17334

61  Initial assessments showed  Social need high when Medical need high  Financial need high irrespective of Medical needs  Financial need high irrespective of MH needs  When Medical need low MH need low  Social needs do not impact Financial needs and Financial need does not impact Social needs  Social support and MH needs reciprocally impact each other, e.g low-low, mod-mod, high-high Data summary: Comparing needs across domains

62  Final assessments showed  When Medical need low Social support needs low, when Social support need low Medical need low  When Financial need low Medical need low, when Medical need low Financial need low  When MH need low Financial need low, when Financial need low MH need low  When MH need low Medical need low  When MH need moderate, Social supports need moderate, when Social need low MH need low  When Social supports need low Financial need low, but low Financial need has no impact on Social supports need Data summary: Comparing needs across domains

63  Data summary: Comparing clients’ needs from initial intake to discharge

64   Compared changes in Grid scores between initial assessment and final assessment and with Benefits status, Mental Health linkage, Health care linkage, Case Management Data Summary

65   7/34 clients with no case management had scores improve 1-9 points  2/60 clients with no Case Management had scores improve points (10 points and 16 points)  58/60 clients had Case Management support and high improvement of scores (10-39 points) Data summary: Comparison of change in scores from initial intake to discharge with CM support

66   72% Clients linked in a behavioral health or support program  93% Clients linked with Primary care  (4 refused) Data Summary: Percent Linkage by discharge

67  Lessons Learned –Implementation at Organizational Level Consortium on Chicago School Research, Five Essentials for School Improvement

68  Five Essentials for Homeless Service Program Implementation Lessons Learned –Implementation at Organizational Level

69  1. Leadership  Inclusive leadership with vision, continuity, power to make decisions, and strong understanding of intervention model and staff needs  Management wanted internal leader but program manager turnover and lots of organizational change  E.g. Initially had clinical case manager do initial engagement of the women, with leadership changes the APN did the initial engagement of the client and referred clients needing counseling to CCM Lessons Learned –Implementation at Organizational Level

70  2. Community Ties (Issue of interagency silos)  Importance of community context and external relationships  If >90% clients have SMI, need linkages with behavioral health programs and agencies  Lack of clinical services and programs to transition to  Helpful to have staff member to talk across systems  APN able to communicate with health service providers  Addressing cracks in service or turnover at other agencies sensitively but effectively Lessons Learned –Implementation at Organizational Level

71  3. Professional capacity: Development  Staff in various roles need to understand purpose, strategy, tactics, outcome measures, etc.  Even though expert staff, still need support and professional development pertaining to model  Staff training-took time, and not prioritized, given experienced project staff.  Engagement different in time-limited program Lessons Learned –Implementation at Organizational Level

72  3. Professional capacity: Collaboration  Silos intra-agency  With a new program and with this population, the unexpected will occur, need to be able to collectively adapt  Funding flexible, but must communicate progress and changes  Agency growth and change. Overall positive, but  Clients separate between programs (4), buildings (2) and shifts (3) - new need for centralized intake/referrals  Staff turnover  Move to new building impacted housing #s second year  Individual vs. team approach Lessons Learned –Implementation at Organizational Level

73  4. Client-centered, Trauma-informed Climate  Client-centered at all stages and levels  Design, direct service, and evaluation  Making sure there is enough support for staff around trauma Lessons Learned –Implementation at Organizational Level

74  5. Quality Service Provision  Great staff!  Enough time per client? Lessons Learned –Implementation at Organizational Level

75   Housing the whole person worked  Improved health and housing retention  Getting housing retention data at 12 months for those who needed lower levels of service difficult, but  85% of women placed in first year of program confirmed housing retention at 12 months  NONE confirmed as losing housing within 12 months Lessons Learned – Project Specific

76   Process for referrals and engaging clients before move  How the program was framed to clients (initially as a separate program, but later as a standard continuation of services)  Ability to provide these types of services for a limited amount of time when other supports were not available in the community to transition to  Who should engage client first, CCM or APN?  APN was opening newly housed clients and closing “graduating” clients who were housed for a year.  Clients did not want to close.  Time constraints made this difficult Lessons Learned – Project Specific

77   Staffing limitations-only 2 part-time staff, limited time and funding  Better housing placements on front end (e.g. 3 rd floor no elevator not ok for woman with mobility issues)  Clients often geographically dispersed, people go where the housing is, which was difficult due to limited staff time Lessons Learned – Project Specific

78   Developing implementation and evaluation goals to meet objectives: What if objectives change?  Ethics questions  When to speak up?  Who to talk with when there is no manager?  How to process and deescalate after trauma with staff? Lessons learned

79   Quotes from staff  “never feeling like I was alone in the work, team approach which made us look at the whole person b/c we all had different education, backgrounds, experience”  “this program made a lot of us clinicians better clinicians and that’s something that isn’t possible in a lot of other agencies”  “Now we are all going in different directions and making other agencies better than they already are”  “I wouldn’t be as skilled and knowledgeable without you and that program” Lessons learned

80   Elizabeth Dunn  Regina Shasha Contact info


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