Skip Navigation
Service Delivery Innovation Profile

Care Coordination, Peer Support, and Discretionary Fund Improve Quality of Life and Reduce Costs for Adults with Serious Mental Illness


Tab for The Profile
Comments
(2)
   

Snapshot

Summary

The Westchester County Department of Community Mental Health (DCMH) Care Coordination program provides intensive, person-centered case management to adults with serious mental illness and a history of emergency department use, hospitalizations, jail time, or homelessness. Modeled after a successful program in another part of New York, the Westchester version is a collaboration with the Mental Health Association of Westchester and The Empowerment Center and adds peer support and a discretionary fund to help achieve participants' recovery goals. Offered at no cost to participants, the program has enhanced access to treatment, employment, and job training; reduced suicide and self-harm attempts, hospitalizations, emergency department visits, incarcerations, and homelessness; and significantly lowered health care and other mental illness–related costs.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key metrics, including access to services, crisis situations, hospitalizations, emergency department visits, incarcerations, and illness-related costs, along with post-implementation reports from participants, care coordinators, and the broader social service community.
begin do

Developing Organizations

Westchester County (NY) Department of Community Mental Health
end do

Use By Other Organizations

As noted, this program is based on a care coordination model developed by the New York Care Coordination Program and implemented in six counties in Western New York. In 2010, Westchester County joined the New York Care Coordination Program. Today, the seven-member counties work together to promote adoption of the model throughout the State.

Date First Implemented

2007
begin ppxml

Patient Population

The program serves individuals 18 and older.Vulnerable Populations > Mentally illend pp

Problem Addressed

Mental disorders are a leading cause of disability among adults in the United States. Many patients with serious mental illness do not receive necessary services on a regular basis, instead accessing care only during a crisis or emergency (when such care tends to be expensive and ineffective). Consistent, comprehensive support can help prevent these crises and emergencies, but relatively few programs offer such services.
  • Leading cause of disability: Roughly one-fourth of adults in the United States have a mental disorder, with 1 in 17 having a serious mental illness. Many people with mental illness also have substance abuse disorders and/or a chronic illness, which can complicate treatment, compromise quality of life, and lead to earlier death.1
  • Lack of regular treatment and support: Less than half of patients with mental disorders receive treatment, and less than one-third of those with serious mental illness receive services.1 Barriers to accessing support include provider shortages, stigma, lack of insurance, and unstable living situations.
  • Leading to expensive, difficult-to-treat crises: Untreated mental illness often leads to repeated psychiatric crises. These crises frequently require expensive hospitalizations, intervention by the police, and/or incarceration, all of which are expensive and often ineffective without adequate follow up support. Patients often cycle in and out of the community, making it difficult to hold a job, maintain relationships, and be contributing members of the community. Many patients feel isolated and become desperate, leading to additional crises and a repeat of the same destructive cycle.
  • Unrealized potential of ongoing, coordinated support: Mentally ill patients with high health care and related costs are generally not being served well by the system. More intensive, consistent support may help these individuals, but relatively few programs exist to provide such services on an ongoing basis.

