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Ann Marie T. Sullivan, M.D., Commissioner
Governor Andrew M. Cuomo

Round 2 Grants
2011-2014

For the second round of service demonstration program grants, the Office of Mental Health (OMH) solicited proposals in April 2011 to integrate physical and behavioral health care in either behavioral health care settings (Model 1) or physical health care settings (Model 2) to assist older adults with mental health and/or substance use disorders in New York State. The integrated programs are to (1) identify and treat physical and behavioral health disorders more effectively; (2) address related behavioral issues, such as smoking, overeating, and adherence to treatment, that have an impact on health care; and (3) address psychosocial issues, such as family caregiving, housing, and financial problems, that also have an impact on health care.

A total of 21 awards were made throughout the State for these two-year service demonstration projects, which are expected to be sustainable and fiscally viable without OMH support by the end of the grant period. Awards were made in two phases.

Phase I (10/1/11 - 9/30/13)

Model 1 Projects: Integrated Care in Behavioral Health Care Settings

  1. Clubhouse of Suffolk
    Clubhouse of Suffolk’s plans to operate an integrated health care program for adults age 55 or older with a serious mental and/or substance use disorder were partially implemented. With an emphasis on coaching for the prevention and management of metabolic syndrome, peer wellness coach mentors were trained and engaged members in healthy lifestyle choices. Clubhouse continues to work on plans with Family Residences and Essential Enterprises to provide physical health services at its Personalized Recovery-Oriented Services program.

  2. Flushing Hospital Medical Center
    Flushing Hospital’s outpatient mental health clinic established an integrated health care program – still in operation after the grant period – that enabled their older adult patients to access primary care services at the clinic. An organizing principle to implement the program was a Metabolic Syndrome performance improvement initiative. An adult health nurse practitioner, who focused on preventive care and the interrelationship between a patient's medical and psychiatric illnesses, coordinated physical and mental health care.

  3. Interborough Developmental and Consultation Center
    Interborough implemented an integrated physical and behavioral health care program for the elderly – still in operation after the grant period – at its Flatbush outpatient mental health clinic. This site has high concentrations of older Russian immigrants seeking care. A nurse practitioner worked in collaboration with a physician to provide integrated care, which included physical exams, health wellness groups, complex care management, and integrated physical and behavioral health treatment plans.

  4. Mercy Medical Center
    Mercy renovated space at its outpatient behavioral health services site in Garden City to conduct physical examinations, added part-time physical health care staff, and reorganized procedures to integrate the delivery of care provided by both physical and behavioral health staff. The integration project – still in operation after the grant period – recently acquired the part-time services of physicians affiliated with the hospital to prepare for the transition of fee-for-service Medicaid behavioral health services to managed care.

  5. Southeast Nassau Guidance Center
    Southeast Nassau planned and initially implemented an integrated health care program operating within the model of a person-centered healthcare home in which a nurse practitioner and other specialty staff assessed and medically monitored adults age 55 or older receiving treatment in its outpatient mental health clinic. When the program’s nurse practitioner resigned, Southeast Nassau was unable to recruit a qualified replacement and withdrew from the service demonstration program prior to the end of the grant period.

Phase II (7/1/12 - 6/30/14)

Model 1 Projects: Integrated Care in Behavioral Health Care Settings

  1. Comunilife
    Comunilife established Mi Salud, a program of coordinated behavioral and physical health care management for Latino adults age 55 or older in an outpatient mental health clinic in the Bronx that serves primarily Latino adults, children, and families. A nurse practitioner was added to a designated clinical team that includes a bi-lingual psychiatrist and a number of part-time social workers and therapists to address behavioral, physical, and socio-economic needs of low income seniors with psychiatric disorders and chronic physical illness.

  2. Coney Island Hospital
    Coney Island planned but was unable to staff an outpatient mental health clinic satellite it established at the Council Center for Senior Citizens in Brooklyn with a part-time social worker and nurse practitioner to integrate a variety of physical health services with behavioral health care for a multi-ethnic population of older adults that includes Jewish-Americans, Russian, and Asian immigrants. The hospital withdrew from the service demonstration program prior to the end of the grant period.

  3. Hudson Valley Mental Health
    Hudson Valley is partnering with Hudson River HealthCare, an Article 28 health facility, to integrate physical health care into its outpatient mental health clinics. The agency began by integrating care at its Dover Plains site, where physical health care visits are provided by a nurse practitioner from Hudson River.

  4. Institute for Community Living
    ICL co-located a part-time physician, nurse care manager, and peer wellness coach in its outpatient mental health clinic in Canarsie to provide on-site health assessment/monitoring and care management/coordination. The target population is elderly clients who do not have primary care providers, those who are not using primary care providers listed in their records, and those receiving treatment from multiple health providers without the benefit of care coordination.

  5. Mental Health Association of Nassau County
    MHA Nassau, in partnership with Nassau University Medical Center, co-located a physician at its behavioral health site in Hempstead. The expectation is that the co-location of a primary care provider in this setting will allow it to function as a health home for their consumers. For mental health consumers age 55 or older, the goals are to improve overall health, promote recovery, foster independence, and reduce public expenditures.

