“A CENTER FOR ALL PEOPLE”

Martha Adams Sullivan, DSW, Executive DirectorRafaela Santos, Project Coordinator

Darrell Wheeler, Ph.D., M.P.H., Evaluator260 East 188th St, RM 425, BX, NY 10458

2021 Grand Concourse, RM 605, BX, NY 10453(718) 960-3332

Fordham-Tremont CMHC CARE INTEGRATION PROGRAMUnion Community Health Center

Cohort 3, Region 5 Learning Community, Bronx, NY

“A CENTER FOR ALL PEOPLE”

Background/Partnership History

Fordham-Tremont CMHC is a multicultural, community-based organization committed to improving mental health and overall quality of life for the diverse residents of the Bronx since 1978. In partnership with the community, Fordham-Tremont CMHC promotes individual and family well-being and social justice through innovative, holistic practices that enhance recovery. Fordham-Tremont CMHC is part of St. Barnabas Health Care Network providing services at three primary sites and three New York City public schools. Fordham-Tremont encompasses thirteen service-delivery programs. Seven specialty programs operate within these programs.

Union Community Health Center provides general medical care, preventative care and diagnostic testing; and currently serves approximately 35,000 individual residents yearly in

the central and southwest Bronx.

Fordham-Tremont CMHC CARE INTEGRATION PROGRAM

The Care Integration Program (CIP) is designed to promote overall wellness by enhancing primary care and community services, thus improving health outcomes for the diverse population of the Bronx in New York City.

During the length of the project, CIP will enroll 1,055 seriously mentally ill clients who suffer from or at risk for serious health conditions and

chronic illnesses. We have tailored a program that compliments the needs of the diverse people in our community.

Our Wellness curriculum is designed to motivate, empower, reduce isolation and support client goals: Walking on Mondays (low impact exercise, walking in the neighborhood) Current Events on Mondays ( A platform to discuss community and societal concerns) Take a Break Tuesdays (socialization, clients can play the Nintendo Wii(exercise) or board games) Wednesday’s Knitting Group (socialization, confidence builder, creative expression, goal setting) Thursday’s African Dance Class ( low impact dance class and an opportunity for physical exercise as well as

socialization) Friday’s Art Class (socialization, artistic expression) Friday’s Salsa Class (Socialization, low impact aerobic exercise, relaxation and laughter)

Clients are screened during baseline and a Medical Review and History form is administered along with the NOMS.

If client does not have a PCP or has not seen a PCP in more than a year, the nurse does the following: She personally escorts client to Union Community Health Center and arranges for the client to get a physical If the PCP is located at another site, client is encouraged to follow up with the PCP


About our program

Aaron Bruce is our Health Educator/Group Leader supervises the peer counselors, coordinates wellness activities and calendar. Aaron is also responsible for creating the curriculum for the wellness activities and administering the NOMS and reassessments.

Manuel Cuevas is our half time Peer Counselor. Manuel co-facilitates the Peer Support Classes, and the CIP Consumer Council and teaches an art class on Fridays.

Jessica Melendez is our Data Entry Specialist /Program Registrar. She assists with special program projects and wellness activities, creates our pamphlets/flies and as we move towards sustainability, will register clients.

Josephine A. Panford the LPN conducts Health Screenings, administers the Medical Review and History form and administers the NOMS and reassessments. She teaches an African Dance Class every Thursday.

Luz Santana is the full time Peer Counselor. Luz co-facilitates many of the wellness activities and the CIP Consumer Council. Rafaela Santos, the Program Coordinator is responsible for ensuring that grant goals are met. She teaches crotchet classes on

Wednesdays and Salsa on Fridays. She also assists in administering the NOMS and reassessments.


