HEALTH CARE POLICY AND PRACTICE MEETING HIGHLIGHTS FEBRUARY 28, 2002

HEALTH CARE POLICY AND PRACTICE MEETING HIGHLIGHTS FEBRUARY 28, 2002

BETWEEN AGENCY AND COMMUNITY: WEAVING NETS UNDER THE CRACKS Innovative Social Work Roles in Health / Mental Health

Speakers:

Sandra Talavera, Coordinator, Senior Caring Program, Mount Sinai Hospital
Miguel Ortiz, Intensive Case Manager, Intensive Case Management Program, Federation Employment and Guidance Services
Judy Uman, Director, Social Work, Bronx Jewish Community Council

SPEAKER I: Sandra Talavera: I'm going to present the Senior Caring Program, the origins goals, objectives, present a case, briefly describe some qualitative, quantitative outcomes, challenges and opportunities encountered by the project.

In 1997, representatives from the Mount Sinai Department of Geriatrics, Community Medicine, The Union Settlement Association and The City University of New York initiated a community health organization for the elderly. In 1998 an assessment of the health and social service needs of the East Harlem elderly was conducted. The study found that self reported physical health responses were lower than national norms and social service gaps were identified. As a result, Mount Sinai planned the development of a two year pilot: Senior Caring. In order to formulate the goals and objectives of the program, a number of focus groups took place in East Harlem senior centers and subsequently, a large scale self-reporting health needs assessment was conducted by an independent consultant.Over 3,900 seniors in East Harlem were surveyed within two Housing Cooperatives and 16 New York City Housing Authority (NYCHA) complexes. The method for compiling the data was both congregate and door to door.

Mount Sinai's Senior Caring Planning Group is an inter-departmental effort represented by: Community Relations, Social Work, Gero - Psychiatry, Health Education, Primary Care and Program Planning. The goal of the program is to increase the quantitative and qualitative primary /geriatric care and impatient services in a culturally competent matter, based on a community based health care model for seniors 65 years and older. The Senior Caring team is comprised of a Board-Certified Geriatrician, an MSW Coordinator, Nurse, Health Educator, Social Worker and Outreach Worker. The team is fully bilingual and 3 out of the 5 members are residents of East Harlem. The program has 3 objectives:

Provide primary / geriatric care
Care Coordination for patients in the program
Ongoing Health Education for seniors in designated community sites

Since the primary outreach/marketing effort is through Health Education, the same will be described in some detail. Health presentations are conducted by the team Health Educator on a monthly basis in 2- Housing Cooperatives, 3- federally funded 202 senior housing, 1- Single Room Occupancy (SRO) building, and 8- senior centers within the East Harlem community. Before each health topic presentation, the team is introduced and the program explained. Sensitive to issues of cultural diversity, the team acknowledges some of these during the presentations: a) loyalty - to services, providers, products purchase; b) respect - of seniors' choice of providers; the team does not encouraged seniors to change their relationship with an existing provider if satisfied with the same; and c) choice- if senior does not have a relationship or is unhappy with their provider they may consider Senior Caring as an option. Another area stressed is to that Senior Caring is not an HMO and there is no formal sign up process.

The health educator develops curriculums, schedules presentations, identifies guest speakers, prepares and identifies bilingual hand-out materials, the latter being a challenge. Although the focus of the presentation is health promotion, playing an active role in the seniors primary care is always stressed. Seniors are encouraged to read the hand out materials, and use them as a basis for discussions with their primary care doctor and /or share with friends and family. When feasible, health screenings are part of the health education presentations, such as vision, memory, bone density or blood pressure. As part of health promotion, an exercise program was developed at the request of a senior group, a Walking and Tai-Chi Group. The community outreach worker works closely with the health educator. The Outreach Worker is at sites prior to the presentations, bringing event flyers, reminding the seniors of the presentations, special activities and serving as a liaison between the Senior Caring staff, and community organizations staff and seniors.

Seniors most likely to participate in the program are those with: a) history of good health but without a primary care provider ; b) unhappy with their current provider ; c) a provider close to where s/he worked prior to retirement, yet no longer feasible to travel due to ambulation limitations, memory loss, or fear of using mass transit. Access to the program is a simple process with the ability to schedule appointments relatively quickly. Appointments with the team Geriatrician are scheduled at a primary center convenient to the senior's residence. Patients receive a full physical and mini mental, and they are referred to Mount Sinai for specialty care and /or major diagnostic test. The team Geriatrician frequently refers patients for care coordination to the team Social Worker/Nurse. In the area of Social Work, the patient's receive assistance learning about and /or accessing community social services, medical services and receiving supportive counseling. In the area of nursing, vital signs, compliance with medications, clarifying diagnosis related information and nutritional counseling. Any new symtoms or side effects of new prescriptions are reported to the Geriatrician. Both Social Work and Nursing Care Coordination are provided through telephone and /or face to face contacts at the clinic or home via visits.

