THE 2023 INNOVATOR AWARDS PROGRAM
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“Much of this collaborative work stemmed from the fact that clients or patients who were struggling in the be- havioral area were not able to keep up with their primary or preventive care, and they were high ED users. We wanted to make sure all their needs were met; and the social determinants of health [SDOH] are a huge factor; and that’s where the case management and care management came in.” — Kirstyn Applin, M.A., CASAC
need, 2) a universal i-ACT approach that emphasizes best practices in integrated engagement, anti-stigma language, trauma-responsiveness, cultural com- petence, and person-centered collabora- tive goal setting, 3) an Integrated Acuity Assessment to identify urgent needs and barriers across physical and behavioral health, and social care needs/SDOH
barriers, 4) ongoing integrated care coordination and cross-team commu- nication, and 5) a modest discretionary budget to enhance engagement (e.g., take the patient out for breakfast to enhance engagement) and overcome structural barriers (e.g., pay fee to get a copy of a birth certificate to apply for benefits, buy cell phone minutes, purchase a pair of sneakers or a coat for a patient wanting to start a trail walking program).” Kirstyn Applin, M.A., CASAC
[Credentialed Alcoholism and Substance Abuse Counselor]-AD, care management supervisor at CASA-Trinity, an Elmira- based behavioral care organization that provides addiction, mental health, and social determinants services, explains that “Much of this collaborative work stemmed from the fact that clients or patients who were struggling in the behavioral area were not able to keep up with their primary or preventive care, and they were high ED users. We wanted to make sure all their needs were met; and the social determinants of health [SDOH] are a huge factor; and that’s where the case management and care management came in.” Brenda Pruden, R.N., director of
clinical operations at Tri-County Family Medicine, a primary care clinic based in Dansville, adds that “We wanted to
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partner to be able to similarly make sure they were following up with their treatment; we only saw pieces here. We wanted a relationship with the folks at CASA, so patients knew they had a full circle of folks looking out for them.” Per that, she says, “Process was the thing we really had to nail down: when we were meeting, what we were bringing to the table, biggest concerns. Another barrier was consent process, so that patients feel safe across both organizations.” Going back to the origins of the collab-
orative initiative, Robert Grolling, CASAC, supervisor of the center of excellence at CASA-Trinity, explains that “We applied an integrative care model; and the source of that was that the University of Rochester developed the bio-psychosocial model about 100 years ago; they had concluded that one had to pay attention to all those factors to help a patient recover. And that developed into an integrative care model. Historically,” he says, “medical facilities acted on their own and didn’t connect with addiction and mental health organizations. It was a really fragmented system. This particular model, which has to do with behavioral health and primary care integration, we use a cohort manage- ment approach. So rather than connecting a patient to services and disappearing, which usually results in attrition—with the
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