Communities of Care

MHVC comprises seven counties of great diversity, each with inspiring examples of Communities of Care. We will be sharing partner stories here, and we hope you will contact us at with even more.

MHVC Regional Meetings: Where Communities of Care Come Together

MHVC thanks you for attending the MHVC Regional Forums in Poughkeepsie, Tarrytown, and Middletown on June 19, 20, and 21, strengthening our “Communities of Care.” These Regional Forums provided opportunities for MHVC contracted partners, community-based organizations, and key community members to bring forth innovative ideas and partnerships, and to network with neighboring organizations. Over 200 people participated in the three full days, which offered plenary, break-out, and workshop sessions, including plenty of opportunities for networking -- and for our ice cream social and “DSRIP Bingo” game! Here are links to the Regional Meeting presentation and other materials discussed at the meeting:

"What Matters to You?" Video by Damara Gutnick, MD, MHVC Medical Director, entitled “Being Patient Centered About Things that Matter.”  While you watch, consider the impact we could have if we shifted health care from “What’s the Matter?” to "What Matters to You?," and designed care that always addresses what's most important to our patients.

MHVC Innovation Fund. We really enjoyed brainstorming with partners on potential collaborations and projects for the Innovation Fund. Information relevant to the Innovation Fund including the Guidance Document V1.0, Contracted partner list, FAQ and  pre-recorded webinars are available on the MHVC Innovation Driving Change website page.

MHVC Training Calendar. Throughout the day we referred to trainings MHVC has developed to support partners. You can identify and register for upcoming trainings here.

VBP Training. After the break-out sessions, many participants requested access to the videos used in the VBP Training. MHVC is currently compiling these videos so that they can be accessed soon via an online learning module. In the interim, here are the slides that were used in the session.

HDSW Ribbon-Cutting Launches the “Living Room”

Crisis respite space is the first in the region; an alternative to ED

On May 3, 2017, Human Development Services of Westchester (HDSW) launched “The Living Room,” a comfortable, non-hospital environment that offers guests a safe and calming home-like setting in which to talk through their immediate situation and receive best-practice services and supports by a well-trained certified staff. According to Kathy Pandekakes, HDSW Chief Operating Officer, “With the Living Room available we will offer an innovative alternative to traditional services that will impact both the overall wellness of an individual while also addressing the DSRIP goal of reducing avoidable hospitalizations and ED visits.”

The Living Room Program is a short-term crisis intervention respite setting that is open seven days a week, 8:30 AM-8:30 PM, and is better-suited than institutional care to support recovery, reduce symptoms, and de-escalate the immediate crisis. Kelly Darrow, LCSW, HDSW Director of Recovery Services, adds, “A consistent theme I have heard from program participants over the years is that there are times when all they want is a peaceful place to rest, and a place where someone understand them and will listen to them. The Living Room is a place to promote personal wellness, to reduce symptoms, and to manage an immediate crisis.”

The Living Room is staffed by Certified Peer Care Managers, Licensed Certified Social Worker, and an on-call Registered Nurse. According to one guest, who uses emergency departments regularly, “Having the Living Room available will give me an opportunity to choose something other than the emergency room for respite.” Staff also follow up with contact after the guest arrives home and into the following days. If the guest needs longer or more intensive support, they are offered HDSW’s 24-hour crisis/respite services in the area.

The Living Room is dedicated to the memory of Mark Rubinstein, a former HDSW care manager whose family and friends funded the renovation and furnishing -- making the Living Room even more special to HDSW.

“HDSW is proud to be the first in Westchester County to establish a Living Room Program,” said Pandekakes. “There are at present no viable alternatives to the Living Room in Westchester, or similar services available in the region.”

High IMPACT, High Success for HRHCare Walden

Team approach, collaboration using IMPACT Model 3

When HRHCare’s Wallkill Valley Health Center at Walden embraced the Behavioral Health Integration (BHI) Model 3 -- IMPACT (Improving Mood - Promoting Access to Collaborative Treatment) -- for DSRIP project 3.a.i in August 2016, it already had a long history of incorporating BH specialists into primary care coordination teams using collaborative care standards.

The IMPACT model embodies collaborative care, where a patient's primary care physician works with a care manager to develop and implement a depression treatment plan. The care manager and primary care provider consult with a psychiatrist to change treatment plans if patients does not improve.

“We were already doing a lot of collaborative care, so we had a base of knowledge,” said Christine Oriani, LCSW, Project Lead and Depression Care Manager. “As part of our IMPACT work we added a consulting psychiatrist and changed our process, which had immediate results.”

Part of the process change involved administering the depression screening Patient Health Questionnaire-9 (PHQ-9) upon check-in. “We saw that patients who clearly had problems were not being identified with the PHQ-2; opening up the PHQ-9 to the total population was much more effective,” Oriani said.

Having the time and an appropriate environment for filling out the questionnaires proved to be key. “We have private areas for patients to complete the questionnaire, which are also provided in Spanish. We also incorporate time into the visit, either before or after meeting with the doctor, if they need more time” said Dr. Sumitra Dhanyamraju, Medical Director.

Dr. Dhanyamraju also leads morning huddles with staff. “We take 15 minutes at the beginning of the day to review all patients -- prior visits, medications, and emotional as well as physical health. It is hard to get it all done many days, but we know a lot of our patients well, so that helps.” The huddles are indicative of the highly-collaborative team approach at the site, which emphasizes “warm hand-offs” between team members.

Further emphasizing the collaborative approach, all three principals are from different agencies. Dr. Dhanyamraju is from HRHCare; Oriani is from ACCESS: Supports for Living; and Dr. Margarita Munoz, the IMPACT Psychiatric Consultant, is the Medical Director of Westchester Jewish Community Services. “We call ourselves the ‘Dream Team,’” said Oriani. “There is a ‘family-feel’ at the site -- we are a small site, we have a lot of fun, and there is a lot of spirit.”

“We are seeing success with our approach with our patients,” said Dr. Dhanyamraju. “Patients are very engaged -- they follow up with appointments and take their medications. This gives us a lot of encouragement: we won’t give up, they are responding, and they know we will follow up with them.” Walden’s support staff of nurses, medical assistants, and patient representatives epitomize compassionate care and create their own connections with the patients.

“There is a lot of connection to the community, and we are doing what we love to do,” said Oriani. The Walden site fills a need geographically, since many patients can’t get to neighboring towns, and there is no psychiatrist available anywhere else -- at Walden, Dr. Munoz is available for phone consults weekly. Many patients walk to the site, which sees about 4400 patients per year.

“We have a lot of provider buy-in,” said Dr. Dhanyamraju, “but as new providers come into the area, we know we have to get them on the ‘IMPACT train' too.’”


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