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


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.
Sincerest thanks to NFMMC team members for sharing insights into their daily efforts to provide compassionate, comprehensive care, and truly make a major difference in their patients’ lives.


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 regards 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 years, 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 the 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 twenty-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.

Paul Ketterer stands in front of the waterfall display in the NFMMC Welcome area.  Paul joined NFMMC in January as DSRIP Mental Health Screening Coordinator. His prior experience includes Addictions/Family Counselor at Horizon Health Services; and Addictions Counselor at Northpointe Council Inc. He holds three degrees from the University at Buffalo including Master of Science,  Vocational + Rehabilitation Counseling; Master of Science, Mental Health Counseling; and Bachelor of Science, Psychology.



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