Behavioral Health Collaborative Care Model

Lead Organization

Central Nursing Services, Inc.

Joint Applicants

Somml Health

Rehabilitative Support Services Inc.

CPESN USA LLC

Areas Project Intends to Serve

Rensselear County, Albany County and Schenectady County

Overview

Our proposal would be to develop a Collaborative Care Model targeted at the Behavioral Health Population. Our goal is to develop a collaborative network that would provide behavioral health and medical management to homebound and clinic encounter behavioural health patients. The entities and description of the participants and applicant status are listed below:
Capital District Psychiatric Center-Outpatient clinic- this clinic serves Albany and Schenectady county. The clinic operates M-F 0830-5:00pm and services outpatients. The Director is amenable to collaborating referrals through a discharge process to Rehabilitative Support Services (RSS). The Clinic roughly serves 3000 clients per year.
Rensselaer County Mental Health- established mental health clinic that provides full behavioral health service line functions. A current agreement is in place with established referral process.

DSRIP Measures Addressed

  • Preventative Health
    • Primary Care Visit (Age 20-44)
    • Primary Care Visit (Age 45-64)
    • Primary Care Visit (Age 65+)
  • Behavioral Health
    • Antidepressant Medication Management – Acute
    • Antidepressant Medication Management – Continuation
    • Antipsychotic Med Users with Diabetes Screening
    • Cardiovascular Disease Schizophrenics with CVD Monitoring
    • Diabetic Schizophrenics with Diabetes Monitoring
    • Potentially Preventable Emergency Visit
    • Schizophrenics with Antipsychotic Medication Adherence
  • Avoidable Hospital Use
    • Potentially Preventable Admissions – Adult
    • Potentially Preventable Emergency Department Visits
    • Potentially Preventable Re-admissions