InvisALERT Solutions – ObservSMART

Integrated Health Care for Older Adults: A Model Partnership

When Sonia was discharged from New York-Presbyterian (NYP) hospital last winter her Care Coordinator arranged for home care, meals, nurse visits, transportation, medical equipment and prescriptions. She went home confident that she would be safe and would receive ongoing care at home as she regained her strength.

Sonia’s Care Coordinator also connected her with Service Program for Older People/SPOP, an independent nonprofit behavioral health center in New York City, and encouraged her to meet with a social worker to discuss behavioral health services. Sonia had expressed anxiety about managing on her own and her lack of a family support system. However, she resisted the idea of receiving services and the Care Coordinator spent time with her to answer questions and reassure her before introducing her to the SPOP intake staff.

Following a comprehensive assessment Sonia learned that she was eligible for home visits from a clinical social worker and psychiatrist from SPOP based on her diagnosis and her homebound designation (she lives in a third-floor walk-up apartment). She has been receiving weekly home visits from her therapist and has learned relaxation techniques to manage her anxiety. Most important, Sonia has not been readmitted to the hospital.

New York-Presbyterian and SPOP are engaged in a unique partnership to make certain that behavioral health care is an integral part of discharge planning and medical care for older patients (SPOP serves adults age 55 and older). The partnership is supported by an Impact Grant through the NYP Performing Provider System, which seeks to improve overall health and quality of life while reducing unnecessary hospital emergency room usage.

Now in its second year, the partnership has been successful in fostering a culture of integrated care within the hospital, with a focus on Medicaid patients. Our Clinic has received referrals from throughout the NYP hospital system, and our therapists work with hospital staff and medical teams to coordinate patient care. As a relatively small agency entirely focused on mental health services for older adults, we are able to respond quickly and meet client needs before they worsen. “SPOP’s community-focused expertise in meeting the behavioral health needs of older adults is invaluable to us,” said Brian Youngblood, LCSW, of the Division of Community and Population Health at NYP. “Working together, SPOP and the hospital have expanded access to care for a very fragile population.”

Building a culture of integrated care relies on relationships throughout the hospital system. SPOP and NYP have developed systems to train hospital staff in the basics of geriatric behavioral health and strategies to support a warm hand-off for assessment and services. Psychotherapists make home visits to those clients who are unable to travel for appointments and often engage with family members and caregivers as part of the treatment plan. And because SPOP provides a continuum of treatment – intensive intervention, medication management, weekly therapy sessions, or non-clinical bereavement support – clients receive care that is appropriate to their level of need.

The program has also benefited family members and caregivers. Not all hospital referrals are the right fit for SPOP, particularly when there is cognitive impairment and the client can’t engage in psychotherapy. In one such case, Henry, age 62, called SPOP on behalf of his 87-year-old mother, who has Alzheimer’s disease and who had been referred by NYP. When Henry learned that his mother did not meet the criteria for SPOP services he became distraught. Our intake staff first connected Henry to an agency that could care for his mother, made a call to provide background, and completed a warm hand-off. The intake worker then asked Henry if he would like to speak with a therapist with expertise in caregiver distress. Henry was initially surprised – he had been focused entirely on his mother’s needs – but he said he liked the idea is now enrolled for psychotherapy in our Clinic address his own feelings.

SPOP and New York Presbyterian have developed a model program to care for older adults, coordinate treatment plans, and prevent re-hospitalization rate. Working together, the two organizations have been able to increase their scope of service to care for the whole person – which benefits everyone.

Nancy Harvey, LMWS, has served as the chief executive of Service Program for Older People since 1990. To learn more about SPOP’s community-based behavioral health programs for older adults visit or contact Nancy at

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