Since 2016, Coordinated Behavioral Care (CBC), a city-wide Behavioral Health IPA and a lead Health Home, has overseen an incredibly successful preventive case management program, funded by the Staten Island PPS, and in collaboration with Staten Island (SI) community-based behavioral health agencies (SIMHS, Project Hospitality, CHASI). The program, Staten Island Community At Risk Engagement Services (SICARES) was developed to bridge gaps in care by connecting community members to necessary support services so that they could be empowered to manage their own health care while being connected to the broader health and wellness community. This successful, brief intervention model of care, using community Health Coaches, ensured that over 7,000 Staten Islanders were meaningfully connected to community-based health care services, offered annual check-ins and addressed social determinant of care needs.
SICARES, because of DSRIP funding, was set to sunset at the end of March, but as the first cases of COVID-19 emerged in NYC, CBC recognized that dismantling the current care coordination infrastructure would have disastrous effects on the most vulnerable population on SI. CBC proactively worked with the SI agencies and self-funded the program for an additional 6 months as a response to the emerging pandemic devastating NYC residents. Based on some preliminary data analytics of the program’s outcomes, especially with the population over 55 years old and medically frail, CBC worked on changing some critical aspects of the program to meet the new demands of managing care during COVID-19. With Health Coaches already in place, the SICARES program was uniquely positioned to provide immediate telephonic support and advice through tele-care management to those at highest-risk from COVID-19. The Health Coaches have been able to connect with and reach people with underlying health conditions who, by following the Governor’s stay at home order, are isolated, stressed and have heightened levels of anxiety. While social distancing minimizes the risk of exposure it does create additional stress through financial burdens and isolation that can negatively impact people, particularly their mental health.
The SICARES Health Coaches have been working hard to provide telephonic support (using Zoom), referrals to services, and advocacy for their client with the goal of creating a mental health response rooted in concrete interventions while also addressing the underlying social care needs of this vulnerable population. Health Coaches are also working closely with medical care providers to ensure that members continue to attend necessary appointment and that prescriptions are filled and delivered. In addition, they have found that they can play a valuable role in providing education and support on the symptoms and treatment of COVID-19. The core elements of SICARES’s telephonic care management include ensuring that physical health and mental health concerns are addressed as well as inquiring about and assisting in connections to services and resources re: finances and social determinant of health needs.
CBC’s response to the current healthcare crisis—adapting an established, light-touch, preventive case management program into a seamless access point for community members that would otherwise not be eligible for care coordination—was a critically needed public health strategy. Through a response focused on check-ins, coordination, and addressing concrete social factors that inhibit health care access, SICARES Health Coaches are addressing the unmet needs of the most vulnerable and at-risk at this unprecedented time. Additional workflows that bring together Health Coaches to address needs through the lens of collective impact strategies also creates culture shifts in how front-line staff collaborate. Lastly, by adopting new technologies in their support of the medically and economically vulnerable community, they are embedding education and tele-health opportunities in the fabric of their relationships with the clients served.