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

Daniel J. Maughan Amy Anderson–Winchell Darcie Miller

Senior VP Transformation, President & CEO, Commissioner Mental Health and Child/Family Svcs.

70 Dubois Street





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

St. Luke´s Cornwall Hospital (SLCH), licensed as a NYS Department of Health (DOH) Article 28 hospital, provides services to more than 250,000 patients living in the Hudson Valley each year. SLCH´s mission is to provide exceptional health care that improves the lives and wellbeing of individuals living in the hospital´s service area of Orange, Ulster and Dutchess counties. In 2015, SLCH developed a five– year transformation plan designed to facilitate the hospital´s transformation and growth within NYS´ delivery system reform initiatives, ultimately moving the hospital towards achievement of the Quadruple Aim in a manner aligned with its own and Delivery System Reform Incentive Payment´s (DSRIP) goals. The plan outlined a series of corporate restructuring activities, all of which are in various stages of completion, that relate directly to its goals of further developing primary care and other outpatient services, preserving and expanding essential health care services, as well as creating a financially sustainable system of care.

Overall, SLCH is one of the Hudson Valley´s highest quality providers, as demonstrated by its numerous awards and accolades. Continuing and expanding high quality services for medically disparate populations, including those who are publicly insured or uninsured, are essential goals for SLCH as we make a substantial impact on decreasing the high rates of chronic disease and health disparities experienced by these communities today.

Orange County (LGU):

As the local government unit defined by New York State Mental Hygiene Law, the Orange County Department of Mental Health (OCDMH) exists to ensure appropriate supports and services are available to meet the needs of people, and their families, with Mental Illness, Chemical Dependency, Developmental Disabilities or any combination. This is accomplished through collaboration with other county departments, community and state agencies, schools, peers, self–advocates and families.

Our vision is to ensure a system of services exists that embraces complexity, promotes wellness, provides culturally responsive, trauma informed and accessible supports that assist individuals in achieving their potential through all phases of life.

Access: Supports for Living (Access)

Access: Supports for Living´s mission to help people live the healthiest and fullest lives possible. Founded over 50 years ago by a group of families who believed in a bright, positive future for their children with disabilities, Access, today, is a nearly $90 million organization that touches more than 10,000 lives annually across nine counties in the Hudson Valley. Access provides services to people with Intellectual and Developmental Disabilities, Behavioral Health needs as well as children and families with a range of needs. Programs and services are person–centered, recovery–oriented and designed with the flexibility to meet each person´s unique needs. Access works toward a world in which no one is marginalized because they are different, and our communities are richly diverse and welcoming to all.

Q3 Please indicate which category your organization falls under.

Health Care Provider,

Community Based Organization,

Other (please describe below: 150 character maximum):
We are a Hospital, Behavioral Health Organization, & LGU

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).

SLCH in collaboration with Access and OCDMH entered into an agreement whereby Access provides Mobile Mental Health (MMH) services. These services are provided by an independently licensed clinician who is credentialed by the hospital to patients determined to have a behavioral health need in its community Emergency Department (ED) that is a non–9.39 psychiatric hospital/ED. Prior to the agreement, patients presenting with a behavioral health need would be evaluated by the ED provider and if necessary, sent to a 9.39 psychiatric facility to be evaluated further. MMH services up were not offered to the ED as these services were specifically to cover emergent calls from people in distress where they may not be safe vs the safety of a hospital ED. Once in the ED, patients were exposed to various challenges, the controlled chaos of an ED, no access to a mental health professional for immediate evaluation and treatment, required costly medical clearance prior to the transfer, were sent out of their local community and often did not have the funds to return to the community after discharge.

This program seeks to reduce the total cost of care associated with having had transferred 100% of this population prior to the program´s inception in October of 2013. Every patient entering our ED who required a transfer to a 9.39 facility prior to October 2013, would require a costly medical clearance that required specific testing to complete the transfer at minimum. Since October 2013, 673 (64%) patients have presented to our ED requiring an evaluation by MMH where we did not need to provide this level of care nor the costly medical clearance. As such, using only these patients and the information above, at an approximate conservative cost of $725 per patient, we have avoided over $487K dollars in unnecessary spend by the health care system.

