Millennium Collaborative Care has been proud to extend Delivery Service Incentive Payment Program support, including Innovation Fund support, to innovative initiatives under the leadership of Sheila Kee, Executive Vice President and Chief Operating Officer, that are currently addressing social determinants of health and improving the delivery of healthcare for patients at Niagara Falls Memorial Medical Center in Niagara Falls, NY. Recently, NFMMC team members shared insights on Millennium’s website into their daily efforts to provide compassionate, comprehensive care, and truly make a major difference in their patients’ lives.

NFMMC ER Emerging Hot Spotters Program: ‘Wrapping in Compassionate, Comprehensive Care’

By Jenna Genova, SW, Emergency Department Social Work

Throughout my time in the role of an Emergency Department social worker with the population of “emerging hot-spotters” I’ve had an opportunity to meet people of all different socio economic status with all different reasons to present to the ED.

An emerging hot-spotter can be described as a high utilizer in the emergency department with three to nine visits in a four month prior. Though these people originally present seeking help from the interdisciplinary staff, they ultimately require the touch and discharge plan from a social worker to ensure both safety and empathy for their present social issue that exacerbates a chronic medical condition.

When we think of having to come to the ER, one would imagine someone experiencing an emergent crisis requiring prompt medical attention. For some, coming to the ER may be their first opportunity for positive social interaction, a free meal and safety. I can specifically recall a time meeting with a patient who presented to ED for “general malaise”. This patient had a primary care doctor that he had been neglecting seeing. He was asking for a free sandwich and after receiving an alert for his multiple visits to ED, I was given the opportunity to intervene, educate and link him to local resources.

After talking with this patient extensively, at first, he was apprehensive to share the root cause of the visit and discussed some of his medical diagnoses instead and his health challenges at present. While providing empathy and building rapport with this patient about his medical history he started to divulge about his son’s recent overdose leading to son being intubated and this patient, being his health-care proxy, was responsible to make the decision to extubate him and have him pass peacefully as there were weeks of no improvement.

This patient became tearful in the ER and discussed having no one to talk to, to guide him through this situation and provide him with education, resources and support and therefore, has not been physically caring for himself properly.

I was able to link this patient to outpatient mental health counseling, arrange for a sooner follow up primary care appointment and give him my card to call me should he need support (and he has on multiple occasions seeking encouragement and a lending ear).

What is important to note is that although people present to ED requesting medical treatment, often the root of their visit stems from their need for a social worker to reduce the likelihood of a return for social barriers by wrapping them in as many services as possible to help their everyday living in their community.


NFMMC Medication Adherence Program: Building Up Trust, Breaking Down Stigma

By Emily Buzzard, MSW, Medication Adherence Coordinator

Throughout my time working in the Medication Adherence Coordinator position, there have been many eye-opening experiences and key opportunities to help individuals in the community reach their wellness goals.

However, one encounter in particular really speaks to the difficulties and the circumstances in which many individuals who are non-compliant fall within. Below is a vignette that describes this encounter and the successes that came about because of this program. All names have been changed to respect and maintain the confidentiality of the individuals mentioned.

Sally (patient) is a 46-year-old woman that the Medication Adherence Coordinator reached out to over the phone in June 2019 to offer services and assistance with medication difficulties. Sally did not answer at first but returned the Medication Adherence Coordinator’s call. The first thing she stated was, “I can’t believe I’m calling you back, I have so much social anxiety. But I really need help and I think you can help me”. Sally was ready to make a change and was agreeable to meeting to talk about her experiences with other healthcare providers well as her current challenges.

When the meeting took place, Sally expressed that she was disappointed with her previous professional supports and felt as if she was let down. Sally shared that due to her past of substance use, she felt judged and stigmatized by her peers and professionals in the field.

Through conversation, listening, and validating Sally’s feelings, a relationship of trust began to build, and Sally stated that she felt comfortable engaging with services again to help her get where she wants to be. Sally agreed to enroll in our Health Home Program as well as continue to engage with the Medication Adherence Coordinator for support and discuss questions that she may have about medication. The Medication Adherence Coordinator provided education to Sally on her pharmacy’s delivery program as well as their medication fill reminder program. They also provided

Sally with support and helped her schedule a cab for her upcoming appointment so that she would not have to miss it for a second time. Sally shared how happy she was to learn that there were people there to help her and that she was not alone.

Since this meeting, Sally has been open and actively communicating with the Medication Adherence Coordinator about her progress and utilizing the program as a support for her when she feels stuck. This program has encouraged this individual to engage in services again and slowly break down the stigma of substance use and mental health. Only time can tell what other successes will come along as this program and its members continue to outreach, empower, and support these individuals in our community in reaching their wellness goals.


NFMMC Home Visit Program: Meeting People ‘Where They Are’

By Chenelle Cruz LMSW, Mental Health Therapist

When I began home visits in July of 2018, I was eager to go to the client’s homes and get a better understanding of who they were and really see their environment rather than a professional setting.