CASE STUDY

In order to "give a face" to the program, following is a case example of a senior who has gone through the various components of the program. Mrs. J. is a 69 year old, African American female; she is a retired licensed nurse practitioner who lives alone, and cares for a young grandchild. She was diagnosed with multiple myaloma. She's legally blind from glaucoma, has hyperthyroidism and history of hepatitis.

Ms. J. first attended a senior care presentation in April of 2000. She expressed an interest in the program and asked to be contacted. The Coordinator made the initial telephone contact in order to answer her questions and discuss issues of insurance. At that time, she was enrolled in an HMO for 20 years and was not happy; the Coordinator assisted her with dissenrollment . By the second appointment with the team Geriatrician, the patient was diagnosed with cancer. A troubling question posed by the patient was one the Coordinator could not answer "How is it possible that after 20 years of going for care elsewhere, after just two appointments with the Geriatrician I get this diagnosis? What happened? When did it (the cancer) happen?"

After seeing Mrs. J, the team Geriatrician assessed the need for Care Coordination, the team nurse made telephone, home visits, monitored her vital signs, provided information on her Hepatitis C , and reported back all information to the Geriatrician. The team Social Worker made phone and home visits in order to conduct a psychosocial assessment and provide emotional support. The team Social Worker communicated with the Inpatient Social Worker, to inform of the community relationship with the senior and ensure communication of senior's functional limitations (legally blind due to glaucoma); impact of traveling to hospital for treatment and concerns about the treatment cost implications. During hospitalization the inpatient Social Worker processed a request for a transportation voucher through Cancer Care and referred the patient to the Safety Net program in order to assist with the high cost of treatment.

Once back home on two occasions she burned her food, because as a result of her treatment the patient lost her sense of smell. The team Social Worker referred Mrs. J. to a community based Meals-on-Wheels program. Referrals were made to Cancer Care for a telephone support group; the Guild for the Blind for special equipment and training (providing patient with a special cane and binoculars designed to assisted with crossing the street); and to Access-A-Ride for long-term transportation needs, which patient still uses.

To date, the patient is receiving primary care and specialty care at Mount Sinai and continues to live independently in her home. She is currently not receiving treatment; the patient continues to receive Meals-on-Wheels, uses Access-A-Ride, which allows the patient not to worry about crossing the street since it is very difficult to see the traffic lights. Senior Caring facilitated the access to quality medical care, care coordination, community, and social services, health promotion and emotional support which enabled the senior to remain safely within the community. The senior has been an inspiration to all of us, seeing her participate in the walking group or meeting her in the community. It is rewarding to see that Mrs. C is still with us.

CURRENT STATUS: In 2001, the program made approximately 5,000 community contacts through the provision of community outreach, health education, primary care, and care coordination. Through care coordination, the program assisted seniors in receiving psychiatric services, increased home care hours, Medicaid, Meals-on-Wheels, transportation, friendly visiting. Over 1,300 telephone and face to face contacts were made by the team Social Worker and Nurse. Through the Health Education program, the institution's visibility has been enhanced; the institution's efforts at serving the community have been recognized and acknowledged by key senior activists.

For those in the audience who work with seniors, you know how critical the opinion of a senior activist can be. We recently had an 87 year old senior who had been coming to our presentations for the past year , approach us after a health education to say, "I've been going to upper Manhattan because I used to work there, but it is little bit difficult for me to take those 2 buses, I would like for you to take care of me." The senior was given a scheduled appointment and now only walks 3 blocks to receive her primary care and states she is "very, very happy".

Some of the challenges have been those seniors enrolled in HMO's, those with limited income; seniors with no supportive services such as home care or family/significant other and with cognitive impairment. Seniors in some of these or all these categories are the most challenging to help gain access to services, and are usually the ones in greatest need. The institutions fiscal constraints has been another challenge, assessing the ability to sustain a new program during a period of fiscal crisis.

There are many opportunities, based on census projections, particularly within diverse groups, for facilitating access to primary care services and enhancing the quality of life of those seniors enrolled in our program. The increased program awareness by staff of community based organizations, seniors and relatives enhances the possibility of meeting future service demands.

