InvisAlert Solutions – ObservSMART

One Mental Health Clinic’s Journey into Integrated Care

We have heard the statistic countless times over the past few years, yet they are still shocking. People with serious mental illness will die, on average, 25 years sooner than the general population. WJCS, like many mental health providers, has predominantly focused on the area of the human body “above the neck,” concerning ourselves with the mind, behaviors, emotions, and cognitions. Inadvertently, we have not focused on the total person. At the same time, it can be surmised that many traditional medical facilities have not focused on the psychological challenges and behaviors experienced by their patients.

Over the past two years, WJCS has successfully launched a series of initiatives that more realistically recognize the need to look at the whole person – to “connect” the minds and bodies of our clients to more fully address their complex physical and mental health needs. To conquer the troubling statistics and best serve our clients, WJCS has embarked on the journey to establishing an integrated model of client care through a partnership with the pediatric clinic of Hudson River Health Care in Yonkers (HRHCare).

The Yonkers Family Mental Health Center of Westchester Jewish Community Services (WJCS) is a busy urban clinic which provides mental health services to over a thousand consumers annually in the southwest corner of Yonkers, a community of very high need and distress. Half of our clients are children and many have experienced trauma in their lives. The vast majority of children designated as seriously emotionally disturbed within Westchester County live in this community.

In the spring of 2012 WJCS submitted two very different and seemingly unrelated proposals to the NY State Office of Mental Health. Both were funded. An “Early Recognition Screening” initiative, now in its third year, supports universal social/emotional wellness screenings to children in community settings, such as schools, pediatric medical clinics, and other natural environments. The goal is to intervene early and reach children who need and would often not receive mental health services in a timely manner. As part of that proposal we partnered with our local Federally Qualified Health Center (FQHC), Hudson River Health Care, to provide screenings for social and emotional wellness to children on site in their Valentine Lane pediatric clinic, located a half a block from the WJCS Yonkers Family Mental Health Clinic. At the same time, WJCS also received startup funding from the NY State Office of Mental Health to co-locate a mental health clinician in a Federally Qualified Health Center to provide mental health services to children on-site. Again, the WJCS Yonkers Family Mental Health Clinic partnered with Hudson River Health Care at their Valentine Lane pediatric clinic. These two initiatives have led to the development of a close partnership between our two institutions, ensuring that children entering the physical health side of care can get free confidential emotional wellness screenings and referrals as well as on-site mental services without being referred out to a clinic. We did not realize the potential of these collaborations to foster positive systemic change and move us towards a more integrated model of care.

From the logistics of obtaining MOU’s, working out releases, developing the work flow, obtaining a satellite clinic license, and figuring out two computer systems with two electronic medical records to bringing two different organizational cultures and disciplines together, the initial startup presented a variety of challenges. However, these challenges were met by the commitment of both partners to the community, high standards of excellence, and a willingness to roll up our collective sleeves and tackle the issues we faced.

Meetings with a variety of staff including administrators of each organization, medical directors, and line staff needed to be done to work out details and to develop protocols. Despite changing personnel on both sides, starts, stops and slowdowns, an exciting and successful collaborative effort emerged. The WJCS “early recognition screener” and co-location therapist have been valued welcomed and integrated into the staff of the Valentine Lane Pediatric Clinic of HRHCare. From the ground up, we have forged strong relationships and have been able to resolve concerns and challenges in a collaborative spirit of honesty and mutual respect.

Out of this initial collaboration, other mutually beneficial practices have emerged. Referrals for behavioral health services from HRHCare to the WJCS mental health center, for both adults and children, have been prioritized and this year we received over 162 referrals from HRHCare in Yonkers. At the same time, our mental health center has been more focused on the overall health needs of clients. As part of the health monitoring performed on all clients in the WJCS mental health center by our Licensed Practical Nurse (LPN), we provide referrals to HRHCare for any clients who do not have a primary care physician.

Each organization has learned more about what specialized services the other offered and how they worked with clients. The cultures and demands of a busy FQHC and a mental health clinic can be very different. Professionals participated in interagency meetings and staff trainings and our collaboration was greatly enhanced by consultations of the clinical professionals. Psychiatrists and physicians on the working on the physical health side were talking directly to each other between the organizations and consulting on shared cases. Vital health and mental health information began flowing more regularly, allowing the different providers to have more knowledge of the health or mental health needs of their consumers, regardless of which “door” (mental health or physical) was entered.

For the families agreeing to be screened through the early recognition screener or referred to the co-located mental health provider, mental health needs are assessed in a preventive manner and early detection of concerning behaviors can occur in a trusted, non – stigmatizing environment. Children are seen at their pediatrician’s office and receive mental health services more quickly. Historically, a high number of referrals for children to mental health services were not successful due to the barriers of stigma, limited access and fear. Mental health services are slowly being understood by families as one of the supports they may need to help ensure their child’s overall wellbeing.

As the partnership between WJCS and HRHCare moves toward a fully integrated model, there are more and more signs of reciprocal “warm handoffs” between the two agencies, often reducing the need for more intensive behavioral health interventions. .We plan to have all children within our community screened for emotional wellness as part of the well visit at the pediatric clinic; and we plan to provide mental health care to all children who need services either through the co-located WJCS mental health satellite clinic at HRHCare, the mental health counseling available through HRHCare’s article 28 services, or the WJCS Mental Health Center down the block. As a result of this journey, children in southwest Yonkers are receiving a higher level of quality care and those who need behavioral health care are receiving it in a more holistic and timely manner, with inter-agency sharing of both knowledge and information.

WJCS is a member of CBHS, Consolidated Health Behavioral Services, a group of 9 behavioral health and disability service providers committed to achieving the “triple aim” in health/mental health care- improving the experience of care, improving health and reducing cost.

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