What They Did

Back to Top

Description of the Innovative Activity

The Westchester County Department of Community Mental Health Care Coordination program provides intensive, person-centered case management to adults with serious mental illness and a history of emergency department use, hospitalizations, jail time, or homelessness. Modeled after a successful program in another part of New York, the Westchester version is a collaboration with the Mental Health Association of Westchester and The Empowerment Center and adds peer support and a discretionary fund to help participants achieve their recovery goals and create a sense of empowerment, responsibility, and community connectedness. Key program elements include the following:
  • Identification and voluntary enrollment of eligible patients: Program staff identify adults with serious mental illness who might benefit from the program, including heavy users of the health care system and related services. Eligibility indications include frequent use of emergency rooms and/or acute psychiatric services with no link to community-based services, discharge from jail with no active link to services, frequent arrests or incarcerations, and homelessness. Anyone meeting these criteria must be willing to participate in the voluntary program, which can serve up to 48 individuals at a time. Steps in the enrollment process include:
    • Referral from various sources: Potential clients are identified by emergency responders (police, emergency medical technician, etc.), health care professionals (mental health providers, emergency room staff, physicians, etc.), or others in the social service community.
    • Completion of Single Point of Access (SPOA) application: Working with their mental health provider, clients fill out the application, which is used to obtain housing, case management (including care coordination), or other mental health services. 
    • Review of application by DCMH staff: Applications that seem appropriate for care coordination are flagged for review.
    • Confirmation of high use of services: Staff consult with several sources, including Medicaid records, emergency responders, and others to confirm that clients have incurred at least $50,000 in health care and related services in the previous year.
    • Followup by care coordinator: Those confirmed eligible are assigned to a care coordinator who follows up with the referral source and the potential client to explain the program in detail, gauge interest, and enroll.
  • One-on-one, intensive care coordination by trained social workers: Trained social workers provide care coordination services that go beyond the county's traditional case management services for those with serious mental illness. These social workers spend more time with each participant and work with him/her to formulate recovery goals and treatment plans based on individual needs, preferences, and experiences. Offered at no charge to participants, care coordination consists of the following:
    • Person-centered practices: Care coordinators employ person-centered practices that emphasize participant involvement and empowerment. Care coordinators take on the role of a guide or mentor rather than authority figure, working with the client to identify and encourage strengths, skills, interests, and preferences; to address needs; and to develop recovery goals. These person-centered practices represent 1 of 10 fundamental components that have been identified to promote recovery.2
    • Frequent contact to establish trust and consistency: Care coordinators meet with participants at least once a week (and often more frequently) to build trust and establish a consistent relationship. Client interest and preferences dictate the activities that take place during visits. For example, the care coordinator may accompany the client to the library to research treatment options or to a music store to explore an interest in learning to play guitar.
    • Motivational interviewing: Throughout the visit, care coordinators engage in motivational interviewing to strengthen the participant's commitment to change. A client who wants to regain custody of her children but may not take appropriate actions to attain that goal is an example. By identifying the discrepancy between her behavior and her stated goal, the care coordinator may help her become motivated to attend parenting classes, take her medication, and followup with treatment so that she can maintain her housing and eventually create a stable home for her children.
    • Customized plan: Care coordinators work with clients to develop an individualized services plan that lays out mutually agreed to recovery goals and outlines the services (medical, social and financial) and informal and formal support needed to reach them. For example, for a client with an interest in a career as a DJ, his recovery plan may include not only regular treatment for his psychiatric condition but also connecting him with educational programs to help him learn the skills necessary for his chosen field. 
  • Peer "recovery mentors": Each client has access to a trained peer mentor who helps promote recovery and connect the individual to the community. Recovery mentors often accompany participants to support group meetings, doctor's appointments, and/or the pharmacy. They may also meet participants on a social basis (e.g., to see a movie or to talk over a cup of coffee). Peers often gain higher levels of trust with the individual and do so more quickly than the social worker can. Because mentors are also in their own recovery process, the program serves as a way for them to build stronger connections with the community. Recovery mentors receive payment for their services, and the experience sometimes leads to other opportunities. For example, some mentors have secured full-time employment in social services.
  • Discretionary fund to support recovery: Each participant has access to $1,500 from DCMH that can be used, as the care coordinator and client see fit, to promote achievement of goals outlined in the individual services plan. For example, funds have been used to purchase computers (to help in securing employment and/or building social contacts), furniture for an apartment, job training services, dental implants, and reference materials in an area of special interest to the client.
  • Periodic meetings to support coordinators and mentors: Care coordinators, mentors, and their supervisors meet monthly to review specific cases and reinforce the principles of person-centered care coordination. These meetings, which last about 90 minutes, are led by the program directors from the Department of Community Mental Health and Mental Health Association of Westchester.

Context of the Innovation

Located just north of New York City, the Westchester County Department of Community Mental Health plans, oversees, and coordinates services for individuals and families affected by mental illness, developmental disabilities, and substance abuse disorders. The Mental Health Association of Westchester County, Inc., a nonprofit organization affiliated with Mental Health America, advocates and provides services for individuals with diagnosable mental illnesses. The New York State Office of Mental Health supports the program. The Mental Health Association and Empowerment Center were selected through a competitive process to partner with the Westchester County Department of Community Mental Health to provide care coordination and recovery mentor services in the county.

Did It Work?

