MRT Innovations in Social Determinants of Health Initiative

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Q1 Please provide your contact information below.


Title and Organization




ZIP/Postal Code

Email Address

Phone Number

Carrie Doran

COO, Liberty Resources, Inc.

1045 James Street






Q2 Please describe your company or organizations overall goals and mission.

Liberty Resources, Inc. (LRI) is a 501(c)(3) organization, headquartered in Syracuse NY, with services provided throughout NYS. LRI employs over 1400 professional staff, providing services to 17000 individuals annually. LRI belief, values and mission are as follows: Our Beliefs – All people deserve the opportunity to make decisions regarding their lives and to achieve their highest potential. We believe each person has the ability to change and that all people should be treated with dignity and respect.

These beliefs are demonstrated in the value and support shown to those served as well as to the staff of Liberty Resources. Our Core Values – Liberty Resources´ values drive its service provision, administrative practice, staff development and business management.

Excellence: Liberty Resources demonstrates its commitment to excellence by striving to exceed established standards to achieve optimal outcomes.

Integrity: Liberty Resources strives to align daily practice with its mission and values.

Diversity: Liberty Resources is strengthened when it embraces a broad array of diverse talents and perspectives. Liberty Resources strives to maintain welcoming and inclusive environments that ensure that all people are treated with dignity and respect.

Self–Determination: All people deserve the opportunity to make decisions regarding their lives and to have the opportunity to achieve their highest potential.

Service Staff go above and beyond to meet the needs of individuals, families and communities through consistent, compassionate service.

Innovation: Liberty Resources is willing to take risks and engage in creative approaches to respond to the challenges of a constantly changing environment and society.

Fiscal Responsibility: Business management and financial stability enable the agency to achieve strategic goals, to be an employer of choice and to maintain a supportive environment so that employees can focus on high quality service delivery.

Our Mission – To assist individuals and families in need of achieving an improved quality of life by providing residential and non– residential services tailored to meet their particular needs. We offer progressive services in the least restrictive, most community–based setting possible for each individual. We are committed to excellence in all aspects of service delivery, staff development and business management.

Our Vision – To be a center for excellence with demonstrated effectiveness in serving individuals and families with special needs. On a broad regional level, we will offer a comprehensive continuum of services through partnerships and through internal integration of services.

Liberty Resources is willing to take risks to meet the challenge of delivering the highest possible quality services to diverse populations.

Q3 Please indicate which category your organization falls under.

Health Care Provider,
Community Based Organization

Q4 Innovation Executive Summary. Please describe the innovation, and how it addresses the social determinants of health. Please identify how the innovation addresses the 6 innovation criteria (i.e. ROI, scalability, feasibility, evidence–based support for innovation, relevance to the Medicaid population and speed to market).

Project Description

Liberty Resources Inc. proposed to develop and implement The Parent Peer Support Program within the existing Integrated Care Clinic. This clinic currently operates under licensure with OMH (A31), DOH (A28) and DSRIP (A32), (OASAS A32 application pending). Currently, services within the clinic include: Individual psychotherapy; Family Therapy; Group Therapy; Crisis Intervention; Psychiatric Evaluation and Monitoring; Health Monitoring by a Registered Nurse; Health Home Care Coordination; Substance Abuse Evaluation; Substance Abuse Treatment Services (7 Challenges); and Primary Care. Children´s services are offered in the clinic setting as well as in the schools (Syracuse City, Rochester, Baldwinsville, and BOCES).

The Parent Peer Support program will offer an extended "helping hand" of someone who has "been there, done that." The Parent Peers will have their own lived–experiences that will help remove the barriers of shame, isolation, and stigma that often prevent parents from seeking out and being receptive of tradition treatment approaches.

Navigating the mental health, child welfare, and children´s services world can be a daunting process for anyone, let alone caregivers who are trying to do so while maintaining supervision, safety, and adequate levels of support for their child with mental illness. The unique vulnerabilities for children with mental illness (including trauma, depression, mania, anxiety, schizophrenia, and substance use disorders) heighten the need for compassionate, well–coordinated care. Person–centered, collaborative treatment strategies, in partnership with the family, is imperative in each care setting and across care settings to promote family confidence and overall transition resilience.

