PRESENTED BY SERVICES FOR THE UNDERSERVED, INC.
YVES ADES, SENIOR VICE PRESIDENT
WA N DA C R U Z LO P E Z , V I C E P R E S I D E N T - M E N TA L H E A LT H P R O G R A M S
NANCY SOUTHWELL, VICE PRESIDENT- AIDS SERVICES & URGENT
HOUSING
SERVICES FOR THE UNDERSERVED (SUS)
SUS is an innovative organization strategically
positioned to deliver authentic personcentered, wellness-focused, integrated and
coordinated care and housing for homeless
and institutionalized people with behavioral and
substance use disorders.
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
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, TraumaInformed 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
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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 grants
 Grants to enhance existing programs
 Research opportunities, pilot programs and
demonstration projects
 Developing new capacity by expanding agency mission
and/or services
ACHIEVING INTEGRATED HEALTHCARE
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Training and development of Wellness Coaches as enhanced Case Managers.
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Introduction of Nursing to housing support teams.
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Specific service protocols corresponding serious health (medical and behavioral)
conditions and level of risk.
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Collaborative admission and discharge planning with hospitals (e.g. Woodhull).
CO-LOCATION OF SERVICES
The Recovery Center
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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
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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 Services
 New 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 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.
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
W H AT W E H A D
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
W HAT W E WA NTED
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
PROGRAM STRUCTURE
Team Leader
Administrative
Assistant
Assistant Team
Leader
Community
Liaison
Service
Coordinator
Service
Coordinator
Service
Coordinator
Service
Coordinator
Psychiatrist
Nurse
Service
Coordinator
Service
Coordinator
Service
Coordinator
Service
Coordinator
Peer Specialist
Maintenance /
Central Maintenance Dept.
TEAM MEETINGS / ACT
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Team Meetings
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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:
1.
2.
3.
4.
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
LEVEL OF CARE / RISK MANAGEMENT
SERVICE 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
NEW FUNDING/PROGRAM ENHANCEMENT
Wellness Works! in AIDS Services Transitional Housing Programs
Problem:
 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 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 Informed
Take Risks
Have Fun