Application of a Multi-disciplinary Team Approach to Supportive Housing Case Management

1. Application of a Multi-disciplinary Team Approach to Supportive Housing Case Management for High Risk People Living with HIV/AIDS (PLWHA) Danielle Strauss, MPH Monika Grzeniewski, MPH 141st Annual APHA Meeting November 5, 2013

2. Program Background and Overview • In 2009, Harlem United received a grant from the New York CityHuman Resources Administration (HRA) to provide permanent supportive housing to triply diagnosed PLWHA. • This grant was issued as part of New York State and New York City’s landmark NYNY III Agreement aimed at creating 9000 new units of supportive housing in New York City. • With this grant, Harlem United proposed an innovative approach to supportive housing case management based on the Assertive Community Treatment (ACT) model.

3. Program Background and Overview • What is Harlem United’s NYNY III Program? • 70 units of housing and supportive services to triply diagnosed single adults in the Bronx and Upper Manhattan • Eligibility criteria: • History of chronic homelessness (continuously homeless for > 1 yr.) • HIV/AIDS • Substance Use and/or Mental Illness Diagnosis

4. Population Demographics • Gender: • 69% Male • 24% Female • 7% Transgender • Race: • 66% Black/African American • 19% White • 1% American Indian/Alaska Native • 1% Multi-racial • 13% unknown • Ethnicity: • 27% Latino/a

5. Population Demographics • 77% are unstable due to mental health, active substance use and/or medical frailty: • 53% are MICA (Mentally Ill/Chemically Addicted) • 13% have a Mental Health Diagnosis (no Substance Use) • 9% have a Substance Use Diagnosis (no Mental Health Diagnosis) • 36% are medically frail (CD4 counts < 200)

6. What is Assertive Community Treatment (ACT) • ACT was developed in 1980 by Drs. Leonard Stein and Mary Ann Test as an alternative to traditional mental health and case management interventions. • Targeted towards individuals with severe and persistent mental illness, ACT was conceived as an intervention designed to help clients that do not benefit from traditional outpatient models for various reasons (limited mobility, lack of insight regarding need for treatment, prior negative experiences in treatment, etc.). • The primary purpose of ACT is to provide comprehensive, home and/or community-based treatment to this population, in order to help stabilize them in the community and minimize chronic psychiatric hospitalizations and emergency room visits.

7. What is Assertive Community Treatment (ACT) • ACT does not link clients to needed services but rather provides highly individualized services directly to clients within their own homes and communities. • The model grew out of research conducted by Drs. Stein and Test on an in-patient psychiatric unit and is based on the multi-disciplinary, round-the-clock services offered by such units. • They observed that the improvements made by clients during their hospital stays were often lost almost immediately upon discharge. Thus, they hypothesized that these clients needed the same level of support provided on an inpatient unit when they returned to the community.

8. What is Assertive Community Treatment (ACT) • A traditional, fully resourced and fully staffed ACT team usually consists of: • A Team Leader who serves as the clinical and administrative supervisor of the team • A Psychiatrist and/or Psychiatric Nurse • A Social Worker • An Employment and/or Life Skills Specialist • A Substance Abuse Specialist • Key services directly provided by the ACT team in the home and/or community usually include: • Psychopharmacological treatment • Individualized supportive therapy, counseling, and skills building • Mobile crisis intervention

9. What is Assertive Community Treatment (ACT) • ACT differs from the more traditional case management model in the following ways: • It involves a multi-disciplinary team that works collaboratively on each case, integrating services and coordinating care. • The more traditional model assigns one case manager to a case to coordinate all services related to that one client, or the clients on his/her caseload. • There is a significantly lower client to staff ratio (~ 1:10). • Services are provided directly to the client in the home or community (as opposed to in the office). • 24 hour coverage is available from the treatment team.

10. NYNY III’s Modified Version of ACT • The NYNY III program is not funded to provide ACT services. • However, we believed the model was still a good fit for our population and therefore decided to modify it to meet our needs with the funding and resources we had available. • This presentation is about how we modified the model to fit our needs, the challenges we faced in the process, and the pros/cons of our decision.

11. The ACT Model Team includes a : Team Leader Psychiatrist/Psychiatric Nurse Employment/Life Skills Specialist Substance Abuse Specialist. Services include: Psychopharmacological treatment Individual supportive therapy Crisis intervention Services in the home/community 1:10 staff ratio Multi-disciplinary team coordinating/integrating care 24 hour coverage NYNY III’s Modified ACT Team includes a: Program Coordinator Licensed MSW/CASAC (NYS Certified Alcohol and Substance Abuse Counselor) 2 experienced Case Managers Peer Specialist Services include: Individual supportive therapy Crisis intervention Services in the home/community ~1:20 staff ratio Multi-disciplinary team coordinating/integrating care NYNY III’s Modified Version of ACT The following compares the ACT model to the NYNY III modified version of ACT. Items in bold are items we cannot sustain in NYNY III.

