SERVICE IN

TEGRAT

ION:

RECOVERY F

ROM THE

GROUND UP

PRESENTED BY SERVICES FOR THE UNDERSERVED, INC.

YVES ADES, SENIOR VICE PRESIDENT

WANDA CRUZ LOPEZ, VICE PRESIDENT- MENTAL HEALTH PROGRAMS

NANCY SOUTHWELL, VICE PRESIDENT- AIDS SERVICES & URGENT HOUSING

SERVICES FOR THE UNDERSERVED (SUS)

SUS is an innovative organization strategically positioned to deliver

authentic person-centered, wellness-focused, integrated and

coordinated care and housing for homeless and institutionalized

people with behavioral and substance use disorders.

A vision of recovery is based on the notion that people can grow beyond a diagnosis

and lead a meaningful life in the community

of their choice

THE VALUE OF A RECOVERY BASED PHILOSOPHY

CULTURE AND STRUCTURE

Since 2001, SUS has invested in an ethical and related philosophical transformation that puts the person receiving services at the center of practice and desired outcomes.

Organizational immersion in best practices that reflect person centered care: Wellness Self- Management, Integrated Dual-Disorder Treatment, Trauma-Informed Care, Diabetes Self-Management, Smoking Cessation, Cultural Competency, Family Psycho-education, WRAP , Peer Counseling, ACT and structured supervision.

Robust staff training and supervision in best practice interventions to ensure staff competency.

Robust Risk Management and Utilization Review protocols.

SERVICE INTEGRATION

• Expected outcomes▫ Service fragmentation and overlap is decreased▫ Improved communication between providers▫ Housing stability improved▫ Health and mental health outcomes improve including decrease

in hospitalizations, decrease in hospitalization days, reduction in ER visits & 911 calls.

• Challenges/ Barriers▫ Funding Silos▫ Limitations in funding▫ Staffing limitations and staff turnover

• Benefits▫ To the individual▫ To the agency

INTEGRATING SERVICES USING EXISTING FUNDING

Staying current on best practices “Borrowing” service models from other fields Co-location of services Staff capacity building Re-allocating resources Deploying new initiatives Developing data management Employment of Peers

INTEGRATING SERVICES

NEW FUNDING

Short term grantsGrants to enhance existing programsResearch opportunities, pilot programs and demonstration projects

Developing new capacity by expanding agency mission and/or services

ACHIEVING INTEGRATED HEALTHCARE

• Training and development of Wellness Coaches as enhanced Case Managers.

• Introduction of Nursing to housing support teams.

• Specific service protocols corresponding serious health (medical and behavioral) conditions and level of risk.

• Collaborative admission and discharge planning with hospitals (e.g. Woodhull).

CO-LOCATION OF SERVICES

The Recovery Center

• Article 31, Wellness Works Mental Health Clinic

It serves as a “clinical home” for individuals living with serious and persistent mental illness by providing continuity in care as well as coordination across the domains of their lives (residence, work or training, family, and mental health); specialized tracks address the specific issues of the medically frail, young adults, and individuals with past experience with the criminal justice system. 

• Psychosocial Clubhouse

Operates in accordance with the International Center for Clubhouse Development (ICCD) standards with an emphasis on the work ordered day; the SUS Clubhouse also provides Transitional Employment Program. Additional services include GED classes, computer and Internet classes, evening and weekend recreation, Wellness Self Management, Integrated Dual Disorder Treatment, and vocational counseling groups 

CO-LOCATION OF SERVICES

• Employment Services

Consist of Supported Employment, Assisted Competitive Employment, and Vocational and Educational Services. Services include vocational counseling, benefits counseling, and job placement services.  Individuals are not required to meet any prerequisites in order to receive these services other than a primary diagnosis of serious and persistent mental illness.   

• Assertive Community Treatment

This mobile interdisciplinary team of professionals (psychiatry, nursing, social work, and rehabilitation) and peers deliver treatment services to persons who have a serious and persistent mental illness that seriously impairs their functioning in the community in their own natural setting.

THE SUS RECOVERY CENTER

Combination of existing funding and new funding

Co-location of existing ServicesNew capacity and service for agency (MH Clinic, Veteran’s Programs)

Utilization of Best Practices (ACT, Clubhouse Model, Supported Employment, Wellness Self-Management).

Developing new capacity by expanding agency mission and/or

servicesVeterans Service Coordination

SUS’ Veterans Services include three federally-funded programs • Two U.S. Department of Labor Homeless Veterans Reintegration Programs (HVRP) targeting homeless veterans, homeless female veterans, and homeless male veterans with dependent children.

• U.S. Veterans’ Affairs funded Supportive Services for Veteran Families Program (SSVF) tasked with Veteran-focused care coordination, homeless prevention, and rapid re-housing.

BORROWING FROM OTHER SERVICE MODELS

Scatter-site Mobile Team• An interdisciplinary Team assigned

to 252 formerly homeless and institutionalized individuals living in scatter-site supportive housing. Team care coordination practice incorporates many elements of ACT.

