This year, CCN will be awarding over $2 million, from their Innovation Fund program, to local hospital systems and community-based organizations. Eleven different organizations will be awarded funds from the program to support 14 projects. The projects ranged from opening new centers for addiction and trauma recovery to expanding Mental Health First Aid Training to first responders to expanding mental health and primary care services.
Care Compass Network (CCN), launched their Innovation Fund Program back in 2015 to support partner organizations develop or expand programs and services that support the transformation of healthcare delivery and improve overall patient outcomes. The primary goal of CCN’s Innovation Fund program is to support partners in their efforts to increase access to healthcare and improve patient health outcomes. These funds allow partners to create new and innovative programs or expand outreach services that help increase engagement of the Medicaid population within our nine-county region.
Innovation Fund Proposal Descriptions
Addiction Center for Broome County – Open OASAS Part 822 Outpatient Clinic & Rehab Program
The Addiction Center of Broome County, Inc. (ACBC) is opening a location in Endicott, New York to focus on substance use disorder and trauma recovery, “The Center for Addiction and Trauma Recovery.” Core services include outpatient clinic, outpatient rehabilitation, medication-assisted treatment, peer recovery services, and health home services. Specialized interventions, along with psychotherapy and psychiatry services will assist with reducing symptoms of PTSD and preventing relapse. It’s time to reduce the stigma and change the conversation from “What’s wrong with you?” to “What happened to you?” Addressing the traumas more directly allows individuals receiving services to work on the root causes of issues and restore self-esteem. Data suggests that enhanced awareness of the comorbidity between PTSD and substance abuse is critical both in understanding mechanisms of substance addiction as well as in improving prevention and treatment.
The new clinic will also provide wrap-around services, also trauma-informed, to address the participant’s social determinants of health. ACBC will work to ensure that members are connected with primary care services, dental providers, have transportation, stable housing, food, and clothing. This will assist individuals with reducing the life stress that they may be experiencing and can interfere with therapy efforts and seeking/maintaining vocational and educational efforts.
Alcohol and Drug Council of Tompkins County – Medication-Assisted Treatment
The Council and the Local Governmental Units of the Tompkins, Cortland, Schuyler, and Tioga county region have identified the need for the development of a 24/7 Open Access Center that will provide individuals who are experiencing addiction-related issues with an easily accessible comprehensive assessment and referral process. Individuals will be able to seek support at their convenience, and when they are ready, versus at the convenience of the system. The Council intends for the center to be co-located with a detox/stabilization facility as funding is secured for that phase of services. Co-location will create efficiencies and more streamlined support. In cases where detox/stabilization treatment is indicated, individuals may easily begin treatment within the same facility. The facility will also offer outreach space for mental health and other relevant service providers and forge strong relationships with physical health care providers.
This program, innovative for our county and region, fills gaps in the existing community continuum of care for addiction and related services, and creates opportunities for weaving substance abuse treatment with physical and mental health services. This funding, specifically, will ensure the program provides appropriate medical components to meet the increasing need for these elements from those seeking help. The Medication-Assisted Treatment (MAT) program and other services at Open Access on the weekends will relieve pressure on emergency services, reducing emergency department visits for substance abuse issues. The proposed program also helps address the shortage of medical and behavioral health staffing with this focus within the Southern Tier.
Catholic Charities of Chenango County – Relocate Roots & Wings Program
Catholic Charities of Chenango County is relocating its Roots & Wings division to an alternate available location that will allow Catholic Charities to enhance the safety, security, confidentiality, cost effectiveness and overall program and facility efficiency in order to enhance the provision of services to more than 10,000 unique individuals and more than 4,000 Medicaid members annually. Roots & Wings provides self-help services that target a reduction in social determinants of health that include housing assistance, food security and education, job skills training, patient navigation and an array of other services provided in house and by partnering agencies on site.
