Notes and Disclaimers:
- Projects shown may also be operating in other states (see the Geographic Reach)
CLIFFORD W. BEERS GUIDANCE CLINIC, INC.
Project Title: "New Haven WrapAround"
Geographic Reach: Connecticut
Estimated Funding Amount: $9,739,427
Summary: The Clifford W. Beers Guidance Clinic, Inc. project will deliver evidence-based, culturally-appropriate integrated medical, behavioral health, and community-based services coordinated by a multidisciplinary Wraparound Team. Services include: 1) family engagement, recruitment, and education provided by trained community health workers in community-based settings; 2) multidisciplinary triage, screening, and assessment conducted by the Wraparound Team and including assessments of each family's physical, behavioral, and psychosocial risks, needs, and strengths; 3) family-focused care plans developed with the family, family supports, and the Wraparound Team and used to guide care and interventions; 4) care coordination provided by a Wraparound Team and focused on coordinating the provision of appropriate care across multiple care settings, managing care transitions, reconciling and managing medications, and coordinating access to crisis support and wellness and social support services; and 5) wellness and social support services provided at the hubs and at community-based organizations to address chronic and toxic stress (e.g., smoking cessation, parenting courses, diabetes prevention, meditation). The model focuses on high-need families, addresses medical and behavioral health care needs, integrates services across multiple health care institutions, and addresses the "chronic and toxic stress" experienced by the target population families. This project integrates care for families and integrates care delivery across multiple health care and community-based institutions, which will reduce the fragmentation that currently puts families at risk for poor care, poor outcomes, and excessive costs.
NATIONAL HEALTH CARE FOR THE HOMELESS COUNCIL
Project Title: "Medical Respite Care for People Experiencing Homelessness"
Geographic Reach: Minnesota, Oregon, Connecticut, Washington, Arizona
Estimated Funding Amount: $2,673,476
Summary: The National Health Care for the Homeless Council (NHCHC) is receiving an award to test a model that will provide medical respite care for homeless Medicaid and Medicare beneficiaries, following discharge from a hospital with the goal of improving health, reduce readmissions, and reduce costs. Medical respite care is defined as acute and post-acute medical care for homeless persons who are too ill or frail to recover from a physical illness or injury on the streets but are not ill enough to stay in a hospital; these programs can provide a cost-effective discharge alternative for hospitals and provide patients with a place to receive ongoing post hospital care while working on their health and housing goals. The service model will incorporate evidence based practices including transitional care, patient centered self-management goal setting, and case management to address socio-economic and other factors affecting health outcomes and access to timely and appropriate care.
Project Title: "Paramedic Referrals for Increased Independence and Decreased Disability in the Elderly (PRIDE)"
Geographic Reach: Connecticut
Estimated Funding Amount: $7,159,977
Summary: Yale University will test a model targeting elders and others with impaired mobility who contact 9-1-1 for falls or lift assists but choose to remain at home. Emergency Medical Services providers are trained to perform enhanced evaluations during the initial 9-1-1 call. Paramedics are trained to make follow-up visits to perform detailed risk assessments, home medication reviews, and referrals to primary care doctors and skilled home services. The expanded paramedic workforce with advanced training is a community-based resource that will improve care coordination and health outcomes for elders staying in their homes. Pilot studies have shown that similar interventions decrease repeat ambulance transports, reduce inpatient hospitalizations, and lower health care costs. Because lift assist patients share many risk factors, such as advanced age, cognitive and physical disability, limited mobility, social isolation, and polypharmacy, with patients who fall, the program's community interventions are modeled after evidence based fall prevention strategies.