To conclude, the Senior Caring Team feels very strongly that the program has been able to enhance the quality of life of many seniors in East Harlem by facilitating access to services. The team has been challenged and rewarded through the ability to work and provide services within the dynamic community of East Harlem.

SPEAKER II: Miguel Ortiz, Intensive Case Manager, FEGS:

As an intensive case manager at FEGS program in Brooklyn, I currently coordinate services for people who are diagnosed with mental disabilities and also receive a court order for treatment, due to their violence history, lack of compliance, psychiatric treatment, or medication non-compliance. This program is known as Assisted Out Patient treatment, AOT. The ICM program at FEGS is client centered, it's for the need of the client. The purpose is to provide the clients with continuing care and also pay attention to community safety. Tragedies within the community have highlighted gaps within the mental health field. The system has failed to engage the client population that traditionally is marginalized and oppressed. When the issue becomes political, lawmakers begin to invest. This has changed the nature of case management because it is responding to incidents that are political and place the community at risk.

In August 1999, Gov. George Pataki signed legislation known as Kendra's law also known as AOT. Case managers were hired to monitor clients within the community. There are 5 in the 5 boroughs and different hospitals run them. It is coordinated by the team and includes outpatient treatment, psychiatric services, individual group therapy, IPRT, medication, substance abuse counseling and treatment, education and vocational activities, urine tests for those who are MICA mandated for treatment under a court order for 6 months. For the client to be eligible for an ICM program, the individual has to have severe mental disability and be 18 and up, have had a psychiatric hospitalization within one year, or 3 psychiatric hospitalizations within 2 years, have ongoing symptoms which are difficult to treat in existing mental health care systems, or need support to maintain the treatment connection.

I took the time to profile my caseload, and it was pretty interesting to do that. In terms of race, in my caseload, whites are 4-6%, African Americans are 23%, Latinos are 30%. In terms of gender, I have more males in my caseload (84%) compared to females (15%). In terms of sexual orientation, clients who identify themselves as heterosexuals are 76%, bisexual 15%, homosexual 7%. In terms of family class, we have 38% working class. In terms of living arrangements, those who are living independent on their own in their own apartment in the community is 7%. Those who are residing with family members is 38%. And those in residential communities are 15%. Unfortunately, those who happen to be homeless in my caseload are 23%. And in terms of criminal history, those who have been arrested or have a history of being incarcerated is 76%, which is congruent to those who are mandated for treatment, also 76%.

The challenge is huge. We deal with the most marginalized clients in terms of the system. And I think the problem that ICM faces is not the clients, but rather the providers. Often times the residential facilities are pretty rigid in terms of what type of clients they will accept--the best clients. Those who come through our door who are mandated definitely are not those wanted by most facilities. So the level of advocacy is really strong. We also have to work to engage the client. The client has lost a sense of hope; they don't trust anyone at all when they come to me. These clients are emotionally and cognitively impaired, and the ICM's use the "strength's perspective in assessing client functioning. In the first 15 days that the ICM meets the client, we have to do a 15-day function assessment; it's a state requirement. The assessment itself is based on the strengths model. We establish a rapport with the client and support the client's abilities, not disabilities. In working with the MICA patients, the relationship is the most essential core of the treatment. Steps often taken with ICM clients are often around harm reduction, how to obtain treatment with a sense of hope. We have to be aware of our countertransference as workers, and document all client activities in context. Clients often use substances because they are socially isolated.

After the 15 day assessment plan, we have to create a treatment plan The plan always starts with the client and the ICM worker. And the client must work with you- who's going to do what? We have been able to identify, together with the client, not only their needs, but their abilities, deficits, and barriers in the system. Through the treatment plan, we involve the providers for additional monitoring and support. Also, part of the ICM goal is to link them with natural resources. What are some of the social resources within the community? Family members? The church? Significant others? Boyfriends, girlfriends, kids, siblings? The goal is to form a support system for the individual. We try to use those social community connections because that's where the client lives. We also look to reinforce positive identities for the clients. Resources should adapt to the clients needs.

That's what we're faced with. You have a system program, a MICA facility for example, that won't take a client who is on methadone. That's a contradiction. Substance abuse is a medical problem, but the program will take some one with diabetes. So we try to make those arguments all the time, that this is a medical condition and they should take this client.

Sometimes we are successful, sometimes we aren't. I find my strongest leverage in terms of advocating for my client is that we do have service dollars, so we do try and help pay for medication for a client who is waiting for his Medicaid or who needs to wait another year to get his Medicaid insurance card. So we'll use these dollars to buy the medication for the client. We will also use persuasion.