The primary goal of LRI´s Parent Peer Support Program will be to improve health outcomes for children receiving mental health care in our community, as evidenced by improving engagement in and the effectiveness of treatment interventions while reducing hospitalization/ER visits. In addition to this primary goal, parents will become empowered to effectively parent and advocate on behalf of their child, while reducing stigma and feelings of isolation. This secondary goal is highly relevant and motivating, meeting the ethical and moral imperative of wrapping intensive support, caring, and guidance around the families of the most in–need children in our community. In addition to these overarching goals, Parent Peers will further impact change by:

  • Empowering the parent to have a voice in their child´s treatment and their community and increasing their feelings of self–efficacy;
  • Providing the parent with information, support, and advocacy;
  • Assisting the parent in their navigation through various systems (educational, behavioral health, primary care, child welfare, social services, etc.);
  • Assisting the parent in their understanding of various options available for their child and family and assisting in informed decision– making;
  • Assisting the parent in utilizing primary and prevention care providers for their child´s medical care needs, whenever possible;
  • Assisting parent in learning more about meeting the needs of a child with behavioral, emotional, or physical health care needs;
  • Promoting productive partnerships between parents and professionals; and
  • Linking families with formal and informal supports.

Participants in the program will participate in a comprehensive assessment, resulting in the creation of a family–driven, individualized parent support plan. Participation in the Parent Peer Support Program can range from short–term (less than 90 days) to long–term (more than 90 days), depending on the needs and goals identified. The level of each parent´s participation with the Parent Peer Support Program will be individualized, providing the level of participation and support that is desired by and necessary for the parent and family to achieve the goals and objectives in the individualized Parent Support Plan. Throughout involvement in the program, progress on the Parent Support Plan will be formally assessed quarterly, with the interventions titrated to higher or lower intensity and frequency as needed. In addition, during times of crisis or disruption, the intensity and frequency of Parent Peer Support Program services will be modified accordingly.

Services delivered through the Parent Peer Support Program will be provided by 3 full–time Parent Peers (Some high school education required, Diploma or GED preferred) and 1 full–time Program Supervisor (Bachelor/Master´s Degree in Social Worker/Human Services). The Parent Peer Support Program will provide the following service deliverables, through the implementation of a family–driven, individualized Parent Support Plan:

  • Individualized one–on–one parent support in the home, school, or community;
  • Attendance with parents to care planning and treatment meetings, school meetings, outside provider/cross–sector appointments, and other meetings/appointments identified by the family;
  • Intensive family support during episodes of crisis;
  • Attendance to child/family treatment team meetings;
  • A Telephone Support–Line (warm line) for parents to utilize for support and guidance;
  • Parent Peer–led education and support groups, to increase parent knowledge and skills;
  • Evidence–Based Parent Education Trainings;
  • Multi–Family Social Events and Public Awareness Events; and
  • Linkage to Case Management support for family stabilization and capacity–building supports.

The Parent Peer Support Program will partner with any caregiver, regardless of whether the caregiver is the child´s biological, foster, or adoptive parent, a grandparent, a family member, or some other unique relationship to the child. Eligible participants for the program will be the caregiver of a child (age 4 to 20) who is experiencing significant mental and behavioral health disorder symptoms, not achieving academically, struggling with problem behaviors in the community, and a high utilizer of emergency room and/or inpatient hospital care. Caregivers can also self–identify as desiring additional guidance, support, or advocacy as they care for their child with mental health struggles.

Participants of the Parent Peer Support Program do not have to be consumers at LRI. Possible participants can be identified by LRI providers, key stakeholders and community partners, or the parent/caregiver themselves. Referrals for the Parent Peer Support Program will be accepted from our collaborators across the Central New York area. In addition, LRI will utilize HealtheConnections and PSYCKES data, as well as internal electronic health record data dashboards, to identify LRI–enrolled children who fit the criteria noted above. Participation in the Parent Peer Support Program will be voluntary and cannot be mandated. For LRI consumers, participation in the program can occur at any point within a child´s treatment. It is not required for families to opt into the program upon admission to care with LRI as they can opt into the program at any time if the meet the above criteria. Once a referral is identified, LRI will outreach to the parents/caregivers to offer participation in the Parent Peer Support Program.

