Project Name: Community Care of Brooklyn Navigator: Addressing Health Equity through Community-based Behavioral Health, Social Service and Care Coordination Support
Maimonides Medical Center, in partnership with the Brooklyn Health Home, has launched the Community Care of Brooklyn (CCB) Navigator, a centralized virtual navigation center bringing together the medical, behavioral, and social service providers across our network. The CCB Navigator was developed in response to a salient need to simplify the process by which community members are connected to the care they want and need. In health and social services systems that are often siloed and fragmented, it can be incredibly challenging to a find a service that checks all the boxes: right type of care, eligibility criteria, and insurance coverage. The goal of this project is to expand care management to drive optimal utilization of healthcare and community resources, and use this proof of concept to engage payors in supporting care management that falls outside of existing payment streams. The objectives are: 1) to complete the buildout of a centralized navigation resource for individuals, their families, and providers utilizing a web-based platform to streamline the referral process and reduce the administrative burden on the referring providers, 2) deploy a model of right-sized care management for individuals regardless of payment, and 3) improve Brooklynites' quality of life by reducing barriers to address health equity. The anticipated outcomes include: 1) increased connections to community-based care and resources and 2) increased engagement in primary/specialty/outpatient physical and behavioral health care.
The CCB Navigator serves as one-stop shop for all referrals within our growing network and is comprised of three primary components: a living guide of resources from across the network housed in a web-based platform, a person-centered Care Management Needs Assessment and Matching Tool, and the navigation center staff. The CCB Navigator receives referrals from CCB IPA practices, Maimonides clinical departments, CBO partners, other Brooklyn-based hospitals, and the community at-large. Navigators conduct an assessment with participants over the phone, utilizing the MMC translation services as needed, focusing on behavioral health and social determinants of health (food and housing security, employments, education, legal, etc.) and, with the support of trained care coordinators, connect them to over 200 services already available in their community. Our aim in conducting assessments is not strictly the collection of information regarding the person's health, but also as a first step in the development of the empathetic and therapeutic relationship between our team and the people we serve. The CCB Navigator aims to develop and embed an integrated approach to care management throughout Maimonides and the communities it serves.
Through the continued collaboration with our community and provider partners, and provision of this resource, this initiative aims to reach approximately 7000 Brooklynites and their families with significant behavioral health and social needs over the course of the proposed funding year. We will screen/assess at least 50% (3500) of the individuals referred to the CCB Navigator and successfully connect 75% (2625) of assessed individuals to care coordination and/or community-based services. The team of care navigators will follow up and confirm connection to care for all individuals assessed and referred to care.