Case conferences can be very helpful. Sometimes providers will say, "We can't take this client because he's very aggressive," so we sit there and we explain what that means to the individual who is aggressive. They live a very difficult life; they don't trust any one, they're very hostile. They will walk out of the meeting if they think you don't trust them either. ICM's do have the leverage of power. We have information power- the more you know the stronger you are as an ICM worker. We have the personal power to work with the client and the provider. We can exercise "power" on behalf of FEGS and on behalf of the Office of Mental Health. And also, we have reward power, again around the service dollar. We create some contracts with clients helping them to create and then fulfill their needs through the service dollars. And unfortunately we also have negative power; we can hold back information if we need to, which can be counterproductive.

I believe in educating my client as much as I can. Psychiatrists don't always think that's the best approach, but I think you have to do that. It's their right to know what's going on. And as an ICM, you have to know where the point of entry into an organization and how to navigate the system. We are the watchdogs of the system. We know what's going on, we visit, we're in their faces. So we're very critical of what's going on, but we have to be very diligent in how we work with other people in order to create partnerships. Often times the problem can be within the clients themselves; maybe they're not stable enough, so we definitely have to take that into consideration. And again, providers can be very rigid. Insufficient resources limit the system as well. And then you have to deal with larger systems problems-- sometimes you need to speak about institutional racism, sexism, classism, and homophobia.

And as an ICM, you have to be aware that your client population is very, very diverse. You have to look at what's impacting this individual. I talk about that with some of the directors and supervisors and managers. The clients that are in our program do have difficulty navigating through the mental health system, and ICM's respond to the social and economic contraints that clients experience on a daily basis. This approach helps me to provide the client and ICM programs with both quality and quantity of services simultaneously. You have to help the client gain his voice, and acknowledge that poverty is a stressor for the individual. The ICM's have to be proactive. You always update your supervisor when you are in the field, in terms of safety measures. We meet the client in a safe environment- it can be in a pizza shop; it doesn't have to be in the home of the patient. We do have cell phones and beepers for safety measures. We also promote the strength of the client by asking them to be very involved; and to also continue to revisit the treatment plan if it's not working. We don't underestimate client's violence history.

Staff should always be able to be emotional and be vulnerable to clients when they want to be emotional, and have empathetic abilities in being hopeful, being kind, validating the client's experience, being non judgmental, and accepting what the client has to say. We also listen to what they have to say in terms of their culture and spiritual background. Sometimes you may have a client who talks about seeing spirits or praying to spirits or to their ancestors, and the psychiatrist quickly runs out and increases the dosage. This may be something that may just be part of their culture, and we have to take that into consideration. And as a person of color, I definitely do advocate and listen to what the client has to say, and how they control some of these issues they talk about. Is the spirit really impacting their body? Can they function? What does that mean for them? And we do promote people to be who they are overall, and definitely support them in that?

SPEAKER III: Judy Uman, Director, Social Work, Bronx Jewish Community Council

Good evening, first I would like to present a brief history of the Bronx Jewish Community Council. In 1972, our agency, along with other "ethnic" organizations were funded by HRA at the request of Mayor John Lindsay. Our original mission was to work with the Jewish community that remained in the Southwest Bronx along the Grand Concourse. I came to work for BJCC 17 years ago. During this time the funds from HRA have been funneled into the budget of the Department for the Aging and we are now a borough-wide organization with a client base that reflects the demographics of the Bronx. We are unique among DFTA agencies because our contracts still allow us to serve persons under the age of 60. BJCC also receives direct philanthropic grants from the United Jewish Appeal and the agency's housing component receives money from HPD.

We are a client centered, community service organization working hand in hand with other service providers. We participate in 4 NORC's ("naturally occurring retirement community"); located in COOP-City, the Amalgamated, Parkchester, and Pelham Parkway Houses. NORC's occur in communities where people moved into a housing complex when they were young, and have continued to live there. They have, Aged-In-Place, and the community is designated a NORC because a certain percentage of the population is over the age of 60. Contracts to provide social services are awarded by the Department for the Aging and require partnering of community agencies. For example, in the Amalgamated Houses, we work jointly with Jewish Home and Hospital, the tenants and the Management. There is a nurse from Jewish Home, and social services as well as health related activities are provided at a local senior center and from a BJCC office within the Amalgamated complex. In Parkchester, we supervise the NORC services although the direct providers are Beth Abraham Health Services and JASA.