Scalability of this project has not been an issue. The MMH team has been able to successfully continue its work in the community as well as cover the ED without issue. Two months ago, the MMH team moved its Newburgh office to the SLCH ED, allowing the team to provide timely follow up and any time not needed in the community, to support the hospital for those waiting for disposition.

To our surprise, once the decision was made to allow the MMH staff into the ED, contracts, credentialing and education went very smoothly and the entire process from initial discussion to start of the program was about eight months. We believe this would not take as long for others to implement as we would be willing to share the Policies and Procedures, MOU´s that were entered and education plans that were used to educate all partners.

Evidence based support for innovation:
Other than multiple patients presenting to our ED for behavioral health complaints that we felt did not require a 9.39 center but did require immediate engagement from a mental health professional and our recognition that patients were not appropriately connected to services or not sure of how to access those services, there was not much evidence to base our request to have MMH services extended to the ED. Initially we told the LGU, as well as Access, we knew patients were being discharged same day from the 9.39 because, in some cases, those patients were leaving the 9.39 and coming directly back to our ED or would be back within 24–48 hours despite a "treatment plan" stating they were connected to services. We knew by the number of presentations patients may also be unsure or not want to connect to the agency they were referred to or had been lost to follow–up. We believed if there was a presence in our ED to manage these folks on arrival, there would be more success in understanding why they had not connected to a service provider and in ensuring a connection from the ED. The MMH team also follow the patients until the engagement with the identified community service provider has occurred to ensure the warm handoff, further lowering the possibility of a patients return to the ED for unmet behavioral health needs. As we researched, we could not find programs that existed in this format. Most programs had a model whereby the hospital paid for mental health services in an employment model, which we dare say does not have the same outcomes as the model we have created.

Since that time, our evidence has proven that MMH presence in an ED prevents unnecessary transfers to 9.39 centers, in our case by 64% over the last 4 years, cuts the overall cost of care for this population by approximately and conservatively $487K dollars and reduces overall recidivism to the ED, currently less than 4%.

Because of this program, another innovative program being submitted by our partners is the 24/7 addition of six care management agencies in our ED. By allowing these agencies into our ED, they are able to connect with patients that are lost to follow up or are newly entering the system that have one or more unaddressed Social Determinants of Health (SDH) need. As such, we are able to connect them to needed services, improve their quality of life, reduce presentations to the ED and other settings which ultimately provides better outcomes, while reducing the total cost of care for this population.

Relevance to the Medicaid population:
To date, the Medicaid population remains the highest percentage of utilization at 54%, followed by Commercial at 23% and the remainder Medicare and Self Pay. Issues surrounding the five major SDH play a factor into most of the presentations along with either chronic or an acute behavioral health issue without the necessary coping mechanisms, skill set or support services.

Speed to market:
As previously stated, our program took approximately eight months to implement, however, as we would be willing to share the program Policy and Procedures, MOU´s and Education Plans, this program could be implemented very quickly, within 90 days.

It should be noted that not every County uses funding to support a MMH program, however, a closer look at how current County funded programs are impacting the population, specifically the Medicaid population. This may help to reallocate funds where impacts were less than anticipated. It was eye opening for Access to see the number of patients that either they themselves as a Care Management Agency (CMA) could find who were previously lost to follow–up or were able to connect back to another CMA. As we have proved in our program, the resources dedicated to MMH and now having them co–located in our ED, as well as still accessible to the broader geography, has impacted our community in a way that would not have been possible without the collaboration of all three organizations. The commitment of our LGU Commissioner of Mental Health to allow Access to service the ED cannot be underscored.

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):

The MMH program being in mid–October of 2013. Eight months of discussion, planning and training prepared both sides for the program´s operation. The current process for behavioral health patients determined to have a need beyond the scope of the ED is for an evaluation by the MMH team. Patients are assessed and a determination to discharge them with a connection to the community services or transfer them to a 9.39 facility for potential admission, is made in collaboration with a mental health professional, and ED provider. Prior to the program´s inception, all patients presenting with a behavioral health issue beyond the capabilities of the ED setting were sent for evaluation. Patients are connected to services and followed up on in the community by the MMH team or by the service(s) for which they were referred to.

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