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Service Integration: Recovery from the Ground Up

Discover how Services for the Underserved provides person-centered, integrated care for homeless and institutionalized individuals. Learn about their recovery-based philosophy and service integration strategies, aiming to improve health outcomes and housing stability. Explore co-location of services and new funding opportunities.

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Service Integration: Recovery from the Ground Up

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  1. Service Integration: Recovery from 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

  2. 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.

  3. The value of a Recovery based Philosophy 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

  4. 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.

  5. 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

  6. 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

  7. Integrating Services New funding • Short term grants • Grants to enhance existing programs • Research opportunities, pilot programs and demonstration projects • Developing new capacity by expanding agency mission and/or services

  8. 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).

  9. 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 

  10. 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.

  11. The SUS Recovery Center • Combination of existing funding and new funding • Co-location of existing Services • New capacity and service for agency (MH Clinic, Veteran’s Programs) • Utilization of Best Practices (ACT, Clubhouse Model, Supported Employment, Wellness Self-Management).

  12. Developing new capacity by expanding agency mission and/or services • Veterans 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.

  13. 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.

  14. Decision to Change What We Had What we Wanted Better coordination of services To Provide staff with efficient and effective methods of intervention, particularly in times of crisis Quicker response to ongoing issues Reduction in incidents, hospitalizations and grievances • 10 distinct Housing Programs • Staffing pattern consisted of a Program Director, Assistant and Case managers • Staff had no particular specialty training • We were limited in the services which we could provide to our tenants • High number of grievances, incidents, hospitalizations

  15. Team Leader Assistant Team Leader Psychiatrist Community Liaison Nurse Service Coordinator Service Coordinator Service Coordinator Service Coordinator Service Coordinator Service Coordinator Service Coordinator Service Coordinator Maintenance / Central Maintenance Dept. Program Structure Administrative Assistant Peer Specialist

  16. Team Meetings / ACT • Team Meetings • The Mobile team meets three times per week. The team meeting are critical for sharing information about consumers functioning and expressed needs. • Team Meetings are short and include: • A discussion of all tenants receiving Protocol III services • Routine service review of 20-25 tenants at each meeting • Updates and revisions to the staff schedule to meet tenant needs • Treatment plan review and revisions, as needed

  17. LEVEL OF CARE / RISK MANAGEMENTService 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 need time limited services from other team members. • PROTOCOL II- CRISIS PREVENTION • Tenant receive services from his/her Service Coordinator/Case Manager. Assessment indicates tenant’s need for services from other team members, particularly the services of the, Nurse and Psychiatrist due to crisis and medical need. • Maintenance management-Tenant’s maintenance issues, concerns and repairs are discussed and a plan of action is immediately formulated • Rent Collection-helping tenants to avoid court litigation/eviction • PROTOCOL III-CRISIS INTERVENTION • Assessment indicates tenant’s need for extended services from several team members

  18. 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/AIDS • Enhances existing programsthrough new staff competencies to achieve better health outcomes.

  19. 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

  20. 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

  21. 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

  22. Summary • Integrated Healthcare delivery is possible even when resources are limited • Rigorous staff training in, and application of , wellness promoting evidence based practices enhances healthcare integration. • Even in an environment of funding silos, it is possible to deliver integrated healthcare by importing proven service models across diagnostic boundaries. • Re-allocation of existing funding to create integrated healthcare service models results in better health outcomes and use of agency resources. • Getting involved in demonstration projects and finding grant opportunities are essential for testing new models and maximizing organizational capacity for integrated healthcare.

  23. Summary (continued) • Be Nimble • Be Creative • Be Informed • Take Risks • Have Fun

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