  6. Monsignor Carr Institute
    Monsignor Carr’s integration program is providing health screening and assessment, as needed physical examinations, health monitoring, follow-up, and care coordination services for clients age 55 or older at its outpatient mental health and chemical dependency clinics in Erie County. The agency hired a full-time medical assistant and contracted for a part-time nurse practitioner, who maintains regular hours at the two clinics and also consults with mental health and chemical dependency staff on treatment options.

  7. Montefiore Behavioral Health Center (formerly Sound View Throgs Neck Community Health Center)
    Montefiore provides primary health care screening, intervention, and treatment services tailored to individuals age 55 or older with serious mental health and substance use disorders at its outpatient mental health clinic in the Bronx. The integrated program includes the employment of primary care health professionals as well as referrals for highly complex cases to Montefiore Medical Center.

  8. Service Program for Older People
    SPOP's health integration program utilizes a psychiatric nurse practitioner to coordinate all medical services for their outpatient mental health clinic and homebound clients, and expanded the hours of their psychiatrist to work in partnership with her. While the program serves adults age 55 or older who come to the agency for behavioral health services, it especially seeks to focus on hard-to-reach groups of older adults, such as the frail homebound elderly and Spanish-speaking older adults.

  9. Union Settlement Association
    Union Settlement added a full-time nurse practitioner to the staff of its Johnson Counseling Center outpatient mental health clinic and its satellite senior centers in East Harlem to integrate health care for their clients age 55 or older. Working as part of a team with each client's therapist or social worker and primary psychiatrist, the nurse practitioner provides on-site physical health assessments, screening, monitoring, treatment, and referrals to partners and others for additional health services.

Model 2 Projects: Integrated Care in Physical Health Care Settings

  1. Adirondack Medical Center
    Adirondack Medical's integrated behavioral health care services for adults age 55 or older into its primary health clinics in Essex and Franklin counties. A psychiatric nurse practitioner is co-located at the clinics, completing assessments and consulting with care team members. The program has enabled the medical home care team – which consists of primary care providers, care coordinator, nutritionist, doctor of pharmacy, psychiatrist, and health educator – address a larger range of patient issues.

  2. Bassett Medical Center
    Bassett is integrating behavioral health care for the elderly into its primary care clinic in Cobleskill, which is also a satellite location of Bassett's outpatient mental health clinic in Cooperstown. Patients complete basic behavioral health screens that are scored by primary care nursing staff, who refer those with positive scores to an on-site LCSW; she then completes the assessment process, in collaboration with the primary care team, and provides behavioral health treatment services, including counseling.

  3. Cayuga Counseling Services
    Cayuga Counseling is providing behavioral health services to residents of two recently merged nursing homes (formerly Mercy Health and Rehabilitation Center and the Cayuga County Nursing Home). A licensed psychiatric nurse practitioner provides medication consultation services, and two licensed therapists provide therapy for adults age 55 or older. Program goals include the alleviation of symptoms of depression, anxiety, and psychosis, and improving the quality of life of residents who live there.

  4. Family Services of Chemung County
    Family Services is adding behavioral health assessment and treatment services to primary care at Arnot Medical Services’ Eastside Family Medicine primary care office in Elmira. The office is also a satellite location of Family Services’ outpatient mental health clinic. Designed to serve as a blueprint for integrated treatment in Chemung County, the program emphasizes the importance of illness prevention, early intervention, and relapse prevention.

  5. Henry Street Settlement
    Henry Street's health integration program targets low income adults age 55 or older in New York City's Community District 3, including the Lower East Side and Chinatown, with a focus on older adults living in the Vladeck Houses Naturally Occurring Retirement Community. A LMSW is stationed at the agency's Article 28 medical health care facility, which is located in the same building as its outpatient mental health clinic, and facilitates the integration of physical and behavioral health care and senior services.

  6. Kingsbrook Jewish Medical Center
    Kingsbrook utilizes a psychiatric nurse practitioner to integrate behavioral health care services for the elderly at the hospital's Pierre Toussaint Family Health Center in the Bedford Stuyvesant – Crown Heights neighborhood of Brooklyn. With integrated patient care teams, the program seeks to identify and treat behavioral health disorders more effectively, modify negative lifestyle behaviors, improve self-management skills for those with one or more chronic diseases, and prevent avoidable hospitalizations.

  7. Lincoln Medical and Mental Health Center
    Lincoln employs an enhanced chronic care model for the integration of care in its medicine and geriatric outpatient practices. The model co-locates a full-time LCSW and a consulting psychiatrist with primary care staff in a primary care setting and uses a collaborative, integrated, holistic approach to more effectively identify and treat behavioral health disorders among older patients with both chronic physical and mental health conditions.

Comments or questions about the information on this page can be directed to the Bureau of Program and Policy Development/Division of Adult Services.