Super Storm Sandy is Over but the Problems Are Not: A Creative Community-Based Integrated Health Care Initiative

The Staten Island Mental Health Society, Inc. (SIMHS as lead agency) and Community Health Action of Staten Island (CHASI) partnered, in April 2014, to form a Mobile Integrated Health Team (MIHT) to provide in-home health and mental health services to Staten Island residents still suffering the effects of Super Storm Sandy.

The MIHT is modeled on the research findings from Hurricanes Katrina and Rita and data from Super Storm Sandy’s FEMA-sponsored Project Hope Crisis Counseling Program (Norris 2009). Findings suggested that communities experiencing the most destruction tended to have the highest rates of untreated health and mental health concerns, while the corresponding use of formal health/mental health services was low (Madrid 2007).

On Staten Island, the model developed demonstrated clients accepted into the program exhibited at least one major medical condition along with at least one mental health condition. The model verified that clients could address their health and mental health concerns with the goals of reconnecting with their family, friends, community resources and service providers. While the MIHT was designed for post-disaster services, the model can easily be adapted and utilized to assist other high-risk and underserved populations.

The MIHT is designed to provide integrated health and mental health care to high-risk residents who remain seriously affected 1½ years post-Sandy. Each of the MIHT’s three teams is comprised of a licensed Registered Nurse (RN) and a Master’s-level mental health professional (MHP). These teams stay constant throughout the program and change only if a team member resigns from the MIHT. The MIHT also utilizes a Nurse Manager and an overall Program Director. All nursing staff are CHASI employees, while mental health professionals and the Director are SIMHS employees. When psychiatric services are required, a SIMHS staff psychiatrist is available for evaluation and medication therapy.

Following the storm, due to the level of destruction to their homes and communities, residents were not leaving their homes/neighborhoods for health care appointments. Residents were focused on rebuilding their homes, their families’ safety and then their own safety and survival. Most residents who owned cars lost them in the flood waters. Traveling to health care appointments via public transportation was exhausting and time consuming. Attempting to get residents to attend scheduled clinic appointments for their health or mental health had failed.

This is why all MIHT services are designed to be home-based. However, if a team cannot see a client in the home, services are provided in the community at a relief “hub,” a coffee shop, house of worship, park bench, etc.

It was important at the outset of the program to address the relationship between the mental health and nursing philosophies of treatment. Simply put, nursing can be seen as direct and scientific, versus “exploratory” for mental health. The team concept was designed with the goal of each discipline functioning in a complementary manner. Each member of a team was to have an active, concurrent part in the treatment process. The RN does not sit quietly for 30 minutes while the MHP explores, nor does the MHP sit quietly while the “vitals” are taken. Team members become involved in each other’s disciplines in the course of treatment.

To help develop this model, In-Service Trainings were instituted in weekly staff meetings with the MIHT staff, Nurse Manager and Program Director. The RN staff trained the MHP in such disciplines as Understanding Blood Pressure, Diabetes, Obesity and Cardiovascular Disorders. The MHP trained the RN staff in Understanding Anxiety, Depression, Traumatic Stress Disorder, Resistance and Therapeutic Questioning. The weekly staff meetings continue to address the team’s development.

The entire MIHT staff completed two full days of training in Hamblen (2009) Cognitive Behavioral Therapy for Post Disaster Distress (CBT-PDD), a community-based treatment program developed from work with Hurricane Katrina survivors. This training experience helped the RN staff feel more connected to the mental health field. Each team manages a caseload of up to 20 clients with weekly appointments for 45-60 minutes per session. All client sessions are conducted by the team; clients are never seen by just the RN or MHP.

At the initial intake interview, and every three sessions thereafter, clients are asked to complete the Adult Self-Report (Osofsky & Osofsky, LSUHSC-NO, 2013). The Report rates clients in five areas: anxiety, physical problems, depression, suicidality, and alcohol abuse.

The MIHT is an integral part of the Staten Island community recovery and resiliency building process that quickly became relied-upon as a valuable resource. The MIHT maintains close working relationships with the various grassroots disaster relief and recovery groups including the Island’s Long-Term Recovery Organization (LTRO), Coalition of Organizations Active in Disasters (COAD), and Connect to Recovery. MIHT teams incorporate into their weekly assignments visiting relief hubs and recovery centers and talking with residents and workers/volunteers.

Community outreach also targets houses of worship/community centers, elected officials, schools, and health care centers in the heavily affected areas. MIHT teams were present at the many community disaster preparedness trainings and health fairs providing health/mental health screenings and information.

