Integration of Care – Minutes – 4/6/22

INTEGRATION OF CARE COMMITTEE

Veronica Fortunato & Donald Powell, IOC Co-Chairs

Wednesday, April 6^th, 2022, 10a-12p

Zoom Meeting

https://health-nyc-gov.zoom.us/j/9831410930

Attendance:

Guests: Josh Seidman, RE Lunderman, Minhee Cho, Mirnelly Fernando, Marcelo Maia, Alyssa Aguilera, Dave Guggenheim

DOHMH/PHS Staff: 

Agenda Item #1: Welcome/Introductions w. Pronouns/Moment of Silence/Review of Minutes

Introductions conducted. Icebreaker: why do you love/hate the rain? Minutes accepted. Asia Betancourt conducted the moment of silence.

Agenda Item #2: Provider Panel (Providers External to Ryan White Funding) 

Josh Seidman of Fountain House (FH):

Fountain House was founded 74 years ago by people with serious mental illness. At that time there was only a medical model, and no psycho social rehabilitation. Called themselves “We are Not Alone”. Given a house in Hell’s Kitchen – began the clubhouse model which has been widely replicated and designed to break economic and social isolation – very focused on social drivers of health.

35-40% of pop. Comes in with a history of homelessness. Refer to those involved as members – people want to be there, its where they have community and feel comfortable. Staff and members do the work of the house together. It’s a true definition of a health home. 

Has a beneficial impact on medical utilization costs, and higher success with employment among members. FH doesn’t offer clinical care – have partnered with clinics to ensure members needs are met.

Core of funding is from NYC. Housing funds come from the state. Opposite of fee for service medicine – launching a value based payment plan with Health First to be evaluated by NYU. Looking at measures like quality of life, loneliness.

Have some small Medicaid contracts.

All of the clubhouses require documentation of serious mental illness to become a member. Members are part of the review process. FH works in coalition with other clubhouses. FH has 1200-1300 members, and due to the pandemic, now offers virtual options.

In the 90’s an accreditation program was developed – spun off to tis own organization. They do a low of technical assistance, as does FH. 

For people without documentation, chief medical officer helps provide needed documentation.

FH now doing more street outreaches through pop-ups, and accommodate people without documentation.

There is a lot of silos in medical care for people with co-morbidities

Develop partnerships with medical providers to address community needs. The extensive trust of members in the house – this helped in the case of vaccinations. 

Are there programs for people with physical disabilities?

People with SMI with disabilities are members of FH. People with SMI have early death rates, due to many issues, including the medications for SMI.

Because FH doesn’t provide medical services, on the WHO pyramid, FH would be considered informal support.

FH is trying to validate social practice as a model. FH is an intentional community. 

The hierarchy of the medical system is what makes interventions like FH be considered informal. Even though it is critical to supporting people.

How do you address stigma?

There are 14.2 million people or more living with SMI in this country – we create the conditions that allow people to thrive. Need to think deeper about how we forge community.

How does FH manage clients in crisis?

Have a category of staff called social practitioners who have built a trust relationship with members. Peers play an important role in that.

How do clients come to FH

Sometimes by referral, usually clinical providers.

How does FH manage substance use disorder?

A third to a half of members have a history of substance use. Have groups that address this, but do not have a specific program.

Diff between accredited and not accredited?

Clubhouse Intl has 37 standards that a house must meet – usually takes 2-3 years to get accredited.

Asia Betancourt (VOCAL):

We need more FH’s. A lot of people are falling though the cracks and not getting the help that they need. When someone goes in for detox, they come back out and there’s no thought to their recovery. They come back to the streets, or the same situation. 

A lot of people are scared of accessing the services that would get them documentation. We have detox and rehab- average person relapses within 3 months – no continuum of care. Need to train parents and loved ones on how to support family members with mental health issues. And there needs to be support 24 hours a day.

Dave Guggenheim of Callen Lorde:

Work with primarily LGBT clients. Try to normalize and integrate all of our mental health care. Try to be very intentional with the language – bipolar, versus living with bi-polar. Have done a lot of work on strengthening our anti-stigma work. Try very hard to create wrap around services where you are able to get everything you need.

Josh Seidman:

Maybe we need to bring psycho-social rehab into other settings, other BH settings. Create the community as therapy model in other settings too. Our country needs to move to more holistic, value based payment. Can’t solely focus on clinical measures without social measures. Must understand importance of considering whole client.

