Evaluation and Sustainability of a Home Based Care Coordination Model for Older Adults with Behavioral Health Disorders

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

About Eve H Byrd MSN/MPH

NHWSON DNP student
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4 Responses to Evaluation and Sustainability of a Home Based Care Coordination Model for Older Adults with Behavioral Health Disorders

  1. Olga Turner says:

    That is interesting, Eve. I did not know that. It certainly does seem like a big need!

  2. Eve H Byrd MSN/MPH says:

    Erin and Olga,
    Thank you both for your thoughtful comments. Erin, all of our patients’ are entered into our Emory EMR however most of the patients are not solely seen by Emory. Almost all access services through numerous systems whether it be for their primary care or emergency services. Therefore, there is not one system which captures the individuals healthcare utilization. Georgia does not yet have a Health Information Exchange(HIE) system.
    Olga, Interesting that you brought up competition among providers. Our behavioral health patients are usually not patients systems seek out. Reimbursement for BH services is grime. However, HRSA has recently implemented a payment structure which really incentivizes Federally qualified health systems/ primary care providers for indigent to offer BH services. The unintended consequence is that it now hard to get these clinics to collaborate with public mental health bc they can make better money hiring someone on their own. The incentive for all of these providers to participate (md’s generally don’t provide home base services) is that they need to provide only the service that they get paid for so need to work with others in order to provide adequate care. Interestingly, the SW in my clinic was very hesitant when a for profit HH agency joined the network and they sent their marketing person. Didn’t bother me, our patients need their service and they need the business.

  3. Erin Sing Biscone says:


    I love the fact that your program is using social workers and NPs together. The two professions have complementary skill sets and I would think this would be a wonderful pairing. I believe social workers are often underutilized and undervalued.

    I have a question about the IT platform. How would it differ from an EMR like EPIC?


  4. onturne says:

    Dear Eve,
    I think that this is very interesting to read and it seems that a form of IT to aid in the communication between key providers would be very instrumental for organizational capacity. One thing that we have not talked about yet in class is readiness to coordinate services One study by Guerrero et. al. (2014) looking at organizational capacity for service integration in community-based addiction health services, noted that there also needs to be motivational readiness, in addition to organizational climate, and funding (part of the triple bottom-line). What would motivate physicians, LCSW, APRNs to coordinate care activities? It is the right thing to do, yes. It would probably enhance patient satisfaction, yes. It may reduce costs, as you have suggested. But is there also not some competition between organizations (even healthcare organizations), and professions for business? In the article I read, the readiness-for-change framework was used to assess program resources and climate as well as staff motivation and attributes to explain the process of exposing, adopting, implementing, and sustaining new practices. Some factors that contributed to this motivational readiness included a climate for change focused on specific strategic imperatives like safety and customer service, leadership (although not significantly), program type, and funding sources.

    Guerrero, E.G., Aarons, G.A., Palinkas, L.A. (2014). Organizational capacity for service integration in community-based addiction health services. American Journal of Public Health. 104(4): e40-e47.

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