illustration of community holding hands to support health

Bronx Partners for Healthy Communities (BPHC) is funding an expansion of Critical Time Intervention (CTI) services in the Bronx through the non-clinical workforce. CTI is a nine-month, evidence-based, high-intensity care coordination program, conducted in three phases, that targets high-utilizing patients with serious mental illness who are precariously housed.

Patients enrolled in the program will be referred initially from the inpatient units at BPHC’s partner hospitals: SBH Health System and Montefiore Medical Center’s Bronx-based campuses.

BPHC is funding the operations of the program within four community-based organizations and has funded the Center for Urban Community Services to train the organizations. CTI provides care transitions support for patients who are often hard to reach by traditional telephonic care transitions programs because of their unstable housing situations. BPHC is funding an expansion of Coordinated Behavioral Care’s existing CTI program to a new Bronx-based provider, Project Renewal. In addition, BPHC is funding three new providers: Visiting Nurse Service of New York, SCO Family of Services and Riverdale Mental Health Association.

CTI’s nine-month approach has three three-month phases, each with a gradual reduction of intensity in care coordination so that the client can build self-efficacy and meet goals. CTI workers are usually non-clinical professionals with case management experience who are supervised weekly by a licensed mental health professional.

The first phase provides intense specialized support and implements a transition plan for the client. During this time, the CTI worker sets goals with the client in three of six focus areas: housing, mental health, physical health/wellness, employment, life skills and family/friends. Small caseloads not only allow the CTI worker to make in-person visits to either the client’s home, shelter or a safe place in the community, but also to accompany the client to medical and behavioral health appointments. The CTI worker leverages family, caregiver and community support systems for the client and helps establish linkages to health homes and other agencies that can provide further sustainable support for housing or other needs. During the second phase, the CTI worker tests the methods of support built in the first phase and adjusts supports that are not serving the client until a sustainable network is built around the client. In BPHC’s model, the third phase will occur within the Health Home and the CTI worker will transfer knowledge to the Health Home care manager to reaffirm the roles of the support network.

The evidence-based program has shown great success in connecting patients to medical and behavioral health follow-up appointments, establishing trusted relationships between clients and their providers. One of the BPHC providers, Coordinated Behavioral Care, has shown a 94 percent success rate in preventing readmission within 30 days for patients enrolled in their Pathway Home program. BPHC will collect data throughout 2017 to assess the success of the program.

Funding to all four organizations is structured so they must demonstrate a reduction in avoidable hospital and ED utilization in the cohort served. BPHC linked 25 percent of the annual budget to a 25 percent reduction in these measures. Tying a significant component of payment to performance will enable these community-based organizations to experience value-based payment downside risk and prepare them to be competitive in future value-based payment opportunities. BPHC expects that CTI workers will help clients build trust based relationships with existing or new medical and behavioral providers that will result in increased adherence to medical and behavioral regimens and in turn decrease avoidable ED and hospital use.

Dr. Lizica Troneci, chair of Psychiatry at SBH Health System, has been a key partner and supporter of the BPHC CTI program and helped to create a referral strategy to enroll patients who meet criteria into the program. Visiting Nurse Service of New York and Riverdale Mental Health Association will take referrals from SBH.

By involving a range of hospital-based and community based partners, this approach seeks to establish meaningful community supports that will result in greater stability for the patient, as well as reduce hospital and ED utilization.