Poster Presenters - Community Based Organization Category

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Q1 Please provide your contact information below.


Title and Organization




ZIP/Postal Code

Email Address

Phone Number

Lena Johnson

Director, Service Development - Rehabilitation Support Serivces

5172 Western Turnpike





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

Operating for nearly 40 years, RSS, a not–for–profit organization, have dedicated ourselves to enriching and empowering the lives of individuals with severe psychiatric disabilities and substance use disorders by providing services and opportunities in 16 upstate NY counties for meaningful emotional, social, vocational and educational growth. Through our diverse array of recovery–oriented services including residential, employment, treatment, rehabilitation, care management and community support services and leveraging our well–established community resources, we continuously work to effectively and innovatively address the social determinates of health that affect so many of our members. Our goal is to improve the quality of their lives through recovery–oriented housing, work, treatment, socialization, and health and wellness services (total annual service enrollment exceeds 4,200 unique individuals).

Q3 Please indicate which category your organization falls under.

Community Based Organization,
Other (please describe below: 150 character maximum):
Behavioral Provider

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).

A successful transition from inpatient care toward community living often demands traversing a complex and siloed healthcare system – a daunting task for any individual. This task is especially challenging for those suffering from a serious mental illness and a long–stay admission, for example at a State Psychiatric Center. These individuals are often insufficiently prepared for direct re–entry into the community, thus increasing the likelihood of avoidable re–admissions.

Rehabilitation Support Service´s Outreach Team work with long term stay individuals at State Psychiatric Centers in Albany, Saratoga and Dutchess Counties to locate and secure housing, develop innovative residential discharge options allowing them to move out of the hospital and back into their community. Funded by the New York State Office of Mental Health, our outreach program offer community– based, time–limited services for adults with serious mental illness who have experienced long–stays in psychiatric inpatient care. It aims to reduces recidivism rates while providing strategic and intensive outreach to improve one´s access to a community–based system of care, including ambulatory care that will over time meet their emerging behavioral, social and vocational needs.

Our services begin shortly before discharge to build trust and continues with the individual into the community for up to nine months post discharge. Our multidisciplinary teams comprised of Licensed Mental Health Clinicians, Nurses and Peers as well as a residential counselor, address a host of issues–housing, food, economic security, medication adherence, linkage with outpatient providers, family conflict, and social isolation–faced by individuals transitioning to the community.

RSS Outreach teams offers:

  • A comprehensive needs assessment of community transition supports essential to stabilizing the individual; Discharge Planning before discharge
  • Primary care linkage to address physical health issues that impact a patient´s ability to successfully live in the community;
  • Peer support from individuals with shared experiences;
  • Short term counseling (substance use, coping skills, trauma informed, decision making);
  • Medications Management – Pre and post discharge;
  • Intensive transitions of care by accompanying to behavioral health and medical appointments, obtaining health insurance, reengagement in community care, referral to services;
  • Linkages and appointments with community providers of outpatient clinics and programs for individuals with serious mental illness (SMI) and substance use disorder (SUD), clubhouses, vocational and educational programs, and other services
  • Facilitate enrollment and engagement with a Health Home Care Manager and Home and Community Based Services if eligible;
  • Skills–building and engagement, with an emphasis on identifying goals that help provide the individual with the motivation to take care of their health and learn the skills needed to be successful in community housing;
  • Timely access to Crisis Intervention services including RSS Short–Term Crisis Stabilization Program, once in the community including respite referrals and other diversion and stabilization services; and

Initial Outcomes have shown that RSS decreases hospital readmissions, reduces emergency department use for Medicaid–eligible patients with serious mental health disorders. Additionally, recent reports published by NYS OMH the average daily inpatient census for forensic populations in State PC decreased from 714 (Dec 2016) to 303 (April 2018).

We believe this model has significant relevance to the Medicaid population as the majority of individuals discharged from State Psychiatric Centers are Medicaid Eligible. This model can easily be modified to serve individuals discharged from Nursing Homes and other long–term care facilities where there can often be a shortage of necessary supports. RSS operates in 16 upstate New York Counties, provided cost efficient rates, scalability of this program to additional counties is achievable. Similar models can be deployed rather quickly due to the small staffing model, and minimal overhead required to operate this program, it can be implemented within 6 months (contingent on staff hiring).

The annual program budget is approximately $250K which is lower than the annual cost per member in a State PC ($800 per diem).

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

Yes (please specify when and the estimated number of people impacted):

Late 2016. Approximately 40 individuals served. Initial Outcomes have shown that RSS decreases hospital readmissions reduce emergency department use for Medicaid–eligible patients with serious mental health disorders.

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


Social and Community Context,

Health and Health Care,

Neighborhood and Environment,

Economic Stability

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