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DSRIP BEHAVIORAL HEALTH COHORTS 9 & 10Health is a state ofcomplete physical,mental and socialwell-being and notmerely the absenceof disease orinfirmity.World Health Organization
JPS Homeless Services ProgramsTrue WorthMedical HomeAcclaim IntegratedMHMR Program*ResearchAcademicsHomelessServicesCare ConnectionsOutreachPathways toHousingRecuperative Care
True Worth Medical HomeSERVICES PROVIDED-Family MedicineLaboratory ServicesRadiologyJPS EligibilityPsych Day RehabDentalSocial WorkCare Connections Outreach
Pathways To HousingSERVICES PROVIDED-Regular home visitsConnect with a PCPHealth coachingNavigating health careMedication adherenceCoordinating care
Recuperative CareTSA MENSPNS MENSSERVICES PROVIDED-Daily nurse visits (M-F)Provider visitsMedication managementsWound careHealth navigationSocial service coordination-Limited support – not a SNFMust be ADL self sufficientFor JPS Connections patientsonly
Care Connections OutreachSERVICES PROVIDED-Primary & Preventive CareHospital Follow UpJPS Eligibility AssistanceIn-patient roundingClinic based social supportHomeless services navigationHealth care navigation-Don’t do housingFollow up can be difficultNeed detailed location(s)Descriptive information
Academics & ResearchACADEMICS-Resident and Student rotationsAll JPS Family Medicine InternsJPS Family Medicine Street MedicineTrack – 2nd & 3rd YearJPS Family Medicine 4th YearRESEARCH-Increasing knowledge and dataCollaborations with JPS, TCU, UNT
AnnieDIFFICULT TO ENGAGE - PRETREATMENT TO HOUSING- 1st contact 8/2017- Initially reluctant- Obvious needs- Prior treatment- Rapport building- Trust- Team effort- Establish PCMH- Navigation- Treatment- Stabilized living situation
Behavioral Health MetricsDSRIP MetricsDepression Screening & Management-12yrs and olderAge appropriate standardized toolFollow up plan if positive screenSuicide Risk Assessment-18yrs and olderDiagnosis of DepressionAt visit where diagnosis made orrecurrent episodeAlcohol Use Screening & Management-18yrs and olderAt least every 24 monthsBrief counseling if positive
JPS In-Patient Behavioral Health ServicesJPS Behavioral HealthIn-Patient- PEC – Psychiatric Emergency Center- TSP – Trinity Springs Pavilion- LCA – Long term Care Alternative Unit
JPS Out-Patient Behavioral Health ServicesHOURSPROCESSHemphill Assessment Clinic8AM-5PMScreener Prescriber ClinicOut-Patient Clinics8AM-5PMScreener PrescriberBehavioral Health Day Rehabs9AM-3:30PMNurse and SW and CRC ProgramPartial Hospitalization9AM-3PMPrograms/Intensive OutpatientProgramPost-Hospitalization or Clinic Referral ProgramCall Center8AM-4:30PMScheduling OnlyMHMR/Acclaim Clinic8AM-5PMMHMR Patients Only Clinic
Community Behavioral Health PartnersMHMR-Behavioral Health Out-Patient clinicsBilly Gregory DetoxPine Street RehabIntegrated Outreach ServiceIDD ProgramsCRU – Crisis Respite UnitACT – Assertive Community TreatmentFACT – Forensic Assertive Community TreatmentMCOT – Mobile Crisis Outreach TeamCATS – Community Addiction Treatment Services
Behavioral Health Systems NavigationNavigating Behavioral Health-Self presentJPS Community Health WorkersJPS/MHMR Peer SupportsJPS Transition CoordinatorsBehavioral Health Specialists- Clinics- Emergency Department- MHMR Liaison
OliverRECEPTIVE TO ENGAGEMENT - PRETREATMENT TO HOUSING- 1st contact 5/2017- Receptive- JPS Connection 1st day- Restarted medications 1st contact- Prior treatment- SUD- Significant physical health needs as well- Whole team engaged- Multiple outreach teams- SUD barriers- SUD struggle continues- Health is declining- Behavioral health care on streets- Follow through streets and into housing- Now in housing through MHMR
It takes a village ioralOutreach
Takeaways- Takes a team- Know the system and resources- Building rapport is essential- Reduce suffering and offer hope
Thank YouQUESTIONS?
- Billy Gregory Detox - Pine Street Rehab - Integrated Outreach Service - IDD Programs - CRU –Crisis Respite Unit - ACT –Assertive Community Treatment - FACT –Forensic Assertive Community Treatment - MCOT –Mobile Crisis Outr
