William F. Ryan Community Health Center

110 West 97th street

New York, NY 10025

Eishelle Tillery, MSW

Nancy Andino, LCSW

www. Ryancenter.org

ObjectivesList 3 important characteristics of a successful

Supportive Case Management Program

Identify 3 important characteristics of a patient in need of Supportive Case Management. (SCM)

Identify coordinating strategies used by SCM in our renewed health care system that integrates the work of Social services and clinical providers as a team to meet patient needs.

Identify two aspects of supervision necessary to SCM that facilitates patient change and satisfaction

Map of Service Area

William F. Ryan Network Four main sites, 6 School

based, 4 Shelters and the Women and Children’s Center

2011 Network served 49,192 patients

Race: 74% minority Sex: 58% F

Insurance: 27% uninsured & 67% public insurance

Homeless: 2,645 (5%)Age: 34% pediatric patients,

57% adult, 10% 65+

HIV/AIDS Spectrum of Services

Medical Mobile Van

Electronic Medical Record

Mental Health Counseling

Harm ReductionServices

Prevention Education and Outreach

Confidential HIV Counseling and Testing

Primary Health CareTreatment Education/

Adherence

Medical Case Management

HIV Specialty Care

Hepatitis C Treatment

Program SCM SkillsHealth Care Disparities Advocates

Support and Guidance Culturally Sensitive / Interpersonal Skills/Awareness of Services

Education Ongoing Training

Coordinated Care Health Care/ Community Knowledge

Health and Social Barriers

Problem Solving SkillsEmpower others

William F. Ryan Supportive Services Programs Women In Care Program- Provides support

to HIV Positive women i.e. advocacy, escort, financial assistance and referrals.

Harm Reduction Program- For HIV positive Men and Women who are currently active substance abusers who wish to change their behavior.

AIDS Institute Support Case Management- Advocacy, escort, referrals, home visits etc.

Ryan White Part C Supportive Case Management- support services that are not covered by other CM grant programs.

SCM and the Community ConnectionPatient assessed needs

SCM are Directly linked to community resources. Communication, Relationships, SCM style & knowledge of resources results in patient positive results.

Cultural awareness allows for appropriate referrals.

Supervision Coordination of Care

Adequate Supervision eliminates role confusion

Strength based supervision/ Effective Trainings

Pt’s share different information with Different providers.

Case Conferencing also informed patient can participate in a collaborative model resulting in appropriate services and referrals.

COORDINATION between SCM, Community and clinical provider.

Patient ExampleMaria has a diagnosis of HIV, Diabetes,

Hypertension.

Unstable diabetes and hypertension, stable HIV

DV in the household.

No health coverage, no collateral agencies

Medical provider is not aware of patient’s home situation and or home environment or lack of health coverage.

SCM Strategies for Coordination Patients will have assistance with achieving

their health goals by overcoming barriers. Practitioners will have knowledge of patient’s

barriers prior to treating patient & work that SCM is doing.

Practitioners will treat a well informed patient ready to collaborate b/c SCM has made appropriate referrals.

Decrease duplication of services. The SCM becomes the Coordinator in

coordinated care.

William F. Ryan Community

Health Network

www. Ryancenter.org

Thank You