InvisALERT Solutions – ObservSMART

Integrated Care Models to Improve Health Outcomes and Reduce Poverty

FEGS Health & Human Services, in partnership with the Institute for Family Health (IFH), Healthfirst, Bronx-Lebanon Hospital, McSilver Institute of New York University, Mount Sinai Hospital, and Promoting Specialized Care and Health (PSCH) has been awarded a $925,000 grant from the Robin Hood Foundation to develop a new, integrated care model to improve health outcomes and reduce poverty among adults and children with mental illness living in New York City.

This transformative initiative aims to improve patient access to quality healthcare and social support by integrating the services of historically separate and distinct service providers. Additionally, the grant supports the development of a blueprint for citywide implementation of this model with a financially sustainable model through Medicaid. The grant partners will work collaboratively to improve the overall health of 2,000 adults and 3,000 children living in poverty in NYC. Importantly, this work will advance integrated care models among hospitals, Federally Qualified Health Centers (FQHC), non-profit agencies and Managed Care Organizations leading to true “population health” in the New York Metropolitan area. Finally, the grant will require that all partners (and eventually the entire health and social service delivery sector) redefine the core focus of its collective efforts…which is about improving the lives of all our citizens.

Not only is this critical but it is time sensitive. As a nation we spend 2 ½ times more than any other developed country on health care services, which means U.S. health care costs consume about 18% of GDP and growing; yet we rank below 16 other countries in overall life expectancy. Moreover, we under-invest in social services: for every dollar spent on health care, only 50 cents is invested in social services, whereas other developed countries spend roughly $2 on social services for every dollar spent on health care. In addition, we know that a small percentage of Medicaid recipients, especially those with complex health and social problems, drive more than 50 percent of all program costs; too many of them have chronic complex medical, behavioral health, and/or social service needs. Given the limited social service supports available through the current healthcare settings and the lack of coordination among the different service providers, these patients tend to end up in emergency rooms, have high rates of avoidable hospital admissions, and have harder times engaging in and being adherent with treatment.

Mental health disorders are all too common and oftentimes mis- or under-diagnosed and/or inappropriately treated. In any given year, 1 in 4 New York adults have a diagnosable mental disorder. Untreated mental illness is connected to poverty, unemployment, academic failure, homelessness and poor health. The resulting impacts have been catastrophic; 90% of adults in New York with serious mental illness are unemployed, an estimated one-third to one-half of people who live with serious mental illness live at, or near, the Federal poverty level, 30% of young new Yorkers with a serious emotional disturbance graduate with a standard diploma, and approximately 35% of the homeless have untreated mental illness.

Moreover, lack of access to critical mental health services and care comes at unreasonably high costs, despite the fact that not only do we know how to treat mental illnesses but there are effective treatments for the major mental health disorders. Regrettably, the mental health system has operated in isolation from the general health care system, utilizing a “casualty model,” where patients typically need to have very serious mental illness symptoms before they receive treatment and support; further enhanced by misaligned financial incentives, archaic State regulations and a separation between health and mental health care.

Something has to change in how we approach these issues; the current traditional healthcare system does not do a great job at effectively treating physical and behavioral health conditions due to a limited reach into the non-health care services such as supportive housing, vocational training and transportation, among others. This groundbreaking grant and its partners are poised to be transformative and ultimately show that delivering integrated care is feasible and makes clinical and financial sense. The grant will address many of these challenges and barriers that have such negative consequences on New Yorkers by creating an Integrated Delivery System (IDS) among the grant partners across the continuum of care. The IDS will be based on the implementation of collaborative care at several clinical sites (hospital-based as well as within FQHCs) as well as the creation of a “promising practice” in the delivery of integrated care for children and their families in the South Bronx. Additionally, the grant partners will work closely to develop standards of work, processes, and practices for the development of the IDS as well as performance and outcomes metrics with clear lines of accountabilities across the partners.

Another important component of this grant will be an intensive impact analysis of the integrated care pilot for children will be conducted with a sub-set of 200 children, using rigorous methods designed by the New York University McSilver Institute for Poverty Policy & Research in collaboration with FEGS, Bronx Lebanon Hospital and Healthfirst. The McSilver Institute for Poverty Policy & Research oversees numerous applied research studies aimed at addressing the root causes of poverty, as well as examining approaches to reduce its effects.

The grant partners are confident that this grant will provide New York with the needed tools to replicate and scale IDS throughout the city and state as well as demonstrate a return on investment for this type of collaborative care service model(s) that Managed Care Organizations will want to fund and promote. Lastly, the grant will provide direct medical and specialty services to a large number of New Yorkers and will track overall outcomes… with the aim of improving the lives of these New Yorkers, their families and communities…which should be our # 1 priority.

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