Meeting them on their turf, in their personal space, a place they called home, where they found comfort. or so I thought. I quickly learned how important building a rapport with the client would be. Home Visits also allowed me to better link them to services that may have been missed or unnoticed while in the hospital. I needed to show them that I was not the stigmatized “white coat” there to judge them or criticize them. I wanted them to feel comfortable with me and be able to not only let me in to their homes but most importantly for them to open up to me about more personal subjects; their mental health.

Providing the clients with a free meal was a great way of “breaking bread”, building a relationship with the client thus reducing suspiciousness and increasing trust. Home visits bridge the gap between the Inpatient and Outpatient units, allowing a strong continuum of care.

Home visits allow us to meet the client where they are at. Both literally and figuratively. I have met clients at the bus terminal, grocery store, client’s employment, and in my vehicle. Often clients are homeless and struggle to find a warm safe meeting place during the cold winter months. Agreeing to meet them where they are shows the clients that we are working towards their best interest and we can accommodate to their needs, thus building a strong rapport in hopes of better continuum of care.

While in the home I was able to see what some of the real barriers to care were. I was able to get a firsthand view of the clients living situation (the neighborhood, overcrowding, presence or absence of food in the cupboards, medication, supplies, hygiene), and a sense of their organizational abilities.

I quickly learned one huge barrier to their care was medication adherence. I was able to see the piles of medication that they would sift through, some outdated, some new and the majority of clients did not know what the medication was for. Leaving them struggling with the same symptoms they were seen and treated while they were Inpatient. Creating a revolving door of care.
Another barrier that I saw was situational depression.

Many of the clients we met with struggled with adequate housing. I made home visits in communities that were predominantly low income, subsidy housing. While on a home visit we presented to a home of a young women who lived in a basement that appeared to be added to an apt complex. Low ceiling, poor upkeep, and crumbling foundation and walls.While in the home the client presented appreciative and engaged with our visit. Her apartment was her home, candles lit, and clean to the best of her ability, however appeared to have dirt floor.

The client was grateful for the free meal and discussed barriers to her mental health such as situational depression and anxiety that has led her to ongoing suicidal thoughts and prior inpatient visits. We were able to gain a better understanding of her depression and were able to link her with follow up mental health appointment. Going on these home visits showed me a different perspective to the clients we treat daily lives. Living in housing such as this created even more depression and anxiety for them.
Lastly, the home visits showed me that you never truly get a good understanding of our clients until you meet them in their environment. You see their living arrangements. I understand why many of them seek inpatient services so often. There are many benefits of the home visits. Being an extra pair of eyes and being able to help another person who is in need.


NFMMC Medication Adherence Program: Listening to Understand; Reaching Out to Help

By Cearrah Rickard, NFMMC Health Home

The following are a few stories of patients that have been touched by the Medication Adherence project. Their names have been changed to respect their privacy.

The first patient discussed is one who seems to be on the journey to success. Mary F. is a 55-year-old black woman that showed up on the New York State Psyches list. She first met with the Medication Adherence Team on May 16, 2019, the hope being that helping her return to counseling would aid her in resuming her necessary medications. This patient was very welcoming and kind, opening her home with no hesitation for this meeting. She spoke of her love to cook and how she often ran low on food due to her feeding the neighborhood. Through the conversation the smell of alcohol was present on Mary’s breath and several empty cans were noticed on her end table. After a bit of lighthearted talking, Mary began to discuss her current needs. She spoke of needing help to find mental health counseling and trying to find a rehab center to stay in.

At this point, the patient was given information on the hospital’s Health Home. She was excited and wanted to sign up, so she was enrolled during that meeting. The Medication Adherence Team scheduled an appointment for her to start counseling and also scheduled transportation. Later, it was found that the patient was already linked with another health home and a care manager. The care manger provided the information that the client gets very forgetful when drunk and will “go with the flow” of whatever is going on around her to conceal her state.

The care manager also stated that the patient has been given all the necessary information about rehabs but Mary always refuses to go when the time comes. While she has not accepted rehab yet, Mary has made it to both of her mental health screenings and gotten to meet the psychiatrist. She was started on a new medication regimen which she has gotten the first fill for. The Medication Adherence Team has met with her since and followed up over the phone, the patient has several upcoming appointments for counseling and plans on attending them.

The next patient is one that has a long history of non-adherence to his medications. Greg R. is a 26-year-old white male fighting his schizophrenia diagnosis. Greg met with the medication adherence team during his latest inpatient stay on the NFMMC behavioral health unit.

Upon meeting him, he spoke of his counselor and how she was a great asset. However, when it came to his psychiatrist, he felt as though the man did not listen to him and only wanted to get him on more medications. Greg admitted that even though he was taking his medications while inpatient he would not continue once he was released.

