William F. Ryan Community Health Center 110 West 97 th street New York, NY Eishelle Tillery, MSW Nancy Andino, LCSW www. Ryancenter.org

Objectives List 3 important characteristics of a successful Supportive Case Management Program Identify 3 important characteristics of a patient in need of Supportive Case Management. (SCM) Identify coordinating strategies used by SCM in our renewed health care system that integrates the work of Social services and clinical providers as a team to meet patient needs. Identify two aspects of supervision necessary to SCM that facilitates patient change and satisfaction

Map of Service Area

William F. Ryan Network  Four main sites, 6 School based, 4 Shelters and the Women and Children’s Center  2011 Network served 49,192 patients  Race: 74% minority Sex: 58% F  Insurance: 27% uninsured & 67% public insurance  Homeless: 2,645 (5%)  Age: 34% pediatric patients, 57% adult, 10% 65+

HIV/AIDS Spectrum of Services Medical Mobile Van Electronic Medical Record Mental Health Counseling Harm Reduction Services Prevention Education and Outreach Confidential HIV Counseling and Testing Primary Health Care Treatment Education/ Adherence Medical Case Management HIV Specialty Care Hepatitis C Treatment

ProgramSCM Skills Health Care DisparitiesAdvocates Support and GuidanceCulturally Sensitive / Interpersonal Skills/Awareness of Services EducationOngoing Training Coordinated CareHealth Care/ Community Knowledge Health and Social Barriers Problem Solving Skills Empower others

William F. Ryan Supportive Services Programs Women In Care Program- Provides support to HIV Positive women i.e. advocacy, escort, financial assistance and referrals. Harm Reduction Program- For HIV positive Men and Women who are currently active substance abusers who wish to change their behavior. AIDS Institute Support Case Management- Advocacy, escort, referrals, home visits etc. Ryan White Part C Supportive Case Management- support services that are not covered by other CM grant programs.

SCM and the Community Connection Patient assessed needs SCM are Directly linked to community resources. Communication, Relationships, SCM style & knowledge of resources results in patient positive results. Cultural awareness allows for appropriate referrals.

Supervision Coordination of Care Adequate Supervision eliminates role confusion Strength based supervision/ Effective Trainings Pt’s share different information with Different providers. Case Conferencing also informed patient can participate in a collaborative model resulting in appropriate services and referrals. COORDINATION between SCM, Community and clinical provider.

Patient Example  Maria has a diagnosis of HIV, Diabetes, Hypertension.  Unstable diabetes and hypertension, stable HIV  DV in the household.  No health coverage, no collateral agencies  Medical provider is not aware of patient’s home situation and or home environment or lack of health coverage.

SCM Strategies for Coordination  Patients will have assistance with achieving their health goals by overcoming barriers.  Practitioners will have knowledge of patient’s barriers prior to treating patient & work that SCM is doing.  Practitioners will treat a well informed patient ready to collaborate b/c SCM has made appropriate referrals.  Decrease duplication of services.  The SCM becomes the Coordinator in coordinated care.

William F. Ryan Community Health Network www. Ryancenter.org Thank You