MRT Innovations in Social Determinants of Health Initiative

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Q1 Please provide your contact information below.

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

Gateway Community Industries is a 501(c) (3) nonprofit corporation incorporated in the State of New York in 1957. For over 60 years, Gateway has been a leading provider of human services in Ulster and Dutchess Counties serving a diverse population including Medicaid members (e.g. individuals with serious and persistent mental illness, individuals with intellectual/developmental disabilities, individuals recovering from alcohol and substance abuse, individuals receiving public assistance, seniors with dual eligibility and, across all populations, individuals with serious physical health comorbidities.).

Gateway´s mission is to "assist people in choosing, acquiring, using and maintaining the skills and supports necessary to achieve success and satisfaction in their lives through integrated vocational, therapeutic, residential and business services." Throughout its 61–year history Gateway has maintained its commitment to offering individuals an array of person–centered, recovery–oriented, evidence– based services designed to assist them in achieving their goals to live hopeful, healthy, contributing and satisfying lives. This goal is achieved through the cultivation of engaged, meaningful and sustained relationships that facilitate self–awareness, self–efficiency and optimism. As a result of these relationships, members come to better understand internal and external resources, the power of choice and the benefits of a hopeful mind set.

Gateway´s services are funded through a variety of contracts and grants with the New York State Office of Mental Health (OMH), Office of Persons With Developmental Disabilities (OPWDD), Office of Alcohol and Substance Abuse Services (OASAS), New York State Education Department/ACCES VR, Dutchess County Department of Behavioral and Community Health, Ulster County Mental Health Department, Ulster County Office for the Aging, Ulster County Department of Social Services, Ulster County Office of Employment and Training, Medicaid, Medicare and Managed Care Organizations. To serve its consumer population, Gateway employs a staff of over 200 individuals including social workers, psychiatrist, nurses, rehabilitation counselors, residential counselors and housing specialists, benefits counselors, case managers, care/service coordinators, employment specialists, transportation workers, and nutrition specialists. It should be noted that a percentage of Gateway´s employees achieved employment as a result of their utilization of services and the achievement of their recovery plan.

Gateway´s consumer population has access to an integrated system of community–based services designed to support individuals as they overcome obstacles related to their acute physical and/or behavioral health issues and to address the social determinants that adversely affect health outcomes. Services focus on preventative care offered in an accessible, non–stigmatizing community–based environment.

Gateway offers a full array of programs/services that address the economic stability and health/healthcare determinants primarily serving public assistance recipients, many of whom have physical and behavioral health comorbidities; individuals in treatment for alcohol and substance abuse disorders; individuals with behavioral health conditions including persons with serious and persistent mental illness, persons with intellectual/developmental disabilities (SSI and SSDI recipients); histories of trauma and/or ACES; and seniors at nutritional risk and at risk for social isolation.

Services include:

1. Employment services designed to assist Medicaid Members in choosing, obtaining and maintaining employment and achieving financial self–sufficiency.
   • Job Training
   • Computer/Technology Training
   • Vocational Evaluations/Assessment
   • Psychiatric Rehabilitation Readiness Assessments
   • Career Counseling
   • Vocational Internships
   • Benefits and Financial Counseling
   • Accommodation/Disclosure Counseling
   • Job Seeking Skills/Work Readiness Training
   • Job Development
   • Job Placement
   • Supported Employment/Job Coaching
   • Vocational Case Management/Job Retention
   • Gateway–operated businesses integrating employees with and without disabilities
2. Housing and residential services designed to increase housing security and stability.
   • Office of Mental Health licensed Community Residences
   • Office of Mental Health licensed Supportive and Supported Housing
   • Office of Persons with Developmental Disabilities licensed Individual Residential Alternatives
   • HUD–funded housing
   • Housing for Women with Children
   • Housing for Veterans
   • Residential Support Services
3. Access to nutritional foods and meals designed to improve food security and nutrition.
   • Home Delivered Meals to Seniors
   • Facility–based café providing meals to individuals accessing agency services
   • Community Cafes for Seniors in 7 locations across Ulster County
   • Nutrition Education classes
4. Transportation
   • Agency–operated vehicles providing access to employment and health care
   • Transportation training
5. Access to Healthcare
   • Personalized Recovery–Oriented Services (PROS)
   • Psychiatric and Health Assessments
   • Clinical Counseling and Therapy
   • Symptom Monitoring
   • Development of Safety Plans
   • Medication Management/Literacy
   • Family Psycho Education
   • Integrated Treatment for Co–occurring Disorders
   • Intensive Relapse Prevention
   • Care/Service Coordination facilitating access and use of healthcare services
   • Day Habilitation
   • Onsite Nursing Services
   • Mobile Nursing Services
6. Health Literacy
   • Wellness and Recovery Plans (WRAP)
   • Recovery Coaching
   • Resilience Training
   • Intensive Rehabilitation: Goal Setting classes
   • Advanced Directives
   • Education on Health Conditions including:
     1. Obesity
     2. Diabetes
     3. Tobacco Dependency
     4. Malnutrition
     5. Hypertension
     6. Depression/Suicide Risk

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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).

This innovation is designed to serve individuals who, by virtue of disability–related challenges and/or generational poverty, often experience inadequate nutrition, unsafe or unstable housing, lack of financial self–sufficiency, lack of social cohesion and are at higher risk for life–altering health conditions.