Cayuga Health System – Primary Care Health Center
With receipt of innovation funds, Family Health Network (FHN) will be expanding their services into Tompkins County via the development of a Cayuga Medical Center adjacent primary care health center. The new health center will allow for expanded patient access to primary care services of which there is a critical shortage in the community. Family Health Network is Patient Centered Medical Home (PCMH) Level 3 accredited organization and, healthcare is provided in a comprehensive, team-based, coordinated, accessible way that is always focused on quality and safety.
Cayuga Health Systems (CHS), the active parent holding company of Cayuga Medical Center, and Family Health Network, a Federally Qualified Health Center operating primarily out of the Cortland region, entered into a Memorandum of Agreement on November 29, 2017 to provide and arrange for the provision of, high quality, cost-effective, community-based comprehensive primary and preventative health care services to residents of medically underserved communities in Cortland County and surrounding communities, regardless of the individual’s or family’s ability to pay for such services or their insurance status.
Chenango Health Network – Youth Mental Health First Aid Training Project
Chenango Health Network will provide Youth Mental Health First Aid training to local Fire Departments, 911 Dispatchers, Emergency Medical Technicians, Medical professionals, Law Enforcement, School Administrators, Teachers, and other individuals handle effectively a mental health situation in Chenango County. Youth Mental health First Aid is a public education program that introduces participants to risk factors and warning signs of mental health problems in adolescents. The program builds understanding of the importance of early detection and intervention. Trained Leaders will teach individuals how to help an adolescent in crisis or experiencing a mental health challenge.
Chenango Health Network will provide local Fire and Police Departments, EMTs, schools, healthcare facilities with “Do It For You” comfort bags for the child/youth in a crisis situation. Each draw string bag contains a journal notepad, How to Handle Stress and Conflict coloring book, colored pencils, mood bracelet, glitter bottle, sport water bottle, a plush teddy bear and a Do It For You inspiration card with contact information for local mental health resources. Rural populations are often underserved and experience notable health and behavioral health disparities. Mental Health First Aid can address these disparities by increasing mental health literacy, knowledge, and beliefs about mental disorders that aid their recognition management or prevention. Youth Rural Mental Health First Aid is a way to build Chenango County’s capacity to identify mental health and substance use and abuse issues early and for rural residents to gain confidence in intervening and referring a person to the resources that exist.
Cortland County Health Department – Radon Reduction
With innovation funds, Cortland County Health Department can expand our work to address the problem of extremely high radon rates in Cortland County, through education, outreach and policy change, with the ultimate goal of reducing morbidity and mortality related to lung cancer. Radon is a leading cause of lung cancer, second only to smoking. Smokers who are exposed to high radon levels experience a higher incidence of lung cancer (8 times higher when exposed at 10 pCi/L). Cortland County has been designated as a high radon risk area by the Environmental Protection Agency (EPA) and the NYS Department of Health.
Our homes have the highest average basement and first floor readings in NYS, with an average basement reading of 14.44 pCi/L. New York State has determined that a level of 4.0 pCi/L or greater is considered high. Further, with our lung cancer rates well above NYS and national averages, we must impact change at a population health level. The main target of this initiative is to lower radon rates in rental properties, mostly inhabited by low income residents, to below the acceptable level of 4.0 pCi/L. Thirty-five percent of all housing units in the county are renter occupied. Fifty-three percent of renters live in the City of Cortland/ Village of Homer. This outcome will be achieved through policy development, outreach and education.
Human Service Development – Community Health Workers at Corning, Arnot & IRA Davenport
This project will provide a true regional partnership between the clinical community and a community-based provider in which the strengths of each type of provider are complimented and maximized to yield the best service for the patient, accomplishing the goal of system transformation and system integration.