Our housing component has offices in both the South Bronx and the North West Bronx and its staff works with both tenants and landlords. We assist landlords in obtaining building loans, and we help tenants to obtain senior entitlements, maintain tenant owned buildings, prevent unwarranted evictions, and by advocating with landlords to assure that repairs are made in a timely and appropriate fashion. BJCC also has a separate Medicaid Home Attendant program. We have walk-in social service sites in Co-Op City, the South Bronx, the Northwest Bronx near Montefiore Hospital, and the Pelham Parkway area. We are spread throughout the borough and have become the eyes and ears for frail and needy Bronx residents, as we seek to insure their health and safety.

Referrals come to our office from many places. We get referrals from senior centers, hospital emergency rooms, landlords, merchants, banks, etc. BJCC Staff might be called several times a week from various Bronx hospitals as social workers attempt to discharge seniors who are a bit confused and might be without caregivers in the community. We get phone calls from neighbors, we get phone calls from banks, we get phone calls from the local drug store pharmacist who tells us about," this little lady who can't come down and get her medication any more. Do you think you could send somebody up to her house to see how she is doing?" We will then send a social worker to the apartment to assess the home situation and devise an appropriate client centered plan to enable this person to remain safely at home as long as possible. If we are unable to provide sufficient community care and additional assistance is required we will make a referral to Adult Protective Services for more intensive case management services.

We often get referrals from elected officials. This goes two ways, because we feel free to contact these same elected officials when we're having trouble with the Social Security Administration or when we need somebody to help one of our clients who might have a problem with his or her immigration status, or the way that person is being treated at a Public Assistance office. The Bronx District Attorney recently initiated an innovative program focusing on elder abuse. A skilled geriatric social worker was hired to work with the police and the DAs to increase their understanding of this population and to add to their awareness of the assistance provided by the social service community in the borough. We have established a very close working relationship with this team and if we see something that seems like exploitation or neglect we are able to immediately assess their assistance, and the team now feels comfortable in making referrals to our staff.

We also work very closely with the CHHA's (Certified Home Health Care Agencies) throughout the borough. They call us up when they can only work for two or three weeks with somebody who has recently been discharged from the hospital and there is concern about the person's ability to maintain his/her activities of daily living without on-going help. Unfortunately we are rarely contacted by Medicaid Home Care Providers or staff from the local CASA office. Many people who receive Medicaid home care have no relatives or friends and no interaction with anyone other than their home attendant. Our staff would do their best to provide a friendly visitor, a telephone call, a holiday package, something to brighten up the life of a frail, homebound person.

I would like to give you a brief example of the creative work BJCC is able to do: I recently received a phone call from the social worker at the Loeb Center, Montefiore's Short-Term Rehab Center. A 92-year-old gentleman was unable to be discharged to his apartment because he had no family in the community, and the staff at Loeb was not certain that he would be able to manage his affairs by himself. He also needed supervision paying his monthly bills, and managing his medications. Because of these holes in his safety net none of the Homecare agencies would accept his case. It looked as if he would have to go into a nursing home. The social worker picked up the phone, got me at a weak moment, and said, "You know, we've got this really nice man, he has a lovely apartment and wants to go home. Would you consider supervising his bill payments and his medications?" So I went over and I naturally fell in love with him; he's a charming gentleman. He has now been home for 2 months. He had 24 hours x 7 home care for 4 weeks from the CHHA, and his case has now been transferred to a Medicaid Home Attendant Agency. He has two lovely home attendants and I visit twice a month to help him pay his bills and put his medications in his pillbox. Hopefully he will be able to continue living at home for the rest of his life.

Our Agency's Mission has allowed our staff to become involved with our clients in many non-traditional ways. Although this places an unusual burden on our staff, it has produced many wonderful moments for everyone concerned. We kid around about our involvements, and every one on staff knows that when I retire I'm going write a book to be called, "Every body's Daughter." The Mentality and the Mission of the agency is a result of the work of our former Director, Arnold Eisen, and our present Director, Brad Silver. Thanks to them and the continuous supervision staff receive we are allowed the latitude to really take the time to be able to "Be There" for our clients.

Unfortunately much of the funding received by BJCC is in great jeopardy. We are facing massive budget cuts in the New York State Budget. We also understand that the United Jewish Appeal fundraising campaign was flat this past year and that BJCC might not receive as much in philanthropic funds as we have in the past. Together these funding streams are instrumental in providing the agency staff with the flexibility we require to provide the intensive kind of work we do.

FOR MORE INFORMATION ABOUT THE HEALTH CARE POLICY AND PRACTICE NETWORK, CONTACT CO-CHAIRS, TERRY MIZRAHI (212) 452-7112, tmizrahi@nyc.rr.com OR JERRY BEALLOR (718) 796-4185, gbeallor@earthlink.net