To improve health conditions, increase social connection and enhance quality of life, Gateway envisions a model in which individuals are supported in the achievement of outcomes beyond the goals and objectives of any specific service or program. This will be achieved by the development of sustained and meaningful relationships with individuals with the intent of supporting them while they are using Gateway services, companion services and beyond.

In this model, individuals will meet with a "navigator" for the purposes of education, identification of individualized needs and development of a Plan of Action. The navigator will offer the sustained relationship that is critical to supporting the individual in making life changes. The relationship will be informed by evidence that demonstrates that when people experience judgement–free, empathic relationships their self–concept becomes more positive, their goals become more realistic and they become more self–directed resulting in improved outcomes.

The individual, in collaboration with the navigator, will:

• Review services used in the past, benefits derived from the use of the services, and barriers that contributed to discontinuation of services. This process will include a joint review of Psyckes data
• Assess stage of change, health literacy, and awareness of resources that may support change
• Identify the means by which they will qualify for and/or access services/resources (including personal relationships)
• Develop a person–centered, recovery–oriented Plan of Action including goals, objectives, interventions and collaborations
• Benefit from a "coaching model" that will support the individual in preparing for and carrying out the Plan of Action. The needs of the individual will dictate the level of involvement of the navigator in accessing services

This model will be informed by the following principles:

• Behavioral change is a process that unfolds over time through a sequence of stages. Interventions that do not match an individual´s readiness/stage of change are less likely to succeed and are more likely to damage rapport, create resistance and impede change, therefore, interventions and supports will be aligned with the individual´s stage of change and change profile
• Values and characteristics that support change are critical elements of the service delivery model and will inform all interventions. These include:
• hope
• optimism
• self–awareness
• resilience
• self–efficacy
• choice

To ensure that these underlying principles are infused in the model, all staff will be trained in "best practices" that support the process of making a change.

The staff development plan includes training and/or retraining on:

• the social determinants of health
• the core constructs of the Transtheoretical Model of Change
• the principles and techniques of Motivational Interviewing
• health conditions commonly experienced by the Medicaid population
• health screenings and immunizations for optimal health
• screening tools that identify a need for behavioral health treatment services
• trauma informed care
• the development and implementation of person–centered planning
• the goal setting process
• the coaching model
• benefits and entitlement counseling
• community resources
• "stigma busting"/systems advocacy

As stated above, GCI has extensive experience and demonstrated expertise in providing services that address social determinants of health with a primary focus on economic stability and behavioral health care. This innovation proposes an expansion of current services. To implement this project, GCI proposes to repurpose space within its facility to create a Center for Arts, Recreation, Education, Socialization (CARES) that will offer an array of social, educational and enrichment opportunities designed to increase social connectedness, strengthen cognitive functioning, enhance emotional well–being, and improve physical health. It is envisioned that this Center be a safe, accessible environment in which Medicaid members will become engaged, enjoy nutritious meals, participate in social and civic activities, access nursing services that offer healthcare monitoring (i.e. blood pressure screening, diabetes education), and receive supportive services in entering the health system. Individuals will have opportunities to participate in fitness, wellness and stress reduction activities, to access transportation services (i.e.to grocery stores/food pantries) and to access the array of employment, housing and behavioral health services offered at GCI.

ROI
Persons who are accessing GCI services often have behavioral health issues, health comorbidities and a high utilization of emergency services. Gateway´s navigator will collaborate with individuals to address the underlying social determinants of health and health conditions directly by assisting with access and use of ongoing physical health care. In this way, Medicaid savings will be achieved.

Scalability
The navigator model can be implemented across community–based organizations. Individuals often access multiple health and human service providers simultaneously. Navigators will be available to handle referents from one another and in that way they will have a shared responsibility for the sustained relationship of their clients. The pool of navigators will be recruited, trained and managed by a lead agency. This will better insure the consistency of the underlying principles of this model. The number of navigators needed in any one region or CBO can be flexible and will be determined by demand.

Feasibility
CBOs are uniquely positioned to attack the principle barriers that prevent individuals from achieving and sustaining health. It should be noted that care provided in clinical settings (i.e. hospitals and primary care) account for only 20% of overall health outcomes. In those clinical settings, providers do not have the relationships, knowledge, or time to assist their patients in achieving social determinant improvements.
This model is feasible as Gateway and other CBOs currently reach a great number of Medicaid members, many of whom have comorbidities and would benefit from social determinant improvements.

Evidence based Support for Innovation
GCI´s array of services that address social determinants are considered to be strongly associated with improved health outcomes. In this model, the navigator will facilitate a greater number of connections to evidence–based services, thereby improving health outcomes for a greater number of Medicaid members.

Relevance to the Medicaid Population
Medicaid members with behavioral and/or substance abuse issues often live in conditions that contribute to poor health outcomes. This is a population that may be chronically unemployed or underemployed, failing to achieve economic self–sufficiency at levels that provide for safe and stable housing, access to good nutrition, and the development of social connectedness. This model serves to mitigate and/or obviate barriers including lack of direction, lack of confidence, fear created by past experiences as well as internal and external stigma.

Speed to Market
This model can be implemented quickly. The CBOs choosing to use navigators would be self–identified. The lead agency (GCI) would provide the requisite education and training to the pool of navigators. Within a matter of months, navigators will be interviewed, selected, hired and trained.

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