DSRIP BEHAVIORAL HEALTH COHORTS 9 & 10 Health is a state of - - PowerPoint PPT Presentation

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DSRIP BEHAVIORAL HEALTH COHORTS 9 & 10 Health is a state of - - PowerPoint PPT Presentation

Oct 20, 2023 398 likes •571 views

DSRIP BEHAVIORAL HEALTH COHORTS 9 & 10 Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. World Health Organization JPS Homeless Services Programs True Worth

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SLIDE 1

DSRIP BEHAVIORAL HEALTH COHORTS 9 & 10

Health is a state of complete physical, mental and social well-being and not merely the absence

  • f disease or

infirmity.

World Health Organization

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SLIDE 2

JPS Homeless Services Programs

True Worth Medical Home Acclaim Integrated MHMR Program* Care Connections Outreach Recuperative Care Academics Pathways to Housing Research

Homeless Services

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SLIDE 3

True Worth Medical Home

SERVICES PROVIDED

  • Family Medicine
  • Laboratory Services
  • Radiology
  • JPS Eligibility
  • Psych Day Rehab
  • Dental
  • Social Work
  • Care Connections Outreach
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SLIDE 4

Pathways To Housing

SERVICES PROVIDED

  • Regular home visits
  • Connect with a PCP
  • Health coaching
  • Navigating health care
  • Medication adherence
  • Coordinating care
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SLIDE 5

Recuperative Care

SERVICES PROVIDED

  • Daily nurse visits (M-F)
  • Provider visits
  • Medication managements
  • Wound care
  • Health navigation
  • Social service coordination
  • Limited support – not a SNF
  • Must be ADL self sufficient
  • For JPS Connections patients
  • nly

TSA MENS PNS MENS

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SLIDE 6

Care Connections Outreach

SERVICES PROVIDED

  • Primary & Preventive Care
  • Hospital Follow Up
  • JPS Eligibility Assistance
  • In-patient rounding
  • Clinic based social support
  • Homeless services navigation
  • Health care navigation
  • Don’t do housing
  • Follow up can be difficult
  • Need detailed location(s)
  • Descriptive information
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SLIDE 7

Academics & Research

ACADEMICS

  • Resident and Student rotations
  • All JPS Family Medicine Interns
  • JPS Family Medicine Street Medicine

Track – 2nd & 3rd Year

  • JPS Family Medicine 4th Year

RESEARCH

  • Increasing knowledge and data
  • Collaborations with JPS, TCU, UNT
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SLIDE 8

Annie

DIFFICULT 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
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SLIDE 9

Behavioral Health Metrics

DSRIP Metrics

Depression Screening & Management

  • 12yrs and older
  • Age appropriate standardized tool
  • Follow up plan if positive screen

Suicide Risk Assessment

  • 18yrs and older
  • Diagnosis of Depression
  • At visit where diagnosis made or

recurrent episode

Alcohol Use Screening & Management

  • 18yrs and older
  • At least every 24 months
  • Brief counseling if positive
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SLIDE 10

JPS In-Patient Behavioral Health Services

JPS Behavioral Health

In-Patient

  • PEC – Psychiatric Emergency Center
  • TSP – Trinity Springs Pavilion
  • LCA – Long term Care Alternative Unit
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SLIDE 11

JPS Out-Patient Behavioral Health Services

HOURS PROCESS Hemphill Assessment Clinic 8AM-5PM Screener  Prescriber  Clinic Out-Patient Clinics 8AM-5PM Screener  Prescriber Behavioral Health Day Rehabs 9AM-3:30PM Nurse and SW and CRC  Program Partial Hospitalization Programs/Intensive Outpatient Program 9AM-3PM Post-Hospitalization or Clinic Referral  Program Call Center 8AM-4:30PM Scheduling Only MHMR/Acclaim Clinic 8AM-5PM MHMR Patients Only  Clinic

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SLIDE 12

Community Behavioral Health Partners

MHMR

  • Behavioral Health Out-Patient clinics
  • 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 Outreach Team
  • CATS – Community Addiction Treatment Services
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SLIDE 13

Behavioral Health Systems Navigation

Navigating Behavioral Health

  • Self present
  • JPS Community Health Workers
  • JPS/MHMR Peer Supports
  • JPS Transition Coordinators
  • Behavioral Health Specialists
  • Clinics
  • Emergency Department
  • MHMR Liaison
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SLIDE 14

Oliver

RECEPTIVE 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
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SLIDE 15

It takes a village…

Homeless Services

EMS Police Behavioral Outreach Shelters Health System

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SLIDE 16

Takeaways

  • Takes a team
  • Know the system and resources
  • Building rapport is essential
  • Reduce suffering and offer hope
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SLIDE 17

Thank You

QUESTIONS?