12. NYNY III’s Modified Version of ACT • The NYNY III team works with all 70 clients enrolled in the program. There are no assigned caseloads. • Services are coordinated and integrated among members of the team. • To accomplish this, we had to set up systems in order to ensure: • Chart documentation was getting done accurately and timely. • Clients did not fall through the cracks (get left unseen because there was no one specific person assigned to their case). • Communication among team members was happening so that all members were up-to-date on every client.

13. NYNY III’s Modified Version of ACT • Managing Chart Documentation • Clients are assigned to Case Managers who are their primary contact with the program but are introduced to all members of the team and informed that all members of the team are available to serve them as needed. • Primary contacts are responsible for all chart documentation except for progress notes (e.g. reassessments, treatment plans, medical documentation, etc.). • Any member of the team who has a direct client contact or collateral contact, even if he/she is not the primary contact for that client, does a progress note on that engagement. • This system helped us be able to hold individual staff members accountable for getting work done while still implementing the team approach to case management.

14. NYNY III’s Modified Version of ACT • Preventing clients from “falling through the cracks”: • Team members are provided with aMonthly Matrix– a schedule of home visits that is updated on a monthly basis.

15. NYNY III’s Modified Version of ACT • Preventing clients from “falling through the cracks”: • Clients are categorized into risk categories (low, medium, high) and scheduled for 1-2 home visits per month, depending on their category (low = 1 HV, medium = 2 HVs, high = at least 2 HVs ). • Within the first 2 weeks of the month, the client’s primary contact is scheduled on the matrix to visit the client in the home. • The 2nd half of the month, another member of the team is scheduled to do a home visit with those clients who are medium to high risk. • The matrix is a guide not a script to assist Case Managers in planning their week and home visits and to ensure that every client is contacted at least once. • A client in crisis may get more scheduled visits, be seen in the office for a case conference, visited in the hospital instead of the home, etc., depending on their needs and the situation.

16. NYNY III’s Modified Version of ACT • Managing Communication: • Team meets daily for Daily Rounds to discuss each case and update all members of the team on changes to a client’s situation that occurred since the last discussion so that all members of the team are up-to-date on every client. • During Daily Rounds: • Each client’s name is read out loud • Team members present direct or collateral contact with the client that day and logs contact in the Contact Log Book (see attached). • Team members present challenging or difficult cases and collectively the team strategizes on how to best handle the case. • Team members discuss plan for the next day (who needs immediate follow up, who needs monitoring, who needs a regular visit) and agree on who would be responsible for doing what, based on the matrix, geography (if someone will be in the neighborhood), and other factors. • While out in the field, Case Manager call or email other members of the team or their supervisor as needed.

17. PROGRAM OUTCOMES • of Harlem United’s • NYNY III Supportive Housing Program

18. NYNY III Program Outcomes • For Harlem United’s 2012 annual report, data from the NYNY III program was analyzed to assess the program’s ability to achieve outcomes. • Client demographic and service data was reviewed for 64 NYNY III clients who had been enrolled in the program since 2009 and were still active at the end of 2011. • The results revealed that our NYNY III program has a higher retention rate compared to the national average reported by the Federal HUD program.

19. NYNY III Program Outcomes • Research on supportive housing supports the belief that clients with stable housing are more likely to be connected to medical care, adherent to treatment and experience lower rates of morbidity and mortality. • (Aidala, A.A., Lee G., Abramson, D.M., Messeri, P., & Siegler, A. (2007). Housing need, housing assistance, and connection to HIV medical care. AIDS Behavior, 11, S101-S115) • Similarly, application of ACT supports the belief that clients engaged in ACT will be more medically stable as well as adherent to treatment. • Of the NYNY III clients from 2009 who remained in the program through 2011, 100% were connected to primary care and 76% visited their primary care provider every 4 months in 2011.

20. NYNY III Program Outcomes • By remaining stably housed for a period of 3 years, the NYNY III clients were able to engage in medical care and see significant improvements in their health outcomes. • CD4 counts remained steady. In addition, there was a 10% increase in the amount of clients with CD4 counts > 350 over the course of this period, suggesting that the clients became more medically stable and improved in their health. • 38% of the clients had undetectable viral loads at program entry. By the end of 2011, the number of clients with undetectable viral loads doubled to 65%.

21. Advantages Additional staff support when working with a challenging client (helps prevent burnout). Clients are connected to multiple staff members in the program which helps minimize. disengagement with the program in the case of staff turnover Clients benefit from having multiple staff members from different perspectives working to address their multiple and complex needs. Crisis intervention is more efficient because all staff members are up to speed on each case. Disadvantages An added layer of complication in terms of program management. Need for systems to ensure communication among team members is happening (e.g. the matrix, daily rounds, etc.) which are time consuming. Need to manage team dynamics in addition to individual personalities. It is challenging to hold individual staff members accountable for job performance when it is the team that is ultimately responsible for getting the job done (management of chart documentation). Discussion: Advantages and Disadvantages of our program model

22. Contact Information: • Danielle Strauss, MPH • Managing Director • Harlem United • 306 Lenox Avenue • New York, NY 10027 • (212) 803-2850 • Dstrauss@harlemunited.org • www.harlemunited.org