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 Innovation Grant Project Puts the "Public" into Yonkers Public Library

YPL and CLUSTER know that answers require more than books, offering on-site case management services

"More Than Books" is the innovative program that brings case management and health services into the Yonkers Public Library. Partnering with CLUSTER Community Services, YPL received an MHVC Innovation Grant that funded on-site case workers who have been successfully helping Yonkers residents with everything from health and social-services referrals to housing to the loan of blood pressure monitoring kits (in partnership with the American Heart Association).

New Collaboration, New Opportunity: ADHD Treatment Partnership

CMG and Astor use care coordinators to work with parents, schools, teachers

MHVC is a great proponent of the high level of collaboration and coordination developed between the Children’s Medical Group (CMG) and Astor Clinics of Ulster and Dutchess County (Astor) to address critical problems together. “There is so much need for mental services for kids,” said Dr. David Fenner, president of CMG and a pediatrician there for 32 years. Child and adolescent mental health needs and ways to deliver treatment are different from those of adults, just as the pediatric world differs from adult primary care. “Working with Astor, we ask ourselves, ‘How do we integrate child and adolescent mental health with the pediatric world?’”

Dr. David Fenner counseling a patient.

The problem is especially acute with the increased awareness of Attention-Deficit/Hyperactivity Disorder (ADHD), and with evaluation and management falling heavily on primary care practitioners. “There is a lack of mental health providers everywhere, especially those with expertise with children and adolescents. Kids are often treated like little adults in the mental health arena. However, many of their issues and needs are different and trying to get that treatment integrated with pediatrics is difficult -- there are different flows and work patterns,” explained Fenner. “This project is trying to create an organized, systematic, standardized approach to how we handle ADHD in the real-life situation of a very busy medical practice. It’s ‘boots on the ground” for us.” Fenner continued, “We see DSRIP as an opportunity to stop, think, and reorganize the care of ADHD so we have a more coordinated approach in our projects with mental health providers like Astor and the use of care coordinators.”

Partners in the program include Astor, parents, and the schools for their input through standardized evaluations by teachers. The new process makes changes: In the past, a parent would call to say a child is having a problem at school. A doctor would see the child and schedule a follow-up appointment, but there was no tracking of the child in the system.

Under this new system of care coordinators, when the parent calls, the child is given to the care coordinator who contacts the parent with basic information and forms, teacher evaluation forms, parent evaluation forms, etc., so when a visit is set up with the provider, a lot of information is available. If a diagnosis of ADHD is made, then the child is put within the ADHD registry and the follow-up appointments and calls are scheduled. The care coordinator calls the parents to ask if the forms are filled out before the child comes in again. CMG has nine offices, 27 providers (pediatricians and Nurse Practitioners) in the mid-Hudson Valley. Centered in Poughkeepsie, it is using existing care coordinators with the hope of adding more as enrolment grows.

“All of the kids who meet the criteria for the study protocol are followed as a group, not just randomly followed without any overarching analysis and coordination and tracking,” said Fenner. “We are trying to be sure we are using evidenced-based criteria that requires input from teachers and parents with the evaluation of the doctor.”

IDD and BH: Jawonio Focuses on the Integration of Two Diagnoses

Caring for those with IDD and Behavioral health needs requires special skill and innovative programs

Jane Mullin, LCSW-R, and Jawonio are on a mission: To integrate services for people with Behavioral Health (BH) issues who happen to have an Intellectual or Developmental Disability (IDD). “As the community at large becomes more educated in the reality that persons with developmental disabilities are not immune to the challenges of mental illness, diagnosticians and treatment providers are more willing and able to recognize the needs of this special population.“

“Jawonio strives to ensure that people understand those with IDD and BH,” continued Mullin, who is Chief Strategic Integration Officer of Jawonio, Inc., in New City, NY. “Inclusion and integration are vital because the two disability groups are not mutually exclusive. Jawonio recognizes the need to be innovative because we understand that a person may experience depression and also be physically challenged, or be on the autism spectrum, a developmental disability, and have BH needs.”

Founded in 1947, Jawonio provides services in the Mid-Hudson Region of New York for children, adults and families with intellectual/developmental disabilities, behavioral health challenges and chronic medical needs. It employs over 1,000 people throughout the Mid-Hudson Valley region of New York State and provides care to over 10,000 people every year. Jawonio has three program sites: Main Campus (New City), Jawonio TECH (New Hempstead), and Jawonio Westchester (Yonkers).

One of Jawonio’s precepts is to integrate people with IDD into community-based programs so they can experience the community just like everyone else, with no regard to disability. Participation in MHVC has given Jawonio the unique opportunity to encourage, push, and assert recognition of the needs of the person with IDD and co-occurring mental health needs through projects that keep this cohort front and center. “We participate in MHVC on a comparatively small but significant scale, since participation provides us with a platform to co-locate and integrate services for those we support,” said Mullin. “Our IDD population is at a significantly higher risk of mental illness -- over 33%. Co-location and integration with Cornerstone Family Healthcare helps us provide primary care to this special population with complicated needs -- primary care just like everyone else.” Cornerstone FQHC, located at the New City site, provides a full array of integrated primary and BH care services. Mullin declares that, “It is unique in our region since it is an integrated center with an expertise in serving persons with IDD.”

“We have integrated our IDD participants into our mental health programs, such as The Front Porch, a peer-run program, and Transitions, a short-term Intensive Outpatient Program (IOP),” said Mullin. “We are very proud of the fact that we are the only organization in the state that has been able to integrate people whose primary diagnosis is IDD, into PROS (Personalized Recovery Oriented Services).” PROS, a program of the NYS Office of Mental Health, is a comprehensive model that integrates rehabilitation, treatment, and support services for people with serious mental illness. Jawonio serves about 200 people a year through the program, about 20% of whom have IDD.

“We are all about innovation and trying to determine the best and most creative ways to serve this population,” said Mullin. An example of this non-traditional thinking is Jawonio’s efforts in the vocational area., which gives its clients the satisfaction of a job well-done in the community. It created The Jawonio Commercial Cleaning Company, which is a separate business that has governmental cleaning contracts in Westchester and Rockland counties. Jawonio is the largest regional provider of job placement and employment supports for persons with IDD and/or behavioral health needs.

These public-facing activities support Jawonio in its advocacy efforts at the state and federal levels. “One of the things Jawonio does well is advocacy,” said Mullin. “If you don’t talk about it. it doesn’t happen. My hope is that people who are diagnosed with IDD are recognized and not excluded; one way to ensure this is to talk about it.”



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