A pilot program in the Bronx that provides intensive care coordination services to patients with serious mental illness and unstable housing situations is having a positive effect in helping these people, many of whom in the past tended to fall through the cracks.

Led by Bronx Partners for Healthy Communities (BPHC), the DSRIP Performing Provider System headed by SBH Health System, the program uses “Critical Time Intervention” (CTI) to provide these patients with sustainable healthcare and community support systems.

CTI is a time-limited, evidence-based model that started in New York City in the mid-1980s. DSRIP is the state’s five-year Medicaid transformation initiative (now in year four) designed to reduce avoidable hospital admissions and re-admissions by 25% by building a provider system of community-based care that is coordinated, patient-focused and improves health outcomes.

Victor P. was homeless and in a state of mental decompensation when he met with a case manager at Mosaic Mental Health (one of the partner organizations in the BPHC provider system).

“I needed someone to advocate for me because I didn’t know how to say it,” says Victor.

Today, Victor’s mental health has stabilized and he is following his medication regimen. He sees both primary care and mental health providers regularly. He has a place to live and wants to go to school to become a patient navigator so he can help others like himself.

These patients have complex health conditions that are compounded by such circumstances as financial and housing instability, and an absence of family or social structures. The goal of the program is to help patients achieve long-term health improvements, become integrated back into the community, and reduce their stays in the hospital and other acute care settings.

Recent data shows the program is having an effect. The first group of 119 patients (from January – September 2017) realized a 62% reduction in the number of days spent in a hospital setting and a 57% reduction in the number of hospital admissions in the six months following the program’s start.

“Our initial goal was to reduce hospital utilization by 25%, so we are very excited by these promising results,” says Irene Kaufmann, BPHC Executive Director. BPHC has partnered with four community-based organizations (CBOs) on the CTI pilot: Coordinated Behavioral Care, Mosaic Mental Health, SCO Family of Services, and Visiting Nurse Service of New York.

Case managers work closely with patients – supported by an extensive network of providers including physicians, hospitals, specialists, therapists, housing services, food programs, and job training – to satisfy such goal areas as medical and behavioral health treatment, medication adherence, employment, housing, money management, and family intervention.