InvisALERT Solutions – ObservSMART

Building an Integrated Delivery System Through Community Collaborations

Coordinated Behavioral Care (CBC) was launched in 2011 by a committed group of NYC not-for-profit behavioral health organizations to meaningfully participate in NYS’s Medicaid Redesign and Value Based Purchasing initiatives. CBC is dedicated to improving the quality of care for New Yorkers with serious mental illness, chronic health conditions and/or substance use disorders. CBC has developed a citywide Health Home, which is currently the largest of its type in NYC providing care coordination services to tens of thousands of New Yorkers of all ages, through 50+ community-based Care Management agencies located in all five boroughs. CBC has launched innovative community-based programs that build on the expertise of its community-based agencies; organized as an Independent Practice Association (IPA) that includes a citywide network of primary care, mental health and substance use treatment providers, thousands of units of supportive housing, recovery and support services, and assistance with concrete needs such as food, employment and housing. The CBC IPA Network “knits together” programs to holistically address individuals’ treatment and recovery needs, while assessing community deficiencies and connecting individuals to needed supports.

Over the years, CBC has worked closely with multiple stakeholder groups and developed strong relationships and collaborations to fulfill its mission of leveraging community partnerships toward the goal of integrated medical and behavioral health interventions that, coupled with a specialized emphasis on social determinants of health, promote a healthier New York. These collaborative efforts serve as the foundational underpinning of a clinically integrated delivery system that allow CBC and our partner agencies to participate in the healthcare system transformation underway as we move toward Value Based Payment.

One such example of an effective collaboration with amazing outcomes is the CBC, Bronx Partnership for Healthy Communities (BPHC) SBH Health System’s Performing Provider System (PPS), and Project Renewal innovative care transition partnership. This PPS initiative, including three other provider groups, was intended to provide a six-month Pathway Home/Critical Time Intervention (CTI) program to support individuals with serious mental illness as they transitioned from a hospital setting back to a homeless shelter or a precariously housed living situation. Based on first year data (2017) this model resulted in a reduction in hospital utilization, an increase in primary care and outpatient utilization, and increased access to housing and employment services. The initial goal was a 25% reduction in hospital days measured by a 6 month pre- and post-intervention review. The impact was far greater than expected with a 62% reduction in hospital days for the cohort and a 57% reduction in inpatient admissions. The CBC/Project Renewal Bronx Pathway Home Team had an even more extraordinary impact with an 85% reduction in inpatient and emergency utilization.

Another successful collaborative effort is exemplified by the Staten Island PPS (SI PPS) partnering with CBC and Project Hospitality on an innovative intensive care management program providing targeted outreach, engagement and support to individuals with a goal of reducing their reliance on emergency settings by connecting them to community-based services. The project, Helping, Engaging, and Linking to Health interventions (HEALTHi), modeled on the successful Camden Coalition’s Healthcare Hot-Spotting Initiative, uses data analytics to identify high utilizers and focuses on providing a safety net of resources to individuals with complex chronic conditions who are also affected by the social determinants of health.

The HEALTHi project is aligned with the other initiatives funded by SI PPS under the Delivery System Reform Incentive Payment (DSRIP) Program, and overall goals of the Medicaid Redesign. The HEALTHi project locates and actively engages individuals who have serious behavioral and medical conditions and uses wrap-around enhancement funds to address immediate, easily resolved social needs, such as food and clothing, to secure trust and engagement in care. The HEALTHi multidisciplinary teams’ outreach efforts are in person at the individual’s address, known hangouts, and/or through known social networks. If an individual is hospitalized at the time of referral, the HEALTHi team engages with them, as well as the inpatient staff, at the hospital and plays an active role in the discharge and aftercare planning process as both their advocate and a community services expert. This is a time-limited 6-month intervention that begins with assertive outreach and engagement, continues with intense care management, and ends with transition to community-based services to maintain recovery. The teams have small caseloads to enable the level of intensity needed to connect and manage the care needs of this population.

The HEALTHi team provides 24/7 on call coverage, ensuring individuals have access to community services and care at all times. The team also utilizes CBC’s network of community-based services to expedite access to crisis care such as respite beds and weekend clinic services. Since April 2018 the HEALTHi team has enrolled 48 individuals, with 92% engagement and connection to primary care; 90% of those discharged from a hospital had an outpatient visit within 30 days, and 100% of people with schizophrenia prescribed an antipsychotic medication were adherent with their prescribed medication regimes. Though outcome data for the DSRIP year is preliminary, the team has closed over half of the identified “Gaps in Care,” which promote better health and community tenure.

Additionally, CBC is working closely with the Mount Sinai PPS on another hot-spotting intervention program, Community Outreach for Recovery and Engagement (CORE). This partnership with The Bridge was launched in mid-July to provide outreach and engagement for high-utilizers of Emergency Department (ED) and inpatient services identified by the MS PSS partner agencies. CORE consists of a multi-disciplinary team with a primary goal to outreach, enroll and provide care coordination to 50 high utilizers over the year. In the first 2 months of the program, the staff has outreached 33 individuals with over 50% successful enrollment in CORE. The team continues to work on engaging individuals in outpatient behavioral health treatment, facilitating appointments for primary care to manage chronic health conditions, and tackling many of the social determinates of health, like housing stability and food security. During this 6-month intervention, the mission of CORE is to provide intensive support in order to stabilize and transition individuals to ongoing community-based services.

In 2014, CBC embarked on the implementation of an innovative care transitions program called Pathway Home, which has, through a multidisciplinary team approach and the use of Critical Time Intervention (CTI) techniques, significantly improved community outcomes after long-term psychiatric inpatient hospital stays. Initially, a one year grant funded program, the astonishing outcomes and improvement in health outcomes led to a partnership with the New York State Office of Mental Health (OMH) and the expansion of the program to serve additional populations. Pathway Home is a high-touch, intensive, care coordination program that promotes pre-discharge engagement, immediate needs assessments, peer role modeling and connection and engagement with community providers. During this 9-month intervention, individuals are supported by a team, with a focus on increasing community tenure and avoiding readmission to the inpatient setting. CBC partners with Services for the Underserved (SUS), Catholic Charities Neighborhood Services (CCNS) and Institute for Community Living (ICL) in the care delivery and the teams use the extensive services of the wider CBC provider network to ensure successful community outcomes. Currently serving over 500 people annually, Pathway Home outcomes include over 90% aftercare follow-up to behavioral health appointments, 94% with no hospital readmissions and a 77% enrollment in Health Home care management services.

CBC’s network of community-based providers understands their communities and have been historically addressing gaps in care and will continue to realize better health outcomes for individuals most in need. In an era of significant and serious healthcare system transformation occurring at the Federal, State and local level, community-based partnerships like these will continue to be the future of healthcare reform. By understanding communities, addressing gaps, and working together, CBC network providers will continue to improve on population health outcomes, reduce healthcare costs and increase consumer satisfaction.

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