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Helping, Engaging, and Linking to Health Interventions (HEALTHi)

The Staten Island Performing Provider System (SI PPS) is partnering with Coordinated Behavioral Care (CBC) on an exciting new project – HEALTHi (Helping, Engaging, and Linking to Health interventions). The program will focus on providing a safety net of resources to individuals with complex chronic conditions who are also affected by the social determinants of health.

“The SI PPS partners are passionate about serving our community members. This new vehicle, HEALTHi, will allow them to bring more resources to those with the most need – early intervention is key,” said Dr. Joseph Conte, PPS Executive Director.

SI PPS has supported numerous innovative and successful projects such as the telemedicine program serving individuals with disabilities, 24/7 Resource and Recovery Center, ED Warm Handoff, HOPE Program, and training and deployment of peer recovery specialists. The HEALTHi project will align with the other initiatives funded by SI PPS under the Delivery System Reform Incentive Payment (DSRIP) Program, and overall goals of the Medicaid Redesign Project.

The HEALTHi project will locate and actively engage individuals who have serious behavioral and medical conditions and use wrap-around enhancement funds to address immediate, easily solved social needs, such as food and clothing, in order to secure trust and engagement in care. The HEALTHi interdisciplinary teams’ outreach efforts will be in person at the individual’s address, known hangouts, and through known social networks. If an individual is hospitalized at the time of referral, the HEALTHi team will engage with them, as well as the inpatient staff, at the hospital and take on an active role in the discharge and aftercare planning process as both their advocate and a community services expert.

The HEALTHi team will provide 24/7 on call coverage, ensuring support network have access to community services and care at all times. The team will utilize CBC’s network of services to expedite access to crisis services such as respite beds and weekend clinic services.

Dr. Sal Volpe, Chief Medical Officer at SI PPS added, “Our network has surpassed its goal of reducing preventable emergency room and hospital visits by 25 percent two years ahead of schedule and is nearing a 50 percent reduction in avoidable behavioral health-related ER visits. This means better, more integrated care before the onset of an acute phase which could require hospitalization.

“CBC is proud to be partnering with a strong community advocate like the Staten Island PPS,” said Jorge R. Petit, MD, CBC’s CEO. “Our working relationship with the PPS has been strong and deep in the Staten Island community. We are currently partners on a Health Home at Risk Project (SI CARES) and have found a willing, thoughtful and supportive partner to engage with us on these community-based care initiatives. Joseph Conte and his team are tremendous advocates for the needs of their community and are willing to think outside the box and work with the community-based provider community. I am very excited to get this project implemented and start to improve the lives of the individuals we will be working with.” SI PPS has been referred to as the most successful PPS in New York State and CBC is proud to be their partner.

“We are very excited to collaborate with CBC on this new program. HEALTHi will be able to support a group of individuals who are high utilizers of ED, inpatient, and EMS services with complex chronic conditions who are affected by social determinants of health, such as housing instability, food insecurity, language and health literacy barriers, etc.” said Victoria Njoku-Anokam, MPH, Director, Behavioral Health Initiatives at SI PPS

In an era of policy uncertainty, partnerships like this will continue to be the future of healthcare reform. By understanding communities, addressing gaps, and working together, SI PPS and CBC will continue to bend the healthcare cost curve and realize better population health outcomes for Staten Island.

About CBC

Coordinated Behavioral Care (CBC) was launched in 2011 by NYC not-for-profit behavioral health organizations in order 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 operates two related service entities: A Health Home that provides care coordination services to tens of thousands of New Yorkers of all ages, with 50+ community-based care management agencies located in all five boroughs, and an Independent Practice Association (IPA) that includes a citywide network of primary care, mental health and substance use treatment services, thousands of units of supportive housing, recovery and support services, and assistance with concrete needs such as food, employment and housing.

As a recipient of a New York State Behavioral Health Value Based Payment Readiness Program (BHCC) award, CBC is poised to build the infrastructure that will enable the IPA to better understand, manage and predict the service patterns, utilization and costs of the individuals receiving care in our network agencies as well as ascertain and monitor quality and outcomes across the continuum.

About Staten Island PPS

Staten Island Performing Provider System (SI PPS) is an alliance of clinical and social service providers focused on improving the quality of care and overall health for Staten Island’s Medicaid and uninsured populations, which include more than 180,000 Staten Island residents.

SI PPS is one of 25 groups across the state working on the New York State Department of Health’s Delivery System Reform Incentive Payment (DSRIP) program.

They are co-led by Staten Island University Hospital and Richmond University Medical Center. Their network of over 70 partners includes skilled nursing facilities, behavioral health providers, home health care agencies and a wide range of community-based clinical facilities, treatment centers, social service and community organizations, primary care physicians and medical practices across Staten Island.

Ongoing efforts of SI PPS impacts 4 out of 10 Staten Island residents by:

  • Improving access to high quality, culturally sensitive care
  • Improving population health and health literacy
  • Reducing preventable hospital admissions and readmission

These goals are being reached through the implementation of 11 DSRIP Projects, identified by a Community Needs Assessment, and address primary care, mental health, substance abuse, chronic disease, long term care, social determinants of health, and population health.

SI PPS is constantly creating new programs to enhance care and expand services. Their provider relationships are being continually developed through the Population Health Improvement Program (PHIP). They continue to lead several state-wide initiatives on health information technology, workforce and health literacy.

For project related inquiries, contact Joseph Conte at Jconte@statenislandpps.org (917) 830-1141, or Victoria Njoku-Anokam at Vnjoku-anokam@statenislandpps.org, (917) 830-1153. For press related inquiries, contact Val Lajqi at Vlajqi@statenislandpps.org, (917) 830-1141.

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