Community Health Navigators (CHN) will be embedded in the Emergency Departments (ED) of participating hospitals, becoming part of the hospital care team. Hospital staff will identify and refer their high utilizing/high need patients to the ED CHNs, who will provide assistance in assessing social and support needs, arranging follow-up appointments and other services, and following up with the patient to assist them with overcoming any barriers that exist on the road to better health. In addition to medical follow-ups, this includes help in obtaining supplemental, food, transportation to needed services, assistance in obtaining health insurance, housing, substance use disorder support services, prescriptions or other services. Hours of availability will increase service capacity and access, and will be tailored to the hours of highest need at each hospital, including evenings and weekends as needed. The GSI Health Coordinator platform will be used to track patient data and produce reports, feeding into the population health management analytics system to measure and compare outcomes, and determine return on investment.
Our Lady of Lourdes Memorial Hospital – Expand Diabetes Prevention
The Lourdes Diabetes Prevention Project will continue to collaborate with primary care providers to develop and implement procedures and interventions to improve the health status for Medicaid beneficiaries and the uninsured in Broome, Tioga, and Delaware counties. Lourdes proposes to increase the awareness of prediabetes and to encourage lifestyle modifications among individuals who are at risk for developing diabetes. The focus will remain in utilizing existing resources, maximizing partnerships with community-based organizations, and integrating reasonable and affordable interventions into the existing primary care medical practice model.
The Lourdes Diabetes Prevention Project will continue to identify individuals at risk for developing diabetes and notify their primary care providers of this risk status prior to scheduled follow-up visits. There will be ongoing education and support to primary care providers and patients. An individualized approach to diabetes prevention will be supported among practices and patients. Monthly feedback and data analysis will be shared with providers. For example, a process has been implemented to notify primary care providers and support staff of individuals who have an increasing A1c.
Our Lady of Lourdes Memorial Hospital – Expand Mental Health through Training Social Workers
Our Lady of Lourdes Memorial Hospital is seeking to expand mental health services delivered through an existing Primary Care Network initiative to integrate brief intensive mental health treatment within the outpatient clinic setting. Patients currently receive timely baseline mental health assessment and 1:1 assistance gaining access to the appropriate level of mental health treatment needed. Patients with depression/anxiety spectrum diagnosis gain almost immediate on-site access to a variety of mental health services including collaborative psychotropic medication management, access to a skilled therapist delivering evidence-based brief counseling intervention, and mental health care management. Many patients can even receive phone-based therapy.
The patient cohort is tracked through an EMR tool and reviewed regularly with a collaborating psychiatrist and clinical supervisor. Enrollees receive periodic evidence-based measures to determine treatment effectiveness and guide clinical and pharmaceutical intervention. In 2018 social workers in our Primary Care Network served approximately 2400 patients; of the population assessed, approximately 50-55% of patients presented with co-occurring trauma histories complicating treatment of anxiety and depression.
Although our MH treatment providers have been trained and certified in several prescriptive interventions to target depression and anxiety, we have identified need for a short-term evidence-based treatment for underlying trauma-related symptomology causing the target symptoms. We wish to increase the value of our behavioral health integration project by securing funding for additional therapist certifications in Eye Movement Desensitization and Reprocessing (EMDR).
The REACH Project – Implement Behavioral Access to Rural Health Program
REACH Medical (REACH) is an integrated medical practice providing comprehensive primary care, medication-assisted treatment (MAT) for individuals with Opioid Use Disorder (OUD), behavioral health services, and HIV and Hepatitis C testing and treatment. Since opening approximately 11 months ago, REACH has provided services to over 750 unique patients, including MAT for 500 unique patients. Approximately 17% of patients at REACH received behavioral health services onsite in 2018. However, the wait time to access services is eight or more weeks, and the shortage of providers for behavioral health services is severe in the Southern Tier.