The effectiveness of the Parent Peer Support Program will be evaluated via:

  1. administering a Pre– and Post–Intervention Assessment Tool,
  2. the facilitation of a parent participant focus/feedback group,
  3. the analysis of applicable data from PSYCKES and the LRI electronic health record data, and
  4. consumer feedback surveys.

In order to sustain the Parent Peer Support Program, LRI will work with its partners to create a data driven measurement system and will tailor these services to be packaged to managed care organizations in a Value Based Payment arrangement. The Health Care system is experiencing a dramatic shift toward Value Based Care, which requires the design and delivery of services and supports that actively facilitate recovery and build resilience. Key to effective transformation and high–quality services, Liberty Resources has adopted and refined the practices of integrated physical and behavioral healthcare, person–centered treatment, and clinical performance related analysis. To succeed in the competitive value–based environment, children´s outpatient services must embrace targeted strategies focused on quality, outcomes, performance, and long–range cost savings. Essential to the success of this approach is the development of a comprehensive system of care providing collaborative and well–integrated services to our consumer. LRI will participate in OMH Children´s State Plan Amendment (SPA) Services, which is slated for a phased roll out beginning in January 2019. LRI will maximize billing opportunities under SPA Services, contributing to the longevity and financial sustainability of this program, allowing for long–term stability.

Timeline of Implementation
Upon notification of approval of this project, LRI is prepared to conduct recruitment and hiring of the staff necessary to implement this program. Based on the positive outcome of recruitment and hiring, program service deliverables will begin within two to three months. This timeline will allow for adequate staff hiring, orientation, and training, as well as outreach to referrals sources (collaborators and stakeholders). As our Parent Peers will likely have limited to no formal training beyond their lived–experience, a high level of initial and ongoing training will be critical to ensure quality service delivery. Treatment topics will include but will not be limited to: effective use of lived experience; listening skills and cultural competence; confidentiality and ethics; effective assertive written and verbal communication; mentoring leadership in others; cultural diversity and the use of family–driven, strength–based approach to mental and physical health; current issues in the areas of children´s developmental, emotional, behavioral (including substance use), or mental health; parenting skills and strategies; coaching for personal change and crises prevention; development and use of community resources, including natural supports; and strategies for advocacy across and within systems.

Evidence Based
At this time, there are no parent peer programs that have achieved the designation of being "evidence–based." A literature review of the available research and guidance regarding the use of parent peers as we propose for use in our Parent Peer Support program, resulted in the following outcomes being seen consistently across programs as a result of a family´s participation in a parent peer model:

  • Families have enhanced capacity and increased feelings of empowerment to take action and to provide for children´s needs;
  • Families are better able to access appropriate preventive services to meet their child´s needs;
  • An increased sense of collaboration between parents and providers;
  • A decrease in feelings of isolation and a parent´s internalized blame regarding their parenting;
  • A reduction in hospitalizations as families are helped to keep their children safely maintained in their homes whenever possible and appropriate;
  • A decrease in the length of a child´s hospital stays and costs of services;
  • Improved well–being, self–esteem, self–care, and social functioning for children and families;
  • Increase social support and participation in the community; and
  • More thorough and longer–lasting recoveries for children.

Compelling Need
Locally, HealtheCNY data released in 2017 indicates that children under the age of 18 in Onondaga County experienced the following between 2014 and 2016: a) 15.2 per 10,000 for Pediatric Mental Health Related Hospitalizations; and b) 44.6 per 10,000 for Pediatric Mental Health Related Emergency Room Visits (source Nationwide, the National Institute for Mental Health (NIMH) indicates that 1 in 5 children ages 13–18 have, or will have, a serious mental illness. Additionally, they report that just over half (50.6%) of children aged 8–15 received mental health services in the previous year. Their research shows that half of all lifetime cases of mental illness begin by age 14. NIMH data further asserts that 50% of all lifetime cases of mental illness begin by age 14 and 75% by age 24; 37% of students with a mental health condition age 14 and older drop out of school–the highest dropout rate of any disability group; 70% of youth in state and local juvenile justice systems have a mental illness; and that suicide is the third leading cause of death in youth ages 10–24 and the second leading cause of death for people aged 15–24 (source:

In addition to these compelling statistics, locally we are experiencing high census numbers and consumer need at outpatient behavioral health centers, there is a shortage of psychiatric child prescribers, and there is an active social discourse on the ethical imperative of providing mental health care to children and adolescents. As a result, it is evident that the Central New York region is in high need of focused, effective, and lasting treatment interventions. The implementation of the Parent Peer Support Program will occur at a time when the awareness of need is great and engagement by parents/caregivers is acknowledged as critical for positive, safe outcomes for youth in our community. Parent Peers will be able to assist parents/caregivers in engaging effectively with available service providers and bridge the gap between provider and parent.

The Social Determinants of Health
Liberty Resources embraces a person–centered, culturally and linguistically aware, trauma–informed approach to care, examining and responding to the influence and impact of the social determinants on health. One of the main tenets guiding the creation of the Parent Peer Support Program at LRI is our keen awareness that true health and well–being for children starts in our homes, schools, neighborhoods, and communities. The Parent Peer Support Program intends to make a direct positive impact on the social determinants of health for a child and their family. Being attuned to and responding to the impact the social determinants of health have on a child and their family will be a critical component of the Parent Peer Support Program.

Our Parent Peers will work with participants to remove barriers created by disparities in socioeconomic status, insurance status, race, gender, community or neighborhood location and safety, disadvantaged schools, and much more. The hope is, that as parents work with our Parent Peers, the social determinants of health impacting the child and the family will become clearer. Parent Peers will closely work with the family to further identify their needs and explore community resources available to address those needs. This will allow our Parent Peers to provide concrete support to families, helping them address day–to–day barriers faced that are negatively impacting their ability to support and respond to the needs of their child. The Parent Peer may help a parent explore different income sources, find more sustainable employment, connect them to Primary Care Providers, identify safer or more stable housing, or manage a household budget, to name a few specific areas. The Parent Peer Support Program team will maintain an awareness of and connection to the various community resources available, allowing them to create the direct linkages necessary to address needs related to overall health. These community resources will include but not be limited to: Pediatric Care Providers, WIC, food banks, child care supports, transportation services and supports, preventive child welfare support, homeless shelters, housing supports, apartment listings, domestic violence shelters, free/reduced medication opportunities, pharmacy locations and contact information, smoking cessation programming, HIV/AIDS resources, soup kitchens, substance–use treatment facilities, AA, NA, NAMI, The Family Tapestry Program, and more. Parent Peers will ensure that appropriate referrals are made and tracked for effectiveness.

LRI provides care to anyone seeking our services. Currently, 88% of the population of individuals receiving behavioral health treatment at Integrated Health Care at LRI are Medicaid or Medicaid Managed Care insured (33% Medicaid, 55% with MMC). We do not turn away individuals who are uninsured. LRI is well prepared to continue serving a diverse population that includes non–English speakers, differing dialects, and those with a broad range of disabilities. Language interpretation services are provided through Cyracom, a telephone translation service, or through MAMI in–person as necessary. As an experienced provider of services to those with special needs, disabilities, or other barriers, LRI is committed to extending this linkage of services to clients in need. In addition, LRI approaches gender, gender identity, and sexual orientation in an inclusive, supportive, and open manner, seeking to build on different ways of knowing, communicating, and problem–solving with all those we serve.

Q5 Was your innovation implemented? If so, please explain when, the number of people impacted, and the results.


Q6 Please identify the SDH Domain that your innovation addresses. (Select all that apply.)


Social and Community Context,

Health and Health Care

Q7 I give the Department of Health the right to share the information submitted in this application publicly (for example: on the DOH website). I understand that there is no monetary reward/reimbursement for my submission or for attending the summit should my innovation be selected.

I consent to have my innovation shared