making supportive case management work at the ryan network
Post on 30-Dec-2015
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William F. Ryan Community Health Center
110 West 97th street
New York, NY 10025
Eishelle Tillery, MSW
Nancy Andino, LCSW
www. Ryancenter.org
ObjectivesList 3 important characteristics of a successful
Supportive Case Management Program
Identify 3 important characteristics of a patient in need of Supportive Case Management. (SCM)
Identify coordinating strategies used by SCM in our renewed health care system that integrates the work of Social services and clinical providers as a team to meet patient needs.
Identify two aspects of supervision necessary to SCM that facilitates patient change and satisfaction
William F. Ryan Network Four main sites, 6 School
based, 4 Shelters and the Women and Children’s Center
2011 Network served 49,192 patients
Race: 74% minority Sex: 58% F
Insurance: 27% uninsured & 67% public insurance
Homeless: 2,645 (5%)Age: 34% pediatric patients,
57% adult, 10% 65+
HIV/AIDS Spectrum of Services
Medical Mobile Van
Electronic Medical Record
Mental Health Counseling
Harm ReductionServices
Prevention Education and Outreach
Confidential HIV Counseling and Testing
Primary Health CareTreatment Education/
Adherence
Medical Case Management
HIV Specialty Care
Hepatitis C Treatment
Program SCM SkillsHealth Care Disparities Advocates
Support and Guidance Culturally Sensitive / Interpersonal Skills/Awareness of Services
Education Ongoing Training
Coordinated Care Health Care/ Community Knowledge
Health and Social Barriers
Problem Solving SkillsEmpower others
William F. Ryan Supportive Services Programs Women In Care Program- Provides support
to HIV Positive women i.e. advocacy, escort, financial assistance and referrals.
Harm Reduction Program- For HIV positive Men and Women who are currently active substance abusers who wish to change their behavior.
AIDS Institute Support Case Management- Advocacy, escort, referrals, home visits etc.
Ryan White Part C Supportive Case Management- support services that are not covered by other CM grant programs.
SCM and the Community ConnectionPatient assessed needs
SCM are Directly linked to community resources. Communication, Relationships, SCM style & knowledge of resources results in patient positive results.
Cultural awareness allows for appropriate referrals.
Supervision Coordination of Care
Adequate Supervision eliminates role confusion
Strength based supervision/ Effective Trainings
Pt’s share different information with Different providers.
Case Conferencing also informed patient can participate in a collaborative model resulting in appropriate services and referrals.
COORDINATION between SCM, Community and clinical provider.
Patient ExampleMaria has a diagnosis of HIV, Diabetes,
Hypertension.
Unstable diabetes and hypertension, stable HIV
DV in the household.
No health coverage, no collateral agencies
Medical provider is not aware of patient’s home situation and or home environment or lack of health coverage.
SCM Strategies for Coordination Patients will have assistance with achieving
their health goals by overcoming barriers. Practitioners will have knowledge of patient’s
barriers prior to treating patient & work that SCM is doing.
Practitioners will treat a well informed patient ready to collaborate b/c SCM has made appropriate referrals.
Decrease duplication of services. The SCM becomes the Coordinator in
coordinated care.
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