St. Catherine’s Center for Children St. Catherine’s Center for Children provides a comprehensive range of human services designed to offer hope, foster growth, and improve the lives of the children and families we serve.
St. Catherine’s Center for Children St. Catherine’s Center for Children provides a comprehensive range of human services designed to offer hope, foster growth, and improve the lives of the children and families we serve.
Who Are We ? St. Catherine’s is a publicly funded, not-for-profit human services agency. We are a haven for hope, offering services, treatment, and education for our community’s most at -risk children and families in order to heal and preserve family life.
Current Agency Services Comprehensive homeless services for families and adults Residential services for children 5-13 Foster care services Day treatment/Special education elementary school Community-based and prevention services
Marillac Homeless Family Program Funded through the Office of Temporary Assistance and Albany County Department of Social Services Emergency shelter for 24 families Case management Supported employment On-site childcare/transportation/recreation
Permanent Supportive Housing and Project Connect Permanent Supportive Housing: HUD funded for the chronically homeless Serious mental illness and/or substance abuse Scattered sites in Albany/Columbia counties Albany County-houses 12 families/7 singles Columbia County-houses 4 families/4 singles Project Connect: Funded through a 3-year Substance Abuse and Mental Health Services Administration (SAMHSA) grant Outreach and engagement to homeless individuals Houses 30 single chronically homeless individuals per year
Project HOST Healthy Outcomes through Supportive Transitions (HOST) NYS Department of Health funded since 2015 (MRT) Houses and provides case management for 30 homeless/unstably housed individuals at scattered sites Primary focus: decrease Medicaid costs and improve health outcomes Serves high users of crisis services, including those who struggle with severe mental health, substance abuse and/or chronic illnesses
Outreach and Engagement Based on evidence-based practices, including: Housing First, Motivational Interviewing, Critical Time Intervention, Supported Employment, Harm Reduction, and SOAR, (SSI/SSDI, Outreach, Access and Recovery) Client driven service delivery Street outreach Engaging community resources and contacts Medicaid/Health Homes Shelters Emergency rooms and police Mental Health Units Detox
Contracting with Managed Care Organizations
Building a Relationship Quality care to high cost Medicaid patients Utilizing health care resources Clarifying roles and case conferencing PSH, MCO and Community Providing high quality services to the highest need
Starting the Conversation Formalizing the relationship Serving individuals identified by the MCO MCO has a different threshold than homeless supportive housing programs Trust and quality of care established
Barriers and Mitigation Establishing level of service provided by CBO Finances Staffing and Case Load Business model/ consistency
Where Are We Now? Final talks of contract negotiations Identifying additional MCO’s and PPS’s that want to contract with CBO’s Market ourselves and our services through quality of care and decrease in Medicaid costs to high need clients
How Project Host Addresses Social Determinants of Health
Health and Healthcare Health Homes/Care Coordination Managed Care Organizations CDPHP Fidelis Hospitals Program Services Coordinating Committee (PSCC)
Economic Stability 29 highly vulnerable individuals currently housed Supported Employment Case Manager offers employment assistance Staff are trained in the SSI/SSDI Outreach, Access and Recovery (SOAR) model Albany and Rensselaer County Departments of Social Services secure mainstream benefits (housing allowance, food stamps and Medicaid)
Social and Community Context Peer Support Services connecting clients to support groups, Drop in Centers Clients participate in focus groups to share their story to educate and raise awareness of homelessness, mental illness and addiction. Client engagement activities Annual summer cookout Thanksgiving Breakfast with Albany Medical Center Coat drive Client participation in event panels
Neighborhood and Environment Secure safe, affordable and stable housing Encourage healthy foods & eating (i.e. Price Chopper partnership) Crime & Violence Albany PD Law Enforcement Assisted Diversion (LEAD) Albany PD Neighborhood Engagement Unit
Project HOST Outcomes Currently serving 30 individuals over two counties (Albany and Rensselaer) 67% decrease in ED visits 56% decrease in inpatient days An example of a high utilizer: Pre housing ER spending $43,600.29 and 181 ER visits. Post housing ER spending $325.50 and 9 ER visits.
