Arbour Counseling Services is participating in an innovative program with Neighborhood Health Plan (NHP) and Beacon Health Options (Beacon). NHP and Beacon launched Here-for-You, which aims to reach up to 10,000 NHP members suffering with serious and persistent mental illness, specifically psychotic or bipolar disorders.

Here-for-You provides care coordinators in community mental health and outpatient centers where these patients receive most of their care. Integrated teams target a patient’s most immediate and crucial needs, then customize a culturally and linguistically-appropriate treatment plan that links medical, community-based and behavioral health services. Depending upon patient resource utilization, patients are placed in different tiers of care coordination intensity to enable them to best achieve a positive outcome.

The goal of Here-for-You is to improve health outcomes and reduce emergency room and acute hospital admissions. This program improves the communication and coordination between behavioral and physical health care providers to ensure patients care is better integrated as they transition between different kinds of care.

In addition to funding and training care coordinators who will be employed by the community-based clinics, NHP and Beacon also provide technical assistance including making its team of registered nurses and nurse practitioners available to ensure those with serious mental issues also receive the primary care they need.

Arbour Counseling Services was one of the programs NHP and Beacon reached out to when they began implementation. According to Judith Merel, Regional Director, Business Development, Arbour Health System, “Many of the patients that Beacon identified who were in the high utilizer categories were affiliated with one of the thirteen Arbour Counseling Services (ACS) locations. NHP and Beacon wanted to include ACS in the initial phases including for program development as we have experience in community outreach for care management. ACS staff utilizes a strengths-based, individualized and person-centered approach, and has experience in community-based care coordination.”

Gina Desmond, Director, Community Services, ACS has led the “Here-for-You” effort including to assure staff training, communication with NHP/Beacon and patient engagement. ACS has enrolled 80 individuals who are current patients of ACS, Allston, or ACS, Woburn. Patients remain in the program until the goals of the care coordination plan have been reached or other transition of care criteria is met. According to Gina, “We are working with patients to assure compliance with treatment or assist with other needed social services. We want our patients to achieve goals at the lowest level of care possible. In addition, our skilled care coordinators are ensuring all medical providers work together so that all treatment, testing, and medications make sense for the individual. This new approach to health care could significantly improve the quality of life for those with the most need.”

 

From AHS News, March/April 2016