The Care Integration Program Team Members

Enrollment - CIP receives referrals from three of our programs at Fordham-Tremont. In the recent past, self-referrals has increased exponentially and this is how we did it:

Peers and other team members conduct presentations daily in waiting areas and groups, we also do the following:1. Greeting clients that are in the program as they wait in the waiting area2. Discuss wellness classes in the waiting area (with loads of enthusiasm) when they are held and who can join the program3. Encourage clients to visit wellness classes without any obligation to join the program

Reassessment – CIP has been able to follow through with client reassessments in a variety of ways. In the recent past, the program has seen a significant improvement in our overall reassessment rate.

CIP team members contact clients daily to schedule appointments for reassessment to accomplish this takes great diligence.1. Staff may find clients that are coming due in the waiting area and ask to reassess them as they wait. 2. Daily phone calls are made to client homes to schedule appointments to come and be reassessed.3. Individual emails are sent out to clinicians with a list of those clients coming due.4. The team also identifies clients who need to be reassess during our classes.

Team Building – Staff are greatly encouraged to be innovative. In the recent past, self-referrals have increased exponentially and this is how we did it:

Peers and other team members conduct presentations daily in waiting areas and groups; we also do the following:1. Program classes are run by various staff members and participation is not limited to clients, teams members are also

encouraged to join. 2. Team brainstorming sessions take place on a daily basis regarding program policy, functionality and innovations. 3. Staff are encouraged to become familiarized with all teams positions regardless of their scope of practice in order to

provide backup support.


What Works: Enrollment, Team Building and Wellness

msullivan

same as above. review all speaking notes with Patty

Consumer Tracking Form

Fordham-Tremont CMHC Care Integration Program

Fordham-Tremont Consumer Tracking Form – Intake Numbers April, 2012 (version1 December 8, 2011) created by Dr. Darrell Wheeler, Evaluator

Project Year

Project Month

Oct. Nov. Dec. Jan. Feb. Mar. Apr. May Jun. Jul. Aug. Sep. Total

Year 1 2010

To 2011

Actual Number Served

0

0

0

1

(2.3%)

14

(28.84%)

14

(46.77%)

32

(83.56%)

23

(101.20%)

16

(107.52%)

19

(114.42%)

5

(107.82%)

4

(102.4%)

129

(102.4%)

Number Consumers Projected

10

21

31

42

52

62

73

83

93

104

115

125

125

Year 2 2011

To 2012


6

(35.3%)

17

(72.72%)

27

(102%)

26

(116.66%)

25

(122.89%)

18

(120%)

9

(111.20%)

0

(111.20%)

129

(64.5%)


17

33

50

66

83

100

116

133

149

166

183

200

200

Year 3 2012

To 2013



30

61

91

122

152

182

213

243

274

304

334

365

365

Year 4 2013

To 2014



30

61

91

122

152

182

213

243

274

304

334

365

365

Total



1055

“Eraser: Love Life, Erase the Hate”By: A Sustainable Project by CIP Clients

Medium: 53”x 48” Cardboard, Acrylic Paint, Bubble Wrap and Foam


“A Little Piece of Me”By: CIP Clients - Crotched Patch Quilt (In Progress)


“From the Heart” A running mural by CIP Clients

This mural is a work in progress. Clients are allowed to paint, draw anything that they feel on a particular day. This form of personal expression lets the client share feelings that they may not yet be able to express verbally.


Where do we go from here?


Sustainability:-Fordham-Tremont is reviewing billable service requirements for the Care Integration Program. - In addition to providing services for current clients , clients transitioning in to aftercare will be referred to CIP-Staffing patterns are designed to support sustainability-The Care Integration Program is developing joint groups with the clinical team that will allow the agency to bill for services

Clinical:-The integration of program activities and services will address the clinical component.-Groups held jointly by clinical and CIP staff-Developing a pervasive smoking cessation program

Administration:-Supports grant goals and sustainability by:-Identifying billable services-Supporting staffing changes to meet sustainability

Next six months:-Our main objective is to continue working on meeting grant goals -Work toward full integration of CIP with the clinical component -Make changes to the program where needed to meet sustainability goals

Documents

“A CENTER FOR ALL PEOPLE”