The MIHT treatment model can be viewed as successful on four levels: team design, treatment services provided, community rebuilding, and resiliency and continuity of care. The integrated RN and MHP team approach proved successful. Initially uncomfortable in the conjoint treatment team approach, the RNs and MHPs, through supervision, training and practice, learned to work together and support each other in the treatment sessions and grew to respect and become involved in each other’s treatment philosophies and practices.

For example, after taking K’s blood pressure, the RN reported, “K, your pressure is high, 160/90.” The MHP spontaneously, and to her own surprise, responded, “K, it’s never been this high. What do you think is going on?” As the program progressed, the team members coalesced to effectively address both health and mental health issues in each session.

To reiterate, all treatment services are provided in the client’s home, although when that is not possible, community relief “hubs,” such as coffee shops or park benches are utilized. Home-based services allow the MIHT teams to reach the most vulnerable populations and provide services within severely damaged neighborhoods and homes. The home-based model allows the teams to experience the smells, sounds, sights, chaos, despair and life-as-they-live-it views (Trout, 1987) of clients. This direct experience of clients’ living conditions aid in the teams’ connections to individual residents, families, and the community, ensuring continuity of care.

One year post-startup, the MIHT had opened 72 cases, provided 1,240 individual and/or family sessions and completed over 500 outreach screenings.

When analyzing the health and mental health conditions, upon admission, of Sandy-affected residents of Staten Island, New York, the MIHT team found clients exhibited a pronounced co-occurrence of health and mental health problems. The most common behavioral health diagnoses were depression, anxiety, and PTSD. The most frequent medical conditions were Hypertension, High Cholesterol and Chronic Obstructive Pulmonary Disease. These data mirror the findings from the aftermath of Hurricanes Katrina and Rita.

Health Conditions: 87% had one serious medical condition; 67%, two medical conditions; and 50% had three medical conditions. Mental Health Conditions: 100% received a positive screening score on the Adult Self Report for a mental health condition; 90%, two positive screenings scores; and 65% three positive screening scores.

Analysis of the Adult Self Report data indicates a significant decrease over time in the Anxiety, Depression and Physical Problems scores resulting in improvement in the client’s symptomology.

Case Example: Kay, age 42, and Rob, age 46, along with their three children, ages 13, 10 and 6, are clients of the MIHT. Kay applied for services in May 2014 due to increased anxiety and fears related to Super Storm Sandy. Kay was also concerned about her husband’s depression and fears, as well as anxiety evident in her children related to the hurricane. The family lives in the Midland Beach section of Staten Island, which was severely impacted by the storm. The family did not evacuate the night of the storm, and witnessed the flood waters approach and encircle their home. The couple reported watching neighbors and relatives escaping the rising waters while they remained in their home. The children often speak about hearing fearful screaming and yelling the night of the storm. Kay and Rob report fearing for their lives when the waters came in. Fortunately, after the flood waters receded, their home was damaged but livable. However, both Kay and Rob’s parents’ homes were severely damaged and unlivable, creating extra pressure on the entire family. When the MIHT team went to Kay and Rob’s home for an initial assessment they found Kay and her children in good physical health, but experiencing increased fears and anxiety, while Rob was depressed, with high blood pressure, diabetes and obesity. The team began weekly meetings with them to address both the post-Sandy mental health issues, and Rob’s health concerns. At one meeting, Rob was having difficulty breathing, with high blood pressure, abnormal heart rate and increased sugar levels, necessitating immediate transfer to the ER. However, because Rob became anxious and fearful of going to the hospital, the MHP began addressing these symptoms, while also working with Kay, in a relaxed, calm manner to arrange child care while the couple went to the hospital. The MHP also provided support to the children, who had become fearful and anxious regarding their father. Rob was admitted to the hospital with possible heart failure due to a leaky heart valve and pneumonia. The MIHT team remained in contact with Kay while Rob was hospitalized and visited the couple after he returned home the following week. Both Kay and Rob told the team that they “saved his life.”

Four months into the MIHT program, several clients independently requested the formation of a “social” group to facilitate meeting and mingling with other MIHT clients. The MIHT Community Support Group was launched. The group meets monthly for 2½ hours in a community center in the heavily damaged Oakwood Beach section of Staten Island. All MIHT clients and their families are invited. The format is casual, with food, games, crafts, music and relaxation/stress reduction exercises including yoga, breathing techniques or “ice breaker” exercises. This group is an asset for the clients where they can re-connect to their community and develop new friendships

The MIHT has proven to be an essential resource in the post-Sandy disaster recovery and community resiliency rebuilding process on Staten Island, New York. Providing home-based health and mental health services to the most medically and psychologically at-risk residents is successful. The model confirms that community-based health and mental health care can be comprehensive, culturally sensitive, stigma-reducing, family-centered, resiliency-based and continuous.

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