The Behavioral Access to Rural Health (BARH) program at REACH will rapidly expand access for Medicaid beneficiaries with behavioral health needs utilizing a three-tiered approach that incorporates multiple evidence-based program components. The BARH program will include a multi-disciplinary team of licensed and non-licensed providers including Peer community health workers (people with lived experience), licensed therapists and a psychiatrist. All BARH staff will be trained in core behavioral health topics including motivational interviewing, ACE scores, trauma informed counseling, harm reduction principles and stigma-free, compassionate care. BARH will build on the successes of the integrated medical model at REACH by expanding the target population to include individuals with low, medium or high acuity behavioral health needs. During the twelve-month period, it is expected that over 500 unique Medicaid patients will access BARH services from counties across the Southern Tier region. Expected outcomes of the program include decreased hospitalization, improved social functioning, and decreased self-stigma.
Truth Pharm – Evaluation of ‘Clearing the Confusion’ for Accreditation
Clearing the Confusion is a 10-week program educating family members and care providers on a range of topics related to substance use disorders developed by Truth Pharm. The program topics were developed based on the questions and help family members most often seek. The program “clears the confusion” many family members face and provides tools to reduce the stress and anxiety associated with caring for someone who has problematic substance use. This innovative project will provide a comprehensive study by Binghamton University School of Psychology and School of Social Work of Truth Pharm’s “Clearing the Confusion” family educational program which is funded by Care Compass Network through Lourdes Hospital. The goal of the study is to substantiate the program as an evidence-based practice as well as to show the impact family involvement can have on the outcomes of those suffering from Substance Use Disorder. A report of the project will be published as a result of the study. Formal accreditation of the program will be sought from The New York State Office of Alcoholism and Substance Abuse Services (OASAS) and Substance Abuse and Mental Health Services Administration (SAMHSA) upon completion of the study and report.
UHS Hospitals – Initiate Medication-Assisted Treatment in the BGN Emergency Department
The project will touch approximately 600 individuals/480 Medicaid recipients with opioid use disorders. It will be sustained by UHS through third party revenue and value-based contracts. Many of the services provided by the Peers will be billable. The project will be revenue positive for UHSH’s New Horizons Outpatient Clinic. Engagement and retention efforts will stabilize this cohort of new patients that previously had significant no show and drop-out rates. The project will also positively impact readmission rates to the emergency department, CPEP and inpatient psychiatry. This will be more in line with future value-based payment financing structures.
UHS Hospitals – Housing Coordinator
In an effort to accommodate the full spectrum of our patients’ needs, UHS is implementing a Housing Coordinator to work in conjunction with local housing agencies to secure affordable, safe, and stable housing for our high need Medicaid Members. New York State Department of Health has identified Housing Security as one of the leading Social Determinants of Health resulting in adverse health outcomes. The Housing Coordinator will work with a team, including providers, Wellness Coordinators, social workers, and Complex Case Managers to identify Medicaid Members in need of stable and safe housing. Once identified, they will perform outreach to the patient to set up a time to meet and discuss options. This position will have constant lines of communication with community-based organizations and local housing agencies in order to provide the most affordable and appropriate housing for patients in need. Additionally, the Housing Coordinator will serve as a Transportation Coordinator for those patients on their housing panel that also have transportation needs.
UHS Hospitals – Community-Based Nutrition Wellness
UHS will be implementing Nutrition and Wellness Programs designed to focus on improving overall family nutrition & wellness for Medicaid Members. The program comprises of three (3) one-hour long sessions dedicated to nutrition education, healthy food choices, how to shop for healthy foods, yoga, and meditation. This program is being offered at the Cornell Cooperative Extension of Broome County during the hours of the Broome County Farmers Market. In addition to the seminar and yoga, participants will have the opportunity to be led through the Farmers Market by a staff member who will teach them how to shop for locally sourced produce on any budget. Additionally, UHS and the Rural Health Network of South Central New York will be collaborating to enroll participants into the Fruit and Vegetable Prescription Program to ensure Medicaid Members participating in the Nutrition & Wellness program have access to fresh, healthy, quality produce for a 6-month period.