Back to Top

Results

The program enhanced access to treatment, employment, and job training; reduced suicide and self-harm attempts, hospitalizations, emergency department visits, incarcerations, and homelessness; and significantly reduced health care and other mental illness-related costs.
  • Improved access to treatment, employment, and job training: Before enrolling in the program, only 23 percent of participants had attended chemical dependency programs, and 15 percent went to self-help groups. These figured climbed to 58 percent and 31 percent, respectively, 12 months after enrollment.3 Comparing other pre- and post-enrollment numbers, participant involvement in work, job training, and other educational activities increased by 27 percent after 12 months in the program.4
  • Fewer crises, less use of emergency care: After 12 months enrollment, participants experienced significant reductions in suicide/self-harm attempts (55 percent), emergency department visits (also 55 percent), arrests (18 percent), and inpatient days (58 percent, from 21.2 to 8.8 days).4 
  • Significantly less jail time: Participant time spent in jail fell by 96 percent, as the vast majority who joined after release from prison remained out of jail 2 years later. 
  • Less homelessness: In one group of participants, the average number of days of homelessness fell from 52 before enrollment to 24 afterward.3 
  • Lower illness-related costs: Before enrolling in the program, the average participant's annual health care and related costs totaled $167,692, with costs ranging from roughly $50,000 to $480,000. During the first 2 years after enrollment, this average fell by 52 percent.4 Also during this time period, Medicaid expenditures fell by 35 percent, incarceration costs dropped by half, and state-funded hospitalization costs fell by 78 percent. By reducing homelessness, the county saved $148,812 on shelter-related expenses.3
  • High participant and staff satisfaction: In surveys, participants reported feeling that their care coordinator listened to them and treated them with respect. Care coordinators and others trained on person-centered care management reported increased job satisfaction as a result of the program.3 Staff and others in the social service community reported being more aware of person-centered practices and their importance in promoting recovery.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key metrics, including access to services, crisis situations, hospitalizations, emergency department visits, incarcerations, and illness-related costs, along with post-implementation reports from participants, care coordinators, and the broader social service community.

How They Did It

Back to Top

Planning and Development Process

Key steps included the following:
  • Adapting existing model: Leaders of the Westchester County Department of Community Mental Health adapted the program from a similar one under way in six counties in Western New York. (This program has also been profiled on the Healthcare Innovations Exchange; go to http://innovations.ahrq.gov/content.aspx?id=2935). While the Western New York program offers care coordination to any individual hospitalized for severe mental illness, Westchester program developers decided to focus on the 48 most severe cases in the county—that is, those who have had multiple hospitalizations, incarcerations, or episodes of homelessness due to mental illness. Leaders also expanded the program to include the aforementioned mentor and discretionary fund, thus expanding its reach beyond standard case management.
  • Developing training program for coordinators and others: The program developers worked with two trainers and consultants on person-centered care management (Janis Tondora, PsyD, and Diane M. Grieder, MPH) to develop training programs and support for the care coordinators. All coordinators attended this three-day training, which was also offered to other case managers and mental health professionals in the county. To date, the program has been conducted three times in the county, with approximately 200 individuals participating.
  • Partnering for peer training: Program leaders partnered with The Empowerment Center, a local nonprofit organization, to train peers on how to support individuals in recovery. The training follows the protocol of New York State Office of Mental Health advocacy training policy. Sessions run 2 days a week for 8 weeks and cover topics such as diversity, cultural competence, benefits and entitlements, hope and recovery, ethics, mental hygiene law, cooccurring disorders, spirituality, negotiation, and communication skills.

Resources Used and Skills Needed

  • Staffing: Program staff include four full-time care coordinators (two employed by the Department of Community Mental Health and two by the Mental Health Association of Westchester), six to seven part-time mentors (employed by the Empowerment Center), and three part-time administrators (one at each partner organization) who provide staff supervision and support. As noted, each care manager can handle 12 clients at a time.
  • Costs: The annual program budget totals $385,000, which covers salaries and benefits for staff, the discretionary fund for each participant, and the recovery mentor per diem as well as care coordinator training.
begin fsxml

Funding Sources

Westchester County (NY); Westchester County (NY) Department of Community Mental Health
Local taxes support program costs borne by the Westchester County Department of Community Mental Health. The New York State Office of Mental Health funds one care manager at the county level. The State Medicaid program provides reimbursement to the Mental Health Association for Medicaid-eligible clients.end fs

Tools and Other Resources

Grieder D, Adams N. Making recovery real: the critical role of treatment planning. Behav Healthc Tomorrow. 2004 Oct;13(5):24, 27-9. [PubMed]

Adams N, Grieder D. Treatment planning for person-centered care: the road to mental health and addiction recovery. Elsevier; 2005.