Some of the people who help make it all happen!
October 2017 Social Determinants of Health (SDH) & Community Based Organizations (CBOs) March 21, 2018
22 October 2017 Agenda • Social Determinants of Health • New Opportunities: VBP and SDH/CBOs • CBO Resources and Supports • Bureau of Social Determinants Of Health: Purpose and Goals
23 October 2017 Social Determinants of Health (SDH) VBP Roadmap Standards & Guidelines
24 October 2017 Key Insights to Keep In Mind • Understand Community Needs • Know Your Key Community Partners: ➢ Performing Providers Systems (PPS) ➢ Managed Care Organizations (MCOs) ➢ Large Provider Systems ➢ CBOs • Understand the Local VBP Level 2 or 3 Arrangements ➢ TCGP, IPC, Maternity, HIV/AIDS, HARP, MLTC • Determine the SDH Intervention Needed ➢ e.g. Housing, Nutrition, Health-based Housing Design • Develop Your Value Proposition
25 October 2017 What Are Social Determinants of Health and Why Are They Important? Social determinants of health are the structural conditions in which people are born, grow, live, work and age Addressing social determinants can have a significant impact on health outcomes SDH Interventions can be less costly than traditional medical interventions___ Under VBP, VBP contractors aim to realize cost savings while achieving high quality outcomes ➢ The VBP program design incentivizes VBP contractors to focus on the core underlying drivers of poor health outcomes — the Social Determinants of Health
26 October 2017 Standard: Implementation of SDH Intervention “To stimulate VBP contractors to venture into this crucial domain, VBP contractors in Level 2 or Level 3 agreements will be required , as a statewide standard, to implement at least one social determinant of health intervention . Provider/provider networks in VBP Level 3 arrangements are expected to solely take on the responsibilities and risk.” (VBP Roadmap, p. 41) Description: VBP contractors in Level 2 or 3 arrangement must implement at least one social determinant of health intervention. Language fulfilling this standard must be included in the MCO contract submission to count as an “on - menu” VBP arrangement.
27 October 2017 Guideline: SDH Intervention Selection “The contractors will have the flexibility to decide on the type of intervention (from size to level of investment) that they implement…The guidelines recommend that selection be based on information including (but not limited to): SDH screening of individual members, member health goals, impact of SDH on their health outcomes, as well as an assessment of community needs and resources.” (VBP Roadmap, p. 42) Description: VBP contractors may decide on their own SDH intervention. Interventions should be measurable and able to be tracked and reported to the State. SDH Interventions must align with the five key areas of SDH outlined in the SDH Intervention Menu Tool, which includes: 1) Education, 2) Social, Family and Community Context, 3) Health and Healthcare 4) Neighborhood & Environment and 5) Economic Stability The SDH Intervention Menu Tool was developed through the NYS VBP SDH Subcommittee and is available here: https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/vbp_library/
28 October 2017 Housing Security: Outcomes of MRT Supportive Housing
29 October 2017 Food Security: Outcomes of Medically Tailored Meals (MTM) God’s Love We Deliver Nutrition Intervention Outcomes • Low-cost/High-impact intervention: Feed someone for half a year by saving one night in a hospital • Reduce overall healthcare costs by up to 28% (all diagnoses compared to similar patients not on MTM) • Reduce hospitalizations by up to 50% (all diagnoses compared to similar patients not on MTM) • Reduce emergency room visits by up to 58% (pre- post MTM intervention) • Increase the likelihood that patients receiving meals will be discharged to their home, rather than a long term facility (23%) (all diagnoses compared to similar patients not on MTM) • Increase medication adherence by 50% (pre-post MTM intervention)
30 October 2017 Community Based Organizations (CBOs) VBP Roadmap Standards & Guidelines
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