This patient is completely in the mindset that his diagnosis is wrong, and that anxiety is the only thing wrong with him. He blames his hallucinations on lack of sleep and the lack of sleep is due to anxiety. Similarly, in his mind every symptom he has can be traced back to anxiety. The medication adherence team has reached out to his counselor and advised the client that starting with a new psychiatrist may be ideal.

While it may be the case that this a new doctor will diagnose him the same way, having him stay with someone he thinks is against him will negatively impact his journey. The team is still working with Greg to help him get on track with the right providers and to help him stay positive when it comes to reaching out and getting more help.


NFMMC No Diabetes and Cardiovascular Disease Screening Project: Reaching Out, Lending a Hand Up

By Paul Ketterer, DSRIP Mental Health Screening Coordinator

The DSRIP No Diabetes and Cardiovascular Disease Screening Project on the surface, appears to be a fairly simple and straightforward project of having people just complete some lab work and have them follow-up with their primary care doctor regarding the results. However, after building the project from the ground up, we’ve realized that in completing this lab screening, the overall patient experience has caused many compound effects to happen both within and outside of the hospital.

In regard to completing the actual screen, the patient receives psychoeducation about what the test is and why it can help them, as well as having a goal to build on for their next point of contact to continue to address their overall health.

That next point of contact is with their primary care provider and/or psychiatrist to discuss the lab work results. With the information received about the screening, it is the goal to have the patient better understand their mental health and how addressing physical health concurrently can potentially improve treatment outcomes due to the connectedness of mental and physical health.

Additionally, with my clinical background as a substance use counselor for the past five, I have the ability to add another layer of understanding for the patient by providing additional information on how substance use can further exacerbate any mental and physical health conditions.

Additionally, a major part of recovery as it pertains to mental health, physical health and substance use, is the added component of the impact on family. By allowing family to accompany the patient to the lab, when information is presented to the patient about the screening and the recommended follow-up, an added layer of responsibility and support is added to the patient’s recovery process.

Helping the patient obtain information about the impact of their physical and mental health on their family/loved ones, can help provide more incentive for patient to stick to addressing their overall health. Family relationships can also improve due to the family support being more cognizant of the patient’s discharge plans, as well as, the family gaining an understanding and/or asking questions they may have previously been afraid to ask.

There have been several examples of how the screening project has had a positive impact on family relationships. One example was when my van driver and I completed a home visit, the patient was not home, but her mother answered. It was identified that the patient suddenly moved to Arizona and left her mom with her child, as the patient returned to a domestic violent relationship, abandoning her family responsibilities.

With the help from my van driver, we were able to normalize and validate the mother’s experience, provide emotional support and psychoeducation to resources available. I was also able to leave my contact info for if and/or when the patient returned home, to help them re-link with services. The mother expressed a deep amount of gratitude for us just showing up and thanked us for just being people who listened in that moment.

Later, the patient did return home and called to relink with services and to complete screening.
Another example of how the screening project turned out to be more than just completing lab work, was an example of picking up the patient to complete lab work from their home.

At the home visit, the patient did not appear to be doing well. In asking how the patient was doing, the patient had self-disclosed a suicide attempt from the night before and present ideations and desires to act upon these thoughts to harm himself again. Due to clinical experience, I was able to assess the need to bring the patient to emergency room for a psychological evaluation where he was later re-admitted to inpatient behavior health unit.

After his discharge from our inpatient behavioral health unit, he called and thanked me for helping him in that situation, as he was not sure what would’ve happened if I did not pick him up that day. He had identified improved and increased communication with his family and significant other as a result of returning to inpatient behavioral health and addressing some lingering internal issues and feeling a little more comfortable to talk about those issues when he returned home.

One last example was another home visit where the patient was not home, but, his 20-something-year-old daughter was. She stated we would not likely be able to find her father due to recent alcohol relapse. She presented as distraught and anxious and began to justify his negative actions towards her as a result of the relapse.

My van driver and I were able to provide support and information about AL-Anon, the support group for family members of alcoholics. The daughter was extremely grateful as she didn’t know there was support available to her and a sense of relief appeared to come over her, knowing she didn’t need to tackle this problem alone anymore. There have been many more examples of how the project appeared to impact both patient and family life but those were three that stuck out as most impactful.

Lastly, this project has had the compound effect of building a network out in the community as well as within the hospital where many disciplines are asked to work together to have the patient complete the screening.

The project has made it necessary, that in order to have the patient complete the screening, one has to navigate and connect the many disciplines of the hospital/community including some of the following; emergency department, primary care, health homes, inpatient and outpatient behavioral health, OB/GYN, registration/admissions, Quest labs, other primary care physicians as well as, the lab technicians at the lab.

It took many hours of networking and relationship building to help turn an idea for a project, into a complex but smooth operation where every part of the team is aware of their job duty in helping the patient complete the screening.

The project has been a huge benefit to the hospital staff in providing education on the screening itself (how and why needed) as well as the role of Mental/Physical Health on family. This has allowed many members of NFMMC staff and community to gain further insight on how to provide the best healthcare available to the community and our patients.


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