New Directions in Healthcare and the Promise of Recovery

In case you didn’t notice, this is a time of radical change in the behavioral health and health fields. However, challenging the policy and fiscal landscapes have become, it’s important to remember that we’re all still in the business of helping people to recover, achieve goals, and be part of a community. The notion of recovery for the person with serious mental illness is empowering simply by virtue of the hope it implies about the future. Belief in the ability to recovery by all who engage to achieve it, however critical, is not enough; there must be substance and structure to support the process.

Long before the Medicaid Redesign Team came into being, SUS has been making significant inroads toward addressing disparities in health outcomes for people with behavioral health challenges. In fact, for the past ten years, we have worked as an organization to transform our practice values and treatment philosophy to position the person receiving services at the center of practice and desired outcomes. Consistent with this orientation, Services for the UnderServed (SUS) has established a Recovery Center in the heart of Bedford-Stuyvesant, one of New York City’s most underserved areas. Launched in 2009, The SUS Recovery Center represents the next evolution of our housing, community support and treatment services for people with mental illness and multiple co-occurring primary health and substance abuse disorders, and HIV-AIDS.  Consisting of our Wellness Works Mental Health Clinic, Brooklyn Clubhouse, Assisted Competitive Employment Services, Homeless Veterans Reintegration Program, Assertive Community Treatment (ACT) and a Peer Counselor Training Academy, as co-located services, all operating from a platform of recovery, we are able to offer an integrated approach to achieving and maintaining wellness and recovery, while simultaneously providing the requisite flexible structure to promote hope and recovery.

The substance of the recovery platform shared by all Recovery Center service components is a tool kit composed of seven evidence-based practices: Wellness Self-Management (WSM), Integrated Dual Disorder Treatment (IDDT), Diabetes Self-Management, Family Psychoeducation, Trauma-Informed Care, Cultural Competence and Peer Counseling. With few exceptions, the individual Recovery Center enrollee can participate in as many Recovery Center services as he/she needs to stay engaged and achieve improved overall health. For high utilizers of emergency rooms and hospitals, the Recovery Center serves as both an anchor to less costly community-based health care and a sustainable alternative to managing health and well-being outside of institutional settings. While the greater majority of 1200 individuals who live in SUS supportive housing are not enrolled at the Recovery Center, those who pose the greatest risk for recidivism to institutional settings (e.g. hospitals, shelters, prisons), are encouraged to enter the Center through any of its service doors. For some, the entry point is through employment, while for others it is simply an opportunity to enjoy lunch served at the Clubhouse.

Developed throughout over 30 years of experience in treatment, support and housing programs, particularly through the integration of embedded nursing, care coordination, mobile wellness teams and Wellness Recovery Action Plans (WRAP) in supportive housing, we’ve come to understand well the presenting priorities of people in recovery from mental illness and co-morbid health conditions. Despite an emergent physical health care condition, the effects of poverty, substance abuse and the symptoms of mental illness most often take precedence in the “hierarchy of needs” among those that come to SUS for help. In essence, it is only subsequent to deep investment in the engagement process and ensuing behavioral health treatment and recovery, that physical health needs are considered and ultimately addressed. The physical co-location of services under a single roof, however necessary to service integration, is insufficient toward providing truly integrated care. Even more important to the recovery process and the achievement of integrated wellness is the shift in clinical culture that ensues when health and behavioral health services are down the hallway from one another; social workers, internists, nurses, peers, and psychiatrists are able develop real relationships and synergies otherwise difficult to secure and maintain. These clinical relationships across medical and behavioral health disciplines, centered on individuals, break down traditional silos of care: medical “patients” and psychiatric “patients” cease to exist and a person with multi-faceted, complex needs emerges.

While for most individuals behavioral health services act as the “launch pad” for other Recovery Center offerings, irrespective of how an individual chooses to begin his or her journey at the Recovery Center, enrollees soon begin to experience a reinvigorated sense of hope for the future that permeates in the language, expressed beliefs and attitudes of staff and other enrollees. Coupled with nearly seamless access to the full cadre of Recovery Center services, the high-risk enrollee is better able to transition into recovery and the services needed to support it in the community.

In the midst of the extensive healthcare reform strategy aimed at reducing healthcare costs and improving the health outcomes of the highest utilizers of Medicaid dollars now being realized in New York State, the SUS Recovery Center serves as an effective integrated service model for engaging and managing the complex healthcare needs of the “disconnected”, emergency room and hospital dependent, Medicaid recipient living with a behavioral health condition.  Fully cognizant of the need to actively address physical health concerns, we are engaged in efforts to incorporate medical services into our Recovery Center service array. This addition will afford Recovery Center enrollees access to truly integrated primary medical and behavioral healthcare services in a single practice setting.

The Recovery Center also serves to meet the healthcare needs of people with HIV-AIDS, many of whom also live with behavioral disorders ranging from Post-Traumatic Stress Disorder to serious mental illness with co-occurring substance abuse disorders. As a particularly medically complex subset of the Medicaid population, people with HIV-AIDS will be better served by the Recovery Center once primary medical services are established there. While our Recovery Center presents new opportunities to offer integrated care at SUS for people HIV positive individuals, since 2010, we have been providing care coordination for high risk individuals with AIDS and advanced HIV disease living in commercial SRO hotels who are not engaged in effective medical treatment and management of HIV-AIDS. The project is structured as a partnership with private primary medical practitioners who have agreed to serve as the “health homes” for this high-risk, high-need population, engaging participants in on-going health monitoring and treatment leading to improved health status.

Put simply, our SUS Recovery Center is positioned as an effective behavioral health setting poised to reach and engage people with complex healthcare needs, neglected by the health care system, living without the supports necessary to recover. As we know at SUS, once engaged in recovery-oriented system of care, emphasizing total wellness, the overall well-being of the people we serve improves. Our recovery mindset and associated services, informed by an organizational culture that values recovery, provides consumers with a thoughtful and organized environment conducive to wellness and personal fulfillment. With the RecoveryCenter’s new addition of primary medical health services, SUS will have even greater capacity to engage and support the recovery of people who are at greatest risk for health crises that result in repeated and avoidable dependence on emergency rooms and hospitals.

The SUS Recovery Center is located at 1125 Fulton Street, 2nd and 3rd Floors, Brooklyn, N.Y. 11238. The phone number at the Center is, (347) 226-9025.

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