Pre-Work Clinical Changes: What Clinical Practices Have You Changed Or Expanded in the Last Six Months? Provide 2 examples

Citizen Advocates, Inc. Clinical Changes: What Clinical Practices Have You Changed Or Expanded in the Last Six Months? Increased information sharing between primary care practitioner and therapist (integrate, not co-locate) Follow up screenings and outreach for high risk patients who initially refused BH care. Sharing of EMR (access/messaging) Designated Customer support staff for data entry, PC communication and documentation sharing Use Your Champions! Nurse Bonnie helping to incorporate flow, screening and follow-up process at other sites.

Liberty Resources, Inc. Over the past nine months we have implemented the following clinical practices and operating efficiencies: Centralized Scheduling – expanding to all therapists Same Day Access – children/adults every weekday Just in Time Prescribing Eliminated bridge scripts but provided walk in hours Health Physicals and Health Monitoring for Article 31 clients Created workflows and templates to reduce time and improve the client experience Researching and selecting a Primary Care EMR

Odyssey House Clinical Changes: What Clinical Practices Have You Changed Or Expanded in the Last Six Months? Screening Existing Clients Identify at-risk clients Referral to treatment Expansion to Younger Adult Cohort Age range Provides greater reach Daily visit goal Warm hand offs Assisting w/ engagement in additional services Example

Niagara Falls Clinical Changes: What Clinical Practices Have You Changed Or Expanded in the Last Six Months? We have added telephonic screening to our Care Management portion of treatment. This means for patients on antidepressants, whom do not want to take part in traditional counseling, we now can administer our behavioral health screens over the phone and provide treatment recommendations without the patient needing to be physically present. We are currently working on putting together a group therapy program. Each group will last from 4-6 sessions long and be focused on specific topics, including: Grief/Loss, Abuse, and relationship issues.

Central Nassau Clinical Changes:  What clinical practices have you changed or expanded in the last six months?  Provide 2 examples: First Example – improve at-risk BMI’s: New patients with at risk BMI’s are provided with counseling on ways to decrease at-risk behavior. Exercise, and nutritional counseling are discussed such as increase fiber, decease starches, soda, fried foods. Returning patients with continued at risk BMI’s are referred to a nutritional counselor or if morbidly obese, medication such as Metformin is considered/prescribed. April 30, 2015 data indicates 28 at-risk BMI individuals had valid follow-up.  Results showed count of  individuals with any improvement was 12 or 43%.  Count of individuals who improved risk categories was 1 or 4%

Central Nassau Clinical Changes:  What clinical practices have you changed or expanded in the last six months?  Provide 2 examples:   Second Example – improve no show rate: Increased warm hand-offs and ease of access – coordinator connecting patient appointments to same day appointments at Agency as much as possible; collaborative approach with MH Clinic; Agency Health Home Care Management; and other programs on all clients. Appointment reminder calls to clients made and reminder emails to staff Follow up calls to patients on their no-shows and tracking reasons why client did not come to appointment Major reason – cab company does not show to pick up client and weather. As of April 30, 2015, data indicates number of individuals at risk at 101.  42% showed at 3 months; 13% showed at 6 months and 6% showed at 9 months (Program began seeing patients 5/5/14.) 

Catholic Charities of Brooklyn and Queens We were lucky enough to begin with excellent clinicians. So the main clinical practice we’ve changed in the last six months is the administration of referrals, which clients have trouble handling themselves.

Glens Falls Hospital Clinical Changes: What Clinical Practices Have You Changed Or Expanded in the Last Six Months? Expanded BH screening to second PCP patient panel Launched integrated clinical social work services to compliment existing NPP services in PC office setting

JBFCS/Maimonides Clinical Changes Ongoing communication with staff generating more referrals for screenings. Participation in monthly meetings, trainings: morning “huddle” meetings. Maintaining very accessible/ open door policy.

JBFCS/Maimonides Examples: Due to participation in the morning huddle, we were referred clients that scored positive and we were able to identify and screen them and assess their needs and continue to monitor clients and provide f/u services. In addition, we were able to engage the nurses in the process of referring to us Clients that score positive on PHQ-2. MD referred a client due to declining cognitive functioning, confusion and lack of family support. SW was able to screen the client, reach out to the family to develop a plan of action, facilitate further assessment by a nurse in the home, provided education regarding nursing home placement and procedures. Help the family with the placement process. As a result, the client was successfully placed in a Nursing home, where he can receive the care he needs.

Equinox Clinical Changes Increased number of patients referred to specialty care Increased communication between providers