Clinical Community Integration Program Addressing SDOH and Mental Health - StayWell Health Care Inc: Clinical Community Integration Program Addressing SDOH and Mental Health Abstract StayWell Health Care, Inc. is expanding the Clinical Community Integration Program in Waterbury, CT. This innovative initiative employs a two-step approach to significantly enhance case management, referrals, and care coordination. Focused on addressing Social Determinants of Health (SDOH), mental health, and substance use disorders, the program aims to expand access to essential services and support within the community. Uninsured clients who demonstrate extensive needs and hospital recidivism through screening will be referred into the Community Care Team (CCT) and their hospital utilization will be analyzed for improved outcomes. Clients may be referred to an array of community or clinical providers by program staff, including internally to StayWell Health Center for primary, dental or behavioral health care as applicable. This project will serve a total of 960 unduplicated adult individuals annually and during the funding period. Population of focus: adult uninsured/Medicaid recipients of any gender identity who have a.) positive screening results on multiple indicators of the PRAPARE social determinant of health screening tool and no medical home; b.) >=6 Emergency Department visits in a period of 4 months; c.) homelessness and d.) dual diagnoses of mental health disorder and chronic conditions or substance use disorder. The geographic catchment area is Waterbury, CT with a population of 114,403 residents. Demographics of Waterbury: White 37,760 (33%;) Black 22,269 (19%); Latino 45,281 (40%); Asian 2,349 (2%); Native American 307 (<1%); Other Race/Ethnicity 6,437 (6%) (US Census Bureau, American Community Survey 2016-20). Clinical characteristics of the Waterbury, CT area: 16% of Waterbury adults, ages 18-64 have no health insurance, and 40% are on Medicaid. [5] Overall, 18% of Waterbury adults report experiencing anxiety regularly and 15% report being impacted by depression. Prior to the pandemic, 26.5% of adults with any mental illness in Connecticut reported having Medicaid coverage in the past year. [6] In 2016 and 2017, 51% of the drug overdose deaths in Waterbury involved fentanyl; in 2020 and 2021, this share was 87%. [7] Waterbury has a 22% poverty rate and the life expectancy is one of the lowest in the state at just 76.8 years Consequently, the population in need requires a whole-person intensive case management approach from many entities to put in place the foundational supports of income, health insurance, identification, transportation and medical home before the focus can shift to addressing the more significant issues of mental health treatment, medication adherence, and substance abuse treatment. Project goals include increased screening of the uninsured for SDOH and expediting clients to mental health resources/referring them to CCT as necessary; creating opportunities to serve more CCT clients through thoughtful discharge processes; developing improved outcome data demonstrating linkages to care and reduction in hospital recidivism; maintaining adherence to equitable and culturally competent care and services aligned with CLAS standards. The project will address these goals and needs through innovative collaboration that sets participants on a path of independence, stable housing, security, employment and health while imparting an improved quality of life, while saving money in the overall health system.