Dave Guggenheim:

Callen Lorde has two models, but medical model is fee for service (FFS) – have to use this model, does not look at quality of life, or social measures and creates a box – how many patients we are seeing, how much is state spending on ED visits – its very siloed. Newer surveys look at more than clinical outcomes, such as empowerment, social needs.

Not looking at social connections, vocational skills, etc. Not included in FFS model. And cannot provide some services that are super valuable, because they are not in our model.

What are the licensure challenges between substance use and mental health? Ow does it inhibit patient centered care?

NY has OASAS, DOH, and OMH – artificial barriers to providing care. If we identify s/u needs, we can’t see the client, because we don’t have an s/u license. We have an OMH license, but many don’t have an article 31, so provide MH services under DOH and restricted. Mental health and substance use should be treated in concert. Hopefully OASAS and OMH will merge. The article 31 regulations are super convoluted.

Alyssa Aguilera of VOCAL:

VOCAL is a syringe services organization, have wanted to build out Hep C testing – partnered with Mount Sinai to do so. Incredible amount of restrictions that are needed to get a space in line with state requirements. Very expensive. Not very clear. Makes it difficult for community organizations to meet needs of clients.

We don’t have an EHR, tried to get this started, but its an incredibly heavy lift – and the systems do not meet our needs. Our funding is grant based. Medicaid is now paying for these services, but getting to the point where we can bill Medicaid is incredibly difficult – also begs question of embracing a more medicalized version of harm reduction. How do we build out the programming we want, continue to ensure our participants feel safe and provide the services they need?

Changing how grant based funds operate – including increasing the size of grants that have been flat funded, even for inflation.

Create flexibility where CBOs don’t have to figure out billing to be able to offer new services, 

When thinking about the state, how are we creating a spectrum of ways for people to plug in. Great to see safe injection sites – and expanding those to the community syringe exchange sites. People love VOCAL because they can shower, use the bathroom, get lunch, get coffee, etc.

Dave Guggenheim –

Tried to open a smaller location to provide services but could not because of state regulations. DOH had an exception where very small clinics had less regulations, but there are still too many. Don’t have the funding to renovate spaces to meet these regulations.

State should be listening to smaller orgs

What do the orgs do to support people who have gotten sober? Psycho social support needed to be in community?

Alyssa Aguilera, VOCAL: Do acupuncture, reiki, writing workshops – mostly led by volunteers – rarely get funded to do these things. Lie skills are out of our wheel house, but have a network of orgs we refer people to

Dave Guggenheim ,Callen Lorde: have health education, try to get grants, don’t have a holistic programming, no sources of funding for this

How does harm reduction work with psychotropic medication and the conflict that can exist there? What’s happening with the subway and encampment sweeps where peoples things are being destroyed?

Alyssa Aguilera, VOCAL: do a lot of street-based outreach, one of our sites was swept – some of the people that are most resistant to relationships with providers. Sweeping up the encampments forces us to lose touch with people. Done under the guise of dignity, but violence against these people lacks dignity.

Dave Guggenheim, Callen Lorde

Trying to develop housing program – not funded, or even part of what medical centers are supposed to do. Last 4 years were very hard in terms of harm reduction. Unable to offer this in-house, have to separate care. 

What would integration look like?

We would have all of the services under one roof.

How do you leverage peers?

Alyssa Aguilera, VOCAL: Do an in house 8 week mini workforce training program on how to be a peer. Not the highest graduation rate, but usually hire people who graduate. Pay a minimum of $20/hr and provide health care to everyone who works more than 20 hours/week.

Dave Guggenheim ,Callen Lorde: Web of regulations and issues with malpractice to have peers come in, have not succeeded in integrating care. Still working on it.

NYS has more regulations than other state. 

Do you have insights into where RW dollars can be provided?

Alyssa Aguilera, VOCAL: Mental health services, Harm reduction providers that are culturally responsive, pop-ups

Dave Guggenheim, Callen Lorde: more mobile facilities. Health and wellness services, health education services. More of those services the better. 

Asia: More peers, more people with lived experience, to deliver these services to the community, because peers know what the needs are.

Never Use Alone National Hotline – 24 hours a day!

Discussion:

Important to think about who can support people when they go into crisis. Especially when it is outside of banking hours.

Ryan White funding to conduct outreach and go where people are was cut. 

Agenda Item #2: Housing Directive Subcommittee

Housing directive: (short-term housing, rental assistance and housing placement assistance) needs to be revised in order for new contracts to be issued due to the age of the old RFP. The directive and contract can be revised after award. 

Volunteers for the subcommittee:

Paul Carr

Asia Betancourt

Deborah Greene

Marcelo Maia

John Schoepp