Miller WR, Rollnick S. Motivational interviewing: preparing people to change addictive behavior. New York: Guilford.

More information on the New York Care Coordination Program can be found at http://carecoordination.org.

Adoption Considerations

Back to Top

Getting Started with This Innovation

  • Collect baseline data: To allow for program evaluation, collect at least 6 months of baseline data before the program begins; collecting a year's worth allows for a more robust evaluation of the program. 
  • Expect resistance: Some case managers felt they already followed a person-centered approach and resisted the distinction between intensive case management and the even more intensive care coordination. In other cases, health care professionals resisted the idea of including clients in care planning meetings. Training on the differences between this approach and the standard model and on the need for more intense services helped, but program developers still needed to advocate for the approach.
  • Establish mechanism to identify eligible individuals: Program leaders identified the original participants by reviewing Medicaid records to find those with the highest expenses. However, staff have found it difficult to obtain this data on an ongoing basis.
  • Budget adequately for discretionary fund: The discretionary fund is a critical part of the program. Would-be adopters should ideally plan on allocating enough money to provide at least $1,000 per year for each participant.

Sustaining This Innovation

  • Consider partnering with police: Frequent contact with police can be a sign of untreated or inadequately treated mental illness. Consequently, DCMH provides special training on mental health issues for police officers and embeds social workers into precincts that frequently respond to calls involving people with serious mental health issues. The social workers accompany uniformed officers on response calls to help connect people in crisis to appropriate services (e.g., care coordination) and followup with them as needed. To date, 88 percent of those receiving a referral and follow up visit did not require police intervention in the ensuing 6 months. 
  • Promote adherence to program: Care coordinators can easily revert to "business as usual" rather than maintaining the person-centered focus. To avoid this problem, regularly bring care coordinators together to reinforce the program's key concepts and allow them to review specific cases in conjunction with the recovery mentors who bring the participants' viewpoint to the fore. 
  • Look for opportunities to spread program message: Care coordinators and program supervisors routinely look for opportunities to reinforce the person-centered message at team meetings and in their other professional interactions.
  • Maintain adequate proportion of Medicaid-eligible patients: Medicaid payments help provide an adequate funding stream for the program, thus allowing it to serve individuals without coverage as well. 

Use By Other Organizations

As noted, this program is based on a care coordination model developed by the New York Care Coordination Program and implemented in six counties in Western New York. In 2010, Westchester County joined the New York Care Coordination Program. Today, the seven-member counties work together to promote adoption of the model throughout the State.

More Information

Back to Top

Contact the Innovator

Annette M. Peters-Ruvolo, LCSW
Program Director, Community Support Services
Westchester County Department of Community Mental Health
112 East Post Road, 2nd Floor
White Plains, NY 10601
Phone: (914) 995-5278
Fax: (914) 995-6220

Innovator Disclosures

Ms. Peters-Ruvolo has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Bernstein R, Warren M. Asking why: reasserting the role of community mental health: a report on the Performance improvement project in five states. Judge David L. Bazelon Center for Mental Health Law; September 2011. Available at: http://www.bazelon.org/Where-We-Stand/Access-to-Services/Improving-Public-Systems.aspx

Footnotes

1 Bazelon Center for Mental Health Law, Mental Illness and the Need for Health Care Access Reform Fact Sheet. Available at: http://www.bazelon.org/LinkClick.aspx?fileticket=Tgq0Qq-w6_c%3d&tabid=220
2 Center for Mental Health Services. National Consensus Statement on Mental Health Recovery. Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, January 2006. Available at: http://www.samhsa.gov/recoverytopractice
/RTP-Contribution-Detail-For-National%20Consensus%20Statement%20on%20Mental%20Health%20Recovery-133.aspx
3 Mitchell GE. Care Coordination Project: 2007-2011 overview and results. Westchester County Department of Community Mental Health. Presentation available at: http://www.nyaprs.org/conferences/executive-seminars/executive-seminar/index.cfm
4 Mitchell GE. Coordinating care program improves outcomes, reduce costs. Mental Health Weekly. August 17, 2009.
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: February 15, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: February 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: January 13, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

Back Story
After 8 years in prison, "Tom" (not his real name) finally gained his freedom from prison. But, that freedom came with a price—with no family to turn to and no supportive services in place, he ended up living on the streets. Although prison officials had identified him as someone with psychiatric...

Read more

Look for Similar Items by Subject
Patient Population:
IOM Domains of Quality:
Organizational Processes: