Community Access and Foothold help NYC tackle psychiatric crises on the streets

Instead of the short-term fix of emergency room visits and medication, people in psychiatric crisis may be better helped with a full continuum of care in the community that includes family and aims toward long-term recovery.

Officially launched in January by the New York City Department of Health and Mental Hygiene (DHMH), the program, Parachute NYC, was two years in the making. According to Steve Coe, CEO of Community Access, a group that was instrumental in the program’s development, Parachute NYC will provide a “soft landing” for individuals in crisis. In a statement made at the launch of the program, Coe said that Parachute NYC is projected not only to improve the health care of participants, but also to reduce health care expenditures by $50 million over the next three years, according to the NYC Department of Health and Mental Hygiene (DHMH).

The AWARDS behavioral health and human services software of Foothold Technology, a New York City-based software company, will serve as the electronic record for one of Parachute NYC’s providers, Community. The program got rolling through a three-year, $17.6 million Innovation grant from the federal Centers for Medicare and Medicaid Services (CMS). AWARDS is an electronic health record with roots in social and human services.

Parachute NYC works “by shifting the locus of care from hospitals to community settings,” according to the Fund for Public Health NY, a public-private partnership with DHMH. Resources and interventions include peer health navigators, nurse practitioners, mobile crisis teams, a confidential and anonymous telephone “warm line,” and crisis respite centers to engage people in treatment that includes continuity of care. The project “will shift the focus of care from crisis intervention to long-term, community-integrated treatment with access to primary care, thereby improving crisis management and reducing emergency room visits and hospital admissions.”

Community Access, a group that serves the working poor and those with psychiatric disabilities, has been having a conversation about this program with New York City for a number of years, Coe told Behavioral Healthcare. The biggest concern is diverting patients away from the hospital, he says. “When CMS came out with this grant, we went to the city, and they jumped on it,” Coe says of the DHMH.

The interventions offered in the program will focus on less medication management and “more on engaging the family and the participant in developing a comprehensive recovery plan,” he explained, noting that instead of emergency room visits which focus on “short-term stabilization using medication,” Parachute NYC will focus on “long-term recovery and wellness.”  This focus will be accomplished through respite centers, which will serve more than 2,000 people over a 3-year period.

The program will also include a “warm line,” which is expected to field an expected 12,000 calls per year. Unlike a “hot line,” which is for crises that often involve an extended amount of time on the telephone, a warm line is designed to address many of the occasional needs that come up among the families and consumers. By addressing these needs early, the warm line can refer the patient or family to a therapist before there is a crisis, for example. Importantly, the Parachute NYC program is designed to offer extended follow up to people in the aftermath of a crisis. This addresses one of the core problems of psychiatric crisis care in hospital emergency departments: there’s no follow up on the individual’s recovery. “Someone needs to follow up for a year,” says Coe. “Nobody pays the hospital to do that.” In the future under the Affordable Care Act, there will of course be a concerted effort to prevent readmissions. This is where the Parachute NYC respite centers come in; their role is to provide needed care while keeping people out of the hospital.  

Improved health = reduced costs

In addition to its psychiatric crisis component, Parachute NYC will also engage people in primary and preventive medical care with an on-site nurse practitioner and by training some staff as peer health navigators.  This primary care component is expected to reduce healthcare expenses for the entire group of  participants. “This is a high-needs group,” he said. “Forty-four percent of them had an ER visit for mental illness within the previous year.”

“This is a perfect representation of the shift that’s envisioned in the ACA in breaking down the wall between physical care and behavioral health care,” said Marlowe Greenberg, founder and CEO of Foothold Technology. “The point is to focus on the person, not the issues.” Health homes in New York are using regional health information organizations – data warehouses – that include all kinds of information on a person from homeless shelters, hospitals and other health care organizations, he said. “We need to treat the person and not worry so much about the funding.”

Electronic health record system

Money for an EHR system was not included in the budget developed for the winning CMS grant proposal, concedes Coe, “so I asked Foothold to do this on spec with the expectation that funding would be identified from other sources. He noted that Community Access is already a Foothold client, as are several of the participating providers in Parachute NYC, including Transitional Services, Inc., and Services for the Underserved  “Our goal is social integration,” says Coe, noting that Community Access operates 1,100 units of housing. “We have people living in apartment buildings, in an integrated setting,” he says. Another part of the project involves employing peers. About 100 will be hired for this project, with 14 already hired to work in the respite center. They will be trained, he says.

Database security

The security of Community Access’s participant data is protected by technical safeguards against intrusion, as well as data encryption, “all normal for a SaaS provider,” says Greenberg (Software as a Service, or SaaS, provides online or ‘cloud-based’ software – the client doesn’t have hardware). Parachute is creating a data system for which the city is responsible for access, administration, and security. This data system, however, is not an EHR.