The Fuqua Center provides on-site psychiatric services in 16 affordable housing facilities in Atlanta. Over the years the model shifted from a primarily nurse practitioner (APRN) model to an LCSW care coordination and APRN care model. The Atlanta Housing Authority and Atlanta Regional Commission Area Agency on Aging are community champions of this work. Thirty housing staffd, behavioral health providers (both public and private) and WellCare (CM0) consistently attend network meetings aimed at pulling together the vast array of healthcare workers needed to address the psychosocial and medical needs of residents and to create a continuum of psych/ mental health services needed to adequately care for an older adult with mental illness (Sandberg et al, 2014). No one organization provides the continuum of psychiatric services needed to support Recovery. A barrier to evaluating the financial impact as well as providing an efficient care coordination model is that there is no one information system platform (Sandberg, SF et al, 2014; Graetz, I et al, 2014). The desired outcomes are to decrease hospitalizations/ crisis services utilization and improve housing stability (decrease lease violations and evictions). An average of 119 patients are served a year by the model, with greater demand than capacity to adequately serve residents.
A “Sustainability Map” will assist in developing a strategy based score card for a service which can be expected to evolve over time given the rapidly changing healthcare environment in Georgia and at Emory, as one provider among many needed to adequately care for this vulnerable population (Rohm, H & Montgomery, D, 2011) . The strategy told by a map is to improve Organizational Capacity by identifying an information technology (IT) platform which communicates between key providers allowing for measurement of care coordination and desired outcomes. The ARC/Area Agency on Aging will through braided funding provide care coordination. The identification of an Emory Healthcare champion which provides technical assistance and NP services is critical to sustainability. The identification/creation of a an IT platform will create Process efficiencies including the ability to measure care coordination according to AHRQ Care Coordination Measures Atlas standards which include information availability, timely information transfer, treatment goals agreed upon by the array of clinicians (partnering agencies) and agreed upon roles of the various clinicians (partnering agencies) (Graetz et al, 2014). With efficiencies will come cost savings for partnering agencies and the ability to be innovative (add to the array of services or increase capacity). The addressing of organizational capacity and internal processes will increase Customer/ patient satisfaction as well as other stakeholders (housing providers) satisfaction. Care coordination supported by an IT platform will support the Financial objective of reduced costs (e.g., Medicare/ Medicaid expenses, housing expenses related to lease violations/evictions).
Graetz, I, Reed, M, Shortell, SM, Rundal, TG, Bellows, J & Hsu, J (2014) The next step towards making use meaningful, Medical Care 52(12), 1037 – 1041
Rohm, H & Montgomery, D (2011) Link sustainability to corporate strategy using the balance scorecard Balanced Scorecard Institute
Sandberg, SF, Erikson, C, Owen, R, Vickery, KD, Shimotsu, ST, Linzer, M, Garrett, NA, Johnsrud, KA, Soderlund, DM & DeCubellis, J (2014) Hennepin health: a safety-net accountable care organization for the expanded Medicaid population, Health Affairs, 33(11), 1975-1984