As we closely examine the topic of housing, it is important to stress one of the main catalysts for success in a supportive housing environment: the mobile transition team. Mobile transition teams have revolutionized the way in which we deliver care to individuals and are the future of treatment for people who are typically difficult to serve via traditional treatment approaches. In addition, logistically, these teams make care accessible to some of the most vulnerable populations. It is safe to say that without mobile support teams, many individuals transitioning out of institutionalized care would not be able to successfully live independently.
Federation of Organizations has seen first-hand the positive effects of delivering care to individuals through mobile means and providing customized care and services to address specific needs. The agency operates the only two Residential Transitional Support (RTS) teams in Suffolk County, New York both of which originated with the Office of Mental Health closure of the Residential Care Center in Kings Park, NY (RCCA). They also operate one of the four Mobile Residential Support (MRS) teams in Nassau County. These teams step in and play a critical role when individuals, who may have been living in institutional settings for a number of years, transition into a more independent supported housing environment and are now charged with taking care of themselves, managing their medications, making decisions about their nutrition, cooking meals, buying groceries, navigating public transportation, and deciphering what benefits they are entitled to in addition to many other responsibilities.
One of the most unique and important services the RTS team offers is medication management services. They educate individuals on their medications, showing them how to order their prescriptions and pick them up, and encouraging them to take their medication independently—sometimes providing daily support. Teams also work with clients to help them get to AA meetings, teach harm reduction models and coping skills, and link them to PROS and outpatient services. Nurses interpret medical information and advocate for their client. They also show individuals how they can have a life outside of the programs they attend.
Each RTS team is comprised of 11 staff members including master’s level behavioral health professionals, RNs, LPNs, direct care staff and peers. The team provides skill building as needed where residents are accompanied to local stores with staff to assist them with integrating into the community. Staff assists with making healthy food choices, medication management, budgeting, nutritional meal planning, benefit assistance, socialization, appropriate daily living skills, and community safety. RTS staff provides recreation trips to the library, concerts, parks, movies, and any other trips residents would like to attend that assist with community integration. RTS provides linkages and education on any additional services that assist residents with their recovery goals. These teams work very closely with residents, meeting with them several times a week and are available 24 hours a day, seven days a week. In the first quarter alone of 2017, RTS teams conducted over 2,300 face to face visits with 146 clients with visits lasting on average 33 minutes. The work is intense, but the results are nothing short of astounding.
Since the RTS teams’ inception in 2015, they have served 270 individuals, 52 of whom have graduated into even less supportive settings. Last quarter alone, 13 individuals graduated to less supportive care with 21 individuals increasing their ability to manage their own medication from the previous quarter. For individuals who have spent a lifetime institutionalized, this is nothing short of remarkable and a testament to the power of support, determination, and hope.
The MRS team is comprised of three staff members and serves as a step-down for clients who no longer require more intensive RTS services. When individuals are able to stepdown to an MRS team, the other services they are linked to phase in and bridge the gap. These can include primary care and behavioral health treatment teams, care coordinators, transportation and social linkages, and any residential services that have been set up. In areas where RTS teams are not present, such as Nassau County, the MRS team steps up to try and meet the need, despite having a much smaller staff.
Despite exceptionally strong results, challenges remain in implementing more mobile transitional support teams. Because the programs are still relatively new and there are a limited number of teams in operation in NYC and Long Island, hospitals typically neglect to think of these units as the first referral and opt for sending individuals back to traditional congregate care settings. This is unfortunate because these teams will meet individuals in the hospital and begin the transition process immediately and seamlessly, an aspect that is of utmost importance when treating an individual in crisis. To counter this problem, Federation’s staff routinely meets with community members, health professionals, mental health providers, and hospital discharge units in an effort to establish strong relationships and provide education that will foster more referrals.
So why are these mobile teams important? Because they work. Obviously, one program cannot work for everyone, but enhanced mobile team services do bridge the gap for individuals with severe mental illness to be able to enjoy successful independent housing with opportunities to grow and focus on their recovery.
As the healthcare landscape evolves, we as providers need to start thinking outside of the box when it comes to holistic care of the individual. When a client relapses, instead of automatically referring them back to a congregate care setting, we need to critically evaluate what support and tools we can provide them with so that they have a chance at achieving the dreams they hold in their hearts. For many, we may find that a different approach may be the one that leads to success.
Elizabeth Galati, MA, is Director of Strategic Partnerships and Resource Development; Karen Gorman, LCSWR, CASAC, is Director of Strategic Partnerships and Resource Development; Karen Leggio, LMHC, Director of Strategic Partnerships and Resource Development; and Kimberly Tucker, MA, Development Implementation Specialist, at Federation of Organizations. For more information about Federation of Organizations, please visit www.fedoforg.org.
