to provide home visits and accompaniment to follow-up appointments. More than 1,100 patient discharges were reached in 2017.
Health Information Exchange Expansion (Patricia Hernandez, LCSW; Manager: email@example.com): Through DSRIP, the Division has expanded its use of Health Information Exchange to support team-based care across the Hospital and the network of community-based collaborators. The Division has rolled out Healthix — a New York State-sponsored information exchange platform — to support the flow of information and patients across providers in New York City. Healthix utilization enhances access to patient records across health providers; improves receipt of clinical event notifications (targeted messages on patients’ use of emergency departments, inpatient facilities, and so forth); and improves community provider access to a patient’s health data from across New York State.
Behavioral Health Crisis Program (Brian Youngblood, LCSW; Manager: firstname.lastname@example.org): Supported by DSRIP funding and project management support, the Division launched a Behavioral Health Crisis (BH Crisis) Program featuring a telephonic screening and triage system known as the “HUB”; the Treat-Link-Connect (TLC) Brief Crisis Treatment program; a community-based Critical Time Intervention (CTI) team focusing on the most vulnerable patients with complicated medical, behavioral health, and social determinant needs; and embedded staff from community-based organizations, ACMH Inc., and The Bridge. The BH Crisis Program quickly identifies, assesses, and connects patients to a richer variety of wraparound services tailored to patients’ needs to reduce emergency department and inpatient admissions and increase community access to rapid mental health care, substance use services, “warm handoffs,” case management, and home-based and community care. The HUB provided services to nearly 500 patients in 2017, with nearly 100 receiving CTI services and 30% graduating with a strong system of care.