DECISION TO CHANGE

WHAT WE HAD

10 distinct Housing Programs Staffing pattern consisted

of a Program Director, Assistant and Case managersStaff had no particular

specialty trainingWe were limited in the

services which we could provide to our tenantsHigh number of grievances,

incidents, hospitalizations

WHAT WE WANTED

Better coordination of servicesTo Provide staff with

efficient and effective methods of intervention, particularly in times of crisisQuicker response to

ongoing issues

Reduction in incidents, hospitalizations and grievances

PROGRAM STRUCTURE

Assistant Team Leader Psychiatrist

Team Leader

Community Liaison

Nurse

Service Coordinator

Service Coordinator

Service Coordinator

Service Coordinator

Service Coordinator

Service Coordinator

Service Coordinator

Maintenance / Central Maintenance Dept.

Service Coordinator

Peer Specialist

AdministrativeAssistant

TEAM MEETINGS / ACTTEAM MEETINGS / ACT

Team Meetings The Mobile team meets The Mobile team meets threethree times per week. The team times per week. The team

meeting are critical for sharing information about meeting are critical for sharing information about consumers functioning and expressed needs.consumers functioning and expressed needs.

Team Meetings are short and include:1.1. A discussion of all tenants receiving Protocol III A discussion of all tenants receiving Protocol III

servicesservices2.2. Routine service review of 20-25 tenants at each Routine service review of 20-25 tenants at each

meetingmeeting3.3. Updates and revisions to the staff schedule to meet Updates and revisions to the staff schedule to meet

tenant needstenant needs4.4. Treatment plan review and revisions, as neededTreatment plan review and revisions, as needed

LEVEL OF CARE / RISK MANAGEMENTLEVEL OF CARE / RISK MANAGEMENTSERVICE INNOVATIONSERVICE INNOVATION

The Mobile Team has the capacity to increase and decrease contacts based

upon daily knowledge of the tenant’s behavioral and primary healthcare needs

PROTOCOL I- ONGOING SERVICES

Tenants receive services from his/her Service Coordinator/Case Manager. May Tenants receive services from his/her Service Coordinator/Case Manager. May need time limited services from other team members.need time limited services from other team members.

PROTOCOL II- CRISIS PREVENTION

Tenant receive services from his/her Service Coordinator/Case Manager. Tenant receive services from his/her Service Coordinator/Case Manager. Assessment indicates tenant’s need for services from other team members, Assessment indicates tenant’s need for services from other team members, particularly the services of the, Nurse and Psychiatrist due to crisis and particularly the services of the, Nurse and Psychiatrist due to crisis and medical need.medical need.

Maintenance management-Tenant’s maintenance issues, concerns and repairs Maintenance management-Tenant’s maintenance issues, concerns and repairs are discussed and a plan of action is immediately formulatedare discussed and a plan of action is immediately formulated

Rent Collection-helping tenants to avoid court litigation/evictionRent Collection-helping tenants to avoid court litigation/eviction

PROTOCOL III-CRISIS INTERVENTION

Assessment indicates tenant’s need for extended services from several team Assessment indicates tenant’s need for extended services from several team members members

NEW FUNDING/PROGRAM ENHANCEMENT

Wellness Works! in AIDS Services Transitional Housing ProgramsProblem:

High incidence of Incidents including fights, arguments, arrests, and hospitalizations.

High incidence of substance use High incidence of program participants with histories of

Mental Health issues Staff feeling overwhelmed and frustrated.

Solution:New short term grant funding (SAMHSA)Apply mental health evidence based best practices to meet service needs of people with HIV/AIDSEnhances existing programs through new staff competencies to achieve better health outcomes.

WELLNESS WORKS!

• Program Goals include, in equal importance:• Treatment Services (assessment, individual counseling, and groups)

• Service integration through improved linkages with other systems of care

• Staff Training and Capacity Building for sustainability

• Opportunity for data collection to measure outcomes

WELLNESS WORKS!

• Tools• Motivational Interviewing• Wellness Self Management Curriculum• Integrated Dual Diagnosis Treatment Groups

• Individual on site counseling• Joint Service Planning• Follow up on housing discharges

WELLNESS WORKS!

• Outcomes after 2 years:• Increase in permanent housing placement rate• Increase in treatment engagement• Decrease in deaths in general, including deaths on site and

overdoses• Decrease in substance use.• Decrease in mental health symptoms.• Decrease in Incidents involving interpersonal conflicts.• Improved staff satisfaction and self assessment of competency.

Need to look further into measuring:• Health Outcomes• Consumer Satisfaction

SUMMARY

1. Integrated Healthcare delivery is possible even when resources are limited

2. Rigorous staff training in, and application of , wellness promoting evidence based practices enhances healthcare integration.

3. Even in an environment of funding silos, it is possible to deliver integrated healthcare by importing proven service models across diagnostic boundaries.

4. Re-allocation of existing funding to create integrated healthcare service models results in better health outcomes and use of agency resources.

5. Getting involved in demonstration projects and finding grant opportunities are essential for testing new models and maximizing organizational capacity for integrated healthcare.

SUMMARY (CONTINUED)

Be Nimble Be Creative

Be InformedTake Risks

Have Fun